Medical Case Studies: Various Conditions and Treatments, Exams of Nursing

Download Medical Case Studies: Various Conditions and Treatments and more Exams Nursing in PDF only on Docsity! NBME CBSE ACTUAL TEST QUESTIONS AND ANSWERS TEST BANK| NBME PRACTICE STEM- COMPLETE SOLUTION RATED A 56 y/o - brought to ER - Chest Pain mowing the lawn - Hypotension, PE shows cool, clammy, diaphoretic skin. 2 hours after admission, pulmonary catherization shows pulmonary artery pressure 40/25. Left Atrial Pressure 25 g (pulmonary emboli). Compared with a healthy person- sets of pulmonary pressure changes? Hydrostatic Pressure High, Capillary hydrostatic pressure high Interstitial Oncotic pressure Low **cardiogenic shock, the extra blood increases capillary hydrostatic pressure, driving fluid into the interstitial space. 67 y/o - brother has history of colon cancer. Physician recommends colonoscopy, but the patient says she would prefer stool culture instead. Physician explains that testing the stool for occult blood is not appropriate. Physician concerned about? Low Sensitivy A 62 y/o - 1 week of muscle cramps - trouble opening jars and using silverware. PE shows muscle weakness and exaggerated deep tendon reflexes. What is appropriate systemic treatment for muscle cramps and spasms? agonist at GABA-B Receptors aka: Baclofen 41 y/o schedule for dialysis catheters. Surgeon asks the resident to get the consent. The resident has never seen this procedure performed and has read little about it. Which of the following actions by the resident is most appropriate? Ask attending to obtain informed consent A 2 year old - undergoes resection of right kidney - chronic infection secondary to influx. The left kidney is grossly normal. Which structural adaptations will eventually occur in left kidney? Increase in glomerular size **Congenital solitary functioning kidney compensatory hypertrophy of contralateral kidney A 54 y/o woman - terminal metastatic pancreatic cancer - She asks physician to prescribe sufficient meds to commit suicide due to unbearable pain. Physicians A Newborn with lethal chromosome defect. He is unable to suck sufficiently. He has episodes of crying that occur every 2.25 hours and relieved by tube feeding. Which best describes the most appropriate clinical approach? feed by whatever necessary to maintain comfort An 18 y/o woman - fever, sore throat, fatigue for 1 week. Temp 100.6. PE shows pharyngeal erythema, generalized tender lymphadenopathy, splenomegaly. Lab show 20% atypical lymphocytes. Which accounts for atypical lymphocytes in patients peripheral blood smear? Reactive T - Lymphocytes 51-year-old man - acute onset of fever and respiratory failure 6 weeks after cadaveric renal transplant. He currently takes cyclosporine, bactrim, prednisone, and TMP_SMX. Temp high - Respirations increased. Diffuse inspiratory and expiratory crackles. Creatinine increased. X-ray of chest shown. Cause? Cytomegalovirus **Organ transplant patients are at an increased risk of CMV pneumonia. A 2 month old - 6 week history of constipation. She has poor feeding, sleepiness, and yellow skin. Her parents are migrant workers and have not received routine medical care. PE shows lethargy, hypotonia, jaundice, large fontanelles, macroglossia, and umbilical hernia. Most appropriate next step to establish diagnosis? Correct Answer: Thyroid Function Test CRETINISM A 39 y/o reports bright red spots on toilet paper after defecating. Rectal examination shows large swollen rectal veins. Which is predisposing cause of these lesions? Constipation Large swollen rectal veins --> patient has external hemorrhoids. Swollen and inflamed veins in the rectum and anus that cause discomfort and bleeding. The most common cause of external hemorrhoids is repeated straining while having a bowel movement. A 45 y/o develops proteinuria and hematuria. She has taken 3g of ibuprofen for headaches daily for the past 2 years. Which of the following is most likely obtained on renal biopsy? Correct Answer: Tubulointerstitial nephritis Acute interstitial renal inflammation. Pyuria (classically eosinophils) and azotemia occurring after administration of drugs that act as haptens, inducing hypersensitivity (eg, diuretics, NSAIDs, penicillin derivatives, proton pump inhibitors, rifampin, quinolones, sulfonamides). A 92 y/o - recently admitted to a nursing home because of progressive dementia has large purpuric lesions over the dorsa of both forearms and hands. Family states shew had similar lesions over the years. Lesions occur in absence of trauma. Platelet count is normal. Which is most likely explanation for purpura? atrophy of dermal collagen 10-year-old boy has mass in ventral midline of the neck just inferior to hyoid bone. This structure is developed from which of the following embryonic tissues? Endoderm of Foramen caecum The frequency of autosomal recessive disease in a population is 1/1600. A deletion has been identified that accounts for 80% of mutations at this locus. 20% of mutations result in point mutations. Frequency of deletion carriers in the population is closest which of the following? square root q2 = 1/40 p=1-q=1-(1/40)= rounded to 1 Freq of carrier=2pq= (2 * (1/400))= 1/20 deletion is 80% frequency = .04 or 1/25 Systemic Vascular Resistance low - cause of hypotension? Early Septic Shock *distributive shock which is marked by massive vasodilation causing decreased SVR, decreased preload / PCWP, and increased CO 23-year old - 1-month history of weakness and muscle pain after vigorous exercise. (Family history similar). A muscle biopsy specimen shows ragged red fibers. Mutation in a gene located in which structure on photomicrograph? Area labeled B Mitochondrial myopathies show "ragged red fibers" on muscle biopsy due to the accumulation of diseased mitochondria in the subsarcolemma of the muscle fiber A 32 y/o woman - receives prescription for tetracycline and is instructed to not to take tetracycline with milk. If tetracycline is taken with milk, its absorption is decreased due to which? Formation of complexes with mineral ions A 23 year old F - Sjogren syndrome 6 years - she has burning pain in her toes for past month. Which neurotransmitters is most likely mediating patients pain? Substance P undecapeptide(11 AA chain peptide) present in the CNS and the peripheral nervous system. involved in the synaptic transmission of pain and other nerve impulses. 22 y/o fever, chills, muscle aches. 6 hours ago - injection with Penicillin G for syphilis. Temp is 102. PE shows no abnormalities. Which explains patient's symptoms? Release of bacterial products Administration of Penicillin for Syphilis may lead to the Jarisch-Herxheimer reaction. Herxheimer reaction is that treatment results in the sudden death and destruction of large numbers of treponemes, with the liberation of protein products and toxins A 48 year old - 2 hours of dizziness and palpitations with sustained, rapid, irregular heartbeat. ECG shows AFIB. If Amiodarone administered, the patient is at greatest risk of which adverse effects? Hypothyroidism amiodarone - associated with a number of side effects, including thyroid dysfunction (both hypo- and hyperthyroidism Removal of Thymus at birth results in severely impaired immune responses. However, if the thymus is removed from adults, little if any deficit in immune responsiveness occurs because of which of the following reasons? Thymic lymphocytes produce before thymectomy are long lived Thymus produces all of your T cells by the time you reach puberty. By age 75, the thymus is little more than fatty tissue. thymus produces all of your T cells by the time you reach puberty. Thymocytes are long-lived and that's why you can lose your thymus without impairment of your immune system. Arsenic inhibits what AA in biochem? arsenic Inhibit Lipoic Acid. Lipoic Acis is part of the the cofactor complex of the Dehydrogenase complex. The Arsenic metabolite arsenate interferes with which of the following enzymes of glycolysis? Glyceraldehyde 3-Phosphate Dehydrogenase 62 year old man - pain in left hip for 3 weeks. An x-ray of the hip shows a 4.5cm, destructive, osteoblastic lesion with associsted fracture in the proximal femur and two separate smaller lesions in the bony pelvis. A needle core biopsy of the femur shows metastic carcinoma. Which is the most likley primary site of the cancer? Prostate Osteoblastic lesions are associated with prostatic adenocarcinoma mets. Increased serum ALP OB = osteoblastic OC = osteoclastic/osteolytic P=prostate, B=breast, K=kidney, T=thyroid, L=lung P--B--K--T--L P = OB B = OB/OC K = OC T = OC L = OB/OC During a clinical study, investigator tests a new drug for treatment of breast cancer. A population of 10,000 patients with breast cancer is recruited and randomized into a treatment group and control group. Analysis shows a p-value of 0.1 with no significant difference in the treatment outcomes between the experimental and control. When repeating, which is most likely to decrease making a beta error? Increase sample size You are aiming to increase power and you can do so by increasing sample size (reduce B error). "power in numbers" 23-year-old man - 3-year history of schizophrenia. He has been taking an antipsychotic medication for hallucinations, paranoia, and disorganized thoughts. Pt does not make eye contact. Lab show serum sodium of 120 mEq/l, urine sodium of 8, and urine osm of 80. Which is most likely cause of lab finding? Psychogenic Polydipsia hyponatremia + a low ADH = psychogenic polydipsia A 12 year old - girl - 3 months ago, she sustained a complex fracture of the left tibia, which required cast immobilization. The cast is removed. Examination of the left calf shows that it is smaller than the right calf. Which of processes in the patient's myocytes is most likely cause of findings? polyubiquitnation atrophy is decrease in tissue mass due to decrease in size (increased cytoskeleton degradation via ubiquitin-proteasome pathway and autophagy A 45-year-old man - tooth abscess - He has not seen a physician or a dentist in over 10 years. He lives alone, unemployed. He has no friends, maintains minimal contact with relatives. No thought disorder. Which is most likely DX? Schizoid personality disorder 60 y/o prolonged apnea - after general anesthesia. Plasma cholinesterase is abnormal. Which agent is most likely responsible for prolonged apnea? succinylcholine Strong AcH Receptor Agonist cause respiratory depression duration of action of Succinylcholine is determined by its metabolism by plasma. cholinesterase. abnormal plasma cholinesterase (=pseudocholinesterase), it will lead to delayed metabolism complications = hypercalcemia, hyperkalemia, and malignant hypertension Two days after admission to hospital for drug induced thrombocytopenia, a 37 year old woman develops severe headache and becomes comatose. She has few petechia and low platelets. A CT scan of the head shows intracranial hemorrhage. A platelet transfusion is recommended, but the patient is a Jehovah's witness and stated she did not want a transfusion of any blood products. Husband wants her to with CNS effects. Alkalization of her urine will cause greatest absolute increase in elimination of the unmetabolized drug if it has which of the following pharmacokinetic profiles? pKA 6.0 protein binding in plasma = 20% Volume Distribution = 1 L/kg drug to be cleared by the kidney, it must first be filtered in the glomeruli. Drugs with a high VD have more of the drug in tissue - not available to filtered by kidney Drugs with high protein binding won't be filtered either. We want a drug with low Vd and low binding if you want it cleared via the kidneys/urine pKa is pH at which any drug is at its 50% ionized stat if pKa of drug is 6---at pH 7 we will start eliminating 18 y/o women screening for colon cancer - Her father and grandfather died of colon cancer at ages of 36 and 45 years, respectively. PE shows no abnormalities. Colonoscopy shows approx. 200 lesions throughout the colon. Colectomy is done (Photograph) Which is the chance that the offspring will develop adenocarcinoma? 50% inherited Familial adenomatous polyposis is an autosomal dominant mutation. Thousands of polyps arise starting after puberty; pancolonic; always involves rectum. Prophylactic colectomy or else 100% progress to CRC. Autosomal dominant diseases have, on average, 50% chance of being passed down to offspring. 23y/o excessive bleeding while brushing teeth - PE shows multiple ecchymoses. Intensive chemotherapy is planned. Before this treatment is initiated to decrease this patients risk for kidney failure, it is most appropriate to administer a drug that inhibits or binds to which of the following sites? Xanthine Oxidase Allopurinol inhibits xanthine oxidase. It is used for chronic gout as well as prevention of tumor-lysis associated urate nephropathy A 17-year-old comes - swollen tender ankle. X-ray strongly suggestive of osteosarcoma. She and her parents are told only that "further evaluation is needed." Next Steps? Speak to both girl and patient and family A 25 year old woman - mass in right axilla. 1 week history of malaise, headaches, and night sweats. Pt adopted a kitten and has sustained several bite and scratch marks. Tenderness in right axiallry lymph node. The skin over the node is erythematous, tough, and warm. Bartonella Henselae antibody test is positive. A biopsy of this lymph node is most likely to show which histological pattern? Granulomas containing stellate micro abscesses + Axillary mass catch scratch competent immune system - stellate necrotizing granulomas. A 35-year-old man - comes to physician to discuss donating kidney to his sister who has T1DM. Which describes likelihood that this donors HLA type will match his sister? Correct Answer: 1:4 You have a 25% chance of inheriting the same HLA markers as your siblings. Two siblings have a 25% chance of being genotypically HLA identical, a 50% chance of being HLA haploidentical (sharing one haplotype), and a 25% chance that they share no HLA haplotypes. 1:4 You have a 25% chance of inheriting the same HLA markers as your siblings. Two siblings have a 25% chance of being genotypically HLA identical, a 50% chance of being HLA haploidentical (sharing one haplotype), and a 25% chance that they share no HLA haplotypes. Decreased total, normal free (unbound) = Thyroid hormone-binding globulin deficiency Thyroxine-binding globulin (TBG) deficiency is characterized by low serum total T4 but normal free T4 and TSH; the diagnosis is confirmed by measuring TBG concentrations A study conducted to assess the effect of a new screening test on the mortality of prostate cancer. Prior to implementation, the overall 5-year survival was 70%. After screening of random population, 5-year survival rate increases to 85%. No changes in treatment. The decrease in mortality could be due to which type of bias? Lead Time caused by early detection being confused with increased survival. early detection makes it seem as though survival has increased, but the natural history of the disease has not been impacted. 50 y/o come to physician because of a 6-week history of depression, anxiety, difficulty sleeping, decreased appetite, and poor memory and concentration. He has an MI 3 months ago. He has one glass of wine each evening. Which of the following most likely decrease this patient's risk of mortality over the next 2 years? Antidepressant Therapy 6-week history (e.g. >2 weeks) of depression (1), difficulty sleeping (2), fatigue (3), decreased appetite (4), and poor memory/concentration (5) At a postnatal checkup - 6-week female newborn weighs 20 ounces less than delivery. Vomits and regurgitates bile-tinged fluid after every feeding. Which of the following is the most likely cause of abnormalities? Annular Pancreas bile in the vomit; abnormal rotation of ventral pancreatic bud forms a ring of pancreatic tissue encircles 2nd part of duodenum; may cause duodenal narrowing (arrows in) and vomiting An investigator compares the DNA sequence of a newborns with achondroplasia and healthy newborns. DNA sequence shows a G-C mutation in the FGF3 gene on chromone 4. Achnodroplasia 5'TACCGGGT-3' Healthy 5'TACGGGGT-3' As a result of this mutation an MspL restriction enzyme site is created that allows for a convenient diagnostic test. Which of the following sequences most likely represents the substrate specificity for Mspl? 5'CCGG restriction enzymes bind palindromes. both 5'CCGG or 3'GGCC would have been acceptable in this scenario. 18 y/o F - never had a menstrual period. PE shows a 1 -cm invagination where vagina would normally be present. No uterus palpable. Lab show FSH, LH, estradiol, and testosterone in normal range. Which of the following structures is most likely normal? Ovaries Ovarian mullerian agenesis. Normal ovaries but absent uterus. Underdevelopment of the Mullerian system leading to congential absence of the vagina. Usually no cervix or uterus. 25 y/o man - severe Pain in low back radiates down his left leg- he started a weight-lifting - tried to lift a 200lb bar form ground over his head. Pain began immediately after this attempt. Cause of this patient's pain? Rupture of an intervertebral disc radiculopathy - disc herniation (radiates to the leg aka lasegue sign), degenerative Ubu=iquitin Ligase starts degradation cycle p53 targeted degradation cycle A 28 year old woman - Eastern European Jewish Descent - lump in her left breast. Maternal grandmother was diagnosed with ovarian cancer, her maternal aunt was diagnosed with breast cancer at age 36. Pt concerned about genetic mutation. Genetic testing most likely to show a mutation in a component of which of the following pathways? Recombinational Double Stranded DNA breaks Defective homologous recombination is seen in breast/ovarian cancers with the BRCA1 gene mutation. Graph (PICTURE) shows radiolabeled protein X that is bound by anti-X antibodies in the presence of varying concentrations of protein Y. With respect to anti-X. which of the following interpretations regarding the epitopes expressed by proteins X and Y is correct? Proteins X and Y express the same epitopes. If they share the same epitopes, it will have a downward slope. If they share none of the same epitopes, the line will be horizontal across the graph A previously healthy 32 year old - 2 hours of severe epigastric pain, nausea, and vomiting blood. Pulse is 125/min, respirations are 18/min, and blood pressure is 85/45 mm Hg. PE shows cool skin and tender abdomen. A decrease in which hemodynamic parameters is most likely to cause patients hypotension? Preload Vomiting blood and cool skin indicates this is a type of hypovolemic shock Decreased EDV means that the "filling volume" is decreased, which also means the preload will be decreased Which of the following changes in the cardiovascular system occurs with normal Aging? Increased Basal Systolic blood pressure vascular sclerosis and stiffening- changes with aging- leads to high sys BP A 55-year-old - constipation since starting an OTC medication 2 weeks ago for chronic, persistent cough, and sinus congestion. Which ingredients in this medication cause symptoms? Dextromethorphan An -antitussive - (antagonizes NMDA receptor) mild opioid effects when used in excess Mild abuse potential 19 y/o college student -sudden onset of right-sided chest pain and difficulty breathing after an accident in which he was thrown from his bicycle. He has difficulty walking and cannot climb stairs because of pain and shortness of breath. He is slightly cyanotic, afebrile, and tachypneic. Which of the following is most suggestive that fractured ribs caused the respiratory problem? subcutaneous crepitus pneumothorax - inspiratory stridor When there is a fractured rib it will cause a trauma pneumothorax which can cause air to escape and become trapped under the skin leading to crepitus. Subcutaneous crepitus is very specific sound referencing air finding its way into 66 y/o old man - comes to ED after MVC. Pronounced dead on arrival. Photomicrograph of a section of distal left ureter taken at autopsy are shown. Which of the following was the most likely predisposing factor in the development of the ureteral lesions in this patient? Cigarette Smoking transitional cell carcinoma, which smoking is a common risk factor for; it can involve the renal pelvis/calyces. histo image shows the papillary nature of the tumor A 36 y/o woman - 1-month history of joint pain, frequent headaches, and fatigue. PE shows edema of the upper and lower extremities. An abdominal CT scan is shown. Which findings most likely seen in this patient? Splenomegaly 56 y/o -frequently burned herself while cooking over the past months. Exam shows loss of pain and temperature sensation in both upper extremities. Touch, vibration, and proprioception are normal. Some wasting of her hands. Which of the following findings on MRI of the head and spine? Syrinx of the central region of the spine C4 - T5 70 y/o man - 3-month history of weakness and a 22lb weight loss. 2 pack of cigarettes daily for 50 years. An x-ray shows a 4-cm lesion in right upper lobe. Serum calcium concentration is 13.5 mg/dl. A malignant lesion arising in a segmental bronchus is seen during lobectomy. DX? squamous cell carcinoma ARISE FROM BRONCHUS , Cavitation, Cigarettes, HyperCalcemia (produce PTHrp) 23 y/o woman - fever, hypotension, and DIC for 24 hours. She splenectomy following trauma. Which bacteria is cause of sepsis? Streptococcus pneumonia Encapsulated organisms run rampant in patients who have no spleen, whether physically or functionally. (Recall the wide-array of sequalae sickle cell patients experience thanks to their functional autosplenectomy.) Female Newborn - Respiratory Distress, Cyanosis, Nasogastric tube placed - what embryologic events cause issue? incomplete formation of Pleuroperitoneal membrane Diaphragmatic hernia A 70-year-old - woman - transferred to rehab service 2 days after operative repair of a fracture of femur. She weighs 6Kg (143 lb). PE exam in unremarkable. Most important predictor of success in rehab. Activity level before the fracture Activity level increase in Bone density(Specially Weigh bearing) and OsteoBlastic activity 27 y/o woman - 3-month history of intermittent headaches, palpitations. Blood pressure 125/80 in a chair. When asked to sit on the exam table, she has flushing, and her blood pressure is 185/115. PE shows no abnormalities. Most likely diagnosis? Pheochromocytoma When standing up, the body normally activates sympathetic system to avoid 65 y/o man - substernal chest pain, nausea, sweating for 1 hour. 10-year history of T2DM. Pulse is 120/min. BP 98/60. PE shows a JVD of 12cm. Crackles are heard halfway up lungs fields. ECG findings? ST elevation Continued or severe ischemia (>20 minutes) leads to transmural necrosis involving most of the myocardial wall (transmural infarction); EKG shows ST-segment elevation. ST will first decrease; however, after 20 min it will increase (elevate) 30 y/o comes to physician - 3-month history of pain in his jaw and left arm. Intense thirst and urination. Found to have peptic ulcer for 2 month. Serum calcium 13.5. PTH 110 (N= 10-65). X-ray normal. Which explains impaired calcium homeostasis? Increased Osteoclast and Maturation activity hypercalcemia (stones, bones, groans, THRONES [increased diuresis}, and psychiatric overtones). Following a wedding reception - 25 adults develop low grade fever, abdominal cramping, vomiting, and diarrhea. No blood in stool, No pathogens on stool culture. Several family members exhibit similar symptoms 3 days after initial outbreak. Causal organisms? Norovirus Legionella Pneumophilia gram negative rods use silver stain. Grow on charcoal yeast extract medium with iron and cysteine. Aerosol transmission Noperson-to-person transmission 31 y/o man - large, yellow, soft mass deeply infiltrating the gluteus maximus muscle. Microscopic exam shows irregular vacuolated cells and clear cells with frequent mitoses. DX? Liposarcoma malignant, increased mitotic activity most common soft-tissue tumors in adult high mitotic index & infiltrative nature indicate that the mass is malignant An otherwise healthy 4-month-old girl is brought to physician because of lesion shown (strawberry hemangioma). The lesion has been present for 2 months and growing rapidly. Which is expected over the next 5 years? spontaneously involution strawberry hemangiomas tend to grow and then randomly involute. appears early in life, grows rapidly and regresses spontaneously by 5-8 years old A 2-year old boy - increased thirst, urinary frequency, and failure to thrive. He is 5th % for height and 7% for weight. PE shows dehydration and decreased muscle tone. The diagnosis of Fanconi syndrome is made. Which sets of changes in fractional reabsorption in the kidneys is most likely in this patient? All Decreased Amino Acid Decreased Glucose Decreased Phosphate Decreased HCO3 Decreased A 28-year-old - man - fatigue and back pain for 6 weeks. 13-lb weight loss. DX of TB of lumbar spine. When placed in supine position, patient holds right lower Anti-toxoplasma IgM antibody concentrations baby does not get any maternal IgM, IgA or IgE as they do not cross the placenta, so if IgM is found it may suggest the baby has encountered an infection in utero. IgG is passed down to the baby as a means of passive immunity until the baby can form their own antibodies of different types. So, if you see anything other than IgG (e.g. IgM) you know it must be d/t an infection. 50 y/o man comes to the physician because of persistent cough for past 2 months. He is farmer and started itraconazole therapy for histoplasmosis acquired through chicken coops. Current medications include hydrochlorothiazide, enalapril, atenolol, omeprazole, and metoclopramide for HTN. An interaction between itraconazole and which following drugs most likely accounts for the lack of effect of itraconazole? Omeprazole CYP 450 inhibitor (SICKFACES.COM) S odium valproate I soniazid C imetidine K etoconazole F luconazole A cute alcohol abuse C hloramphenicol E rythromycin/clarithromycin S ulfonamides C iprofloxacin O meprazole M etronidazole A miodarone Grapefruit juice A 75-year-old woman - burning, itching, and rash. Exam shows clustered skin lesions overlying two ribs near the right axillary line. Some of the lesions are fluid- filled blisters and have crusty scabs. Light microscope shows which findings? Multinucleated giant cells and neutrophil infiltrates Shingles., Herpes simplex and herpes zoster viruses cause abnormal cell division in epidermal cells, and this creates multinucleated giant cells. A Tzank smear showing multinucleated giant cells is characteristic of Varicella Zoster Virus infections A 5-year old girl with AIDS develops vesicular rash. Antiviral therapy is ineffective and the lesions become hyperkeratotic. The genetic mutation responsible for the ineffectiveness involves the activity of which enzymes? Thymidine-Kinase 60 y/op man - 2 pillow orthopnea - severe dyspnea, edema of lower extremities. Onset was preceded by an episode of prolonged substernal chest pain for 5 days. Which of the following is most consistent with these findings? Jugular Venous Pressure 12 mm Hg patient has heart failure. Normal JVP is 6-8 mmHg. A 10-year-old girl - not yet menstruated. PE shows absence of breast bud development and no pubic or axillary hair. The most asks what is the first objective sign of puberty? Breast Bud Development first Females: Thelarche -> Pubarche -> growth spurt -> Menarche trigeminal neuralgia MIDBRAIN - 1,2,3,4 PONS- 5,6,7,8 Medulla 9,10,11,12 Serum cholesterol study for women by age. Assuming gaussian distribution, what is probability that a woman between 50 and 54 has a serum cholesterol greater than 296? Age Cholesterol 50-54 246+50 16% 68% of the data will fall within 1SD of the mean. 100%-68% = 34 16% will fall above and 16% will fall below 1 SD. 2STD = top 5% 36 y/o - not urinated for 24 hours. Intermittent renal calculi - Ultrasound shows bilateral hydronephrosis. Creatinine increased, K+ increased - Bilateral nephrostomy tubes are placed. Which predicts likely changes in urine and potassium excretion during next 24 hours? Increased Urine Output Increased Urine Potassium urine output increased: pretty simply they are putting tubes in to increase the urine flow into the bag. If you increase urine flow rate you increase K+ secretion. That's why diuretics like thiazides and loops increase K+ secretion A 26-year-old man - stab wound in LUQ - laceration of fundus of the stomach. During mobilization, he develops bleeding due to damage to short gastric arteries. Short gastric arteries are a branch of which arteries? splenic Short gastric a. branch from the splenic a. Branches of the celiac trunk that constitute the blood supply to the stomach: common hepatic, splenic, and left gastric. During an experiment, an investigator isolates abnormal elastin from connective tissue of mice. Analysis of elastin shows a decreased number of desmosine cross links. Which amino acids in the abnormal protein would be most likely different compared with normal elastin? Correct Answer: Lysine Lysine is used in elastin and collagen cross linking; it is cross linked by lysyl oxidase to make collagen fibers Desmosine is an amino acid found uniquely in elastin, a protein found in connective tissue such as skin, lungs, and elastic arteries. Desmosine is made up of four lysine residues. Therefore abnormal elastin is likely missing lysine necessary for the formation of these desmosine cross-links. 17-year-old girl - 4-day history of headache and vomiting. Right sided hemiparesis. Serum pyruvate and lactate increased. Muscle biopsy show Deficiency in NADH dehydrogenase. Pedigree shown. Which is mode of inheritance of the disorder? Mitochondrial. - passed by the mother Mothers have diseased children; Fathers don't A 50-year-old man - 3 hour history of confusion and difficulty seeing. He sees white spots that interfere with vision. 3-year history of alcohol disorder. He has been drinking methanol. He is confused and incoherent. PE shows dilated pupils and diminished pupillary reflex. Cause of visual symptoms due to an excess of which of the following metabolites? A 13 month old girl has a history of recurrent bacterial infections. Production of O2-, H2O2, and OH- by neutrophils is normal and production of HOCl is decreased following stimulation by opsonized bacteria. The most likely cause is deficiency of Myeloperoxidase A 42 year old woman has dizziness and ringing in her ears 7 days after starting a drug. Which of the following drugs is the most likely cause? Aspirin A 39 year old woman with rheumatoid arthritis develops proteinuria after treatment with penicillamine. Examination of tissue obtained on renal biopsy shows diffuse fine granular deposits of IgG and C3 in the glomerular basement membrane. The most likely diagnosis is Membranous glomerulonephritis Which of the following is the most likely consequence of impaired synthesis of interleukin-1 (IL-1)? Impaired function of T lymphocytes After a full course of immunization with a new vaccine consisting of a recombinant polypeptide, 10 % of adults fail to make antibody to the polypeptide. The nonresponders have an increased frequency of one HLA type. What is the most likely explanation for the failure of this group to respond to immunization? Lack of class II MHC presentation of polypeptide 2 Yo girl brough to ER after ingesting a substance in mother's purse. On arrival, patient is sedated, resp and BP are normal. Which of the following is most likely to reverse the sedation ? Flumazenil 72 yo man difficult urinating, Digital exam shows enlarged, frim prostate. PSA positive at 3.5. Exam of tissue obtained on biopsy of the prostate is most likely to show? Glandular hyperplasia. A 60-year-old woman - T2DM - substernal chest pain radiates to her left arm. She is diagnosed with MI. 2 days later she develops acute respiratory distress. PE shows elevated JVP. Crackles are heard over the lower half of her lungs. A grade 4/6 apical systolic murmur is heard. Mechanism of worsening pain? Rupture of a papillary muscles most important MI complications that occur within a 2-5 day span are papillary muscle rupture and interventricular septum rupture. Papillary muscle rupture leads to severe mitral regurgitation, heard as a systolic murmur at the apex. 8-year-old boy - evaluated for ventricular systolic overload. ECG shows left axis deviation of the main QRS vector (upward in lead 1 and downward in lead II). Which is most likely explanation for patients condition? Coarctation of the aorta leads to increased LV overload causing LV hypertrophy and a L axis deviation. 30-year male - completed Hodgkin Lymphoma 2 months ago-calls physician on an increasingly frequent basis. He takes temp several times per day. After evaluation he shows no evidence of recurrence, he is increasingly fearful that the disease many not be detected. DX? Adjustment Disorder with anxiety Emotional symptoms (eg, anxiety, depression) that occur within 3 months of an identifiable psychosocial stressor (eg, divorce, illness) lasting < 6 months once the stressor has ended. A 3-month old boy - 1 month history of lump on right side of his groin. Bulge increases when patient crises. PE shows soft mass in the right groin that decreases easily. Which best describes the relationship to the hernia sac? craniopharyngioma. Most common childhood supratentorial tumor. Derived from remnants of Rathke pouch (oral ectoderm). Calcification is common. Cholesterol crystals found in "motor oil"-like fluid within tumor. A cystic suprasellar mass with calcifications and enhancement of the wall or solid portions in a child or adolescent is almost always a craniopharyngioma. A 50-year-old man - brought in by wife because of personality change and cognitive decline. He used to be kind - now yelling all the time. He almost invested all family money in a startup / scam. He has inappropriate cursing. A CT scan shows atrophy of the frontal lobes bilaterally. DX? Pick Disease Fronto-temporal dementia characterized by personality change is usually Picks A 1 -month old - 5 days of vomiting after feeding - vomiting is forceful - PE shows decreased skin turgor. Which set of serum findings - most likely in this newborn? Na 132 K 3.2 Cl- 90 HCO3 37 hypochloremia, hypokalemia, hyponatremia, and metabolic alkalosis chronic vomiting, you lose electrolytes and a lot of acid. It triggers metabolic alkalosis which is why all the serum values are low (or on the lower end of the normal range) except for bicarbonate. 66-year-old fatigue, SOBs, temp. X-ray of chest shows cavitary fluid level in right lower lobe of lungs. Culture of sputum gram stain grows Klebsiella pneumonia. Symptoms resolve with antibiotic treatment. Which is found in right lower lobe 6 months later? Focal pulmonary fibrosis Visible air-fluid level = large lesion Six months following resolution of symptoms you can expect healing in the form of a scar; that is, fibrosis but only in a single spot.' Fibrosis seen in chronic diseases such as pulmonary fibrosis is often responsible for organ dysfunction and even organ failure 16 y/o - 4 day history of severe vaginal itching discharge and a yellow discharge. She uses condoms inconsistently. Saline wet mount shows motile organisms. Causal organisms? Trichomonas vaginalis thin, yellow-green, malodorous, frothy discharge and vaginal inflammation / itching. Lab findings: pH >4.5 and motile trichomonas 50 y/o discharge from both breast- History of HTN and T2DM - She takes hydrochlorothiazide. PE shows a thin, milky discharge from both breasts. Which is responsible for this patient's condition? Drug Effect three major causes of galactorrhea as nipple stimulation, prolactinoma of anterior pituitary, and drugs (see 16.1 - Breast Pathology). Only drug effect is an answer choice for this question. A 6-week-old girl - 6-day history of vomiting a small amount of milk 2 to 3 times daily. She is average weight and height. PE shows no abnormalities. Which is most likely cause of this patient's findings? Immature Lower Esophageal Sphincter vomiting a small amount No abnormalities, only some vomiting, looks well w/ no failure to thrive. Most MR angiography of the renal arteries A 37-year-old nurse stuck with a needle used to obtain blood for HIV positive. Receives antiretroviral therapy. 4 weeks later develop anemia and neutropenia. Which is the MOA of antiretroviral responsible for anemia and neutropenia? reverse transcriptase NRTI's are associated with possible side effects of anemia, granulocytopenia, and myelosuppression. A 70 y/o man dies of coronary artery disease - He had cerebral infarction 8 years ago. A photo of brain stem is shown. Which neuro deficits most likely present after his cerebral infarction? Spastic Hemiparesis on the right Left crus cerebri was damaged (see what it should normally look like below). This contains the corticospinal tract. Since the corticospinal tract decusates at the medulla, below the midbrain section we're looking at, you would see Contralateral (Right) Spastic Hemiparesis A 16-year-old student - uncontrollable sleepiness, falling asleep several times a day while sitting in class. The slightest noise or touch is enough to awaken him. Which characterizes the onset of his sleep at night? Direct transition from wakefulness to REM sleep "Narcolepsy can be conceptualized as a disorder of sleep-wake control in which elements of sleep direct transition from wakefulness to REM sleep. Basically instead of going through the early stages and gradually falling into a deep sleep, you just suddenly go from being awake to being in a deep sleep. A study is conducted to identify healthy women at risk of cardiovascular disease. Because atherosclerosis is inflammatory, the concentration of c-reactive protein is increased. Which is likely site of CRP biosynthesis? Liver CRP is an acute phase reactant, these are synthesized primarily by the liver location (Acute Phase Reactant) Investigator looking at effectiveness in TX (substance X) for Sjogren Syndrome. Substance X produces 2X saliva as placebo. Placebo group contains half as much sodium chloride as that from Substance X. Bicarb is the same in both groups. Which explains these findings? Ductal ion reabsorption more efficient at low flow rates Ductal cells reabsorption is hindered at high flow rates At low flow = High concentration of potassium; low concentrations of sodium, bicarb, & chloride at high flow = low concentration of potassium; high concentrations of sodium, bicarb, & chloride 20 y/o brought to office by mother. Pt is hearing voices and bizarre behavior for 6 months. He used to be a good student, and now he is failing his classes. Pt appears unkept, distracted. Mother thinks he is scaring the family because he is hearing voices. Which initial response is most appropriate? How frightening- Do you have an idea what might be causing the problem? A 53-year-old man - 4-hour history of severer headache, anxiety, sweating, palpitations. He has a 2 year history of HTN. PE shows diaphoresis. Which is the effects of propranolol in this patient? Increase TPR Decrease CO Gastrin Zollinger Ellison Tumor - GASTRIN SECRETING 47 y/o female- 6-month history of severe cough and shortness of breath. She has no fever, chills, or muscle aches. Nonsmoker works as a librarian. She lives alone with 4 parakeets. She is a knitter and can spin wool. A CXR - shows reticulogranular changes. Examination shows interstitial infiltrates of lymphoocytes and granulomas. Cause? Contact with Parakeets Chlamydophila psittaci Hypersensitivity pneumonitis—mixed type III/IV hypersensitivity 16 yo girl brought to ED 45 minutes after her mom found her with an empty bottle of ACETAMINOPHEN. Which of the following events would contribute directly to Hepatic Toxicity in this patient? Peroxidation of lipids in cell membranes A 20 y/o woman - 10 day history of vaginal discharge, itching, soreness. Pelvic exam shows vulvar erythema, edema, and thick white vaginal discharge. Vaginal ph 4.2. Photomicrograph of vaginal discharge is show. Most appropriate pharmacotherapy is an oral agent with which mechanism of action? Inhibition of the cytochrome P450-dependent demethylation reaction -Azoles (fluconazole) (inhibit the production of egosterol by inhibiting Cyt P450- dependent demethylation that synthesizes ergosterol from lanosterol) An investigator - study efficacy of capsular polysaccharides - Neisseria Meningitidis - Which of the following compounds is most likely to induce increased titers of these antibodies when conjugated to polysaccharides? Flagellin Flagellin is a highly conserved protein on many bacterial cells -> aids in motility and adhesion. N. Meningitidies does not possess flagellen- conjugate polysaccharide component uniquq to N.meningitos to flagellar component= long lasting immune resp via Th1 and Th2. Flagellin bind to TLR-5 and activate APC => Th1 and Th2 response. n 56 y/o - long history of chronic back pain undergoes operative placement of electrode in his midbrain for pain management. When implant is activated, pain decreases. Administration of which substances would most likely result in the return of the patient's pain? Naloxone opioid antagonist - block mu receptors would lead to increase in mediators that induce pain. A 55-year-old man - severe emphysema comes to physician for evaluation of SOB- Findings on lung exam? Percussion Hyperressonant Tactile Fremitus Decreased Expiratory Phase Prolonged 37 y/o healthy woman - 6 month history of fatigue - She has 18-kg weight gain during this period. Round face, truncal obesity, purple striae. Plasma ACTH low < 5 (normal < 120). Serum cortisol does not become suppressed at low or high dexamethasone doses. Which is is most likely cause of findings? Tumor of adrenal Zona Fasciculate and aldosterone. Following administration of ACE-inhibitor, plasma renin increases further. Most likely cause of HTN? Renal Artery Stenosis ACE-I likely Renal Artery Stenosis Vasoconstriction of efferent 65-year-old dies 6 months after onset of headaches - Brain autopsy shown in the photograph. Which is likely cell origin of this neoplasm?? Meningeal Meningioma- parasagittal region - 23-year-old with significant blood loss from MVC - She is given 3 units of blood and has an uneventful recovery. 4 weeks later she becomes jaundiced. Lab show anemia and reticulocytosis. Which is most useful in establishing the diagnosis? Direct Antiglobulin Test Hemolysis due to transfused blood Delayed onset of hemolytic reaction 15 y/o - 1-day history of a rash on her face, arms, and legs. She noticed rash on sunny day at the beach. She is receiving ABX treatment for ACNE. PE shows diffuse erythema and mild edema over the face and extremities. Which ABX cause findings? Doxycycline Bind 30s subunit buy AT - 30S--- CELLL @ 50S 5-year-old boy - DX with genetic defect - inability to reabsorb in the proximal tubule. Serum studies are likely to show which of the following findings at this time? Hypophosphatemia b. 85% of Phosphate absorbed in PCT c. 25% Na reabsorbed in TAL 78 y/o dies of CHF- Exam shows passive congestion of lungs, hypoxic changes, hydropic changes im the renal tubular epithelial cells. Which of the following cause hydropic change? Failure of Na+/K+ pump ATP STOPS WORKING Hydropic Changes - one of the early signs of cellular degeneration in response to injury that results in accumulation of water in the cell. Hypoxia decreased in aerobic respiration Cellular injury causes swelling 25-year-old - - collapses in ICU where she works as a nurse. Coworkers report she felt fine all morning. Shortly after lunch she became pale and diaphoretic and then collapsed. She has a history of episodes of hypoglycemia without apparent precipitants. She is unresponsive and low blood 2- concentration, given bolus of 50% dextrose. Several episodes of confusion. Glucose is less than 20 - bolus of 50% dextrose is administered. Lab studies show. Glucose 32 C-peptide <0.075 Proinsulin < 1 pmol/L Which of the following is most likely diagnosis? Factitious Disorder EXOGENOUS INSULIN Low C-peptide, low proinsulin, high plasma free insulin and low glucose, in a nurse Endogenous Insulin - increased C-Peptide An Investigator is studying patients with West Nile Virus infection. During a 5- year period, data are collected on 25 patients. Demographic information on the 62 y/o mild cough, purulent sputum for 2 weeks. She smoked 2 packs for 42 years. She drinks 3 to 6 beers. PE shows, swelling of the in fingers, arthritis of joints, and clubbing of the digits. What is the most likely underlying disease? Bronchogenic carcinoma Immediately after a cerebral infarction, a 62 y/o right handed man has decreased fluency but his comprehension is normal. Pt most likely has lesion in which of the following areas? Area Labeled A - BROCAS areas: fluency decreased, comprehension intact Wernicke area: poor comprehension, fluent speech 55 y/o - 2 month history of decreased appetite. 20lb weight loss and an intermittent rash. PE shows necrolytic migratory erythema over the axilla and groin. Glucose 280 and Glucagon 1500 (N- 20-100). A CT scan shows mass at head of pancreas. Which is most likely occurring in liver? Partial Oxidation of Fatty acids Glucagon upregulates - CAT1 and CAT2 are important enzymes of fatty acid beta oxidation. Glucagonoma: migratory erythema Dermatitis (necrolytic migratory erythema), Diabetes (hyperglycemia), DVT, Declining weight, Depression 28 y/o - 32 weeks gestation, 4 day history of fever and back pain. PE shows costophrenic tenderness, photomicrograph shown represents her disease. What mechanism is likely cause? Obstructive nephropathy pregnancy dilation of the upper urinary tract can occur due to compression of the ureters by the growing fetus/uterus and the linea terminalis postrenal azotemia 65 y/o woman - 25 year history of chronic alcoholism - vomiting blood—She eats very little, Exam of her legs show -perifollicular hyperkeratosis and hemorrhage. Abnormally decreased function of which metabolic pathways is most likely in this patient? Hydroxylation of proline Vit. C deficiency- curvy features swollen gums, easy bruising, petechiae, perifollicular and subperiosteal hemorrhages. 16 y/o girl with cystic fibrosus - 3-week history of numbness, tingling of her arms and legs, and difficulty walking. She has not adhered to her medication region for 6 months. PE shows bilateral weakness and decreased deep tendon reflexes in the upper and lower extremities. She walks with ataxic gait. Deficiency in which of the following? Vitamin E fat soluble (neurologic with ataxia) A 33-year-old - HIV infection - generalized tonic-clonic seizures. 2 month history of headaches. CD4 count is 22. CT shows 3-cm lesion in right cerebral cortex. Serologic studies - positive for IgG antibody to Toxoplasmosis Gondii. Tx with pyrimethamine and sulfadiazine is initiated. During next 2 weeks, 3 more seizures. CT shows lesion increased to 3.5cm. Cause of mass? Non-Hodgkin Lymphoma Activating LH receptor will lead to more Testosterone from the Leydig cells. More testosterone can lead to more estrogen formation via aromatase. A 48-year-old man - overdose on ferrous sulfate. Na and K in normal range. What happens to bicarb and cl serum concentrations? HCO3 8 Cl 96 IRON OVERDOSE- high metabolic acidosis High anion gap metabolic acidosis due to Iron excess (the I in MUDPILES). Serum anion gap = (Na) - [(HCO3 + Cl)]. Chloride levels low;HCO3 low, which results in the high anion gap. A 61-year-old man - erectile dysfunction due to spinal cord injury at L-2. Sildenafil used to correct ED by acting at which of the following labeled structures (Image Shown)? corpus cavernosum Sildenafil increases blood flow to the penis by dilating the corpus cavernosum (increased NO via inhibition of PDE5 --> cGMP --> smooth muscle relaxation) A 32-year-old woman -- confused and lost consciousness - fell from ladder an struck the right side of her head on the edge of her desk. She felt well enough to continue working. PE shows edema on right anterior temple. Right pupil dilated. Left pupil normal. What is DX? Arterial laceration epidural hematoma Meningeal Artery Pts bumps head, gets back up - severe issues/ dies 6 hours later -- = epidural hematoma middle meningeal artery laceration => epidural hematoma. Epidural hematomas are known to cause transtentorial herniations and CN III palsy Branch of maxillary artery A 12-year-old boy - 3 episodes of meningococcal bacteremia during past 4 years. He has had not other significant infections. The most likely cause of the recurrent meningococcal infections is a deficiency in which of the following? Terminal Component of Complement MAC Complex (C5-C9) Deficiencies increase susceptibility to recurrent Neisseria bacteremia. A 33-year-old - 3 month history of pain in right thigh. No history of trauma. PE shows mild swelling but no erythema. MRI shows tumor in anterolateral muscle. Which muscle is infiltrated with the tumor? Rectus Femoris 51-year-old- develops diaphoresis, tachycardia - 24 hours after undergoing abdominal operation -BP 155/100 - 2 hours late he has generalized tonic-clonic seizures. Which is responsible for the adverse effect seen in the patient? alcohol withdrawal 40 year old brought to ER after wife found him unresponsibve- PCO2 60, PO2 50 HCO3 12 - acid base status? Metabolic acidosis and respiratory acidosis Check pH - NONE Check Bicarb - low - metabolic acidosis Check CO2- high - respiratory acidosis (hypoventilating) 35 year old woman - undergoes flexible nasopharyngoscopy - Purulent discharge from the right sphenoethmodial recess. Location of structure? Correct Answer: superior to superior concha