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A 68 year old Caucasian woman came to ER with complaints of left lower abdominal pain, fever, nausea and vomiting. She denies passing blood in her stool. She was a known hypertensive and hypercholesterolemia patient for the past 20 years who was on regular treatment. She also had the complaint of chronic constipation for the past 7 years. On physical examination, tenderness was elicited over the left lower quadrant without any guarding and rigidity. Vitals were recorded as blood pressure 130/80 mmHg, pulse rate 92/minute, respiratory rate 18/ minute and temperature 38 C. A complete blood count reveled leukocytosis of 18 x 109/L. An abdominal CT revealed a sigmoid diverticulitis. The patient was admitted for an in-patient conservative management like nil oral, intravenous fluids, analgesics and anti emetics along with intravenous ciprofloxacin and metronidazole. The patient’s condition gradually improved in the next couple of days and finally she got discharged with oral antibiotics and relevant counseling regarding drug compliance and dietary advice. Which of the following is recommended during this patient follow up? +
A 18 month old male child was brought to the ER by her mother with a complaint of crying for the past 6 hours. When it started, his mother carried him and he settled down after a few minutes and then fell back asleep. Over the next few hours, he woke up again intermittently crying and drawing his legs closer towards his abdomen. He vomited once while on his way to the ER. His vitals are blood pressure 90/60 mmHg, heart rate 118/minute, respiratory rate 24/minute and temperature 37 C. On physical examination, his skin was found to be pink with brisk capillary refill, and his oral mucosa was pink and moist. His abdomen was soft and not distended, with normoactive bowel sounds, and no masses. An abdominal X-ray revealed a soft tissue density, raising the suspicion of intussusception. It was followed by a water-soluble contrast enema that identified an ileocolic intussusception at the hepatic flexure and was successfully reduced. The child was then admitted for observation over the next 24 hours. After 12 hours, the child began to have the same presentation due to recurrence of ileocolic intussusception. What is the next best step in management of this child? +
A 26 year old Caucasian male comes to his physicians office for his regular checkup. He is a known type 1 diabetes mellitus patient for the past four years who was on NPH insulin, 30 U each morning and 15 U every night. But following a persistent morning glycosuria that did not improve, the evening dose was increased to 20 U during his last visit. He strictly adheres to his diet schedule. His following lab tests reveal worsening of his morning glycosuria with moderate ketones in his urine. Several consecutive nights glucose monitoring did not reveal any hypoglycemia. He is diagnosed with hyperglycemia due to reduced sensitivity to insulin and increase in early morning catabolic hormones called as dawn phenomenon. The evening dose of NPH is switched over to glargine. But neither did this help. What will be the next step in management of this patient +
A 18 year old boy is brought to the physicians office by his mother, with complains of sweats and headaches during the nights. Initially he was started on NPH insulin, 30 U each morning and 15 U every night. But following a persistent morning glycosuria that did not improve, the evening dose was increased to 20 U during his last visit. His recent lab tests reveal worsening of his morning glycosuria with moderate ketones in his urine. Several consecutive nights glucose monitoring was done and it revealed hypoglycemia. Somogyi phenomenon is diagnosed. What will be the next best step in management of this patient +
A 45 year old female presents to her primary care physician with complaints of fatigue and pain in her proximal interphalangeal joints, metacarpophalangeal joints, wrists, elbows and knees for the past 10 days. The pain in her joints is accompanied by stiffness lasting for less than 30 minutes after prolonged rest. She also has complaints of pruritus and rashes over her arms and legs for the past 2 days. She denies any history of fever. She is a daycare worker and has been in good health previously. She further denies any history of smoking, alcohol or recent travel. She is sexually active only with her husband. Her vital signs are heart rate 82 beats/min, respiratory rate 16/minute, blood pressure 120/80 mm Hg and oral temperature 37.2 C. On physical examination, erythematous and reticular rashes are noted in her arms and legs. A swelling is elicited at the area of ulnar styloid process of the right wrist. Other joints appear to be normal. An MRI of the right wrist revealed an osseous density at the ulnar styloid process, minimal degenerative changes of the radiocarpal joint, and positive ulnar variance. A series of lab tests are ordered. Which of the following will be most likely elevated, pointing towards the diagnosis? +
A 35 year old male is admitted following a complaint of progressive dysphagia for the past three weeks. He has dysphagia for both solids and liquids. There is no history of fever or odynophagia. He denies any history of vomiting and weight loss. He has a past history of severe upper abdominal pain that lasted for 2 days following a binge of alcohol 2 months back and it relieved with symptomatic treatment. Physical examination is unremarkable and vitals are stable. His lab tests are normal except for elevated serum amylase and lipase levels. An endoscopy showed stasis at the lower end of esophagus with an extrinsic compression of the lower esophagus and an ultrasound abdomen showed a cystic lesion of 10 cm diameter in the upper abdomen in close relation to the tail region of the pancreas. A following abdominal CT showed the same cystic lesion with thickened capsule at the same location with similar size. What will be the next best step in the line of management of this patient? +
A 62 year-old man comes to ED complaining of acute shortness of breath, fatigue, and worsening exertional dyspnea. He hardly can talk, and mentioned waking up several times at night on sever cough with frothy sputum. He used to sleep on two pillows but now he is using three. The patient has past medical history of hypertension for 15 years, and diabetes mellitus for 20 years. On examination, his BP 90/70, pulse 120, respiratory rate 28, and temperature is 36.9 C (98.5F). Chest examination revealed decreased breath sounds and dullness at both bases with bibasilar rales. Cardiac examination revealed diffuse, laterally and inferiorly displaced apex, with distant heart sounds and S3 gallop. There is a jugular venous distention, with JVP of 12 cm, and oxygen saturation of 83%. Extremities are cool and show 2+ pitting edema in both legs up to the knee. After he is been admitted to ICU, and being on Oxygen, furosemide, nitrates, and morphine, his oxygen saturation is not improving, and you notice no improvement in his case, which of the following is the best next step in his management? +
A 6-year-old boy is brought to the pediatrics clinic by his concerned mother. She explains that her son often wakes up during the night screaming and continues to cries inconsolably. However, in the morning he appears to be normal and doesn’t remember anything regarding the incident the previous night. The physician suggests a sleep study to further evaluate the child's condition. Which of the following wave forms are most likely to be observed directly prior to this patient's episodes? +
A 26-year-old woman presents to her primary care physician for fatigue that started shortly after her husband passed away. She complains of having difficulties sleeping, waking up very early in the morning and not being able to fall asleep again. She also reports difficulties concentrating, a general lack of interest in her old hobbies, and a constant desire to be alone. The patient reports losing 12 pounds in the past few months. Which of the following is the most common sleep pattern expected in this patient? +
A 50-year-old man presents with complaints of diffuse abdominal pain and non-bloody diarrhea. He states that he recently experienced joint pains, unintentional weight loss, and decreased night vision over the past few months. Physical examination is remarkable for inflammation at the angle of the mouth, loss of papillae on the tongue, generalized lymphadenopathy, and diffuse hyperpigmentation of the skin. Fecal occult blood test is positive, and ELISA is negative for HIV antibodies. What is the characteristic finding on intestinal biopsy in this patient? +
A 35-year-old man is treated for acute promyelocytic leukemia with a sustained course of arsenic trioxide and All-trans-retinoic acid (ATRA). If he develops a secondary malignancy due to this therapy, which of the following is most probable? +
A 26-year-old woman is admitted to the emergency department for severe right lower quadrant pain. Following appropriate work-up, she is diagnosed with acute appendicitis and undergoes emergency appendectomy. Her postoperative course is complicated by persistent, diffuse abdominal pain, with palpable distension. She is unable to tolerate an oral diet due to nausea and vomiting after any food ingestion. Despite feeling bloated she has not passed any flatus 5 days after the operation. Upright abdominal X-rays are negative for signs of bowel obstruction. Which of the following pharmacotherapies may help treat this patient’s condition? +
An investigational drug called Ro 47-0203 is being evaluated for the treatment of pulmonary hypertension. Scientists find that in an in-vitro assay measuring the isometric tension of pig aortic rings, Ro 47-0203 is able to induce a potent rightward shift of the concentration-response curve to endothelin-1. However, it has no additional effect when used concurrently with a selective endothelin A antagonist. Which of the following drugs does Ro 47-0203 most likely refer to? +
A 6-year-old boy is brought to the emergency department by his parents after he began vomiting and exhibiting signs of intoxication. The patient reports that the symptoms started after he drank a blue liquid he found in the garage. The patient's labs reveal a creatinine of 3.6 mg/dL, a serum sodium of 140 mEq/L, a serum bicarbonate of 14 mEq/L, and a chloride of 98 mEq/L. Urinalysis reveals hematuria. Which of the following should be promptly administered to this patient? +
A 55-year-old smoker presents to his primary care physician for dyspnea. Physical examination reveals a right sided pleural effusion and chest-CT is concerning for malignancy. The physician is set to perform a thoracentesis, but must recall the positioning of the neurovascular bundle in the intercostal space. Which of the following represents the order of structures in the intercostal space from inferior to superior? +
Lenalidomide is a highly effective chemotherapeutic agent against multiple myeloma. A scientist is investigating the anti-neoplatic mechanism of lenalidomide. She finds that addition of lenalidomide to multiple myeloma cells decreases the protein abundance of the plasma cell essential transcription factors IKZF1 and IKZF3. She finds that lenalidomide binds to the CRBN-CRL4 complex, which then induces a post-translational modification of IKZF1 and IKZF3. Which of the following enzymatic activities does CRBN-CRL4 most likely possess? +
A scientist is studying the mechanism of exercise-induced insulin sensitivity in diabetic patients. A biopsy of the vastus lateralis muscle is obtained from a patient's left leg at rest. Three to six weeks later, the subjects performs 60 minutes of cycling at 70% VO<sub>2</sub> max, and immediately thereafter another biopsy is obtained from the right vastus lateralis muscle. The investigator performs immunohistochemistry for both obtained tissues. Which of the following will demonstrate increased localization to the plasma membrane? +
An anatomy PhD student is performing an experiment to determine the muscles involved in mouth opening and clenching. He records electromyographic (EMG) activity from the inferior and superior heads of muscle A. Little EMG activity was noted in the inferior head during clenching of the mandible. However, strong activity was recorded from the inferior head during opening of the jaw. Which of the following does muscle A most likely represent? +
A 60-year-old man attempts suicide by consuming his entire bottle of propranolol pills. He suffers extreme cardiovascular collapse and tonic-clonic seizures. Which of the following may serve as an antidote to his overdose? +
A 25-year-old man presents to his primary care physician after he noticed an irregular hard lump in his right testicle. Serum placental alkaline phosphatase and lactate dehydrogenase are elevated and testicular ultrasound demonstrates a hypoechogenic homogeneous intratesticular mass. Which of the following sites would be the most likely first step in metastatic spread of this tumor? +