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New NBME® Comprehensive Clinical Science Self-Assessments / New Versions of NBME TESTS - T- 18, T-20, T-21, T -22, T-23 , T-24, T -120 (answered_2022)

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New NBME® Comprehensive Clinical Science Self-Assessments / New Versions of NBME TESTS - T- 18, T-20, T-21, T -22, T-23 , T-24, T -120 (answered_2022) 56 y/o - brought to ER - Chest Pain mowing the ... lawn - Hypotension, PE shows cool, clammy, diaphoretic skin. 2 hours after admission, pulmonary catherization shows pulmonary artery pressure 40/25. Left Atrial Pressure 25 g (pulmonary emboli). Compared with a healthy person- sets of pulmonary pressure changes? ✅ - Hydrostatic Pressure High, Capillary hydrostatic pressure high Interstitial Oncotic pressure Low cardiogenic shock, the extra blood increases capillary hydrostatic pressure, driving fluid into the interstitial space. 67 y/o - brother has history of colon cancer. Physician recommends colonoscopy, but the patient says she would prefer stool culture instead. Physician explains that testing the stool for occult blood is not appropriate. Physician concerned about? ✅ - Low Sensitivity A 62 y/o - 1 week of muscle cramps - trouble opening jars and using silverware. PE shows muscle weakness and exaggerated deep tendon reflexes. What is appropriate systemic treatment for muscle cramps and spasms? ✅ - agonist at GABAb Receptors 41 y/o schedule for dialysis catheters. Surgeon asks the resident to get the consent. The resident has never seen this procedure performed and has read little about it. Which of the following actions by the resident is most appropriate? ✅ - Ask attending to obtain informed consent A 2 year old - undergoes resection of right kidney - chronic infection secondary to influx. The left kidney is grossly normal. Which structural adaptations will eventually occur in left kidney? ✅ - increase in glomerular size Congenital solitary functioning kidney compensatory hypertrophy of contralateral kidney A 54 y/o woman - terminal metastatic pancreatic cancer - She asks physician to prescribe sufficient meds to commit suicide due to unbearable pain. Physicians refuses - but will do anything to help pain. Physician decision is most consistent with which? ✅ - Nonmaleficence 22 y/o woman - recently emigrated from rural Mexico - 20 minutes after generalized tonic-clonic seizures. 6 week history of headaches, nausea, vomiting. Funduscopic exam shows bilateral papilledema. An MRI of the brain shows enlargement of right ventricle consistent with Cysticercosis. Which is mostly likely mechanism of hyderocephalus? ✅ - Obstruction of right interventricular foramen (foramen of Monroe) 22 y/o woman - recently emigrated from rural Mexico - 20 minutes after generalized tonic-clonic seizures. 6 week history of headaches, nausea, vomiting. Funduscopic exam shows bilateral papilledema. An MRI of the brain shows enlargement of right ventricle consistent with Cysticercosis. Which is mostly likely mechanism of hyderocephalus? ✅ - Obstruction of right interventricular foramen (foramen of Monro) 59 y/o - develops fatigue and decreased appetite 3 months after receive mechanical aortic valve replacement. PE shows scleral icterus and elevated JVP. Lab studies show total bilirubin 4 elevated and direct bilirubin 1. Which is the cause of the jaundice in this patient? ✅ - Hemolysis Prosthetic heart valves / aortic stenosis- hemolytic anemia secondary to mechanical destruction of RBCs. 71 y/o man - 6 month history of calf pain and discomfort when he walks. He has HTN, T2DM, weak dorsalis pedis, and ankle brachial index. The physician knows a drug that would improve symptoms by altering platelet function and providing direct arterial vasodilation- Which drug? ✅ - Cilostazol phosphodiesterase inhibitor; leads to increased cAMP which inhibits platelet degranulation/activation while also causing vasodilation A 3 month-old boy - facial abnormalities and weakness since birth. PE shows coarse facial features and hypotonia. Mucopolysaccharides within reference range. Concentrations of lysosomal enzymes are increased in serum and decreased in cultured skin in fibroblasts. Which of the following is decreased in patient's lysosomal enzymes? ✅ - Decreased Mannose-6-phosphate A Newborn with lethal chromosome defect. He is unable to suck sufficiently. He has episodes of crying that occur every 2.25 hours and relieved by tube feeding. Which best describes the most appropriate clinical approach? ✅ - feed by whatever necessary to maintain comfort An 18 y/o woman - fever, sore throat, fatigue for 1 week. Temp 100.6. PE shows pharyngeal erythema, generalized tender lymphadenopathy, splenomegaly. Lab show 20% atypical lymphocytes. Which accounts for atypical lymphocytes in patients peripheral blood smear? ✅ - Reactive T - Lymphocytes 51-year-old man - acute onset of fever and respiratory failure 6 weeks after cadaveric renal transplant. He currently takes cyclosporine, bactrim, prednisone, and TMP_SMX. Temp high - Respirations increased. Diffuse inspiratory and expiratory crackles. Creatinine increased. X-ray of chest shown. Cause? ✅ - Cytomegalovirus Organ transplant patients are at an increased risk of CMV pneumonia. A 2 month old - 6 week history of constipation. She has poor feeding, sleepiness, and yellow skin. Her parents are migrant workers and have not received routine medical care. PE shows lethargy, hypotonia, jaundice, large fontanelles, macroglossia, and umbilical hernia. Most appropriate next step to establish diagnosis? ✅ - Thyroid Function Test CRETINISM A 39 y/o reports bright red spots on toilet paper after defecating. Rectal examination shows large swollen rectal veins. Which is predisposing cause of these lesions? ✅ - constipation Large swollen rectal veins --> patient has external hemorrhoids. Swollen and inflamed veins in the rectum and anus that cause discomfort and bleeding. The most common cause of external hemorrhoids is repeated straining while having a bowel movement. A 45 y/o develops proteinuria and hematuria. She has taken 3g of ibuprofen for headaches daily for the past 2 years. Which of the following is most likely obtained on renal biopsy? ✅ - Tubulointerstitial nephritis Acute interstitial renal inflammation. Pyuria (classically eosinophils) and azotemia occurring after administration of drugs that act as haptens, inducing hypersensitivity (eg, diuretics, NSAIDs, penicillin derivatives, proton pump inhibitors, rifampin, quinolones, sulfonamides). A 92 y/o - recently admitted to a nursing home because of progressive dementia has large purpuric lesions over the dorsa of both forearms and hands. Family states shew had similar lesions over the years. Lesions occur in absence of trauma. Platelet count is normal. Which is most likely explanation for purpura? ✅ - atrophy of dermal collagen 10-year-old boy has mass in ventral midline of the neck just inferior to hyoid bone. This structure is developed from which of the following embryonic tissues? ✅ - Endoderm of Foramen caecumThe frequency of autosomal recessive disease in a population is 1/1600. A deletion has been identified that accounts for 80% of mutations at this locus. 20% of mutations result in point mutations. Frequency of deletion carriers in the population is closest which of the following? A 62-year-old woman - progressive bilateral lower abdominal pain and distention. Pelvic exam shows adnexal mass. Malignant cells. Paclitaxel is initiated. Treatment targets which in tumor? ✅ - B- Tubulin hyperstabilizes polymerized microtubules (made up of alpha- and beta- tubulin) Taxes Stabilize society The frequency of autosomal recessive disease in a population is 1/1600. A deletion has been identified that accounts for 80% of mutations at this locus. 20% of mutations result in point mutations. Frequency of deletion carriers in the population is closest which of the following? ✅ - 1/25 =sqrt(1/1600) = 1/40 (1/40)*80% = .02 2* 1* .02 = .04 = 1/25 A 46 y/o has dyspnea, orthopnea, midsystolic murmur best heard over the cardiac apex. An ECG shows a left atrial abnormality. Echo shows enlarged left atrium and normal sized ventricles. Which findings? ✅ - Mitral Regurgitation A 19-year-old woman - refractory pustular acne - unresponsive to several topical and systemic therapies. Treatment with isotretinoin. Which of the following pharmacologic effects is dependent on binding to the RXR receptor? ✅ - Teratogenic effects in the embryo hormone superfamily of nuclear receptors (NRs) that predominately function as transcription factors with roles in development, cell differentiation, metabolism, and cell death A 35 y/o man comes to physician because of a 2 month history of inflamed thickened silvery scales on scalp, trunk, elbows, and knees. This condition not responsive to coal tar, calcipotriene, and triamcinolone. Which drug is most appropriate? ✅ - Methotrexate A 55-year-old with T2DM, HTN, hyperlipidemia develops myalgias with weakness. Serum CK increased. Urine is positive for myoglobin. Which drugs responsible for symptoms? ✅ - Pravastatin statin-induced myopathy In patients with breast cancer, metabolically stable agonists of gonadotropin-releasing hormone are effective because they inhibit release of which? ✅ - Gondatropin by the pituitary Gland GnRH agonists like Leuprolide - continuous fashion, they downregulate the GnRH receptor in the pituitary and ultimately decrease FSH and LH. 83 y/o home bed-ridden and confused. Temp 96F. Hypotensive (BP 85/50). Given 1 liter of saline hypotension. Pulmonary catheter inserted (Cardiac Output high, Pulmonary Cap Wedge Pressure Low, Systemic Vascular Resistance low) - cause of hypotension? ✅ - Early Septic Shock distributive shock which is marked by massive vasodilation causing decreased SVR, decreased preload / PCWP, and increased CO 23-year old - 1-month history of weakness and muscle pain after vigorous exercise. (Family history similar). A muscle biopsy specimen shows ragged red fibers. Mutation in a gene located in which structure on photomicrograph? ✅ - Area labeled B Mitochondrial myopathies show "ragged red fibers" on muscle biopsy due to the accumulation of diseased mitochondria in the subsarcolemma of the muscle fiber A 32 y/o woman - receives prescription for tetracycline and is instructed to not to take tetracycline with milk. If tetracycline is taken with milk, its absorption is decreased due to which? ✅ - Formation of complexes with mineral ions A 23 year old F - Sjogren syndrome 6 years - she has burning pain in her toes for past month. Which neurotransmitters is most likely mediating patients pain? ✅ - Substance P undecapeptide present in the CNS and the peripheral nervous system. involved in the synaptic transmission of pain and other nerve impulses. 22 y/o fever, chills, muscle aches. 6 hours ago - injection with Penicillin G for syphilis. Temp is 102. PE shows no abnormalities. Which explains patient's symptoms? ✅ - release of bacterial products Administration of Penicillin for Syphilis may lead to the Jarisch-Herxheimer reaction Herxheimer reaction is that treatment results in the sudden death and destruction of large numbers of treponemes, with the liberation of protein products and toxins A 48 year old - 2 hours of dizziness and palpitations with sustained, rapid, irregular heartbeat. ECG shows AFIB. If Amiodarone administered, the patient is at greatest risk of which adverse effects? ✅ - Hypothyroidism amiodarone - associated with a number of side effects, including thyroid dysfunction (both hypo- and hyperthyroidism Removal of Thymus at birth results in severely impaired immune responses. However, if the thymus is removed from adults, little if any deficit in immune responsiveness occurs because of which of the following reasons? ✅ - Thymic lymphocytes produce before thymectomy are long lived Thymus produces all of your T cells by the time you reach puberty. By age 75, the thymus is little more than fatty tissue. thymus produces all of your T cells by the time you reach puberty. Thymocytes are long-lived and that's why you can lose your thymus without impairment of your immune system. A 4-week infant - vomited after feeding for past 2 days. Recent episode was very forceful regurgitation through the nostrils. Physical exam shows mild abdominal distention with visible peristalsis. Explanation of these findings? ✅ - Hypertrophic Pyloric Stenosis olive-shaped mass in epigastric region, A 45-year old woman - asymmetric enlargement of the thyroid gland during PE 6 weeks ago. She underwent adrenalectomy for pheochromocytoma 3 years ago. Thyroid lesions are composed of spindle cells arranged in small clusters. Deposits of amyloid are present between neoplastic cells. Foci of C-Cell Hyperplasia are also present. The lesions are confirmed as malignant. Which of the following marked is most appropriate for the development of the recurrence of the thyroid neoplasm? ✅ - Calcitonin Patient has medullary carcinoma. Malignant proliferation of parafollicular "C" cells that produce calcitonin and have sheets of cells in an amyloid stroma. Patient likely has MEN 2A or 2B with the presence of medullary thyroid cancer and pheochromocytoma 62 year old man - pain in left hip for 3 weeks. An x-ray of the hip shows a 4.5cm, destructive, osteoblastic lesion with associsted fracture in the proximal femur and two separate smaller lesions in the bony pelvis. A needle core biopsy of the femur shows metastic carcinoma. Which is the most likley primary site of the cancer? ✅ - Prostate Osteoblastic lesions are associated with prostatic adenocarcinoma mets. Increased serum ALP OB = osteoblastic OC = osteoclastic/osteolytic P=prostate, B=breast, K=kidney, T=thyroid, L=lung P--B--K--T--L P = OB B = OB/OC K = OC T = OC L = OB/OC During a clinical study, investigator tests a new drug for treatment of breast cancer. A population of 10,000 patients with breast cancer is recruited and randomized into a treatment group and control group. Analysis shows a p-value of 0.1 with no significant difference in the treatment outcomes between the experimental and control. When repeating, which is most likely to decrease making a beta error? ✅ - Increase sample size You are aiming to increase power and you can do so by increasing sample size (reduce B error). "power in numbers 23-year-old man - 3-year history of schizophrenia. He has been taking an antipsychotic medication for hallucinations, paranoia, and disorganized thoughts. Pt does not make eye contact. Lab show serum sodium of 120 mEq/l, urine sodium of 8, and urine osm of 80. Which is most likely cause of lab finding? ✅ - Psychogenic Polydipsia hyponatremia + a low ADH = psychogenic polydipsia A 12 year old - girl - 3 months ago, she sustained a complex fracture of the left tibia, which required cast immobilization. The cast is removed. Examination of the left calf shows that it is smaller than the right calf. Which of processes in the patient's myocytes is most likely cause of findings? ✅ - polyubiquitnation atrophy is decrease in tissue mass due to decrease in size (increased cytoskeleton degradation via ubiquitin-proteasome pathway and autophagy A 45-year-old man - tooth abscess - He has not seen a physician or a dentist in over 10 years. He lives alone, unemployed. He has no friends, maintains minimal contact with relatives. No thought disorder. Which is most likely DX? ✅ - Schizoid personality disorder 60 y/o prolonged apnea - after general anesthesia. Plasma cholinesterase is abnormal. Which agent is most likely responsible for prolonged apnea? ✅ - succinylcholine Strong AcH Receptor Agonist cause respiratory depression duration of action of Succinylcholine is determined by its metabolism by plasma. cholinesterase. abnormal plasma cholinesterase (=pseudocholinesterase), it will lead to delayed metabolism complications = hypercalcemia, hyperkalemia, and malignant hypertension Two days after admission to hospital for drug induced thrombocytopenia, a 37 year old woman develops severe headache and becomes comatose. She has few petechia and low platelets. A CT scan of the head shows intracranial hemorrhage. A platelet transfusion is recommended, but the patient is a Jehovah's witness and stated she did not want a transfusion of any blood products. Husband wants her to have a transfusion. Most appropriate management? ✅ - Do not proceed with transfusion Autonomy = always, always follow the patient's wishes (in this case you are aware that the patient did not want a transfusion 13 y/o girl has episode of severe cellular rejection necessitating maximal immunosuppression 6 months after a cadaveric renal transplantation. Two weeks later, she develops lymphadenopathy and hepatosplenomegaly. Exam of lymph nodes shows monomorphous population of B lymphocytes. Which finding is most likely on evaluation of these cells? ✅ - Epstein Barr Virus Genome A new drug has the following effects on the activity of the primary arachidonic acid metabolites: neutrophils, Leukocyte chemotaxis - inhibition Platetlets - no effect Mast Cell - no effect Endothelium - no effect Which of the following is the most likely site of drug action (image shown)? ✅ - Leukotriene B4 Leukotriene B4 is a potent chemotactic molecule for neutrophils. Selective loss of this would have no effect on platelets, mast cells, or endothelium C5a, IL-8, LTB4 4 y/o has a a fever, abdominal cramping, and repeated bloody mucoid stools with tenesmus- Several other children in the daycare have a similar illness. Direct microscopic exam of methylene blue-stained fecal smear shows numerous neutrophils. Which is causal organism? ✅ - Shigella Sonnei A 3y/o boy is brought to physician because of 1 month history of pale skin. PE shows pallor. Lab studies show: Hemoglobin and hematocrit low. A photomicrograph of a peripheral blood smear is shown. Genetic testing is most likely to show which of the following? ✅ - Heterozygoues mutation of Ankyrin Gene Hereditary spherocytosis - defect in proteins interacting with RBC membrane skeleton and plasma membrane (ankyrin, band 3, protein 4.2, spectrin). Mostly autosomal dominant inheritance (so heterozygous mutation since you only need one mutant allele to get the disease). A 50-year-old woman - brought to ED by her husband - found her in semicomatose state with an empty bottle next to her. The bottle had contained a sodium salt drug with CNS effects. Alkalization of her urine will cause greatest absolute increase in elimination of the unmetabolized drug if it has which of the following pharmacokinetic profiles? ✅ - A 50-year-old woman - brought to ED by her husband - found her in semicomatose state with an empty bottle next to her. The bottle had contained a sodium salt drug with CNS effects. Alkalization of her urine will cause greatest absolute increase in elimination of the unmetabolized drug if it has which of the following pharmacokinetic profiles? ✅ - pKA 6.0 protein binding in plasma = 20% Volume Distribution = 1 L/kg drug to be cleared by the kidney, it must first be filtered in the glomeruli. Drugs with a high VD have more of the drug in tissue - not available to filtered by kidney Drugs with high protein binding won't be filtered either. We want a drug with low Vd and low binding if you want it cleared via the kidneys/urine pKa is pH at which any drug is at its 50% ionized stat if pKa of drug is 6---at pH 7 we will start eliminating .18 y/o women screening for colon cancer - Her father and grandfather died of colon cancer at ages of 36 and 45 years, respectively. PE shows no abnormalities. Colonoscopy shows approx. 200 lesions throughout the colon. Colectomy is done (Photograph) Which is the chance that the offspring will develop adenocarcinoma? ✅ - 50% inherited Familial adenomatous polyposis is an autosomal dominant mutation. Thousands of polyps arise starting after puberty; pancolonic; always involves rectum. Prophylactic colectomy or else 100% progress to CRC. Autosomal dominant diseases have, on average, 50% chance of being passed down to offspring. 23y/o excessive bleeding while brushing teeth - PE shows multiple ecchymoses. Intensive chemotherapy is planned. Before this treatment is initiated to decrease this patients risk for kidney failure, it is most appropriate to administer a drug that inhibits or binds to which of the following sites? ✅ - Xanthine Oxidase Allopurinol inhibits xanthine oxidase. It is used for chronic gout as well as prevention of tumor-lysis associated urate nephropathy A 17-year-old comes - swollen tender ankle. X-ray strongly suggestive of osteosarcoma. She and her parents are told only that "further evaluation is needed." Next Steps? ✅ - Speak to both girl and patient and family A 17-year-old comes - swollen tender ankle. X-ray strongly suggestive of osteosarcoma. She and her parents are told only that "further evaluation is needed." Next Steps? ✅ - Speak to patient and her parents about findings Sex Drugs or Psych - speak to patient alone A 25 year old woman - mass in right axilla. 1 week history of malaise, headaches, and night sweats. Pt adopted a kitten and has sustained several bite and scratch marks. Tenderness in right axiallry lymph node. The skin over the node is erythematous, tough, and warm. Bartonella Henselae antibody test is positive. A biopsy of this lymph node is most likely to show which histological pattern? ✅ - Granulomas containing stellate micro abscesses + Axillary mass catch scratch competent immune system - stellate necrotizing granulomas. A 35-year-old man - comes to physician to discuss donating kidney to his sister who has T1DM. Which describes likelihood that this donors HLA type will match his sister? ✅ - 1:4 You have a 25% chance of inheriting the same HLA markers as your siblings. Two siblings have a 25% chance of being genotypically HLA identical, a 50% chance of being HLA haploidentical (sharing one haplotype), and a 25% chance that they share no HLA haplotypes. A 50-year-old woman - restrictive pulmonary disorder with no obstructive component is most likely to have which of the following sets of pulmonary volumes? ✅ - FRC - Decreased Residual Volumes - Decreased Vital Capacity - Decreased restrictive lung disease- all lung values are DECREASED ("restricted") except for the FEV1/FVC ratio. FEV1/FVC ratio may be normal or increased 29 y/o - 1 week history of fever, muscle aches, sore throat, and non-productive cough. Rhonchi Heard on auscultation of chest. CXR shows bronchopneumonia of right lower lobe. Symptoms persist after 7 days of amoxicillin therapy. Cold Agglutinins positive. Which of the following features of the causal organism best explains the ineffectiveness of the pharmacotherapy? ✅ - Absence of peptidoglycan Mycobacterium - does not CELL WALL A 16 year old - 2 month history of wheezing and shortness of breath while participating in track meets. Diagnosed with exercised-induced asthma. Exposure to which is most likely to precipitate a similar episode in this patient in the future? ✅ - Cold, Dry Air exercise induced asthma. when exercising, breathing through the nose is decreased and replaced by more vigorous mouth breathing. This means the air is not humidified and warmed up. The air is less dense and the asthma ensues. A 43 y/o female -initial prenatal visit. PE shows uterus consistent in size with a 10-week gestation. This patient is at increased risk for a child with Down Syndrome if she has which of the following sets of ultrasound and serum findings? ✅ - Fetal Ultrasound Translucency - Increased Pregnancy Associated Plasma Protein- Decreased Human Chorionic Gonadotropin - Increased A male newborn - decreased blood thyroxine on newborn screening. PE shows no abnormalities. Serum T3 and T4 decreased - Serum free T4 and TSH within reference ranges. Which best explains findings? ✅ - Thyroid Hormone Binding Globulin deficiency Decreased total, normal free (unbound) = Thyroid hormone-binding globulin deficiency Thyroxine-binding globulin (TBG) deficiency is characterized by low serum total T4 but normal free T4 and TSH; the diagnosis is confirmed by measuring TBG concentrations A study conducted to assess the effect of a new screening test on the mortality of prostate cancer. Prior to implementation, the overall 5-year survival was 70%. After screening of random population, 5-year survival rate increases to 85%. No changes in treatment. The decrease in mortality could be due to which type of bias? ✅ - Lead Time caused by early detection being confused with increased survival. early detection makes it seem as though survival has increased, but the natural history of the disease has not been impacted. 50 y/o come to physician because of a 6-week history of depression, anxiety, difficulty sleeping, decreased appetite, and poor memory and concentration. He has an MI 3 months ago. He has one glass of wine each evening. Which of the following most likely decrease this patient's risk of mortality over the next 2 years? ✅ - Antidepressant Therapy 6-week history (e.g. >2 weeks) of depression (1), difficulty sleeping (2), fatigue (3), decreased appetite (4), and poor memory/concentration (5) At a postnatal checkup - 6-week female newborn weighs 20 ounces less than delivery. Vomits and regurgitates bile-tinged fluid after every feeding. Which of the following is the most likely cause of abnormalities? ✅ - Annular Pancreas bile in the vomit; abnormal rotation of ventral pancreatic bud forms a ring of pancreatic tissue encircles 2nd part of duodenum; may cause duodenal narrowing (arrows in) and vomiting An investigator compares the DNA sequence of a newborns with achondroplasia and healthy newborns. DNA sequence shows a G-C mutation in the FGF3 gene on chromone 4. Achnodroplasia 5'TACCGGGT-3' Healthy 5'TACGGGGT-3' As a result of this mutation an MspL restriction enzyme site is created that allows for a convenient diagnostic test. Which of the following sequences most likely represents the substrate specificity for Mspl? ✅ - 5'CCGG restriction enzymes bind palindromes. both 5'CCGG or 3'GGCC would have been acceptable in this scenario. 18 y/o F - never had a menstrual period. PE shows a 1 -cm invagination where vagina would normally be present. No uterus palpable. Lab show FSH, LH, estradiol, and testosterone in normal range. Which of the following structures is most likely normal? ✅ - Ovaries mullerian agenesis. Normal ovaries but absent uterus. Underdevelopment of the Mullerian system leading to congential absence of the vagina. Usually no cervix or uterus. 25 y/o man - severe Pain in low back radiates down his left leg- he started a weight-lifting - tried to lift a 200lb bar form ground over his head. Pain began immediately after this attempt. Cause of this patient's pain? ✅ - Rupture of an intervertebral disc radiculopathy - disc herniation (radiates to the leg aka lasegue sign), degenerative osteoarthritis (positional relieved with rest), spinal stenossi(pain with standing), spondylorpathy(relieved with exercise,dominant at rest), spinal metastasis (constant pain, worse at night, not relieved by positional changes vertebral osteomyelitis(focal tenderness, acute back pain, and fever), aortic dissection (severe restrosternal pain, radiating to the back) A 28-year-old man - excessive thirst and polyuria. Labs Baseline Serum Glucose 75, Serum Osm 310, Urine Osm 175 Water deprivation - no change in serum glucose, serum Osm, or urine OsM With ADH added - Urine OsM icnrease Which is the primary site of the pathophysiolohic process in this patient? ✅ - Hypothalmus Central DI= responds to vasopressin, high serum Na Nephrogenic = responds to nothing, normal serum Na 80 y/o - T2DM - 2 month history of severe constipation. Laxatives provide no relief. Distention of abdomen. Patient most likely has dysfunction of the following nerves? ✅ - pelvic splanchnic Parasympathetic- no rest and digest 80 y/o - T2DM - 2 month history of severe constipation. Laxatives provide no relief. Distention of abdomen. Patient most likely has dysfunction of the following nerves? ✅ - pelvic splanchnic a. Constipated - Parasympathetic- no rest and digest 25 y/o - F - 2 day history of fever, malaise, and a rash. Single painless lesion on labia which resolves spontaneously. Sexually active and does not use condoms. PE shows diffuse rash on palms and soles. A sensitive but non-specific rapid serologic test uses which reagents is most likely to support diagnosis? ✅ - A phospholipid (Cardiolipin) antibodies on charcoal particles Single painless lesion on labia Visualized by immunofluorescence or dark-field microscopy; serology is important - two types of antibodies: Cardiolipin sensitive but not specific for treponoma A 44-year-old woman - pap smear for atypical squamous cells. Protein is known to promote cell growth and malignancy by causing p53 protein degradation. This degradation begins when the p53 protein is targeted by which of the following types of cellular enzymes? ✅ - Ubiquitin Ligase starts degradation cycle p53 targeted degradation cycle A 28 year old woman - Eastern European Jewish Descent - lump in her left breast. Maternal grandmother was diagnosed with ovarian cancer, her maternal aunt was diagnosed with breast cancer at age 36. Pt concerned about genetic mutation. Genetic testing most likely to show a mutation in a component of which of the following pathways? ✅ - Recombinational Double Stranded DNA breaks Defective homologous recombination is seen in breast/ovarian cancers with the BRCA1 gene mutation. Graph (PICTURE) shows radiolabeled protein X that is bound by anti-X antibodies in the presence of varying concentrations of protein Y. With respect to anti-X. which of the following interpretations regarding the epitopes expressed by proteins X and Y is correct? ✅ - Proteins X and Y express the same epitopesIf they share the same epitopes, it will have a downward slope. If they share none of the same epitopes, the line will be horizontal across the graph A previously healthy 32 year old - 2 hours of severe epigastric pain, nausea, and vomiting blood. Pulse is 125/min, respirations are 18/min, and blood pressure is 85/45 mm Hg. PE shows cool skin and tender abdomen. A decrease in which hemodynamic parameters is most likely to cause patients hypotension? ✅ - Preload Vomiting blood and cool skin indicates this is a type of hypovolemic shock Decreased EDV means that the "filling volume" is decreased, which also means the preload will be decreased Which of the following changes in the cardiovascular system occurs with normal Aging? ✅ - Increased Basal Systolic blood pressure vascular scleorsis and stiffening- changes with aging- leads to high sys BP A 55-year-old - constipation since starting an OTC medication 2 weeks ago for chronic, persistent cough, and sinus congestion. Which ingredients in this medication cause symptoms? ✅ - Dextromethorphan antitussive - (antagonizes NMDA receptor) mild opioid effects when used in excess Mild abuse potential 19 y/o college student -sudden onset of right-sided chest pain and difficulty breathing after an accident in which he was thrown from his bicycle. He has difficulty walking and cannot climb stairs because of pain and shortness of breath. He is slightly cyanotic, afebrile, and tachypneic. Which of the following is most suggestive that fractured ribs caused the respiratory problem? ✅ - subcutaneous crepitus pneumothorax - inspiratory stridor When there is a fractured rib it will cause a trauma pneumothorax which can cause air to escape and become trapped under the skin leading to crepitus. Subcutaneous crepitus is very specific sound referencing air finding its way into the skin which you can hear but also feel by rubbing your hand over the affected area A physician prescribes newly marketed drug to 45 patients. Over the next several weeks, she notes good efficacy, but elevated enzymes in 5 patients. Physician unable to find any official data linking the new drug to liver dysfunction. Which is most appropriate action of physician? ✅ - Discontinue the new drug in people who have effects and report the cases 14 y/o girl - 1 month history of migraine-like headaches, vomiting, and multiple left sides seizures. She has hearing loss. Her mother and maternal grandmother have high tone deafness. Pt most likely has a mutation of which of the following? ✅ - Mitochondrial tRNALeu It's a mitochondrial disease. - present in successive generations, always with maternal transmission - damage to high-energy tissues - CSF lactic acidosis An 18-y/o boy - diagnosed with Schizophrenia - Identical Twin brother is unaffected. Parents are concerned that twin will have the disorder. Which represents brother's risk for developing schizophrenia? ✅ - 50% psychosis of about 50% in monozygotic twins seems to be a realistic estimate, which is significantly higher than that in dizygotic twins of about 10-19% 32 y/o fecal incontinence after pregnancy - what was damaged? ✅ - Damage to anal sphincter A stretch injury during childbirth will result in damage to the external ureteral and anal sphincters and damage to the pudendal nerve (S2-S4). This can lead to decreased sensation in the perineal and genital area and fecal or urinary incontinence 78 y/o - 3 week history of severe weakness and fatigue. 16lb weight Loss - Daughter usually bring groceries twice per week. Daughter on vacation. He is only eating crackers and black coffee. PE shows generalized muscle weakness. Serum studies most likely to show an increased concentration of which hormones? ✅ - Cortisol b. cortisol's functions is to increase gluconeogenesis, lipolysis, and proteolysis. c. helps maintain blood pressure even in the setting where he is malnourished. 66 y/o old man - comes to ED after MVC. Pronounced dead on arrival. Photomicrograph of a section of distal left ureter taken at autopsy are shown. Which of the following was the most likely predisposing factor in the development of the ureteral lesions in this patient? ✅ - Cigarette Smoking transitional cell carcinoma, which smoking is a common risk factor for; it can involve the renal pelvis/calyces. histo image shows the papillary nature of the tumor A 36 y/o woman - 1-month history of joint pain, frequent headaches, and fatigue. PE shows edema of the upper and lower extremities. An abdominal CT scan is shown. Which findings most likely seen in this patient? ✅ - Splenomegaly 56 y/o -frequently burned herself while cooking over the past months. Exam shows loss of pain and temperature sensation in both upper extremities. Touch, vibration, and proprioception are normal. Some wasting of her hands. Which of the following findings on MRI of the head and spine? ✅ - Syrinx of the central region of the spine C4 - T5 70 y/o man - 3-month history of weakness and a 22lb weight loss. 2 pack of cigarettes daily for 50 years. An x-ray shows a 4-cm lesion in right upper lobe. Serum calcium concentration is 13.5 mg/dl. A malignant lesion arising in a segmental bronchus is seen during lobectomy. DX? ✅ - squamous cell carcinoma ARISE FROM BRONCHUS , Cavitation, Cigarattes, HyperCalcemia (produce PTHrp) 23 y/o woman - fever, hypotension, and DIC for 24 hours. She splenectomy following trauma. Which bacteria is cause of sepsis? ✅ - Streptococcus pneumonia Encapsulated organisms run rampant in patients who have no spleen, whether physically or functionally. (Recall the wide-array of sequalae sickle cell patients experience thanks to their functional autosplenectomy.) Female Newborn - Respiratory Distress, Cyanosis, Nasogastric tube placed - what embryologic events cause issue? ✅ - incomplete formation of Pleuroperitoneal membrane Diaphragmatic hernia A 70-year-old - woman - transferred to rehab service 2 days after operative repair of a fracture of femur. She weighs 6Kg (143 lb). PE exam in unremarkable. Most important predictor of success in rehab ✅ - Activity level before the fracture Activity level increase in Bone density(Specially Weigh bearing) and OsteoBlastic activity 27 y/o woman - 3-month history of intermittent headaches, palpitations. Blood pressure 125/80 in a chair. When asked to sit on the exam table, she has flushing, and her blood pressure is 185/115. PE shows no abnormalities. Most likely diagnosis? ✅ - Pheochromocytoma When standing up, the body normally activates sympathetic system to avoid orthostatic hypotension. But since there is now an additive effect of the pheochromocytoma adrenergics, it will lead to a hypertension Pt with 1-week history of diarrhea has reduced tissue turgor. Arterial pH 7.3. Serum bicard is 15 mEq/L. Pt is most likely to have which of the following? ✅ - Decreased arterial PC02 chronic diarrhea leading to normal anion gap metabolic acidosis pH = HCO3/CO2 12 y/o girl - dentist found many unerupted and supernumerary teeth. PE shows frontal bossing, hytpertelorism, and retained deciduous teeth. Decreased ALK phos. A CXR shows hypoplasia of clavicles. Skull X-rays show open sutures and Wormian bones. Mutation of CBFA1 gene. Which cell types is affected by the mutation? ✅ - Osteoblast ALP is decreased. Osteoblast activity is measured by bone ALP A 57-year-old man - hemoglobin concentration of 18.5 g/dl. A peripheral blood smear shown. Findings most consistent with which disorder? ✅ - Chronic Obstructive Pulmonary Disease Absolute polycythemia vera, which is due to high altitude or lung disease. 38 y/o African American - recently diagnosed with hypertension - patient aggreed to initiate a regime including physical activity, low sodium diet, and pharmacotherapy. PE shows no abnormalities. What is the role of ethnicity when selecting appropriate medication? ✅ - It should play a role because the efficacy of certain classes of medications varies among different ethnicities A new antiplatelet agent for prevention in stroke. In a large randomized trial, the rate of stroke are lower in patients receiving the new agent than in patients receiving standard treatment. Results Stroke New Platelet Drug Women =. .12 .04 Based on results which of the following is the absolute risk reduction in women? ✅ - 8% Absolute risk: the difference in risk (not the proportion) attributable to the intervention as compared to a control. (.12) - (.04) = .08 ARR = 8% 65 y/o man - substernal chest pain, nausea, sweating for 1 hour. 10-year history of T2DM. Pulse is 120/min. BP 98/60. PE shows a JVD of 12cm. Crackles are heard halfway up lungs fields. ECG findings? ✅ - ST elevation Continued or severe ischemia (>20 minutes) leads to transmural necrosis involving most of the myocardial wall (transmural infarction); EKG shows ST-segment elevation. ST will first decrease; however, after 20 min it will increase (elevate) 30 y/o comes to physician - 3-month history of pain in his jaw and left arm. Intense thirst and urination. Found to have peptic ulcer for 2 month. Serum calcium 13.5. PTH 110 (N= 10-65). X-ray normal. Which explains impaired calcium homeostasis? ✅ - Increased Osteoclast and Maturation and activity hypercalcemia (stones, bones, groans, THRONES [increased diuresis}, and psychiatric overtones). Following a wedding reception - 25 adults develop low grade fever, abdominal cramping, vomiting, and diarrhea. No blood in stool, No pathogens on stool culture. Several family members exhibit similar symptoms 3 days after initial outbreak. Causal organisms? ✅ - Norovirus Legionella Pneumophilia ✅ - gram negative rods use silver stain. Grow on charcoal yeast extract medium with iron and cysteine. Aerosol transmission Noperson-to-person transmission 31 y/o man - large, yellow, soft mass deeply infiltrating the gluteus maximus muscle. Microscopic exam shows irregular vacuolated cells and clear cells with frequent mitoses. DX? ✅ - Liposarcoma malignant, increased mitotic activity most common soft-tissue tumors in adult high mitotic index & infiltrative nature indicate that the mass is malignant An otherwise healthy 4-month-old girl is brought to physician because of lesion shown (strawberry hemangioma). The lesion has been present for 2 months and growing rapidly. Which is expected over the next 5 years? ✅ - spontaneously involution strawberry hemangiomas tend to grow and then randomly involute. appears early in life, grows rapidly and regresses spontaneously by 5-8 years old A 2-year old boy - increased thirst, urinary frequency, and failure to thrive. He is 5th % for height and 7% for weight. PE shows dehydration and decreased muscle tone. The diagnosis [Show More]

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