USMLE_Basic II

A 24-year-old male experiences syncope while shovelling snow. He regained consciousness within one minute. He has been having some shortness of breath and chest pains recently, mostly related to exercise. He denies any illicit drug use. His temperature is 37.2°C (98.9°F), and blood pressure is 126/76 mmHg, pulse is 76/min and respirations are 14/min. Physical examination shows a well-built male in no apparent distress. Lungs are clear. A crescendo-decrescendo systolic murmur is heard along the left sternal border without carotid radiation. Chest X-ray is normal. Which of the following is the most likely cause of his syncopal episode?

A 24-year-old man presents to the emergency room with abdominal pain and fever. CT scan of the abdomen reveals inflammation of the colon. He is referred to a gastroenterologist to be evaluated for inflammatory bowel disease (Crohn disease versus ulcerative colitis). Which of the following indications for surgery is more prevalent in patients with Crohn disease?

A 24-year-old man returns from Iraq after a 13-month tour of duty. During that tour he was involved in battle situations and saw one of his friends injured by a car bomb. What percentage of American soldiers returning home from Iraq have posttraumatic stress disorder (PTSD)?

A 24-year-old man whose father was just diagnosed with colon cancer presents to his family physician to discuss screening colonoscopy. His physician suspects that he has hereditary nonpolyposis colon cancer (HNPCC) or Lynch syndrome and recommends screening colonoscopy beginning at age 25. Which of the following is most supportive of a clinical diagnosis of HNPCC?

A 24-year-old primigravida with twins presents for routine ultrasonography at 20 weeks gestation. Based on the ultrasound findings, the patient is diagnosed with dizygotic twins. Which of the following is true regarding the membranes and placentas of dizygotic twins?

A 24-year-old woman presents with chills and rigors. She looks unwell, and her temperature is 39.4°C, blood pressure 100/60 mm Hg, pulse 110/min, and oxygen saturation 95%. There is a 3/6 pansystolic murmur at the right sternal border, which increases with inspiration. Her arms have multiple tattoos and needle marks from injection drug use. Blood cultures (2/2 sets) are positive for S. aureus, and she is started on appropriate antibiotics. Her renal function is mildly impaired and her urinalysis is positive for protein, and microscopy reveals red cell casts. Which of the following mechanisms is the most likely explanation for her renal abnormalities?

A 25-year-old African American woman presents with a photo distributed skin rash and arthralgias. She is found to have low-range proteinuria and abnormal urinary sediment. Renal biopsy findings are consistent with focal proliferative glomerulonephritis. Her complete blood count shows: Erythrocyte count 3.2 mln/mm3, Platelets 60,000/mm3, Leukocyte count 2,500/mm3. Which of the following is the most likely cause of these hematologic findings?

A 25-year-old complains of fever and myalgias for 5 days and now has developed a macular rash over his palms and soles with some petechial lesions. The patient recently returned from a summer camping trip in Tennessee. Which of the following is the most likely cause of the rash?

A 25-year-old man comes to the physician because of a mass in his mouth. He has had the lump for many years. He denies weight loss. He was in a motor vehicle accident several years ago and sustained a concussion of the brain. He does not use tobacco, alcohol, or illicit drugs. Physical examination shows a nontender 2 x 2-cm mass located on the hard palate of the mouth that is immobile and has a bony hard consistency. Which of the following is the most likely cause of this patient's oral finding?

A 25-year-old man presents to the same day surgical center for repair of an old injury to his lateral collateral ligament. The anesthesiologist wants to perform an axillary block for local pain control. If the posterior wall of the axillary artery is pierced during placement of the block, which of the following nerves will most likely be affected?

A 25-year-old married female is brought to the emergency department by her mother for excruciating right-sided abdominal pain. A urine pregnancy test is positive and a pelvic ultrasound reveals an empty uterus. Ruptured ectopic pregnancy is suspected, and an operating room is reserved for an emergent laparotomy. The patient's medical history is unremarkable except for a psychiatric diagnosis of paranoid schizophrenia. Who should sign the informed consent paperwork for the procedure?

A 25-year-old primiparous woman comes to your office 12 weeks after vaginal delivery of a healthy female baby. She has not had a menstrual period since delivery. She is nursing, and is using barrier methods for contraception. Examination shows no abnormalities. Which of the following is the most likely mechanism for this patient's amenorrhea?

A 25-year-old woman comes into the office with a three-month history of weight loss, irritability, insomnia, and palpitations. Her past medical history is insignificant. She is not taking any current medications and denies drug abuse. Her blood pressure is 155/70 mmHg and heart rate is 110/min. Physical examination reveals lid retraction, fine tremor of the hands, and increased neck circumference. The most probable cause of hypertension in this patient is?

A 25-year-old woman comes to the office for the evaluation of pale patches of skin around her mouth. She noticed these lesions a few months ago, but they have become more prominent now. There is no itching, burning, or numbness over the patches. Her vital signs are stable. On examination, you notice pale white patches symmetrically distributed around her mouth. The borders of these macules are well-circumscribed and hyperpigmented. Similar lesions are also found over the areola of her breasts. She denies any history of trauma or infection. Which of the following best explains the pathology of her condition?

A 25-year-old woman comes to the physician with abdominal bloating, headache, fatigue, weight gain, anxiety, and decreased libido. She experiences these symptoms intermittently in 7 to 10-day episodes. In retrospect, she is unable to identify any triggers for her symptoms. The patient has a history of postpartum depression but has no recent feelings of hopelessness or guilt Physical examination is normal. Complete blood count, serum chemistries, and thyroid-stimulating hormone levels are within normal limits. Which of the following is the most appropriate next step in management of this patient?

A 25-year-old woman comes to your office for counseling. She says that her husband has cystic fibrosis, and that she has no family history of this disease. They are planning to have a child. She wonders what the probability is for their baby to have cystic fibrosis. Which of the following is your best response in this situation?

A 25-year-old woman experiences sudden-onset palpitations and generalized weakness. During this episode, her blood pressure is 100/60 mmHg and her heat rate is 160/min and regular. She has no significant past medical history and does not take any medications. She reports having a few similar episodes in the past which she has self-treated by immersing her face in cold water. Generally, she says, cold water immersion relieves her symptoms within several minutes. This cold water therapy works by affecting which of the following?

A 25-year-old woman is admitted with fever and hypotension. She has a 3-day history of feeling feverish. She has no history of chronic disease, but she uses tampons for heavy menses. She is acutely ill and, on physical examination, found to have a diffuse erythematous rash extending to palms and soles. She is confused. Initial blood tests are as follows: White blood cell count: 22,000/μL, Na+: 125 mEq/L, K+: 3.0 mEq/L, Ca++: 8.0 mEq/mL, Activated partial thromboplastin time (PTT): 65 (normal 21 to 36), Prothrombin time (PT): 12s (normal < 15s), Aspartate aminotransferase: 240 U/L (normal < 40), Creatinine: 3.0 mg/dL, Antinuclear antibodies: negative, Anti-DNA antibodies: negative, Serologic tests for RMSF, leptospirosis, measles: negative. Which of the following best describes the pathophysiology of the disease process?

A 25-year-old woman presents to your office complaining of a seven-week history of amenorrhea. She also states that she has had nausea and vomiting for five weeks. She is sexually active. Her medical and obstetrical histories are unremarkable. Serum hCG level is elevated. Which of the following is the most important direct role of hCG in pregnancy?

A 25-year-old woman presents to your office complaining of a seven-week history of amenorrhea. She also states that she has had nausea and vomiting for five weeks. She is sexually active. Her medical and obstetrical histories are unremarkable. Serum hCG level is elevated. Which of the following is the most important role of hCG in pregnancy?

A 25-year-old woman presents with a benign nevus on the right upper arm. She desires removal and undergoes a clean incision and then closure of the incision without complication. With regard to the healing process, which of the following cell types are the first infiltrating cells to enter the wound site, peaking at 24 to 48 hours?

A 25-year-old woman presents with nausea and vomiting of 2 days duration. She is not on any medications and was previously well until now. Her physical examination is normal except for a postural drop in her blood pressure from 110/80 mm Hg supine to 90/80 mm Hg standing. Her serum electrolytes are sodium 130 mEq/L, potassium 3 mEq/L, chloride 90 mEq/L, bicarbonate 30 mEq/L, urea 50 mg/dL, and creatinine 0.8 mg/dL. Which of the following electrolytes is most likely to be filtered through the glomerulus but unaffected by tubular secretion?

A 26-year-old G1P0 woman at 12 weeks gestation presents to her obstetrician for her first visit. Her pregnancy thus far has been notable only for some mild nausea and vomiting that lasted throughout her first trimester. She reports feeling overly tired lately and very weak. Her past medical history is significant for pernicious anemia. On physical examination she is an anxious-appearing, thin woman. Her blood pressure is 130/85 mmHg, heart rate is 115/ min, and respiratory rate is 18/min. Fetal heart tones are present at 135/min. The uterine fundus is at 12 cm. The woman has a diffuse, non- tender goiter, a resting tremor, and poor global muscle strength. Which is the most likely mechanism underlying this woman’s condition?

A 26-year-old G1P1 is now postoperative day (POD) 6 after a low transverse cesarean delivery for arrest of active phase. On POD 2, the patient developed a fever of 39C (102.2F) and was noted to have uterine tenderness and foul-smelling lochia. She was started on broad-spectrum antibiotic coverage for endometritis. The patient states she feels fine now and wants to go home, but continues to spike fevers each evening. Her lung, breast, and cardiac examinations are normal. Her abdomen is nontender with firm, nontender uterus below the umbilicus. On pelvic examination her uterus is appropriately enlarged, but nontender. The adnexa are nontender without masses. Her lochia is normal. Her white blood cell count is 12 with a normal differential. Blood, sputum, and urine cultures are all negative for growth after 3 days. Her chest x-ray is negative. Which of the following statements is true regarding this patient’s condition?

A 26-year-old male presents to your office with periodic flank pain. He also noticed that his urine was red during the last several days. He is known to be HIV-positive. One month ago, he presented with thrush. At that time, he was found to have a CD4 count of 100, and was started on anti-retroviral therapy. His current CD4 count is 250. Physical examination reveals no oral cavity lesions. The lungs are clear on auscultation. The serum creatinine level is 2.2 mg/dl. Urinalysis shows hematuria and needle-shaped crystals in the sediment. Which of the following is the most likely cause of this patient's current condition?

A 26-year-old man comes to his physician with a two-week history of fatigue, fever, muscle aches, and arthralgias. He denies any weight loss. His temperature is 37.7°C (99.9°F), blood pressure is 115/75 mm Hg, respirations are 14/min, and pulse is 75/min. Physical examination is unremarkable, except for splenomegaly. Laboratory studies show: Hemoglobin 13 gm/dL, WBC count 12,000/microL, Neutrophils 22%, Lymphocytes 70%, Monocytes 5%, Basophils 1%, Eosinophils 2%, Platelet count 220,000/microL. Peripheral blood smear shows large basophilic lymphocytes with a vacuolated appearance. Heterophile antibody test is negative. What is the most likely cause of this patient's symptoms?

A 26-year-old man comes to the emergency department because he is "suffering from the worst headache of his life." He feels nauseated and is photosensitive. His blood pressure is 160/90 mm Hg, heart rate is 88/min, and temperature is 36.5°C (97.7°F). The physical examination reveals no focal neurological symptoms, except for some meningismus and vertigo, which is not localized to either side. CSF examination reveals the presence of xanthochromia. What is the major cause of morbidity and mortality in a patient with the above condition?

A 26-year-old woman comes to the physician for follow-up after a recent spontaneous abortion at 14 weeks gestation. She had one other spontaneous first trimester abortion two years ago. She has no other medical problems and does not use tobacco, alcohol or drugs. Review of systems reveals photosensitivity and occasional hematuria. On examination, you observe a bilateral malar rash. What is the most likely pathophysiology for her abortions?

A 27-year-old alcoholic man presents with decreased appetite, mild generalized weakness, intermittent mild abdominal pain, perioral numbness, and some cramping of his hands and feet. His physical examination is initially normal. His laboratory returns with a sodium level of 140 mEq/L, potassium 4.0 mEq/L, calcium 6.9 mg/dL, albumin 3.5 g/dL, magnesium 0.7 mg/dL, and phosphorus 2.0 mg/dL. You go back to the patient and find that he has both a positive Trousseau and a positive Chvostek sign. Which of the following is the most likely cause of the hypocalcemia?

A 27-year-old basketball player jumps to block a shot with his right hand. As his hand contacts the ball, he feels severe pain in his right shoulder. He presents to the emergency department with continuing shoulder pain. You note that he holds his right arm in slight external rotation, supporting its weight with his left hand. On physical examination, he resists internal rotation of his right arm. Which of the following nerves is most likely to be injured in this patient?

A 27-year-old female is brought into the emergency room by the local paramedics. She was found unconscious at the scene of a house fire. On examination it does not appear that she has suffered any burns. Black soot is noted near her nares and mouth. Her respirations are slow but spontaneous. Her capillary refill time is 4 seconds. Supplemental oxygen by a non-rebreather mask is begun. Her arterial blood gas and preliminary laboratory values are shown below: Blood pH 7.22, PaO2 100 mmHg, PaCO2 39 mmHg, HC03- 11 mEq/L, WBC count 9,000/cmm, Hb 14 mg/dl, Na+ 138 mEq/L, K+ 4 mEq/l, CI- 98 mEq/L, Troponin 0.4ng/ml. Which of the following is the most likely primary cause of the patient's acid-base disturbance?

A 27-year-old man presents to the emergency department with unremitting nose bleeding. He reports having a similar bleeding episode one year ago that was stopped in the ER. He works as a computer programmer and has a sedentary lifestyle. He drinks alcohol on social occasions but does not smoke or use illicit substances. On physical examination, there are several ruby-colored papules on his lips that blanch partially with pressure. Digital clubbing is also present. His abdomen is soft and non-tender. The liver span is 8 cm and the spleen is not palpable. Laboratory findings are: Hematocrit 60%, WBC count 8,000/mm3, Platelets 180,000/mm3. Which of the following is most likely responsible for this patient's increased hematocrit?

A 27-year-old man presents with symptoms of fever, chills, malaise, and joint discomfort in his hands and knees. He looks unwell, his temperature is 39.4°C, blood pressure 115/70 mm Hg, pulse 110/min, head and neck is normal, and his jugular venous pressure (JVP) has a prominent c-v wave. There is also a 3/6 pan-systolic murmur heard at the right sternal border that increases with respiration. His lungs are clear, abdomen is soft, and hand joints are normal. He has multiple puncture sites on his forearms from injection drug use. Which of the following is the most likely causative organism?

A 27-year-old woman has used oral contraceptives (OCs) without problems for 5 years. However, she just read an article about complications of OCs in a popular women’s magazine and asks you about the risks and hazards of taking OCs. You correctly tell her which of the following?

A 27-year-old woman presents to the emergency room with a panic attack. She appears healthy except for tachycardia and a respiratory rate of 30. Electrolytes include calcium 10.0 mg/dL, albumin 4.0 g/dL, phosphorus 0.8 mg/dL, and magnesium 1.5 mEq/L. Arterial blood gases include pH of 7.56, PCO2 21 mm Hg, and PO2 99 mm Hg. Which of the following is the most likely cause of the hypophosphatemia?

A 27-year-old woman, gravida 2, para 1, at 20 weeks' gestation comes to the physician for a prenatal visit. She has no complaints. Her obstetric history is significant for a primary low transverse cesarean delivery because of a non-reassuring fetal tracing 3 years ago. She has no medical problems. She takes prenatal vitamins and has no known drug allergies. She is debating whether to have an elective repeat cesarean delivery or to attempt a vaginal birth after cesarean (VBAC). She wants to know her chances for a successful VBAC. Which of the following most accurately represents the patient's likelihood of having a successful vaginal delivery?

A 28-year-old avid mountain climber and his friend are vacationing in Andes, South America. During their mountain climbing expedition, the pair somehow manages to get lost. It has been over 16 hours since their food supply ran out. Their glycogen stores are becoming depleted, and their bodies are beginning to utilize the process of gluconeogenesis. Which of the following intermediates is alanine being converted into during this process?

A 28-year-old G3P3 presents to your office for contraceptive counseling. She denies any medical problems or sexually transmitted diseases. You counsel her on the risks and benefits of all contraceptive methods. Which of the following is the most common form of contraception used by reproductive-age women in the United States?

A 28-year-old man with a history of intravenous drug abuse presents to the emergency department with a 2-day history of fever, chills, and shortness of breath. On physical examination the patient has a new heart murmur, small retinal hemorrhages, and subungual petechiae. Which of the following is the most likely causative organism?

A 28-year-old nulliparous woman is being evaluated for infertility. She has no other medical problems. Pelvic examination reveals abundant mucous and a clear cervical secretion, which when lifted vertically extends in a long thread; pH is 6.5. This visit took place at which of the following phases of the menstrual cycle?

A 28-year-old nulliparous woman is being evaluated for infertility. She has no other medical problems. Pelvic examination reveals abundant mucus and a clear cervical secretion, which when lifted vertically extends in a long thread; pH is 6.5. This visit took place at which of the following phases of the menstrual cycle?

A 28-year-old nulliparous woman presents to your office complaining of fatigue, low mood, and amenorrhea. She says that it all started two months ago and progressively worsened. She is sexually active and uses condoms for contraception. Her medical history is unremarkable, and she denies taking any drugs or medications. Examination reveals dry skin, short eyebrows, a painless and enlarged thyroid gland, and galactorrhea. The uterus has a normal size, and the adnexae are not palpable. Initial investigations reveal the following: Serum pregnancy test: Negative; Free T4: 2.5 μg/dL (N= 5- 12); SerumTSH: 11.0 μU/ml (N= 0.5-5.0); Prolactin: 30 ng/ml ( < 20 ng/ml); Antimicrosomal antibodies: Positive. Of the following, which represents the association between hypothyroidism and hyperprolactinemia in the above patient?

A 28-year-old nulliparous woman presents to your office complaining of fatigue, low mood, and amenorrhea. She says that it all started two months ago and progressively worsened. She is sexually active and uses condoms for contraception. Her medical history is unremarkable, and she denies taking any drugs or medications. Examination reveals dry skin, short eyebrows, a painless and enlarged thyroid gland, and galactorrhea. The uterus has a normal size, and the adnexae are not palpable. Initial investigations reveal the following: Serum pregnancy test: Negative, Free T4: 2.5 μg/dl (N= 5-12), Serum TSH: 11 .0 μU/ml (N= 0.5-5.0), Prolactin: 30 ng/ml ( < 20 ng/ml). Antimicrosomal antibodies: Positive of the following, which represents the association between hypothyroidism and hyperprolactinemia in the above patient?

A 28-year-old primigravida is admitted to the hospital at 10weeks gestation. Her right leg is swollen. Her BMI is 30 Kg/m2. Her temperature is 36.7°C (98.2°F), respirations are 12/min and pulse is 96/min. Her ABG shows the following: pH 7.49, PaCO2 50 mm Hg, HCO3- 44 mEq/L. Which of the following is the most likely cause of her abnormal arterial blood gas?

A 28-year-old woman at 39 weeks gestation is admitted to the hospital. She has regular uterine contractions. Her blood pressure is 120/70mmHg, pulse is 80/min and respirations are 18/min. Fetal heart monitoring is placed and shows a baseline rate of 130 beats/min, without any associated abnormalities. Pelvic examination shows the cervix is 50% effaced and 3 cm dilated. Amniotomy is performed. Immediately after the rupture of membranes, the baseline fetal heart rate increases to 160 beats/min and then drops to 70 beats/min with repetitive late decelerations. There is severe acute vaginal bleeding. Repeat vital signs of the patient shows a blood pressure of 130/70mmHg, pulse of 80/min and respirations of 18/min. Which of the following is the most likely cause of the current condition?

A 28-year-old woman comes to your office for an annual visit. She has been in good health over the past year. She exercises regularly and watches her diet. She has hypothyroidism for which she takes thyroid hormone replacement. She has no other medical problems. She had an appendectomy at the age of 18 and has had no other surgeries. She takes no other medications and has no known drug allergies. Physical examination, including breast and pelvic exam, is normal. She has three children and does not wish to become pregnant again. She has tried the oral contraceptive pill and the intrauterine device (IUD), but stopped both of these methods because of side effects. She is now considering tubal ligation. Counseling of this patient should include the fact that if she does have a tubal ligation she will be at increased risk for which of the following conditions?

A 28-year-old woman is brought to see a psychiatrist by her mother. The patient insists that nothing is wrong with her, but the mother notes that the patient has been slowly but progressively isolating herself from everyone. She now rarely leaves the house. The mother says she can hear the patient talking to “people who aren’t there” while she’s in her room. On examination, the patient is noted to have auditory hallucinations and the delusional belief that her mother is going to kick her out of the house so that it can be turned into a theme park. Which of the following is the lifetime prevalence for this disorder?

A 28-year-old woman presents to her gynecologist for her annual examination. She mentions that she and her husband have been trying to conceive for 9 months without success and that her menstrual cycles have become irregular. Her gynecologist suggests that she and her husband continue to try to conceive and that the woman return in 3 months for some laboratory studies if she still has not become pregnant. In the interim, a routine visit to the ophthalmologist reveals bitemporal hemianopsia. Which of the following is the most likely cause of this woman’s infertility?

A 28-year-old woman with 28-day menstrual cycle is attempting to conceive and is considering the use of a home ovulation predictor kit to time intercourse at ovulation. She asks you what day of her menstrual cycle her luteinizing hormone (LH) peak is most likely to occur. What should you tell her?

A 28-year-old woman with no past medical history presents for her initial prenatal visit. Her last menstrual period (LMP) was 6 weeks ago. Vital sign: BP, 125/78 mmi P, 73 beats/mini R, 13 breaths/min, T: 98°F (37 C). She denies leakage of fluid, denies vaginal bleeding, denies fetal movement, denies contractions, nausea and vomiting present. Labs: Complete blood count (CBC): white blood cells (WBCs), 8 x l03/ [1L hemoglobin(Hgb), 11.0 g/dL hematocrit (Hct), 33.5%; platelets, 167 x103/microL. CMP: Sodium, 128 mmol/ L; potassium, 4.5 mmol/L; chloride, 100 mmol/L; bicarbonate, 22 mmol/ L; blood urea nitrogen (BUN), 0.9 mg/dL; creatinine, 1 mg/dL; glucose, 97 mg/dL. Rubella IgG: positive. HIV: positive. CD4 count: 750. Viral load: 20,000 copies/mL. Hepatitis B sAg: Negative. HgbAlc: 5.6%. What drug is contraindicated in pregnancy?

A 29-year-old Caucasian primigravida patient is 20 weeks pregnant with twins. She found out today on her routine ultrasound for fetal anatomy that she is carrying two boys. In this patient’s case, which of the following statements about twinning is true?

A 29-year-old male with a 6-year history of HIV infection presents with chronic, severe diarrhea associated with malaise, nausea, anorexia and abdominal cramps. His last CD4 count was 80cells/mm3. A modified acid-fast stain of a stool specimen shows 4-6 mm oocysts. Which of the following is the most likely microorganism responsible for this condition?

A 29-year-old man is brought to the ED by EMS for a syncopal episode that occurred during a basketball game. A friend states that the patient just dropped to the ground shortly after scoring a basket on a fast break. On examination, you note a prominent systolic ejection murmur along the left sternal border and at the apex. An ECG reveals left ventricular hypertrophy, left atrial enlargement, and septal Q waves. You suspect the diagnosis and ask the patient to perform the Valsalva maneuver while you auscultate his heart. Which of the following is most likely to occur to the intensity of the murmur with this maneuver?

A 29-year-old man returns home to Colorado after a diving trip to Honduras in Central America. He was gone for 6 days. The day he returns, he starts to develop diarrhea, abdominal cramping, and nausea. There is no mucus and blood in the stool. He has no other medical problems and does not take medications. He does not use tobacco, alcohol or drugs. His temperature is 37.2°C (98.9°F), blood pressure is 120/74 mm Hg, pulse is 80/min, and respirations are 15/min. There is no lymphadenopathy. Chest is clear to auscultation. Abdomen is soft and non-tender. There is no organomegaly. Bowel sounds are increased. Stool is negative for leukocytes and fecal occult blood. Which of the following is the most likely pathogen responsible for his symptoms?

A 29-year-old man with acquired immune deficiency syndrome (AIDS) comes to the emergency department because of progressively increasing abdominal discomfort. Examination shows voluntary guarding in the upper abdomen. His biochemistry is normal except for an elevated amylase at 370 U/L (25–125 U/L). Which of the following infections can trigger this disorder in AIDS patients?

A 29-year-old man with HIV, on a highly active antiretroviral therapy (HAART) regimen including the protease inhibitor indinavir, presents with severe edema and a serum creatinine of 2.0 mg/dL. He has had bone pain for 5 years and takes large amounts of acetaminophen with codeine, aspirin, and ibuprofen. He is on prophylactic trimethoprim-sulfamethoxazole. Blood pressure is 170/110 mm Hg; urinalysis shows 4+ protein, 5 to 10 RBC, 0 WBC; 24-hour urine protein is 6.2 g. The serum albumin is 1.9 g/L (normal above 3.7). Which of the following is the most likely cause of his renal disease?

A 29-year-old patient comes to the physician for an annual examination. She has normal menstrual periods every 30 days. She was 15 years old when she first began having intercourse. She uses condoms for contraception. Her past medical history is significant for multiple sclerosis. This condition has required her to use a wheelchair for the past 4 years, which makes pelvic examination somewhat difficult for her. She smokes one pack of cigarettes per day. Given her difficulty with the pelvic examination, she inquires as to how often she needs to have a Pap smear performed. Which of the following is the correct answer?

A 29-year-old white female presents to the emergency department with nausea, vomiting, severe generalized abdominal pain, and hypotension. She is subsequently admitted to the intensive care unit. Her past medical history is significant for hypothyroidism secondary to Hashimoto's thyroiditis, for which she has been taking levothyroxine. She denies smoking cigarettes, drinking alcohol, and using any intravenous drugs. Her mother also has hypothyroidism. Her blood pressure is 70/50 mmHg, heart rate is 110/min, temperature is 98.4°F (37.0°C) and respiratory rate is 24/min. Physical examination reveals dry and pigmented mucous membranes. The skin creases also show increased pigmentation. Lab studies show: Serum chemistry: Serum Na 130 mEq/L, Serum K 6.1 mEq/L, Chloride 96 mEq/L, Bicarbonate 18 mEq/L, BUN 33 mg/dL, Serum creatinine 1.3 mg/dL, Blood glucose 56 mg/dL. CBC: Hemoglobin 10.8 g/L, Platelets 300,000/mm3, Leukocyte count 6,500/mm3, Neutrophils 70%, Eosinophils 10%, Lymphocytes 20%. The random serum cortisol level is 3.2 mcg/dL (normal=5 to 25 mcg/dL), and ACTH level is 142 pg/mL (normal= 9 to 52 pg/mL). What is the most likely involved pathophysiologic mechanism of this patient's disorder?

A 29-year-old woman, gravida 2, para 0, comes for a routine prenatal visit. According to her history, she is at 16-weeks gestation. She had a first trimester miscarriage during her previous pregnancy. She does not take any vitamin supplementation. Vital signs are stable and physical examination is unremarkable. Initial laboratory studies show increased maternal serum alpha-fetoprotein (MSAFP) levels. Which of the following is the most likely cause of the abnormal laboratory finding?

A 2950-g (6.5-lb) black baby boy is born at home at term. On arrival at the hospital, he appears pale, but the physical examination is otherwise normal. Laboratory studies reveal the following: mother’s blood type A, Rh-positive; baby’s blood type O, Rh-positive; hematocrit 38%; and reticulocyte count 5%. Which of the following is the most likely cause of the anemia?

A 3-day-old infant, born at 32 weeks’ gestation and weighing 1700 g (3 lb, 12 oz), has three episodes of apnea, each lasting 20 to 25 seconds and occurring after a feeding. During these episodes, the heart rate drops from 140 to 100 beats per minute, and the child remains motionless; between episodes, however, the child displays normal activity. Blood sugar is 50 mg/dL and serum calcium is normal. Which of the following is most likely true regarding the child’s apneic periods?

A 3-month-old girl is brought to the pediatrician for a scheduled visit. She has been meeting all development milestones but has been vomiting after each feeding. The infant weighed 3 kg (6 lb 10 oz) at birth and now weighs 6 kg (13 lb 3 oz). She does not have diarrhea and is afebrile. The remainder of the physical examination is unremarkable. Which of the following is the most likely cause of this patient's vomiting?

A 3-month-old infant is taken to the emergency department with constipation and behavioral changes. Physical examination demonstrates ptosis and an absence of facial expression. The child appears conscious but has trouble following a toy with her gaze. The crying is very weak, and saliva is pooling in her mouth. She is also developing a generalized hypotonia, and breathing is becoming more shallow. This child's condition is most likely related to ingestion of which of the following food products?

A 3-month-old infant without significant past history was brought to the emergency center by her mother with a generalized tonic-clonic seizure. She is found to have glucose of 5 mg/dL. After correction of her hypoglycemia, she is admitted to your service for further evaluation. Several hours later, her nurse calls to tell you that her bedside glucose check was now 10 mg/dL. You order laboratory work suggested by the pediatric endocrinology team and again correct the infant’s hypoglycemia. The results of the laboratory tests you drew include an elevated serum insulin level of 50 μU/mL, and a low IGFBP-1 (plasma insulin-like growth factor binding protein-1). C-peptide levels are not detectable. Which of the following is the likely cause of this child’s recurrent hypoglycemia?

A 3-month-old Jewish infant is brought to the emergency department because of a generalized seizure 1 hour ago. He is lethargic, weighs 2.7kg (61b), and has a doll-like face with fat cheeks, relatively thin extremities, and a protuberant abdomen. His liver is felt 5cm (2in) below the right costal margin. His kidneys are enlarged. His blood sugar level is 40mg/dl. His serum uric acid, total cholesterol, triglycerides and lactic acid levels are elevated. The levels of his liver transaminases are normal. What is the most likely cause of this infant's symptoms?

A 3-month-old male infant is brought to the emergency department by his mother because of difficulty in breathing. His mother was admitted in the hospital ten days ago due to a urinary tract infection, and he was cared for by his grandmother during that period. His mother had just been discharged from the hospital yesterday, and noticed that he was constipated and having difficulty with breastfeeding. On examination, he is afebrile. His pulse rate is 110/min, respirations are 36/min with shallow breathing efforts, and blood pressure is 90/50mm Hg. His weight is at the 35th percentile. Examination shows ptosis, dilated pupils with sluggish reaction to light, diminished deep tendon reflexes and decreased muscle tone. What is the most likely mechanism of his illness?

A 3-week-old African American boy is brought to the Emergency Department because of a generalized seizure 2 hours ago. The infant is highly irritable with incessant high pitched crying. The infant's weight is 2.5 kg (250 gm below birth weight), blood pressure is 70 /40 mm Hg, pulse is 145/min and respirations are 50/min. Laboratory results show: Blood glucose 120 mg/dL, Urea nitrogen 50 mg/dL, Serum sodium 170 mEq/L, Serum calcium 8.5 mg/dL, Serum magnesium 1.5 mg/dL. Which of the following is the most likely cause of this infant’s seizure?

A 3-week-old boy presents to the physician's office with a 1-week history of forceful, projectile vomiting. He has been vomiting after almost every feeding. The vomitus contains mostly undigested formula and is non-bilious. On examination, his oral mucosa is dry, his anterior fontanel appears to be depressed, and his capillary refill is 3-4 seconds. An abdominal examination reveals an olive-sized mass in the epigastrium. Which of the following electrolyte findings will most likely be seen?

A 3-week-old female is brought into the emergency department with a fever and irritability. She was born after a normal pregnancy and delivery. Her mother had routine prenatal care and has no history of sexually transmitted infections. The infant's mother is 14 years old and the father is 17 years old. They are not married, and the father is not involved in the care of the infant. The infant lives with her mother and maternal grandparents at the maternal grandparents' home. You are concerned about meningitis and decide to do a lumbar puncture. The mother and maternal grandparents are present in the emergency department. Informed consent should be obtained from which of the following individuals?

A 3-year-old boy is brought by his father to the Emergency Department with fever, headache and neck pain that developed over the past several hours. The father states he is not the birth father, and that he and his wife adopted the boy at 18 months of age after his birth mother abandoned him. Physical examination reveals a lethargic male with a temperature of 39.7 C (103.5 F). There is photophobia, and mildly injected conjunctiva are appreciated. Pupils are equal and reactive and funduscopic examination is unremarkable. The patient has neck stiffness with a positive Kernig's sign. A complete blood count reveals a leukocyte count of 24,000/mm3 with 64 segmented neutrophils and 25 bands. A lumbar puncture is performed that reveals elevated CSF pressure, decreased glucose, and elevated protein. A Gram's stain shows gram-negative pleomorphic rods. There is no growth on blood agar. Growth on chocolate agar reveals white colonies. Which of the following is the most likely pathogen?

A 3-year-old boy is brought to the emergency department three hours after having a seizure. He has been having severe diarrhea for the last three days. His mother recently read about the importance of maintaining adequate hydration during diarrhea, so she had been giving him a lot of milk mixed with water. On examination, his vital signs are stable and mucus membranes are moist. Initial lab results are: Hb 13 g/dl, WBC 6,000/mm3, Platelets 300,000/mm3, Blood Glucose 98 mg/dl, Serum Na 120 mEq/L, Serum K 3.4 mEq/L, Chloride 92 mEq/L, BUN 22 mg/dl, Creatinine 1.2 mg/dl. What is the most likely cause of this patient's seizure?

A 3-year-old boy is brought to the office by his 27-year-old white mother for the evaluation of recurrent bone fractures. His first fracture was that of the femur, and occured when he was 6 months old. He had a fracture of the wrist 4 months ago. His mother also has a history of multiple fractures since childhood. She lost all her teeth at a very early age and is complaining of deafness. Her husband has a history of severe alcohol abuse. On examination, both mother and son have blue sclerae. What is the most likely involved disease process?

A 3-year-old boy is brought to the office by his parents for the evaluation of dry eyes and photophobia. He has some difficulty in adapting to darkness. He is a very poor eater, and his diet consists mainly of canned foods, and very rarely, fresh vegetables or milk. Examination reveals dry, scaly skin, follicular hyperkeratosis in the extensor surfaces of the extremities, and dry, silver-gray plaques on the bulbar conjunctiva. What is the most likely diagnosis of this patient?

A 3-year-old male is brought to the emergency department for evaluation of right neck swelling. His parents noticed a lump on his right neck yesterday, which has since increased in size and is now erythematous and tender. He has been previously healthy except for mild upper respiratory tract symptoms last week. His temperature is 38C (100.4F), pulse is 90/min, and respiratory rate is 25/min. On examination, he is nontoxic appearing. A 5-cm anterior cervical lymph node is palpated on the right side. It is poorly mobile, warm, erythematous, and tender to palpation. There is no fluctuance or induration. What is the most likely organism causing these symptoms?

A 3-year-old-boy ingests 40 of his older sister's chewable vitamin tablets, as well as 3 tablets of 250 mg of acetaminophen. The ingredients in the multivitamin tablets are as follows: Vitamin A 3000 IU, Thiamine 1 mg, Vitamin C 75 mg, Vitamin B6 1 mg, Vitamin D 400 IU, Iron 12 mg, Fluoride 1 mg. The child is brought to the emergency department in no acute distress. Which of the following complications may occur if appropriate therapy is not undertaken?

A 30-year-old Caucasian male comes to the office due to symmetric weakness of his lower extremities. He also has paresthesias in his toes and fingers, and lower back pain. The neurological examination shows symmetric weakness, diminished reflexes, and intact sensation in his lower extremities. Orthostatic hypotension is also noted. Electrophysiological studies show slowed nerve conduction velocities. Lumbar puncture reveals normal opening pressure. CSF examination shows few cells, and a protein concentration of 90 mg/dL. Which of the following organisms is involved in the pathogenesis of this disorder?

A 30-year-old class D diabetic is concerned about pregnancy. She can be assured that which of the following risks is the same for her as for the general population?

A 30-year-old female presents with a circumferential pruritic rash over her right wrist. The rash has been present for the last two days, and she denies ever having a similar rash before. She bought a new bracelet two weeks ago, and has been wearing it on her right forearm since. Which of the following metals in jewellery is most likely to cause such symptoms?

A 30-year-old G3P3 is postoperative day 4 after a repeat cesarean delivery. During the surgery she received 2 units of packed red blood cells for a hemorrhage related to uterine atony. She is to be discharged home today. She complains of some yellowish drainage from her incision and redness that just started earlier in the day. She states that she feels feverish. She is breast-feeding. Her past medical history is significant for type 2 diabetes mellitus and chronic hypertension. She weighs 110 kg. Her vital signs are temperature 37.8C (100.1F), pulse 69 beats per minute, respiratory rate 18 breaths per minute, and blood pressure is 143/92 mm Hg. Breast, lung, and cardiac examinations are normal. Her midline vertical skin incision is erythematous and has a foul-smelling purulent discharge from the lower segment of the wound. It is tender to touch. The uterine fundus is not tender. Which of the following is not a risk factor for her condition?

A 30-year-old man is concerned about "floating spots" and blurred vision in his right eye. He had a serious injury of his left eye several weeks ago, which eventually led to vision loss in that eye. Inspection reveals a moderate perilimbal flush. What is the most probable cause of this patient's condition?

A 30-year-old woman presents to your office for her well-woman examination and contraception. She has two prior vaginal deliveries without any complications. Her medical and surgical histories are negative. Her family history is significant for coronary heart disease in her father and breast cancer in her mother diagnosed at the age of 62 years. In addition to effective contraception, health benefits for women taking oral combination contraceptives include which of the following?

A 30-year-old woman, gravida 3, para 1, abortus 1, is at 30 weeks’ gestation by dates. She has been married for 7 years to the same husband. Her first pregnancy ended in a spontaneous first-trimester loss. Her second pregnancy was unremarkable until delivery at term, when she underwent an emergency lowtransverse cesarean section because of double footling breech presentation. She has worked in a child daycare center for the past 5 years. She vacationed in Thailand for 2 weeks last year. On routine prenatal laboratory testing, you find that she is hepatitis B surface antigen positive, and anti-HBc IgM negative. She inquires about the significance of this finding concerning herself, as well as her baby. Which of the following statements best summarizes what you will say?

A 30-year-woman presents to your office with the fear of developing ovarian cancer. Her 70-year-old grandmother recently died from ovarian cancer. You discuss with her the risks factors and prevention for ovarian cancer. Which of the following can decrease a woman’s risk of ovarian cancer?

A 31-year-old biker is involved in a motor vehicle accident after attending a party where he drank a lot of soda drinks. He describes a direct blow to his lower abdomen and pelvis during the accident. He complains of diffuse abdominal pain that refers to his left shoulder. Which of the following injuries most likely accounts for this patient's current symptoms?

A 31-year-old primigravid woman comes to the physician for a prenatal visit. She is known to be HIV positive. She also has asthma, for which she uses an inhaler. She had a diagnostic laparoscopy at age 20 for pelvic pain and has had no other surgeries. She has no known drug allergies. Extensive counseling is given to the patient regarding vertical transmission of HIV to the fetus. It is recommended to her that she take antiretroviral therapy during the pregnancy to decrease the vertical transmission rate. It is also recommended to her that she have a scheduled cesarean delivery. After consideration of these options, the patient chooses not to take the antiretrovirals and opts for a vaginal delivery. Which of the following represents the approximate risk of vertical transmission (from the mother to the fetus) for this patient?

A 31-year-old primigravida develops gestational diabetes mellitus and is managed appropriately during pregnancy. She asks you about the consequences of gestational diabetes to her and her fetus. Which one of the following statements is correct?

A 31-year-old woman voices her anger at the increasing number of immigrants who compete for job opportunities in her chosen field of computer science. She observes that many of her friends in the local community are also experiencing difficulty in securing appealing employment because of the influx of immigrants. This woman volunteers in her spare time to provide vocational guidance to new immigrant families in the community. Which of the following psychological defense mechanisms is she demonstrating?

A 31-year-old, HIV-infected man from New York presents to the ER with anorexia, malaise, night sweats, fever, and weight loss of 6.8kg (15 lb) over the past one month. He also has a cough productive of yellow sputum. He was diagnosed with HIV two years ago. When last checked two months ago, his CD4 count was 220/microL. He is not taking any medications. His temperature is 39.2°C (102.2°F), pulse is 96/min, and blood pressure is 120/80 mm Hg. Physical examination reveals rales in his right upper chest. Laboratory studies show: Hematocrit 30%, WBC count 3,400/microL, Neutrophils 86%, Bands 2%, Lymphocytes 4%, Monocytes 8%. PPD test shows 3 mm induration. Chest x-ray reveals a right upper lobe cavitation. Sputum examination shows partially acid-fast, filamentous, branching rods. Based on these findings, which of the following organism is the most likely cause of this patient's pulmonary disease?

A 31-year-old, HIV-infected man from New York presents to the ER with anorexia, malaise, night sweats, fever, and weight loss of 6.8kg (151b) over the past one month. He also has a cough productive of yellow sputum. He was diagnosed with HIV two years ago. When last checked two months ago, his CD4 count was 220/microL. He is not taking any medications. His temperature is 39.2°C (102.2°F), pulse is 96/min, and blood pressure is 120/80mm Hg. Physical examination reveals rales in his right upper chest. Laboratory studies show: Hematocrit 30%, WBC count 3,400/microL, Neutrophils 86%, Bands 2%, Lymphocytes 4%, Monocytes 8%. PPD test shows 3 mm induration. Chest x-ray reveals a right upper lobe cavitation. Sputum examination shows partially acid-fast, filamentous, branching rods. Based on these findings, which of the following organism is the most likely cause of this patient's pulmonary disease?

A 32-year old woman comes to the physician because of pain and paresthesias in her thumb, first two fingers and the radial-half of the ring finger. Her pain is worse at night and interferes with sleep. She feels tired and unable to work effectively in her office lately. She takes an over-the-counter stool softener for constipation but otherwise has no known medical problems. Her vital signs are within normal limits. When you ask the patient to maintain acute wrist flexion for 30seconds she experiences severe pain and paresthesias. Her skin is dry. Which of the following is the most likely cause of her hand symptoms?

A 32-year-old Asian female presents to the office with a mole on her foot that recently became darker. She has always had skin that is very sensitive to sunlight. She is unable to tan, and has had several sunburns when she did not use sunscreens. Her past medical history is insignificant. Her mother had 'a kind of skin cancer.' Physical examination reveals a dark mole with irregular borders on the left foot. Which of the following is the strongest risk factor for malignancy in this patient?

A 32-year-old Caucasian male presents to the ER with a 12-hour history of anorexia and vomiting. He says that he feels “a little dizzy”. He denies abdominal pain or diarrhea. His past medical history is insignificant His blood pressure is 110/70 mmHg while supine and 100/60 mmHg while sitting. His heart rate is 90/min. His laboratory values are: Serum sodium 139 mEq/L, Serum potassium 3.1 mEq/L, Serum calcium 8.9 mEq/L, Serum chloride 88 mEq/L, Serum bicarbonate 33 mEq/L, Blood glucose 95 mg/dl, BUN 20 mg/dl, Serum creatinine 1.1 mg/dl. Which of the following is the most likely cause of the decreased chloride level in this patient?

A 32-year-old female is brought to the emergency department with complaints of weakness, tingling and numbness of her extremities. She is not on any medication. Her pulse is 90/min, respirations are 14 /min and blood pressure is 110/70 mm Hg. The physical examination is unremarkable. Her laboratory profile is shown below: Blood pH 7.56, HCO3- 37 mEq/L, Urine Na+ 16 mEq/L, Urine K+ 20 mEq/L, Urine Cl- 7 mEq/L, Serum sodium 135 mEq/L, Serum potassium 2.9 mEq/L, Serum chloride 92 mEq/L, Blood urea nitrogen 22 mg/dl, Serum creatinine 0.9 mg/dl. Which of the following is the most likely cause of this patient's condition?

A 32-year-old G2P2 develops fever and uterine tenderness 2 days after cesarean delivery for nonreassuring fetal heart tones. She is placed on intravenous penicillin and gentamicin for her infection. After 48 hours of antibiotics she remains febrile, and on examination she continues to have uterine tenderness. Which of the following bacteria is resistant to these antibiotics and is most likely to be responsible for this woman’s infection?

A 32-year-old male complains of progressive weakness and exertional dyspnea. His past medical history is significant for a knife injury to the right thigh two months ago. He has been arrested several times for robbery. He consumes alcohol regularly, and smokes crack occasionally. His younger brother died of cystic fibrosis. His blood pressure is 160/60 mmHg, and heart rate is 100/min. His extremities are warm and flushed. Carotid upstroke is brisk. The point of maximal impulse is displaced to the left, and a soft, holosystolic murmur is heard over the cardiac apex. The murmur does not change with the Valsalva maneuver. Which of the following is the most likely cause of this patient's symptoms?

A 32-year-old male with type 1 diabetes and severe depression is brought to the emergency department because of a 2-day history of nausea and abdominal pain. His temperature is 37.6°C (99.7°F), blood pressure is 122/86 mmHg, respirations are 25/min and pulse is 88/min. His lab values are as follows: Blood pH 7.31, PaO2 90mm Hg, PaCO2 29 mmHg, HCO3- 14 mEq/L, Blood glucose 450 mg/dl, Serum sodium 132 mEq/L, Serum potassium 5.0 mEq/L, Serum chloride 85mEq/L, Blood urea nitrogen 19 mg/dl, Serum creatinine 1.1 mg/dl. Which of the following best describes this patient's acid-base status?

A 32-year-old man develops symptoms of wheezing, cough, and shortness of breath. He has bilateral expiratory wheezes, and the rest of the examination is normal. Further evaluation with pulmonary function tests reveals a reduced FEV1/FVC ratio that corrects with bronchodilators. Which of the following statements about a diagnosis of idiosyncratic asthma (also called nonatopic) is correct?

A 32-year-old man is admitted to the psychiatric unit after his wife brought him to the emergency room in a severe major depression. The patient signs himself in voluntarily because he “didn’t think he is safe” at home. Which of the following factors most increases a patient’s risk of suicide while on the inpatient unit?

A 32-year-old man is brought to the emergency department by paramedics after being found wandering downtown, apparently delirious and agitated. During transport to the hospital the patient becomes diaphoretic and tremulous and has a blood pressure to 163/100 mmHg, pulse of 102/min, and temperature of 39°C (102.2°F). On examination the patient has dilated pupils and ulcerations of his nasal septum mucosa with the residue of a white powder along the nasal alae in addition to his tachycardia, hypertension, hyperthermia, and agitation. Which of the following is the reason why nonselective β-blockers should be avoided in this patient?

A 32-year-old poorly controlled diabetic G2P1 is undergoing amniocentesis at 38 weeks for fetal lung maturity prior to having a repeat cesarean section. Which of the following laboratory tests results on the amniotic fluid would best indicate that the fetal lungs are mature?

A 32-year-old pregnant female is being evaluated at her 32nd week of gestation. Her lab profile shows the following: Blood pH 7.44, PaO2 100 mmHg, PaCO2 30 mmHg, HCO3- 20 mEq/L, WBC count 9,000/cmm, Hb 11 mg/dl, Na+ 134 mEq/L, K+ 3.6 mEq/1, Cl- 98 mEq/L, BUN 5 mg/dlCreatinine 0.6 mg/dl. Which of the following can best explain her acid-base status?

A 32-year-old woman presents to your office to discuss contraception. She has recently stopped breast-feeding her 8-month-old son and wants to stop her progestin-only pill because her cycles are irregular on it. You recommend a combination pill to help regulate her cycle. You also mention that with estrogen added, the contraceptive efficacy is also higher. In combination birth control pills, which of the following is the primary contraceptive effect of the estrogenic component?

A 32-year-old woman presents with progressively worsening dyspnea on exertion one month after returning from a vacation in Texas. She says that her symptoms have progressed to the point that she now wakes during the night with a choking sensation that improves only with sitting up. Recently her shortness of breath has required her to significantly limit her physical activity. She denies having associated chest pain, skin rash or joint pain. She has no significant past medical history. Family history is significant for thyroid cancer in her aunt and lung cancer in her father, a heavy smoker. On physical examination, her temperature is 37.2°C (99°F), pulse is 96/min, blood pressure is 110/70 mmHg, and respirations are 14/min. Bilateral pitting ankle edema is present. Her liver is enlarged 2 cm below the right costal marginal. Lung auscultation reveals decreased breath sounds at the bilateral bases. Cardiac exam reveals the presence of a third heat sound. Chest x ray shows an enlarged cardiac silhouette and small bilateral pleural effusion. EKG is unremarkable. Which of the following is the most likely cause of her symptoms?

A 32-year-old woman who presents with menometrorrhagia is found to have a 4.0-cm mass within her left ovary. This mass is resected surgically and a histologic section reveals the tumor to be composed of small polygonal cells growing sheets and anastomosing cords. Rare Call-Exner bodies are present. The tumor cells are found to stain positively with an immunoperoxidase stain against inhibin. Which one of the following is most likely to be secreted by these tumor cells?

A 32-year-old woman with a history of diabetes presents with an IUP at 5 weeks. She has been taking metformin, glyburide, and lisinopril. Her glucose has been well controlled on these medications. Vital sign: BP, 120/80 mm Hg; P, 75 beats/min; R, 12 breaths/min; T, 98°F (37 C). She denies leakage of fluid, denies contractions, denies fetal movement, denies vaginal bleeding, and denies abdominal pain. What is the mechanism of action of glyburide?

A 32-year-old woman with a history of diabetes presents with an IUP at 5 weeks. She has been taking metformin, glyburide, and lisinopril. Her glucose has been well controlled on these medications. Vital sign: BP, 120/80 mm Hg; P, 75 beats/min; R, 12 breaths/min; T, 98°F (37 C). She denies leakage of fluid, denies contractions, denies fetal movement, denies vaginal bleeding, denies abdominal pain. What is the definition of gestational diabetes?

A 32-year-old woman, gravida 3, para 2, at 37 weeks' gestation comes to the physician for a prenatal visit. She has no current complaints. Her past medical history is significant for hepatitis C infection, which she acquired through a needle stick injury at work as a nurse. She is hepatitis B and HIV negative. She takes no medications and has no allergies to medications. Her prenatal course has been uncomplicated. She wants to know whether she can have contact with the baby or breast-feed given her hepatitis C status. Which of the following is the correct response?

A 33-year-old diabetic man receives a renal allograft. The physicians choose cyclosporine as one of the antirejection medications. Which of the following functions does cyclosporine A primarily inhibit?

A 33-year-old man presents with low-grade fever, abdominal cramps, and diarrhea for the past six hours. He has had eight episodes of loose, watery stool containing blood and mucus over this time period. Last night, he ate shrimp and crab meat at a local restaurant. His current pulse is 85/min, blood pressure is 110/80 mm Hg, and temperature is 37.7°C (99.9°F). There are no significant findings on abdominal or rectal examinations. Stool examination shows numerous red blood cells and leukocytes. Which of the following is the most likely causative organism of this patient's condition?

A 33-year-old white female comes to the office for the evaluation of weakness in her upper extremities. She thinks she is unable to feel pain or heat, because she recently noted some burn wounds on her fingertips, and does not know how she got them. She denies weakness in her lower limbs, as well as any history of trauma, headache, bowel or bladder problems, neck pain or facial pain. Examination reveals absent reflexes in her upper limbs. There is absent pain and temperature sensation on the nape of neck, shoulders and upper arms in a 'cape' distribution. Vibration and position sensations are preserved. Which of the following is the most likely pathology of the patient's condition?

A 33-year-old woman comes to the physician because she has not had a menstrual period for 8 months. She had menarche at the age of 12 and, after a few years of irregular menses, has since had normal monthly menses. She has no medical problems and takes no medications. Examination reveals a normal-appearing female with no abnormalities noted. Urine human chorionic gonadotropin (hCG) is negative. Serum thyroid stimulating hormone (TSH) and prolactin are also normal. The patient is given a 10-day course of medroxyprogesterone acetate. Upon completing the 10 days, she has a heavy menstrual period. This patient's withdrawal bleeding in response to the progesterone provides good evidence for which of the following?

A 33-year-old woman comes to the physician for her first prenatal visit. Her last menstrual period was 7 weeks ago. She has had no bleeding or abdominal pain. She has no medical problems and takes no medications. She has no family history of congenital anomalies. Her husband is 55 years old. He is in good health and also has no family history of birth defects. The patient is concerned that her husband's age may place their fetus at increased risk of a chromosomal anomaly. She wishes to know the paternal age above which amniocentesis or chorionic villus sampling should be considered. Which of the following is the correct response?

A 33-year-old woman develops mild epigastric abdominal pain with nausea and vomiting of 2 days duration. Her abdomen is tender on palpation in the epigastric region, and the remaining examination is normal. Her white count is 13,000/mL, and amylase is 300 U/L (25–125 U/L). Which of the following is the most common predisposing factor for this disorder?

A 33-year-old woman is undergoing an elective, open cholecystectomy after 2 episodes of acute calculous cholecystitis. She suddenly becomes hypotensive, and a generalized rash is noted. Her past medical history is significant for a hypotensive episode 8 weeks ago while having protected sex with her new partner. Which of the following is the most probable cause of this patient's condition?

A 33-year-old woman seeks assistance because of a swelling of her right parotid gland. Biopsy is performed and reveals acinar carcinoma. You consent the patient for resection and inform her that at the very least, she will require superficial parotidectomy. Which of the following intraoperative findings would require sacrifice of the facial nerve?

A 33-year-old, gravida 3, para 3 woman comes to the physician because of amenorrhea of 9-month duration. She denies symptoms of any kind. She had a tubal ligation after the birth of her last child 2 years ago. She did not breast feed. Her menarche was at the age of 13 years, and her menses were regular until 18 months ago. At that time, her menses skipped every other month, and then they stopped. She currently takes no medication. She weighs 120.2 kg (264lb) and is 160 cm (5'3") tall. Initial physical examination shows no abnormalities except for morbid obesity. In the initial blood work, serum TSH and prolactin levels are within normal limits. Follow-up laboratory test show: FSH 20 mIU/mL (normal: 5-30 mIU/mL), LH 15 mIU/mL (normal: 5-20 mIU/mL). Which of the following is the most likely explanation for this patient's amenorrhea?

A 34-year-old female presents to your office complaining of pressure-like, substernal chest pain that has been affecting her recently when she plays active sports. Resting consistently alleviates the pain. She denies any associated nausea, vomiting, diaphoresis, dyspnea, palpitations or syncope. Family history is non-contributory. On physical examination, her pulse is 79/min and blood pressure is 130/70 mmHg. Cardiac auscultation reveals a high-pitched 3/6 systolic murmur best heard at the second right intercostal space. The lungs are clear to auscultation. Chest x-ray shows a normal sized heart and clear lung fields. What is the most likely cause of this patient's chest pain?

A 34-year-old homosexual male with a history of HIV presents to the clinic complaining of a wheezing and multiple violaceous plaques and nodules on his trunk and extremities. Physical examination of the oral mucosa reveals similar findings on his palate, gingiva, and tongue. Chest x-ray is also significant for pulmonary infiltrates. What is the most likely pathogenesis of this process?

A 34-year-old male is brought to the emergency department with altered mental status. His girlfriend reports that he has had fever and cough for the past two days. His past medical history is significant for abdominal trauma two years ago that required splenectomy and left-sided nephrectomy. On physical examination, his temperature is 39° C (102.2°F), blood pressure is 80/50 mm Hg, pulse is 110/min, and respirations are 32/min. Gram-positive cocci are cultured from his blood. Which of the following is most likely impaired in this patient?

A 34-year-old male who recently emigrated from Asia comes to the clinic and complains of a two-month history of exertional shortness of breath and easy fatigability. He has been taking isoniazid and rifampin for his tuberculosis, which was diagnosed four months ago. Due to his religious beliefs, he completely turned into a vegetarian for the last year. Physical examination reveals severe pallor. Peripheral smear shows macrocytosis with hypersegmented polymorphonuclear neutrophils. His WBC and platelet counts are within normal limits. This patient's most likely problem is due to which of the following?

A 34-year-old male who recently immigrated from Brazil presents with a 5-month history of exertional dyspnea without associated chest pain, palpitations, dizziness, or syncope. His past medical history is significant for an episode of megacolon, which was treated 2 years ago. On physical examination, there is 1+ pedal edema and mild jugular venous distention. Cardiac exam is significant for the presence of an S3, but no murmurs are heard. Chest x-ray reveals prominent cardiomegaly. Based on these findings, which of the following is most likely causing his symptoms?

A 34-year-old man is brought to the emergency department after being involved in a motorbike accident. Examination shows a hematoma on the forehead and bleeding from his leg. His pupils are bilateral round and eactive; he has papilledema. He responds to pain, has decorticated posture and speaks incoherently. After the initial resuscitation you start the treatment with intravenous fluids, hyperventilation, head elevation and intravenous mannitol. Which of the following is the mechanism of action of hyperventilation in this patient?

A 34-year-old man rushes into the ER complaining of severe substernal chest pain that began abruptly 30 minutes ago. He says that he also feels as though his heart 'is racing,' but denies any shortness of breath, cough or fever. He has never experienced pain like this before. His past medical history is significant for an appendectomy one year ago. The patient reports that his father died at age 64 due to "some heart problem" and his mother died of ovarian cancer. On physical examination, the patient is agitated and sweating profusely. His pulse is 110/min, blood pressure is160/100 mmHg, and respirations are 14/min. Physical examination is normal except for dilated pupils and a small amount of blood at the external nares. EKG shows ST elevations in leads v1-v4. What is the most likely explanation for his symptoms?

A 34-year-old obese Caucasian female complains of periodic visual obscurations. She has episodes during which she "goes blind" for several seconds when standing up or stooping forward abruptly. She also describes frequent morning headaches over the last two months for which she has had to take ibuprofen or aspirin almost every morning. She takes no other medications. Past medical history is insignificant aside from one uncomplicated vaginal delivery. She denies use of alcohol, tobacco, or illicit drugs. She is afebrile with a blood pressure of 138/88 mmHg and pulse of 93/min. Visual field testing shows enlarged blind spots. There are no other significant findings on neurologic examination. Which of the following is the most likely cause of this patient's symptoms?

A 34-year-old obese female is brought to the emergency department complaining of severe right upper quadrant abdominal pain that began suddenly earlier this morning. She is accompanied by her husband. An ultrasound evaluation is performed and the woman is diagnosed with acute cholecystitis. Because her symptoms worsen with conservative treatment, the decision is made to operate. The patient is discharged home five days after her successful cholecystectomy. Upon discharge, the patient and her husband request all medical records associated with her stay. What is the most appropriate response on the behalf of the physician?

A 34-year-old primigravida develops severe postpartum bleeding requiring aggressive volume resuscitation and transfusion of 5 units of packed red blood cells. Her pregnancy was complicated by mild hypertension and trace proteinuria that was treated with low-dose methyldopa. Her mother suffered from premature menopause and severe osteoporosis. Seven days after giving birth, she has failed to lactate. Her urinalysis is insignificant and her blood pressure has ranged from 95 to110 mmHg systolic and 69 to 75 mmHg diastolic. Fundoscopy shows no retinal changes. Which of the following is most likely deficient in this patient?

A 34-year-old woman who describes herself as a "holistic healer" brings her two children aged four years and three years to the pediatrician for routine physical examinations. This is a first visit as they have recently moved from another state. The medical records for the children indicate that no immunizations have been given. When the mother is questioned about this, she proudly replies, "My children are wonderfully healthy on their own and have no need for these artificial vaccines." The principles and benefits of immunization are discussed at length, as well as the risks inherent in not being immunized. The physician recommends that the children be given all age-appropriate vaccinations today. The mother remains convinced that immunizations cause more harm than good, and she steadfastly refuses to allow her children to be vaccinated. What is the most appropriate next step?

A 35-year-old African American woman presents to a physician complaining of irregular menstrual periods. She had her first menses at age 15 and states that her periods come irregularly every 2 to 6 months. She has been in a monogamous relationship with her husband for 15 years; for 10 years they have been trying unsuccessfully to conceive. She gets yearly Pap smears, which have been normal. Her height is 5 feet 2 inches (157.5 cm), and her weight is 200 pounds (90.9 kg). Her temperature is 37 C (98.6 F), blood pressure is 118/78 mm Hg, pulse is 80/min, and respirations are 14/min. She has acne, as well as excess hair, on her face and between her breasts. Her abdomen is obese. Examination is otherwise within normal limits. This patient is at greatest risk for developing which of the following diseases?

A 35-year-old Caucasian male presents to the emergency department with two episodes of bloody vomiting which occurred one-half hour ago. He has a history of migraines. For the past two days, he has been having severe headaches and has taken 20 tablets of aspirin without relief. He then resorted to heavy drinking and forgot about the pain. He drinks alcohol "occasionally" and has been smoking 1 pack of cigarettes daily for the past 18 years. Which of the following is the most likely explanation for this patient's hematemesis?

A 35-year-old Caucasian male with aplastic anemia undergoes bone marrow transplantation. The donor is an HLA-matched sibling. Two weeks after the procedure, he develops a maculopapular pruritic rash that is predominantly found on his face, hands, and feet. He also complains of diarrhea. The stool is positive for occult blood. Liver function tests are abnormal. Which of the following is the most likely pathophysiologic mechanism of this patient's condition?

A 35-year-old HIV-positive male is complaining of deterioration of his vision over the past week. He initially experienced eye pain and mild conjunctivitis, followed by rapid progressive visual loss. Examination of his eyes reveals marked keratitis. Funduscopy shows widespread, pale, peripheral retinal lesions and central necrosis of the retina. Which of the following is the most likely causative organism of this patient's condition?

A 35-year-old white female is complaining of blurry vision and pain with eye movements. She is on no medications and denies any trauma. Last year, she developed bladder incontinence and an episode of leg weakness, which both improved without therapy. Physical examination reveals reduced vision and swollen optic discs. The one diagnosis that may explain her symptoms is:

A 35-year-old woman undergoes an elective laparoscopic cholecystectomy for symptomatic cholelithiasis. Which of the following wound classes best describes her procedure?

A 35-year-old woman who has recently emigrated from Asia presents to the emergency room with acute onset of dyspnea. She denies any cough, chest pain, or fever. She has a history of rheumatic heart disease as a teen. On examination, she has an irregular pulse of 97/min, blood pressure of 125/75 mmHg and temperature of 37.2°C (98.9°F). The first heart sound is loud and a mid-diastolic rumble is heard at the apex. Crackles are present in both lung fields. ECG shows an irregularly, irregular heart rhythm and the absence of 'P' waves. Which of the following is the most likely cause of this patient's abnormal heart rhythm?

A 35-year-old woman, gravida 3, para 2, underwent a spontaneous vaginal delivery at 39 weeks’ gestation of a 3,295 g (7 lb 4 oz) male neonate who has done well. She had a prolonged third stage of labor, resulting in an attempted manual removal of the placenta. The placenta was not completely removed, and bleeding progressed to hemorrhage. Ultimately, she underwent an emergency total abdominal hysterectomy due to placenta accreta. She received 5 units of packed red blood cells (PRBCs). Her blood pressure was in the hypotensive range for 30 minutes during the procedure. Which of the following pituitary hormones is most likely to be affected by her clinical course?

A 36-year-old male AIDS patient comes in due to a painful red eye. He complains of pain, discharge and redness in his left eye for the past 10 days. On physical examination, you notice redness in his left eye as well as multiple skin lesions on his face, left eyelid, inner thighs, penis and pubis. The lesions are painless, pale, shiny, dome-shaped papules with a central umbilication measuring 2-5mm in diameter. These lesions were not present on his previous visit. His CD4 count thirty days ago was 100/uL. What is the most likely etiology of this patient's skin lesions?

A 36-year-old morbidly obese woman presents to your office for evaluation of irregular, heavy menses. An office endometrial biopsy shows complex hyperplasia of the endometrium without atypia. The hyperplasia is most likely related to the excess formation in the patient’s adipose tissue of which of the following hormones?

A 36-year-old white male is brought to the emergency department because of dyspnea, tachypnea, crampy pain and paresthesias in his extremities. He gives an unclear history about how he "rapidly ascended to a height of 10,000 feet” His pulse is 70/min, blood pressure is 120/80 mmHg, temperature is 36.7°C (98.5°F) and respirations are 24/min. The significant physical finding on examination is carpopedal spasm. At this point, the suspected diagnosis is acute respiratory alkalosis secondary to hyperventilation. Which of the following is true regarding this patient's serum calcium level?

A 36-year-old woman whose mother has just undergone treatment for breast cancer is asking about how this affects her and what can be done to lessen her chances of having the disease. Which of the following has the lowest risk factor for breast cancer?

A 36-year-old woman, gravida 5, para 4, at 30 weeks' gestation comes to the physician for a prenatal visit. She feels the baby moving and has not had bleeding per vagina, contractions, or loss of fluid. The prenatal course has been uncomplicated thus far. The patient is interested in having a postpartum tubal ligation. She has many questions regarding the procedure, including whether there is a risk of failure. Which of the following represents the closest estimate for the likelihood of failure of a postpartum tubal ligation?

A 37 year-old man with chronic schizophrenia is brought to see a new psychiatrist for treatment. While taking the history, the psychiatrist finds that the patient functions with a flat affect and circumstantial speech all the time. He has few friends. He is able to hold a menial job at the halfway house where he lives, and his behavior is not influenced by delusions or hallucinations currently. What should the psychiatrist rate the patient on Axis V (global assessment of functioning)?

A 37-year-old G3P2 presents to your office for her first OB visit at 10 weeks gestation. She has a history of Graves’ disease and has been maintained on propylthiouracil (PTU) as treatment for her hyperthyroidism. She is currently euthyroid but asks you if her condition poses any problems for the pregnancy. Which of the following statements should be included in your counseling session with the patient?

A 37-year-old G4P2 presents to your office for new OB visit at 8 weeks. In a prior pregnancy, the fetus had multiple congenital anomalies consistent with trisomy 18, and the baby died shortly after birth. The mother is worried that the current pregnancy will end the same way, and she wants testing performed to see whether this baby is affected. Which of the following can be used for chromosome analysis of the fetus?