Anatomy
A 62-year old right handed man is evaluated for an episode of left leg weakness that spontaneously resolved within 30 minutes of onset. The patient also has transient vision loss in the right eye. Medical history is significant for hypertensions and diabetes mellitus. Evaluation reveals an atherosclerotic plaque in the extracranial portion of the supplying artery. During percutaneous stenting of the lesion, the vascular catheter is inserted into the right common femoral artery and gradually advanced to the level of the aortic arch. Which of the following is the most likely path of the catheter before stenting of the culprit lesion can be performed?
A. Aorta -> brachiocephalic artery -> common carotid artery -> external carotid artery
B. Aorta -> brachiocephalic artery -> common carotid artery -> internal carotid artery
C. Aorta -> common carotid artery -> external carotid artery
D. Aorta -> common carotid artery -> internal carotid artery
E. Aorta -> subclavian artery -> vertebral artery
B. Aorta -> brachiocephalic artery -> common carotid artery -> internal carotid artery
A 6-hour-old boy is in the newborn nursery with feeding difficulties. The patient was born at 39 weeks gestation to a 33-year-old primigravida via ceasarean delivery sue to failure to progress and late decelerations seen on fetal heart tracing. Apgar scores were 8 and 9, but examination shows an infant with excessive drooling and coughing. Cardiac, respiratory and abdominal examinations are otherwise normal at rest. When the infant attempts to breastfeed, however, several bouts of coughing and perioral cyanosis develop with oxygen saturation of 85% on room air. Which of the following is the most likely cause of this patients condidition?
A. Atresia of small intestine
B. Collapse of supraglottic structures during respiration
C. Failure of primitive foregut to separate from airway
D. Obstruction of posterior nasal passages
E. Thoracic herniation of abdominal viscera
C. Failure of primitive foregut to separate from airway
A 6-year-old boy whose family recently immigrated to the US is brought to the office due to sore throat and fever. Examination shows mild tonsillar erythema with exudates. A sample from the exudates is obtained. On microscopic evaluation, there are clumped, gram-positive bacteria with polar granules that stain deeply with aniline dyes. Which of the following best explains the pathogenicity of the organism most likely responsible for this patient's condition?
A. Activation of electrolyte transport
B. Blockade of neurotransmitter release
C. Cellular membrane disruption
D. Impairment of protein synthesis
E. Widespread T cell activation
D. Impairment of protein synthesis
An 18-year-old woman comes to the clinic due to intermittent dry cough, wheezing, and shortness of breath. She recently began practicing twice a day for her college track team and has been experiencing these symptoms with running. Her symptoms have been limiting her ability to complete practice but usually resolve after several minutes of rest. Medical history includes childhood asthma that has not required treatment for the past 5 years. The patient is prescribed a medication that reduces bronchoconstriction by inhibiting the interaction of inflammatory mediators with cell surface receptors. Which of the following was most likely used in this patient?
A. Albuterol
B. Dextromethorphan
C. Fluticasone
D. Ipratropium
E. Montelukast
F. Zileuton
E. Montelukast
A 66-year-old man comes to the office due to 2 episodes of hematuria over the past month. Digital rectal examination reveals an indurated prostate with no palpable nodules. An image from a transrectal prostate biopsy is shown in the exhibit. Which of the following is the most likely underlying cause of this patient's symptoms?
A. Acute bacterial infection of the prostate
B. Benign hyperplasia of the prostate stroma
C. Chronic bacterial inflammation of the prostate
D. Invasive carcinoma arising from the urethra
E. Neoplastic proliferation of prostate gland cells
E. Neoplastic proliferation of prostate gland cells
(This older man with an indurated prostate has histopathologic evidence of crowded glands composed of atypical cells with large nuclei and prominent nucleoli, raising strong suspicion for prostate adenocarcinoma)
A 64-year-old woman is brought to the emergency department due to stroke-like symptoms. The patient has a history of transient ischemic attacks as well as other risk factors for cerebrovascular disease, including hypertension, type 2 diabetes mellitus and hyperlipidemia. Urgent brain imaging reveals occlusion of vessel indicated by the arrow in the exhibit. Which of the following findings is most likely to be observed in this patient?
A. Down-and-out right eye with impaired extraocular movements
B. Left-sided motor weakness, including lower facial region
C. Loss of conjugate lateral gaze on both sides
D. Sensory loss over the right side of the face and left side of the body
E. Vision loss over the left half of the visual field in both eyes
D. Sensory loss over the right side of the face and left side of the body
A 45-year-old man comes to the office due to chronic insomnia. The patient has trouble sleeping because he claims he must remain alert to protect himself from workers at a nearby chemical plant. He says they are poisoning him by secretly dumping toxic waste in his backyard at night. The patient's wife says "He's been like this for the past 10 years. He gets very upset when asked for proof, so he's going to install cameras next week." She has never seen any unusual activity in the backyard and says that her husband has never received an actual threat or endured actual harm. He has ordered numerous soil toxicity tests over the years, all which have been negative. The patient started working as a taxi driver at the age of 21 and continues to work for the same company. He has no history of psychiatric treatment. Which of the following is the most likely diagnosis for the patient?
A. Delusional disorder
B. Major depressive disorder with psychotic features
C. Paranoid personality disorder
D. Schizophrenia
E. Schizophreniform disorder
F. Schizotypal personality disorder
A. Delusional disorder
This patient's persistent belief that he is being poisoned is consistent with delusional disorder which is characterized by 1 or more delusions for 1 or more months. Other positive psychotic symptoms are absent such as hallucinations and disorganization.
A 2 month old girl is brought in to the clinic due to perinatal hepititis B exposure. Her mother is age 22 and migrated to the US shortly after giving birth. The pregnancy was complicated by maternal hep B infection. However, the mother recieved no prenatal or parinatal care and was not diagnosed with chronic hep B until the immigration process. Maternal HBsAg, HBeAg and anti-HBc are all postitive; anti-HBs is negative. The infant has not been evaluated previously and has not recieved and immunizations or other medications. She is exclusively breast fed and has been gorwing normally. Vital signs are normal and physical examonation is unremarkable. No hepatomeagly or jaundice is seen. The infant's laboratory results will most likely show which of the following?
A. Antibody against HBsAg
B. HBeAg
C. Markedly elevated direct bilirubin
D. Markedly elevated liver function tests
E. Neither HBsAg nor ant-HBs
B. HBeAg
A 56-year-old man comes to the urgent center with severe knee pain. He was feeling well until he awoke this morning with acute pain, redness, and swelling in the knee. The patient does not smoke but did drink heavily at a wedding reception the night before. Past medical history is notable for recent peptic ulcer disease. He is treated with oral colchicine and experiences significant relief of symptoms within 12 hours. The drug used in this patient most likely affects which of the steps shown in the diagram?
A. A
B. B
C. C
D. D
E. E
F. F
F. F
(Colchicine works primarily by inhibiting microtublar polymerization)
A 74-year-old man is hospitalized with acute urinary retention complicated by urospesis. He has a urinary catheter placed and is started in intravenous anitbiotics. The patient requires andotracheal intubation and mechanical ventilation for 24 hours but is extubated successfullt on the 2nd hospitalization day. On the 3rd day of hospitalization, he develops fever and right jaw pain. Physical examination shows firm swelling of the preauricular area on the right side extending to the angle of the mandible. Which of the following serum markers is most helpful for confirming the diagnosis?
A. Alkaline phosphatase
B. Amylase
C. Gamma-glutamyl transpeptidase
D. Lipase
E. Parathyroid hormone
B. Amylase
A 65-year-old woman comes to the office for a follow-up examination 1 year after she underwent operative resection of the right colon and chemotherapy for stage III colon cancer. She reports fatigue. Physical examination shows no abnormalities. A staging CT scan of the chest and abdomen shows five new 2- to 3-cm masses in the liver and both lungs. This patient's cancer most likely spread to the lungs via which of the following structures?
(A) Inferior mesenteric vein
(B) Inferior vena cava
(C) Left colic vein
(D) Middle colic artery
(E) Pulmonary vein
(F) Superior mesenteric artery
(G) Superior vena cava
(B) Inferior vena cava
A previously healthy 33-year-old woman is brought to the emergency department by the Secret Service for stalking the president of the USA for 2 months. She claims to be married to the president's twin brother and states that the president just had his twin kidnapped to avoid competition. She speaks rapidly and is difficult to interrupt. Her associations are often loose. She says, "I haven't slept for days, but I won't even try to sleep until my husband is rescued. God has been instructing me to take over the White House. I can't wait to be reunited with my husband. I hear his voice telling me what to do." When asked about drug use, she says she uses only natural substances. She refuses to permit blood or urine tests, saying, "I don't have time to wait for the results." Which of the following is the most likely diagnosis?
(A) Bipolar disorder, manic, with psychotic features
(B) Brief psychotic disorder
(C) Delusional disorder
(D) Psychotic disorder due to general medical condition
(E) Schizophrenia
(A) Bipolar disorder, manic, with psychotic features
A 5-year-old girl is brought to the office by her mother due to 2 weeks of anorexia, nausea, epigastric discomfort and loose bowel movements. She has had no fever or bloody stools. The patient recently returned from rural Brazil, where she spent the summer with family. She had no gastrointestinal symptoms during the trip but developed intensely pruritic eruptions between the toes of her right foot. The skin rash spontaneously resolved within a few days and was attributed to insect bites from walking barefoot in the fields. The patient has no prior medical conditions, takes no medications and has received all age appropriate vaccinations. On physical examination, the abdomen is soft and nontender with normoactive bowel sounds. Stool microscopt reveals smooth, thin-walled eggs. If left untreated, the patient's conditions can lead to which of the following complications?
A. Chronic lymphedema
B. Dilated cardiomyopathy
C. Granulomatous endophthalmitis
D. Microcytic anemia
E. Vitamin B12 Deficiency
D. Microcytic anemia
She has human hookworm infection
A 63-year-old man comes into the office due to blurred vision in both eyes for the last 2 days. The bluriness is worse when he read but is not noticeable when he drives. The patient has no associated headache, double vision, or weakness. However, he did start taking diohenhydramine several days ago for seasonal allergies. Past medical history is unremarkable. Vital signs are normal. On physical examination, there is edema and clear drainage affecting the nasal mucosa. Funduscopic examination is normal. The patient's visual symptoms are most likely due to blockade of which of the following mediators?
A. Acetylcholine
B. Histamine
C. Leukotrienes
D. Norepinephrine
E. Serotonin
A. Acetylcholine
(This patient has impaired visual accommdation dur to anticholinergic (anti-muscarinic) effects of first-generation antihistamines)
A 43-year-old male with advanced HIV is hospitalized for evaluation of recent-onset headaches and personality changes. Imaging of the brain shows a solitary mass within the temporal love. Biopsy of the mass reveals uniform cells containing the Epstein-Barr virus genome. This patient most likely suffers from which of the following?
A. Pilocytuc astrocytoma B. Glioblastoma
C. Oligodendroglioma D. Epemdyoma
E. Medulloblastoma F. Primary CNS lymphoma
G. Meningioma H. Craniopharyngioma
I. Schwannoma J. Pituutary adenoma
F. Primary CNS lymphoma
A 25-year-old woman comes to the emergency department because of a 3-hour history of fever, severe headache, light-headedness, dizziness, shaking chills, and muscle aches. Five hours ago, she was diagnosed with Lyme disease and began doxycycline therapy. She has no other history of serious illness and takes no other medications. Menses occur at regular 28-day intervals. She is currently menstruating and using a tampon. She appears anxious. Temperature is 37.0°C (98.6°F), pulse is 120/min, respirations are 30/min, and blood pressure is 90/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 94%. Physical examination shows flushing and diaphoresis. Cardiopulmonary examination shows no other abnormalities. Which of the following is the most likely mechanism of this patient’s current condition?
(A) Exacerbation of infection by Borrelia burgdorferi
(B) Infection-mediated sepsis
(C) IgE-mediated allergic reaction to doxycycline
(D) Release of bacterial products producing acute inflammation
(E) Secretion of bacterial endotoxins
(D) Release of bacterial products producing acute inflammation
A 64-year-old woman comes to the ED due to intractable nausea and vomiting. She has not been able to keep anything down and feels weal and tired. The patient has had no diarrhea, constipation, or abdominal pain. She was diagnosed with breast cancer 4 weeks ago and received her first cycle of chemotherapy 1 week ago. Vital signs are within normal limits. Mucous membranes are dry. Cardiopulmonary examination is normal. Bowel sounds are normal. Which of the following agents would be most helpful in treating this patient's symptoms?
A. Histamine, H1 blocker
B. Motilin receptor agonist
C. Mu opioid receptor agonist
D. Muscarinic M1 receptor antagonist
E. Serotonin 5-HT3 receptor antagonist
E. Serotonin 5-HT3 receptor antagonist
A 65-year-old woman comes to the office due to progressively worsening weakness of the legs for 5 months. Examination shows increased muscle tone, brisk deep tendon reflexes, and decreased muscle strength in the lower extremities. The Babinski sign is positive in both legs. Upper extremities are normal. MRI of the spinal cord at the T12 level; the lesion is extramedullary but is surrounded by cerebrospinal fluid, as shown in the exhibit. Which of the following is most likely the origin of the lesion?
A, Ependymal cells
B. Meningothelial cells
C. Metastatic tumor cells
D. Osteoblasts
E. Vascular endothelial cells
B. Meningothelial cells
This patient has spinal cord compression due to a contrast-enhancing tumor located in the intradural extramedullary space. This is most likely a meningioma, a slow-growing, benign tumor that arises from the meningothelial cells of the archnoid
A 68-year-old woman is brought to the emergency department due to worsening lethargy. Her family sates that the patient has had headache and nausea for the past several days., and today she was confused and lethargic. Medical history is significant for seizure disorder, hypertension, type 2 diabetes mellitus and bipolar disorder for which she is on a number of medications. Vital signs are within normal limits. On physical examination, the patient is somnolent and responds to painful stimuli only. Mucous membranes are moist and jugular venous pressure is normal. The lungs are clear to auscultation and heart sounds are normal. There is no extremity edema. Laboratory evaluation reveals severe hyponatremia with a serum sodium of 118 mEq/L; blood urea nitrogen and serum creatinine are within normal limits. Serum osmolality is low and urine osmolality is high. Which of the following medications is the most likely cause of this patient's condition?
A. Canaglifozin
B. Carbamazepine
C. Furosemide
D. Lithium
E. Spironolactone
B. Carbamazepine