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A 58-year-old woman comes to the physician because of worsening shortness of breath and productive cough for the past year. The patient has not seen a physician in several years. She has smoked a pack of cigarettes daily for the past 45 years. Vital signs are within normal limits. Physical examination shows a thin woman who breathes through pursed-lip. Lung auscultation reveals diffuse wheezing bilaterally. Which of the following parameters is most likely to be increased in this patient?
An 87-year-old woman is brought to the emergency department from a nearby skilled nursing facility with confusion and vomiting for the past day. According to the nursing staff, the patient was in her usual state of health before the last 24 hours, during which she was complaining of nausea. She is normally alert and oriented to person, place and time. She has a past medical history of diabetes and hypertension, and she was recently discharged from the hospital after having an obstructed kidney stone removed and a postoperative course complicated by recurrent urinary retention. Her temperature is 38°C (100.4°F), pulse is 107/min, respirations are 22/min, blood pressure is 121/64 mmHg, and oxygen saturation is 96% on room air. She is oriented to person but not to place or time. Physical examination shows tenderness to palpation over her left flank. A Foley catheter is in place and draining dark brown urine. Which of the following is the strongest risk factor for this patient’s current clinical condition?
A 40-year-old man comes to the office because of chills and a headache. His temperature is 39°C (102.2°F), pulse is 85/min, respirations are 18/min, and blood pressure is 120/80 mm Hg. He has an erythematous maculopapular eruption that he says began on his trunk and spread to his arms and legs. Ten days ago, he returned from working in a clinic in Algeria. His infection is determined to be caused by a microbe closely related to mitochondria. Which of the following is the most likely causative agent?
A 61-year-old man is brought to the emergency department by his partner after a 2-day history of abdominal pain, fever, and altered mental status. He is oriented only to self and is unable to name the city in which he lives or the current year. The patient has a history of chronic alcohol use and was found to have cirrhosis several years ago. His other medical conditions include hypertension, hypercholesterolemia, and type II diabetes mellitus. His temperature is 39.0°C (102.2°F), pulse is 109/min, and blood pressure is 130/84 mmHg. Physical examination reveals jaundice and palmar erythema. The abdomen is tense, distended, and tender to palpation. Shifting dullness to percussion is present. Which of the following is the most likely cause of this patient’s clinical presentation?
A 19-year-old man presents to the clinic with low-grade fevers, fatigue, paleness, shortness of breath, and a nonproductive cough for the past 2 weeks. His temperature is 38.4°C (101.1°F), pulse is 86/min, respirations are 20/min, and blood pressure is 122/84 mmHg. Chest auscultation reveals mild wheezing and crackles bilaterally. Chest X-ray shows bilateral patchy infiltrates. Direct Coombs test is positive. Which of the following classes of antibodies is most likely implicated in this disease process?
A 56-year-old woman comes to the office because of a 1-week history of left flank pain. Her medical history is relevant for fibromyalgia and osteoarthritis. She currently takes low-dose aspirin, acetaminophen, and ibuprofen. Upon further interrogation, the patient claims no relief of her symptoms despite taking more pain medication than usual. She also noticed an increased urinary frequency and “cloudy and pink” urine. Physical exam shows dry skin and conjunctivae. Her temperature is 36.5°C (97.7°F), pulse is 91/min, respirations are 16/min, blood pressure is 140/90 mmHg. An abdominal CT scan reveals an atrophic and small left kidney with papillary calcifications. This patient most likely has which of the following conditions?
A 20-year-old man is brought to the emergency department for evaluation of sudden onset palpitations, dyspnea, and dizziness. His medical history includes anxiety and atopic dermatitis, managed with fluoxetine and topical corticosteroids, respectively. His temperature is 36.0°C (96.8°F), pulse is 102/min, and blood pressure is 135/86 mmHg. Examination of the chest demonstrates pectus excavatum. Cardiac auscultation reveals a midsystolic click followed by a late-systolic crescendo murmur over the cardiac apex. ECG demonstrates normal sinus rhythm with occasional premature ventricular contractions and early repolarization abnormalities. The patient is provided with lorazepam with improvement in his clinical condition. Which of the following is the most likely diagnosis?
A 40-year-old comes to the office for the evaluation of an abdominal lump. The patient also reports intermittent pain in the upper abdomen that gets worse when they lift heavy weights at the gym. The rest of the review of systems is unremarkable. Past medical history is noncontributory. BMI is 35 kg/m2. Vitals are within normal limits. Physical examination shows a 2 cm midline bulge between the umbilicus and xiphoid process. The bulge is erythematous, tender to palpation, and increases in size when the patient is asked to cough. Which of the following is the most likely cause of this patient’s condition?
A 45-year-old man with a history of systemic lupus erythematosus, end-stage kidney disease on dialysis, diabetes, and hypertension presents to the emergency department with a two day history of fever, chills, and dyspnea on exertion. The patient reports he receives dialysis 3 times/week and has not missed any of his scheduled appointments. He last received dialysis two days ago. Temperature is 38.7°C (101.6°F), pulse is 104/min, respirations are 24/min, blood pressure is 90/62 mmHg, and oxygen saturation is 90% on room air. On physical examination the patient is ill-appearing. There are erythematous lesions noted on the chest and arms bilaterally, as well as a fistula with a palpable thrill in the left arm without evidence of overlying erythema, discharge, or excoriation. A holosystolic murmur is appreciated at the lower left sternal border. Which of the following best describes the pathogenesis of this patient’s disease process?
A 33-year-old man presents to his primary care physician to evaluate low back pain. The patient was helping his sibling lift furniture yesterday when he experienced acute onset low back pain, requiring him to lay in bed the remainder of the day. The patient is otherwise healthy and does not take any medications. The patient has tenderness to palpation over the lumbar spine on physical examination. Strength is 5/5 with foot dorsiflexion, toe extension, and foot inversion and eversion in the right lower extremity, while 4/5 in the left lower extremity. Sensation is also diminished on the lateral aspect of the left lower extremity compared to that of the right side. Which of the following is the most likely affected nerve root responsible for this patient’s clinical findings?
A 45-year-old man comes to the emergency department because of a high fever, chills, and a painful ulcer on his right upper arm. He developed these symptoms after returning from a camping trip in Nebraska last weekend. His temperature is 39.4°C (103°F), pulse is 90/min, respirations are 18/min, and blood pressure is 110/70 mm Hg. Physical examination shows nodular lymphangitis and enlarged right axillary and cervical lymph nodes. Palpation does not show any hepatosplenomegaly. He does not recall any animal bite. Which of the following microbes is most likely responsible for his condition?
A 25-year-old man comes to the clinic because of several months of intermittent, unilateral, severe headaches that occur suddenly and typically resolve within 1-2 hours. He explains that the pain is greatest around his left eye and can be associated with a watery eye and running nose on the ipsilateral side. Vital signs show his temperature is 37.1°C (98.8° F), pulse is 66/min, and blood pressure is 122/76 mm Hg. Basic ophthalmologic examination is unremarkable. A non-contrast CT head examination is within normal limits. In light of the patient’s presentation and negative imaging study, which of the following is the most likely diagnosis?
A 44-year-old man comes to the emergency department with abdominal pain and nausea for the past 24 hours. The pain started a few hours after dinner, and he describes it as a constant pain in the upper part of his abdomen that radiates to his back and flanks. The patient also reports nausea, intermittent vomiting, and abdominal distention. Family history is significant for recurrent episodes of pancreatitis in his father and paternal uncle. He reports drinking an average of 2 alcoholic drinks per week. His temperature is 37.7ºC (99.9ºF), pulse is 92/min, respirations are 20/min, peripheral oxygen saturation is 96%, and blood pressure is 149/94 mmHg. He appears distressed and anxious. Abdominal examination shows tenderness and rigidity over the epigastric and periumbilical regions. Bowel sounds are diminished. No bruising of the umbilicus or flanks are seen. Which of the following laboratory results is the most specific in diagnosing this patient’s condition?
A 65-year-old man comes to the clinic due to progressive back pain for the past 2 months. The pain is dull, 3/10, and often wakes him at night. The patient denies any trauma, weight loss, or history of radiation. The patient has been smoking 1 pack of cigarettes per day for 40 years and drinks 2 beers every night. Vital signs are within normal limits. Laboratory tests show elevated alkaline phosphatase, calcium level is 7 mg/dL, PTHrP is not detected, and hemoglobin is 8 g/dL. Imaging of the spine shows sclerotic lesions at the L3-4 vertebrae. Which of the following is the most likely diagnosis?
During anatomy lab, a student is dissecting a cadaver and identifies the female internal reproductive organs and several surrounding ligaments. One of these ligaments is found to contain the ovarian vessels. Which of the following is true regarding this ligament?
A 12-year-old boy comes to the office with his parents because he has started stumbling and tripping lately. He is thinking about quitting his soccer team since he is embarrassed by his frequent falls when his legs sometimes “give out” under him. He was diagnosed with scoliosis by his school nurse last month. During his workup, an ECG shows hypertrophic cardiomyopathy and an ECHO is ordered. Which of the following is the most likely genetic abnormality underlying his condition?
A 35-year-old man presents for evaluation of a painless right testicular mass. The patient first noticed the mass 3 weeks ago while showering, and he is not sure if it has been enlarging. Medical history is notable for right-sided cryptorchidism as a child, which was treated via orchiopexy at the age of 1. Temperature is 37.1°C (98.8°F), pulse is 67/min, and blood pressure is 105/77 mmHg. Physical examination reveals a nontender nodule on the right testicle which does not transilluminate or decrease in size when the patient lies flat. After further diagnostic testing is performed, the physician suspects a testicular cancer and schedules an orchiectomy. Gross analysis of the tumor reveals a homogenous mass with no hemorrhage or necrosis. Histological examination reveals the following:
A 26-year-old woman, G2P1, comes to the emergency department in active labor. She has not received prenatal care during this pregnancy. A 3500g boy is delivered by an uncomplicated vaginal delivery. His temperature is 36.7°C (98°F), pulse is 120/min, respirations are 40/min, and blood pressure is 85/60 mmHg. Physical examination shows low-set ears, micrognathia and clenched fingers. Abdominal examination shows a midline non-reducible mass covered by a whitish membrane. Which of the following is the most likely cause of this patient’s abdominal findings?
A team of scientists are examining the pathophysiology of extrinsic asthma. They observe in a group of rats that initial exposure to an allergen elicits production of an immunoglobulin. The immunoglobulins then attach to the Fc receptors located on Cell X, an immune cell identified by the researchers. On subsequent exposure to the same allergen, the allergen binds to the immunoglobulins on Cell X and induces cross-linking, resulting in immediate bronchospasm, mucus production, and eventual recruitment of additional immune cells. Which of the following cells was likely identified by the researchers as Cell X?
A 52-year-old Caucasian man comes to the office because of a 3-week history of coughing and shortness of breath. The patient is originally from Maine and works as a mountaintop coal miner in the Appalachian Mountains. His medical history is relevant for occasional smoking and type II diabetes mellitus. Upon further interrogation, the patient reports morning stiffness on both hands, that fades away with hand warmers or physical activity. Physical exam shows slightly deformed and swollen proximal interphalangeal joints on both hands. Auscultatory findings reveal late inspiratory crackles. His temperature is 36.7°C (98.2°F), pulse is 81/min, respirations are 16/min, blood pressure is 120/71 mmHg, oximetry on room air shows an oxygen saturation of 95%. Which of the following findings is most likely to be found in this patient?
A 68-year-old, right-handed man is brought to the emergency department to evaluate sudden onset weakness. The patient awoke with left-hand clumsiness that rapidly progressed to left-sided weakness, affecting the left arm more than the left leg. Past medical history is significant for hypertension, type 2 diabetes mellitus, and hyperlipidemia. The patient’s last refill of medications was one year ago. He has smoked one pack of cigarettes per day for the past 40 years. Temperature is 37.3°C (99.1°F), pulse is 98/min, respirations are 20/min and blood pressure is 200/110 mm Hg. On physical examination, the patient has slurred speech, left-sided facial weakness sparing the forehead, 2/5 muscle strength in the left upper limb, and 4/5 muscle strength in the left lower limb. Right-sided strength and sensation are normal. A right-sided infarct localized to the paramedian pontine base is seen on MRI. Which of the following additional findings will likely be observed in this patient?
A 24-year-old woman comes to the emergency department because of progressive bilateral muscle weakness. She had first noticed blurry vision and dry mouth a day ago, which was followed by nausea and vomiting later in the day. She had initially attributed her symptoms to a mild case of food poisoning because she was returning from a visit to a farm, where she had eaten homemade canned beans and unpasteurized cheese. Physical examination shows bilateral muscle weakness of the face and limbs as well as reduced deep tendon reflexes. Which of the following pathologic processes best explains the patient’s symptoms?
A 48-year-old man comes to the office to establish routine care. He reports intermittent diarrhea and on-and-off crampy abdominal pain for the past 2 years. The diarrhea is nonbloody and is not associated with food intake. Past medical history is significant for pain in his knee joints that partially responds to ibuprofen. Temperature is 37.0°C (98.6°F), pulse is 95/min, respirations are 20/min, and blood pressure is 115/70 mmHg. Physical examination shows pale conjunctiva and mild right lower quadrant tenderness. Colonoscopy later reveals focal linear ulcerations adjacent to areas of normal appearing mucosa, along with nodular mucosal changes in the descending colon and ileum. The rectal mucosa is spared. Which of the following is the most likely diagnosis?
A 40-year-old woman, gravida 2 para 2, presents to the clinic because of heavy and painful menstrual bleeding for the past 2 months. The pain starts with the onset of menstrual bleeding and has now become severe in intensity. Her last menstrual period was a week ago. Menarche was at age 11. Her menstrual cycle is regular, with 5-6 days of heavy bleeding. She is sexually active with her male partner and denies any pain during intercourse. Past medical history is significant for diabetes mellitus for 2 years treated with metformin and Neisseria gonorrhoeae cervicitis as a teenager, for which she received appropriate treatment. Family history is unremarkable. Vitals are within normal limits. Bimanual examination shows a uniformly enlarged, mobile, tender and boggy uterus. Urine pregnancy test is negative. Which of the following is the most likely etiology of this patient’s symptoms?
An 18-year-old African American comes to the office because of a recently developed limp. He says the pain in his right groin worsens with weight bearing. He says that the pain has worsened over the past month and notes a history of painful attacks that occur once or twice a year and affect his hands and back. However, he states that this pain feels “different.” Examination shows marked tenderness to palpation over the head of the right femur and a slight limp of his right leg but otherwise normal ambulation. Which of the following is the most likely diagnosis?
A 55-year-old man comes to the clinic due to the recent onset of throat pain, fever, and substernal burning pain. Medical history is notable for hypertension, hyperlipidemia and end-stage renal disease, for which he received an allograft renal transplantation from a deceased donor 6 months ago. Medications include azathioprine and TMP-SMX. Temperature is 38.4°C (101.1°F), pulse is 80/min, and blood pressure is 145/85 mmHg. Cardiopulmonary examination is within normal limits. Examination of the oropharynx is normal without exudate or erythema. The abdomen is soft with mild epigastric tenderness. Leukocyte count is 5000/mm3. An endoscopy is obtained and reveals multiple shallow linear ulcers in the distal esophagus. Which of the following best characterizes the organism responsible for this patient’s findings?
A 61-year-old man comes to the office for evaluation of progressive exertional dyspnea. He states he has had worsening shortness of breath when walking down the block to the grocery store. He does not have a productive cough. Past medical history is significant for hypertension. He has a 42-pack-year smoking history. Vitals are within normal limits. Physical examination shows a thin male with an increased anterior-posterior chest diameter. Lung auscultation reveals scattered wheezes bilaterally. Cardiac auscultation reveals normal S1 and S2. Neck veins are nondistended. Which of the following additional findings is likely to be seen in this patient?
An 80-year-old woman presents to her family physician with noticeably worse confusion and memory problems. Her husband reports that her cognitive changes have been present for some time, but were generally manageable until recently. There is no family history of similar symptoms. She has poorly-controlled diabetes, has not monitored her blood sugar closely at home, and refuses to adhere to a low-glycemic-index diet. Physical examination shows obesity with a BMI: 34 kg/m2 and blood pressure is 174/94 mm Hg. She is on insulin glargine but takes it sporadically, and reports no other medications, despite an additional diagnosis of hypercholesterolemia. She complains of history of severe headaches with changes of vision and weakness in her extremities, but had never been seen by a physician for such symptoms. The husband feels that after each episode, her cognitive abilities declined without a return to baseline. Which of the following is the most likely diagnosis?
A 44-year-old man comes to the emergency department after multiple episodes of painless hematemesis. He was at home eating dinner when he felt nauseous and vomited bright red blood. The patient has multiple prior admissions for alcohol intoxication. He has been drinking a pint of vodka daily for the last 15 years. He does not smoke cigarettes. The patient tried heroin several years ago, but has not used it since. Past medical history is otherwise not significant for any abnormal bleeding episodes. His temperature is 37.0°C (98.6°F), pulse is 105/min, and blood pressure is 104/74 mm Hg. Physical examination reveals scleral icterus and engorged paraumbilical veins. There is 2+ pitting edema of the lower extremities. Despite appropriate management, the patient is told there is a high likelihood of his symptoms recurring. Which of the following best explains why this patient is likely to experience a similar episode in the future?
A 52-year-old man comes to the ophthalmology clinic because of poor vision for a week. He states that he has also experienced painful ulcers in his mouth during the same period. Medical history is noncontributory. Examination of the mouth shows multiple aphthous ulcers. Visual acuity is 20/60 in both eyes. Examination of the anterior segment is noncontributory, and fundus examination shows white, superficial infiltrates. Which of the following is the most likely diagnosis?
A 20-hour-old female infant is reviewed on the ward because of neonatal jaundice. She was born at term following an uncomplicated pregnancy. She has passed meconium. Physical examination shows she is alert, well perfused, feeding normally, and afebrile. She is jaundiced over face, trunk, and limbs, and has no organomegaly. Laboratory studies show an elevated unconjugated bilirubin of 426 μmol/L (25mg/dL) (reference range 2–14 μmol/L [0.1-0.8 mg/dL]), normal liver function tests, and no evidence of hemolysis. Which of the following diagnoses is the most likely cause of jaundice in this newborn?
A 4-year-old boy is brought to the emergency department with a chief complaint of severe pain over his right cheek and upper jaw. The cheek area is warm, red, and tender to palpation. Patient’s mother states that the child has nasal congestion and white ‘pus-like’ nasal discharge. Patient’s mother reports that the patient has always been prone to infections, and is ill multiple times each year. Most recently the patient was hospitalized with post-infectious glomerulonephritis which he developed after another upper respiratory tract infection. Laboratory tests show elevated white blood cell count with neutrophil predominance. Serum antibody differential is as follows: IgG 82%, IgA 13%, IgM 5%, IgD trace, IgE trace. Which of the following is the most likely diagnosis?
A 34-year-old woman presents to a family medicine clinic with her partner due to excessive day-time fatigue. She feels tired throughout the day despite sleeping for over eight hours nightly. The patient’s partner states that she goes through a pattern of breathing at night, during which she stops breathing, then rapidly hyperventilates. During these episodes, the period of apnea is longer than the period of hyperventilation. The patient currently smokes one pack of cigarettes per day. Her BMI is 26 kg/m2. Vitals are within normal limits. Physical exam is unremarkable. In laboratory polysomnography testing demonstrates six episodes of central apneas per hour of sleep. Which of the following best describes the underlying pathophysiology of this patient’s clinical condition?
A 33-year-old woman presents to her primary care physician due to persistent right wrist pain. The patient has been experiencing pain on the thumb-side of the wrist every time she holds or grips an object. She recently delivered a healthy, full-term baby four weeks ago. Her past medical history is unremarkable, and she does not take any medications. Vitals are within normal limits. On physical examination, swelling and tenderness to palpation are noted at the radial aspect of the right wrist. Repetitive tapping over the volar part of the wrist does not reproduce the pain. While the patient is grasping the right thumb with the right four digits, the physician places the wrist in ulnar deviation. This maneuver reproduces the pain. Which of the following best describes the pathogenesis of this patient’s disease process?
A 28-year-old woman comes to the office for a routine physical exam. The patient has no chronic medical conditions. The patient has had multiple sexual partners and takes oral contraceptives. She was previously uninsured and has not seen a physician for several years. Her temperature is 37.2°C (99.0°F), pulse is 67/min, and blood pressure is 123/71 mmHg. A Pap smear is performed and results are notable for high-grade squamous epithelial dysplasia. Subsequent colposcopy with biopsy confirms the presence of cervical intraepithelial neoplasia (CIN) grade II. Which of the following best describes the portion of the cervix that is affected in this patient?