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A 56-year-old man presents to the neurology clinic for 3 weeks of upper and lower extremity weakness. The patient explains that he works as a plumber and that his everyday chores have become much harder since he has started to notice this weakness. Despite this, he has noticed a pattern that allows him to overcome it. He reports that the longer he is at rest, the weaker he feels, and as soon as he exerts himself he restores a lot of the strength in his extremities. Physical exam reveals 2/5 strength in all four extremities, bilateral eyelid ptosis, and absent deep tendon reflexes. With a certain diagnostic suspicion, the physician orders a chest CT that reveals a 2.5 cm mass adjacent to the left stem bronchus. Biopsy of the mass is likely to reveal which of the following findings? +
A 28-year-old man visits his primary care physician for a regular check-up. During his visit, the patient tells the physician that he will be visiting Tibet in a month and was wondering if he was fit enough to go mountain climbing in the Himalayas. The physician assures the patient that he is in good health and that he can proceed with his plans as long as he does it safely. Which of the following physiologic reactions would be expected if the patient reaches the highest point in the Himalayan strip? +
A medical student is examining a tissue sample from a human lung. Microscopically, he notices several thin appearing interconnected cells with a few larger interspersed cuboidal granular cells with several intracellular inclusions. If the student was able to isolate the cytoplasmic content of the cuboidal cells, what would he most likely find large contents of? +
A 9-year-old boy is brought to the pediatrics clinic by his mother due to complaints of shortness of breath. The child reports occasional chest pain and dyspnea mostly when he is playing with his older brother. He also complains of pain in both his knees that seem to be increasing in the past few days. Upon further questioning the mother reports that the child had an episode of sore throat a couple of weeks back which was thought to be viral and for which he was not prescribed any antibiotics. On physical exam, the physician notes a high-pitched, blowing, holosystolic, apical heart murmur. Lab work-up reveals high titers of ASO antibodies. Which of the following diseases has a pathophysiologic mechanism similar to the condition described in this patient? +
A 65-year-old lung transplant patient presents to the transplant clinic for several months of gradually worsening shortness of breath. He had been out of the country and was not able to see a physician until now. After proper examination, the physician orders a set of pulmonary function tests and a high resolution chest CT. The results obtained raise the suspicion for chronic transplant rejection. If the physician was to order a transbronchial lung biopsy, what findings would confirm his suspicion? +
A 34-year-old woman diagnosed with HIV 6 months ago with latest CD4 count of 222 presents to the HIV clinic for follow-up. The patient had been doing well, but complains of difficulty losing weight despite proper exercise and diet. On physical exam, the physician notices significant fat loss in the face, arms and legs with marked abdominal obesity. He also notes fat collection in her upper back in close proximity to her neck. Which of the following medications can explain the patient's current presentation? +
A 19-year-old girl presents to the emergency department for 2 days of severe abdominal pain involving mainly the upper quadrants. Although the pain started insidiously, it has become unbearable. She also decided to seek medical care because she started noticing blood in her stools. The patient denies consuming any food other than her home cooking. Upon further questioning, the patient reports recent onset articular pain she attributed to recent heavy exercise. On exam, the physician notes several findings including cervical lymphadenopathy, a nontender palpable purpuric rash in the lower extremities, and moderate nonpitting pedal edema. If the physician was to biopsy the patient's rash, which of the following findings would be expected on immunofluorescence? +
A 16-year-old boy presents to the pediatrics clinic for 2 weeks of fatigue and dyspnea on exertion. On physical exam, the physician notices mild finger cyanosis and clubbing and an elevated jugular venous pressure. The pediatrician orders an echocardiogram that shows apical displacement of the septal tricuspid leaflet of 9 mm/m<sup>2</sup> with a dilated right ventricle and decreased contractility. Which of the following drugs was the patient's mother most likely receiving during her pregnancy? +
A 66-year-old man presents to the pulmonary clinic for a cough that has been present for the past 3 months. The patient reports recent fatigue and joint pain that has been interfering with his daily activities. He also reports significant morning stiffness lasting at least an hour and sometimes more. The patient has never smoked in his life and denies any recent sick contacts or travel. Further questioning reveals that he worked for several years as a coal miner but retired 2 years ago. Chest x-ray reveals 3 pulmonary nodules of approximately 1.5 cm each. PPD does not show any induration. Blood analysis reveals excess IgM antibodies reactive to the Fc portion of IgG. What is the most likely diagnosis in this patient? +
A researcher is studying the effects of insulin on human muscle cells. After successfully culturing a line of skeletal muscle cells, he applies doses of insulin in small increments and then monitors the effective changes by analyzing samples of cell lysate and samples of the culture broth. He notices that as insulin doses increase the intracellular concentration of glycogen increases while the extracellular concentration of glucose steadily decreases. Which of the following intracellular pathways in responsible for the regulation of both occurrences? +
A 75-year-old man with history of severe emphysema maintained on home oxygen is admitted to the intensive care unit for desaturation on 100% FiO2. On admission, his heart rate is 133/min, blood pressure is 80/53 mmHg, and temperature is 39.1 °C (102.4 °F). Despite efforts, the patient dies shortly after admission. Post-mortem examination reveals several black necrotic lesions with a surrounding erythematous edge most prominent on the lower extremities. Blood cultures withdrawn on admission, reveal growth of rod shaped gram-negative organisms. What is the most likely organism involved in the patient's presentation? +
A 43-year-old woman presents to the emergency department with acute onset flank pain increasing in severity over the past 2 hours. After initial evaluation, a non-contrast abdominopelvic CT scan reveals 2 small, 1 cm stones lodged at the left ureteropelvic junction. The patient expresses her frustration and explains that this is the fourth time she has been admitted to the hospital for urinary stones in the past 2 months. The complete work-up subsequently reveals a normal creatinine, normal vitamin D levels, with elevated urinary calcium and elevated serum parathyroid hormone. Which of the following additional findings can be expected in this patient? +
A researcher is studying the various functions of the hypothalamus in rats. He selectively stimulates 4 different areas of the hypothalamus numbered 1 till 4 by local application of 250 nl of 1 M solution of glutamate and then monitors the bodily responses in the anesthetized rats. After repetitive stimulation of area 3, the researcher notices a sharp but transient increase in interscapular brown fat thermogenesis and core temperature. Which nucleus of the hypothalamus is most likely represented by area 3? +
A 14-year-old girl presents to the pediatrics clinic for 1 week of dull headache, with recent onset nausea and vomiting. The girl's mother also reports that her daughter is assuming weird head postures in order to look at objects or persons higher that her eye level. On physical exam, the physician notices total loss of vertical gaze, with nystagmus on attempted convergence. He also notes large pupils that only faintly react to light. Brain MRI detects a significant intracranial mass in close proximity to the brainstem. Which tumor is most likely associated with this patient's presentation? +
A 56-year-old man is admitted to the hospital for severe angina, dyspnea, and diaphoresis. His initial labs are significant for elevated troponins. The man undergoes emergent PCI and is discharged home the second day on dual antiplatelet therapy consisting of aspirin and clopidogrel. Which of the following steps in primary hemostasis is inhibited by aspirin and clopidogrel respectively? +
A new drug is being developed for the treatment of intermittent claudication. One of the main studied mechanisms of action of this drug is the inhibition of phosphodiesterase III leading to arterial vasodilation to improve blood flow to ischemic areas and decrease the symptoms of claudication. What would you expect drugs with a similar mechanism of action to have as added benefit? +
A 42-year-old man presents to the rheumatology clinic for several weeks of fatigue, weight loss, and generalized arthralgias. He initially did not pay much attention to his symptoms until he started losing sensation in both his lower extremities. His history is otherwise unremarkable. On physical examination, the physician notices several cutaneous nodules of different sizes on the patients arms and proximal legs. He also notes significant sensory loss below the knees bilaterally. Faced with a difficult clinical presentation, the physician decides to biopsy the skin nodules. The pathologist reading the specimen describes significant transmural fibrinoid necrosis of blood vessels with lesions of different ages seen on the same biopsy specimen. Which of the following clinical tests should be considered in this patient? +
A 38 year old woman is undergoing work-up for idiopathic pulmonary hypertension. During pulmonary artery catheterization her cardiologist takes the measurements shown below. What is this patient's estimated cardiac output? <br>
*''Pulmonary capillary wedge pressure'' = 9 mmHg<br>
*''Right atrial pressure'' = 3 mmHg<br>
*''Pulmonary artery pressure'' = 23 mmHg<br>
*''AV CO<sub>2</sub> difference'' = 28 ml/m<sup>2</sup><br>
*''AV O<sub>2</sub> difference'' = 36 ml/m<sup>2</sup><br>
*''Rate of O<sub>2</sub> consumption'' = 190 ml/min/m<sup>2</sup> +
A 4-year-old boy is brought to the pediatrics clinic for his regular well baby check-up. The child seems to be developing well and has not missed any of his milestones so far. His physical exam is unremarkable except for a persistent soft spot on the skull suspicious for delayed closure of the fontanelles. Which of the following tissues share the same embryologic origin with the bones responsible for fontanelle closure? +
A child born to a 28-year-old homeless woman is transferred to the neonatal intensive care unit directly after birth for treatment of respiratory distress. Although the mother had several personal difficulties in the past months, she reports that the pregnancy was smooth and she was always followed up at community healthcare facility. After the infant is stabilized, the physician proceeds with an initial physical examination. Although the physical exam is mostly unremarkable, the physician notices a small tuft of hair of the infant's lower back. What is the most likely congenital anomaly in this patient an example of? +