#10

Question 1

43 yo man bad cold last about 10 days

• Burst of coughing unable to clear mucur
• He is a karate teacher

Cause of symptoms?

Answer 1

Pertussis whooping cough

- Gram-negative coccobacillus

Question 2

48 yo wo, involuntary passage of urine when sneezing or coughing
- 4 uncomplicated vaginal deliveries

Cause of condition?

Answer 2

Urethral sphincter dysfunction
- Pudendal nerve damage
Stress incontinence with increased intraabdominal pressure due to prior vaginal deliveries

Question 3

23 yo wo recent onset diplopia and ataxia

• Areas of T2 hypersensivity consistent with axonal demyelination
• Multiple sclerosis is diagnosed
• Neuronal properties most likely to decrease as a result of demyelination?

Answer 3

Length (space ) constant

Question 4

6 week old term

• Wet diapers
• anterior fontanelle is flat and mucous membrane are dry
• Na 148 / ADH increased

Appropriate treatment ?

Answer 4

Hydrochlorothiazide

• Nephrogenic diabetes insipidus
• Thiazides reduces renal water losses by increasing water and Na reabsorption

Question 5

13 yo boy acute appendicitis

• Burning pain at scar radiating to suprapubic region
• Loss of sensation over right suprapubic area

Cremasterix reflex is normal

Nerve most likely injured?

Answer 5

Iliohypogastric

Question 6

28 yo man pruritic papule on dorsal of right foot prior to returning from florida beach 2 days ago
- Rash looks like worm

Cause of condition?

Answer 6

Hookworm infection
- Necator americanus penetrate basement membrane and spread to bloodstream

• Vibrio vulnificus would cause necrotizing fasciitis

Question 7

54 yo wo progressive pain and prolonged morning stiffness
- naproxen didn’t help with pain
- MCV of 86
Patient is prescribed methotrexate

What changes were present before start of methotrexate?

• Circulating Iron level
• Bone marrow iron

Answer 7

Circulating iron level low
Bone marrow iron High
- anemia of chronic disease mediated by hepcidin

Question 8

46 yo wo episodes of dehydration due to ileostomy

• reports right flank pain
• Bowel gas pattern with no evidence of renal calculi
• Stone in ureter, pure uric acid stone

Mechanism underlying stone formation?

Answer 8

Concentrated acidic urine

- Dehydration, kidneys compensate by excretion of hydrogen ions which lowers urine pH

Question 9

35 yo man coffee-ground emesis and lightheadedness

• Asthma, hepatitis C and HIV
• CD4 was 550
• Started on NAPROXEN for back pain
• Allergy to penicillin that causes a rash and pruritus
• Gastric mucosal erythema and erosions

What explains patient’s symptoms?

Answer 9

Predictable drug reaction

- NSAIDS inhibit COX which inhibits GI mucosal protection

Question 10

36 yo man undergoes emergency cricothyrotomy

Procedure passes through which structures?

Answer 10

Superfical cervical fascia and cricothyroid membrane

Question 11

17 yo girl yellow eyes

• Prepating for high school exit examination and has felt stressed
• 2 weeks after examination symptoms resolve

What contributed to hyperbilirubinemia ?

• Hepatocyte bilirubin storage
• Hepatocyte bilirubin excretion
• Bilirubin conjugation

Answer 11

• Hepatocyte bilirubin storage normal
• Hepatocyte bilirubin excretion normal
• Bilirubin conjugation decreased

Patient has gilbert syndrome

Question 12

48 yo wo metastatic cervical cancer
- Bilateral hydronephrosis and renal failure due to ureteral compression by the tumor
- Pain controlled by morphine
- Respiration are 10/min
Patient shows respiratory acidosis 

What medication-related events precipitated her condition?

Answer 12

Increased metabolite accumulation

Question 13

27 yo man hardly slept for past 7 days

• Spent thousand of dollars on new power tools
• He feels spectacular , but had 2 previous episodes of depressive moods.

Long term management of this patient should be?

Answer 13

Valproate

- Bipolar disorder

Question 14

Study on manifestations of covid
- 11 patients with COVID-19 are recruited and their CT are studied

What best describes this study?

Answer 14

Case series

Question 15

60 yo man

• 35 pack year history of smoking
• Dullness to percussion at lung base
• Multiple pockets within pleural space
• Small amount of thick pus

Intrapleural administration of a medication would improve chest tube drainage how?

Answer 15

Activation of fibrin bound plasminogen
- Empyema ‘’ pus accumulation’’ and organized fibrosis

Fibrinolytic agent can improve drainage

Question 16

43 yo south asia man recent onset hemoptysis

• 15 pounds weight loss
• Culture shows acid-fast bacilli

Isoniazid mono therapy in this patient would result in?

Answer 16

Selective survival of bacterial cells secondary to gene mutation

Question 17

Chromatin fibers with a beads on a string appearance
- DNA wrapped around a core of proteins

Which proteins is found outside this core and helps promote chromatin compaction?

Answer 17

Histone H1

Question 18

42 yo man headache, nausea, vomiting

• Primary essential hypertension
• BP 240/150
• Bilateral papilledema / S4
• Platelets and hematocrit have decreased
• Numerous schistocytes

Pathological finding found on renal biopsy?

Answer 18

Fibrinoid necrosis of small arteriolar walls

- Hypertensive emergency MAHA

Question 19

42 yo man syncopal episode

• Computer programmer spends time indoors
• Liver span is increased
• Skin is darkly tanned
• Abnormal diastolic relaxation of left ventricle

Cause of condition?

Answer 19

Iron accumulation

Question 20

32 yo wo

• 4 abortions
• Exhibit shows bicornuate uterus

Failure of which Mechanism cause condition?

Answer 20

Incomplete Lateral fusion of paramesonephric duct

• Whereas complete lack of lateral fusion lead to uterine didelphys

Question 21

33 yo primigravida

• maternal alpha-fetoprotein is reduced
• Increased nuchal translucency
• Villous sampling shows 47 XX + 21

Fetus at risk of developing ?

Answer 21

Duodenal atresia

- Down syndrome

Question 22

25 yo recurrent ear infections

• Feel anxious in examination room
• Heart start to race when she sees her roommate stethoscope

Phenomena?

Answer 22

Classical conditioning

Question 23

19 yo hispanic woman
abdominal pain
- When asked about sex life she says no
- Diagnosis of rupture ectopic pregnancy is made

Intervention most likely have prevented delay in diagnosis?

Answer 23

Determining whether the patient needs language assistance

Question 24

8 yo boy mass in right mandible

• Immigrate from East africa
• Diffuse lymphoid cells with numerous mitotic figures

Chromosomal translocation that directly alters which process?

Answer 24

Transcription activation
- Burkitt lymphoma
Epstaein barr virus

Question 25

Pulmonary tissue regeneration capacity derived from which cells?

Answer 25

type II pneumocytes

Question 26

44 yo man - Renal transplant - 1 week later, low fever, body aches, decreased urine output - Graft biopsy demonstrate interstitial infiltration by mononuclear cells Cause of condition ?

Answer 26

Host T cell sensitization against graft MHC antigens | - Acute rejection

Question 27

35 yo woman - Weight loss abdominal pain - Pigmentation around areola and anal and vaginal mucous membranes Findings on autopsy?

Answer 27

Atrophy of both adrenal glands | - Chronic adrenal insufficiency '' acute adrenal crisis''

Question 28

4 day old boy progressive jaundice - Scleral icterus and jaundice Total bilirubin 8 Indirect bilirubin 7.2 Changes in bilirubin metabolism compared to an adult? - Bilirubin production - Bilirubin conjugation - Enterohepatic bilirubin circulation

Answer 28

Bilirubin production increase Bilirubin conjugation decreased Enterohepatic bilirubin circulation increased

Question 29

32 yo wo Father apical baldness beginning at 20 - Maternal side no sign of baldness - She start having thinning of hair at temporal areas Inheritance pattern of hair loss?

Answer 29

Polygenic

Question 30

25 yo leg is fixed in a cast - 2 weeks later he has right upper extremity weakness and numbness - Absent triceps reflex Nerve injured?

Answer 30

Radial nerve

Question 31

2 yo boy rash on cheeks, trunk and arms - Vax up to date - He attends day care facility - Rash shows atopic dermatitis Patient at increase risk for?

Answer 31

Asthma - Immune hypersensitivity allergic rhinitis

Question 32

60 yo man - Brain injury in motor vehicle collision - Difficulty tasting food Cause of patient's symptoms?

Answer 32

Avulsion of olfactory nerve rootlets

Question 33

14 yo girl - Sickle cell disease takes folic acid supplement - Dyspnea and weakness preceded by a illness a few days ago - Reticulocyte is 0.1, hematocrit 16% Virus responsible for current condition?

Answer 33

Parvo virus - Nonenveloped single stranded DNA virus Aplastic crisis

Question 34

34 yo woman reveals cardiomegaly and pulmonary congestion - Presence of arteriovenous fistula Changes due to fistula? - CO - SVR - Venous return

Answer 34

CO increased SVR decreased Venous return increased

Question 35

34 yo epigastric pain worse at night - Move from china 4 years ago - 1cm ulcer in duodenum In addition to PPI's what therapy would prevent recurrence of ulcer?

Answer 35

Antibiotics H. Pylori infection

Question 36

Pop 1000 - Prevalence asthma is 10% Sensitivity 95% Specificity 90% Likelihood that child with positive result really has asthma?

Answer 36

95/ ( 95+180)

Question 37

9 yo girl - Mild intermittent headaches - CT brain reveals mass lesion - Enlarged lateral and 3rd ventricles, normal 4th Site of obstruction?

Answer 37

Cerebral aqueduct

Question 38

66 yo man lightheadedness - Medications for hypertension, angina pectoris, gout, BPH - Takes NSAIDS occasion - BP 120/80 pulse 70 in supine - BP 90/60 pulse 87 standing Blockage of what receptors is causing current condition?

Answer 38

Orthostatic postural hypotension | - caused by blocking of A1 adrenergic

Question 39

45 yo man fever, headache, chest pain - Segmental pulmonary infiltrates - Empiric antibacterial therapy - Lung tissue shows spherules packed with endospores History would reveal?

Answer 39

Travel to arizona | - Coccidioides

Question 40

38 yo man fevers, chills cough and shortness of breath - Temperature 39.4 - Dullness to percussion and crackles over right lung - Th1 cells, interferon gamma and interleukin 2 Pathogen responsible for pneumonia?

Answer 40

Legionella pneumophila | - Other types are Mycobacteria tuberculosis or listeria monocytogenes

Question 41

3 yo boy left ear pain - Runny nose and cough - Normal external canal - Erythematous tympanic membrane with purulent fluid pooling within distal external canal Cause?

Answer 41

Strep pneumo cause of otitis media - Other agents are H. Influenza and mortadella catarrhalis

Question 42

7 yo boy became inattentive, restless - Thyroid is Diffusely enlarged to palpation without tenderness -TSH 7/ Thyroxine 16 Triiodothyronine 210 Etiology of thyroid function?

Answer 42

Resistance to thyroid hormone | - All the levels are increased

Question 43

60 yo man nagging cough - occasional dizziness - He doesn't make sense - Na 120 / K 4 / Ca 9.0 Mass in right lung Additional finding?

Answer 43

apparent euvolemia | - SIADH, small cell lung carcinoma

Question 44

21 yo thirsty and drinking lots of water lately Study would be best next step to establish diagnosis?

Answer 44

Hemoglobin A1c Type 1 DM - Or fasting plasma glucose

Question 45

50 yo wo, severe upper abdominal pain - Sudden sharp and colicky pain - Cessation of inspiration with deep palpation of right upper quadrant Diagnosis most specific for acute cholecystitis?

Answer 45

Failed gallbladder visualization on radionuclide biliary scan - acute cholecystitis, gallstone obstruction of cystic duct

Question 46

62 yo - Hypertension 10y ago - Currently takes ramipril and chlorthalidone - BP 160/92 - PR is prolonged and sinus bradycardia which medication would lower BP without worsening ECG ?

Answer 46

Nifedipine | - Calcium channel blockers affect arterial smooth muscle

Question 47

41 yo wo for 5 years has eaten only vegetables, fruits and grains ``` Increased risk for deficiency of? Folic acid Iron Thiamine Vitamin B12 ```

Answer 47

Folic acid No Iron yes Thiamine No Vitamine B12 yes

Question 48

66 yo wo shortness of breath - Normal oropharynx - flat neck veins, midline trachea - Arterial pressure of O2 is normal at rest but fall with exercise Which exercise related changes contributes to latter observation?

Answer 48

Increased pulmonary blood flow

Question 49

Estimate association between pesticide and head neck carcinomas - Controls were matched to cases by age and gender - Exposure was determined by interviewing subjects - Which of following will affect validity of study?

Answer 49

Misclassification bias | - questionnaires or interviews prone to this

Question 50

34 yo treatment for chemotherapy - Severe vomiting - Site of brain responsible for symptoms?

Answer 50

Area postrema

Question 51

80 yo man dry mouth, difficulty chewing - Decreased saliva production but no tenderness or swelling of salivary glands - Extensive caries are present Age-related changes?

Answer 51

Acinar atrophy and fatty infiltration of salivary glands

Question 52

25 yo wo, jitteriness and mood swings - She may be having a heart attack - Warm moist skin and fine tremor Which drug would provide fastest relief?

Answer 52

Propranolol | - Thyrotoxicosis beta blockers alleviate adrenergic symptoms

Question 53

64 yo man acute knee pain - Redness, swelling, severe pain - History of polycythemai vera, non-compliant with phlebotomy Finding of synovial fluid?

Answer 53

Needle-shaped, negatively birefringent crystals | - Patient has gout '' increased uric acid''

Question 54

35 yo motor vehicle collision - lacerations on extremities and rib contusion - Treated with morphine and NSAIDS - Patient worried about developing dependance Appropriate action by physician?

Answer 54

Prescribe a brief course of opioids to reused only for breakthrough pain

Question 55

80 yo man - Weight loss - Mass in right lung I prefer not to be told anything, you can discus everything with my son. I trust his judgement Response by physician?

Answer 55

I understand that you would not like to be told the results of the biopsy. I will share them with your son.

Question 56

26 yo man fevers, chills, vomiting, diarrhea - Epistaxis after a bar fight - Diffuse erythematous rash, anterior nasal packing in the left nostril Essential in pathogenesis of the condition?

Answer 56

Binding of T-cell receptors by bacterial secretory products - Staphylococcal toxic shock syndrome Pyrogenic toxin superantigens TSST-1

Question 57

36 yo wo, dyspnea and weakness that are brought - Medial hypertrophy, intimal fibrosis, decreased intraluminal diameter of small branches of pulmonary artery Appropriate pharmacotherapy?

Answer 57

Bosentan | - Pulmonary hypertension

Question 58

5 month old boy - Unable to roll front to back or back to front does not seem to recognized his parents - Impaired tetrahydrobiopterin synthesis Likely Deficiency of?

Answer 58

Serotonin

Question 59

67 yo man - MI a year ago - White scarring and enlargement of left ventricle Type of collagen seen , is also present where?

Answer 59

Tendon type I collagen present in wound healing | - Tendon, skin, ligament

Question 60

65 yo man from eastern europe - Erythematous rash on his face and trunk - Positive for ANA antibodies - Coronary artery disease Congestive heart failure and cardiac rhythm abnormalities Patient should be question about taking which drug?

Answer 60

Procainamide