#9

Question 1

35 yo man decreased libido and erectile potency

• B-hCG is elevated and serum TSH is normal
• Irregular testicular mass with cystic area

Cause of gynecomastia?

Answer 1

Increased Leydig cell aromatase activity

• Increase ratio of estrogens
• HCG secretion germ cell tumor

Question 2

46 yo wo slipped while getting out of shower

• Left knee pain
• Patella fracture is present

Findings on examination?

Answer 2

Inability to extend the knee against gravity

Question 3

4 yo boy worsening cough for past 2 days

• history of recurrent pulmonary infections
• High chloride content in sweat

Abnormality seen?

Answer 3

Abnormal post-translational processing of a transmembrane protein
CFTR

Question 4

Urine + Urine -
test + 60 20
test - 140 180

Specificity of the test?

Answer 4

90%

180/200

Question 5

80 yo wo urinary incontinence

• Leaking urine all the time
• Mild cognitive impairment
• Vaginal atrophy
• No leaking with cough

What medication would be most helpful?

Answer 5

Stimulation of B3 adrenergic receptors
- Urgency incontinence ‘’ detrusor instability’’

Mirabegron causes detrusor smooth muscle relaxation

Question 6

48 yo wo painless left breast mass
- Dimpling of the skin
- Mass invasive ductal carcinoma, overexposes HER2
Treated with monoclonal antibody

Which host factor is responsible for mediating response?

Answer 6

Natural killer cells and granzymes

- Fc portion is identified by NK CD16

Question 7

8y boy fever, runny nose
Lymph node is shown, pointing at germinal centers

Process undergoing at this location?

Answer 7

Isotype switching

Question 8

46 yo wo nausea , sweating, feeling like going to pass out

• Glucose was 50
• Glyburide was added to her regimen

MOA?

Answer 8

Membrane ion channels

K-ATP

Question 9

Agent activates G protein dependent phospholipase C

Which intracellular substance is likely to increase after exposure ?

Answer 9

Ca

- IP3 activates protein kinase C via an increase in intracellular Ca

Question 10

42 yo man acute shortness of breath

• Box handler at a warehouse
• Short systolic murmur is heard at apex
• Chordal rupture and severe mitral regurgitation

Patient left ventricular hemodynamics compared to normal heart ?

Answer 10

Afterload decrease
Preload increase
Ejection fraction increase

Acute mitral regurgitation, which leads to pulmonary edema

Question 11

42 yo man tonic clonic seizure

• Works on construction
• MRI of brain shows multiple circle enhancing lesion

Most likely cause?

Answer 11

Toxoplasmosis

- Patient likely has HIV , low CD4, toxoplasmic encephalitis

Question 12

55 yo forced into early retirement

• Irritable, started to curse his coworkers
• Developed a sweet tooth

Neuropathologic finding?

Answer 12

Aggregations of phosphorylated tau protein & abnormal TDP-43 protein inclusions

• Frontotemporal dementia
  ‘‘disinhibition’’

Question 13

65 yo wo sudden chest heaviness

• Extremities are cold and clammy
• ST segment elevation in lateral leads

Changes in Cardiac contractility / SVR / Pulmonary artery systolic pressure?

Answer 13

Cardiac contractility Decreased
SVR increased
Pulmonary artery systolic pressure Increased

Question 14

1 day old boy hyperphenylalaninemia

• phenylalanine restricted diet with tyrosine
• Axial hypotonia and microcephaly
• Elevated prolactin

Physician suspects cofactor deficiency , which enzyme is it?

Answer 14

Dihydrobiopterin reductase

Question 15

35 yo man swelling of leg

• Crepitus is present
• Gas in tissues

Microorganism commonly associated with which condition?

Answer 15

Transient watery diarrhea and abdominal discomfort

• Clostridium perfringens

Question 16

14 yo anterior knee pain

• swelling 3 cm below inferior border of patella
• Overuse of which muscle contributed to this?

Answer 16

Quadriceps femoris

- Osgood - Schlatter disease

Question 17

64 yo occasional dizziness
- left vertebral artery reveals retrograde flow instead of anterograde

artery most likely occluded ?

Answer 17

Left subclavian

- Subclavian steal syndrome

Question 18

56 yo wheezing, cough
- Smoked 2 packs per day

Best Ratio to explain pathological index to determine severity is?

Answer 18

COPD
Reid index
Mucous gland / submucosa + lamina propria

c/ b+c+d

Question 19

42 yo heavy weight lifter
- his arm suddenly and involuntary give away and he drops the weight

What structure is responsible for sudden muscle relaxation?

Answer 19

Golgi tendon organ

Question 20

14 yo girl
- Short and thick neck
Shortened fourth metacarpals

Most likely seen in echocardiogram?

Answer 20

Bicuspid aortic stenosis

Question 21

24 yo wo give birth and 5 days later she finds herself crying constantly
- She has no suicidal ideation of thoughts of harming the baby

Appropriate response?

Answer 21

Postpartum mood changes are common, please call me if you do not start to improve within the next week

Question 22

19 yo wo, dysuria, urinary frequency and urgency
- Day after having sexual intercourse with boyfriend

Reveal bacteria and white blood cells

Appropriate pharmacotherapy?

Answer 22

TMP-SMX

Question 23

7 yo boy swelling of hands and feet

• Anaphylaxis following a bee sting
• urine became frothy + protein

Biopsy of kidney will show what under Light microscopy / Immunoflorescence / Electron microscopy?

Answer 23

• Light Normal histology
• Immune Negative for complement and IgG
• Electron Effacement of podocytes

Question 24

Crohn disease patients start new treatment ( monoclonal antibody)
- Some have renal or hepatic dysfunction

Which of following is most appropriate dose adjustment to decrease drug toxicity?

Answer 24

No dose adjustment is necessary

- Monoclonal antibody not eliminated by hepatic or renal clearance

Question 25

32 yo woman fatigue, malaise - Severe thrombocytopenia - TTP is suspected What is required to make the diagnosis?

Answer 25

Hemolytic anemia | - Adamts13 deficiency result in MAHA

Question 26

44 yo greenish sputum - Dullness to percussion, crackles and egophony What account for the color of patients sputum?

Answer 26

Myeloperoxidase

Question 27

32 yo wo, 35 weeks - Fetus reveal incomplete separation of cerebral hemispheres with single ventricle Associated mutation with?

Answer 27

Trisomy 13 | - Holoprosencephaly

Question 28

39 yo robbed and hit in the head - Initially had difficulty walking - Since the attack terrible rude , insults customers Damage to which region of the brain?

Answer 28

Orbitofrontal cortex

Question 29

74 yo forgetfulness over past 2 years - Don't have movement or gait abnormalities, feelings or depression - Hypertension and renal artery stenosis Pathogenesis associated with this condition?

Answer 29

Microtubule-associated protein polymerization - Alzheimer disease present with Beta amyloid plaque and neurofibrillary tangles

Question 30

68 yo recurrent syncopal episodes - History of hypertension and chronic kidney disease - Takes lisinopril, amlodipine and clonidine Offending medication is discontinued and syncopal episodes stop. Drug MOA?

Answer 30

Decreasing presynaptic release of norepinephrine | - Clonidine (alpha 2 adrenergic receptors) bradycardia

Question 31

34 yo weight gain - Easy bruising, irregular periods - elevated cortisol not suppressed after low dose dexamethasone Pathological finding in adrenal glands?

Answer 31

Hyperplasia of the zone fasciculate and reticularis | - Cause of cushing syndrome , excess ACTH

Question 32

45 yo woman numbness and painful tingling of right hand - Plays tennis - Diminished sensation in lateral palm, thenar eminence Injury at which nerve?

Answer 32

Humeral and Ulnar heads of the pronator teres muscle - damage to median nerve

Question 33

15 yo boy difficulty with movement - Kyphoscoliosis and high plantar arch - Brother suffered from neurologic disorder and died of heart failure Neuropathological finding?

Answer 33

Degeneration of spinocerebellar tracts | - Friedreich ataxia

Question 34

32 yo man substernal burning sensation - associated with fatty meals and food regurgitation - History of cystic fibrosis complicated by pancreatic insufficiency - He is prescribed omeprazole Absorption of nutrients most likely improve after medication?

Answer 34

Dietary fat | - PPI's decreased gastric hydrochloric acid production and increase lipase activity

Question 35

Counseling patient regarding diet and exercise habits would be an example of which of the following?

Answer 35

Health promotion

Question 36

34 yo man fatigue and lightheadedness - Upper respiratory infection last week - Pulse becomes undetectable to palpation during inspiration - Jugular veins are distended Diagnosis?

Answer 36

Cardial tamponade - Constrictive pericarditis can present the same way but it takes several weeks to months to develop

Question 37

46 yo worsening blurry vision, dry mouth - Potluck event he consumed home-canned foods - Shows bilateral ptosis which step in neuromuscular transmission is affected?

Answer 37

Botulinum toxin block snares protein | - Block Ach release

Question 38

25 yo wo week of cough and dyspnea - Travelled to myanmar - Intermittent pain and diarrhea - Immune thrombocytopenia - Scattered wheezes and eosinophilia Pathogen transmitted via?

Answer 38

Larval skin penetration - Strongyloidiasis - Rhabditiform larvae

Question 39

62 yo wo, hyperlipedimia - T2DM, obese - 30 pack year history - Cardiac arrest due to ventricular arrhythmia - Obstruction of left anterior descending artery + narrowing of right renal artery Compared to right kidney, left kidney will demonstrate what?

Answer 39

Arteriolar wall thickening | - Systemic hypertension

Question 40

22 yo man - 9 months ago decided to work on his research without being disturbed - Showers once a week, he is agitated and accused her parent of being one of the black suits when ask him about his project Most appropriate medication MOA?

Answer 40

Dopamine receptor antagonism | - Schizophrenia

Question 41

Osteocytes remain connected to each other by?

Answer 41

Gap junctions

Question 42

57 yo man, severe pyelonephritis - Diabetes, hypertension - He needs to start antibiotic that depends mainly on non-renal clearance Which characteristics should antibiotic have if hepatic metabolism and clearance is desired?

Answer 42

High lipophilicity | - Drugs more lipophilic are processed by liver into more polar compounds for easier elimination in bile and urine

Question 43

Influenza epidemic - Cause is antigenically novel virus strain carrying strain hemagglutinin and neuraminidase - Reassortment between influenza and swine influenza occurs Which virus can undergo similar process?

Answer 43

Rotavirus ( segmented )

Question 44

28 yo man bump on his right testicle - Lactate dehydrogenase and alpha-fetoprotein levels are elevated Histological diagnosis?

Answer 44

Nonseminomatous germ cell tumor

Question 45

38 yo man - 5 y history of lumbar pain - 2y history of bilateral knee pain - Works in construction - Blue black sports on his sclerae and auricular helices Cause of arthritis ?

Answer 45

Homogentisic acid dioxygenase deficiency | - Alkaptonuria '' autosomal recessive''

Question 46

68 yo man - right lower lobe consolidation and right sided pleural effusion - Exudate shows rapid neutrophil locomotion Component responsible for this?

Answer 46

Leukotriene B4

Question 47

31 yo man progressive dyspnea - recurrent episodes of nosebleeds since childhood - Accentuated S2 over upper left sternal border - Diggital clubbing - exhibit shows spider angiomatas Cause of patient dyspnea?

Answer 47

- Vascular malformation | Patient has rendu-osier weber syndrome '' hereditary hemorrhagic telangiectasia

Question 48

22 yo man 3 month of back pain - Emigrated from neap - Lumbar spine reveals destruction of anterior portion of L1-L3 bodies - Fluid collection beneath anterior longitudinal ligament Diagnosis?

Answer 48

Tuberculosis | - potts disease

Question 49

12 yo boy gait instability and pruritic skin rash - Several episodes of similar skin rash - Scaly erythematous skin lesion in sun-exposed areas and cerebellar ataxia - Increased level of amino acids in urine Patient will respond to which supplement?

Answer 49

Niacin | - Hartnup disease patients have pellagra like symptoms

Question 50

52 yo wo metastatic non-small cell lung cancer Treated with cisplatin and neurokinin1 antagonist Later medication will improve what?

Answer 50

Chemotherapy induced nausea

Question 51

56 yo wo with schizophrenia - Diagnosed with cholecystitis - Patient doesn't want surgery, God will take care of her - She wants to go home - She is oriented to person, place and time Next step in management?

Answer 51

Assess patient's understanding of the risk of going home

Question 52

4 yo girl fever, vomiting, tenderness over mastoid - Recurrent episodes of otitis media - Mother prefers natural healing appropriate response by physician?

Answer 52

Can you please tell me what you currently understand about your child's infection?

Question 53

``` 4 week old boy - Urine appeared dark yellow and pale colored stools, skin has also appeared yellow - mildly enlarged and firm liver Total bilirubin is 7.3 Direct 5 ``` Mechanism causing this?

Answer 53

Extrahepatic obstruction of bile ducts

Question 54

Androgens synthesized in this patient's ovaries are converted to estradiol in which cell?

Answer 54

Granulosa, this is done thanks to aromatase

Question 55

69 yo sudden onset and palpitations - Hypertension and GERD - Irregularly irregular rhythm, narrow QRS complex and no P waves What determines ventricular contraction rate in patient?

Answer 55

AV refractory period | - atrial fibrillation

Question 56

25 yo man requires kidney transplant - Takes medication that inhibits lymphocyte proliferation by blocking interleukin 2 signal transduction MOA of which drug?

Answer 56

Sirolimus

Question 57

19 yo man stabbed in right arm - Laceration of volar(flexor) surface of proximal forearm - Wound to nerve that course between flexor digitorum superficial and profundus Movement impaired?

Answer 57

Opposition of the thumb - Median nerve - Ulnar nerve courses between flexor digitorum profundus and flexor carpi ulnaris

Question 58

43 yo man painful muscle cramps - Tingling sensation in mouth - High BP and thyroid disorder - Light tapping anterior to ear elicits twitching Patient will reveal ?

Answer 58

Recent thyroid surgery | - Removed PTH glands by accident - hypocalcemia

Question 59

Lesions on vulvar area are shiny, round paupers with central indentation Cause of condition ?

Answer 59

Poxvirus is cause of molluscs contagiosum

Question 60

24 yo wo with male fetus - He has enlarged fetal kidneys with diffuse small cysts - Amniotic fluid volume is very low Present in newborn after delivery ?

Answer 60

Respiratory distress | - autosomal recessive polycystic kidney disease causes oligohydramnios