Question Bank Flashcards
A 45 year old male presents to the emergency department with fever, malaise, nausea, headache and neck stiffness. PMH reveals chronic HIV infection with poor adherence to his prescribed antiviral therapy. Lab studies reveal a CD4+ count of 90 cells/mcL. Cerebrospinal fluid is obtained via lumbar puncture, and a pathogen is identified on India ink staining. The most likely etiology of this patient’s symptoms is a(n):
A. DNA virus
B. encapsulated yeast
C. Gram-negative diplococcus
D. Gram positive coccus
E. protozoan
B. encapsulated yeast:
Cryptococcus neoformans is a common cause of fungal meningitis in immunocompromised patients. It is an encapsulated yeast that can be identified by India ink staining of cerebrospinal fluid.
A research team is developing novel anti-HIV drugs targeted at inhibiting the viral life-cycle step in which genomic HIV single-stranded RNA is converted into proviral double-stranded DNA. Which HIV polyprotein contains the viral enzyme that is responsible for this crucial step of the HIV life cycle?
A. env
B. gag
C. gp120
D. long terminal repeats
E. pol
E. pol
The HIV polyprotein named pol encodes the 3 major viral enzymes: protease, integrase, reverse transcriptase (which is an RNA-dependent DNA polymerase).
A 49-year-old female with a history of atrial fibrillation and anxiety presents to the office with an unintentional 11.3 kg (25 lb) weight loss and thinning of her hair that has occurred during the past 6 months. She states she occasionally has night sweats and also feels warm frequently, even in well cooled environments. She attributed some of these symptoms to being premenopausal. She takes metoprolol and aspirin for her atrial fibrillation and citalopram for anxiety. She quit tobacco use 2 years ago, and denies alcohol use. Vital signs reveal:
Temperature: 37.0° C (98.7° F)
Blood pressure: 150/58 mmHg
Heart rate: 112/min
Respiratory rate: 16/min
Oxygen saturation: 98% on RA
Physical examination reveals slight protrusion of the eyes with a palpable, enlarged thyroid gland without palpable nodules. Patellar reflexes are 3+, similar to the biceps. Results of lab work done 1 year ago was normal. If left untreated, this patient will most likely develop:
A. constipation
B. erythema nodosum
C. dry, cool skin
D. myxedema coma
E. pretibial myxedema
E.
Hyperthyroidism manifests as heat intolerance, weight loss, hyperreflexia, diarrhea, warm and moist skin, and cardiac arrhythmias. Graves disease, the most common cause of hyperthyroidism, is associated with the classical triad of a goiter, ophthalmopathy, and pretibial myxedema. Pretibial myxedema is a waxy, orange-peel-like texturing of the anterior lower legs.
A 29-year-old male presents to the office with the complaints of chronic rhinosinusitis, fatigue, and headache. Although this has been a reoccurring issue throughout his childhood and adolescent years, it continues to progressively worsen and occurs with increased frequency. Recently, he was seen by his pulmonologist who ordered a CT scan of his chest and diagnosed him with bronchiectasis. Although he has copious amounts of sputum in the morning, nebulized bronchodilator treatments and chest physiotherapy have been effective. Vital signs today are remarkable for a temperature of 38.4°C (101.1°F). Physical examination reveals frontal sinus tenderness to palpation. Fine crackles are auscultated throughout his lung fields without wheeze. A chest radiograph and abdominal CT scan are obtained as shown in the exhibit. The most likely diagnosis of this patient’s underlying condition is:
A. adult polycystic kidney disease
B. cystic fibrosis
C. eosinophilic granulomatosis with polyangiitis
D. granulomatosis with polyangiitis
E. Kartagener syndrome
E.
Kartagener syndrome is characterized by the triad of situs inversus, chronic sinusitis, and bronchiectasis. It is a subcategory of primary ciliary dyskinesia, leading to impaired respiratory cilia, thereby causing poor respiratory mucus clearance. The embryonic nodal cilia cells that determine organ asymmetry are also affected, leading to situs inversus in 50% of cases. Treatment is supportive, with most patients enjoying a normal life expectancy.
A 70-year-old man presents to the office with muscle spasms and paresthesias in his arms and legs. Past medical history reveals heart failure and alcohol use disorder. His symptoms of heart failure are well controlled with an angiotensin-converting enzyme inhibitor and furosemide. Physical examination reveals a brief contraction of the facial muscles when the examiner taps the area 2 cm in front of the ear. The most likely electrolyte abnormality is:
A. hyperkalemia
B. hypernatremia
C. hypocalcemia
D. hypokalemia
E. hyponatremia
C.
Hypocalcemia typically presents with paresthesias, muscle spasms, and positive Chvostek and Trousseau signs. Loop diuretics are one of many causes of a low serum calcium.
A 32-year-old male with a histor of asthma and major depressive disorder presents to a primary care clinic complaining of difficulty ambulating. He complains of weakness, which started in his feet and has spread upward over the past 48 hours. History reveals that he returned from a weekend camping trip a week ago, during which he prepared his own food, including pancakes, eggs, pork sausage, orange juice, chicken, potatoes, carrots, and granola. He states that he had an episode of 3-day bloody diarrhea upon his return, but this has since resolved. Physical examination reveals normal respiratory effort and air entry without wheezes, crackles or rhonchi, and an abdomen that is nontender and nondistended with normoactive bowel tones in all 4 quadrants. Motor strength is 3/5 bilaterally in the feet, 4/5 bilaterally at the knees and hips, and 5/5 bilaterally in the upper extremities. If the patient’s stool from his earlier diarrheal episodes had been sent for laboratory analysis, laboratory evaluation would most likely have revealed the presence of
A. paramyxovirus
B. orthomyxovirus
C. cysts and trophozoites with spherical nuclei
D. gram-negative curvy rods
E. gram-negative rods producing Shiga-like toxin
D.
Gram-negative curvy rods
Campylobacter jejuni is one of the most common causes of bloody diarrhea in the United States and is associated with Guillain-Barré syndrome, which presents as ascending weakness.
A 32-year-old woman presents to the emergency department because of a 3-hour history of nausea, vomiting, and abdominal cramps. She reports that her symptoms started 2 hours after attending a catered lunch party. She ate an egg salad sandwich that she brought from home for lunch but also ate a custard for dessert that was made by the catering company. She has not had any subjective fevers or diarrhea.
She has no chronic medical conditions and takes no medications. The abdomen is soft and nontender.
The most likely cause of this patient’s symptoms is
A. Bacillus cereus
B. Escherichia coli
C. nontyphoidal Salmonella
D. rotavirus
E. Staphylococcus aureus
E. Staphylococcus aureus
Staphylococcus aureuscan cause food poisoning that presents with rapid-onset nausea, vomiting, and abdominal cramps. It is associated with the consumption of contaminated dairy and eggs.
A 25-year-old female presents to the emergency department with complaints of nausea, vomiting, and diarrhea. Her symptoms began one week after returning from a backpacking trip in South America where she wore open footwear. She also reports a loss of appetite and feeling fatigued. Vital signs reveal a normal temperature, blood pressure 90/70 mmHg, and heart rate 90/min. A pruritic maculopapular rash is noted on her arm. Her laboratory results reveal an elevation in eosinophils. There are no ova present in her stool sample. The most appropriate therapy to treat this patient involves which of the following mechanisms?
A. binding to the 30S ribosomal subunit to prevent elongation
B. binding to the 50S ribosomal subunit to prevent translocation
C. decreased microtubule polymerization by binding tubulin
D. inhibition of dihydrofolate reductase
E. inhibition of calcium influx
C. decreased microtubule polymerization by binding tubulin
Albendazole is the drug of choice for treating hookworm, an infection caused byAncylostoma duodenale orNecator americanus. This drug binds to tubulin to decrease microtubule polymerization and reduce glucose uptake by the organism.
A 50-year-old female presents to the emergency department with shortness of breath and sharp right-sided chest pain of 3 days’ duration. She has a productive cough of thick, bloody sputum. The patient has a past medical history of insulin-dependent diabetes mellitus and hypertension. She consumes at least 6 alcoholic drinks per day. Current home medications include insulin glargine, metformin, and lisinopril. She has no known medication allergies. Vital signs reveal:
Physical exam of the lungs reveals the findings heard in the audio exhibit over the right upper lung field.
Temperature: 38.8°C (101.8°F)
Blood pressure: 140/85 mmHg
Heart rate: 100/min
Respiratory rate: 28/min
Oxygen saturation: 86% on room air
Based on the patient’s presentation, which of the following best describes the most likely etiological organism?
A. gram-negative bacillus that grows on buffered charcoal yeast extract
B. gram-negative bacillus that grows on chocolate agar
C. gram-negative, lactose-fermenting bacillus
D. gram-positive, a-hemolytic coccus
E. non-gram staining bacillus
C. gram-negative, lactose-fermenting bacillus
Klebsiellapneumoniaeis a common cause of typical lobar pneumonia in patients who misuse alcohol and patients with diabetes, and it is associated with production of currant jelly sputum.Itis a gram-negative, lactose-fermenting bacillus.
A 77-year-old female with a history of chronic obstructive pulmonary disease is hospitalized for treatment of pneumonia. Her hospitalization is complicated by deep venous thrombosis. On day 7 of her admission, she develops a fever, diarrhea, and significant abdominal pain. An abdominal radiograph is obtained, as shown in the exhibit. Which of the following best describes the organism responsible for the current condition?
A.
aerobic, Gram-positive rod
B. curved rod that grows at 42°C
C. hydrogen sulfide producing rod
D. lactose-fermenting, Gram-negative rod
E. spore-forming, anaerobic rod
E. spore-forming, anaerobic rod
Clostridioides difficileis a spore-forming, anaerobic, Gram-positive rod that causes antibiotic-associated diarrhea and pseudomembranous colitis. Toxic megacolon is a potential complication of severe C. difficile infection.
A 33-year-old female presents to the office with low back pain. The pain began when she stood up after bending over for hours while working in her garden earlier that day. Physical examination reveals reduced active lumbar extension, as well as tenderness and warmth in the paraspinal tissues of L2-L5. The most likely additional finding is
A. cool skin
B. fibrotic soft tissue
C. moist skin
D. pale color
E. prolonged blanching
C. Moist skin
Acute somatic dysfunction may present with swelling, warmth, moisture, fullness, bogginess, hypertonic muscles, edema, tension, erythema, and tenderness.
A 65-year-old man presents to the clinic on a cruise ship with difficulty urinating and reading small print.
He has been taking an over-the counter antihistamine during the cruise to prevent motion sickness. In addition to blocking histamine H1 receptors, the medication he is most likely taking also
A. blocks dopamine receptors
B. blocks muscarinic receptors
C. blocks nicotinic receptors
D. stimulates alpha,-adrenergic receptors
E. stimulates cannabinoid receptors
B. block muscarinic receptors
Several first-generation antihistamines are useful for preventing and treating motion sickness through their ability to block muscarinic M1 receptors in the vestibular system of the brain. However, M1 receptor blockade can lead to a number of anticholinergic adverse effects, including blurry vision and urinary retention. Second-generation antihistamines are not helpful for motion sickness, as they are more selective for histamine H1 receptors and do not cross the blood-brain barrier.
A 32-year-old female at 31 weeks’ gestation presents to the emergency department with a 14-hour history of vaginal bleeding. She also reports severe abdominal cramping and pain that began shortly before the bleeding. She has a history of substance use disorder, but her pregnancy has been uncomplicated until now. Vital signs reveal:
Temperature: 37.9°C (100.3°F)
Blood pressure: 125/85 mmHg
Heart rate: 88/min
Respiratory rate: 18/min
Fetal heart rate monitoring reveals a nonreassuring pattern. The most likely diagnosis is
A. ectopic pregnancy
B. incomplete abortion
C. placenta accreta
D. placenta previa
E. placental abruption
E. placental abruption
Placental abruption (abruptio placentae) typically presents as painful vaginal bleeding at or after 20 weeks’ gestation. Fetal demise or distress can occur, depending on the extent of placental detachment. There are several risk factors for placental abruption, including hypertension, cigarette smoking, and cocaine use.
A 54-year-old male presents to the office with the complaint of difficult urination. History reveals he has problems initiating and maintaining a steady stream. Physical examination reveals no suprapubic tenderness. Digital rectal examination reveals a large, smooth, boggy prostate gland. Which of the following additional findings are most likely?
A. L4 flexed, rotated right, sidebent right
B. T9 extended, rotated left, sidebent left
C. warm, taut paraspinal musculature at T3-T4
D. well-circumscribed area of hypertense tissue at the posterior margin of the iliotibial band
E. well-circumscribed area of hypertense tissue at the superior margin of the pubic ramus
D. well-circumscribed area of hypertense tissue at the posterior margin of the iliotibial band
The Chapman point for the prostate is located anteriorly along the posterior margin of the iliotibial band.
A 35-year-old female presents to the emergency department with complaints of diplopia and severe headache. History reveals these symptoms have progressed over several days. Physical examination reveals lateral strabismus, ptosis, and pupillary dilation for the left eye. Motor examination reveals normal strength and range of motion for upper and lower extremities. A CT scan of the head and orbits reveals an aneurysm. Which of the following is the most likely location for this aneurysm?
A. anterior communicating artery
B. left anterior cerebral artery
C. left posterior communicating artery
D. right posterior cerebral artery
E. right posterior communicating artery
C. left posterior communicating artery
Aneurysm of the posterior communicating artery can compress the oculomotor nerve resulting in oculomotor nerve palsy, including lateral strabismus, ptosis, and pupillary dilation.
Explanation
Lateral strabismus (eye rotated down and out), ptosis (drooping eyelid), and pupillary dilation are characteristic of oculomotor nerve (cranial nerve Ill) palsy. The oculomotor nerve is responsible for innervating all of the extraocular muscles of the eye except the lateral rectus and the superior oblique, which are respectively innervated by the abducens nerve (cranial nerve VI) and the trochlear nerve (cranial nerve IV). Loss of tone of the muscles innervated by the oculomotor nerve results in lateral strabismus, since the lateral rectus and the superior oblique muscles retain tone. The oculomotor nerve also innervates the levator palpebrae superioris (upper eyelid) and contains the parasympathetic neurons to the pupillary sphincter muscle (constricts the pupil).
The posterior communicating artery is the most common site of an aneurysm causing oculomotor nerve palsy due to the proximity of its origin to the oculomotor nerve. In this patient, clinical signs are manifested in the left eye, indicating involvement of the left posterior communicating artery.
Oculomotor nerve palsy can also occur in conjunction with upper motor neuron signs in the contralateral extremities in patients with Weber syndrome, in which the oculomotor nerve and crus cerebri are damaged in the midbrain. However, Weber syndrome is usually caused by a stroke related to the paramedian branches of the posterior cerebral artery, rather than an aneurysm.
Answer A: Aneurysm of the anterior communicating artery could cause a visual field deficit by compressing the optic chiasm, but is inconsistent with ocular motility deficits or oculomotor nerve palsy.
Answer B: Aneurysm of an anterior cerebral artery is common. However, it usually does not manifest with cranial nerve compression and is inconsistent with ocular motility deficits generally or oculomotor nerve palsy specifically.
Answer D: If the aneurysm was of the right posterior cerebral artery, the clinical signs would have manifested in the right eye rather than the left eye. In addition, if the crus cerebri was also compressed, there could be upper motor reuron signs for the contralateral extremities, as is more commonly seen with Weber syndrome.
Answer E: If the aneurysm was of the right posterior communicating artery, the clinical signs would have manifested in the right eye rather than the left eye.
A 75-year-old man with a history of hypertension, hyperlipidemia, and type 2 diabetes was brought to the emergency department with difficulty breathing, accompanied by pain, redness, and tenderness in his right calf. A duplex ultrasound reveals a noncompressible femoral vein, and a CT scan of the pulmonary arteries reveals a segmental embolus. The patient requires 2 liters of oxygen via nasal cannula to maintain oxygenation. He is hospitalized and placed on a continuous intravenous infusion with plans to bridge to an oral anticoagulant prior to discharge. On hospital day 3 his lab work is as follows:
Which of the following areas of the nephron resulted in the electrolyte imbalances caused by the intravenous infusion?
A.Bowman’s capsule
B. collecting duct
C. loop of Henle
D. macula densa
E. proximal convoluted tubule
B. collecting duct
Heparin can induce aldosterone suppression. This leads to a hyperkalemic metabolic acidosis due to inappropriate functioning of the aldosterone-mediated ionic transports of the renal collecting duct.
A 21-year-old woman with no past medical history presents to the Emergency Department with lower abdominal pain for three hours that began as a dull pain and escalated over several minutes. A review of systems is positive for chills, weakness, nausea, and fatigue. Vital signs reveal a temperature of 38.5°C (101.3°F). Urinalysis reveals puria and white blood cell casts. The pathogenesis of her current condition most likely involves
A. an abundance of macrophages
B. an abundance of polymorphonuclear cells
C. eosinophilic casts
D. interstitial fibrosis
E. lymphocytes and plasma cells
B. an abundance of polymorphonuclear cells
The pathogenesis of patients with acute urinary tract infections includes mediators of acute inflammation, primarily neutrophils, also known aspolymorphonuclear cells. Acute urinary tract infection may present with dysuria, abdominal or suprapubic pain, and constitutional symptoms.
A 15-year-old male is being seen by a family psychiatrist. He has recently started to see the psychiatrist because his parents have been concerned with his behavior. Lately, he has been expressing feelings of contempt and disgust toward his parents, disregarding their advice, talking negatively of everything they do, and frequently lashing out at them. This behavior started 2 years ago, but before then, he had been a supportive child with no complaints. He is doing well in school and he is an active member of the drama club. Later in the session with the psychiatrist, the patient admits that he loves his parents very much and is not sure why he lashes out at them. The defense mechanism that this patient is displaying is best classified as
A. acting out
B.identification
C.projection
D. reaction formation
E. sublimation
D. reaction formation
Reaction formation is the adopting of an opposite attitude to avoid personally unacceptable emotions. Teenagers who wish to psychologically separate from their parents and express contempt for them to avoid acknowledging any feelings of love or affection is a classic example.
A 34-year-old man presents to the office for a preemployment physical examination. He has no significant past medical history. His review of systems and physical examination are unremarkable. At the end of the visit, he presents the physician with a form that must be completed. The form requests the results of several genetic tests that the employer requires for all potential salaried employees. The most appropriate course of action is for the physician to
A. advise the patient that this could be a violation of the Americans with Disabilities
B. advise the patient that this could be a violation of the Genetic Information Nondiscrimination Act
C. advise the patient that this could be a violation of the Health Insurance Portability
and Accountability Act
D. order the tests according to the employer’s request
E. report the employer to the Better Business Bureau
B. advise the patient that this could be a violation of the Genetic Information Nondiscrimination Act
Employers cannot require genetic testing as a prerequisite of employment. The Genetic Information Nondiscrimination Act of 2008 was designed to prevent discrimination in health care coverage and employment based on genetic information.
A 45-year-old male presents to the emergency department with right upper quadrant pain. He also states a history of foul-smelling diarrhea. He is subsequently diagnosed with somatostatinomas and informed that he may experience gastritis due to decreased gastrin secretion. The patient is also informed that he may develop pancreatic insufficiency with resultant protein digestion deficiency. As a result, he is most likely to have decreased activity of which of the following enzymes involved in protein digestion?
A. cholecystokinin
B. pepsin
C. secretin
D. trypsin
E. vasoactive intestinal polypeptide
D. trypsin
The inactive form trypsinogen is secreted by the pancreas for protein digestion in the small intestine. Trypsinogen is converted into the active form trypsin by the enzyme enteropeptidase.
Explanation:
Trypsin is produced in the pancreas in the form of the inactive zymogen trypsinogen. When the pancreas is stimulated by cholecystokinin (CCK), trypsinogen is secreted into the duodenum. Once in the small intestine, the enzyme enteropeptidase acts to convert trypsinogen into the active form of trypsin. This active form of trypsin is responsible for the protein digestion in the small intestine from pancreatic secretion. Trypsin also converts chymotrypsinogen, proelastase, and procarboxypeptidase A and B to their active forms. On top of this, trypsin converts trypsinogen to more trypsin. After their digestive work is complete, the pancreatic proteases even degrade each other and are absorbed along with the dietary proteins.
A 60-year-old man presents to the office with progressive difficulty seeing to his right or left that began a few months ago. A confrontational visual field examination reveals that he can see objects in the nasal or medial visual field for each eye but is unable to see objects in the temporal or lateral visual field for each eye. Physical examination is otherwise unremarkable. Which clinical condition is the most likely cause of this patient’s visual field deficit?
A. aneurysm of the internal carotid artery at the lateral optic chiasm
B. aneurysm of the ophthalmic artery at the optic nerve
C. occlusion of the anterior choroidal artery
D. tumor in the inferior temporal lobe
E. tumor of the pituitary gland at the medial optic chiasm
E. tumor of the pituitary gland at the medial optic chiasm
Bitemporal hemianopia, or tunnel vision, can occur with a pituitary gland tumor compressing the medial optic chiasm.
A 43-year-old female presents to the office with the complaints of xerostomia and xerophthalmia. Palpable enlarged parotid glands are found on physical examination. The patient complains that she constantly is carrying a bottle of water with her to stop her tongue from sticking tọ her soft palate. Further questioning reveals that her last dental visit uncovered numerous dental caries, which the patient is scheduled to have fixed. Which of the following antibodies is most closely associated with this patient’s disease process?
A. anticentromere antibodies
B. anti-dsDNA antibodies
C. anti-Jo-1 antibodies
D. anti-SS-A antibodies
E. anti-U1 RNP antibodies
D. anti-SS-A antibodies
Sjögren syndrome is an autoimmune disorder affecting the lacrimal and salivary glands. It is associated with antibodies to SS-A and SS-B (Ro and La) antigens.
A 39-year-old male with a history of HIV presents to the clinic with the complaints of feeling tired, intermittent fevers, and a cough with bloody sputum. On examination, the physician notes the patient has had a 4.5-kg (10-lb) weight loss. A sputum culture is obtained and reveals an organism that is resistant to decolorization by a compound of low pH. A chest radiograph reveals the presence of a left apical infiltrate.
Appropriate medical treatment for this patient’s condition is initiated. A few weeks later, he presents for follow-up with complaints of a pins and needles feeling in his hands and feet. His other symptoms have completely resolved. Which of the following is the most likely cause?
A. ethambutol
B. isoniazid
C. pyrazinamide
D. rifampin
E. sulfamethoxazole and trimethoprim
B. isoniazid
Pyridoxine is vitamin B6, and should be taken by patients who are taking isoniazid to help prevent peripheral neuropathy.
A 64-year-old woman presents to the office with frequent urination. She urinates every 1-2 hours during the daytime and 2-3 times each night. She reports suddenly sensing the need to urinate and feeling like she
“can’t hold it.” She does not drink alcohol and has decreased her caffeine consumption, which has not helped her symptoms. Urinalysis results are normal. She is diagnosed with an overactive bladder. In addition to exercises to strengthen her pelvic floor, her symptoms may improve by taking a drug that blocks
A. alpha,-adrenergic receptors
B. beta1-adrenergic receptors
C. beta3-adrenergic receptors
D. muscarinic M3 receptors
E. nicotinic receptors
D. muscarinic M3 receptors
Overactive bladder is a relatively common condition, especially in older women. Stimulation of muscarinic M3 receptors by parasympathetic input causes contraction of the bladder detrusor muscle and relaxation of the trigone and sphincter, promoting urination. Medications that block M3 receptors (eg, oxybutynin) may reduce detrusor muscle contractions and improve symptoms of an overactive bladder.
An 85-year-old female is transferred from the local retirement home as a direct admission to the hospital for altered mental status. The patient is very lethargic and confused. Her vital signs reveal a blood pressure of 79/55 mmHg, a heart rate of 105/min, a respiration rate of 25/min, and a temperature of 38.4°C (101.1°F).
Upon admission, the patient is transferred to the intensive care unit, placed on a norepinephrine drip, and started on prophylactic antibiotics. Her urine analysis comes back from the laboratory positive for leukocyte esterase, nitrites, 50-100 white blood cell count, and 3+ bacteria that are too numerous to count and are identified as Gram-negative rods. Which of the following virulence factors is most likely responsible for causing the patient’s condition?
A. CAMP-inducing exotoxin
B. capsules
C. lipopolysaccharide
D. superantigen
E. teichoic acid
C. lipopolysaccharide
Septic shock is characterized by hypotension, high cardiac output that becomes depressed as the symptoms progress, low systemic vascular resistance, and low cardiac filling pressures. Gram-negative rod septic shock is caused by the lipid A portion of lipopolysaccharide.
A 17-year-old male presents to the emergency department with a complaint of right ankle pain. History reveals the patient rolled his ankle during a soccer game earlier today. He is able to bear weight with some discomfort. Vital signs are unremarkable. Physical examination reveals mild edema and tenderness over the lateral right ankle without appreciable bony tenderness. There is minimal increase in motion with an anterior drawer test compared with the left side. No evidence of fibular dysfunction is noted. An ankle radiograph is shown in the exhibit. Which of the following ligaments is most likely injured?
A. anterior inferior tibiofibular
В. anterior talofibular
C. calcaneofibular
D. deltoid
E. posterior talofibular
The anterior talofibular ligament is the most commonly involved ligament in grade 1 inversion ankle sprains.
A 5-month-old male presents to his pediatrician with poor feeding. His mother states that he has only been taking an ounce or 2 per feed for the last week, but he had previously taken up to 6 ounces at a time. For the last 24 hours, he has been sweating with each feed. He was born at term via an uncomplicated delivery. He has no significant past medical history and takes no medications. On examination, the infant is well-appearing. Vitals are notable for a respiratory rate in the 60s. Examination reveals a harsh systolic murmur at the left upper sternal border. Distal pulses are +2/4 bilaterally. The infant begins to cry, and the physician notes a blue tinge to his lips shortly thereafter. A chest radiograph is obtained as shown in the exhibit. Given the most likely diagnosis, which of the following is most likely to be seen on echocardiography?
A. atrial septal defect
B. coarctation of the aorta
C. interrupted aortic arch
D. patent ductus arteriosus
E. right ventricular hypertrophy
E. right ventricular hypertrophy
Tetralogy of Fallot includes pulmonic valve stenosis, right ventricular hypertrophy, overriding aorta, and a ventricular septal defect.
A 22-year-old man presents to the office with newly erupted lesions on his penis, groin, and upper inner thighs. The lesions are not painful or pruritic. He is sexually active with multiple partners and does not always use a condom. Physical examination reveals raised, soft, smooth, nontender wart-like lesions that are flesh-colored. Which of the following best describes the most likely etiologic organism?
A. enveloped, with a linear double-stranded DNA genome
B. enveloped, with a negative-sense single-stranded RNA genome
C. enveloped, with a positive-sense single-stranded RNA genome
D. nonenveloped, with a circular double-stranded DNA genome
E. nonenveloped, with a positive-sense single-stranded RNA genome
D. nonenveloped, with a circular double-stranded DNA genome
Human papillomavirus (HPV) is the cause of condylomata acuminata (anogenital warts), a common sexually transmitted infection. HPV infection may also result in nongenital warts (eg, plantar, common, or flat warts), recurrent respiratory papillomatosis,and various cancers (eg, cervical, vaginal, vulvar, anal, or head/neck cancers).HPV is anonenveloped virus with a circular double-stranded DNA genome.
A 24-year-old man presents to the office with a 6-month history of low back pain and stiffness that is worse in the first hour of the morning. The pain bothers him less when he is at work, but it returns in the evening. He states the pain is located in his lower back, and he denies radiation. The patient denies other medical problems and is not taking any medications. Vital signs are within normal limits. Physical examination reveals severe limitation of motion of his lumbar spine and a positive Schober test.
Osteopathic examination reveals tender points 1 cm lateral to the pubic symphysis on the superior rami and over the posterior superior iliac spines. A radiograph of the pelvis reveals bilateral narrowing and sclerosis of the sacroiliac joint. The most appropriate initial pharmacologic treatment is
A. etanercept
B. hydroxychloroquine
C. naproxen
D. prednisone
E. sulfasalazine
C. naproxen
Ankylosing spondylitis is a chronic inflammatory disease of the spine and pelvis.The initial pharmacologic management is with an NSAID, including ibuprofen, celecoxib, ornaproxen. Patients who do not respond to NSAIDs may trial tumor necrosis factor inhibitors or disease-modifying antirheumatic drugs.
A 12-year-old male presents to his pediatrician’s office for well-child care. His medical history reveals an intellectual deficit and a seizure disorder. Seizure frequency is increasing over the past few months. His physical exam reveals hypopigmented macules on his trunk and small growths on his fingernails consistent with fibromas. A recent brain MRI reveals a subependymal astrocytoma. An underlying condition is suspected, and a screening renal ultrasound is performed. Which of the following is the ultrasound most likely to reveal?
A. angiomyolipoma
B. horseshoe kidney
C. hydronephrosis
D. renal cell carcinoma
E. Wilms tumor
A. angiomyolipoma
Patients with tuberous sclerosis often have renal manifestations. The most common is renal angiomyolipomas. Screening ultrasounds should be performed at diagnosis of tuberous sclerosis and every 1-3 years thereafter.
A 70-year-old woman presents to the emergency department with weakness and numbness in her right leg, which began spontaneously 3 hours ago. Past medical history reveals chronic hypertension and type 2 diabetes. Physical examination reveals paresis and anesthesia of the right lower extremity. Neurologic examination is otherwise normal. MRI will most likely reveal findings consistent with a stroke in the distribution of the
A. left anterior cerebral artery
B. left middle cerebral artery
C. right anterior cerebral artery
D. right internal carotid artery
E. right posterior cerebral artery
A. left anterior cerebral artery
The anterior cerebral artery (ACA) supplies the medial portion of the precentral and postcentral gyri, which are the areas responsible for motor and somatosensory functions in the contralateral lower extremity. Thus, a stroke in the distribution of the ACA can cause paresis and anesthesia of the contralateral lower extremity.
A 42-year-old-female presents to the office with a nodule she discovered on her neck. She has noticed it over the past few months and states it has grown slightly. It is not painful. She denies recent illness. She does admit to a weight loss of 2.3 kg (5 lbs) during the past 2 months. She denies current medical problems, but states she had severe scoliosis as a child, which required extensive radiologic evaluation.
She takes no medication and denies alcohol or tobacco use. Vital signs are within normal limits. Physical examination reveals a well-appearing female with a single, nontender, 2-cm fixed thyroid nodule in the left upper lobe. Fine-needle aspiration biopsy shows hollow nuclei and laminar calcified bodies, as shown in the exhibit. The most likely diagnosis is
A.follicular carcinoma
B. Graves disease
C. Hashimoto thyroiditis
D. medullary carcinoma
E. papillary carcinoma
E. papillary carcinoma
Papillary thyroid carcinoma is the most common thyroid malignancy, accounting for 70–80% of all diagnosed thyroid cancers, and is strongly linked to a history of radiation exposure, especially in childhood. It presents as a solitary thyroid nodule and has characteristic histologic findings of psammoma bodies and ground-glass nuclei. With appropriate treatment, the prognosis is usually excellent.
A 23-year-old man presents to the emergency department with severe abdominal pain, darkened urine, nausea, and diarrhea. His symptoms first began this morning after a night of heavy alcohol consumption.
He notes that similar episodes have occurred in the past, although not to this extent. Vital signs reveal:
Temperature: 37.5 °C (99.5 °F)
Blood pressure: 125/82 mmHg
Heart rate: 105/min
Respiratory rate: 12/min
Physical examination reveals:
* Poorly localized abdominal pain without rebound tenderness
* Decreased bowel sounds
* Bilateral deep tendon reflexes of 1+
Laboratory examination includes urinalysis, which is negative for hemoglobin, leukocyte esterase, nitrites, and protein. The most likely cause of this patient’s symptoms is:
A. autoimmune destruction of the large intestine
B. defective heme synthesis
C.increased red blood cell synthesis
D. reduction of intestinal blood flow causing ischemia
E. urinary tract infection
B. defective heme synthesis
Porphyrias are disorders in heme synthesis and include acute intermittent porphyria, porphyria cutanea tarda, and erythropoietic porphyria. Patients commonly present with nonspecific abdominal pain and a change in urine coloration. Heavy alcohol consumption is a common cause of an acute attack.
A 1-day-old newborn female is being evaluated in the newborn nursery for 3 episodes of bilious emesis that occurred following attempted breastfeeding. The child was born at 38 weeks of gestation via an uncomplicated, scheduled cesarean section due to persistent polyhydramnios. There is no evidence of truncal cyanosis during physical examination and the child moves her extremities well. Her abdomen is distended. An abdominal radiograph shows two large, air-filled spaces in the upper abdomen. The most likely cause of this patient’s presentation is
A. an abnormal connection between the trachea and esophagus
B. failed neural crest cell migration
C. gastric outlet obstruction because of smooth muscle hypertrophy
D. failed lateral fold closure during embryologic development
50.6%
E. failed recanalization of a portion of the small intestine
