Medical Case Studies: Diagnosis and Treatment of Various Conditions, Exams of Nursing

Download Medical Case Studies: Diagnosis and Treatment of Various Conditions and more Exams Nursing in PDF only on Docsity! 1 NBME CBSE Actual Test Questions and Answers (Quiz Bank with All the Correct Answers) (USMLE step 1)Medical Examination 62-year-old woman - osteoporosis - a bisphosphonate is prescribed. The expected beneficial effect of the drug is due to which of the following? -Answer= Decreased Osteoclast Activity Cohot Study of elderly women - relative risk ratio for hip fractures among thosewho 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? -Answer= Statistically Significant Overall Increase Risk 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? - Answer= 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? -Answer= 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 2 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? -Answer= a. Adenylyl Cyclase Adenylate Cyclase - ATP - CAMP -- PROTEKINASE A -- Ca v2 A 10 month old boy - 4 day history of fever and cough. He attends day care center. Chest exam shows intercostal retractions along with bilateral, diffuse wheezes and expiratory rhonchi. The infectious agent most likely has which of thefollowing properties? -Answer= Mediation of Cell Entry via a fusion protein A 17 year old girl in ED - 15 minutes after being stung by a bee. Mild light headedness but no difficulty swallowing- Bilateral wheezing - Which is most appropriate pharmacotherapy for this patient? -Answer= B2- Agonist 14 year old boy - 2 day history of sore throat and fever that peaks in late afternoon. 1 week of fatigue. He recentaly had sex with one partner. Physical exam show cervical lymphadenopathy and pharyngeal erythema with a creamyexudate. DX? -Answer= Infectious Mononucleosis 5 51 year old - lump on tongue - 1 pack smoking history for 30 years. 1.5 cm mass on apex of tongue. It is most appropriate to evaluate which lymph nodes first for evidence of metastasis? -Answer= 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? -Answer= 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? -Answer= 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? -Answer= 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? - Answer= Hypogonadotropic Hypogonadism A male stillborn is delivered at 32 weeks - Oligohydramnios - absence of a urethral opening. Which is most likely finding? -Answer= Pulmonary Hypoplasia 6 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? -Answer= 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? - Answer= 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? - Answer= Atrophy b. ALS = Lou Gherig A new severe respiratory illness - Why use a killed vaccine vs a live vaccine? - Answer= Avoids Concerns of reversion to virulence b. Killed vaccines - avoids reversion to virulence 7 c. live vaccines - can (but rarely do) cause the disease they're designed to preve 10 physician? -Answer= You must miss your daughter very much. Tell me about her. b. PT = Transference 9 month old boy - awakens and cries at least once nightly and settles back to sleep after drinking a bottle of formula - Explanation for patient's sleep pattern? -Answer= Normal Development Pubertal gynecomastia in males is norma A 32 year old - abnormal movement in hands and worse when he feels angry - Unable to fix his gaze on one point or protrude his tongue for more than 30 sec - Pt most likely has anatomic abnormalities in which of the following locations? - Answer= Basal Ganglia A 14-year-old boy - recurrent otitis media since infancy - underwent tonsillectomy for obstructive sleep apnea - Cardiac auscultation exam listen - shows S3 - which is most likely finding? -Answer= Normal Findings b. normal physiologic splitting 37 year old woman - right lower extremity edema - sudden SOB+, If present onphysical exam which sign would be the most specific indicator or pulmonary arterial hypertension? -Answer= P2 louder than A2 b. Pulmonary Hypertension - Split S2 43 year old - with t2DM - ER - nausea and vomiting - after drinking 11 champagne. Treated for Trichomonas Vaginalis Infection - TX with metronidazole. What is cause of nausea and vomiting? - Answer= Accumulation of Acetaldehyde b. Metronidazole - disulfiram reaction 45 year old man - right shoulder pain - patient unable to externally rotate the shoulder against resistance - Which of the following tendons is inflamed? - Answer= Infraspinatusb. SITS Muscles 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? - Answer= 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? -Answer= 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 themost appropriate remark? -Answer= Thank you for waiting. 12 How can I help 15 A Study designed to evaluate the feasibility of acupuncture in children with chronic headache - 60 children recruited - In addition to their usual therapy - allchildren are treated with acupuncture three times per week for 2 months - Describe findings? -Answer= 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? -Answer= 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? -Answer= DNA Virus Herpetic Whitlow Herpetic Whitlow -Answer= vesicles on fingers 7 year old - lives in Kentucky - 2 week history of cramping abdominal pain and diarrhea - mother looked in underpants and saw earthworm - no travel history- Transmission via? -Answer= Ingestion of Soil b. Ascaris - fecal oral transmission 23 year old man with multiple sex partners - dysuria and yellow urethral exudate - Gram Stain - numerous neutrophils - many contain gram negative diplococci. He had 3 episodes over the past 2 years. Which property of the organism - explains reinfection? -Answer= Antigenic Variation b. Gram negative Diplococci c. N. gonorrhea can change its pilus, 16 23 year old woman - genetic counseling - brother and maternal uncle had Duchene Muscular Dystrophy - Serum CK of 120 - and mother serum CK 300- What is assessment of carrier status? - Answer= The patients DMD carrier status is uncertain because of random X Inactivation b. Barr Body c. DMD is X-linked. 20 year old woman - heavy bleeding - Platelet Aggregation is normal - PTT elevated - no easy bruising - Which hemorrhagic disorder cause of patients menorrhagia? -Answer= Von Willebrand Disease B. Platelet aggregation time being normal, ok fine I can see that. 32 year old man - ER - for MVC - urethral injury - blood noted at the uretheral meatus. Which portion of the urethra would be at greatest risk ofinjury? -Answer= Membranous a. Pelvic fracture - MVC b. Pelvic Straddle injury = Bulbar (spongy) urethera A 63 year old - ED - unresponsive - Crackles heard over left upper and entire right lung. Pt dies. Photograph of section of right lung obtain - Which is likely cause of the position indicated by the arrow? -Answer= C5a Complement system calls in neutrophils 17 C5a = neutrophil chemotaxis A 22 year old woman - 6 months sever lower backpain - endometrial biopsy shows abundant mitotic figures in the endometrial glands and stroma. Which protein or enzymes regulate the progression of this phase of the menstrual cycle? -Answer= Cyclin Dependent Kinase. 29 year old woman - prescribed carbamazepine for trigeminal neuralgia- family history of osteoarthritis - the most likely reason for this recommendation is that carbamazepine may affect which of the following processes? -Answer= Metabolism An 18 year old woman - fever, dizziness, weakness, and vomiting (toxic shock) - using synthethic pads and tampons - Physical exam shows injected conjunctiva and rash- Pts use of which increased risk? -Answer= Tampons A 53 year old man - - 6 month history of blood in stool - 1 cm anal mass - If mass is malignant, evaluate which lymph nodes? -Answer= Superficial Inguinal 1 cm mass below dentate line 24 year old - brought to ED - MVC - face struck steering wheel - facial pain anddouble vision - Exam of left eye shows infraorbital edema - ocular movement restricted vertically - CT scan shown. Which of the following impaired on left side? -Answer= Sensation over the upper lip V2 = maxillary nerve 23 year old - collapsed at finish line - no loss of consciousness Associated 20 A 65 year old - bilateral wheezing - accumulation of which of the following? - Answer= 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? - Answer= 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? -Answer= 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? - Answer= 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" - Answer= 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 21 andchocolate 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? -Answer= 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? -Answer= 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? -Answer= 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 thoseof drug X? -Answer= Cholinesterase Inhibitor 30 year old women - 28 week gestation - Fetal ultrasound normal - Father's blood group in B, Rh Positive - Physician recommends administration of Rh0Dimmune globulin - This treatment is most likely to prevent? -Answer= Formation of antibodies to RhD 22 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? -Answer= 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? -Answer= Metformin An asymptomatic 44-year-old man - with HIV infection during routine screening to donating blood. A complete blood count- platelets are low - which of thefollowing finds are most likely? -Answer= Petechiae Platelet problem -Answer= epistaxis, ecchymoses, petechia, bleeding from superficial scratches Coagulation problem -Answer= late re-bleed, Menorrhagia, GI bleeds, hemarthroses 23 year old - bone marrow failure - given a large dose of rabbit antimyocyte globulin - 10 days later - develops fever, lymphadenopathy, arthralgias, and erythema on her hands and feet. Which is the most likely cause of these symptoms? -Answer= Immune complex deposition in tissues 25 shaped areas of hypodensity - no nephrolithiasis - strongest predisposing factor? -Answer= Atrial Fibrillation Wedge Shaped renal infarct -Answer= 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? - Answer= Hair Follicle b. Hot Tub Folliculitis = Pseudomonas 45- year-old - picture of H. Pylori - epigastric heartburn and weight loss - Which process likely involved? -Answer= Elaboration of proteases and urease with localsupport tissue A 14-year-old - hit with baseball bat - unable to dorsiflex his foot. Which of thefollowing nerves is most likely injured? -Answer= 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? - Answer= Pouch of Douglas 26 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? -Answer= 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? -Answer= Basement Membrane 47-year-old with organophosphate poisoning - blurred vision, difficult breathing, diarrhea, muscle weakness, fatigue - Most appropriate immediate pharmacotherapy? -Answer= 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? -Answer= 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? -Answer= 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? -Answer= Third Degree AV 27 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? - Answer= 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 -Answer= =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? - Answer= 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? - Answer= 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? - 30 A 62-year-old with interstitial pneumonitis - compared with a healthy man, analysis of this patients biopsy is most likely to show the following patterns in thecell population (Type 1, Type II, and Fibroblast)? -Answer= Type I pneumocytes decreased Type II pneumocytes increased Fibroblasts increased 31 year old - with T2DM - comes to physician because of an oozing, foul smelling wound - patient has crepitant bullae - Gram Statin shows gram- positive rods - The causal organism has which of the following virulence factors? -Answer= A -toxin 4 month year old with SCID received a bone marrow transplant. - six days later - he develops a widespread, erythematous, maculopapular rash - Exam of skinshows diffuse degeneration of basal epidermal cells with mononuclear inflammatory cell infiltrate- Which is cause of rash? - Answer= Graft vs Host Disease 1 -Answer= 1. 36-year-old F with 2 week history of fatigue, bleeding of the gums, and bone pain. Physical examination shows pallor, hepatosplenomegaly, and ecchymotic lesions over extremities. Labs:Hb 8g/dlHt 25%Leukocytes: 36,000segm neutr 4%eosinophils 4%lymph 6%mono 6% promyelo 80%platelets 25,000Polymerase chain reaction test shows an mRNA corresponding to the retinoic acid receptor- alfa/promyelocytic leukemia fusion gene resulting 31 from a reciprocal 32 translocation of chromosomes 15 and 17. Treatment w/ all-trans retinoic acid is started. In response to the therapy, the fusion protein will most likely attract which of the following proteins to form a pre- transcriptional complex? - Answer= a. Histone acetylase b. Histone acetylation allows for relaxation of the DNA e. Histone Acetylation makes DNA Active f. Histone Methylation Mostly Makes DNA Mute. 68-year-old man with 3 days of increasingly severe chest pain, shortness of breath, stridor, hoarseness, difficulty swallowing and nonproductive cough. Long- standing hx of hypertension. Smokes 2 packs of cigarettes for 45 years. T 99 F, pulse 80, rr 15, bp 160/94. PE shows visible pulsation above the manubrium of the sternum and displacement of the trachea to the right. Murmur second right intercostal space. Dx? -Answer= Aorticaneurysm male smoker with HTN + deep chest pain and pulsatile mass = AA all day long 1. 35-year old man w several episodes of squeezing chest pain gets angiogram... gets IV NE. Question shows a graph of coronary blood flow witha drop after the NE and then a rise. Which substance causes increased total coronary blood flow 1-2 mins after NE? -Answer= Adenosine Adenosine and Nitric oxide (NO) increases coronary blood flow 4. Man comes to doc for cast removal. Fracture of left humerus that required 35 - 36 Answer= Extensive solar elastosis Actinic elastosis, also known as solar elastosis, is an accumulation of abnormal elastin (elastic tissue) in the dermisof 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 withurination. T 39 C (102.2 F), pulse 125, bp 96/60. Urine grows gram- negative bacteria. Virulence factor for adherence to bladder? -Answer= 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? -Answer= 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? - Answer= Area labeled D 24-year-old woman overdose on drug X and has serum concentration of 32. 37 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? -Answer= 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? -Answer= 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? - Answer= 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 40 and required cesarean delivery, after 33-year-old woman who three weeks ago, underwent oophorectomy for epithelial ovarian cancer. Recommends adjuvant chemotherapy with paclitaxel. Mechanism? -Answer= a. Inhibits microtubule disassembly "taxes STABILIZE the economy" 4-year-old boy with fatigue and irritability for 2 months. Family visited rural Louisiana 5 months ago and ran around barefoot. Conjunctivae are pale. Labs shows normal wbc with 15% eosinophils. Stool prep shows parasite egg (picture). Cause of fatigue? -Answer= Microcytic anemia Necator or Ancylostoma = running around barefoot (entrance site for laravae hookworms suck blood from the intestines leading to iron deficiency anemia. Parasite in US - unable to absorb nutrient like iron Heart of 76-year-old woman shows concentric enlargement of left ventricle. Micro exam shows enlarged myocardial cells with large nuclei. Dx that causesthis cardiac enlargement? -Answer= Hypertension b. concentric ventricular hypertrophy = increased afterload c. eccentric ventricular hypertrophy = increased preload d. chronic HTN, Friedreich ataxia 23-year-old woman g1p1, not felt well since delivery 2 weeks ago; ongoing fatigue, inability to breast-feed, light-he dedness in upright position. Pregnancy complicated by preeclampsia 41 she required blood transfusions because of hypotension. PE appears lethargic. HR 80, BP 100/50, HR standing 85, BP standing 86/44. Hb 11.6, hct 36%. Serum hormone concentrations? -Answer= Prolactin decreased ACTH decreased TSH decreased Aldosterone increased Sheehan syndrome c. severe bleeding requiring transfusions + inability to breastfeed (decreased prolactin d. All hormones from pituitary - destroyed 50-year-old man with pulmonary embolus. Treated with intravenous heparin. 24 hours later, warfarin added. Day 2, partial thromboplastin time is 52 seconds (control 26 sec), and prothrombin time is 12 seconds (control 12.1 sec; INR = 1). Best explanation for normal prothrombin time and INR? -Answer= Long half-life of factor II (prothrombin) Factor II (prothrombin) has the longesthalf-life Warfarin acts on Factor II, VII, IX, X Heparin = factor IIa inhibited by ATIII - thus low 42 PTT is prolonged 8-year-old boy with persistent disruptive behavior. Teacher says he's in "constant motion" and never completes assignments. Treated in ER several timesbecause of skateboarding injuries. Tx? - Answer= Methylphenidate sxs in 2+ settings--> school, and ER for skateboarding injuries Tx= methylphenidate MOA = stimulates NE and DA 65-year-old man with cancer of cecum found to have metastatic lesion to right lobe liver. Venous route of mets? -Answer= Ileocolic --> superior mesenteric - ->portal --> right hepatic branch of portal right lobe of the liver = all drain into the Superior Mesenteric Vein. left sided structures drain into the Inferior Mesenteric Vein. 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 thewidth of the 95% CI with regard the mean blood pressure -Answer= 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 45 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? - Answer= 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? -Answer= 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? -Answer= 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 hasproblems 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? -Answer= von Willebrand disease prolonged bleeding time + prolonged PTT = 46 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? - Answer= 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? -Answer= Agranulocytosis (rare side effect of PTU) commonly presents with acute pharyngitis. 47 . 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? -Answer= 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? -Answer= 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 Ig - 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 50 6-year-old boy with 5-day history of intermittent vomiting and 3-month hx of progressive clumsiness. Can no longer ride bicycle and difficulty getting out of car. Funduscopic exam shows bilateral papilledema. Neuro exam shows impaired upward gaze and pupil response to light. Walks shuffling gait. CT shows enlarged lateral and third ventricles and a 2-cm mass. Location of mass? - Answer= Pineal gland Pinealoma Parinaud syndrome (compression of the tectum --> vertical gaze palsy) Obstructive Hydrocephalus .34-year-old man burned hands firing pots 3 months ago. He has no pain duringor after burn. PE shows mild atrophy of arms and hands, absence of deep tendon reflexes in upper extremities, and decreased pain and temperature sensations in C4 to T1 dermatomes. Touch is preserved. Dx? - Answer= Syringomyelia Cape like distribution of loss of pain and temperature Touch preserved - lack of degeneration in the DCML. 57-year-old man with alcoholism dies of klebsiella pneumonia. Abscess cavitiesfilled with purulent exudate on autopsy. Pattern of necrosis in lung tissue? - Answer= Liquefaction Abscess (proteolytic enzymes from neutrophils liquify tissue An investigator conducts a meta-analysis of three genome-wide association studies of Crohn Disease. The studies encompassed 3200 cases and 4800 controls, all of European descent. The initial studies identified 11 significant 51 loci with odds ratios above 1.3 and 1.5; the combined meta- analysis identified an additional 21 loci with odd ratio of 1.1 to 1.3. It is estimated that the 32 loci identified explain about 10% of the variance in disease risk with 2 loci accounting for 2% of the variance. Previous studies of twins indicated a 50% heritability rate for Crohn's disease. Which of the following best explains these results? -Answer=The identified loci account for a relatively small part of the variance 5-year-old girls with severe leg pain 1 day after fell off sled. Immigrate to USA from Iceland. Has had three bone fractures since birth. Parents are vegan and don't give dairy products. PE shows tenderness, swelling, and limited range of motion of left lower extremity. Xray shows fracture of fibula. Pt has vitamin deficiency that affects which of the following? -Answer= Intestinal calcium absorption Vegan vitamin D deficiency 36-year-old woman diagnosed with HIV. Two months ago, started antiretroviral therapy with efavirenz, emtricitabine, and tenofovir. Labs: CD4 352 and undetectable HIV viral load. Two months ago, CD4 count was 158 and plasma HIVviral load was 5500. Next step? -Answer= Continue efavirenz, emtricitabine, and tenofovir with no changes If it ain't broke don't fix it. 52 Typical antiretroviral HIV therapy regime is: 3 NRTIs OR 2 NRTIs AND 1 NNRTI OR 1 Protease inhibitor OR 1 Integrase inhibitor 18-year-old woman get general anesthesia for wisdom teeth extraction. After 5 minutes, gets hypertonicity of skeletal muscles and increased body temperature. The treatment is a drug that decreases? -Answer= Sarcoplasmic Ca release Malignant hyperthermia- rare, life-threatening condition in which inhaled anesthetics or succinylcholine induce severe muscle contractions and hyperthermia Dantrolene - TX- Prevents release of Ca2+from sarcoplasmic reticulum ofskeletal 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? -Answer= Idiopathic pulmonary fibrosishoneycomb 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 studiesnormal. Angiography shows no coronary artery blockage. ECG shows prolonged QT. Decreased activity in which of following causes this? - Answer= Outward (delayed) rectifying potassium channel 55 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? -Answer= 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? -Answer= Flattened affect Schizophrenia Positive*hallucinations, delusions, unusual thought processes, disorganized speech, bizarre behavior 56 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? -Answer= 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 ironcontent and cirrhosis Greatest risk? -Answer= 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 courseof 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? -Answer= Contraction radiation therapy caused fibrosis and the myofibroblasts "contract" during fibrosis 19-year-old woman 2-day history of pain in left index finger. Injured it when catching a ball. PE shows erythema of left index finger. Unable to flex the 57 distalphalanx when proximal interphalangeal joint metacarpophalangeal joints restrained. Xray normal. Injured structure? - Answer= Flexor digitorum profundus tendon profound go far - profundus to distal/furthest phalynx 21-year-old woman with 10-days difficulty walking. Two years ago had loss of vision in left eye which improved. Neuro exam shows decreased visual acuity in left eye with pallor of optic disc. Has past-pointing on a finger-nose test. Broad- based gait. MRI shows brain lesions in white matter of cerebellum. Pathogenesis? -Answer= CD4+ T lymphocytes are activated by myelin basic protein Multiple Sclerosis increased IgG level and myelin basic protein in CSF Oligoclonal Bands 69-year-old woman with 3-week history of muscle cramps, weakness, abdominal pain, and constipation. Hypertension treated with metoprolol and hydrochlorothiazide for past 4 months. Labs show hypokalemia. Which drug should be added? -Answer= Triamterene (potassium-sparing) = Keep your SEAT Spirolactone, Eplenone Amiloride, Triametrene Work in Distal Tubule Collecting Duct 82-year-old woman comes to the physician because of constant severe lower 60 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 mechanismsof action is most appropriate for this patient? - Answer= 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? - Answer= 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 61 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? - Answer= 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? - Answer= 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? -Answer= 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? -Answer= Metastatic carcinoma of the breast Prostate, Breast >Kidney, Thyroid, Lung 62 Workbench wiped down with alcohol, successfully inactivates viruses with which characteristic? - Answer= 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? -Answer= 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? -Answer= 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 agoand 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 65 hematochezia 66 24-year-old man with 3-day progressive numbness of both feet ascended to thighs. Last 24 hours, numbness and tingling of hands. PE ataxic gait. Deep tendon reflexes diminished in upper extremities and absent in knees and ankles. Vibration and joint position absent in fingertips and feet bilaterally. Mild weaknessdistal upper extremities ad moderate weakness of lower extremities. Structure involved? -Answer= Myelinated primary afferents Most common subtype of Guillain-Barri syndrome 27-year-old man for psychiatric eval sent by employer because he is "very odd." Is a computer repair specialist and lives alone, Refuses to socialize and has no friends. Extremely preoccupied with science fiction, occult, afterlife. Personality disorder? -Answer= Schizotypal Eccentric appearance, odd beliefs or magical thinking Cluster A 45-year-old man bmi 26, total cholesterol 200, HDL 50, triglycerides 550. Which drug to prescribe? -Answer= Fenofibrate Triglycerides 550 MOA = Activates PPAR-αto induce HDL synthesis 60-year-old man for routine health examination. Has had normal blood 67 pressure measurements. BP today 170/95mmHg. Physical examination shows no other abnormalities. Serum show hypokalemia and metabolic alkalosis. Plasma renin activity and serum aldosterone s are increased. ing the administration of captopril, there is a marked increase in plasma renin activity. Which of the following is the most likely cause of the findings in this patient? - Answer= Renal artery stenosis Decreased renal perfusion (one or both kidneys) Increased renin Increased angiotensin ---HTN After operation, 65-year-old patient has lung region that is under ventilated but well perfused. Which increases? -Answer= Physiologic shunt - Mismatching of ventilation and perfusio - insufficient ventilation to provide the oxygen needed to oxygenate the blood Physiologic shunt -Answer= -Mismatching of ventilation and perfusion with the lung -Results in insufficient ventilation to provide the oxygen needed to oxygenate theblood flowing through the alveolar capillaries Physiologic dead space -Answer= portion of the tracheobronchial tree that does not participate in gas exchange 63-year-old man 2-week sensation of fullness in left upper quadrant. Has lethargy and shortness of breath. 20-lb weight loss during 3 months. PE 70 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? -Answer= 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 monthslater. Which of the following best explains the recurrence? - Answer= 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 71 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? -Answer= 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? - Answer= 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 -Answer= 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? -Answer= alpha1-adrenoreceptors low doses d1 = dilates renal vessels medium b1 agonist = ionotropic and chonotropic 72 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 ofsolid food to the infant's diet. History of gluten sensitivity. 60th percentile for length and 25th percentile for weight. Which cell is dysfunctional? - Answer= Enterocyte Celiac disease, an autoimmune intolerance to gliadin leading to enterocyte damage and subsequent malabsorption 25-year-old woman comes for counseling prior to conception. Has seizure disorder on valproic acid. Fetus at greatest risk for drug-related adverse effect during which pregnancy stage? - Answer= 3 to 8 weeks Neural tube defects Neuropores fail to fuse (4th week) 16-year-old boy who frequently thinks about sex, daydreams about girls before going to sleep, and masturbates one to two times daily. After counseling about safe sex, best next step? -Answer= Schedule next routine examination Normal behavior for a teen boy 35-year-old woman with 3-month progressive shortness of breath with exertion. RR 26. Physical shows jvd and prominent a wave. Lungs clear. Cardiac exam shows loud pulmonic component of S2 and right-sided S4 gallop. Increased pulmonary expression of what? -Answer= Endothelin-1 pulmonary hypertension =imbalance between vasodilation substances and vasoconstrictors. 75 defense mechanism. Organism is found to have decreased HCl prod. After 2 months on biopsy gastric fundus and body show decreased mucosal thicknessand hyperplasia of enterochromaffin like cells. This resembles? - Answer= 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? - Answer= Renal Cell Carcinoma hematuria, palpable masses, 2° polycythemia, flank pain, fever, weight loss 67- year-old woman with atrial fibrillation with sudden onset severe abdominalpain. Ex-lap shows embolus in superior mesenteric artery with complete occlusion of middle colic artery. Ischemic changes where? - Answer= 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? -Answer= Reassortment viruses with segmented genomes (eg, influenza virus) exchange genetic material. 76 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? - Answer= 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? -Answer= 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? - Answer= 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 77 of 80 ventricle CONcentric - CONstricts ventricle 68- year-old man with alcoholism comes for fever, chills and productive cough of purulent sputum for 3 days. Blood cultures positive. Gram stain: gram- positive, lancet-shaped diplococci. Vaccine is against which bacterial component? -Answer= Capsular polysaccharide Strep pneumonia Child with XXY karyotype, genetic studies showed he received the extra "x" from his father. An error of chromosome segregation occurred during anaphase at which of the following stages of spermatogenesis in the patient's father? - Answer= Primary Spermatocyte Most problems with cell division occur in anaphase of Meiosis I. Meiosis ⇒1 from primary to secondary spermatocyte Meios→is S2econdary to spermatid' 28-year-old man with ulcerative colitis, history of partial colectomy, and improved rectal bleeding and diarrhea since then. Meds include mesalamine, hydrocodone and acetaminophen. He says, "I've been taking so much of my opiate prescription that I ran out and stole some from my job." Next step? - Answer= Discuss treatment options and a referral for detoxification program 81 67-year-old man with 1 year progressive difficulty writing and walking. Pt is stooped and talks slowly. PE shows bland facial expression, fine resting tremor in both hands, no tremor when moves, walks with difficulty starting and stopping, cogwheel rigidity. Brain tissue histology shown as well as gross cross sections ofmidbrain both normal and diseased. Substance referred to by arrow. Which Substance? -Answer= Alpha-synuclein 8-year-old boy with pain on back and head since he fell off swing. Tender 2.5cm swollen mass over right occiput. CT shows osteolytic and soft-tissue mass in skull with inward displacement of dura. Biopsy shows sheet-like infiltrate of pale eosinophilic cells with bean-shaped nuclei. Cells positive for CD1a. Electron microscopy of cells shows Birbeck granules. Abnormal cell type? -Answer= Langerhans cells 30-year-old man in bicycle collision and hits right shoulder forcefully. Unable to flex right elbow with decreased sensation to pinprick over right lateral forearm. Brachial plexus lesion? -Answer= E (musculocutaneous nerve) 8-year-old man comes with cracked lips and peeling sunburned skin. Works as lifeguard. PE shows desquamation of sunburned skin. Lips are dry and cracked. Petrolatum to lips may reduce lip symptoms by which of following effects of the compound? -Answer= Barrier During a clinical study of calcium and phosphorus metabolism, a 50-year- old man undergoes series of lab studies. His serum Ca, PO4 and PTH are normal. He is given infusion 2 g Calcium chloride over 2 hours. His serum Ca 82 concentration now is 11.5mg/dl. Compared with pre infusion levels, the serum concentration of which of the following substances is likely to be increased at this time? - Answer= 24,25-Dihydroxycholecalciferol inactive metabolite preferentially synthesized when normal 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? - Answer= 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? -Answer= 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? -Answer= 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 85 weakness, fatigue, headaches, hypertension, loss of appetite and itching. Cr 4. Labs - Answer= 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? -Answer= 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? - Answer= Trigeminal neuralgia 45-year-old homeless man found unconscious. Breath smells of alcohol. Vitals stable. PE shows bronzed skin and spider angiomata on chest. Labs: hemoglobin 10, hematocrit 30%, MCV 110, WBC 9000, platelets 160,000, ferritin 200, b12 500, folate 20. Blood smear shows hypersegmented neutrophils and 3+ oval macrocytes. Labs? -Answer= Methylmalonic acid: normal Homocysteine: increased 55-year-old man with elevated LDL cholesterol is prescribed lovastatin. This treatment would result in which adaptive responses at the cellular level? - Answer= Increased transcription of HMG- CoA reductase 86 63 yo man with mild emphysema has smoked 1 pack for 45 years sudden headache, myalgia and rising temperature. A dry cough develops, with chill andchest pain. Examination of gram stain of sputum disclose neutrophils, but bacteria are not evident. An X-ray of the chest is consistent with severe pneumonia. A culture of sputum is negative, but culture of bronchoscopy specimen on a highly specialized bacteriologic medium yields gram negative rods. The identity of these bacteria is confirmed by staining with specific fluorescent antibodies. The patient respond therapy with macrolide Ab. Mechanism? -Answer= Inhalation of aerosol from an environmental source (Legionella) - Aerosol transmission 50-year-old woman with COPD comes with 3 months of progressive shortness ofbreath. Physical shows JVD, loud pulmonary component of S2. Pulmonary function tests show FEV1:FVC ratio of 20% and decreased diffusing capacity for carbon monoxide. Which is decreased in pulmonary vascular smooth muscle? - Answer= Endothelial nitric oxide synthase production 63- year-old man with abnormal blood pressure. 6 months ago, bp was 135/85. Today bp 170/98. Bruit heard over left renal artery. CT angios hows left arterial stenosis. Labs? -Answer= Total peripheral resistance increased, Plasma renin activity increased, Serum aldosterone concentrationincreased renal artery stenosis. 87 20-year-old woman at 27 weeks' gestation is admitted to the hospital because of a 12-hour history of intense uterine contractions occurring every 8 minutes. Her membranes ruptured 32 hours ago. Her temperature is 39.1°C(102.4°F), and pulseis 115/min. Physical examination shows tenderness of the uterus. Pelvic examination shows a closed cervix that is not effaced. The fetal heart rate is 210/min. Which of the following is the primary stimulus for her uterine muscle contractions? - Answer= Inflamed maternal decidua release of prostaglandin Preterm Premature Rupture Of Membrane 30-year-old woman with 2-years of numbness, blanching, and bluish color to ears, fingers and toes after emotional upset or cold exposure. Vitals and PE normal. Avoid taking which drug? -Answer= Phenylephrine 18-month-old girl with 2 day progressive cough and hoarseness. T 102.2F, HR 88, RR 24, bp 100/70. Oxygen saturation 95%. PE mild erythema of oropharyngeal andlaryngeal mucosa no exudate, harsh, barking cough heard. Improves within 4 days. Cause? -Answer= Parainfluenza Patient with orthostatic hypotension, loose stools for 1 year, and history of type 1 DM. Stool studies are normal. What is the pathophysiological mechanism of the diarrhea? -Answer= Motility disorder 39-year-old man with polycystic kidney disease has 6-month history intermittent blood in urine. T 98.6 F HR 100 RR 24 BP 160/90. Urea nitrogen 90 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? - Answer= 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? -Answer= "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 91 types is most likely to be abnormal in this patient? -Answer= 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 hydronephrosisand lymphadenopathy compressing ureters. Tx to improve renal function? - Answer= 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 paralysiswithin 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? -Answer= 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? -Answer= Autophagic 92 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? -Answer= 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? -Answer= 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? - Answer= 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? -Answer= Neutrophil counts 95 In a 25-year-old patient who underwent splenectomy, target cells are seen on peripheral smear. These cells are seen due to loss of function of which portion ofspleen? -Answer= Red pulp Red pulp -Answer= the region of the spleen composed of blood-filled venous sinuses and thin plates of splenic tissue (cords), which consist of red blood cells and various white blood cells Filter the blood of antigens, microorganisms, and defective or worn-out red blood cell 56-year-old exposed to possible chemical attack. Respirationslabored, diaphoresis, excessive lacrimation, increased salivation, muscle strength 2/5, urinary and fecal incontinence. Besides atropine, another tx? -Answer= Pralidoxime Studying epithelial repair of small intestine in experimental animal. Wants to identify most active cell division location. Where is this cell activity found? - Answer= Base of the crypt 48-year-old recently diagnosed with lupus and difficulty working as schoolteacher because of severe pain and swelling of joints. Current meds include prednisone, hydroxychloroquine, and oxycodone for pain. Best action to encourage patient to adapt to illness? -Answer= Encourage the patient to participate in a support group for persons with her condition 96 A 25-year-old man is admitted to the hospital because of severe crush injuries to the chest and extensive burns over 30% of his body surface area. Three hourslater, he develops tachypnea and dyspnea. Arterial blood gas analysis on room air shows a decreased Po2 and Pco2. A chest x-ray shows bilateral interstitial and alveolar infiltrates. The patient is intubated and mechanically ventilated. Damage to what will preclude restoration? -Answer= 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? -Answer= 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? -Answer= 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 97 result in which of the following sets of serum findings? -Answer= 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 overthe left lower extremity. There are no other sensory or motor deficits. Which labeled structure is site of injury? -Answer= 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 mencoming through window. Dx? - Answer= Delirium 2-month-old female with T 102F, vomiting, diarrhea, dehydration. Exam ofstool shows viral particles with wheel-like shape. Properties of virus? Type of nucleic acid/envelop/capsid symmetry -Answer= Double-stranded RNA, segmented/no/icosahedral Double-stranded RNA, segmented/no/icosahedral "wheel- like shape" -Answer= rotavirus 62-year-old with angina pectoris is referred for cardiac catheterization. Patient worried about hospital-associated infection. Studies show 30% of