JCAT Mock 3

A newborn infant is reviewed on the maternity ward because of persistently low oxygen saturations since birth 30 minutes ago. The infant was born via spontaneous vaginal delivery, and there were no medical concerns for mother or child during labour. Examination shows the child is pale, tachypneic, and grunting. Pulmonary auscultation shows fine inspiratory crackles bilaterally. A chest x-ray is obtained, and the on-duty radiologist reports the lungs have a “ground-glass” appearance. Which of the following embryological mechanisms was most likely defective?

A 29-year-old man comes to the office with a lump on the side of his neck. Last week he had a severe cold and the bump appeared and has grown steadily over the last few days. He denies any fevers, chills, night sweats, or weight changes. On physical examination there is a well-defined, mobile 2-cm nodule just anterior to the sternocleidomastoid muscle that does not move during swallowing. The rest of the exam is unremarkable. Which of the following is the most likely diagnosis?

A 2-week-old girl is brought to the emergency department by her mother because of a blue coloring to her skin. The mother says that her baby seems “purple,” especially her fingers and toes, and looks extremely blue when crying. On physical examination the sleeping baby has mild cyanosis of the face and trunk, but moderate cyanosis of the extremities. Which of the following is the most common cause of this patient’s condition within the first few weeks of life?

A 44-year-old man comes to the office because of an ulcerating lesion on his right elbow. The lesion is painless and nonpruritic but has been gradually increasing in size over the past few months. He works as a farmer and spends most of his time outdoors. He has smoked 2 packs of cigarettes per day for the past 8 years. Past medical history is significant for hepatitis C virus infection 10 years ago. Family history is significant for nodular basal cell carcinoma in his father. Temperature is 37.0°C (98.6°F), pulse is 82/min, respirations are 14/min, and blood pressure is 135/85 mmHg. Physical examination shows a 1.5-cm indurated plaque with ulceration on the right elbow. Biopsy of the lesion shows dysplastic keratinocytes with keratin pearls involving the full thickness of the epidermis. Which of the following factors most increased his risk of developing this lesion?

A researcher is studying the autonomic pathways of the gastrointestinal system. Which of the following best characterizes parasympathetic innervation of the hindgut?

A 52-year-old man comes to the office due to 3 days of progressive dyspnea and purulent sputum production. The patient takes albuterol and tiotropium bromide for moderate chronic obstructive pulmonary disease. His medical history is relevant for a 40 pack-year smoking history, type II diabetes mellitus, hyperlipidemia, and coronary artery stenting 2 years ago. Physical exam shows barrel shaped chest, inspiratory crackles, hepatojugular reflux, pulsus paradoxus, and ventricular gallop. His temperature is 38.1°C (100.5°F), the pulse is 130/min, respirations are 28/min, blood pressure is 130/84 mmHg, and pulse oximetry on room air shows an oxygen saturation of 86%. This patient most likely has which of the following conditions?

A 17-year-old girl presents for evaluation of sore throat and fatigue. The patient’s symptoms have been ongoing for the past week. According to the patient, “I think I picked up a bug from my partner, he had a similar illness about three-weeks ago.” The patient is otherwise healthy and does not take any medications. Temperature is 38.2°C (100.8°F), pulse is 80/min, respirations are 14/min, and blood pressure is 125/71 mmHg. Physical examination demonstrates posterior auricular and posterior cervical lymphadenopathy, as well as bilateral tonsillar swelling. A heterophile antibody screen is negative. Which of the following is the most likely pathogen responsible for this patient’s symptoms?

A 2-hour-old newborn boy is evaluated in the nursery for breathing difficulty. He was born at term to a 22-year-old primigravida mother who received no prenatal care. He is at the 35th percentile for length and below the 10th for weight. Temperature is 36.4°C (97.5°F), pulse is 160/min, respirations are 60/min, and blood pressure is 90/60 mmHg. On physical examination, the infant appears in distress. Subcostal retractions and nasal flaring are present. Low-set ears, retrognathia, flattened nose, and bilateral feet deformities are noted. Abdominal examination reveals bilaterally enlarged masses. Which of the following additional findings would most likely be discovered upon further evaluation of this patient?

A 29-year-old Chinese primigravid woman comes to the clinic at 24 weeks gestation for the first time due to decreased fetal movements. Her prenatal care has been inconsistent, but she has been taking vitamins daily. The patient’s past medical history is significant for anemia. An ultrasound is performed and shows increased placental thickness. The ultrasound also reveals fetal ascites as well as pericardial and pleural effusions. The amniotic fluid index is measured to be 26 cm. Which of the following most accurately describes the predominant form of hemoglobin found in this fetus?

A 72-year-old woman is brought to the emergency department by her daughter for evaluation of left-sided weakness for one hour. She does not have a headache or blurred vision. She has a past medical history of hypertension, hypercholesterolemia, type 2 diabetes, and coronary artery disease. She has smoked one half-pack of cigarettes daily for 45 years. Her medications include atorvastatin, amlodipine, metformin, and aspirin. Temperature is 37°C (98.6°F), pulse is 92/min, respirations are 17/min and blood pressure is 168/90 mm Hg. Examination demonstrates a left facial droop, 3/5 left-sided strength, and 3+ deep tendon reflexes. Sensation to pinprick, light touch, and vibration, as well as two-point discrimination, is normal. Which of the following is the most likely anatomic location of the pathology in this patient?

A 27-year-old woman comes to the emergency room with a fever, chills, abdominal pain, and vaginal spotting that began this morning. Two months ago, she was diagnosed with primary syphilis and treated with intramuscular penicillin. She is sexually active with multiple sexual partners. She uses condoms inconsistently. Her last menstrual period was three weeks ago. She has not received the human papillomavirus vaccination series. Temperature is 38.3°C (100.9°F), pulse is 100/min, respirations are 20/min, and blood pressure is 120/75 mmHg. Speculum examination reveals mucopurulent discharge with a friable erythematous cervix. Cervical motion tenderness and right adnexal tenderness are present on bimanual examination. An external genital examination is non-contributory. Urine pregnancy testing is negative, and a trans-vaginal ultrasound is pending. Which of the following is the most likely diagnosis?

A 64-year-old woman presents to the emergency department because of decreased urine output and dark urine for the last 2 weeks. She also reports fatigue and a worsening headache associated with visual disturbance for the last 2 days. Her past medical history is significant for hypertension, but she states that she has not taken her medication for the past year. Her temperature is 37°C (98.6°F), pulse is 86/min, respirations are 20/min, and blood pressure is 222/146 mmHg. Fundoscopic examination shows papilledema and retinal hemorrhages. Urine dipstick is positive for blood. Which of the following laboratory findings is also most likely to be present in this patient?

A 38-year-old woman is brought to the emergency department due to progressively worsening confusion and inability to walk. She lives at home with her partner, who states that over the past week the patient has had worsening memory and trouble moving the right side of her body. The patient was diagnosed with HIV infection 3 years ago but has been non-compliant with antiretroviral therapy. Temperature is 37.0°C (98.6°F), pulse is 92/min, respirations are 13/min, and blood pressure is 125/72 mmHg. Physical examination reveals oral thrush. The patient is not oriented to time, place, or person. Neurological examination reveals right-sided hyperreflexia and upgoing plantar reflex. CD4 count is 90/mm3. MRI shows multiple, nonenhancing white matter lesions. Reactivation of a pathogen from which of the following locations is most likely responsible for this patient’s current symptoms?

A 57-year-old man comes to the office because of abdominal pain and diarrhea. He has had similar episodes intermittently for years, but they have progressed in severity and frequency. He immigrated from Brazil 30 years ago. Colonoscopy shows granulomatous inflammation and occasional strictures. The stool sample shows eggs with a lateral spine. Which of the following organisms is most likely responsible for his symptoms?

A 68-year-old woman comes to the emergency department because of large red plaques covering her body. Physical examination shows dramatic blisters on her inner thighs and upper arms. These lesions are pruritic. Nikolsky sign is negative. Which of the following is the most likely diagnosis for this patient?

A 9-year-old boy is brought to the emergency department for evaluation of right eye pain of several hours duration. His mother states, “He’s been fighting something all week. He’s been blowing his nose non-stop; I think he had a fever too.” He has no significant past medical history. Temperature is 38.5°C (101.3°F), pulse is 106/min, respirations are 18/min, and blood pressure is 112/84 mmHg. Physical examination reveals tenderness to palpation over the right orbit with associated right eyelid swelling with erythema. The patient reports significant pain with extraocular eye movement. Which of the following is the most likely diagnosis?

A 40-year-old woman is referred to the clinic for the evaluation of a thyroid nodule. Medical history is significant for Hodgkin lymphoma as a teenager, for which she received radiation treatment. Temperature is 36°C (97.4°F), pulse is 82/min, respirations are 14/min, and blood pressure is 120/70 mmHg. Physical examination shows a 2cm x 2cm hard nodule on the right lobe of the thyroid gland. The remainder of the physical examination shows no abnormalities. Ultrasound imaging suggests a malignancy, and fine needle aspiration is performed. Fine needle aspiration is most likely to show which of the following pathological findings?

A 3-month-old girl comes to the clinic because of recurrent illnesses. She is diagnosed with severe combined immunodeficiency, and after months trying different treatments that failed to improve her condition, she begins an experimental gene therapy, which uses a retrovirus as a vector. After several weeks of this treatment, the patient develops a T- cell lymphoma. Which of the following is most likely the main target of the virus to develop this malignancy?

A 42-year-old woman presents to her neurologist with complaints of uncontrollable movements and “slower” thinking. She is unable to multi-task or make decisions as easily as she could in the past. Her mother died at the age of 58 after a 2-year battle with similar symptoms, as did her grandfather who died at the age of 70. Which of the following triplet repeats would you most likely expect to see in this patient?

A 66-year-old man comes to the primary care office because of fatigue and polyuria for the past month, as well as hematuria for the past day. After some laboratory results and a renal biopsy, he is diagnosed with chronic kidney disease. Which of the following would be most likely in this patient’s lab findings?

A 47-year-old man presents to his doctor with epigastric pain that worsens a few hours after eating. He has a history of heartburn and reports loss of appetite, nausea, and an episode of vomiting in the past month. Administration of a breath test identifies a microbial origin of his symptoms. Which of the following proteins best explains the mechanism of the positive test result?

A 37-year-old woman presents to the primary care physician with worsening fatigue and arthralgias. She reports her symptoms started 2-3 weeks ago and states that her eyes have looked “discolored.” She has a history of chronic alcohol use but does not use illicit drugs. She had unprotected sexual intercourse several months ago. She has never received blood products. Vitals are within normal limits. Physical exam is notable for scleral icterus and hepatomegaly. Blood titers are positive for a DNA hepadnavirus, and she subsequently undergoes liver biopsy. Which of the following best describes the most likely histologic features of this patient’s biopsy specimen?

A 60-year-old man comes to the office because of a 6-month history of cough, dyspnea, and weakness. He describes difficulty getting up from a seated position and often needs assistance when rising from the couch. The weakness is worse when he wakes up and improves after he finishes his morning exercise and walks around. Medical history is significant for appendectomy 10 years ago and smoking 1.5 packs per day for 35 years. Physical examination reveals decreased tendon reflexes in the upper and lower extremities. An x-ray of the chest shows flattening of the diaphragm and elongation of the mediastinum, as well as a 2-cm nodule near the hilum. Biopsy of the nodule is most likely to yield which of the following histological findings?

A 32-year-old woman comes to the emergency department because of shortness of breath. She has a body mass index of 36 kg/m2. She denies use of narcotics and has no history of lung disease or neuromuscular disease. Her arterial carbon dioxide concentrations are measured to be 49 mm Hg. Spirometry is performed and shows a restrictive pattern. Which of the following is the most likely diagnosis?

A 35-year-old woman comes to the clinic because she has had 3 months of recurrent abdominal pain, bloody diarrhea, and weight loss. A biopsy from a colonoscopy is analyzed and shows transmural involvement with rare granulomas. Which of the following most likely corresponds with a finding for this disease?

A 28-year-old man presents to the physician because of a 3-month history of left shoulder pain. The pain is reproduced when the shoulder is externally rotated against resistance. He is physically active and plays baseball twice a week. The muscle injured in this patient is typically innervated by which of the following?

A 25-year-old man comes to his primary care physician complaining of occasional palpitations and dizziness for three months. He discloses associated exertional dyspnea. Temperature is 36.7°C (98°F), pulse is 80/min, and blood pressure is 125/86 mmHg. On physical examination, the patient’s height is 200 cm (6’5’’) and BMI is 17.5 kg/m2. An increased arm span to height ratio is noted. Examination of the back demonstrates scoliosis. Cardiac auscultation reveals a mid systolic murmur over the left 5th intercostal space midclavicular line. Which of the following will decrease the intensity and duration of the murmur?

A 60-year-old man comes to the clinic due to several weeks of productive cough, dysphagia, fatigue, and weight loss. He has recently had to resort to drinking smoothies and milkshakes because of the inability to swallow food. He mentions that occasionally when coughing into a napkin, he notices red streaks in the phlegm. The patient is a manager at an electronics store. Medical history is significant for hypertension, hypercholesterolemia, and smoking 1 pack of cigarettes daily for 35 years. Vitals are within normal limits. Chest radiograph is obtained and shows a perihilar mediastinal mass compressing the esophagus. Histopathology demonstrates dark cells that stain positive for synaptophysin. Which of the following is the most likely diagnosis?

A 50-year-old woman comes to the clinic due to fatigue and difficulty breathing. The patient is generally healthy, but over the past few months, she has experienced progressive fatigue and dyspnea. She also has noticed an increase in her weight without changes in her diet. Her last menstrual cycle was 2 years ago; since then, she has had some mild hot flashes that have resolved without treatment. The patient’s last Pap smear 2 years ago was normal, and she has no history of a sexually transmitted disease or abnormal uterine bleeding. Family history is noncontributory. Vitals are within normal limits. On physical examination, heart sounds are normal. There are decreased breath sounds at the lung bases bilaterally and dullness to percussion. Abdominal examination reveals shifting dullness but no peritoneal signs. On pelvic examination, a right-sided, non-tender adnexal mass is noted but the rest of the exam is within normal limits. On ultrasound examination, a calcified hypoechoic mass is observed. Based on these features alone, which of the following is the most likely diagnosis?

A 24-year-old presents to your office with a complaint of left-sided scrotal mass accompanied by dull-aching pain in the scrotal area. They first noticed a small swelling in the area two months ago, which gradually increased in size, and now their left scrotum feels heavy, especially when they stand. They state “Honestly, it feels a bit like a bag of worms.” Review of systems is otherwise unremarkable. Past medical history is noncontributory. The patient is sexually active and uses condoms consistently. Vitals are within normal limits. Physical examination shows a warm, non-tender, non-fluctuant left scrotal mass that does not transilluminate. The swelling increases in size with the Valsalva maneuver and disappears on lying down. Right scrotum and penis appear normal. Which of the following is the most likely cause of this patient’s condition?

A 30-year-old woman comes to the office because of fatigue, diffuse muscle pain, and intermittent fever for the past three weeks. She is an avid hiker and spends most weekends outdoors. One month ago, she returned from a vacation in Brazil. Her temperature is 37.5°C (99.5°F), pulse is 90/min, respirations are 18/min, and blood pressure is 120/80 mm Hg. Buffy coat examination shows intracytoplasmic vacuoles. Which of the following microbes is the most likely cause of her condition?

A 73-year-old man comes to the emergency department with sudden, severe leg pain. He was watching football at home when he experienced an acute-onset, sharp pain in the right calf that has progressively worsened. The patient reports being unable to feel the sock worn on that foot, and he is having difficulty moving his toes. He denies chest pain or shortness of breath. Medical history is significant for a small intracranial aneurysm that has been monitored on serial imaging and has remained stable in size for five years. The patient’s temperature is 37.0°C (98.6°F), pulse is irregularly irregular at 90/min, respirations are 20/min, and blood pressure is 135/85 mmHg. Physical exam shows pale and mottled skin starting 6 cm below the right tibial plateau and extending to the right toes. There is no swelling. Hair growth is normal. Carotid, radial, and femoral pulses are palpable bilaterally. The left posterior tibial artery pulse is palpable while his right is absent on palpation and has no signal on Doppler ultrasound. Which of the following locations is the most likely origin of this patient’s embolus?

A 57-year-old woman comes to the office because of a 3-month history of dyspnea, persistent cough, weight loss, and fatigue. Medical history is significant for smoking 2 packs of cigarettes per day for 40 years. An x-ray of the chest shows a 4-cm hilar mass. A biopsy specimen shows small cells with minimal cytoplasm. Staining is positive for neuron-specific enolase. This patient is at risk of developing which of the following electrolyte abnormalities?

A 68-year-old woman is brought to the emergency department following a fall earlier this morning. She explains that she got out of bed a bit quicker than she normally does, and felt the room spinning before her knees buckled and she fell to the floor. She continued to feel the room spinning for around 10 minutes before her symptoms resolved. On examination, there is a mild laceration above her right eye. She is otherwise stable and has no evidence of any orthopedic trauma. The Dix-Hallpike maneuver and supine roll test are both negative, and there is no nystagmus or problems with hearing. Her past medical history includes coronary artery disease, hypertension, and type 2 diabetes mellitus. Which of the following is the most likely cause of this woman’s fall?

A 56-year-old man presented to the emergency department for evaluation of chest pain radiating to the back. He was diagnosed with a type A aortic dissection and proceeded to the operating room for emergent open repair. Following the procedure, the patient is brought to the post-operative care unit for further monitoring. During the patient’s postoperative assessment, he reports thoracic back pain and an inability to move the bilateral lower extremities. The patient’s temperature is 98.6.0 °C (37 C °F), pulse is 30/min, respirations are 24/min, blood pressure is 195/95 mmHg, and O2 saturation is 97% on room air. Pinprick testing demonstrates bilateral loss of pain sensation below the xiphoid process. The patient has preserved proprioception, vibratory sense, fine touch, and two-point discrimination. Which of the following best describes the underlying etiology of this patient’s clinical presentation?

A 58-year-old woman comes to the clinic due to an itchy, oozing rash from the left nipple for the past few weeks. It first started as a small ulcer which then spread to the areola, with a copious clear yellowish exudative discharge. Medical history is significant for allergic rhinitis, for which she takes nasal corticosteroids and antihistamines as needed. She has tried some steroid cream, but she did not notice any improvement. Vitals are within normal limits. On physical examination, the left nipple is ulcerated and oozing yellowish fluid. There is no palpable mass, and the right nipple appears normal. Which of the following is most likely responsible for this patient’s skin condition?

A 65-year-old man comes to the emergency department because of severe central chest pain for two hours. He says the pain began while he was sitting at the breakfast table, is heavy in nature, and radiates to his jaw. He has a history of uncontrolled hypertension and diabetes mellitus type 2. He also has a history of cigarette smoking. His temperature is 36.8°C (98°F), pulse is 97/min, respirations are 18/min, and blood pressure is 163/91 mm Hg. Cardiovascular examination shows no abnormalities. ECG shows sinus rhythm at 97/min without ST-segment or other changes. Cardiac biomarkers taken six hours after admission are not elevated. Which of the following is the most likely cause of his symptoms?

A 35-year-old woman comes to the office with a 2-month history of menorrhagia. She has no relevant past medical history. She weighs 61-kg (134.48-lb). Her temperature is 37°C (98.6°F), pulse is 68/min, respirations are 16/min and blood pressure is 110/76 mm Hg. The patient has skin pallor. Her uterus can be palpated 2 cm above the pubis and the anterior region has a 4 cm nodule at the fundic area. Hemoglobin concentration is 9 g/dL. Which of the following is the most likely diagnosis?

A 32-year-old man presents to the emergency department to evaluate right lower quadrant abdominal pain. The pain is sharp, stabbing, and has progressively worsened. He has also had decreased oral intake and an episode of vomiting that has since resolved. Past medical and surgical history is unremarkable. Temperature is 37.4°C (99.4°F), blood pressure is 107/67 mmHg, and pulse is 106/min. The examiner passively extends the patient’s right leg with the patient lying on his left side. This maneuver reproduces pain in the right lower quadrant. Which of the following best describes the physical examination finding present in this patient?

A 45-year-old construction worker comes to the office because of 3-month pain in his lower back and anterior right thigh. The patient states that he routinely lifts heavy objects from the ground during work. Physical examination reveals decreased knee extension and hip adduction. An X-ray of the lower vertebral column is ordered. Which of the following abnormalities is most likely to be observed on the patient’s radiograph?

A 24 year-old woman comes to the clinic with fever, myalgias, dyspnea, fatigue, and painless unilateral periorbital swelling. She recently returned from a mission trip to Brazil. Her temperature is 38.6°C (101.4°F), pulse is 112/min, respirations are 22/min, and blood pressure is 124/84 mm Hg. Physical examination shows a holosystolic murmur radiating to the axilla. There is a hardened, erythematous insect bite on her right leg. The left eye has periorbital edema but no discharge, and the right eye is unremarkable. Electrocardiogram shows sinus tachycardia with low voltage. Echocardiogram shows pleural effusion. Peripheral blood smear shows amastigotes of T. cruzi. Which of the following findings is most consistent with chronic infection with this parasite?

A 30-year-old woman comes to the clinic in the summer because of fever and muscle aches. She spent the weekend mostly in a hotel for a conference. She has a headache, but no cough. Physical exam is benign, including lung exam which revealed lungs were clear to auscultation and non-erythemetous oropharynx. Rapid strep test is negative. She is administered supportive care begins feeling well within 2 days. Which of the following is the most likely diagnosis?

A 25-year-old woman comes to her primary care physician for evaluation of darkening of the skin on her face and neck. The patient spends most of her day working indoors as a lawyer. She is currently pregnant and at 31-weeks gestational age. Medical history is notable for type I diabetes mellitus, for which she is currently taking insulin injections. Family history is notable for Addison disease in her maternal grandmother. Temperature is 37.8°C (100.0°F), blood pressure is 122/78 mmHg, and pulse is 77/min. Physical examination reveals the presence of brown hyperpigmented macules on the forehead, cheeks, upper lips, and neck. The macules are neither pruritic nor painful. No similar lesions are found on the remainder of the patient’s body. The rest of the patient’s examination is noncontributory. Which of the following is the strongest risk factor for developing the patient’s current condition?

A professional football player presents to the emergency room with an injury to his right arm. He sustained the injury while being tackled during a game. Physical examination shows right-handed wrist drop and an inability of the patient to extend his right forearm at the elbow. An X-ray also indicates that the patient has a fractured humerus. The nerve that has most likely been damaged in this injury passes through which area on its way from the brachial plexus to the arm?

A 43-year-old man with a history of rheumatic fever comes to the primary care clinic for a check up. Cardiac examination reveals a late systolic crescendo murmur with midsystolic click best heard over the apex and loudest just before S2. Which of the following maneuvers will cause an earlier onset of the click/murmur?

An 8-year-old boy comes to the office because of red spots on his eyes and inside of his mouth for 2 months. Medical history includes epistaxis, which has decreased in frequency and severity over the years. His mother also says that if he gets a cut, it seems to bleed for an abnormally long amount of time.  Examination shows conjunctival and buccal purpura. Laboratory findings are normal, including platelet count and morphology, prothrombin time (PT), ristocetin, and activated partial thromboplastin time (APTT). Administration of DDAVP (desmopressin) does not improve the patient’s bleeding time. Which of the following is the most likely diagnosis?

A 25-year-old woman comes to the clinic because of recurrent, pulsating headaches and transient vision changes for the past week. She initially gained relief from taking non-steroidal anti-inflammatory medications, but they are no longer sufficient due to the worsening of her symptoms. Her current medications include the combined oral contraceptive pill and a tetracycline for acne. Her temperature is 37.2°C (98.9°F), pulse is 88/min, respirations are 12/min, and blood pressure is 138/82 mm Hg. Her BMI is 32 kg/m2. A focused neurological examination shows papilledema during fundoscopy, and testing of visual fields reveals some peripheral constriction. Magnetic resonance imaging is obtained and shows flattening of the posterior sclera and reduced soft tissue occupying the sella turcica. The brain parenchyma and ventricles appear normal. Which of the following is the most likely diagnosis?

A 15-year-old girl comes to her primary care physician for evaluation of abdominal pain, bloating, and diarrhea. The symptoms began several months ago. She describes the diarrhea as bulky and foul-smelling. Over the past week, the patient also developed a pruritic rash on the bilateral forearms. Past medical history is significant for type I diabetes mellitus, which is well managed with insulin. She recently traveled to Mexico and ate food from local street vendors. Vital signs are within normal limits. Physical examination reveals conjunctival pallor, as well as multiple tense, grouped blisters on her forearms and excoriations. The abdomen is mildly tender to palpation. Laboratory testing reveals positive anti-tissue transglutaminase antibodies. If this patient’s condition is untreated, which of the following complications is she at greatest risk of developing?

A 27-year-old man comes to the clinic because of daily unilateral headaches for the past week. Episodes last 1 hour, are abrupt in onset and cessation, localized to the orbital and temporal regions, and are accompanied by lacrimation, rhinorrhea, and facial sweating. His wife says these headaches occur at night and that during the attacks her husband is restless. Which of the following is the most likely diagnosis?

A 67-year-old woman is currently postoperative day 5 after having an open cholecystectomy. She reports worsening subprapubic pain and malaise.  Her vital signs are 37 °C (98.6°F), pulse is 98/min, respirations are 14/min, blood pressure is 137/64 mmHg, and oxygen saturation is 99% on room air. Physical examination shows suprapubic tenderness on palpation as well as cloudy urine in her Foley catheter. Which of the following pathogens is most likely causative of this patient’s clinical presentation?