2nd Basic USMLE 200Q

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 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?

A 38-year-old Caucasian female presents to your office complaining of a small amount of vaginal discharge that appears following sexual intercourse. There is no associated abdominal pain or urinary symptoms. Her menstrual cycles occur with regular 28-day cycles; her last menstrual period was 2 weeks ago. She has never been pregnant. Menarche occurred at age 10, and she has been sexually active with 10 different partners over the last 20 years. She smokes two packs of cigarettes per day and consumes alcohol regularly. She admits that her diet is poor in vegetables and fruit. Her mother died of breast cancer at age 54, and her father, who is living, has hypertension. Cervical biopsy reveals cervical intraepithelial neoplasia III (CIN III). Which of the following is the strongest risk factor for this condition?

A 38-year-old female comes to your office complaining of occasional palpitations. She describes feeling a fast and irregular heartbeat. Over the past two months, she has had three such episodes, each lasting about two hours. She denies any associated chest pain, shortness of breath cough or ankle swelling. She drinks alcohol on social occasions and does not smoke cigarettes. She has no other medical problems and is not taking any medications. On physical examination, her temperature is 37.1°C (98.9°F), pulse is 80/min, blood pressure is 130/70mmHg, and respirations are 14/min. On auscultation of her heat the apical impulse is displaced and there is an S3. You also hear a pansystolic murmur, which is loudest at the apex and radiates to the axilla. Which of the following is the most likely cause of her symptoms?

A 38-year-old G3P3 begins to breast-feed her 5-day-old infant. The baby latches on appropriately and begins to suckle. In the mother, which of the following is a response to suckling?

A 38-year-old G4P3 at 33 weeks gestation is noted to have a fundal height of 29 cm on routine obstetrical visit. An ultrasound is performed by the maternal-fetal medicine specialist. The estimated fetal weight is determined to be in the fifth percentile for the estimated gestational age. The biparietal diameter and abdominal circumference are concordant in size. Which of the following is associated with symmetric growth restriction?

A 38-year-old male with steroid-dependent sarcoidosis presents to the physician's office because of progressive right hip pain. He localizes the pain to right groin and states that the pain is present on weight bearing and at rest. His temperature is 37.2°C (98.9°F) and blood pressure is 156/86 mm Hg. Examination shows decreased range of motion due to pain. He also has a round face and fullness in supraclavicular area. Purple striae are present on skin. Muscle power is slightly decreased in the proximal thigh muscles in both legs. Reflexes are 2+, and there are no sensory deficits. Plain films of the right hip show no significant abnormalities ESR is 10 mm/hr. Which of the following is the most likely cause of his hip pain?

A 38-year-old man is being seen in his physician’s office after being involved in a car accident. He has a vague pain along his right sternal border, where he crashed into the steering wheel. His temperature is 36.6°C (97.8°F), pulse is 80/min, blood pressure is 123/75 mm Hg, respiratory rate is 14/min, and oxygen saturation is 99% on room air. Physical examination is significant for point tenderness over the right sternal border. X-ray of the chest shows no broken ribs but a single, well-circumscribed pulmonary nodule, 1.5 cm in diameter, located in the left lower lung field. A search through the patient’s electronic medical file reveals that he had an x-ray of the chest taken 2 years ago. The radiology report from that time reveals that the nodule was only 0.75 cm in diameter. To characterize the lesion, CT of the chest is performed and shows dense, flocculated calcification within the lesion. Which of the following risk factors most increases the chances of malignancy in this patient?

A 38-year-old Mexican male presents to the emergency department with a history of weight loss, fever, cough with sputum, nausea, abdominal pain, and postural dizziness for the last three months. Adrenal insufficiency is suspected, and cosyntropin (synthetic ACTH) stimulation test is performed. The rise of serum cortisol following an injection of cosyntropin is grossly subnormal. CT scan of the abdomen shows calcification of both adrenal glands. What is the most likely cause of this patient's adrenocortical insufficiency?

A 38-year-old woman who underwent total thyroidectomy for multinodular goiter 6 months ago presents with persistent hoarseness. Which of the following nerves was most likely injured during her operation?

A 39-year-old G3P3 presents for her postpartum examination and desires a long-term contraceptive method, but is unsure if she wants sterilization. She has been happily married for 15 years and denies any sexually transmitted diseases. Her past medical history is significant for mild hypertension, for which she takes a low-dose diuretic. She is considering an intrauterine device and wants to know how it works. Which of the following is the best explanation for the mechanism of the action of the intrauterine device (IUD)?

A 39-year-old patient is contemplating discontinuing birth control pills in order to conceive. She is concerned about her fertility at this age, and inquires about when she can anticipate resumption of normal menses. You counsel her that by 3 months after discontinuation of birth control pills, what proportion of patients will resume normal menses?

A 39-year-old woman presents to the physician’s office for evaluation of a palpable nodule in the neck of 2 years’ duration. Her past history is pertinent for Hashimoto’s disease diagnosed 5 years ago, for which she takes thyroid hormone. She has a history of low-dose chest irradiation for an enlarged thymus gland during infancy. On examination, a 2.5-cm nodule is palpable in the left lobe of the thyroid and is firm and nontender. Which of the following portions of her history increases the risk for thyroid cancer?

A 39-year-old woman presents with generalized malaise and lymphadenopathy. Biopsy of a supraclavicular lymph node reveals non-Hodgkin lymphoma. Fortyeight hours after initiation of chemotherapy, she develops a high-grade fever and her laboratory studies demonstrate hyperkalemia, hyperphosphatemia, and hypocalcemia. Which of the following cells mediate this syndrome?

A 39-year-old woman presents with increasing abdominal distention and pelvic pain. A CT scan finds a slight amount of fluid in the pleural cavity and also a 3.5cm tumor of the right ovary. The tumor is resected and histologic sections reveal the tumor to be composed of spindle-shaped cells. These cells did not stain with an oil red O special stain. Which of the following types of ovarian tumor is most likely to produce this constellation of findings?

A 4-day-old boy is brought to the physician for an outpatient follow-up visit. His mother's pregnancy and delivery were uncomplicated. The patient weighed 3.4 kg (7.5 lb) and was 48.2 cm (1'7") long at birth. He did well in the newborn nursery and was discharged from the hospital on day 2 of life. His mother reports that he is now exclusively breastfed and nurses for 10 minutes on each breast every 3 hours. He has two wet diapers/day and has not had a bowel movement for 2 days. He weighs 2.95 kg (6.5 lb) and is 48.2 cm (1'7'') long. He appears jaundiced on the face and chest. The remainder of the physical examination shows no abnormalities. Laboratory studies reveal: Total bilirubin 15 mg/dl, direct bilirubin 1 mg/dl, Infant's blood type 0 positive, Mother's blood type A positive. Which of the following is the most likely cause of this infant's hyperbilirubinemia?

A 4-month-old baby is in for a well-child check and routine immunizations. The baby had a fever of 39°C the day he received his 2-month immunizations. The parents have read about the vaccine on the Internet and express their concerns. Which of the following is an absolute contraindication to giving the diphtheria and tetanus toxoids and acellular pertussis (DTaP)?

A 4-month-old infant boy has gained only 10 ounces since birth. He has failed to gain weight with multiple formula preparations. His stools have been loose and fatty. An older sister had similar symptoms and has been repeatedly hospitalized for failure to thrive and recurrent pulmonary infections. Which of the following is the most likely cause of this patient's gastrointestinal symptoms?

A 4-week-old boy is brought to clinic by his mother because of a 1 day history of labored breathing. His birth was uneventful and immunizations have been up to date. His mother reports that the patient developed conjunctivitis on the fourth day of life. On physical examination, he is breathing rapidly at 40 breaths per minute and is afebrile. His chest reveals bilateral inspiratory crackles and a slight wheeze. On chest x-ray, bilateral pneumonia is evident. The leukocyte count is elevated at 15,000 with 40% eosinophils. Which of the following is the most likely pathogen causing the patient's symptoms?

A 4-year-old boy is sent to the emergency room because of clinical suspicion of meningitis. He has been ill for 2 days with fever and lethargy. On examination, he is febrile, the neck is stiff, and papilledema is present. There is no rash, the lungs are clear, and heart sounds normal. Which of the following is the most likely causative organism?

A 4-year-old boy, who has a ventriculoperitoneal shunt for congenital hydrocephalus, develops fever, headache, irritability, lethargy, photophobia, and vomiting. His temperature is 39.6 C (103.2 F). He is noted to have nuchal rigidity, with the presence of both Kernig's and Brudzinski's signs. The shunt tract is erythematous on the surface. A lumbar puncture is performed and shows a WBC of 40,000/mm3 with 85% neutrophils, a glucose concentration of 48 mg/dL, and a protein concentration of 169 mg/dL. Which of the following is the most likely pathogen?

A 4-year-old child comes in for a health maintenance visit. His mother is concerned that he is not doing some things that other kids in his preschool do. Which of the following skills would be expected of a 4-year-old?

A 4-year-old child presents in the clinic with an illness notable for swelling in front of and in back of the ear on the affected side, as well as altered taste sensation. Correct statements about this condition include which of the following?

A 4-year-old girl is brought to the physician because of a crusted honey-colored erythema resulting from rupture of tiny vesicles and pustules. Her temperature is 37.7 C (102 F). Skin lesions are distributed over the face and extremities. Physical examination reveals enlargement of lymph nodes in the cervical and axillary regions. Which of the following is the most frequent pathogen of this skin infection?

A 4-year-old male is brought to the physician with fever and headache. His symptoms began two days ago with low-grade fever, cough, and congestion. Last night, he developed a temperature of 102 F (38.9 C) and became fussy and less active. Today, he is crying and complaining of a headache. His parents report that he has vomited twice today. In the office, his temperature is 102.5 F (39 C), pulse is 110/min, and respiratory rate is 20/min. On examination, he is irritable and shows signs of photophobia. His oropharynx is erythematous. Nuchal rigidity is present and when the neck is flexed, the patient flexes his lower extremities. The remainder of the physical examination is normal. Lumbar puncture is performed and the results are shown below. CSF: Glucose 60 mg/dL, Protein 80 mg/dL, RBC 10/mm3, WBC 100/mm3, Neutrophils 10%, Lymphocytes 70%, Monocytes 20%, Gram stain negative. Which of the following organisms is most likely responsible for this patient's presentation?

A 4-year-old previously well African American boy is brought to the office by his aunt. She reports that he developed pallor, dark urine, and jaundice over the past few days. He stays with her, has not traveled, and has not been exposed to a jaundiced person, but he is taking trimethoprim sulfamethoxazole for otitis media. The CBC in the office shows a low hemoglobin and hematocrit, while his “stat” serum electrolytes, blood urea nitrogen (BUN), and chemistries are remarkable only for an elevation of his bilirubin levels. His aunt seems to recall his 8-year-old brother having had an “allergic reaction” to aspirin, which also caused a short-lived period of anemia and jaundice. Which of the following is the most likely cause of this patient’s symptoms?

A 40-year-old female is brought to the emergency department following a motor vehicle accident in which she was the front seat passenger. She reports hitting her head against the windshield and hurting her right leg. She appears completely alert and oriented. Glasgow Coma Scale = 15/ 15. Her pupils are equal and reactive to light. There is a bruise over the right forehead, but no tenderness is present on palpation of the cranial bones. Examination of the right leg reveals a hematoma over the thigh. Knee extension on the right is markedly reduced when compared to the left. Sensory examination reveals decreased sensory perception to both sharp and dull stimuli over the right lower medial leg. All other dermatomes are intact. What nerve injury is most likely present in this patient?

A 40-year-old female presents with altered mental status and confusion. Last year, she was diagnosed with rheumatoid arthritis, for which she is currently using indomethacin and methotrexate. Her temperature is 37°C (98.6°F), pulse is 75/min, blood pressure is 110/70 mmHg, and respirations are 15/min. She is disoriented and irritable. Mucus membranes are moist. There is no jugular venous distention. Lungs are clear to auscultation. Abdomen is soft, nontender and not distended. There is no peripheral edema. Serum chemistry reveals: Sodium 122 mEq/L, Potassium 3.7 mEq/L, Bicarbonate 22 mEq/L, Blood glucose 90 mg/dL, BUN 9.0 mg/dL, Uric acid 3.0 mg/dL. Serum osmolality is 265mOsm/kg, while urine osmolality is 500 mOsm/kg. What is the most likely cause of this patient's hyponatremia?

A 40-year-old G2P1001 presents to your office for a routine OB visit at 30 weeks gestational age. Her first pregnancy was delivered 10 years ago and was uncomplicated. She had a normal vaginal delivery at 40 weeks and the baby weighed 7 lb. During this present pregnancy, she has not had any complications, and she reports no significant medical history. She is a nonsmoker and has gained about 25 lb to date. Despite being of advanced maternal age, she declined any screening or diagnostic testing for Down syndrome. Her blood pressure range has been 100 to 120/60 to 70. During her examination, you note that her fundal height measures only 25 cm. Which of the following is a likely explanation for this patient’s decreased fundal height?

A 40-year-old male patient presents with a thyroid nodule. His other complaints are episodes of palpitations, anxiety and sweating. He denies heat intolerance. His weight and appetite are normal. He has a family history of thyroid cancer. His pulse is 80/min, and blood pressure is 160/100 mmHg. Examination of the neck shows a 4-cm, hard, non-tender thyroid nodule. The urinalysis, serum sodium, serum potassium, serum calcium, serum creatinine, serum PTH, TSH, T3 and T 4 levels, and the EKG are all normal. The serum calcitonin level is elevated. The urinary levels of metanephrine and norepinephrine are increased as well. FNA biopsy of the thyroid nodule shows malignant cells. Genetic testing shows a mutation in the RETproto oncogene. Which of the following abnormalities is also present in most patients suffering from this disorder?

A 40-year-old man comes to the physician because of a two-week history of fatigue, lower extremity edema and dark urine. He has no history of serious illnesses. He takes no medications. He does not use tobacco, alcohol, or drugs. His blood pressure is 130/80 mm Hg and pulse is 80/min. Physical examination shows symmetric pitting edema of lower extremities. Laboratory studies show a serum creatinine level of 1.1 mg/dl. Urinalysis shows 4+ proteinuria and microhematuria. Light microscopy of the specimen obtained from kidney biopsy shows dense deposits within glomerular basement membrane that stain for C3, not immunoglobulins. Which of the following is the most likely pathophysiologic mechanism that explains this patient's condition?

A 40-year-old man comes to the physician because of increasing urinary frequency and urgency. He has had these symptoms in the past, but they are more troublesome now. He has also had urinary hesitancy and interruption of flow. His temperature is 37°C (98.6°F), blood pressure is 130/75mm Hg, pulse is 76/min, and respirations are 15/min. Physical examination shows no abnormalities except increased tone of the anal sphincter and mild periprostatic tenderness. Urinalysis and urine culture shows no abnormalities and expressed prostatic secretions show a leukocyte count of four WBCs/HPF (normal is less than 10 WBCs/HPF). Serum prostate-specific antigen is 2 ng/ml (normal value is less than 4ng/ml). Which of the following is the most likely diagnosis?

A 41-year-old woman undergoes exploratory laparotomy for a persistent adnexal mass. Frozen section diagnosis is serous carcinoma. Assuming that the other ovary is grossly normal, what is the likelihood that the contralateral ovary is involved in this malignancy?

A 41-year-old woman who is 32-weeks pregnant presents to the emergency department in labor. Her pregnancy has been complicated by gestational hypertension. Her medical history is otherwise unremarkable. She does not abuse alcohol, tobacco, or illicit drugs. Despite medical interventions, her preterm labor cannot be arrested, and she delivers a 2 kg (41b, 5oz) female infant. Both she and the child do well after delivery. Which of the following is true regarding immunizations for this infant?

A 4196 g (9 lb 4 oz) infant is delivered via vaginal delivery to a 31-year-old mother with gestational diabetes. The delivery was complicated by shoulder dystocia. He is taken to the newborn nursery where his initial plasma glucose level is 20 mg/dL. The initial spun hematocrit is 65%. Which of the following congenital anomalies is this baby most likely to have?

A 42-year-old morbidly obese man is being evaluated for poor sleep. He complains of frequent awakenings due to a choking sensation and says that the resulting tiredness severely limits his physical activity. He also complains of chronic leg swelling. He denies cigarette, alcohol, or drug use. On physical examination, his blood pressure is 160/100 mmHg and his heart rate is 110/min. Which of the following additional findings is most likely to be present in this patient?

A 42-year-old woman is evaluated for chronic abdominal pain and fatigue. Her pain is epigastric, crampy, and sometimes awakens her from sleep. She denies any recent weight loss, nausea, or vomiting. Her diet consists mainly of fruits and vegetables. She also complains of a "strange appetite" for paper and ice that she has never had before. Upper gastrointestinal endoscopy reveals an ulcer located on the anterior wall of the duodenal bulb. Her unusual appetite is most directly related to:

A 42-year-old woman is evaluated for depression, mood swings and poor. She also complains of mild headaches and muscle weakness. She has had two ER visits for kidney stones over the past year. She denies any illicit drug use. Her blood pressure is 160/105 mmHg and her heat rate is 85/min. Her laboratory findings are shown below: Sodium 140mEq/L, Potassium 3.6 mEq/L, Chloride 101 mEq/L, Bicarbonate 24 mEq/L, BUN 13 mEq/L, Creatinine 0.9 mEq/L, Glucose 98 mEq/L, Calcium 11.7 mg/dL. Which of the following is the most likely cause of this patient's hypertension?

A 42-year-old, right-handed man has had a history of progressive speech difficulties and right hemiparesis for 5 months. He has had progressively severe headaches for the past 2 months, which are worse in the mornings. At the time of admission, he is confused and vomiting, and has blurred vision, papilledema, and diplopia. Shortly thereafter, his blood pressure increases to 190/110 mm Hg, and he develops bradycardia. Which of the following is most likely the significance of the hypertension and the bradycardia?

A 43-year-old Caucasian female has a long history of polyarthritis. She also complains of fatigue, low-grade fever, weakness and recent weight loss. Her current medications are methotrexate, naproxen and ranitidine. Physical examination reveals deformed hand joints and a soft, tender mass palpated in the right popliteal fossa. The latter finding is best explained by:

A 43-year-old HIV-positive male presents to your office with several exophytic purple skin masses on his lower abdomen. Physical examination reveals tender hepatomegaly and an abdominal CT scan shows nodular, contrast-enhanced intrahepatic lesions of variable size. Liver biopsy is attempted but severe hemorrhage results. Which of the following is the most likely cause of this patient's condition?

A 43-year-old man feels vaguely unwell. Physical examination is unremarkable except for evidence of scleral icterus. The skin appears normal. Which of the following is the most likely explanation for why early jaundice is visible in the eyes but not the skin?

A 43-year-old man is being evaluated for one month of blurred vision, frontal headaches and occasional falls. He reports that the blurry vision is worse when he leans forward. He relates his symptoms to a recent break-up with his girlfriend. On physical examination, his blood pressure is 160/100 mmHg and his heart rate is 60/min. Which of the following is most likely responsible?

A 43-year-old man presents to your office with low energy and increased fatigability. He also complains of daytime sleepiness and occasional headaches. He drinks two to three glasses of wine daily but does not smoke. He sleeps in a separate room from his wife because she finds his constant snoring annoying. On physical examination, his blood pressure is 160/100 mmHg and his heart rate is 80/min. His BMI is 31.5 kg/m2. His abdomen is soft and non-tender. The liver span is 10 cm and the spleen is not palpable. Laboratory findings are: Hematocrit 60%, WBC count 9,000/mm3, Platelets 190,000/mm3. Which of the following is most likely responsible for this patient's increased hematocrit?

A 43-year-old man with a gangrenous gallbladder and gram-negative sepsis agrees to participate in a research study. An assay of tumor necrosis factor (TNF) is performed. Which of the following is the origin of this peptide?

A 43-year-old trauma patient develops acute respiratory distress syndrome (ARDS) and has difficulty oxygenating despite increased concentrations of inspired O2. After the positive end-expiratory pressure (PEEP) is increased, the patient’s oxygenation improves. What is the mechanism by which this occurs?

A 43-year-old woman with congestive heart failure, rheumatoid arthritis and chronic hepatitis C complains of abdominal discomfort and difficulty breathing. Physical examination shows dullness to percussion at the right lung base. Chest x-ray reveals a large right-sided pleural effusion. Thoracentesis yields pleural fluid with a glucose content of 30 mg/dl and an LDH of 192units/L. Which of the following explains the pleural fluid glucose concentration?

A 44-year-old G6P3215 presents for her well-woman examination. She tells you that all of her deliveries were vaginal and that her largest child weighed 2900 g at birth. How many full-term pregnancies did this patient have?

A 44-year-old male who has had an extensive small bowel resection for Crohn's disease has been on total parenteral nutrition for two years. He presented to the hospital with epigastric and right upper quadrant pain. He has been taking azathioprine. His vital signs are within normal limits. Physical examination shows mild right upper quadrant tenderness. An ultrasonogram shows several gallstones; an ultrasonogram performed two years ago did not demonstrate gall stones. Which of the following is the most likely cause of his gallstones?

A 44-year-old obese female undergoes an open cholecystectomy for a complicated acute cholecystitis. On her third post-operative day, her temperature is 36.7°C (98.2°F), blood pressure is 110/80 mm Hg and pulse is 92/min. Her arterial blood gas shows the following: Blood pH 7.28, PaO2 62 mmHg, PaCO2 54 mmHg, HCO3- 30 mEq/L. What is the most likely cause of acidosis in this patient?

A 44-year-old woman presents with increased shortness of breath, cough, and sputum production. She has had asthma since childhood and uses her medications as directed. Recently, she noticed that her peak flow readings were decreasing after the symptoms started. On examination, she is in moderate respiratory distress, respirations 25/min, there are bilateral wheezes and oxygen saturation is 90% on room air. On her blood gas, the PCO2 is 50 mm Hg. Which of the following is the most likely mechanism for her carbon dioxide retention?

A 44-year-old woman, gravida 4, para 3, at 8 weeks' gestation comes to the physician for her first prenatal visit. She has mild nausea and vomiting but no other complaints. Her obstetric history is significant for three full-term, normal vaginal deliveries of normal infants. She has no medical or surgical history and takes no medications. Physical examination reveals an 8-week-sized uterus, but is otherwise unremarkable. She wishes to have chromosomal testing of the fetus and wants to have chorionic villus sampling performed, as she did with her last pregnancy. Compared with amniocentesis, chorionic villus sampling may place the patient at greater risk for which of the following?

A 45-year-old Asian male complains of a progressively worsening sore throat and difficulty swallowing for the past 24 hours. You notice that his voice is muffled and he is drooling. He also has a harsh shrill associated with respiration. His temperature is 39.3°C (103°F), blood pressure is 120/80 mmHg, pulse is 106/min, and respiratory rate is 22/min. On examination, a few cervical lymph nodes are palpable and there is tenderness to palpation over his larynx. Which of the following are the two most common organisms that cause this condition?

A 45-year-old Asian man presents to your office complaining of easy fatigability. He denies abdominal pain, distention, nausea, vomiting, or significant weight loss. His past medical history includes a gastrectomy for a non-healing gastric ulcer. He is not currently taking any medications. He quit smoking several years ago and does not use alcohol or illicit drugs. His vital signs are within normal limits. Physical examination reveals a shiny tongue and pale palmar creases. No lymphadenopathy, hepatomegaly, or splenomegaly is present. His blood hemoglobin level is 7.5 mg/dL and W8C count is 3,800/mm3. Stool tests for occult blood are repeatedly negative. This patient's condition involves which of the following pathophysiologic mechanisms?

A 45-year-old Caucasian male presents with a 2-year history of progressive heartburn which is most severe while supine. Over-the-counter antacids have not relieved his symptoms. Endoscopy shows a hiatal hernia. The patient is reluctant to accept any treatment. Which of the following is he at risk for if his condition is left untreated?

A 45-year-old female presents complaining of constipation and abdominal pain for the past two weeks. She also complains of urinary frequency and constant thirst. Her past medical history is significant for obesity. She tells you that she has been trying very hard to lose weight, and over the past six months has even attempted various fad diets. She assures you that she supplements her intake with numerous over-the-counter vitamins and minerals. She has managed to lose 20 lbs during this time. Her medical history is also significant for atrial fibrillation for the past 4 years, for which she takes diltiazem. On physical examination, her temperature is 36.8°C (98.2°F), blood pressure is 120/70 mmHg, pulse is 90/min, and respirations are 13/min. Her mucous membranes are dry, and her abdomen is soft and non-tender without rebound or rigidity. Bowel sounds are present. Urinalysis is within normal limits. Which of the following is most likely responsible for her current symptoms?

A 45-year-old male comes to the physician with a 6-month history of periodic abdominal pain. He tried several over-the-counter medications including H2 blockers and proton pump inhibitors with moderate success. Workup, including an upper GI series and endoscopy, showed multiple duodenal ulcers and a single jejunal ulcer. Test of the stool for occult blood is positive. Test of the stool for fat is positive. Which of the following is the best explanation for this patient's impaired fat absorption?

A 45-year-old man comes to the office and complains of intermittent, bloody diarrhea and abdominal pain for the past month. During this time period, he has lost six pounds. He was diagnosed with HIV infection in the past, but has refused antiretroviral therapy. Laboratory results show a CD4 count of 50cells/μL. The stool examination is negative. Colonoscopy with biopsy shows multiple colonic ulcerations and mucosal erosions. The biopsy shows large cells containing eosinophilic intranuclear and basophilic intracytoplasmic inclusions. What is the most likely cause of this patient's diarrhea?

A 45-year-old man is examined for a yearly executive physical. A mass is palpated in the rectum, and a biopsy suggests carcinoid. Which of the following findings is most likely to be associated with the carcinoid syndrome?

A 45-year-old man presents to the emergency department because of dyspnea, fatigue, poor appetite and weight gain over the past several weeks. He says that about four weeks ago he began to develop worsening shortness of breath with exertion and more recently has been waking at night with breathlessness. He also notes that it is sometimes difficult for him to open his eyes in the morning due to facial edema. He has no significant past medical history and he takes no medications. On physical examination, his blood pressure is 200/120 mmHg and his heart rate is 100/min. You note generalized bodily edema and distention of his jugular veins while he is sitting upright. On lung auscultation you hear bibasilar rales. Urinalysis shows trace protein, no nitrites, trace leukocyte esterase, 50+ red blood cells and occasional neutrophils. Which of the following is the most likely cause of this patient's edema?

A 45-year-old man presents to the emergency room with a two-day history of fever, dyspnea, abdominal pain, and diarrhea. He has no chest pain, but complains of dry cough. His past medical history is significant for bone marrow transplantation for acute myeloid leukemia (AML) three months ago. His temperature is 39°C (102.2°F), blood pressure is 122/80 mm Hg, pulse is 98/min, and respirations are 22/min. Exam of the oropharynx reveals thrush. Lungs exam demonstrates bilateral diffuse rales. Heart sounds are regular. Nonspecific abdominal tenderness is present. The chest radiograph shows multifocal, diffuse patchy infiltrates. Which of the following is the most likely cause of this patient's current condition?

A 45-year-old man was an unhelmeted motorcyclist involved in a high-speed collision. He was ejected from the motorcycle and was noted to be apneic at the scene. After being intubated, he was brought to the ER, where he is noted to have a left dilated pupil that responds only sluggishly. What is the pathophysiology of his dilated pupil?

A 45-year-old white female has undergone a right mastectomy for a node-negative, estrogen and progesterone receptor-positive tumor. She is scheduled to begin adjuvant therapy with tamoxifen. Her menstrual cycles are regular and her last menstrual period was 15 days ago. She has many concerns about tamoxifen therapy and would like to know its risks and benefits. Which of the following is she at risk for?

A 45-year-old woman is seen with wasting of the intrinsic muscles of the hand, weakness, and pain in the wrist. Which of the following nerves has most likely been injured?

A 45-year-old woman with breast cancer undergoes a modified radical mastectomy with lymph node dissection. Six weeks later, she returns complaining of decreased mobility of her shoulder. On physical examination, the scapula protrudes from the body when pressing her outstretched arm on the wall. Which of the following nerves was most likely injured during the operation?

A 45-year-old woman with Crohn disease and a small intestinal fistula develops tetany during the second week of parenteral nutrition. The laboratory findings include: Na: 135 mEq/LK: 3.2 mEq/LCl: 103 mEq/LHCO3: 25 mEq/LCa: 8.2 mEq/LMg: 1.2 mEq/LPO4: 2.4 mEq/LAlbumin: 2.4An arterial blood gas sample reveals a pH of 7.42, PCO2 of 38 mm Hg, and PO2 of 84 mm Hg. Which of the following is the most likely cause of the patient’s tetany?

A 45-year-old woman with long-standing, well-controlled rheumatoid arthritis develops severe pain and swelling in the left elbow over 2 days. She is not sexually active. Arthrocentesis reveals cloudy fluid. Synovial fluid analysis reveals >100,000 cells/mL; 98% of these are PMNs. What is the most likely organism to cause this scenario?

A 46-year -old alcoholic man comes to the emergency department because of several episodes of vomiting. The last episode of emesis contained blood. Five hours ago, he had a fatty meal and several alcoholic drinks. Two days ago, he had an upper GI tract endoscopy and abdominal ultrasound for the evaluation of dyspepsia. The endoscopy was unremarkable, and the ultrasound showed a hyperechogenic enlarged liver and stones in the gallbladder. His temperature is 36.6°C (97.9°F), blood pressure is 120/70 mm Hg, pulse is 95/min, and respirations are 15/min. Laboratory studies show: Hb 12.8 g/dl, WBC 5,400/cmm, BUN 26 mg/dl, Creatinine 1.1 mg/dl, AST 100 U/L, ALT 45 U/L, Bilirubin 0.7 mg/dl. Nasogastric suction shows normal stomach contents mixed with bright red blood. The rectal examination shows no melena. Which of the following is the most likely explanation for this patient's bloody vomiting?

A 46-year-old farmer comes to the physician because of pain and swelling of his right heel. He accidentally stepped on a rusty nail while working 2 weeks ago. Although he applied over the-counter antibiotic cream locally and took acetaminophen orally, he continued to have pain at the site of the injury. He has no other medical problems and takes no medication. He has no known drug allergies. He smokes 2-3 cigarettes a day and drinks alcohol occasionally. His temperature is 38.3°C (101°F), blood pressure is 140/90 mm Hg, pulse is 84/min and respirations are 14/min. On examination, the right heel is swollen, red, and warm and tender to touch. A small puncture wound is visible. Laboratory reports show mild leukocytosis. X-ray of the right foot shows features suggestive of osteomyelitis. The most likely cause of the patient's symptoms is infection with which of the following?

A 46-year-old male presents with swelling of his face that is especially prominent in the periorbital area. He also complains of bilateral ankle swelling. He denies shortness of breath, fever and discoloration of urine. He is a non-smoker and non-alcoholic. His past medical history is not significant. He is currently not taking any medication. His pulse is 78/min, blood pressure is 130/70mmHg, respirations are 14/min and temperature is 37.1°C (99.0°F). Examination shows bilateral pitting ankle edema. Auscultation reveals clear lungs, normal heart sounds, and no murmurs. Dipstick urinalysis is positive for protein. 24-hour urine collection shows proteinuria of 4.6 g/day. Lab studies show: Total serum calcium 7.5 mg/dL, Albumin 2.2 g/dL, Phosphorus 3.5 mg/dL, Magnesium 2.2 mg/dL, Creatinine 0.8 mg/dL. Which of the following is the most likely cause of his low serum calcium level?

A 46-year-old man complains of exertional dyspnea and dry cough. He also describes occasional episodes of a suffocating night-time cough that is relieved only when he stands up. His medical history is significant for a myocardial infarction six months ago. His current medications are metoprolol, aspirin and simvastatin. He does not use tobacco but drinks alcohol on social occasions. His father died of a stroke and his mother suffers from diabetes mellitus. His blood pressure is 150/100 mmHg and his heart rate is 60/min. Chest examination reveals bibasilar rales. His cardiac apex is palpated in the sixth intercostal space. The liver span is 12 cm. Bilateral pitting leg edema is also present. Which of the following most likely contributes to his edema?

A 46-year-old man complains of right flank discomfort. He describes decreased urination over the last week with occasional episodes of high urine output and weakness. He is otherwise healthy. There is no family history of renal disease. On physical examination, his blood pressure is 140/90 mmHg and his heart rate is 80/min. The serum creatinine level is 2.1 mg/dl. Urinalysis shows few red blood cells, white blood cells, trace protein, and no casts. Which of the following is the most likely cause of his complaints?

A 46-year-old woman is hospitalized for agitation, restlessness and poor sleep. She has been complaining of headaches recently and has gained 14 pounds over the past three months. She denies any illicit drug use. Her blood pressure is 160/110 mmHg and her heart rate is 90/min. Her laboratory findings are shown below: Sodium 142 mEq/L, Potassium 3.2 mEq/L, Chloride 98 mEq/L, Bicarbonate 26 mEq/L, BUN 12 mg/dl, Creatinine 0.9 mg/dl, Glucose 205 mg/dl, Calcium 9.4 mg/dl. Which of the following is the most likely cause of this patient's hypertension?

A 46-year-old woman undergoes an abdominal hysterectomy for a “fibroid” uterus. The surgeon requests a frozen section on the tumor, which is deferred because of the lesion’s degree of cellularity. Which of the following histologic criteria will be used by the pathologist to determine if this tumor is benign or malignant?

A 47-year-old male presents to your office with a two-month history of lethargy and decreased libido. His medical records reveal that he has been treated for joint pain and swelling over the last six months and was diagnosed with diabetes mellitus one year ago. Physical examination reveals hepatomegaly and testicular atrophy. Which of the following cardiac abnormalities is most likely to also be present in this patient?

A 47-year-old male was brought to the emergency room with chest pain of acute onset. The pain was associated with nausea, vomiting, and diaphoresis. He has a history of diabetes, hypertension, and hyperlipidemia. ECG reveals ST segment elevation in the anterolateral leads and ventricular premature beats (VPBs). The patient dies within the first hour after the arrival to emergency room. What is the most likely pathophysiologic mechanism responsible for this patient's death?

A 47-year-old man is found to have edema, ascites, and hepatosplenomegaly. The examination of his neck veins reveals elevated venous pressure with a deep y descent. Heart size on x-ray is normal. Which of the following etiologies is not a possible explanation for this syndrome?

A 47-year-old man presents to your office complaining of occasional daytime headaches, dizziness and nausea. He has no significant past medical history. He works as a traffic controller in an underground parking lot. He does not smoke cigarettes, and consumes alcohol only on weekends. He is sexually active in a monogamous relationship with his wife and uses condoms for contraception. His cardiac exam is unremarkable. His abdomen is soft and non-tender. The liver span is 8 cm and the spleen is not palpable. Laboratory findings are: Hematocrit 59%, WBC count 7,000/mm3, Platelets 200,000/mm3. Which of the following is most likely responsible for this patient's increased hematocrit?

A 47-year-old woman has new-onset transient right arm weakness and word finding difficulty symptoms lasting 3 hours. She is also experiencing exertional dyspnea, and had a syncopal event 1 month ago. Her echocardiogram reveals a cardiac tumor in the left atrium, it is pendunculated and attached to the endocardium. Which of the following is the most likely cause of this lesion?

A 47-year-old woman loses consciousness for 2 minutes while shopping in a supermarket. In the emergency room, she recounts feeling nausea and warmth spreading over her body immediately before passing out. She has never had a similar episode before. She has not seen a doctor for several years and does not take any medications, nor does she use tobacco, alcohol or drug. Her family history is unremarkable. Which of the following most likely caused this episode?

A 47-year-old woman who is 2 weeks post triple bypass surgery presents to the emergency department with a chief complaint of sudden onset, sharp chest pain for several hours. She is fatigued and short of breath. On physical examination she has distended neck veins that grow more distended on inspiration. Muffled heart sounds are heard. Her temperature is 37.0°C (98.6°F), pulse is 133/min, blood pressure is 70/50 mmHg, respiratory rate is 30/ min, and oxygen saturation is 100% on room air. An echocardiogram shows a large pericardial effusion and chamber collapse; therefore, pericardiocentesis is performed. Although a large amount of blood is aspirated, the patient’s clinical picture acutely worsens. Her pain level increases substantially; pulse is 150/min, blood pressure is 60/41 mm Hg, respiratory rate is 30/ min, and oxygen saturation is 100%. Repeat echocardiography shows an even larger pericardial effusion with chamber collapse. Which complication of pericardiocentesis is most likely in this patient?

A 48-year-old Caucasian male presents to your office complaining of progressive exertional dyspnea. It has become especially bothersome over the past two months. Presently, he becomes short of breath after climbing one flight of stairs. He denies any significant problems in the past. He is not taking any medications and he denies smoking or drinking alcohol. His temperature is 37.2°C (98.9°F), pulse is 78/min, blood pressure is 130/75 mmHg and respirations are 14/min. Chest examination reveals a harsh systolic murmur that is best heard at the right second intercostal space with radiation along the carotid arteries. An S4 is heard at the apex. Based on these findings, what is the most likely cause of this patient's symptoms?

A 48-year-old woman develops constipation postoperatively and self-medicates with milk of magnesia. She presents to clinic, at which time her serum electrolytes are checked, and she is noted to have an elevated serum magnesium level. Which of the following represents the earliest clinical indication of hypermagnesemia?

A 48-year-old woman notices a firm, fixed mass in her right breast but chooses to ignore it. The mass is then detected on her annual physical examination eight months later. By that point, the mass has increased greatly in size. When questioned as to why she did not report the mass when she first noticed it, the woman states that she was not concerned about the mass because she does not have a family history of breast cancer This response is an example of which of the following defense mechanisms?

A 48-year-old woman presents to your office with the complaint of vaginal dryness during intercourse. She denies any medical problems or prior surgeries and does not take any medications. She still has regular menstrual cycles every 28 days. She denies any sexually transmitted diseases. She describes her sexual relationship with her husband as satisfying. Her physical examination is normal. Components of the natural lubrication produced by the female during sexual arousal and intercourse include which of the following?

A 49-year-old woman presents to her physician with dysphagia, regurgitation of undigested food eaten hours earlier, and coughing over the last 6 months. She was hospitalized 1 month ago for aspiration pneumonia and successfully treated with antibiotics. Examination reveals a thin-appearing woman with normal vital signs and unremarkable chest, heart, and abdominal examination. A UGI contrast study is performed and reveals a pharyngoesophageal (Zenker’s) diverticulum. Which of the following statements is true regarding Zenker’s diverticula?

A 5-month-old boy is brought in for a routine check-up. He was born at 37 weeks' gestation and has had persistent wheezing since shortly after birth despite inhaled bronchodilator and oral corticosteroid therapy. His diet consists of 32 ounces of iron-fortified cow's milk-based formula daily. On physical examination, the child appears well-nourished and happy. You note moderate relief of his wheezing with neck extension. Which of the following is the most likely mechanism of this infant's wheezing?

A 5-month-old infant is brought to the office for the evaluation of persistent vomiting, failure to thrive, and developmental delay. His antenatal and postnatal histories are not known to his Caucasian foster parents, who adopted him when he was 4 months old. The physical examination reveals an infant with blonde hair, fair skin and blue eyes. His urine has a peculiar musty odor. His plasma phenylalanine level is 40 mg/dl and tyrosine level is normal. His urinary phenylpyruvic and a-hydroxy phenylacetic acid levels are both increased. What is the most likely etiology of this child's symptoms?

A 5-year-old boy suffers from a condition characterized by recurrent fungal and viral infections, thymic hypoplasia, tetany, and abnormal facies. Serum levels of immunoglobulins are mildly depressed, and lymph node biopsy shows lymphocyte depletion of T-dependent areas. Which of the following is the underlying pathogenetic mechanism?

A 5-year-old pedestrian is hit by a car in a mall parking lot and he is brought to the emergency department. There was loss of consciousness for less than 1 minute. On evaluation, the child has no neurologic deficits and a CT scan of the head reveals no intracranial abnormalities and no obvious skull fractures. The parents want to know what possible long-term problems there might be. You remember that problems after head trauma may include the development of seizures and that the risk of developing posttraumatic epilepsy is increased by which of the following?

A 50-year-old man presents to the office with fatigue, malaise, and disabling joint pain in his fingers, wrists, shoulder, hips, knees, and ankles. His pain is severe and associated with a mild degree of morning stiffness for 10-15 minutes. He occasionally takes acetaminophen and ibuprofen for this pain. He has a 10-pack-year smoking history. He does not drink alcohol. Family history includes an uncle who died of liver cancer. On examination, there is grayish skin pigmentation, most prominent on the exposed parts. Abdominal examination is significant for liver enlargement 2 cm below the costal margin. Laboratory studies reveal the following: Hemoglobin 13.0 g/L, Leukocyte count 5,500/mm3, Serum creatinine 0.8 mg/dl, Blood glucose 218mg/dl, Aspartate aminotransferase (SGOT) 128 U/L, Alanine aminotransferase (SGPT) 155 U/L, Alkaline phosphatase 120 U/L , Serum iron 450 mol/L (50-170g/dL), Transferrin saturation of iron 62% (22-47%), Serum Ferritin 3000ng/L (15-200 ng/ml, males). X-ray of the joints shows narrowing of joint spaces and diffuses demineralization. This patient's condition makes him more vulnerable to which of the following infections?

A 50-year-old man presents to your office complaining of pain and swelling of the right knee. He bumped his right knee into a pole 2 days ago while working. He had one episode of similar pain two years ago that resolved with over-the-counter analgesics. He denies any illicit drug use. He has no other medical problems and does not take any medications. His temperature is 37.2°C (98.9°F), and blood pressure is 126/76 mmHg. Examination reveals swelling, warmth and decreased range of motion of the right knee. All other joints are within normal limits. Synovial fluid analysis shows positive birefringent crystals and negative Gram stain. These crystals are most likely composed of?

A 50-year-old man wants to talk to you about something, "absolutely confidential". After you assure him, he admits, "He is unable to get an erection and just can't have sex." He wants to figure it out quickly because "he simply can't live like this." He has never been diagnosed with diabetes and denies other complaints. He has a 2 pack/day history of smoking for 30 years. On examination, his BP: 158/90mm of Hg; Temperature: 37.1°C (98.8°F); RR 14/min; PR 82/min. There is upper body obesity, rounded face, increased fat around the neck, and thinning of arms and legs. You find his skin to be bruised, fragile and thin. Laboratory reveals the following results. Serum: Glucose 186 mg/dl, Sodium 142 mEq/L, Potassium 2.5 mEq/L, Bicarbonate 38 mEq/L. Chest X ray shows a large mass in left bronchus. What is the most likely cause of patient's condition?

A 50-year-old obese female is taking oral hypoglycemic agents. While being treated for an upper respiratory infection, she develops lethargy and is brought to the emergency room. Neurological examination is nonfocal; she does not have neck rigidity. Laboratory results are as follows: Na: 134 mEq/L, K: 4.0 mEq/L, HCO3: 25 mEq/L, Glucose: 900 mg/dL, BUN: 84 mg/dL, Creatinine: 3.0 mg/dL, HgA1c: 6.8%, BP: 120/80 mmHg lying down, 105/65 mmHg sitting. Which of the following is the most likely cause of this patient’s coma?

A 50-year-old white male comes into your office for a routine check-up. He has no present complaints. His past medical history is significant for hypertension controlled with a low-dose thiazide diuretic. His family history reveals non-fatal myocardial infarction in his father at the age of 47. The patient does not smoke or consume alcohol. His blood pressure is 130/75 mmHg and his heart rate is 70/min. His previous records show that his HDL level is persistently low in spite of acceptable total cholesterol and LDL levels. You prescribe niacin to raise HDL level. The patient returns in a week complaining of intensive generalized pruritis and flushing. What is the most probable cause of the patient's complaint?

A 50-year-old woman presents to your office complaining of lower extremity edema that stated several weeks ago, and slowly progressed thereafter. Her past medical history is significant for hypertension, treated with metoprolol for 2 years. Amlodipine was added recently because of inadequate control of BP with metoprolol alone. She does not smoke or consume alcohol. She has no known drug allergies. Her blood pressure is 130/80mmHg and her heart rate is 64/min. The physical examination reveals bilateral symmetric 3+ pitting edema of both lower extremities, without any skin changes or varicosities. Her neck vein pulsation is normal. Other physical findings are within normal limits. Her laboratory studies reveal the following: Serum albumin 4.5 g/dL, Total serum bilirubin 0.8 mg/dL, Serum sodium 140 mEq/L, Serum potassium 4.0 mEq/L, Serum creatinine 0.8 mg/dL. Urinalysis is within normal limite. What is the most likely cause of the edema in this patient?

A 51 -year-old man complains of difficulty walking and mild right-sided foot pain for the past several weeks. His medical history is significant for type 1 diabetes mellitus, hypertension and hypercholesterolemia. Physical examination reveals a significantly deformed right foot and a mildly deformed left foot. X-rays suggest effusions in several of the tarsometatarsal joints, large osteophytes, and several extra articular bone fragments. Which of the following is the most likely cause of this patient's complaints?

A 51 -year-old obese male presents to your office complaining of difficulty swallowing solids but not liquids. His medical history is significant for GERD. Six months ago he was diagnosed with Barrett's esophagus. He reports that three months after the diagnosis of Barrett's esophagus, his heartburn resolved. Barium swallow now reveals an area of symmetric, circumferential narrowing affecting the distal esophagus. Which of the following best explains this finding?

A 51-year-old female comes to the office for a routine visit. She is apparently healthy and does not have any complaints. Physical examination reveals a thyroid nodule. She is surprised to hear about the nodule and asks, "How often does this happen? What could have caused this?" Which of the following is the most common cause of thyroid nodules?

A 51-year-old woman comes to your office for a routine health maintenance examination. She has no medical history but states that she has been having irregular menses and occasional hot flashes for the past eight months. Her husband has told her that she appears moody all the time. She has not had any surgeries in the past and currently takes no medications. She has a very stressful job and drinks two to three cups of coffee every morning. She does not smoke, but she does drink four to five twelve-ounce beers a day for the past 20 years to relieve her stress. She is a lacto-ovo vegetarian and walks two miles on a treadmill each day. Her temperature is 36.5C (97.7F), blood pressure is 120/70, heart rate is 84 beats/minute, and respirations are 12/minute. She is 5'4" and weighs 180 pounds (BMI is 30.9 kg/m2). Physical examination is unremarkable. You inform her that she is probably reaching menopause, and that she will be at an increased risk of developing osteoporosis. Which of the following is the most significant risk factor for the development of osteoporosis in this patient?

A 52-year-old African-American woman with type 2 diabetes mellitus (DM) presents to her physician’s office and states that she has been feeling lousy in the morning. She notes that she reliably checks her blood glucose levels, and is frustrated at the fact that she often has a blood sugar level in the 120s at night, followed by a level in the 170s to 180s the following morning. The patient’s primary care physician increased her nightly dose of neutral protamine Hagedorn insulin 1 month ago, but her morning glucose levels have only become more elevated. She has recently begun to limit her carbohydrate intake at night, with no effect. This patient’s morning hyperglycemia might most likely be alleviated by which of the following?

A 52-year-old alcoholic man presents to the emergency department because of anxiety and tremors. His last drink of alcohol was 2 days ago. His initial electrolyte panel is: Sodium 132 mEq/L, Potassium 2.9 mEq/L, Chloride 100 mEq/L, Bicarbonate 25 mEq/L. He is treated for alcohol withdrawal, and given aggressive intravenous and oral potassium supplementation. Three days later, his electrolyte panel is: Sodium 135 mEq/L, Potassium 3.1 mEq/L, Chloride 102 mEq/L, Bicarbonate 28 mEq/L. Which of the following explains why this patient's potassium level is so difficult to correct?

A 52-year-old female presents with a rash over her face for the past few weeks. She also complains of recent-onset difficulty with rising from a seated position and climbing stairs. On examination, you notice a dusky malar rash and a violaceous periorbital edema. Her vital signs are within normal limits. Examination shows symmetric proximal muscle weakness in legs. This patient's condition is most often associated with which of the following?

A 52-year-old male is referred to the neurology clinic for the evaluation of EEG abnormalities. He presented with rapidly increasing memory impairment, and denied any history of seizures or head trauma. The physical examination revealed no abnormalities, except a myoclonus. An extensive work-up ruled out the presence of any medical illness; however, the EEG report revealed sharp, triphasic and synchronous discharges. Which of the following abnormalities is most likely in this patient?

A 52-year-old man has been impotent ever since he had an abdominoperineal resection for cancer of the rectum. The tumor was staged as T3, NO, MO. He gets no nocturnal erections, and his impotence extends to all situations, regardless of sexual partner, and includes inability to masturbate. His erectile dysfunction is most likely due to which of the following?

A 52-year-old man with a family history of multiple endocrine neoplasia type 1 (MEN1) has an elevated gastrin level and is suspected to have a gastrinoma. Which of the following is the most likely location for his tumor?