NBME CBSE ACTUAL TEST 2023/2024 UPDATES, Exams of Nursing

Download NBME CBSE ACTUAL TEST 2023/2024 UPDATES and more Exams Nursing in PDF only on Docsity! NBME CBSE ACTUAL TEST 2023/2024 UPDATES 62 year old woman - osteoporosis – a bisphosphonate is prescribed. The expected beneficial effect of the drug is due to which of the following? Decreased Osteoclast Activity Cohot Study of elderly women – relative risk ratio for hip fractures among those who exercise regularly is 1.2 (95% confidence interval of 1.1 to 1.8). Which of the following is the conclusion about the effect of exercise on the risk of hip fracture? Statistically Significant Overall Increase Risk 00:03 00:49 52 year old man goes to ER with chest pain radiating to his jaw while shoveling snow. Pulse is 80/min and blood pressure is 130/70. The most immediate treatment mechanism of action? Increased nitric oxide concentration 24 year old woman – spilled hot grease on her left leg while working at a fast-food restaurant. Exam of leg shows 7cm pink, soft, granular, edematous wound. The formation of this tissue was most likely caused by increased activity of which? a. Vascular Endothelial Growth Factor VEGF – stimulates angiogenesiss. TYPE III Collagen = Blood Vessels – early wound repair 27 year old man- MVC – skull x-ray shows a linear, nondepressed basal skull fracture – increased serum osm and decreased urin osm. Following desmopressin urine osm increases. Desmopressin’s effect is due to the activation of which of the following? b. ACNE = Propionibacterium ACNE (looks like Burkitts Lymphoma/ Starry night Apoptosis b. Endemic Burkitt lymphoma can happen in Brazil as well as Africa (jaw lesion, puffy face). 1.5 cm mass on apex of tongue Submental 15 year old boy – ER – 2 hour history of confusion and agitation – fever, headache, stiff neck, and vomiting – since returned from summer camp - patient is hallucinating – lumbar puncture – shows cysts and trophozoites- most likely pathogen? a. Olfactory Nerve Naegleria fowleri 17 year old – ED – 30 minutes after being found with a blank stare. Physical exam shows rigidity. During exam he becomes hostile and assaults physician - Pt ingested which drug? PCP Placebo controlled clinical trial - 5000 pts with essential hypertension. 2500 patients receive new drug and 2500 patients receive placebo. If alpha is set at 0.01 instead of 0.05, which of the following is most likely result? Significant findings can be reported with greater confidence 17 year old - gymnast - comes to hospital because of lack of menstrual period for 6 months. BMI 15 Which is the cause of the amenorrhea? Hypogonadotropic Hypogonadism A male stillborn is delivered at 32 weeks – Oligohydramnios - absence of a urethral opening. Which is most likely finding? Pulmonary Hypoplasia A 6 day old – breast fed boy in ED - poor weight gain and irritability since delivery – Physical exam shows jaundice and hepatomegaly. The concentration of which of the following metabolites is most likely increased? a. Galactose – 1 – phosphate b. Congenital intolerance to breast milk A 25-year-old man – comes to ED - severe muscle pain, diffuse, painful swelling of his neck, underarms, and groin after camping in New Mexico Generalized scattered black maculae. Examination of the right upper extremity shows erythematous, solid, tender mass. Mass is draining blood and necrotic material. The most effective antibiotic for patient disorder will interfere with which of the following processes? a. Ribosomal Assembly b. Yersenia Pestis 45 year old - progressive weakness – muscle fasciculations of the upper extremities and weakness of the lower extremity - What additional findings? Atrophy b. ALS = Lou Gherig A new severe respiratory illness – Why use a killed vaccine vs a live vaccine? Avoids Concerns of reversion to virulence b. Killed vaccines - avoids reversion to virulence c. live vaccines - can (but rarely do) cause the disease they’re designed to prevent A 33 year old - keratinizing squamous cell carcinoma of cervix. Which of the following describes pathogenesis of this patient’s disease? Inactivation of Cellular P53 b. p53 protein = tumor suppressor (it activates apoptosis) - most human cancer A 54 year old – 40 year history of T1DM – receiving hemodialysis for end stage renal disease while awaiting a kidney transplant. Receives a drug that induces reticulocyte release from bone marrow and stimulates a cytokine receptor that signals Jak/Stat pathway? Erythropoietin Jak Stat – erythropoietin During a clinical study examining the effects of exercise. The average pulse is 175/min. Compared with measurement before the session, which is most likely decreased? Total Peripheral Resistance An 8-year-old boy – 3-day history of fever, sore throat, and itchy eyes. Returned from week long summer camp that includes hiking trips and swimming - PE shows conjunctival injection and oropharyngeal edema - Outbreak among other campers. Which is most likely cause of this patient’s symptoms? c. Teres Minor and Infraspinatus external rotation d. Innervated by Suprascapular Nerve A 44 year old man – 6 week feet numbness - chemotherapy with vincristine – MOA of Vincristine? Depolymerization of Microtubules 10 year old - 95th percent height and 25th weight – Nurse thinks she has marfans – Molecular testing for FBN1 Gene shows single nucleotide change does not change amino acid at the locus - Explain the single nucleotide change in the patient and the mother? It is a polymorphism 26 year old woman – ED – 2 day history of runny nose – Patient has to wait 6 hours before she is seen. In addition to apologizing, which of the following is the most appropriate remark? Thank you for waiting. How can I help you today? A 26 year old man – ER -m 30 minutes after being shot in the leg – Pulse is 120/min, respirations are 16 /min – blood pressure is 80/60. Findings compared with healthy adult? Baroreceptor Firing decreased SVR increased Pulmonary Vascular Resistance Increased Absorption Increased e. BARORECPTOR – stretch receptors - mirror BP – decreased in hemorrhagic shock A 36 year old man - fluid is presenting adbomen in which of the following areas as indicated by the arrow? Omental Bursa (lesser sac) What is the positive predictive value (refer to chart)? .67 Probability that a patient with a positive test has a disease A/(A+B) A 75 year old woman with T2DM and HTN – Emigrated from Argentina - Which of the following is the most appropriate person to serve as an interpreter for this patient encounter? Telephone Interpreter During a study of renal glomeruli – if efferent arteriole is constricted – which starling forces are likely to change in the glomeruli? Increased Hydrostatic Pressure 2 year old with neurocognitive dysfunction – fine during birth – both parents have learning disabilities – maternal uncle with cognitive disabilities – Irritable making eye contact with flapping his hands? Trinucleotide Repeat Expansion b. Fragile X – intellectual disability - trinucleotide repeat in FMR1 gene A 33 year old man – undergoes radical thyroidectomy – postop serum calcium is 7.5 and albumin concentration of 4g/dl - PTH concentration of 200 - damage to which vessel causes finding? Branch of Thyrocervical Trunk b. inferior thyroid arteries, which arise from the thyrocervical trunk. c. External carotid – superior thyroid treated with thiazide diurectics - Adverse Drug Effect b. Treated with a thiazide diuretic for HTN with measured hypokalemia, hypotension and decreased Hg 55- year old man – nice to nurses – mean to youngest child- Which is the most likely explanation of patient’s behavior? Splitting b. Cluster B - borderline personality (BANH) A Study designed to evaluate the feasibility of acupuncture in children with chronic headache – 60 children recruited – In addition to their usual therapy - all children are treated with acupuncture three times per week for 2 months - Describe findings? Case-Series 6 year old girl - 1 week history – lots of infections -raised neutrophil count- but cells show a delay in bactericidal activity against Staph Aureus– Most likely cause? Myeloperoxidase 2 year old boy - severe pain, swelling, and redness of his left thumb (image). PE shows oral vesicle, cervical lymphadenopathy – infectious agent causing findings in thumb? DNA Virus Herpetic Whitlow Herpetic Whitlow vesicles on fingers 24 year old – brought to ED – MVC – face struck steering wheel - facial pain and double vision – Exam of left eye shows infraorbital edema – ocular movement restricted vertically – CT scan shown. Which of the following impaired on left side? Sensation over the upper lip V2 = maxillary nerve 23 year old – collapsed at finish line – no loss of consciousness Associated with prolonged use of vaginal tampons or nasal packing She is placed on a cot – feet elevated – 30 minutes later her blood pressure is 110/70 mm Hg. Which described patients condition? Orthostatic Hypotension .decrease in systolic blood pressure of 20 mm Hg (110-85) e. decrease in diastolic blood pressure of 10 mm Hg. (70-50) fat stranding in small bowel with areas of inflammation in terminal illeum – 2 cm bulge on antimesenteric border of the inflamed segment Gastric Mucosa b. Crohns with the multiple episodes over the last year, fat stranding, terminal ileum involvement 14 year old girl –parents divorced – starts acting sullen, defiant, and truant at school, sexual intercourse with new partners and no condoms, previously honor studenty- which defense mechanisms? Acting Out 38 year old – pregnant woman – ultrasound shows oligohydramnios and a full term fetus with a large kidney and empty right renal fossa. Need history on maternal use of which during pregnancy? ACE Inhibitors A 65 year old – bilateral wheezing – accumulation of which of the following? Leukotrienes 19 year old – with asthma – comes to ER multiple times for acute asthma exacerbations – “All doctors don’g understand me” – they keep prescribing steroid inhalers. What is the most appropriate statement by the physician? Tell me more about what you know about steroid inhalers and how are they supposed to work? A healthy 22 year old man – in study for glucose metabolism – He consumes an 800 calories meal consisting - 12 hours later serum glucose is within reference range - Which is involved in maintaining serum glucose? Glycogenolysis of Liver 30 year old man – 6 week history of colicky abdominal pain and diarrhea with occasional blood – on autopsy – small bowel is seen in the wall of a thickend loop of small intestine – Photomicrographs (granulomas)- DX? Crohns Disease A 3 month old boy – 2 hour respiratory distress – Physical exam shows cyanosis – blood sample appears brown – most likely cause of patients condition” Decreased activity in the enzyme that reduced Fe3+ to Fe 2 a. the hypoxia and the "blood sample appears brown" should point you towards methemoglobinemia. b. if you want a fun video from "9-1-1" that actually explains a lot of it: c. methemoglobinemia = cyanosis and chocolate colored blood. 68 year old – 1 day history of fever and swelling in left leg – cellulitis – gram stain – gram positive, catalase negative cocci – clear zones of blood agar - Which species of Streptococcus? Strep Pyogenes 67 year old woman – bicuspid aortic valve – admitted to the hospital - 2 day history of fever and chills. Blood culture grows viridans streptococci - In addition to penicillin, which other drug is administered to shorten the duration of treatment? Binding to 30S protein 12-year-old girl – 2 month history of intermittent yellowing of the eyes and skin – PE – no abnormalities except jaundice. Total bilirubin 3mg/dl unconjugated bilirubin > Direct – Findings in patient? Decreased activity of UDP glucoronylytransferase During an experiment, drug X is added to a muscle bath containing a strip of guinea pig intestinal smooth muscle. Agonists are added to the bath, and the resultant effects on muscle tension are shown in table. Acetylcholine increased. Which of the following drugs most likely to produce effects most similar to those of drug X? Cholinesterase Inhibitor 30 year old women – 28 week gestation – Fetal ultrasound normal – Father’s blood group in B, Rh Positive – Physician recommends administration of Rh0D immune globulin - This treatment is most likely to prevent? Formation of antibodies to RhD 55- year -old –man – hypertension and chronic kidney disease – ECG shows low voltage with electrical alternans. Physical exam is most likely to show which of the following? BP 85/60 Pulse 120 JVP Increased Pulse Paradoxus Increased a. Electrical Alternans = Cardiac Tamponade = pleural effusion b. Beck Triad - Hypotension, JVP, muffled heart sounds 52-year-old – newly diagnosed with Type 2 diabetes mellitus. Four weeks later, her hepatic glucose out is decreased and target tissue glucose uptake are increased. Which agent? Metformin coagulative necrosis 24 year old – rash from hot tub- the infectious agent causing these findings most likely began to proliferate in which of the following locations? Hair Follicle b. Hot Tub Folliculitis = Pseudomonas 45-year-old – picture of H. Pylori – epigastric heartburn and weight loss – Which process likely involved? Elaboration of proteases and urease with local support tissue A 14-year-old – hit with baseball bat – unable to dorsiflex his foot. Which of the following nerves is most likely injured? Common Fibular Nerve (peroneal nerve) 26 year old woman – brought to ED – 8 hour history – severe back and abdominal pain – persistent vaginal bleeding - Ultrasonography shows 2 cm ectopic pregnancy in the ampulla – Ampulla ruptured into surrounding tissue. Fluid will most likely be found in the following locations? Pouch of Douglas 46 year od with ankylosing spondylitis – treated with NSAIDs drugs – Sulfasalazine treatment has not resulted in improvement - most appropriate next step in treatment is administration of a drug that inhibits which of the following? Tumor Necrosis Factor 55-year-old with blisters that do not break easily, and no oral lesions – these blisters are most likely the result of adhesions failure of which of the following? Basement Membrane 47-year-old with organophosphate poisoning - blurred vision, difficult breathing, diarrhea, muscle weakness, fatigue – Most appropriate immediate pharmacotherapy? Atropine b. Organophosphate poisoning – DUMMBELLS c. Crosses blood brain barrier – reverses muscarinic effects in CNS 72 year old – difficulty swallowing, chest pain, and cough- tachypnea and equal pulses bilaterally- percussion shows dullness over right lung - chest X-ray shows area of opacification in the lower region of the right lower region of lung - Which is most likely cause of patients condition? Aspiration 62 year old man –abdominal pain – interviewed by physician – used single word and sarcastic answers. No eye contact – FROWNS - tells physician third time he has been asked question- Appropriate response? You Sound Upset. Tell me a little more about that. 54-year-old – ECG shows P wave and R wave no relation between the two. Which is the most likely diagnosis? Third Degree AV Block 42 year old – constipation, abdominal discomfort, mild fatigue, CA increased, P04 decreased, treated for renal calculus – PE shows now abnormalities – Most likely cause of patients condition is a small well defined nodule in which location? Parathyroid Gland 72 year old – ER – stroke symptoms – slurred speech and difficulty walking – left sided hemiparesis – Tongue deviates to right when protruded – proprioception and sensation to light touch are absent over the left upper and lower extremity – Which site in brain stem is damaged =Area Labeled C 68 year old woman – end stage renal disease – initially she did well – within 3 months she has been admitted for fluid overload – poor adherence to fluid and salt restrictions - Which is most appropriate initial response? It is tough to change your diet and fluid intake, but what sorts of things were you doing first when you were following recommendations During an experiment – southern blot analysis - Figure showed resulting pattern with DNA samples isolated from different organs. Southern blot demonstrates? Gene rearrangement 17 year old girl – physical exam shows normal female body habitus - normal breast development – refuses to have a pelvic or rectal examination.- no axillary or pubic hair – most likely clinical presentation? Androgen Insensitivity 16 year old boy – 3 day abdominal pain and vomiting – CT scan shows perforated appendix – Exam of peritoneal fluid shows which organism? Escherichia Coli 45 year old woman 6 month history of hot flashes, night sweats, and insomnia- Physician informed consent on new treatment – most appropriate next step? Could you tell me the results of the hormone treatment options we have discussed? A randomized control trial – assess risk of GI adverse risk using azithromycin compared to erythromycin in the pertussis – 100 children with pertussis enrolled – 50 azithromycin and 50 erythromycin – vomiting among 5 pts in azithromycin group and 15 patients in erythromycin group - Which represents absolute risk reduction? a. 0.2 . 15/50 – 5/50 = .2 34 – year -old woman with a 10 year history of Hep C - progressive fatigue - vitals normal. – liver biopsy shows hepatocellular injury – infiltration and early fibrosis – which mechanism is most likely to cause hepatocyte injury? Foreign Peptides bound to Class I MHC Molecules are recognized by CD8+ T Lymphocytes You can use three classes of medication to treat RA: NSAIDs, corticosteroids, and DMARDs. NSAIDs and corticosteroids have a short onset of action, while DMARDs take a while to take effect. 28-year-old man infertility, weight lifter and takes anabolic steroids. Mechanism of infertility? Suppression of Gonadotropins Anabolic steroid use suppresses the Hypothalamic-Pituitary-Gonadal axis which will down regulate GnRH. FA 2020 p636 62-year-old woman with 3-day hx of fever, shaking chills, and left flank pain. Dx acute pyelonephritis and treated with ciprofloxacin. Five days after, sudden onset watery diarrhea and lower abdominal cramps. T 100.9 F, pulse 80, rr 18, bp 124/88. PE moderate tenderness to palpation in lower quadrants especially on right and increased bowel sounds. Stool is brown and occult blood negative. Next step? Test of the stool for Clostridium difficile toxin b. Pseudomembranous colitis c. Couple days after Ciprofloxin 72- year-old woman comes to the physician because of a 6-month history of increased bruising on her forearms. She appears alert and well nourished. Physical examination shows extensive wrinkling, scaly erythematous patches on the face, and irregularly shaped brown macules on the face and forearms. There are ecchymoses in various stages of healing on both forearms; the ecchymoses are more numerous on the right side. Laboratory studies, including a complete blood count and coagulation studies, are within the reference ranges. S he has noticed no bleeding from her gums after brushing her teeth. Which of the following is the most likely cause of the ecchymoses in this patient? Extensive solar elastosis Actinic elastosis, also known as solar elastosis, is an accumulation of abnormal elastin (elastic tissue) in the dermis of the skin, or in the conjunctiva of the eye, which occurs as a result of the cumulative effects of prolonged and excessive sun exposure, a process known as photo=aging ]21-year-old woman with 2-days history of urinary frequency and pain with urination. T 39 C (102.2 F), pulse 125, bp 96/60. Urine grows gram-negative bacteria. Virulence factor for adherence to bladder? Fimbriae Ecoli 73- year-old man has poor appetite and lost 25 lb over 4 months. Labs show normochromatic normocytic anemia. Xray of chest shows 2-cm perihilar mass. Biopsy shows small cell carcinoma of lung. Which is responsible for weight loss? Cytokine effect Cachexia = increased pro-inflammatory cytokines Mediated by TNF-α, IFN-γ, IL-1, and IL-6 34-year-old man with herniated lumbar intervertebral disc. Laminectomy and removal of hernia scheduled. CT scan of vertebrae shown, which is surgical entrance location into neural canal? Area labeled D 24-year-old woman overdose on drug X and has serum concentration of 32. Drug X follows first-order kinetics. 6 hours later, the serum concentration is 16. Cannot be moved from intensive care unit until concentration 1.1 or lower. Which is minimum number of hours from first blood sample (32) that patient must remain in icu? 30 hours (5 half lives) b. First Order – Constant Fraction c. Zero Order – Constant Amount 45-year-old woman dx with cholelithiasis. She asks why abdominal pain is intermittent and not constant. Pain is produced when gallbladder contracts against gallstone obstructing cystic duct. Where is hormone released from that causes gallbladder contraction? Enteroendocrine cells of the small intestine (CCK) CCK = produced by the I cells in the duodenum and jejunum in response to fatty acids and amino acids. CCK – cause gallbladder to contract . 35-year-old with Chagas disease and 2-hour history of moderate chest pain. 4.4 lb weight loss in 2 months. Vitals stable. Barium swallow shows dilated esophagus with beak-like narrowing at lower esophageal sphincter (LES). Biopsy shows? Loss of neurons in myenteric plexus failure of LES relaxation, causing distal stenosis of the LES ("bird's beak" sign) proximal dilation indicative or achalasia 45-year-old man comes to physician for follow up after appendectomy. There is mild scleral icterus and well healing surgical incision. Lab values show Total bilirubin 3.2 Direct: 0.2 Indirect 3 mg/dL Dx? a. Gilbert Stress related - Mild jaundice with increased unconjugated in an older fellow is decreased UDP- glucuronyltransferase activity. 35yo F has congestive cardiomyopathy and pitting edema. Her serum urea nitrogen concentration is 25mg/dl and serum creatinine is 1.8mg/dl. Furosemide therapy is started. After 5 days, labs show: Na 130K 4.5Cl 90HCO 30 BUN 85 Creatinine 2.2 Albumin 3Urine specific gravity 1.023, rbc 0 wbc0 sediment none Urinary fractional excretion of sodium is less than 1%. Explanation? Prerenal azotemia After the addition of furosemide, her BUN/Cr ratio went up to 38 and Fraction Excretion of Na < 1 48yo man with possible hypertension. based on 20 measurements, his average diastolic pressure is 94mmHg, SD is 8mmHg. If only four measurements were made rather than 20, which of the following statements would best describe the width of the 95% CI with regard the mean blood pressure Larger Width of confidence interval larger with fewer cases Width will become smaller – with more cases 98-year-old woman who lives with daughter and grandson comes for routine exam with type 2 diabetes and hypertension but no complaints. She has had 14-lb weight loss since last visit 3 months ago. BMI 15. PE shows multiple ecchymoses in various stages of healing upper extremities and torso. Physician should ask?Are you safe at home? A transcription factor that activates expression of HMG coA reductase is identified, this TF is initially synthetized as a large precursor protein, with 2 membrane spanning domains. The transcriptional domain is released by proteolysis when the membrane has a decreased cholesterol concentration. The precursor protein is most likely initially produced in which of the following labeled area on this labeled diagram of a hepatocyte? Area labeled F Endoplasmic Reticulum 18-year-old woman comes 12 hours after ingesting 100 aspirin tablets in suicide attempt. PE shows tachypnea. Labs?pH/pCO2/HCO3- pH 7.32 pCO2 15 HCO3 8 aspirin overdose (early) = Resp Alkalosis aspirin overdose (Later) = Metabolic acidosis HCO3- should also be less than normal (22-28) 12 hours = Late Stages 10-day-old male newborn 1-day history red eyes with discharge. Pregnancy uncomplicated but no prenatal care in third trimester. PE bilateral conjunctival injection with water discharge. Cause? Chlamydia trachomatis b. chlamydia occurs 1-2 weeks after birth c. conjunctivitis from gonorrhea occurs 2-5 days after birth 54-year-old man with normal renal functions gets a heart transplantation. One year later, bp 170/110 and serum creatinine 2.1. Which immunosuppressive drug caused these findings? Cyclosporine ADR: hypertension and nephrotoxicity 2-year-old girl with febrile seizure. PE shows nuchal rigidity and bacterial meningitis suspected. LP and immediate abx therapy planned, but parents unavailable for consent. Next step? Initiate the procedure and treatment without consent Implied consent in emergency 14-year-old girl with 4 months of heavy menstrual flow. Menarche at 13 with regular intervals. History of frequent nosebleeds and easy bruisability. Father has problems with nosebleeds and clotting. PE shows mild gum bleeding and ecchymoses. Labs: hb 8.2, hct 24.6, platelet 250,000, bleeding time 10, PT 14 (INR 1.5), PTT 60. Dx? von Willebrand disease prolonged bleeding time + prolonged PTT = A study is conducted to compare the incidence of myocardial infarction in patients undergoing two different types of angioplasty or an operative procedure to manage single-vessel coronary artery disease. A total of 1000 patients are enrolled. Through a chance process, 500 are assigned to undergo the operative procedure, 250 are assigned to undergo one type of angioplasty, and 250 are assigned to undergo a second type of angioplasty. All patients are followed for 3 years to determine the incidence of myocardial infarction. Which of the following best describes this study design? Randomized clinical trial Study design with randomly assigned experimental and control groups is still a randomized clinical trial In cohort study, you don't assign the exposure, you just simply follow them (risk factors). 51-year-old with Graves disease develops ulcerating pharyngitis after 6 months of propylthiouracil. What's the underlying cause of ulcerative pharyngeal disease? Agranulocytosis (rare side effect of PTU) commonly presents with acute pharyngitis. . 22-year-old nulligravid woman has menses that occur at irregular 26- to 32-day intervals. Height 5 ft 4 in and weighs 187 lb. BMI 32. PE shows mild hirsutism and velvety brown, thickened skin at the base of the neck and around axillae. Patient has which condition? Hyperinsulinemia b. PCOS c. Acanthosis Nigrans 3-year-old boy 7 days after dx with severe chronic diarrhea due to Giardia. Immunological studies show peripheral leukocytes that express both CD3 and CD4 and fail to express CD40 ligand. Based on this, the immunoglobulin isotype that predominates has which biological properties? Complement activation Hyper IgM syndrome; without CD40 ligand, T cells are unable to provide the secondary signal to activate B cell class switching. prevents IgM from switching into IgD, G, E and A, and thus an accumulation of IgM - hence the name "hyper IgM" - and deficiency in the rest Complement activation= IgM and IgG 67-year-old woman comes to the physician because of a 1-month history of low back pain. She has hypertension well controlled with a thiazide diuretic. Her pulse is 140/min, and blood pressure is 140/85 mm Hg. Physical examination shows tenderness to palpation over the L2-3 vertebrae. Laboratory studies show:Hemoglobin 13.5 g/dLHematocrit 41%Leukocyte count 10,500/mm3Segmented neutrophils 65%Eosinophils 1%Basophils 1%Lymphocytes 30%Monocytes 3%Platelet count 250,000/mm3 Serum electrophoresis shows a monoclonal spike of IgG kappa. A chest x-ray shows cardiomegaly with bilateral pleural and pericardial effusions. An x-ray of the spine shows a lytic lesion. Echocardiography shows an echodense thickened left ventricle and poor diastolic compliance. A photomicrograph of a specimen obtained on myocardial biopsy is shown. Which of the following is the most likely cause of the cardiac findings in this patient? Amyloid infiltration Dantrolene – TX- Prevents release of Ca2+from sarcoplasmic reticulum of skeletal muscle by inhibiting the ryanodine receptor 48. 66-year-old man with 1-month hx of nonproductive cough and 6 months shortness of breath. Bilateral end-inspiratory crackles heard. CT chest shows diffuse reticular opacities at periphery and bases of lungs. Micro exam of biopsy shows patchy interstitial fibrosis, several fibroblastic foci and no granulomas. Dx? Idiopathic pulmonary fibrosis honeycomb lung 35-year-old man with several episodes of dizziness and fainting during the past 2 months. Father and several paternal uncles died suddenly. PE and lipid studies normal. Angiography shows no coronary artery blockage. ECG shows prolonged QT. Decreased activity in which of following causes this? Outward (delayed) rectifying potassium channel QT is correlated with the repolarization (Phase III), 4-month-old boy with 1-day respiratory distress. Has progressive weakness and difficulty feeding for a month. RR 50/min. PE shows enlarged tongue and generalized hypotonia. Increased lactate, pyruvate, glucose, and uric acid. CXR shows cardiomegaly. Biopsy of skeletal muscle shows increased glycogen. Enzyme impaired? alpha-1,4- Glucosidase Pompe Disease (Type 2) Lack of - Lysosomal Debranching Enzyme (α-1,6 Glucosidase) 58-year-old woman with 6-month shortness of breath and chronic nonproductive cough. 2-year history difficulty swallowing, joint stiffness, diffuse tightening of skin on face, neck, shoulders, arms, fingers. Sensitivity to cold weather, fingers turn white. Hx of esophageal reflux. Biopsy showed atrophy of epidermis and deposition of collagen throughout dermis with loss of dermal appendages. PE cutaneous ulceration, clawlike flexion deformity, decreased joint mobility. At risk for which pulmonary disorder? Pulmonary hypertension systemic sclerosis/CREST complications = interstitial fibrosis, pulmonary HTN CREST - Calcinosis, anti-Centromere antibody, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly Telangiectasia 2-year-old woman has operation for hyperparathyroidism. Three parathyroid glands found but one does not appear in normal superior location on right side. Embryologic event that led to this? Abnormal migration of endoderm from fourth pharyngeal pouch 4th pharyngeal pouch gives rise to superior parathyroid EAR Tonsils - Bottom to Top 46- year-old woman with 1-week low-grade fever and joint pain. Has chronic headaches and takes ibuprofen several times. PE diffuse maculopapular rash. UA 2+ protein, 10-20 WBC and eosinophils. Renal biopsy would show what? Inflammatory infiltrates in the interstitium acute interstitial nephritis urine eosinophils + NSAID use + Rash 47- year-old woman with irregular, raised, multicolored dark lesion on left forearm with frequent sunlight exposure. Biopsy shows malignant pigmented cells. Worst prognosis with involvement of which layer? Subcutaneous tissue highly vascularized and has larger blood vessels than the dermis, leading to a higher risk of metastasis and worse prognosis (TNM staging system) Deeper than basement membrane – no longer carcinoma in situ 33-year-old man dx with epilepsy age 10 years. Most recent generalized tonic-clonic was 5 years ago. Medication was adjusted. Current meds include carbamazepine. He's never had any collisions while driving his motor vehicle. Patient's status with respect to driving? He is medically qualified to drive most of the states a 1-2-year free seizure period is required for epileptic patients to get their license 35-year-old from group home comes for worsening behavior for 2 weeks. He believes CIA is spying on him through television set. Reports hearing voices in hall outside and that CIA now plans to kill him. Appears disheveled with unkempt hair and poor hygiene, difficulty answering questions because listening to internal stimuli. Mental status exam will show which? Flattened affect Schizophrenia Positive—hallucinations, delusions, unusual thought processes, disorganized speech, bizarre behavior Negative—flat or blunted affect, apathy, anhedonia, alogia, socialwithdrawal 45 yr old man with SOB on exertion x 6 months, nosebleeds since adolescence, 2 pics: clubbing + hemorrhagic lesions in tongue (IMAGE), inhaled albuterol doesn't improve his symptoms. Cause of symptoms? Pulmonary AV shunting osler weber rendua hereditary hemorrhagic telangiectasia 55-year-old man northern European descent with 2-month weakness, altered skin color, bilateral knee pain. Siblings have type 2 diabetes and cirrhosis. PE bronzed skin, hepatomegaly, arthritis. Increased saturation of transferrin and ferritin. Liver biopsy increased iron content and cirrhosis Greatest risk? Hepatocellular carcinoma hemochromatosis (bronzed skin, hepatomegaly, arthritis, increased iron content and cirrhosis) Cirrhosis -> hepatocellular carcinoma 52-year-old female with a history of breast cancer who received 4week course of radiations 6 months ago comes for follow-up. Exam shows no cancer recurrence. Respiratory Rate 26/min. CT chest shows b/l atelectasis in upper lung fields. Primary pathophysiological cause? Contraction Reason for decreased platelets? Drug-related antibodies Heparin induced thrombocytopenia: IgG against platelet factor 4 FA 2020 1-year-old has numerous infections of skin and oral mucosa since birth. Infections slow to respond to antibiotic therapy. T 100.4F. PE multiple erythematous lesions of skin some with superficial ulceration. WBC 21,000 77% segmented neutrophils, 6% bands, 14% lymphocytes and 3% monocytes. Biopsy shows no neutrophils in dermis or epidermis. Culture of lesion grows Staphylococcus aureus. Defective? An integrin Leukocyte adhesion deficiency = integrin defect Neutrophils are unable to adhere and migrate to infection sites, instead accumulating in blood. A 25-year-old woman comes to the physician because of a 2-year history of intermittent, diffuse, cramping lower abdominal pain. The pain is usually associated with 2 to 6 days of loose, watery stools, and is typically relieved with defecation. Between these episodes, her stools are normal. Her vital signs are within normal limits. Physical examination shows no abnormalities. Laboratory studies, including complete blood count, metabolic panel, and thyroid function tests show no abnormalities. A drug targeting which of the following mechanisms of action is most appropriate for this patient? Accentuation of μ-opioid myenteric plexus receptor Irritable Bowel Syndrome. Loperamide = opioid anti-diarrheal 35-year-old woman with infertile, receive injection of contrast material into cervix. On hysterosalpingogram (shown), contrast material (indicated by arrows) also seen in peritoneal cavity, which explain this finding? Spillage of contrast which normal fallopian tubes - leak contrast - a gap between fallopian tubes and ovary. no spillage, that means there is a blockage = infertility 27-year-old primigravid woman at 18 weeks gestation comes to physician for routine prenatal examination. The uterus consistent in size with 18-week gestation. Ultrasonography shows a male fetus. The collecting system and pelvis of the left kidney is dilated and the renal cortex appears compressed. The left and right ureters are not dilated. The right kidney appears normal. Amniotic fluid volume is normal. Which causing renal finding in this fetus? Incomplete recanalization of proximal ureter ureteropelvic junction, - LAST to canalize and can lead to congenital obstruction. 25-year-old-man who has a history of facial flushing and rapid heart rate each time he consumes a small amount of alcohol participates in study of alcohol intolerance. Molecular analysis shows presence of a lysine (K487, oriental variant) for glutamate (E487, native variant) substitution in aldehyde dehydrogenase. Kinetic characteristics of the enzyme variants shown:(NAD+))E487 Km 37 KCat 180K487 Km 5600 kCat 9.5based on these findings, which of the following is the most likely cause of this man's condition? Decreased catalytic efficiency of K487 Catalytic efficiency is defined as Kcat/KM 21-year-old man loses 15% total blood volume 2 minute after motor vehicle collision. Finding most likely? Increased sympathetic nerve traffic to sinoatrial node 48-year-old woman with gradual onset back pain past 2 weeks. No trauma. Doesn't smoke cigarettes, drink alcohol or use drugs. Hemogram, serologic studies and urinalysis unremarkable. X-ray of spine shows two lytic lesions, in T-10 and L-1. Dx? Metastatic carcinoma of the breast Prostate, Breast >Kidney, Thyroid, Lung Workbench wiped down with alcohol, successfully inactivates viruses with which characteristic? Enveloped virion Alcohol-based products disrupt the lipid membrane envelope 52-year-old with chronic pancreatitis is deficient in which enzymes that causes inability to digest triglycerides? Colipase cofactor for pancreatic lipase, 35-year-old primigravid woman 36 weeks' gestation with 6-hour history of heavy vaginal bleeding. No prenatal care. Ultrasound shows placenta over cervical os. Can't stop bleeding and has cesarean. Dx? Placenta previa Opening of Cervical OS – preview of Placement 45-year-old woman with 4-month joint pain, muscles aches and fatigue. Had a renal calculus 6 months ago and had cholecystectomy 1 year ago. Appears fatigue, depressed, there is mucosal pallor. No mass45-year-old woman with 4-month joint pain, muscles aches and fatigue. Had a renal calculus 6 months ago and had cholecystectomy 1 year ago. Appears fatigue, depressed, there is mucosal pallor. No masses palpated in neck. Labs: erythrocyte count 3 million, K+ 4, Cl- 106, Ca2+ 13, phosphorous 2.7, alk phos 125. Technetium-99m scan shows 1.2 cm nodule in neck. Mutation?s palpated in neck. Labs: erythrocyte count 3 million, K+ 4, Cl- 106, Ca2+ 13, phosphorous 2.7, alk phos 125. Technetium-99m scan shows 1.2 cm nodule in neck. Mutation? MEN1 Pituitary, Pancreatic, Parathyroid – 3ps = MEN 1 Parathyroid tumor releasing PTH, increasing Ca and ALP. dad." Patient is 175 cm (5 ft 9 in) tall and weighs 70 kg (155 lb); BMI 23. Sex development is Tanner stage 4. After reassurance, Most appropriate next statement to mother Tell me more about your concerns about your son's height 1-year-old boy with rash for 2 weeks. 10th percentile for height and weight. PE scaly, seborrheic eruption over scalp, palms, back, diaper region and soles of feet. Generalized lymphadenopathy and hepatosplenomegaly. Xray of skull shows osteolytic lesions. EM biopsy of skin shows tennis racket- shaped bilamellar granule in cytoplasm. Immuno studies show CD1a antigen expression. Abnormal cells in patient are derived from which cell? Dendritic cells Langerhans cells (LC) are tissue-resident dendritic cells of the skin, and contain organelles 2-month-old boy well child exam, mother with no concerns. 25th percentile for length and 30th percentile for weight. Cardiac exam shows blowing holosystolic murmur best heard at lower left sternal border. Cause? Ventricular septal defect Blowing Holosystolic Murmur at Lower left sternal border Study designed to test the effectiveness of a new drug in the treatment of endometriosis, 100 women randomly assigned to one of two groups. 48 of women receive new drug, 52 receive standard therapy. The primary purpose of this method of assigning patients to different groups is to create which of the following? Two groups with similar underlying characteristics A 70-year-old woman comes to the physician for a routine pelvic examination. During speculum examination of the vagina and cervix, the Valsalva maneuver causes a bulge of the anterior vaginal wall. Which of the following is the most likely cause of this finding? Cystocele prolapsed bladder, is a medical condition in which a woman's bladder bulges into her vagina. Some may have no symptoms 32-year-old man with HIV infection follow up examination, has been treated with HAART for the past 6 years HIV plasma viral load has been undetectable. HIV viral load now increase, antiretroviral resistance suspected. HIV genotype analysis confirms that the virus has resistance mutations, which of the following most likely mutated? Reverse transcriptase and protease HAART therapy = reverse transcriptase and protease enzymes. 32-year-old man with X-linked recessive disease has deafness, hematuria and progressive renal failure. Protein abnormality? Type IV collagen Alport Syndrome Can’t See, Can’t pee, Can’t hear a Bee 65-year-old woman with 6 hour Hx fever and shaking chills. 4 hours ago, she took 325 mg aspirine tablets. Temp 39.4 C, pulse 96/m, respiration 18/m and blood pressure 102/60 mmHg. Physical examination shows marked tenderness bilaterally in the costovertebral areas. Lab studies show: Hb 13 g/dlHt 39% Leukocyte count 32,.000/mm3 Urine ph 6 Nitrites 4+ Leukocyte esterase 4+ A photograph of wright stained peripheral blood smear, which the most likely cause this patient leukocytosis? Leukemoid reaction 25-year-old man just returned from work as worker from Africa begins oral chloroquine therapy for malaria caused by Plasmodium vivax. His initial therapeutic response is good, but he develops recurrent parasitemia 2 months later. Which of the following best explains the recurrence? Chloroquine is ineffective on the exoerythrocytic malaria tissue stages P vivax/ovale, add primaquine for hypnozoite Hypnozoite = inactive dormant – only in P. Vivax and Ovale 28-year-old woman comes to the physician because of a 4-day history of palpitations, severe neck pain, fatigue, and malaise. Her pulse is 120/min and regular. Physical examination shows a diffusely tender, mildly enlarged thyroid gland. There is no exophthalmos. Serum studies show a thyroid- stimulating hormone concentration of 0.01 μU/mL. Which of the following is the most likely diagnosis? Subacute granulomatous thyroiditis de quervain's = pain 68-year-old man with a 10-month history of shortness of breath and swelling of his feet, family history of cardiovascular disease. He smoked 2 packs of cigarettes daily for 50 years. Pulse 80/min, rr 24/min, BP 150/80. PE: 3+ pitting edema of lower extremities. Diffuse, scattered wheezes are heard bilaterally on auscultation of the chest. Grade 2/6 pansystolic mumur heard best at lower left sternal border, which increases on inspiration. Maximal impulse palpated in sub-xiphoid area. S1 and S2 sounds are distant. Liver span 14 cm. Diagnosis? Cor pulmonale Backfilling of blood from the lungs into the R ventricle is stretching out the R side (dilation) and also remodeling the heart via hypertrophy cor pulmonale right ventricular hypertrophy and heart failure due to pulmonary hypertension 17-year-old boy in septic shock unresponsive to ADH (vasopressin). Treat is discontinued, and high-dose dopamine in started. Which receptors are stimulated? alpha1-adrenoreceptors low doses d1 = dilates renal vessels medium b1 agonist = ionotropic and chonotropic high doses a1 agonist = vasoconstriction 8-year-old girl is brought to the physician by her mother because of a 3-week history of poor feeding chronic diarrhea and pale foul-smelling stools. Mother says the symptoms began with colicky abdominal pain following introduction of solid food to the infant's diet. History of gluten sensitivity. 60th percentile for length and 25th percentile for weight. Which cell is dysfunctional? Enterocyte An experimental animal is created that has a defect in an innate gastrointestinal defense mechanism. Organism is found to have decreased HCl prod. After 2 months on biopsy gastric fundus and body show decreased mucosal thickness and hyperplasia of enterochromaffin like cells. This resembles? Chronic Gastritis mucosal inflammation leading to atrophy 56-year-old man comes with vague right-sided flank pain and 7-lb weight loss over past 6 weeks. No recent trauma or back strain. Urine is darker than usual over 2 weeks. Renal ultrasound shows 1.5-cm solid mass in upper portion of right kidney. Urine shows 50 erythrocytes, 6 leukocytes, no bacteria. Dx? Renal Cell Carcinoma hematuria, palpable masses, 2° polycythemia, flank pain, fever, weight loss 67-year-old woman with atrial fibrillation with sudden onset severe abdominal pain. Ex-lap shows embolus in superior mesenteric artery with complete occlusion of middle colic artery. Ischemic changes where? Small intestine, ascending colon, and part of the transverse colon Midgut = major duodenal papilla (of the duodenum) to the proximal 2/3 of the transverse colon. Persons are at risk of influenza are vaccination every year because of antigenic variation, which can be drift (minor) or shift (major). Mechanism of antigenic shift? Reassortment viruses with segmented genomes (eg, influenza virus) exchange genetic material. 2 viruses making a combo virus – 2 genomes 34-year-old man with a 3-month history of a progressive rash on his feet. Rash is not itchy or painful. A photograph of feet is shown = Kaposi Sarcoma. HIV+. In addition to HAART, which of the following pharmacotherapy is most appropriate? Antineoplastic Endothelial malignancy most commonly affecting the skin, mouth, GI tract, respiratory tract. Associated with HHV-8 and HIV Kaposi typically presents in HIV pts earlier, under a 500 CD4 tcell count, bartonella angiomatosis presents <100 70-year-old man with early morning awakening, decreased energy, difficulty concentrating, anhedonia, psychomotor retardation, depressed mood for 3 months. He had myocardial infarction and non sustained ventricular tachycardia 2 years ago. Tx? Paroxetine SSRIs are first line for depression. Avoid TCAs in elderly = anticholinergic side effects. 29-year-old woman comes to the physician because of irregular menstrual periods since menarche at the age of 12. She is 5.3 Ft and weighs 86kgs. BMI 34. She is evaluated and a diagnosis of PCOS is made. After explaining the diagnosis, the physician discusses behavioral changes, including dietary modification and exercise as part of her treatment. Which of the following will ensure adherence? Provide follow ups to monitor progress in attaining her goal Improve Doctor patient relationship - add next appointment 52 yo man is brought to er 30min after the onset of chest pain and shortness of breath. He had played tennis all day and he does not remember how much fluid he had consumed. His temperature is 36.7 oC, pulse 122min, respirations 28min and BP 90/50 mmHg. PE shows dry skin and decreased capillary refill. An ECG and evaluation of cardiac enzymes show no abnormalities. Which of the following findings in the nephron best describes the tubular osmolarity, compared with serum in this patient? PCT Isotonic, Macula Densa hypotonic Medullary Collecting Duct hypertonic 3-week-old male newborn with recurrent vomiting after feeding since birth, and eager to feed after vomiting. Abdominal exam shows firm, mobile mass in epigastrium to right of midline. Dx description? Single Primary Development Defect pyloric stenosis – olive shaped mass - stand-alone defect VACTERL vertebral defects, heart defects, renal and limb abnormalities 65-year-old with sudden onset generalized tonic-clonic seizures. Personality change last 6 months; used to be mild mannered and now verbally abusive. CT shows single mass enhances with contrast in right frontal lobe and crosses to left hemisphere through corpus callosum. Dx? High-grade fibrillary astrocytoma Glioblastoma multiforme- "crosses hemisphere" GFAP + A new antiplatelet agent is developed for the prevention of recurrence of stroke. In a large randomized clinical trial with equal numbers of men and women, the rates of stroke are lower in patients receiving the new agent than in patients receiving the standard treatment. Results are shown:Recurrent Stroke Rates per 1000 Person-YearsStandard Treatment vs. New Antiplatelet Drug Women .12 .04 Men .24 .08 Overall .18. .06 Based on these results, which of the following is the relative risk reduction in women? 30. 35-year-old woman with 2-day history of blistering lesions on sun-exposed face, arms and hands. Recurrent episodes of skin lesions over several years. Taking oral contraceptives for 15y. PE shows fluid-filled vesicles and bullae. Labs: AST increased, ALT increased, total porphyrin increased, urine uroporphyrin III increased. Precursor to uroporphyrin? Succinyl CoA 32-year-old woman brought in after 10-foot fall from ladder. PE suggests severe hemorrhage and shock. Xray shows fracture of left ninth and tenth ribs. Organ injured? Spleen 4-day-old boy with vomiting after breastfeeding. PE shows lethargy and dry mucous membranes. Labs: Na 139, Cl 90, K 7, HCO3 17, Glucose 42, BUN 25, Cr 0.4, 17-hydroxyprogesterone increased. Enzyme deficiency? 21-hydroxylase infancy (salt wasting) or childhood(precocious puberty 70-year-old woman comes to the physician because of increasingly severe pain in the right knee over the past 3 months. She has fallen repeatedly. She has a 10-year history of symptomatic osteitis deformans. She has bowed tibia and tenderness of the proximal right tibia. an X ray shows a fracture of the proximal tibia with elevated periosteum and sunburst pattern. an x-ray of lungs shows pulmonary nodules of various sizes. which of the following findings is most likely on biopsy? Pleomorphic neoplastic cells producing new woven bone Osteosarcoma histological appearance. Paget disease is one of risk factor Cholera toxin catalyzes transfer of ADP-ribose to an arginine residue in stimulatory G protein resulting in inhibition of GTPase activity. Which increases in cells as a result? Concentration of cAMP 10-year-old boy with 4 days nosebleeds and easy bruising. Three weeks ago, upper respiratory tract infection. PE ecchymoses on upper and lower extremities. Labs shows hemoglobin and leukocyte count normal, and decreased platelet count. Bone marrow smear shows increased megakaryocytes. Mechanism of dz? Antibodies directed against glycoprotein (Gp) IIb/IIIa complex Immune thrombocytopenia 60-year-old man 1 day of fever, chills, confusion and memory loss. Returned from Gulf coast where he walked barefoot. Hx of severe cirrhosis and portal hypertension. T 39C (102.2 F), RR 22, bp 90/48. Physical shows early blister formation on right lower extremity. Blood culture: gram-negative, lactose- fermenting organism. Bug? Vibrio vulnificus 45-year-old man with hypertension not compliant with medications. bp 160/100. Cardiac exam shows apical impulse displaced laterally, loud S2 and S4 gallop. Echo shows thickening of left ventricular wall. Mechanism of change in cardiac muscle? Transcription factor c-Jun: increased beta-myosin heave chain: increased endothelin: increased Newborn is found to have a cervical rib. Transformation of seventh cervical segment to thoracic identity. Which is true of HOX gene alteration? Expression of a HOX gene normally expressed only caudal to C7 30-year-old woman with a long-standing history of pelvic inflammatory disease has surgical resection of a scarred segment of a fallopian tube. Which of the following inflammatory cells is most likely to be found in the resected specimen? Macrophages 39-year-old man with 1-week of red spots on shins, joint pain and fatigue. PE shows purpura over lower extremities. Liver palpated 4 cm below costal margin. Labs: WBC 10,000, AST 142, ALT 154, hepatitis C virus RNA positive, anti-hepatitis C virus antibody positive, cryoglobulins positive, C4 120 (N=350-600), urine protein 4+, urine RBC numerous. Hypersensitivity reaction? Type III (immune complex-mediated) 25-year-old woman with polycystic kidneys and 3-month history of weakness, fatigue, headaches, hypertension, loss of appetite and itching. Cr 4. Labs HCO3- decreased - no resorption PO4 increased, PTH increased 5-year-old boy with motion sickness. Planning vacation to Australia, and wants diphenhydramine for motion sickness. Mechanism of action for motion sickness? Antagonist at muscarinic-3 (M3) receptors 63-year-old woman with 2-week history of daily episodes of severe, lancinating, left-sided facial pain. Pain lasts 30 to 60 seconds and shoots down ear along jawline. Precipitated by chewing or brushing teeth. Dx? Trigeminal neuralgia 20-year-old woman with 2-week fever, shaking chills, headaches, fatigue, and joint and muscle pain. Spent summer workin as lifeguard in Long Island, New York. Has splenectomy for motor vehicle collision 6 years ago. T 102.4 F. Peripheral blood smear shows small intraerythrocytic rings. Polymerase chain reaction for Plasmodium is negative. Causal organism from bite of? Tick Male newborn delivered at 28 weeks, neonatal respiratory distress syndrome, ABG shows decreased pH, decreased Po2 increased PCO2. A deficiency in which of the following most likely caused the disorder? Dipalmitoylphosphatidylcholine 55-year-old woman who is a physician has fractured femur during motor vehicle collision. 2 days after admission, has tachycardia, restlessness, diaphoresis, anxiety, seeing "vague shapes" on walls. Dx? Alcohol withdrawal Full-term newborn in respiratory distress. Imaging shows abdominal contents in left pleural cavity. Maldevelopment of which structure led to diaphragm defect? Left pleuroperitoneal membrane Diaphragmatic hernia To decrease risk for cv disease 24 yo man begins diet. 1.53 95 kg BMI 32, Intends to lose 16 kg by limiting caloric intake to 2000 cal. to maintain the recommended protein intake (56g day); a balanced decreased in carbs and fat is required (caloric radio of fat and carbs is 30:55). which best describes number of calories that should be provided by fat in this its diet each day? 630 0.3 fat x 2000 = 600 calories (fat) (Fat 30 + Carbs 55+15 = 100) 35-year-old woman passed out while washing dishes. Began to feel weak and dizzy, husband shares with nursing staff history of bulimia nervosa, and has been binging more frequently. Suspected she has been vomiting. Labs of patient? K+ decreased HCO3- increased/ Anion Gap normal pH increased' Metabolic Alkalosis > loss of HCL Anion Gap Normal = NOT a MUDPILE HCL, NA+ = out the mouth Retrospective study of incidence and outcome of subarachnoid hemorrhage. Incidence is 15 per 100,000 people, mortality is 6 per 100,000 people. Incidence remains constant, case fatality rate? 40% 16-year-old girl calls the physician on a Friday night 2 hours after a condom broke during sexual intercourse with her boyfriend. She asks the physician to prescribe an emergency oral contraceptive. The physician on call is not the patient's regular physician and does not dispense emergency contraception for moral reasons. After the physician respectfully informs the patient that he does not prescribe this contraceptive, it is most appropriate for the physician to state which of the following? "I can have one of my colleagues call you back to further discuss your concerns” 58-year-old man comes to the physician because of a 4-year history of recurrent cough productive of increased sputum. Use of over-the-counter cough suppressants has not resolved his symptoms. He has smoked 2 packs of cigarettes daily for 35 years. He has no family history of lung disease. His temperature is 37°C (98.6°F), pulse is 72/min, and respirations are 18/min. Physical examination shows cyanosis. Diffuse wheezing is heard on auscultation. Which of the following pulmonary cell types is most likely to be abnormal in this patient? Pseudostratified columnar epithelial cells Smoker, Cyanosis – chronic bronchitis squamous metaplasia 64-year-old with non-Hodgkin lymphoma and 3-day history of abdominal pain and nausea. T 99.7F, HR 100, bp 130/80. Abdominal exam tenderness of flanks and lower quadrants. BUN 34 and creatinine 3.8. CT shows bilateral hydronephrosis and lymphadenopathy compressing ureters. Tx to improve renal function? Bilateral stents in the ureters 34-year old man is brought to the ER semiconscious and combative. In addition to sedation, a short- acting neuromuscular blocking agent is administered for intubation to prevent aspiration. Within a few seconds after admin of the drug, he has transient muscle fasciculations in his face; he develops generalized paralysis within 1 minute. Forty five minutes after completion of the procedure, he is still paralyzed. A genetic abnormality of which of the following enzymes is the most likely cause of his unusually slow recovery from paralysis? Pseudocholinesterase Succinycholine – Acetylcholine Agonist increased in system --> longer anesthesia recovery Gy67-year-old man who eight months ago dx with primary lung carcinoma involving adrenal glands, liver, and bone. Had 17.6-lb weight loss during 3 months. PE shows cachexia and significant muscle wasting. Intracellular components increased in patient's muscle cells? Autophagic vacuoles 48-year-old man 2-month increasing abdominal girth and inability to achieve an erection. Smoked 1 pack cigarettes for 20 years and drank 1 pint of liquor daily. Vitals normal. PE shows scleral icterus, spider angiomata, gynecomastia, ascites, and prominent umbilical venous pattern. Testis small. Cause of gynecomastia? Failure of liver to degrade estrogen Alcoholic – cirrhosis – Liver injury Investigator studying vancomycin-resistant strain of Enterococcus faecalis. Ten generations created. Culture inoculated and resulting bacterial colonies are screened for vancomycin resistance. Vancomycin- sensitive colonies observed at frequency of one per 100 cells. Mechanism of decreased vancomycin resistance? Plasmid loss 20-year-old woman with palpable lump in right breast 4 months, no pain, swelling or nipple discharge. Lump is smooth, firm, round, mobile, nontender, well delineated. No skin change. Dx? Fibroadenoma Researching new cancer drug, effective at killing rapidly dividing cells, in mice caused profound myelosuppression. In patients, most appropriate to follow which when at risk for infectious complications? Neutrophil counts 35-year-old woman with fever and sharp chest pain for 3 days. T 101.3F. Friction rub heard. All causes of secondary pericarditis ruled out. Cause of primary pericarditis? Virus 65-year-old woman comes to the physician because of a 1-week history of a swollen, painful left knee. Her temperature is 38°C (100.4°F), and blood pressure is 110/65 mm Hg. Examination of the left knee shows erythema and swelling of the joint and decreased range of motion. A photomicrograph of synovial fluid obtained by arthrocentesis is shown. This patient's synovial fluid most likely contains which of the following? Uric acid needle shape right in the middle was a uric acid crystal interstitial and alveolar infiltrates. The patient is intubated and mechanically ventilated. Damage to what will preclude restoration? Basement membranes 12-year-old boy with mother concerned about enlarged left breast and family history of breast cancer. Left breast is slightly larger than right, nipple mildly tender. Penis slightly enlarged and pubic hair curling and beginning to darken at base. Best next step? Reassure the mother that physical findings are not uncommon for his age 17-year-old boy with syncopal episode, fever, nausea, muscle aches, progressive confusion. T 103.5F, palpable bp 80. PE rash on lower extremities. WBC 26,000. Blood and CSF cultures grow oxidase positive, gram negative diplococcus. Brother with similar infection at same age. Immune disorder? Late component of complement deficiency 75-year-old man comes to the physician because of an enlarging face shoulders and trunk and thinning of his arms and legs. Physical examination shows a large plethoric face, fat pad over the upper thoracic spine and purple striae on the abdomen. Serum studies show undetectable ACTH and an increased cortisol concentration. Administration of low dose dexamethasone would most likely result in which of the following sets of serum findings? ACTH no change cortisol no change 71-year old woman with coronary disease and well-controlled hypertension is brought to the physician 2 hours after sudden onset of weakness of her left leg. Her BP 145/85 mmHg. Neurologic exam: weakness and decreased sensation over the left lower extremity. There are no other sensory or motor deficits. Which labeled structure is site of injury? A (Pre/postcentral gyrus; motor/sensory cortex) 71-year-old man admitted for prostatic resection. Normal mental status. 2 days after surgery, confused and restless. Cannot sleep and restless, seeing little men coming through window. Dx? Delirium 2-month-old female with T 102F, vomiting, diarrhea, dehydration. Exam of stool shows viral particles with wheel-like shape. Properties of virus? Type of nucleic acid/envelop/capsid symmetry Double-stranded RNA, segmented/no/icosahedral Double-stranded RNA, segmented/no/icosahedral "wheel-like shape" rotavirus 62-year-old with angina pectoris is referred for cardiac catheterization. Patient worried about hospital- associated infection. Studies show 30% of patients require admission after procedure, and 2 percent of admitted patients acquire hospital infection. Patient's risk for infection overall? 6/1000 30% * 2% = .0006 Randomized controlled trial evaluating tx of acute otitis media. No statistically significant differences found between infants receiving the antibiotic and those with standard tx. Which aspect results in type II error? Number of subjects in the study .66-year-old woman is brought to the emergency department by her daughter because of a 2-day history of fever, flank pain, pain with urination, and nausea. Ten days ago, she was admitted to the hospital for similar symptoms and was diagnosed with acute pyelonephritis. She was discharged with instructions to take oral ciprofloxacin after a 3-day course of intravenous ciprofloxacin resulted in improvement. She also has hypertension, hyperlipidemia, and osteoporosis. Current medications also include alendronate, calcium carbonate, ezetimibe, hydrochlorothiazide, and simvastatin. Her temperature is 39.1°C (102.4°F), and blood pressure is 130/80 mm Hg. The most likely cause of this patient’s current condition is an interaction between her current oral antibiotic and which of the following medications? Calcium carbonate antacid - chelate tetracyclines and fluoroquinolones 35-year-old man with severe back pain, gained 8 kg in the past 6 months, decreased peripheral vision, compression fracture spine at T10 and L1, healing left rib fracture at T6, imaging shows pituitary macroadenoma. This tumor produces which? ACTH 67-year-old man with 3 months fatigue and shortness of breath. Vitals HR 90, RR 15, bp 150/98. PE conjunctival pallor. Labs: hb 8.5, hct 26%, MCV 90, RDW 14.4% (N=13-15%), Cr 2.9, Ferritin 144, Iron 24, Transferrin saturation 23% (N=20-50%). Besides iron supplementation, most appropriate tx? Erythropoietin 14-year-old girl with type 1 diabetes mellitus and 4-hour history of lethargy, confusion, disorientation. Symptoms gradually developed and she did not take her usual insulin dose during a sleepover. HR 110, RR 24 deep and rapid, bp 95/75. Labs: glucose 450, arterial pH 7.15. ABG? pCO decreased HCO3- decreased Anion gap increase DKA 38-year-old man 1-week shortness of breath with exertion, light palpation of carotid artery shows upstroke is abnormally brisk and downstroke falls precipitously. Cause of finding? Aortic Regurgitation water hammer pulse = brisk upstroke and downstroke in the carotid 65-year-old man with 4-hour history of intermittent severe pain in flank area radiating to genital region. History of hypercalciuria and renal calculi. Drug decrease the urinary excretion of calcium? Hydrochlorothiazide 32-year-old woman has new neuro finding while being tx for acute infection of sphenoid sinus. Imaging shows cavernous sinus thrombosis on left. Additional finding most likely? Inability to abduct the eye 4-year-old male with recurrent UTIs, left kidney found small and non functional; right is normal. Nephrectomy is done, and the picture shown (dilated ureter and renal calyx). Microscopic exam of kidney will show which? Tubular atrophy tubulointerstitial fibrosis of the kidney Girl has chronic cough with thick sputum, abdominal cramps in RLQ, and frequent resp infections. Clubbing of fingers, hyperresonance on chest percussion. Diffuse crackles and scattered wheezes. On 75-year-old – sudden onset of partial loss of vision – Visual fields show R- lower Quadrantopia – pie on the ground – a lesion in which of the following? Parietal Lobe – left Pie on the ground - Contralertal lesion in parietal lobe – baums loop -bombs on ground 53-year-old – GERD – dietary changes and stress reduction have no effect. What drug both relieves symptoms and promotes healing? Omeprazole Irreversibly inhibit H+/K+ ATPASE stomach parietal p. 399-2 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 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 17 year old – evaluated for growth delay – X-ray shows suprasellar calcifications- most likely explanation for this condition? Craniopharyngioma Most common childhood suprasellar tumors Remnants of Rathke Pouch – derived from oral/surface ectoderm of oral cavity 64 y/o man – bronchospastic pulmonary disease – wheezing in spite increasing on b-adrenergic agonist inhaler- hospitalized and systemic prednisone is added – which explains the action of prednisone in enhancing response on B-adrenergic agonist?? Enhanced action of the agonist at B-adrenergic receptors Corticosteroids– upregulates B2 receptors + inhibit b2 Cortisol – permissive effect on catecholamines – 336-1 2-week-old male with Patent Ductus Arteriosus – which finding is likely? Higher than normal Left ventricular cardiac output 33-year-old woman – MVC – splenic laceration – 3 units of RBC administered – 5 hours later – develops Shortness of Breath – crackles heard through lung fields – Chest X-ray bilateral infiltrates – what causes patient’s condition? Transfusion-related acute lung injury 8-year-old girl is brought to the physician for a well-child examination. Her mother says that she has been well except for an occasional cold. Her immunizations are up to date. She is at the 50th percentile for height and 60th percentile for weight. Physical examination shows breast bud development and a few pubic hairs. The mother asks whether her daughter's development is normal. Which of the following is the most appropriate initial response by the physician? Your daughter development is normal Precocious puberty before age 8 in girlsPrecocious puberty before age 9 in boys A 63 y/o – bladder cancer – starts treatment – significant decreased in tumor size. Paclitaxel mechanism of action? Tubulin Polymerization Stabilization M Phase 25 year-old – participating in a study of blood glucose – During study, found to glucose of 100mg/dl after 20 hours of fasting- which would contribute to normal glycemia? Alanine Muscle breakdown – alanine – enter cahill cycle to form glucose 3 y/o boy – recently immigrated to USA – skeletal deformities– frontal bossing, flattening of back of the skull, defects in enamel of the teeth, chest wall grooves- legs are bowed – Serum calcium and phosphorus low - if bone were examined, what finding likely? increased portion of osteoid rickets due to osteoid deposition Vitamin D Decreased, Calcium Decreased, increased PTH 66 year old – pain, fever, chills, - left lower abdominal pain – severe constipation over 5 years -a barium of lower GI – 3 separate area of narrowing of the lumen of the distal sigmoid – Photograph of lesion – DX? Diverticulitis LLQ pain, fever, leukocytosis, wall thickening p. 383-3 > 60 years old – 64 year old women – T2DM and HTN – soreness and muscle Pain in large muscles – She began rosubastatin therapy – her medicatioons include gemfibrozil, HCTZ, losrtan, and metformin, elevated serum creatine kinase – what interaction between rosuvastatin and which of the following? Gemfibrozil Statins - 320- cause Rhabdomyolysis Myopathy when used with fibrates 48-year-old man – ER – 1-hour history of vomiting blood – Physical exam shows ascites. A surgical shunt between which of the following veins – release esophageal bleeding? Splenic and left renal vein 37-year-old – MVC – severe, sharp, chest pain – hyperresonance- decreased tactile fremitus – adventitious sounds are absent- multiple rib fractures – pathway of chest pain? Intercostal nerve Multiple rib fractures and pneumothorax - COPD costal and cervical pleura innervated by intercostal nerve 78 yeasr old women – paroxysomal embolus in left leg – left lower extremity cool and pale, absence pulses- ECG shows irregularly irregular rhythm – which treatment is most appropriate? Embolectomy Originated in heart – sudden acute of pain in the leg Paroxysmal embolus 75 year old man – fever, back pain, pain on urination – long standing prostatitis- gram statin - gram positive cocci in chains – cause of illness? Enterococcus Faecalis Gram + cocci in chains + UTI = enterococcus 65-year-old – vomiting blood – Hypovolemic shock- placement of catheter in internal jugular vein for blood transfusions – improper insertion damage to which of sets of underlying structures? Lung and Common Carotid Artery b. Internal jugular vein – next to common carotid – and lung apex extend above 1st rib 32-year-old woman at 35 weeks’ gestation – during her labor - increased oxytocin concentrations – most likely cause of finding? Birth Canal Reflex Fergusson Reflex – positive feedback loop 75 year old woman – sudden Horner syndrome, dysphagia, difficulty speaking, which occluded? Posterior Inferior Cerebellar Lateral medullary syndrome – nucleus ambigious (IX, X, XI) 65-year-old man in MVC – photograph of lung at autopsy (Centrally located lesion) – Dx? Squamous Cell Carcinoma Centrally located– arising or extending into bronchus Hilar mass arising from bronchus – p. 684 Hypercalcemia – PTHrp- source from cancer 54yo man for exam. P80, R14, BP140/95. Physical exam normal. ACE inhibitor given. Where is MOA in kidney? F - ACE preferentially vasoldiate the efferent arteriole Preserves GFR – by back pressure vasodilation of efferent 61 year old woman – 9 month history increasing forgetfulness – Mini Mental Status 22/30- most appropriate pharmacotherapy? Donepezil anticholinesterase Dona, Riva, at gala – increased ACH 51-year-old woman – burning abdominal pain, sweats profusely, 2 cm- mass in proximal duodenum. Gastrin releasing tumor stimulates which labeled cells in picture? B- parietal Cells Stain Eosinophilic – fried egg appearance- PINK EGGS Parietal cells - secrete gastric acid 25-year old develops shortness of breath – after moving from sea level to a mining town at 3350. At rest, pulmonary hypertension with normal cardiac output – pulmonary function tests are normal – Which explains pulmonary hypertension? Decreased Alveolar PO2 30 year -old comes to the office – 20lb weight loss after initiating a low-carbohydrate diet – low fat diet -it is most important to counsel the patient to include which of the following to maintain a good nutrition? Linoleic Acid Essential fatty acids – OMEGA 6 and Omega 3 Omega 6= linoleic and Omega 3 = alpha linoleic Must be obtained through diet – vegetables, oils, meats, nuts, and egg Deficiency – lead to poor growth, skin lesions, reproductive failure 44-year-old man –altered mental status HTN (210/145)– fundoscopic exam shows papilledema and retinal hemorrhages – A drug with which of the following effects on vascular smooth muscle is likely to decrease blood pressure? Increasing cGMP A test has been developed to screen for HPV infections - If the prevalence increases by 50%– which of the following features of the test will increase? Predictive value of a positive test . A newborn female external genitalia – 46 XY karotype – shows male genital ducts – the most likely cause of this anomaly is a mutations resulting in the absence expression of which of the following hormones or factors? Dihydrotestosterone 36-year-old with AIDS – tx with CCR5 receptor inhibitors – which is natural ligand for HIV co-receptor? Chemokine Maraviroc binds to CCR5 Cysteine-Cysteine Chemokine receptors – found on surface of CD4+ 7 year old – difficulty concentrating in school - “feels tired” - hypochromic anemia – fatigue – increased serum creatinine – additional abnormal concentrations in this patient? Increased Blood Lead Physician prescribes a recently marked drug for 20 patients – After several months, 5 patients develop increased serum AST and ALT - Physician discontinues drug and reports adverse effects to the FDA. Physician participated in what phase of clinical trial? Phase 4 SWIM Post marketing surveillance – detects rare or long term adverse effexts 6-month-old – exaggerated reaction to loud noises- Exam shows muscle weakness, increased start reflex, cherry red spots on retina– most likely cause of this disorder is accumulation of which of the following lipids in the patients lysosomes? GM2 Tay-Sachs – cherry red spot Gm2 gangliosides accumulate Deficiency in Hexoaminidase A 60 year old – ER -thrown from care in high speed automobile accident and struck guardrail– blood in urethral meatus and fractures of the pelvis and left femur. A Foley catheter is unable to be inserted- which is most likely explanation? Urethral Disruption 35-year-old – pain and swelling of his right knee and great toe - needle like crystals – Exam of tiw shows swelling and warmth. Aspirate of effected joint shows numerous neutrophils and needle like crystals what is causes of patients swelling? Increased vascular permeability 25 year - nulligravid and infertile woman – irregular menses -– hirsutism – ultrasound shows ovaries with numerous cysts beneath the capsule. Photograph shown - patient at greatest risk for developing which of the following? Endometrial Hyperplasia Chronically elevated levels of estrogen can cause endometrial hyperplasia. . 10 year old – fever, malaise, loss pf appeptide followed be excess salivation 6 weeks after exploring a cave with her friends. Over the next few weeks, she develops delirium, seizures, paralysis, and hyperexcitability- virus reached brain by which of the following? Retrograde transport through the nerves 21-year-old – comes to ED after MVC – laceration of spleen and undergoes splenectomy – Splenectomy most likely predisposes patient to develop future infections – causal organism? Streptococcus Pneumonia No Spleen Here Neisseria meningitidis, Streptococcus Pneumoniae, Haemophilus influenza 62 year old – farmer – 8 yeas history of lesions indicated by arrow (photo) – picks lesions causes bleeding – numerous similar rough plaques on the scalp, face, ears, and forearms. Likely Diagnosis? Actinic Keratosis Farmer – Picks at it and bleeds – Premalignant lesions – caused by sun exposure Increased risk of skin cancer - keratin pearls A 40 year old – T2DM – TX with pioglitazone – mechanism of action? Stimulation of peroxisome proliferator-activated receptor 47-year-old – severe chest pain – Oxygen Saturation of 85%, CO low, ST elevation, which is decreased? Mixed Venous Oxygen Tension Decreased oxygen delivery to tissues – decreased cardiac output CO=rate of O2 consumption/(arterial O2 content-venous O2 content 53-year-old – breast cancer – taking tamoxifen – what is effect on tamoxifen on breast and Uterus? Breast Antagonist Bone Agonist Uterus partial agonist. 26-year-old – counseling prior to conception – pedigree – fatal to males not born = which is most likely risk to live born? 50% in females, but near 0 in males Fatal to males in utero X linked dominant – males have 50% of getting from mom 43 year old – follow-up exam –underwent cardiac valve replacement – Chest X-Ray shown - which of the following valves most likely replaced in this patient? Aortic 30 year old – pregnant + gram positive rods - pregnant women – fever, chills, muscles aches – which causal organism? Listeria Monocytogenes Normal appearing 17-year-old – normal appearing – vagina ends blinding – no uterus or ovaries to palpate – chromatin negative nuclei – which is likely diagnosis? Androgen Insensitivity Syndrome 27 year-old – 34 weeks pregnant – nausea, vomiting, abdominal pain for 12 hours –HTN 164/104, Elevated Liver Enzymes. platelet count low eve what do you see on peripheral blood smear? Schistocytes 52 year - ER – sudden chest pain – IV morphine – generalized pruritus and warmth in 1 minute - which substance most likely cause new symptoms? Histamine 34-year-old – ER – unconscious after alcohol intoxication – which is interpretation of arterial blood gas. Ph 7.25 Pco2 23 Po2 78 – Na+ 140, Cl – 105, HCO3 10? Primary Metabolic Acidosis with increased anion gap Ph low, Bicard low, CO2 low Na+ - (HCO3+ + Cl-) 140 – (10 + 105) = 25 18-year-old – 2-week history of fatigue – PE shows scleral icterus – Lab shows – Hemogloblin Low– high bilirubin – increased 2,3 BPG, increased reticulocytes – mostly likely deficiency in enzyme in erythrocytes? Pyruvate Kinase 22 year old – frequent episodes of cutaneous urticaria and laryngospsm – allergic cause of his urticaria. Which of the following complement proteins is most likely deficient? C1 esterase inhibitor (binds activated C1r, C1s) 45 year – ER – MVC – patients’ ventilator – adjusted to tidal volume- application of PEEP will most likely prevent which of the following complications? Absorption Atelectasis 35-year-old –DKA - treated with insulin – decreased plasma glucose 900mg/dl to 270. which additional lab finding will likely decreases with insulin therapy? Serum potassium concentrations 67 year sore – fever, sore throat, difficulty swallowing- Corynebacterium diphtheria – the pathogen produced diphtheria toxin – blocks which of the following processes? Translation 40-year-old woman – high triglycerides – 380 mg/dl – taking fish oil and a supplement to treat dislipidemia – MOA of most appropriate vitamin? Antagonize VLDL-cholesterol Secretion Niacin (vitamin B3) antagonizes VLDL 55-year-old woman – broad bait gait, nystagmus, confusion – confabulations – BMI 21 what is most likely to see on MRI of the brain shows? Mammillary Bodies 66-year-old – pancreatic cancer – comes to office because of 2 day history of black tarry stools – Upper endscopy shows gastric varices – A CT shows thrombosis of branch of splenic vein – which is most likely source of bleeding in the patient? Short Gastric 29 year old woman – 10 day history of difficulty walking – broad based gait and spasticity – lesion in white matter of the cerebellum- TX with which of the following agents most likely improve spasticity? Baclofen Gaba B agonist 30 year old – dimness of vision and loss of color vison – 1 month after treatment for TB with RIPE – Which drug responsible for adverse effect treatments? Ethambutol 75-year-old – stroke – 16 hours after onset of left arm and leg weakness – CT scan shows an edematous right hemisphere – No evidence of hemorrhage- but sparing of the right occipital and midline frontal corticies - one hour later dies At autopsy – microscopic examination of right lateral lobe is most likely to show which? Shrunken Eosinophilic Red Neurons within 12-24hours 43 year old woman – irregular jerking movements – profound dementia – her father had similar disorder and died at age 65 year - huntingtin disease- autopsy of the patient is most likely to show severe atrophy of which of the labeled structure? C = Caudate Nucleus 30-year-old man – intermittent severe lower abdominal pain, right flank tenderness, hematuria, brother has kidney stones. Patient urine turns cherry red with nitroprusside. Hexagonal crystals are present in the urinary sediment- Which of substances is most likely increased in patient urine? Cysteine 65 year – prostate cancer – metastasis to L1 underwent orchiectomy – high PSA – Which is most likely increased secondary to orchiectomy? DNA fragmentation Reactive Granulocytosis 19 year old women –1 month of abdominal pain and severe diarrhea – 5.4 KG weight loss colonoscopy shows non-bloody diarrhea and cobblestone appearance of the colonic mucosa - stricture in retroperitoneal portion of the bowel – which is the most likely location of the stricture Descending Colon Which of the following best explain why use of anti-idiotypic antibody is inappropriate therapeutic reagent for treatment? Myeloma Cells do not have membrane surface immunoglobulin a. Plasma cells produce secretory Ab's (aka produce Ab's) -- plasma cells do not have membrane-bound Ig (aka do not have BCR'). 9 year-old – tumor in heart – what is the diagnosis? Rhabdomyoma Tumor heart in child = rhabdomyoma 32-year-old woman – sister recently died of melanoma – Other family members similarly affected. Which lesion is most likely on both sun exposed and nonsun exposed ares on patient skin? Dysplastic Nevi Diastolic blood pressure obtained from two groups of 100 asymptomatic – picture of Diastolic average? Median Group Y = Higher Mode Group Y = Higher 72 year old man – history of nonproductive cough –non hodgkin lymphoma– treated with antineoplastic drugs – chest xray shows diffuse infiltrates- which of the drugs most likely cause of patient symptoms? Bleomycin 47 y/o – jaundice – increased serum bilirubin and positive urine bilirubin test –Which is most likely associated with the positive urine bilirubin test Obstruction of the Bile Duct 70-year-old – persistent fever despite intravenous broad-spectrum antibiotic therapy 3 days after operative incision for cervical carcinoma. PE shows placement of central venous catheter – Blood cultures from cather grow - Gram stain colonies, 4um, elliptical, purple budding organisms- which is the causal organisms? Candida Albicans A 74-year-old with mild dementia is admitted to the hospital because of congestive heart failure. Physician recommends coronary angiopgraphy and angioplasty. The patient states that she wants to go home. It would be appropriate to question patient capacity if? Inability to understand the severity and prognosis of her medical condition informed consent process A 74-year-old with mild dementia is admitted to the hospital because of congestive heart failure. Physician recommends coronary angiopgraphy and angioplasty. “On questioning, the patient does not know the date [time], the name of the hospital [place], or the name of her nurse who had just introduced himself [person].” The patient states that she wants to go home. It would be appropriate to question patient capacity if? inability to understand the severity and prognosis of her medical condition The gene that codes for a protein normally found in the ER is mutated. Which of the following mutations is most likely to impair the transport of the protein in the endoplasmic reticulum? Deletion of the hydrophobic amino acid sequence on N Terminus 25-year-old -increased SOB – exertion 2 weeks after birth of first child – JVD – evidence of edema at lung base, hepatomegaly, and mild pitting edema in lower extremities - which is the following cardiac abnormalities is abnormality is most likely present? Four Chamber Dilation Peripartum Right heart failure – caused by left heart failure