Professional Documents
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com
NBME 18
Annotated with (hopefully) correct answers
- Correct answers are in written in on questions with a large, red ”No” symbol
- Cmd+F or Cntrl+F age of pt or keywords to find the question you’re looking for
- Two questions are missing from the screenshots I was given
- All First Aid references/pictures are from FA2016
- Dipalmitoylphosphatidylcholine
Male newborn delivered at 28 weeks, neonatal respiratory distress syndrome, ABG shows decreased pH, decreased Po2 increased PCO2. A deficiency in which of the following most likely caused the disorder?
- Dipalmitoylphosphatidylcholine
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12-year-old boy with mother concerned about enlarged left breast and family history of breast cancer. Left breast is slightly larger than right, nipple mildly tender. Penis slightly enlarged and pubic hair curling and beginning to darken at
base. Best next step?
- Reassure the mother that physical findings are not uncommon for his age
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- Plasmid loss
Vancomycin-resistant Entercoccus. VRE is a
bacterial strain of Enterococcus that has acquired
resistance to the antibiotic vancomycin through
the uptake of a plasmid that has the resistance.
VRE can be resistant to not just vancomycin, it
can be resistant to other antibiotics commonly
used for Enterococcus infections such as
aminoglycosides, and ampicillin
Investigator studying vancomycin-resistant strain of Enterococcus faecalis. Ten generations created. Culture inoculated and resulting bacterial colonies are screened for vancomycin
resistance. Vancomycin-sensitive colonies observed at frequency of one per 100 cells. Mechanism of decreased vancomycin resistance?
- Plasmid loss
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35-year-old man with severe back pain, gained 8 kg in the past 6 months, decreased peripheral vision, compression fracture spine at T10 and L1, healing left rib fracture at T6, imaging shows pituitary macroadenoma. This tumor
produces which?
- ACTH
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A 25-year-old man is admitted to the hospital because of severe crush injuries to the chest and extensive burns over 30% of his body surface area. Three hours later, he develops tachypnea and dyspnea. Arterial blood gas analysis on
room air shows a decreased Po2 and Pco2. A chest x-ray shows bilateral interstitial and alveolar infiltrates. The patient is intubated and mechanically ventilated. Damage to which of the following is most likely to preclude restoration of
normal tissue architecture and pulmonary function in this patient?
- Basement membranes
66-year-old woman is brought to the emergency department by her daughter because of a 2-day history of fever, flank pain, pain with urination, and nausea. Ten days ago, she was admitted to the hospital for similar symptoms and
was diagnosed with acute pyelonephritis. She was discharged with instructions to take oral ciprofloxacin after a 3-day course of intravenous ciprofloxacin resulted in improvement. She also has hypertension, hyperlipidemia, and
osteoporosis. Current medications also include alendronate, calcium carbonate, ezetimibe, hydrochlorothiazide, and simvastatin. Her temperature is 39.1°C (102.4°F), and blood pressure is130/80 mm Hg. The most likely cause of this
patient’s current condition is an interaction between her current oral antibiotic and which of the following medications?
- Calcium carbonate
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- Calcium carbonate
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48-year-old recently diagnosed with lupus and difficulty working as schoolteacher because of severe pain and swelling of joints. Current meds include
prednisone, hydroxychloroquine, and oxycodone for pain. Best action to adapt to illness?
- Encourage the patient to participate in a support group for persons with her condition
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19-year-old man with gastrointestinal bleeding. Laparotomy done and 5-cm blind outpouching on antimesenteric side of terminal ileum 15 cm from ileocecal
valve resected. Pathology shows?
- Heterotopic gastric mucosa
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- decreased/decreased/increased
Full-term newborn in respiratory distress. Imaging shows abdominal contents in left pleural cavity. Maldevelopment of which structure led to diaphragm
defect?
- Left pleuroperitoneal membrane
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15-year-old girl comes with lack of improvement of facial acne. Tried topical clindamycin and benzoyl peroxide PE severe acne vulgaris. Says, "Please help
me." She has never been sexually active. Tx?
- Isotretinoin
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20-year-old woman with 2-week fever, shaking chills, headaches, fatigue, and joint and muscle pain. Spent summer workin as lifeguard in Long Island, New
York. Has splenectomy for motor vehicle collision 6 years ago. T 102.4 F. Peripheral blood smear shows small intraerythrocytic rings. Polymerase chain
reaction for Plasmodium is negative. Causal organism from bite of?
- Tick Medbook4u.com
16-year-old girl calls the physician on a Friday night 2 hours after a condom broke during sexual intercourse with her boyfriend. She asks the physician to
prescribe an emergency oral contraceptive. The physician on call is not the patient's regular physician and does not dispense emergency contraception for
moral reasons. After the physician respectfully informs the patient that he does not prescribe this contraceptive, it is most appropriate for the physician to
state which of the following?
- "I can have one of my colleagues call you back to further discuss your concerns." Medbook4u.com
35-year-old woman with fever and sharp chest pain for 3 days. T 101.3F. Friction rub heard. All cuases of secondary pericarditis ruled out. Cause of primary
pericarditis?
- Virus
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Virus
“Primary” acute pericardial disease (acute pericarditis or tamponade presenting without an apparent cause)
In a 25-year-old patient who underwent splenectomy, target cells are seen on peripheral smear. These cells are seen due to loss of function of which portion
of spleen?
- Red pulp
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- Red pulp
64-year-old with non-Hodgkin lymphoma and 3-day history of abdominal pain and nausea. T 99.7F, HR 100, bp 130/80. Abdominal exam tenderness of
flanks and lower quadrants. BUN 34 and creatinine 3.8. CT shows bilateral hydronephrosis and lymphadenopathy compressing ureters. Tx to improve renal
function?
- Bilateral stents in the ureters
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http://www.score95.com/blog/blog/usmle-obstruction-of-the-urinary-tract/
40-year-old man with orthostatic hypotension, loose stools for 1 year, and history of type 1 DM. Stool studies are normal. What is the pathophysiological
mechanism of the diarrhea?
- Motility disorder
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- Motility disorder
2-month-old female with T 102F, vomiting, diarrhea, dehydration. Exam of stool shows viral particles with wheel-like shape. Properties of virus?
Type of nucleic acid/envelop/capsid symmetry
- Double-stranded RNA, segmented/no/icosahedral
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- Double-stranded RNA,
segmented/no/icosahedral
17-year-old boy whose mother concerned about physical development. 10th percentile for height and 25th for weight. FSH is 5, testosterone 8 (N=10-35).
Physical finding on patient?
- Gynecomastia
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50-year-old man undergoes operative repair of inguinal hernia. Surgeon has received written informed consent from patient. After epidural received,
patient decides he does not want to have surgery. Best response?
- "Tell me about your concerns and why you want to cancel the operation."
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62-year-old with angina pectoris is referred for cardiac catheterization. Patient worried about hospital-associated infection. Studies show 30% of patients
require admission after procedure, and 2 percent of admitted patients acquire hospital infection. Patient's risk for infection overall?
- 6/1000
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.3 * .02 = 6/1000
Studying epithelial repair of small intestine in experimental animal. Wants to identify most active cell division location. Where is this cell activity found?
- Base of the crypt
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- Delirium
35-year-old woman passed out while washing dishes. Began to feel weak and dizzy, husband shares with nursing staff history of bulimia nervosa, and has
been binging more frequently. Suspected she has been vomiting. Labs of patient?
K+/HCO3-/Anion Gap/pH
- decreased/increased/normal/increased
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65-year-old woman comes to the physician because of a 1-week history of a swollen, painful left knee. Her temperature is 38°C (100.4°F), and blood
pressure is 110/65 mm Hg. Examination of the left knee shows erythema and swelling of the joint and decreased range of motion. A photomicrograph of
synovial fluid obtained by arthrocentesis is shown. This patient's synovial fluid most likely contains which of the following?
- Uric acid
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Researching new cancer drug, effective at killing rapidly dividing cells, in mice caused profound myelosuppression. In patients, most appropriate to follow
which when at risk for infectious complications?
- Neutrophil counts
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- Neutrophil counts
C. Neutrophil counts
- 7.22/28/11
Consequence of renal failure = Metabolic acidosis so Bicarb will be <20 and PCO2 will be decreased too due to hyperventilation.
4-year-old male with recurrent UTIs, left kidney found small and non functional; right is normal. Nephrectomy is done, and the picture shown (dilated ureter
and renal calyx). Microscopic exam of kidney will show which?
- Tubular atrophy
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- Tubular atrophy
Tubular atrophy
(hint: dilated ureter/calyx in
image)
↓
Posterior urethral valves is the
#1 cause of bladder obstruction
in males
Diagnosed
by hydronephrosis and thick-
walled bladder
A previously healthy 20-year-old woman has had palpable lump in right breast 4 months. No pain, swelling, nipple discharge. Lump = smooth, firm, round, mobile, nontender, and well delineated from underlying tissue. No changes in skin around lesion.
- Fibroadenoma
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To decrease risk for cv disease 24 yo man begins diet. 1.53 95 kg BMI 32, Intends to lose 16 kg by limiting caloric intake to 2000 cal. to maintain the
recommended protein intake (56g day); a balanced decreased in carbs and fat is required (caloric radio of fat and carbs is 30:55). which best describes
number of calories that should be provided by fat in this its diet each day?
- 630
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- 630
65-year-old man with 4-hour history of intermittent severe pain in flank area radiating to genital region. History of hypercalciuria and renal calculi. Drug
decrease the urinary excretion of calcium?
- Hydrochlorothiazide
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- Hydrochlorothiazide
48-year-old man 2-month increasing abdominal girth and inability to achieve erection. Smoked 1 pack cigarettes for 20 years and drug 1 pint of liquor daily.
Vitals normal. PE shows scleral icterus, spider angiomata, gynecomastia, ascites and prominent umbilical venous pattern. Tests small. Cause of
gynecomastia?
- Failure of liver to degrade estrogen
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Pseudocholinesterase deficiency is a condition in which a person's body is abnormally slow at breaking down a certain
class of drugs used for surgical anesthesia. Known as choline esters, the most commonly used of these drugs is called
succinylcholine (suxamethonium).
Different from malignant hyperthermia where person presents w/ fever and muscle contractions and its due to mutation
in voltage sensitive ryanodine receptor causing an increase in Ca release from sarcoplasmic reticulum
67-year-old man who eight months ago dx with primary lung carcinoma involving adrenal glands, liver, and bone. Had 17.6-lb weight loss during 3 months.
PE shows cachexia and significant muscle wasting. Intracellular components increased in patient's muscle cells?
- Autophagic vacuoles
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83-year-old with arteriosclerosis undergoes repair of infrarenal abdominal aortic aneurysm. Graft extends just below the renal arteries to the bifurcation of
the aorta. Which organ will lose primary blood supply and rely on collateral circulation?
- Descending colon
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IMA supplies (Hindgut) Distal 1/3 of transverse colon to upper portion of the rectum.
25-year-old woman with fatigue for 3 wks and intermittent fever for 7 days, had teeth cleaned a month ago, no abx for prophylaxis, and had rheumatic
fever as child and endocarditis 4 y ago. PE shows 2/6 murmur, ultrasound shows abnormal mitral valve. Photo of growth from blood cultures shown (GP
cocci in chains). Characteristic of causal organism?
- Greening reaction on blood agar Medbook4u.com
In our patient, ACTH is undetectable so therefore it is likely an ACTH independent Cushing’s syndrome (meaning it doesn’t involve the anterior pituitary)
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58-year-old man comes to the physician because of a 4-year history of recurrent cough productive of increased sputum. Use of over-the-counter cough
suppressants has not resolved his symptoms. He has smoked 2 packs of cigarettes daily for 35 years. He has no family history of lung disease. His
temperature is 37°C (98.6°F), pulse is 72/min, and respirations are 18/min. Physical examination shows cyanosis. Diffuse wheezing is heard on auscultation.
Which of the following pulmonary cell types is most likely to be abnormal in this patient?
- Pseudostratified columnar epithelial cells Medbook4u.com
17-year-old boy with syncopal episode, fever, nausea, muscle aches, progressive confusion. T 103.5F, palpable bp 80. PE rash on lower extremities. WBC
26,000. Blood and CSF cultures grow oxidase positive, gram negative diplococcus. Brother with similar infection at same age. Immune disorder?
- Late component of complement deficiency
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56-year-old exposed to possible chemical attack. Respirations labored, diaphoresis, excessive lacrimation, increased salivation, muscle strength 2/5, urinary
and fecal incontinence. Besides atropine, another tx?
- Pralidoxime
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- Pralidoxime
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Section 2
44-year-old woman 15 weeks' gestation with uterus consistent size with gestational age. Amniocentesis shows increased alpha-fetoprotein (AFP). Fetus at
greatest risk for which defect?
- Spina bifida
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33-year-old woman who three weeks ago, underwent oophorectomy for epithelial ovarian cancer. Recommends adjuvant chemotherapy with paclitaxel.
Mechanism?
- Inhibits microtubule disassembly
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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?
- Hypertension
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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?
- von Willebrand disease
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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?
- Prednisone
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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?
- Enteroendocrine cells of the small intestine (CCK)
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- Adenosine
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- Ileocolic --> superior mesenteric --> portal --> right hepatic branch of portal
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/dL
Hematocrit 41%
Leukocyte count 10,500/mm3
Segmented neutrophils 65%
Eosinophils 1%
Basophils 1%
Lymphocytes 30%
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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?
- Amyloid infiltration
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?
- Microcytic anemia (Necator americanus/Ancylostoma duodenale)
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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?
- Initiate the procedure and treatment without consent
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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 130
K 4.5
Cl 90
HCO 30
BUN 85
Creatinine 2.2
Albumin 3
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Urine specific gravity 1.023, rbc 0 wbc0 sediment none
Urinary fractional excretion of sodium is less than 1%. Explanation?
- Prerenal azotemia
- Prerenal azotemia
Loop diuretic like furosemide is used to treat edematous states because it inhibits the ascending loop of Henle which
prevents concentration of urine.
But in this case it doesn’t work in stopping kidney injury and BUN/ Creatinine increases so it’s most likely:
Prerenal Azotemia due to decrease in renal blood flow which decreases GFR. Na/H2O and BUN held on to by kidney in
attempt to conserve volume (kidney thinks there isn’t enough due to lack of blood flow) --> increase BUN/ Creatinine
ratio (BUN is reabsorbed but creatinine is not) and decrease in fractional excretion of Na.
57-year-old man with alcoholism dies of klebsiella pneumonia. Abscess cavities filled with purulent exudate on autopsy. Pattern of necrosis in lung tissue?
- Liquefaction
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- Liquefaction
- alpha-1,4-Glucosidase
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?
- Syringomyelia
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- Syringomyelia
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?
- Hyperinsulinemia
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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?
- Outward (delayed) rectifying potassium channel
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Don't take anything out. HIV patients should be kept on thier HAART
regimen, which includes 2 NRTIs and one other drug PI/NNRTI/etc).
Prolactin/ACTH/TSH/Aldosterone
- decreased, decreased, decreased, increased
Sheehan syndrome occurred, so all anterior pituitary hormones (and whatever they induce those are
also down)
Aldosterone is up because blood delivery is decreased to juxtaglomerular cells ---> renin ---> ang
II ---> incr aldo.
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 diary 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?
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- Intestinal calcium
absorption
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)?
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- Histone acetylase
Tx APL with Vit A derivative that can bind mutated receptors of cells stuck in blast stage
(promyelocytes) and allow them become PMNs.
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?
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- Complement activation
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?
- Fimbriae
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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?
- Test of the stool for Clostridium difficile toxin
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18-year-old woman comes 12 hours after ingesting 100 aspirin tablets in suicide attempt. PE shows tachypnea. Labs?
pH/pCO2/HCO3-
- 7.32/15/8
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- Aortic aneurysm
- Cytokine effect
Cachexia: weight loss, muscle atrophy, fatigue in chronic disease (cancer, AIDS, heart failure, COPD)
- Mediated by TNF-alpha, IFN-gamma, IL-1, and IL-6
54-year-old man with normal renal functions gets a heart transplantation. One year later, bp 170/110 and serum creatinine 2.1. Which drug caused these
findings?
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- Cyclosporine
3-year-old boy with progressive fever and skin lesions during 24 hours. T 102.9 F, pulse 120, RR 20, bp 110/60. PE shows large, flaccid, bullous lesions over
trunk and abdomen. Another finding in pt?
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Investigator studying immune response to fungi. Fungi express beta-glucans on cell surface and that triggers innate immune response. Which tx decreases
glucan expression?
- Caspofungin
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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. She 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?
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- Sarcoplasmic Ca release
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Section 3
45-year-old homeless man found unconscious. Breath smells of alcohol. Vitals stable. PE shows bronzed skin and spider angiomata on chest. Labs: hemoglobin 10,
hematocrit 30%, MCV 110, WBC 9000, platelets 160,000, ferritin 200, b12 500, folate 20. Blood smear shows hypersegmented neutrophils and 3+ oval macrocytes. Labs? You are also going to see an elevation of Homocysteine levels in Folate Deficiency. This is
because B12 needs to receive a methyl group from Folate so it can pass it on to
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Homocysteine to create Methionine. Less Folate means B12 doesn’t have a methyl group to
pass on and Homocysteine builds up. Unlike B12 deficiencies, Folate deficiency does not
result in a buildup of Methylmalonic Acid or neurological symptoms.
Folate and B12 work closely together handing off methyl groups to each other. It is sort of
like a game of hot potato. Folate doesn’t “want” the methyl group so it passes it on to B12.
B12 doesn’t “want” it either so it passes it off to methionine. In effect, B12 helps recycle
methyltetrahydrofolate back into tetrohydrofolate which can be used to create DNA. This
means that a deficiency of B12 can cause a deficiency of Folate as less Folate is being
recycled into its “active” form. Therefore, B12 deficiency present very similarly to Folate
deficiency. You get Macrocytic/Megaloblastic Anemia with Hypersegmented
Neutrophils and increased Homocysteine levels.
Methylmalonic Acid normal and Homocysteine increased.
Folate and B12 needed for: Homocysteine -> Methionine -> DNA synthesis
The key pathway for the development of these neurological symptoms is odd chain fatty
acid breakdown. Odd chain fatty acids are broken down to eventually give Methylmalonyl
CoA. B12 is a cofactor in the process that converts methylmalonyl CoA into Succinyl CoA
which can then be used in the TCA cycle to generate energy. If there is not enough B12 this
reaction is slowed and Methylmalonic Acid builds up. This Methylmalonic Acid build up
is toxic to neurons and leads to demyelination in the posterior and lateral columns of the
spinal cord. This is called Subacute Combined Degeneration and presents with peripheral
numbness/tingling, spasticity, and loss of vibration and proprioception.
http://www.stomponstep1.com/folate-b12-deficiency-megaloblastic-anemia-hypersegmented/
35-year-old woman with 2-day history of blistering lesions on sun-exposed face, arms and hands. Recurrent episodes of skin lesions
over several years. Taking oral contraceptives for 15y. PE shows fluid-filled vesicles and bullae. Labs: AST increased, ALT increased,
total porphyrin increased, urine uroporphyrin III increased. Precursor to uroporphyrin?
- Succinyl CoA Medbook4u.com
Why it’s the right answer: The board examiners love these up and down
arrow questions, and they are not something to be intimidated by because
they are usually pretty straight forward as long as you’re able to break down
the clinical vignette.
Here, there’s a guy that had good, well-controlled blood pressure 6 months
ago, but now has very high blood pressure that is a result of gradual onset
- Total peripheral resistance increased, renal artery stenosis. When there is a blockage of one or two renal arteries,
- Plasma renin activity increased the kidney(s) are starved by blood. In reaction the kidneys think blood
- Serum aldosterone concentration increased
pressure is low, so they release factors to increase the pressure in the form
of the RAAS cascade (silly little kidneys). One factor/hormone they release is
renin (from the juxtaglomerular cells). Renin then causes a cascade of other
hormones to be released, including aldosterone, which increases blood
pressure so the kidneys are happy and no longer starved. In other words,
total peripheral resistance (TPR) is increased. The other important thing to
remember is the columns do not go in order necessarily– they should really
in fact be reversed to show first increases renin, which increases aldosterone,
which increases TPR, so don’t be fooled by that.
Take home point: Low kidney perfusion (from things like renal artery stenosis
or fibromuscular dysplasia) leads to activation of the RAAS cascade and an
overall increase in BP/TPR.
5-year-old boy with motion sickness. Planning vacation to Australia, and wants diphenhydramine for motion sickness. Mechanism of
action for motion sickness?
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(Legionella)
67-year-old man with 1 year progressive difficulty writing and walking. Pt is stooped and talks slowly. PE shows bland facial
expression, fine resting tremor in both hands, no tremor when moves, walks with difficulty starting and stopping, cogwheel rigidity.
Brain tissue histology shown as well as gross cross sections of midbrain both normal and diseased. Substance referred to by arrow?
- Alpha-synuclein Medbook4u.com
Patient making sexual advances towards physician. Appropriate measure?
- Have a chaperone join them
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Child with XXY karyotype, genetic studies showed he received the extra "x" from his father. An error of chromosome segregation
occurred during anaphase at which of the following stages of spermatogenesis in the patient's father?
- Primary spermatocyte
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Macula Densa (combo of cells from ascending loop of henle and distal tubule)
= reabsorption of all of the Na, H2O, HCO3--Dilute tubular fluid-->
Hypotonic
Medullary collection duct: draws H2O and urea out to create a hypertonic
interstitium
45-year-old man with hypertension not compliant with medications. bp 160/100. Cardiac exam shows apical impulse displaced
laterally, loud S2 and S4 gallop. Echo shows thickening of left ventricular wall. Mechanism of change in cardiac muscle?
- Transcription factor c-Jun: increased, beta-myosin heave chain: increased, endothelin: increased
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Why it’s the right answer: It is pretty clear from the question that this is cancer, and that is why the rest of the answer
choices are also all cancers, and we need to figure out which type of cancer this patient has. The key tip-offs to knowing
this is an astrocytoma are the location and characteristic crossover from one hemisphere to the other. Astrocytomas love
the supretentorial region, specifically the frontal lobe, and therefore present with personality changes. Furthermore, the
classic ‘butterfly lesion’ that goes from one hemisphere to the other is also characteristic of astrocytomas.
Why the others are wrong: A meningioma usually presents with localized neurological deficits since it normally has a
mass effect and pushes on the cerebral hemispheres. It also is described on imaging as a mass with a tail, since it is
“sprouting” from the meninges (or at least that’s how I remember it). A schwannoma is classically located in the
cerebellar-pontine junction (know where this is on imaging), and therefore intratentorial, and also will come with other
s/s of hearing loss, tinnitus, ect. Metastasis is typically 2+ lesions, not just the one, but this could have easily been mets
as well, its just that astrocytoma is a better fit for the clinical picture presented.
Take home point: Astrocytomas are single lesions that are often in the frontal lobe, presenting with personality changes
therefore, and “butterfly” from lobe to the other through the corpus callosum.
68-year-old man with creatinine 2.3 due to chronically increased hydrostatic pressure in Bowman space. Cause?
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39-year-old man with 1-week of red spots on shins, joint pain and fatigue. PE shows purpura over lower extremities. Liver palpated 4 cm below costal margin. Labs: WBC 10,000, AST 142, ALT 154, hepatitis C virus RNA positive, anti-hepatitis C virus antibody positive, cryoglobulins positive, C4 120 (N=350-600),
urine protein 4+, urine RBC numerous. Hypersensitivity reaction? - Type III (immune complex-mediated)
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.04/.12 = .3333
1-0.333 = .67
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- Concentration of cAMP
70-year-old man with early morning awakening, decreased energy, difficulty concentrating, anhedonia, psychomotor retardation,
depressed mood for 3 months. He had myocardial infarction and nonsustained ventricular tachycardia 2 years ago. Tx?
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- Paroxetine
66-year-old man dies 7 days after myocardial infarction. Gross of heart shown (perforated interventricular wall). Histology? -
Erythrocytes, cellular debris, macrophages, and early granulation tissue
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Why it’s right: This is a patient with recent weight loss, flank pain and hematuria, which at his age, is 100% renal cell carcinoma
(RCC) until proven otherwise. The typical triad is the latter two symptoms (flank pain, hematuria) plus palpable mass. But the
triad doesn’t always need to be completed, and they even further support the dx of RCC by sharing the ultrasound results – a
solid mass. Cystic mass is more favorable for a benign process, and here the word “solid” directs the test-taker towards
malignancy.
Why the others are wrong: Metastasis from another cancer wound not have such prominent urinary findings, and they would
have to give other signs/symptoms (s/s) of another malignancy elsewhere in the body. An abscess is less likely to be a solid
mass – similarly, a hematoma would also not be a solid mass, but a combination of cysts, fluid, etc. An abscess would also
present with fever and have an acute onset with bacteria and WBCs (more than just 6, which is borderline normal) in the urine.
Finally, transitional cell carcinoma is referring to cancer of the ureter or pelvis, located either in the ureter or in the inner portion
of the kidney (the pelvis). The cancer described is not only typical of RCC but also is located on the upper portion of the kidney,
or in the cortex, and therefore must derive from the renal cortex parenchyma itself.
Take home point: Patient >50 YO with weight loss, hematuria, and flank pain is RCC until proven otherwise.
During a clinical study of calcium and phosphorus metabolism, a 50-year-old man undergoes series of
lab studies. His serum Ca, PO4 and PTH are normal. He is given infusion 2 g Calcium chloride over 2
hours. His serum Ca concentration now is 11.5mg/dl. Compared with pre infusion levels, the serum Medbook4u.com
concentration of which of the following substances is likely to be increased at this time? - 24,25-
Dihydroxycholecalciferol
Why it’s the right answer: First off, it is important to know the sequence of vitamin D metabolism for step 1 because this concept incorporates
not only physiology, biochemistry, and nutrition, but also high-yield diseases like kidney disease (problem with alpha-1-hydroxylase), crohn’s
colitis (issue with vitD absorption), and sarcoidosis (elevated Ca++). So lets take a look:
1) So we start with Vitamin D3 (AKA cholecalciferol, from diet like fortified dairy products and fish oils; or synthesized from 7-
dehydrocholesterol in the skin when exposed to UV rays) à (via the liver) à
- 24,25-Dihydroxycholecalciferol 2) 25-hydroxyvitamin D3à (via the kidney) à
3) (a) 1,25-dihydroxyvitamin D3 (by enzyme 1-alpha-hydroxylase located in the kidney and gets positive feedback from PTH)
Now, the question is asking about negative feedback. When there is a high level of calcium, there is negative feedback on the amount of PTH
released (because PTH leads to increased calcium). PTH increases the enzymatic activity of 1-alpha-hydroxylase, an enzymes that converts 25-
Vitamin D3 to 1,25-Dihydroxycholecalciferol. Conversely, low PTH does not activate 1-alpha-hydroxylase when calcium levels are high (such as
in the clinical scenario above). So 25-Vitamin D3 is shunted to the other pathway and converted to 24,25-Dihydroxylase (by another enzyme
that is not important for purposes of the boards). The other choices are ruled out based on the above explanation. This is one of the most
difficult questions on NBME 18 because it requires that you not only know the metabolism of vitamin D as well as the back of your hand, but it
also requires that you know the concept of enzyme kinetics, positive and negative feedback, and specifically where Vitamin D3 goes if its not
being converted to 1,25-Vitamin D and shunted to the other pathway.
Take home point: PTH gets positive feedback from low Ca++ and negative feedback from high Ca+. PTH increases Ca++, and does so in part by
increasing the activity of enzyme 1-alpha-hydroxylase, which converts vitamin D3 to 1,25-Vitamin D, the active form of vitamin D that increases
Ca++ absorption from the gut. When vitamin D3 isn’t being converted to 1,25-Vitamin D, it’s being shunted to its other pathway that forms
24,25-Vitamin D.
For more information, and a great schematic on what I said above in words regarding vit D metabolism, follow this
link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2879391/
16-year-old boy who frequently thinks about sex, daydreams about girls before going to sleep, and masturbates one to two times
daily. After counseling about safe sex, best next step?
- Schedule next routine examination
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68-year-old man with alcoholism comes for fever, chills and productive cough of purulent sputum for 3 days. Blood cultures positive.
Gram stain: gram-positive, lancet-shaped diplococci. Vaccine is against which bacterial component?
- Capsular polysaccharide
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8-year-old boy with pain on back and head since he fell off swing. Tender 2.5cm swollen mass over right occiput. CT
shows osteolytic and soft-tissue mass in skull with inward displacement of dura. Biopsy shows sheet-like infiltrate of
pale eosinophilic cells with bean-shaped nuclei. Cells positive for CD1a. Electron microscopy of cells shows Birbeck
granules. Abnormal cell type?
Medbook4u.com
- Langerhans cells
29-year-old woman comes to the physician because of irregular menstrual periods since menarche at the age of 12.
She is 5.3Ft and weighs 86kgs. BMI 34. She is evaluated and a diagnosis of PCOS is made. After explaining the
diagnosis, the physician discusses behavioral changes, including dietary modification and exercise as part of her
treatment. Which of the following will ensure adherence?
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V. vulnificus can cause a wound infection from contact with contaminated water or shellfish.
Haemophilus influenzae is a respiratory gram negative that lactose fermenting doesn’t test for.
50-year-old woman with COPD comes with 3 months of progressive shortness of breath. Physical shows JVD, loud
pulmonary component of S2. Pulmonary function tests show FEV1:FVC ratio of 20% and decreased diffusing capacity
for carbon monoxide. Which is decreased in pulmonary vascular smooth muscle?
- Endothelial nitric oxide synthase production
Medbook4u.com
COPD
↓
Hypoxemia
↓
Alveoli constrict in attempt to send blood to more diffused part of lung
↓
High pressure in pulmonary circuit
↓
Atherosclerosis of pulmonary trunk, smooth muscle hypertrophy of pulmonary arteries, & intimal fibrosis so less vasodilation happening and
less endothelial nitric oxidase synthase production
An experimental animal is created that has a defect in an innate gastrointestinal defense mechanism.
Organism is found to have decreased HCl prod. After 2 months on biopsy gastric fundus and body show
decreased mucosal thickness and hyperplasia of enterochromaffin like cells. This closely resembles? Medbook4u.com
- Chronic gastritis
22-year-old man who is a professional cyclist undergoes extensive physiologic testing as part of his training regimen. His resting pulse
is 33/min, and blood pressure is110/62 mm Hg. Echocardiography shows dilated ventricles with normal function and a left ventricular
ejection fraction of 75%. Which of the following best describes the findings in this patient? Medbook4u.com
- Eccentric hypertrophy
Why it’s the right answer: “Dilated ventricles” is the key phrase in the stem. A
dilated heart is built from eccentric hypertrophy, or in-line (or in-series)
building and enlargements of muscle cells/fibers. In contrast, a thick heart of
normal size (not dilated) is built from concentric hypertrophy, or parallel
building and enlargement of muscle cells. This is a key concept for the boards
that is repeatedly tested. Furthermore, this patient doesn’t necessarily have
anything wrong with him. He is a professional athlete and works his heart to
the max, so much so that it has become big, and not in a pathological way,
since his EF is still preserved and actually more than it should be at 75%
(normal is ~55-65%).
Why the others are wrong: All of the other choices are suggestive of a
pathological process. Congestive cardiomyopathy would have a decreased
EF. Diastolic dysfunction is incorrect because although in diastolic
dysfunction there is preserved EF with impaired relaxation, the ventricles are
not dilated but usually hypertrophied and thicker; the same reason why
also hypertrophic cardiomyopathy and increased myocardial stiffness are
incorrect – both may have a normal to increased EF, but the ventricles would
be thick not dilated.
- Endothelin-1
Why it’s the right answer: Dx is pulmonary hypertension secondary to pulmonary fibrosis. An important
point I want to bring up here is that the boards don’t always follow the demographic rules we know and
love – i.e. a middle-aged woman is the classic demographic category for idiopathic pulmonary fibrosis.
However, the board examiners know that everyone is going to get the answers right if they put that there,
so they try to make the question harder (sometimes) by changing it up and maybe giving you a 40-50-
year-old MAN with pulmonary fibrosis. So again, don’t be tripped up. This clinical vignette is still pretty
obvious sans the demographics of the patient based on physical exam alone. And one of the factors that
is upregulated in pulmonary fibrosis is endothelin-1. Another KEY point is that the lungs is the ONLY
organ system, that when starved for blood, vasoconstricts instead of vasodilating. Vasodilation is a
normal response to decreased blood flow à to let more blood flow in!! However, the vessels in the lungs
CONSTRICT and mainly do so through endothelin-1. And the reason they constrict? To not promote
further deoxygenation through a V/Q or shunt defect. Finally, know the drug to treat this condition, which
decreases pulmonary hypertension by antagonizing the endothelin receptor: Bosentan. It could be on
your test (wink wink).
Take home point: Pulmonary artery hypertension (PAH) results from increase in release of endothelin-1.
PAH is a consequent of pulmonary fibrosis. Bosentan is a medication frequently used to treat PAH
through antagonization of the endothelin receptor.
30-year-old man in bicycle collision and hits right shoulder forcefully. Unable to flex right elbow with decreased sensation to pinprick
over right lateral forearm. Brachial plexus lesion?
- E (musculocutaneous nerve)
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4-day-old boy with vomiting after breastfeeding. PE shows lethargy and dry mucous membranes. Labs: Na 139, Cl 90,
K 7, HCO3 17, Glucose 42, BUN 25, Cr 0.4, 17-hydroxyprogesterone increased. Enzyme deficiency?
- 21-hydroxylase
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67-year-old woman with atrial fibrillation with sudden onset severe abdominal pain. Ex-lap shows embolus in superior mesenteric
artery with complete occlusion of middle colic artery. Ischemic changes where?
- Small intestine, ascending colon, and part of the transverse colon Medbook4u.com
70-year-old man comes with skin blistering for 1 week. No oral lesions. Physical shows tense bullae in joint folds of upper and lower
extremities. Biopsy shows subepidermal blister formation. Immunofluorescence microscopy shows antibodies against proteins at the
dermal-epidermal junction. Target by antibodies?
- Hemidesmosome Medbook4u.com
Why it’s the right answer: This is a pretty basic question on bullous pemphigoid, which is the dx
presented in the vignette. In this autoimmune disease, antibodies are directed against the
hemidesmosomes, which link the dermis to the overlying epidermis. You either know this one or you
don’t, basically.
Take home point: Bullous pemphigoid is a disease of the hemidesmosomes and characterized by a
linear immunofluorescent pattern that highlights the dermal and epidermal junction. Conversely,
pemphigus vulgaris, the other high-yield autoimmune skin disease that’s tested on the boards, is a
disease in which autoantibodies target desmosomes, creating a circular immunofluorescence pattern
INTRAdermally.
Bullous pemphigoid: Layer - deep, age - elderly, blisters - tense/firm, oral lesions - rare, Nikolsky's sign -
negative, Immunofluorescence - Basement membrane, target antigen - hemidesmosome, blister
content - hemorrhagic
Pemphigus vulgaris: Layer - superficial, age - middle-age (not always), blisters - flaccid, easily rupture,
oral lesions - common, Nikolsky's sign - positive, Immunofluorescence - intraepidermal, circular, target
antigen - desmosome, blister content - fluid-filled
Medbook4u.com
Section 4
33-year-old man dx with epilepsy age 10 years. Most recent generalized tonic-clonic was 5 years ago. Medication was adjusted.
Current meds include carbamazepine. He's never had any collisions while driving his motor vehicle. Patient's status with respect to
driving?
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- Colipase
25-year-old woman comes for counseling prior to conception. Has seizure disorder on valproic acid. Fetus at greatest risk for drug-
related adverse effect during which pregnancy stage? - 3 to 8 weeks
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- 3 to 8 weeks
Study designed to test the effectiveness of a new drug in the treatment of endometriosis, 100 women randomly assigned to one of
two groups. 48 of women receive new drug, 52 receive standard therapy. The primary purpose of this method of assigning patients to
different groups is to create which of the following ?
- Two groups with similar underlying characteristics Medbook4u.com
45-year-old man bmi 26, total cholesterol 200, HDL 50, triglycerides 550. Which drug to prescribe?
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- Fenofibrate
- 1/4
32-year-old woman has operation for hyperparathyroidism. Three parathyroid glands found but one does not appear
in normal superior location on right side. Embryologic event that led to this?
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- Drug-related antibodies
21-year-old man loses 15% total blood volume 2 minute after motor vehicle collision. Finding most likely? - Increased
sympathetic nerve traffic to sinoatrial node
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Hb 13 g/dl
Ht 39%
Leukocyte count 32.000/mm3 Medbook4u.com
Urine ph 6
Nitrites 4+
Leukocyte esterase 4+
A photograph of wright stained peripheral blood smear, which the most likely cause this patient leukocytosis ?
55-year-old man northern European descent with 2-month weakness, altered skin color, bilateral knee pain. Siblings have type 2
diabetes and cirrhosis. PE bronzed skin, hepatomegaly, arthritis. Increased saturation of transferrin and ferritin. Liver biopsy
increased iron content and cirrhosis Greatest risk?
- Hepatocellular carcinoma Medbook4u.com
Hemochromatosis!
Contraction Atelectasis: radiation causes local or general fibrotic changes in lung or pleura which makes full
expansion not possibly and causes and increase in elastic recoil during expiration (stiffer lungs).
17-year-old boy brought by mother with concern that puberty is delayed. When mother leaves room, patient states,
"I'm fine. I don't know what's the matter with her. She wants me to be tall like my dad." Patient is 175 cm (5 ft 9 in)
tall and weighs 70 kg (155 lb); BMI 23. Sex development is Tanner stage 4. Most appropriate next statement to
mother?
Medbook4u.com
- "Tell me more about your concerns about your son's height."
82-year-old woman comes to the physician because of constant severe lower abdominal pain and fever for 24 hours.
Laproscopic examination shows severe diverticulosis and perforated diverticulitis. In spite of appropriate therapy she
dies 2 days later. Liver autopsy shown. Which of the following is the primary component of the material shown on Medbook4u.com
the hepatic surface?
- Fibrin
- Fibrin
1-3 days after: yellow pallor on liver lots of neutrophils! Fibrinous so material
shown on hepatic surface is made up of fibrin
35-year-old woman with infertile, receive injection of contrast material into cervix. On hysterosalpingogram (shown), contrast
material (indicated by arrows) also seen in peritoneal cavity, which explain this finding?
- Spillage of contrast which normal
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69-year-old woman with 3-week history of muscle cramps, weakness, abdominal pain, and constipation. Hypertension treated with
metoprolol and hydrochlorothiazide for past 4 months. Labs show hypokalemia. Which drug should be added?
- Triamterene (potassium-sparing)
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60-year-old man for routine health examination. Has had normal blood pressure measurements. BP today
170/95mmHg. Physical examination shows no other abnormalities. Serum show hypokalemia and metabolic
alkalosis. Plasma renin activity and serum aldosterone concentrations are increased. Following the administration of
captopril, there is a marked increase in plasma renin activity. Which of the following is the most likely cause of the
Medbook4u.com
findings in this patient?
- Renal artery stenosis
- Physiologic shunt
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, 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? Medbook4u.com
- Pulmonary hypertension (dx: systemic sclerosis/CREST)
A 25-year-old woman comes to the physician because of a 2-year history of intermittent, diffuse, cramping lower abdominal pain. The pain is usually associated with2 to 6 days of loose, watery stools, and is typically relieved with defecation. Between these episodes, her
stools are normal. Her vital signs are within normal limits. Physical examination shows no abnormalities. Laboratory studies, including complete blood count, metabolic panel, and thyroid function tests show no abnormalities. A drug targeting which of the following
mechanisms of action is most appropriate for this patient?
- Accentuation of μ-opioid myenteric plexus receptor Medbook4u.com
48-year-old woman with gradual onset back pain past 2 weeks. No trauma. Doesn't smoke cigarettes,
drink alcohol or use drugs. Hemogram, serologic studies and urinalysis unremarkable. Xray of spine
shows two lytic lesions, in T-10 and L-1. Dx? Medbook4u.com
- Metastatic carcinoma of the breast
- Angiodysplasia
1-year-old has numerous infection of skin and oral mucosa since birth. Infections slow to respond to antibiotic therapy. T 100.4F. PE
multiple erythematous lesions of skin some with superficial ulceration. WBC 21,000 77% segmented neutrophils, 6% bands, 14%
lymphocytes and 3% monocytes. Biopsy shows no neutrophils in dermis or epidermis. Culture of lesion grows Staphylococcus aureus.
Defective
- An integrin
Medbook4u.com
Leads to recurrent bacterial skin and mucosal infections with absent pus
formation, impaired wound healing, and delayed separation of umbilical
cord (>30 days)
58-year-old man comes to physician for benzodiazepine prescription for situation at work. Feels anxious and thinks
he can complete last 2 years of work if anxiety decreases. Gives 1-month regimen of benzodiazepine. Wife calls, "My
husband got fired! I know it was because he was taking too much of that drug you gave him. Didn't you know he had
history of alcoholism?" Initial action?
Medbook4u.com
- Contact the patient to discuss the situation
35-year-old from group home comes for worsening behavior for 2 weeks. He believes CIA is spying on him through television set.
Reports hearing voices in hall outside and that CIA now plans to kill him. Appears disheveled with unkempt hair and poor hygiene,
difficulty answering questions because listening to internal stimuli. Mental status exam will show which?
- Flattened affect Medbook4u.com
- Flattened affect
32-year-old man with X-linked recessive disease has deafness, hematuria and progressive renal failure. Protein
abnormality?
- Type IV collagen Medbook4u.com
25-year-old man just returned from work as worker from Africa begins oral chloroquine therapy for malaria caused by Plasmodium
vivax. His initial therapeutic response is good, but he develops recurrent parasitemia 2 months later. Which of the following best
explains the recurrence ?
- Chloroquine is ineffective on the exoerythrocytic malaria tissue stages Medbook4u.com
21-year-old woman with 10-days difficulty walking. Two years ago had loss of vision in left eye which improved. Neuro exam shows
decreased visual acuity in left eye with pallor of optic disc. Has past-pointing on a finger-nose test. Broad-based gait. MRI shows brain
lesions in white matter of cerebellum. Pathogenesis?
- CD4+ T lymphocytes are activated by myelin basic protein Medbook4u.com
46-year-old woman with 1-week low-grade fever and joint pain. Has chronic headaches and takes ibuprofen several
times. PE diffuse maculopapular rash. UA 2+ protein, 10-20 WBC and eosinophils. Renal biopsy would show what?
- Inflammatory infiltrates in the interstitium
Medbook4u.com
- Enterocyte
68-year-old man with a 10-month history of shortness of breath and swelling of his feet, family history of
cardiovascular disease. He smoked 2 packs of cigarettes daily for 50 years. Pulse 80/min, rr 24/min, BP 150/80. PE:
3+pitting edema of lower extremities. Diffuse, scattered wheezes are heard bilaterally on auscultation of the chest.
Grade 2/6 pansystolic mumur heard best at lower left sternal border, which increases on inspiration. Maximal
Medbook4u.com
impulse palpated in sub-xiphoid area. S1 and S2 sounds are distant. Liver span 14 cm. Diagnosis?
- Cor pulmonale
Cor pulmonale, as pulmonary hypertensive heart disease is frequently called, constitutes right ventricular hypertrophy,
dilation, and potentially failure secondary to pulmonary hypertension caused by disorders of the lungs or pulmonary
vasculature and is the right-sided counter part of left-sided (systemic) hypertensive heart disease. Although quite
common, right ventricular thickening and dilation caused either by congenital heart diseases or by diseases of the left
side of the heart and the resultant pulmonary venous hypertension owing to postcapillary obstruction to blood flow are
excluded from this definition of cor pulmonale.
http://www.score95.com/blog/blog/usmle-pulmonary-right-sided-hypertensive-heart-disease-cor-pulmonale/
2-month-old boy well child exam, mother with no concerns. 25th percentile for length and 30th percentile for weight. Cardiac exam
shows blowing holosystolic murmur best heard at lower left sternal border. Cause?
- Ventricular septal defect
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47-year-old woman with irregular, raised, multicolored dark lesion on left forearm with frequent sunlight exposure.
Biopsy shows malignant pigmented cells. Worst prognosis with involvement of which layer?
- Subcutaneous tissue
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- Subcutaneous tissue
Deepest layer/ deeper the tissue involvement is the worse the prognosis
6-year-old girl with 15-minute history of severe shortness of breath. Diagnosed with throat tumor 3 years ago. RR 32.
PE nasal flaring. Laryngoscopy shows multiple raised, finger-shaped lesions from vocal cords and epiglottis. Lesions
excised and shows finger-shaped fibrovascular cores lined with benign squamous epithelium. Causal virus? Medbook4u.com
- Human papillomavirus, type 6
32-year-old man with HIV infection follow up examination, has been treated with HAART for the past 6 years HIV plasma viral load
has been undetectable. HIV viral load now increase, antiretroviral resistance suspected. HIV genotype analysis confirms that the virus
has resistance mutations, which of the following most likely mutated?
- Reverse transcriptase and protease (the two targets of HAART therapy, therefore if therapy stopped working, must be these two Medbook4u.com
target proteins of virus mutated)
Dopamine is a sympathomimetic!