#7

Question 1

If incidence stays the same but prevalence increase, what can explain this phenomenon?

Answer 1

Improved quality of care

Question 2

32 yo wo, 28 we gestation

• She has history of epilepsy
• Marked elevated amniotic fluid levels

Which fetal anomaly would account for patient polyhydramnios?

Answer 2

Anencephaly

Question 3

24 yo meningeal irritation
- Naegleria Fowleri is suspected

portal of entry of pathogen?

Answer 3

Nasal mucosa through olfactory nerve.

Question 4

38 yo wo abdominal pain

• watery diarrhea
• History of crohn disease treated with adalimumab

Undetectable trough adalimumab level

Explanation for worsening symptoms?

Answer 4

Development of anti drug antibodies by adalimumab declining effectiveness

Question 5

5yo girl, anorexia, nausea

• Pruritic eruptions between toes
• Attributed to insect bites from walking barefoot
• Stool microscopy reveals smooth thin walled eggs

Untreated condition will lead to?

Answer 5

Microcytic anemia

Question 6

Hereditary defect in fructose metabolism, but asymptomatic

- Patient remains able to metabolize fructose due to compensatory activity of which enzyme?

Answer 6

Hexokinase

Question 7

7 yo boy lethargic, open bottle of pulls

• The mother has medication for anxiety, depression and chronic lower back pain.
• Boy became somnolent but other values are stable.

Drug capable to reverse this?

Answer 7

Flumanezil

Question 8

48 yo man, carpenter

• Lower lobe crackles
• Potassium hydroxide preparation shows broad-based bud

Cause of condition?

Answer 8

Blastomyces dermatitis

Question 9

64 yo, unintentional weight loss

• Massive pulmonary embolism
• Liver shows multiple nodules
• Analysis shows intranuclear fragments of foreign DNA

Pathogen?

Answer 9

Hepatitis B virus

Question 10

50 yo woman
- Ducts distended by pleomorphic cells with prominent central necrosis, it does not extend beyond ductal basal membrane.

Origin of lesion?

Answer 10

Ductal carcinoma in situ, originates in the duct

Question 11

34 yo man daily injections of insulin

• Pain in shoulders, elbows and thighs
• Low serum calcium, high PTH

Inhibition of which of the following enzymatic steps is responsible for this?

Answer 11

25-hydroxivitamin D3 TO
1,25 Dihydroxivitamin B3

Because of chronic kidney disease

Question 12

30 yo wo, excessive weight gain

• more tired lately
• Diffuse enlarged thyroid with no nodules
• Hair is thin and skin appears dry

Values of TSH/T4/T3

Answer 12

TSH increased
T4 decreased
T3 Normal

Question 13

28 yo wo at 31 we gestation

• Increasing shortness of breath
• no abnormalities in heart

Changes due to pregnancy in pH/PaCO2/PaO2/Urine HCO3?

Answer 13

pH 7.46
PaCO2 29
PaO2 102
Urine HCO3 increase

Hyperventilation leads to respiratory alkalosis

Question 14

22 yo wo with turner syndrome

- Method used to achieve pregnancy?

Answer 14

In vitro fertilization

Question 15

MI nMI
Test + 200 50
Test - 120 80

if patient has a + test what is the probability that the patient has MI?

Answer 15

80%

200/250

Question 16

26 yo man + for gonorrhoeae he is treated
But several weeks later he redevelops infection

Reason for lack of long-lasting immunity?

Answer 16

Antigenic variation

Question 17

29 yo man right tibial and fibular shaft fractures
- After immobilization, patient presents with increased tension in anterior compartment

What structure will be compromised?

Answer 17

Deep perineal nerve

Question 18

8 month old infant, sudden death
- Leptomeningeal inflammation and + for enterovirus by PCR

Patient would have present with which laboratory finding?

Answer 18

Low circulating B lymphocyte count

- X linked agammaglobulinemia

Question 19

25 yo man says he has superpowers
- History of bipolar disorder
- Found with 40.6 degree, BP 157/90, pulse 102.
There is diaphoresis and diffuse rigidity in extremities

Explanation for symptoms ?

Answer 19

Neuroleptic malignant syndrome caused by antipsychotics

Question 20

46 yo wo elevated CA-125 shows ovarian mass
- Cells have high telomerase activity

Enzyme promotes cell growth by which action?

Answer 20

Preventing chromosomal shortening

Question 21

86 yo prostate cancer, gout, osteoarthritis
- Indwelling urinary catheter is placed
On 8th day tract infection is diagnosed

Strategy to prevent this?

Answer 21

Prompt removal of catheter when no longer indicated

Question 22

8 yo girl shortness of breath

• Diffuse wheezing
• after medication we see increase in airflow rate

Medication affected how the lungs of patient?

Answer 22

Bronchial smooth muscle tone

- B2 receptor agonist ‘’ increase cAMP’’ ALBUTEROL

Question 23

46 yo dizzy spells

• Symptoms improve after orange juice
• T2DM, she has lost 10kg

Mechanism responsible for symptoms when exercising?

Answer 23

Translocation of glucose transporter 4 to the cell membrane

Muscle contraction uses GLUT4 channels for insulin

Question 24

56 yo puffy face, dry cough

• conjunctival edema, pupils are equal, headache, dyspnea
• Dilated veins noted over his neck
• Cause of condition?

Answer 24

Mediastinal mass- superior vena cava syndrome

• Pancoast tumors can also cause SVC syndrome however shoulder pain is also present and horner syndrome (ptosis, mitosis, anhidoris). This makes the difference

Question 25

26 yo wo 36 weeks gestation - BP 150/100 - Urinalysis shows protein +2 Condition decrease activity of?

Answer 25

Vascular endothelial growth factor - Patient has pre-eclampsia , this cause endothelial dysfunction due to increased antiangiogenic factor release

Question 26

45 yo man gain weight - T2DM - Fasting blood glucose is 157 - No detectable albuminuria Renal change most likely present in this patient?

Answer 26

Increased glomerular filtration rate - Patient has diabetic nephropathy, as this progresses, glomerular filtration falls with a concurrent increase in urine albumin loss.

Question 27

26 yo man insists in wearing a cap lined by aluminium to prevent laser beams - Hears voices Second generation antipsychotic medication compared with first generation is associated with?

Answer 27

Lower risk of acute dystonia

Question 28

23 yo wo chest wound - Penetrating wound in the 4th intercostal space along the left sternal border Structure most likely injured?

Answer 28

Right ventricle

Question 29

28 yo man, fatigue and vivid, disturbing dreams - Irritable, withdrawn , hypersomnolent and hyperphagic - History of substance abuse He appears lethargic and dysphoric Cause?

Answer 29

Cocaine withdrawal

Question 30

4 yo decreased appetite - 3 episodes of otitis media Prescribe amoxicillin Adding clavulanic acid would serve which purpose?

Answer 30

Decrease amoxicillin cleavage by bacterial cells

Question 31

7 yo boy avoids outdoor activities - Holosystolic murmur at the lower sternal border - Apical displacement of tricuspid valve leaflets. Side effect of which drug taken during pregnancy?

Answer 31

Bipolar disorder

Question 32

71 yo wo dyspnea and orthopnea - Started on dobutamine - ECG shows improvement in cardiac contractility MOA?

Answer 32

Gs protein-adenylate cyclase activation

Question 33

14 yo boy parents are getting a divorce - He thinks they are angry at him - Patient appears sullen and report his mood is fine What defense mechanism is using the patient?

Answer 33

Projection

Question 34

65 yo worsening dyspnea - 86% O2 on room air - Decreased breath sound over the right chest - Imaging shows right lung collapse Cause?

Answer 34

Occlusion of right mainstream bronchus by mucus plug

Question 35

58 yo right sided weakness - Anticoagulant was prescribed - Nonadherent with therapy - Weakness and sensory loos in right leg has returned. Embolic occlusion affecting which of the following regions is the cause of symptoms?

Answer 35

Anterior cerebral artery DISTAL to the origin of the anterior communicating artery * If lesion occurs proximally, symptoms may not happened because of anastomoses

Question 36

12 yo episodes of abdominal pain - Diarrhea - Decreased serum C4 & C1 Drug contraindicated?

Answer 36

Captopril '' can cause angioedema = bradykinin accumulation'' - Patient has hereditary angioedema

Question 37

autopsy on MI shows neutrophil infiltration injury timeframe?

Answer 37

1 to 3 days

Question 38

67 yo progressive fever and lethargy - Right shoulder and abdominal pain - Chest x ray shows air under right lung Cause of condition?

Answer 38

Perforated viscus | - Pneumoperitoneum

Question 39

68 yo severe fatigue - 7kg weight loss - Hepatomegaly and enlarged spleen - Pancytopenia, presence of dacrocytes - Bone marrow is attempted but yields no marrow Biopsy will show?

Answer 39

Diffusely fibrotic marrow with clusters of megakaryocytes | - Patient has primary myelofibrosis

Question 40

7 yo facial puffiness - Intermittent asthma controlled with albuterol - Nephrotic range proteinuria mainly of albumin Mechanism causing the finding?

Answer 40

Increased infiltration of plasma protein , loss of negative charge leads to selective albuminuria. - Minimal Change disease - podocyte foot process fusion

Question 41

Circuit has an inflow of 120 and an outflow of 40 4 vessels with resistance of 2 each Total peripheral resistance?

Answer 41

``` 1/TPR = 1/2+1/2+1/2+1/2 = 2 TPR= 1/2 = 0.5 ```

Question 42

Mean SBP + SD 120 + 20 Hypertension considered after SBP>140 What percentage will be classified as having hypertension?

Answer 42

16% | 1sd above the mean

Question 43

23 yo wo premature rupture of membrane at 30's week - Clear vaginal discharge Drug with greatest + impact on fetal survival?

Answer 43

Dexamethasone, decrease surface tension and helps maturation of type II pneumocystis

Question 44

24 yo nurse needle stick injury from a Hep B positive patient - she received complete hep B vaccination series prior to her hospital employment a year ago - Serologies does not show evidence of infection Mechanism of immunity?

Answer 44

Impaired vision entry into hepatocytes

Question 45

54 yo man with cirrhosis - vomited bright red blood - Cirrhosis secondary to hep C - Irregular flexion-extension tremor involving his hands is seen in wrist extension What is elevated in this patient astrocyte?

Answer 45

Glutamine - Patient has hepatic encephalopathy , increased levels of ammonia Disruption of excitatory neurotransmission

Question 46

61 yo wo severe pain in her hands at age 30 - she takes nsaids - deformity of multiple joints shows ulnar deviation Disease would also affect what?

Answer 46

Cervical spine | - Rheumatoid arthritis

Question 47

32 yo wo anxiety and stress over past 6 weeks due to upcoming tax deadline - she feels shaky, dizzy and nauseated - I've stopped going out with friends because i never know when I'm going to feel this way again Diagnosis?

Answer 47

Panic disorder

Question 48

33 yo wo been monogamous for 5 years - used oral contraceptive for 15 years - she was treated with ceftriaxone seven years ago Cause of patients infertility?

Answer 48

Prior incomplete antibiotic coverage - fallopian tube obstruction- PID

Question 49

57 yo man with ALS - Physician tells the wife he is optimistic about a new treatment, and ask if she would like to enrol as a healthy control Physician is violating which principle?

Answer 49

Voluntariness

Question 50

43 yo woman borderline personality - she took some pills - pH 7.46 / PaCO2 19 / Bicarbonate 13 - Na 139 / Cl 98 Acid - base disturbance?

Answer 50

Respiratory alkalosis and metabolic acidosis ( salicylate poisoning) Anion base gap+ 139 - ( 98 +13) = 28 so secondary condition

Question 51

32 yo woman request medication for back pain - MRI was normal - Patient says pain is 10/10 - Becomes frustrated when physician suggest nonprescription pain medication Appropriate next step?

Answer 51

Obtain confirmation of the patient's prescription history

Question 52

38 yo man headaches, loss of libido and erectile dysfunction - peripheral vision loss, gynecomastia - Normal serum prolactin, normal B-HCG, low serum LH, low serum testosterone Mechanism for gynecomastia?

Answer 52

Persistent aromatization of adrenal estrogen precursors. | - Pituitary mass increased estrogen/testosterone ratio in zone reticularis of adrenals

Question 53

71 yo man acute MI, right coronary femoral artery - Arterial wall penetrated superior to right inguinal ligament - patient becomes clammy, cold and hypotensive - 5cm region of ecchymosis surrounding femoral puncture site Location of blood location?

Answer 53

Retroperitoneal space | - Puncture above the inguinal ligament

Question 54

54 yo man pain in left neck and shoulder are - decreased sensation in palm and index and middle fingers along with weakness of left wrist extension - Triceps reflex is diminished Region of brachial plexus affected?

Answer 54

Median and radial nerves deficit | C7 root , cervical spondylosis

Question 55

48 yo man stool as voluminous and found smelling - Excessive excretion of fecal fat Involvement of which structure is common?

Answer 55

Pancreas

Question 56

72 yo man with severe aortic stenosis - Harsh systolic ejection murmur radiating to the neck MCV is 76 Activated PTT is 50 Colonoscopy reveals angiodysplasias in right colon What is contributing to patient bleeding ?

Answer 56

Acquired vWF factor deficiency Decreased ADAMTS13 metalloprotease activity seen in patients with TTP marked by microvascular thrombosis

Question 57

severe pharyngitis reported in immigrants - Thick pharyngeal exudates, neck swelling, and difficulty swallowing - Toxin has a MOA similar to?

Answer 57

Pseudomonas aeruginosa - Patient has diphtheria Both inactivate EF-2 via ribosylation inhibiting cell protein synthesis

Question 58

30 yo wo at 35 we gestation - nausea, vomiting, watery diarrhea - Cultures grow gram + rods Major virulence factor of organism responsible?

Answer 58

Cytotoxin that creates pores in phagosomes ( listeriolysin o) - Caused by gram-positive rods '' listeria monocytogenes''

Question 59

24 yo man bloody diarrhea - trip to egypt - Negative for C difficile - Colonic ulcers with undermining edges that contain trophozoites Causative organism can also produce ?

Answer 59

Liver abscess - Entamoeba histolytica - Flask shaped colonic ulcers Amebic liver abscess, it demonstrate contact-dependent cytotoxicity.

Question 60

56 yo wo T2DM - Takes metformin - Takes lisinopril and amlodipine for hypertension - He decides to add pioglitazone, before starting patient should be educated about which adverse effect?

Answer 60

Weight gain and edema | - Fluid retention, congestive heart failure and increase adipose weight gain