NBME New Tests Compilation 2023 with Verified Answers

External carotid - superior thyroid 46 year old woman - 2 month history of fatigue and muscle weakness - 10 year history of hypertension - treated with thiazide diurectics - measured hypokalemia, hypotension and decreased BP- brisk reflexes. Likely cause? -Answer= Adverse Drug Effect b. Treated with a thiazide diuretic for HTN with measured hypokalemia, hypotension and decreased Hg 55- year old man - nice to nurses - mean to youngest child- Which is the most likely explanation of patient's behavior? -Answer= Splitting b. Cluster B - borderline personality (BANH) A Study designed to evaluate the feasibility of acupuncture in children with chronic headache - 60 children recruited - In addition to their usual therapy - all children are treated with acupuncture three times per week for 2 months - Describe findings? -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, 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 of injury? -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 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 and double vision - Exam of left eye shows infraorbital edema - ocular movement restricted vertically - CT scan shown. Which of the following impaired on left side? -Answer= Sensation over the upper lip V2 = maxillary nerve 23 year old - collapsed at finish line - no loss of consciousness Associated with prolonged use of vaginal tampons or nasal packing She is placed on a cot - feet elevated - 30 minutes later her blood pressure is 110/70 mm Hg. Which described patients condition? -Answer= Orthostatic Hypotension .decrease in systolic blood pressure of 20 mm Hg (110-85) e. decrease in diastolic blood pressure of 10 mm Hg. (70-50) 27 year old - ER - pain in navel - nausea and one episode of vomiting 1 hour ago - underwent appendectomy 2 years ago- CT scan of abdomen shows fat stranding in small bowel with areas of inflammation in terminal illeum - 2 cm bulge on antimesenteric border of the inflamed segment. Histological specimen - most likely to show which of the following? -Answer= Gastric Mucosa b. Crohns with the multiple episodes over the last year, fat stranding, terminal ileum involvement 14 year old girl -parents divorced - starts acting sullen, defiant, and truant at school, sexual intercourse with new partners and no condoms, previously honor studenty- which defense mechanisms? -Answer= Acting Out 38 year old - pregnant woman - ultrasound shows oligohydramnios and a full term fetus with a large kidney and empty right renal fossa. Need history on maternal use of which during pregnancy? -Answer= ACE Inhibitors 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 and chocolate colored blood. 68 year old - 1 day history of fever and swelling in left leg - cellulitis - gram stain - gram positive, catalase negative cocci - clear zones of blood agar - Which species of Streptococcus? -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 those of 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 Rh0D immune globulin - This treatment is most likely to prevent? -Answer= Formation of antibodies to RhD 55- year -old -man - hypertension and chronic kidney disease - ECG shows low voltage with electrical alternans. Physical exam is most likely to show which of the following? -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 the following 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 b. Serum sickness - TYPE 3 hypersensitivity 42 year old - gunshot wound - 36 hours post-operatively she is receiving morphine. she needs morphine - she has expressed concern she is becoming addicted. Which of the following initial actions by the physician is most appropriate? -Answer= Reassure the patient has a miniscule chance of becoming addicted to narcotics A 22 y/o woman -- itchy, red rash on her arm - new hair dye - picture (contact dermatitis) - Which ligand pairs play a role in the proliferation of the T Lymphocytes -Answer= CD28 on T Lymphocytes and CD80 on epidermal Langerhans cells 6 healthy subjects in a study of muscle metabolism - Increased malonyl-CoA directly inhibits which of the following processes in these subjects -Answer= Fatty Acid Oxidation b. Malonyl-CoA inhibits the rate limiting step in beta-oxidation of fatty acid. Over 1 year - study is conducted to assess the antileukemic activity of a new tyrosine kinase inhibitorwith CML in blast crisis - All patients in the study had SML and are informed that they would be treated with tyrosinase inhibitor. What type of study design? -Answer= Open Label Clinical Trial A 63 year old man - 4 day history of increasingly severe left leg pain and swelling on his left calf - CT scan shows no abnormalities - A CT scan of the abdomen shows a 3 cm mass in the body of pancreas - Ultrasound shows a femoropopliteal venous clot - Which of the following is the most likely cause? -Answer= Hypercoagulability of advanced malignancy A 40 year - comes to physician because of 6-month history of facial hair growth - temporal balding and coarse hair on the upper lip chin - ultrasound shows a 12 cm ovarian mass - Describe mass? - Answer= Sertoli - Leydig Cell Tumor 35 year old man - pain and swelling in right arm when scraped a tree branch - Temp 101F- Examination of the right arm shows edema around a lesion - primary mechanism of edema? - Answer= Separation of endothelial Junction 12-year-old - 2 month history of headaches - 6 day history of nausea and vomiting - bilateral papilledema - broad based gait An MRI - shows tumor in pineal region. Pt most likely oculuomotor impairment? -Answer= Upward Gaze Parinaud Syndrome due to compression of tectum- vertical gaze palsy occurs with pineolmas 52 year old man - 1 day history of nausea, vomiting, and right sided abdominal pain - radiates to his back - CT scan - shows enlarged right kidney and wedge 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 local support tissue A 14-year-old - hit with baseball bat - unable to dorsiflex his foot. Which of the following nerves is most likely injured? -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 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 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? -Answer= Androgen Insensitivity 16 year old boy - 3 day abdominal pain and vomiting - CT scan shows perforated appendix - Exam of peritoneal fluid shows which organism? -Answer= Escherichia Coli 45 year old woman 6 month history of hot flashes, night sweats, and insomnia- Physician informed consent on new treatment - most appropriate next step? -Answer= Could you tell me the results of the hormone treatment options we have discussed? A randomized control trial - assess risk of GI adverse risk using azithromycin compared to erythromycin in the pertussis - 100 children with pertussis enrolled - 50 azithromycin and 50 erythromycin - vomiting among 5 pts in azithromycin group and 15 patients in erythromycin group - Which represents absolute risk reduction? -Answer= a. 0.2 . 15/50 - 5/50 = .2 34 - year -old woman with a 10 year history of Hep C - progressive fatigue - vitals normal. - liver biopsy shows hepatocellular injury - infiltration and early fibrosis - which mechanism is most likely to cause hepatocyte injury? -Answer= Foreign Peptides bound to Class I MHC Molecules are recognized by CD8+ T Lymphocytes A 50 year old - high blood pressure - If left untreated, which of the following is most likely to decrease in this patient? -Answer= Baroreceptor Firing 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 the cell 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 skin shows 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 from a reciprocal 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= Aortic aneurysm 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 with a 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 open reduction, internal fixation, cast immobilization. Muscle strength is 2/5 with extension of elbow and 1/5 with extension of wrist and fingers. Patient most likely sustained a fracture at (which location in humerus)? -Answer= Radial groove (radial N. is the extensors of arm, wrist and fingers) Prevalence of high-grade cervical intraepithelial neoplasia in unscreened population is 5%. Prevalence in population with negative Pap smear results is as high 0.2%. Prevalence decreases, which also decreases? -Answer= Predictive value of a positive test result Higher prevalence - higher predictive vales - positive, predictive, prevalance 45-year-old woman with joint pain due to rheumatoid arthritis comes for infective treatment with over-the-counter agents. Initiate disease-modifying antirheumatic drug (DMARD). Delayed onset of action of DMARD, so physician prescribes another until DMARD is effective. Drug? -Answer= Prednisone You can use three classes of medication to treat RA: NSAIDs, corticosteroids, and DMARDs. NSAIDs and corticosteroids have a short onset of action, while DMARDs take a while to take effect. 28-year-old man infertility, weight lifter and takes anabolic steroids. Mechanism of infertility? - Answer= Suppression of Gonadotropins Anabolic steroid use suppresses the Hypothalamic-Pituitary-Gonadal axis which will down regulate GnRH. FA 2020 p636 62-year-old woman with 3-day hx of fever, shaking chills, and left flank pain. Dx acute pyelonephritis and treated with ciprofloxacin. Five days after, sudden onset watery diarrhea and lower abdominal cramps. T 100.9 F, pulse 80, rr 18, bp 124/88. PE moderate tenderness to palpation in lower quadrants especially on right and increased bowel sounds. Stool is brown and occult blood negative. Next step? -Answer= Test of the stool for Clostridium difficile toxin b. Pseudomembranous colitis c. Couple days after Ciprofloxin 72- year-old woman comes to the physician because of a 6-month history of increased bruising on her forearms. She appears alert and well nourished. Physical examination shows extensive wrinkling, scaly erythematous patches on the face, and irregularly shaped brown macules on the face and forearms. There are ecchymoses in various stages of healing on both forearms; the ecchymoses are more numerous on the right side. Laboratory studies, including a complete blood count and coagulation studies, are within the reference ranges. S he has noticed no bleeding from her gums after brushing her teeth. Which of the following is the most likely cause of the ecchymoses in this patient? -Answer= Extensive solar elastosis Actinic elastosis, also known as solar elastosis, is an accumulation of abnormal elastin (elastic tissue) in the dermis of the skin, or in the conjunctiva of the eye, which occurs as a result of the cumulative effects of prolonged and excessive sun exposure, a process known as photo=aging ]21-year-old woman with 2-days history of urinary frequency and pain with urination. T 39 C (102.2 F), pulse 125, bp 96/60. Urine grows gram-negative bacteria. Virulence factor for adherence to bladder? -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. 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 45-year-old man comes to physician for follow up after appendectomy. There is mild scleral icterus and well healing surgical incision. Lab values show Total bilirubin 3.2 Direct: 0.2 Indirect 3 mg/dL Dx? -Answer= a. Gilbert Stress related - Mild jaundice with increased unconjugated in an older fellow is decreased UDP- glucuronyltransferase activity. 35yo F has congestive cardiomyopathy and pitting edema. Her serum urea nitrogen concentration is 25mg/dl and serum creatinine is 1.8mg/dl. Furosemide therapy is started. After 5 days, labs show: Na 130K 4.5Cl 90HCO 30 BUN 85 Creatinine 2.2 Albumin 3Urine specific gravity 1.023, rbc 0 wbc0 sediment none Urinary fractional excretion of sodium is less than 1%. Explanation? -Answer= Prerenal azotemia After the addition of furosemide, her BUN/Cr ratio went up to 38 and Fraction Excretion of Na 1 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 causes this 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-headedness in upright position. Pregnancy complicated by preeclampsia and required cesarean delivery, after 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 longest half-life Warfarin acts on Factor II, VII, IX, X Heparin = factor IIa inhibited by ATIII - thus low 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 times because 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 the width 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 14-lb weight loss since last visit 3 months ago. BMI 15. PE shows multiple ecchymoses in various stages of healing upper extremities and torso. Physician should ask? -Answer= Are you safe at home? A transcription factor that activates expression of HMG coA reductase is identified, this TF is initially synthetized as a large precursor protein, with 2 membrane spanning domains. The transcriptional domain is released by proteolysis when the membrane has a decreased cholesterol concentration. The precursor protein is most likely initially produced in which of the following labeled area on this labeled diagram of a hepatocyte? -Answer= Area labeled F Endoplasmic Reticulum 18-year-old woman comes 12 hours after ingesting 100 aspirin tablets in suicide attempt. PE shows tachypnea. Labs?pH/pCO2/HCO3- -Answer= pH 7.32 pCO2 15 HCO3 8 aspirin overdose (early) = Resp Alkalosis aspirin overdose (Later) = Metabolic acidosis HCO3- should also be less than normal (22-28) 12 hours = Late Stages 10-day-old male newborn 1-day history red eyes with discharge. Pregnancy uncomplicated but no prenatal care in third trimester. PE bilateral conjunctival injection with water discharge. Cause? - 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 has problems with nosebleeds and clotting. PE shows mild gum bleeding and ecchymoses. Labs: hb 8.2, hct 24.6, platelet 250,000, bleeding time 10, PT 14 (INR 1.5), PTT 60. Dx? -Answer= von Willebrand disease prolonged bleeding time + prolonged PTT = A study is conducted to compare the incidence of myocardial infarction in patients undergoing two different types of angioplasty or an operative procedure to manage single-vessel coronary artery disease. A total of 1000 patients are enrolled. Through a chance process, 500 are assigned to undergo the operative procedure, 250 are assigned to undergo one type of angioplasty, and 250 are assigned to undergo a second type of angioplasty. All patients are followed for 3 years to determine the incidence of myocardial infarction. Which of the following best describes this study design? - 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. . 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 IgM - hence the name "hyper IgM" - and deficiency in the rest Complement activation= IgM and IgG 67-year-old woman comes to the physician because of a 1-month history of low back pain. She has hypertension well controlled with a thiazide diuretic. Her pulse is 140/min, and blood pressure is 140/85 mm Hg. Physical examination shows tenderness to palpation over the L2-3 vertebrae. Laboratory studies show:Hemoglobin 13.5 g/dLHematocrit 41%Leukocyte count 10,500/mm3Segmented neutrophils 65%Eosinophils 1%Basophils 1%Lymphocytes 30%Monocytes 3%Platelet count 250,000/mm3 Serum electrophoresis shows a monoclonal spike of IgG kappa. A chest x-ray shows cardiomegaly with bilateral pleural and pericardial effusions. An x-ray of the spine shows a lytic lesion. Echocardiography shows an echodense thickened left ventricle and poor diastolic compliance. A photomicrograph of a specimen obtained on myocardial biopsy is shown. Which of the following is the most likely cause of the cardiac findings in this patient? -Answer= Amyloid infiltration Multiple Myleoma = monoclonal IgG kappa (light chain) spike on electrophoresis, lytic bone lesions in the spine, cardiomegaly all point to multiple myeloma. Amyloid infiltration- Causes a primary amyloidosis that can deposit in multiple tissues, Investigator studying immune response to fungi. Fungi express beta-glucans on cell surface and that triggers innate immune response. Which tx decreases glucan expression? -Answer= Caspofungin Inhibit cell wall synthesis by inhibiting synthesis of β-glucan 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 during or 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 cavities filled 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 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 HIV viral load was 5500. Next step? -Answer= Continue efavirenz, emtricitabine, and tenofovir with no changes If it ain't broke don't fix it. 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 of skeletal muscle by inhibiting the ryanodine receptor 48. 66-year-old man with 1-month hx of nonproductive cough and 6 months shortness of breath. Bilateral end-inspiratory crackles heard. CT chest shows diffuse reticular opacities at periphery and bases of lungs. Micro exam of biopsy shows patchy interstitial fibrosis, several fibroblastic foci and no granulomas. Dx? -Answer= Idiopathic pulmonary fibrosis honeycomb lung 35-year-old man with several episodes of dizziness and fainting during the past 2 months. Father and several paternal uncles died suddenly. PE and lipid studies normal. Angiography shows no coronary artery blockage. ECG shows prolonged QT. Decreased activity in which of following causes this? -Answer= Outward (delayed) rectifying potassium channel QT is correlated with the repolarization (Phase III), 4-month-old boy with 1-day respiratory distress. Has progressive weakness and difficulty feeding for a month. RR 50/min. PE shows enlarged tongue and generalized hypotonia. Increased lactate, pyruvate, glucose, and uric acid. CXR shows cardiomegaly. Biopsy of skeletal muscle shows increased glycogen. Enzyme impaired? -Answer= alpha-1,4-Glucosidase Pompe Disease (Type 2) Lack of - Lysosomal Debranching Enzyme (α-1,6 Glucosidase) 58-year-old woman with 6-month shortness of breath and chronic nonproductive cough. 2-year history difficulty swallowing, joint stiffness, diffuse tightening of skin on face, neck, shoulders, arms, fingers. Sensitivity to cold weather, fingers turn white. Hx of esophageal reflux. Biopsy showed atrophy of epidermis and deposition of collagen throughout dermis with loss of dermal appendages. PE cutaneous ulceration, clawlike flexion deformity, decreased joint mobility. At risk for which pulmonary disorder? -Answer= Pulmonary hypertension systemic sclerosis/CREST complications = interstitial fibrosis, pulmonary HTN CREST - Calcinosis, anti-Centromere antibody, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly Telangiectasia