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National Center for Biotechnology Information 11

usmle-11451

A 3-year-old boy is brought to the pediatrician by his parents with a presentation of severe diarrhea, vomiting, and fever for the past 2 days. The child is enrolled at a daycare where several other children have had similar symptoms in the past week. On physical exam, the child is noted to have dry mucous membranes. His temperature is 102°F (39°C). Questions regarding previous medical history reveal that the child’s parents pursued vaccine exemption to opt out of most routine vaccinations for their child. The RNA virus that is most likely causing this child’s condition has which of the following structural features?

usmle-11452

A 58-year-old woman is hospitalized due to a potentially fatal autoimmune skin disorder. On exam, she has numerous, flaccid bullae involving the skin, and her left upper extremity is pictured in Figure A. The formation of new bullae is observed when gentle pressure is applied to her skin. The autoantibody causing her condition targets which epithelial cell structure?

usmle-11453

A 16-year-old girl is brought into your office. The girl has not yet experienced menarche. Her medical history is notable for an aortic valve abnormality as well as an aortic coarctation. Figure A depicts her general appearance on physical exam. Which of the following findings is most likely associated?

usmle-11454

A 62-year-old female presents to her primary care provider complaining of a mass near her right jaw. She reports that the mass is painless and has grown very slowly over the past six months. She initially did not see a physician due to being very busy at her work as a lawyer. However, she reports that she noticed some right-sided facial weakness in the past week which prompted her to visit the physician. Her past medical history is notable for Hodgkins lymphoma as a child which required radiation therapy to the neck. She has a 20 pack-year smoking history and drinks alcohol socially. Her temperature is 98.6°F (37°C), blood pressure is 120/85 mmHg, pulse is 85/min, and respirations are 18/min. Physical examination reveals a painless firm mass at the angle of the right jaw. There is also a small palpable firm mass beneath the floor of the mouth. A right facial droop along with an inability to elevate her right eyebrow is noted. A biopsy of one of this lesion would most likely reveal which of the following?

usmle-11455

The research of an academic physician helps to discover a novel small molecule that improves outcomes after myocardial infarction in animal models due to decreasing the severity of reperfusion injury. A pharmaceutical company then approached the university of this physician in order to sign an agreement allowing the molecule to proceed to clinical trials. After several years of work, the physician has obtained a wealth of new data from human trials and has published several high profile papers. A major national conference then invites this physician to give a keynote presentation on his work with the novel small molecule. In order to prepare for this speech, the pharmaceutical company offers: 1. A speaking honorarium 2. Compensation for travel expenses 3. Help with preparing slides for the speech Which of these benefits can the physician ethically accept?

usmle-11456

A 21-year-old female presents to the emergency room complaining of two weeks of diarrhea and abdominal pain. She also experienced multiple episodes of hematuria the day prior to presentation. She is a refugee from South Sudan who arrived in the United States one month ago. She has no known past medical history and takes no medications. She is sexually active and does not use contraception. Her temperature is 100.1°F (37.8°C), blood pressure is 135/75 mmHg, pulse is 110/min, and respirations are 20/min. On exam, mild hepatosplenomegaly is noted. She has no costovertebral angle tenderness. A pregnancy test and urinalysis are negative. Results of a complete blood count are shown below: Leukocyte count and differential: Leukocyte count: 13,000/mm^3 Segmented neutrophils: 54% Bands: 5% Eosinophils: 8% Basophils: 0.5% Lymphocytes: 29% Monocytes: 4% Results of a stool analysis are shown in Figure A. Which of the following is most responsible for mediating the immune response in this patient?

usmle-11457

A 23-year-old female presents to the emergency department stating that she is “not thinking clearly.” Her vital signs are as follows: T 101.2 F, HR 110, BP 104/72, RR 18, SpO2 98% RA. Her physical exam is notable for the following findings in her oropharynx (Figure A). Complete blood count reveals: WBC 11.7 x 10^9/L, Hemoglobin 7.3 g/dL, Platelets 54 x10^9/L. Basic metabolic panel reveals: Sodium 137 mEq/L, Potassium 5.2 mEq/L, Chloride 100 mEq/L, Bicarbonate 22 mEq/L, Creatinine 2.78 mEq/L. Which of the following additional findings would you expect in this patient?

usmle-11458

A 5-year-old boy is brought to his neurologist for continued treatment of muscle spasms. His past medical history is significant for a brain abnormality that was detected neonatally when it presented with an enlarged posterior fossa as well as a malformed cerebellar vermis. Since birth, he has had developmental delay, high muscle tone, difficulty with coordination, and speech delay. He has been treated with a number of therapies to relax his muscle tone such as baclofen. Which of the following conditions is associated with this patient's most likely condition?

usmle-11459

A 45-year-old man presents to the clinic for an annual wellness checkup. He is relatively healthy and denies any pressing concerns. He endorses a healthy diet consisting of fruits, vegetables, and fish. He exercises for 30 minutes 3 times per week. He denies any headaches, chest pain, palpitations, fever, weight changes, or gastrointestinal issues. His temperature is 98.6°F (37.0°C), blood pressure is 154/78 mmHg, pulse is 87/min, and respirations are 12/min. As his previous appointment demonstrated elevated blood pressure, he is started on an anti-hypertensive medication. A week later, the patient presents to the office complaining of swelling of the face demonstrated in Figure A. He denies trauma, fever, pain, itchiness, respiratory difficulties, or recent upper respiratory infections. What is the most likely explanation for this finding?

usmle-11460

A 24-year-old woman comes to the physician’s office with concerns about a recent pregnancy. She and her boyfriend had intercourse for the first time a few weeks ago. Two weeks ago she missed her menstrual period. She took several over the counter pregnancy tests that confirmed her pregnancy. She is tearful about the pregnancy and is very concerned. After extensive conversations with her physician and counseling, she decides she wants to medically abort her 6-week pregnancy. Which of the following drugs should be administered to this patient for this purpose?

usmle-11461

A 17-year-old male college athlete visits your clinic for a physical exam prior to starting his first season with the basketball team. He reports that he has no complaints when working out and admits that he is happy about recently surpassing the 7-foot mark. He has extremely long limbs and has grown at a rate of around 3 inches every year since hitting puberty. Although vitals are normal, eye exam shows an unusually placed lens (Figure A) and auscultation at the apex reveals a mid-systolic click. Given these features, what is the most likely gene affected in this patient?

usmle-11462

A 41-year-old woman presents to the emergency room with a 2-day history of flank pain, nausea, and vomiting. She denies any urinary frequency or urgency and denies any recent changes in her diet. Her temperature is 100.4°F (38°C), blood pressure is 152/96 mmHg, and pulse is 104/min. On physical exam, there is bilateral flank tenderness to palpation. In addition, neurologic testing reveals decreased strength in her left upper extremity and an inability to sustain lateral gaze with her right eye. An electrocardiogram reveals an irregularly irregular heart rhythm. Which of the following is associated with the most likely cause of this patient's symptoms?

usmle-11463

A 59-year-old female presents to the emergency department after a fall. She reports severe pain in her right hip and an inability to move her right leg. Her past medical history is notable for osteoporosis, rheumatoid arthritis, and has never undergone surgery before. The patient was adopted, and her family history is unknown. She has never smoked and drinks alcohol socially. Her temperature is 98.8°F (37.1°C), blood pressure is 150/90 mmHg, pulse is 110/min, and respirations are 22/min. Her right leg is shortened, abducted, and externally rotated. A radiograph demonstrates a displaced femoral neck fracture. She is admitted and eventually brought to the operating room to undergo right hip arthroplasty. While undergoing induction anesthesia with inhaled sevoflurane, she develops severe muscle contractions. Her temperature is 103.4°F (39.7°C). A medication with which of the following mechanisms of action is indicated in the acute management of this patient’s condition?

usmle-11464

A 51-year-old female presents to her primary care physician complaining of body aches and constipation. She reports that her “bones hurt” and that she has experienced worsening constipation over the past few months. Her medical history is notable for three kidney stones within the past year that both passed spontaneously. Her vital signs are stable. Physical examination reveals a small nodule near the right inferior pole of the thyroid. Which of the following sets of serum findings is most likely in this patient?

usmle-11465

A 5-year-old boy is brought to the clinic for recurrent bedwetting. The child has an intellectual disability; thus, the mother is providing most of the history. She states that the child constantly drinks fluids and has a difficult time making it to the bathroom as often as he needs. Therefore, he sometimes wets himself during the day and at night. She has tried bedwetting alarms with no success. Review of systems is negative. His past medical history is unremarkable expect for moderate growth retardation. His temperature is 99.5°F (37.5°C), blood pressure is 80/54 mmHg, pulse is 90/min, respirations are 20/min, and oxygen saturation is 99% on room air. Routine laboratory tests and a 24 hour urine test are shown below. Serum: Na+: 138 mEq/L Cl-: 90 mEq/L K+: 2.5 mEq/L HCO3-: 35 mEq/L BUN: 9 mg/dL Glucose: 98 mg/dL Creatinine: 1.0 mg/dL Thyroid-stimulating hormone: 1.2 µU/mL Ca2+: 9.1 mg/dL AST: 13 U/L ALT: 10 U/L pH: 7.49 Urine: Epithelial cells: 5 cells Glucose: Negative WBC: 0/hpf Bacterial: None Protein: 60 mg/24h (Normal: < 150 mg/24h) Calcium: 370 mg/24h (Normal: 100-300 mg/24h) Osmolality 1600 mOsmol/kg H2O (Normal: 50-1400 mOsmol/kg H2O) What is the most likely explanation for this patient’s findings?

usmle-11466

A 26-year-old man with a history of alcoholism presents to the emergency department with nausea, vomiting, and right upper quadrant pain. Serum studies show AST and ALT levels >5000 U/L. A suicide note is found in the patient's pocket. The most appropriate initial treatment for this patient has which of the following mechanisms of action?

usmle-11467

A 9-year-old boy is brought to your office due to nausea and vomiting. He had 4 episodes of non-bloody and non-bilious emesis over the last 24 hours. He denies any diarrhea or changes in his diet; however, his best friend at school recently had viral gastroenteritis and his mother is concerned that he has the same bug. She notes that he has been drinking more water than usual and wet his bed twice over the last two weeks. He is otherwise healthy and is not taking any medications. On physical exam his temperature is 99°F (37.2°C), blood pressure is 100/70 mmHg, pulse is 112/min, respirations are 26/min, and pulse oximetry is 99% on room air. He has lost 10 pounds since his previous visit 6 months ago. There is diffuse, mild abdominal tenderness to palpation. The most likely disease process responsible for this patient's symptoms is associated with which of the following?

usmle-11468

A 31-year-old G1P1 woman presents to the physician with fever, chills, and pain of her right breast in the past week. She recently gave birth to her first child and has been breastfeeding for the past 7 weeks. On physical exam, the patient has redness and swelling of her right breast that is warm to the touch and tender to light palpation. An image of her breast is shown in Figure A. On closer inspection, the physician notes a small fissure in the nipple with surrounding purulence. Which of the following pathogens is the most likely cause of her condition?

usmle-11469

A 30-year-old woman presents to an urgent care center with progressively worsening cough and difficulty breathing. She has had similar prior episodes since childhood, one of which required intubation with mechanical ventilation. On physical exam, she appears anxious and diaphoretic, with diffuse wheezes and diminished breath sounds bilaterally. First-line treatment for this patient’s symptoms acts by which of the following mechanisms of action?

usmle-11470

A 27-year-old male undergoing treatment for bipolar disorder complains of rigid movements. His medication was transitioned from lithium to an antipsychotic four months prior. He also reports worsening neck contractions (Figure A). Which of the following medications is the patient most likely taking?

usmle-11471

A 67-year-old man with hypertension, hypercholesterolemia, and diabetes mellitus presents to the ED with severe chest pain. The pain started suddenly a few hours ago, characterized as sharp and radiating to his back. He has never experienced pain like this before. He also has been sweaty, short of breath, and nauseous, but denies cough, fever, vomiting, or a history of trauma. He has smoked 1 pack of cigarettes per day since age 15, and currently takes lisonopril, amlodipine, metformin, and atorvastatin. In the ED, his temperature is 98.5 deg F (36.9 deg C), blood pressure is 85/50 mmHg, pulse is 115/min, and respirations are 25/min. An EKG is seen in Figure A and appears similar to an EKG obtained 1 month ago. He appears to be in moderate distress. Auscultation of his chest revealed no murmurs and his lungs are clear bilaterally. There is no tenderness to palpation along his chest wall. His abdominal exam is noteworthy for a pulsatile mass. The rest of his exam is within normal limits. Appropriate management is initiated. What is the most likely etiology of this patient's acute chest pain?

usmle-11472

A 31-year-old male presents to his primary care physician complaining of low back pain and fevers. He reports a four-day history of intermittent fevers, chills, and low back pain. He denies trauma or recent illness. His past medical history is notable for recurrent renal stones, diabetes mellitus, and alcohol abuse. He takes metformin but admits to missing several doses. He has had multiple sexual partners and uses condoms intermittently. His temperature is 100.6°F (38.1°C), blood pressure is 110/70 mmHg, pulse is 110/min, and respirations are 21/min. On examination, he demonstrates mild tenderness to palpation along his lower back. Sensation to touch is intact in the bilateral lower extremities. Strength in leg and hip flexion and extension is 5/5 bilaterally. The physician is unable to perform a digital rectal examination due to pain. A urinalysis demonstrates leukocytes. Which of the following treatment regimens is most appropriate in this patient?

usmle-11473

A 23-year-old man presents to an outpatient psychiatrist complaining of anxiety and a persistent feeling that “something terrible will happen to my family.” He describes 1 year of vague, disturbing thoughts about his family members contracting a “horrible disease” or dying in an accident. He believes that he can prevent these outcomes by washing his hands of “the contaminants” any time that he touches something and by performing praying and counting rituals each time that he has unwanted, disturbing thoughts. The thoughts and rituals have become more frequent recently, making it impossible for him to work, and he expresses feeling deeply embarrassed by them. Which of the following is the most effective treatment for this patient's disorder?

usmle-11474

A 54-year-old man is brought to the emergency department after he was found outside in the middle of a blizzard. On presentation, he is conscious but does not know where he is nor how he got there. His wife is contacted and says that he has been getting increasingly confused over the past 6 weeks. This progressed from misplacing objects to getting lost in places that he knew how to navigate previously. Most worryingly, he has recently started forgetting the names of their children. In addition to these memory changes, she says that he now has rapid jerky movements of his extremities as well as coordination and balance problems. Finally, he has become extremely paranoid about government surveillance and has had hallucinations about secret agents in their house. His previous medical history is significant for a previous car crash in which the patient required internal fixation of a femur fracture and a corneal transplant for corneal degeneration. Otherwise he had no neurologic deficits prior to 6 weeks ago. Physical exam reveals myoclonus and ataxia. Which of the following is true of the most likely cause of this patient's symptoms?

usmle-11475

A 59-year-old man presents to his primary care physician with a 5-month history of breathing difficulties. He says that he has been experiencing exertional dyspnea that is accompanied by a nonproductive cough. His past medical history is significant for a solitary lung nodule that was removed surgically 10 years ago and found to be benign. He works as a secretary for a coal mining company, does not smoke, and drinks socially with friends. His family history is significant for autoimmune diseases. Physical exam reveals fine bibasilar inspiratory crackles in both lungs, and laboratory testing is negative for antinuclear antibody and rheumatoid factor. Which of the following is associated with the most likely cause of this patient's symptoms?

usmle-11476

A 27-year-old G2P1 female gives birth to a baby girl at 33 weeks gestation. The child is somnolent with notable difficulty breathing. Pulse pressure is widened. She is profusely cyanotic. Auscultation is notable for a loud single S2. An echocardiogram demonstrates an enlarged heart and further studies show blood from the left ventricle entering the pulmonary circulation as well as the systemic circulation. Which of the following processes was most likely abnormal in this patient?

usmle-11477

A 72-year-old nursing home resident is complaining of pruritis. She is noted to have multiple, tense blisters on her trunk as well as the flexor surfaces of her extremities. The blisters have an erythematous base. You are unable to extend the blisters when you apply lateral traction. You suspect an autoimmune bullous dermatosis. Which of the following is the cause of the likely condition?

usmle-11478

A 1-year-old girl is brought to the pediatric emergency room by her parents due to wheezing and trouble breathing. Her parents note that she has not been feeding well and has had a fever of 101°F (38.3°C) over the past few days along with a runny nose. On physical examination, the patient is found to have increased work of breathing marked by nasal flaring and intercostal retractions, along with bilateral wheezing. The patient’s chest radiograph is shown in Figure A. Which of the following pathogens is the most likely cause of this patient’s clinical presentation?

usmle-11479

A 64-year-old man presents to his primary care provider after noticing the development of a blistering rash. The patient states that his symptoms began 1 week ago after he noticed a blister develop on the inside of his mouth that eventually ruptured. Over the past several days, he has noticed several more blisters on his torso. The patient denies a fever or any other symptoms. He has a history of high blood pressure, for which he takes hydrochlorothiazide. He is otherwise healthy and denies any recent changes to his medication. Today, the patient’s temperature is 99.0°F (37.2°C), blood pressure is 124/84 mmHg, pulse is 66/min, and respirations are 12/min. On exam, the patient’s mouth is notable for a previously ruptured blister on his left buccal mucosa. On his left flank and anterior abdomen are scattered 10-15-cm bullae that appear flaccid and filled with serous fluid. The lesions are erythematous but there is no surrounding erythema. On manual rubbing of the skin near the lesions, new blisters form within minutes. Which of the following is involved in the pathogenesis of this disease?

usmle-11480

A 37-year-old female comes to the clinic complaining of vaginal pruritus and white discharge for 2 days. She also reports having a white plaque on her tongue (shown in Figure A) that has been present “on and off” for the past 10 years. She is currently sexually active with a new partner for the past 2 weeks with inconsistent condom use. HIV testing in the past has been negative. She denies any weight loss, fevers, or chills but endorses some tingling of the fingertips and lip. Laboratory findings are as follows: Serum: Na+: 137 mEq/L Cl-: 101 mEq/L K+: 4.8 mEq/L HCO3-: 25 mEq/L Glucose: 117 mg/dL Creatinine: 1.0 mg/dL Ca2+: 6.6 mg/dL AST: 12 U/L ALT: 15 U/L What is the most likely explanation for this patient’s symptoms?

usmle-11481

A 50-year-old man with a past medical history of diabetes, hyperlipidemia, and uncontrolled hyperthyroidism presents to the hospital with crushing chest pain. He is found to have ST segment elevation and Q wave formation in the precordial and high lateral leads. He is treated for acute myocardial infarction and hospitalized. On the morning of his second day of hospitalization, he continues to be hemodynamically stable and asymptomatic but develops sustained monomorphic ventricular tachycardia. Which of the following best illustrates the cardiac action potential after administration of the antiarrhythmic drug most likely used for this patient?

usmle-11482

A 14-year-old boy presents with right upper quadrant abdominal pain and is found on ultrasound to have a gallstone. Based on clinical suspicion, a CBC, a Coombs test, and a bilirubin panel are obtained to determine the etiology of the gallstone. These tests reveal a mild normocytic anemia with associated reticulocytosis as well as an increased RDW. In addition there is an indirect hyperbilirubinemia and the Coombs test results are negative. To confirm the diagnosis, an osmotic fragility test is performed which shows increased fragility in hypotonic solution. In this patient, what findings would most likely be anticipated if a blood smear were obtained?

usmle-11483

A 50-year-old man presents to the emergency room after having a seizure. He has never had a seizure before. His wife accompanies him and reports that he has been experiencing occasional headaches and nausea over the past 6 months that appear to be worsening. His past medical history is notable for hypertension, for which he takes hydrochlorothiazide. He has a 60-pack-year smoking history and drinks 2-3 alcoholic beverages per day. His temperature is 98.6°F (37°C), blood pressure is 125/75 mmHg, pulse is 94/min, and respirations are 18/min. On exam he is lethargic, but able to respond to questions in complete sentences. Reflexes are 2+ and strength is 5/5 bilaterally in the upper and lower extremities. A brain MRI is performed, and a significant finding is shown in Figure A. Which of the following findings would most likely be seen on histological examination of this patient's lesion?

usmle-11484

A 22-year-old female presents to your office with pruritis, vesicles, and erythematous skin around the clavicle, as shown in Figure A. She reports that her symptoms began shortly after Valentine's Day, when her boyfriend gave her a "beautiful silver necklace." Which of the following would you most expect to see on a biopsy of this patient's skin?

usmle-11485

An 18-year old college freshman presents to his university clinic because he has not been feeling well for the past two weeks. He has had a persistent headache, occasional cough, and chills without rigors. The patient’s vital signs are normal and physical exam is unremarkable. His radiograph shows patchy interstitial lung infiltrates and he is diagnosed with atypical pneumonia. The patient is prescribed azithromycin and takes his medication as instructed. Despite adherence to his drug regimen, he returns to the clinic one week later because his symptoms have not improved. The organism responsible for this infection is likely resistant to azithromycin through which mechanism?

usmle-11486

A 25-year-old female comes to her obstetrician’s office for a prenatal visit. She has a transvaginal ultrasound that correlates with her last menstrual period and dates her pregnancy at 4 weeks. She has no complaints except some nausea during the morning that is improving. She comments that she has had some strange food cravings, but has no issues with eating a balanced diet. Her BMI is 23 kg/m^2 and she has gained 1 pound since the start of her pregnancy. She is curious about her pregnancy and asks the physician what her child is now able to do. Which of the following developments is expected of the fetus during this embryological phase?

usmle-11487

A 65-year-old woman presents with a complaint of a chronic, dry cough of insidious onset since working with her new primary care physician. She has a longstanding history of diabetes mellitus type 2, hypertension, and hyperlipidemia. She has a 10 pack-year smoking history, but does not currently smoke. What is the best next step?

usmle-11488

A 14-year-old boy is brought to the emergency department from school after falling in gym class. He was unable to stand after the accident and has a painful and swollen knee. On presentation he says that he has never had an incident like this before; however, he does suffer from hard to control nosebleeds and prolonged bleeding after minor cuts. Based on his presentation a panel of bleeding tests is obtained with the following results: Bleeding time: Prolonged Prothrombin time: Normal Partial thromboplastin time: Prolonged Which of the following describes the function of the component that is defective in the most likely cause of this patient's symptoms?

usmle-11489

A 10-year-old boy is brought to the clinic by his mother for a rash for the past day. The patient complains that “these bumps are really itchy” and has been scratching them despite protests from his mother. The patient has been relatively healthy with no past medical history except for an episode of otitis media 2 days prior for which he was prescribed antibiotics. His mom denies any change in detergent, clothing, or personal hygiene products but reports that he recently returned from a camping trip 2 days ago. The patient denies fever, weight loss, or chills. Physical examination findings are shown in Figure A. What is the most likely explanation for this patient’s symptoms?

usmle-11490

A 58-year-old male with a history of obesity and hypertension presents to his primary care physician for a follow-up visit. He reports that he feels well and has no complaints. He currently takes hydrochlorothiazide. His temperature is 98.6°F (37°C), blood pressure is 135/80 mmHg, pulse is 86/min, and respirations are 17/min. His BMI is 31 kg/m2. Results of a lipid panel are: Total cholesterol is 280 mg/dl, triglycerides are 110 mg/dl, HDL cholesterol is 40 mg/dl, and LDL cholesterol is 195 mg/dl. Her physician considers starting her on atorvastatin. Which of the following will most likely decrease after initiating this medication?

usmle-11491

A 26-year-old woman comes to the clinic for an annual wellness examination. She is healthy with no prior history of significant illness. She exercises 3-4 times a week and eats a plant-based diet with no carbonated drinks. When asked if anything is bothering her, she reports that she has been having recurring episodes of sneezing, congestion, and itchy eyes for the past year. She denies any fever, sick contacts, cough, headaches, chest pain, urinary symptoms, or constipation/diarrhea during these episodes. She is told to take a medication to alleviate her symptoms as needed. What is the likely mechanism of action of the medication in question?

usmle-11492

A 52-year-old woman presents to her primary care physician for her annual checkup. She lost her job 6 months ago and since then she has been feeling worthless because nobody wants to hire her. She also says that she is finding it difficult to concentrate, which is exacerbated by the fact that she has lost interest in activities that she used to love such as doing puzzles and working in the garden. She says that she is sleeping over 10 hours every day because she says it is difficult to find the energy to get up in the morning. She denies having any thoughts about suicide. Which of the following neurotransmitter profiles would most likely be seen in this patient?

usmle-11493

A 72-year-old man is brought in by ambulance to the hospital after being found down at home. On presentation, he appears cachectic and is found to be confused. Specifically, he does not answer questions appropriately and is easily distracted. His wife says that he has been losing weight over the last 3 months and he has a 40 pack-year history of smoking. His serum sodium is found to be 121 mEq/L and his urine osmolality is found to be 415 mOsm/kg. Chest radiograph shows a large central mass in the right lung. Which of the following treatments would be effective in addressing this patient's serum abnormality?

usmle-11494

A 31-year-old woman scrapes her finger on an exposed nail and sustains a minor laceration. Five minutes later, her finger is red, swollen, and painful. She has no past medical history and does not take any medications. She drinks socially with her friends and does not smoke. The inflammatory cell type most likely to be prominent in this patient's finger has which of the following characteristics?

usmle-11495

A 35-year-old male presents to the emergency room with difficulty breathing. He is accompanied by his wife who reports that they were eating peanuts while lying in bed on their backs when he suddenly started coughing profusely. He has a significant cough and has some trouble breathing. His past medical history is notable for obesity, obstructive sleep apnea, seasonal allergies, and alcohol abuse. He uses a continuous positive airway pressure machine nightly. His medications include cetirizine and fish oil. He has a 10 pack-year smoking history. His temperature is 98.6°F (37°C), blood pressure is 125/30 mmHg, pulse is 110/min, and respirations are 23/min. Which of the following lung segments is most likely affected in this patient?

usmle-11496

A 27-year-old woman presents to her primary care physician because of headaches that she has had over the last three weeks. She has not had any significant past medical history though she does recall that various types of cancer run in her family. She has also noticed that she has been gaining some weight, and her feet no longer fit into her favorite shoes. On presentation, her temperature is 98.6°F (37°C), blood pressure is 159/92 mmHg, pulse is 75/min, and respirations are 16/min. Physical exam reveals 1+ edema in her lower extremities bilaterally. She is placed on captopril and presents to the emergency department two weeks later after a minor motor vehicle accident. She is cleared of any serious injuries, and as part of her workup, labs are drawn with the following results: BUN: 47 mg/dL Creatinine: 1.4 mg/dL Which of the following findings would most likely also be seen in this patient?

usmle-11497

A 60-year-old woman presents to the emergency department with progressive nausea and vomiting. She reports that approximately one day prior to presentation she experienced abdominal discomfort that subsequently worsened to severe nausea, vomiting, and two episodes of watery diarrhea. She recently noticed that her vision has become blurry along with mild alterations in color perception. Medical history is significant for congestive heart failure with a low ejection fraction. She cannot recall which medications she is currently taking but believes she is taking them as prescribed. Which of the following is a characteristic of the likely offending drug that led to this patient’s clinical presentation?

usmle-11498

A 59-year-old man with a history of congestive heart failure presents to his cardiologist for a follow-up visit. His past medical history is notable for diabetes mellitus, hypertension, and obesity. He takes metformin, glyburide, aspirin, lisinopril, and metoprolol. He has a 40 pack-year smoking history and drinks alcohol socially. His temperature is 99.1°F (37.2°C), blood pressure is 150/65 mmHg, pulse is 75/min, and respirations are 20/min. Physical examination reveals bilateral rales at the lung bases and 1+ edema in the bilateral legs. The physician decides to start the patient on an additional diuretic but warns the patient about an increased risk of breast enlargement. Which of the following is the most immediate physiologic effect of the medication in question?

usmle-11499

A 12-year-old boy is brought to the emergency department with a 2-month history of increasing difficulty with physical activity. Specifically, he says that he gets short of breath quickly with exertion even though he used to participate in all activities without a problem. When asked, he endorses sometimes coughing up flecks of blood. His past medical history is unclear because he was recently adopted from abroad and has not yet established care. Physical exam reveals blue discoloration of his lips and fingernails as well as a holosystolic murmur best heard at the lower left sternal border. Which of the following physiologic mechanisms is primarily responsible for this patient's current presentation?

usmle-11500

A 32-year-old male presents to the ED with acute-onset chest pain. His blood pressure is 157/90 mmHg and his his pulse is 116/min. He appears anxious and agitated and a careful exam reveals dilated pupils and a perforated nasal septum. An EKG reveals ST segment elevation so he is urgently taken for cardiac intervention. Upon review, this patient reveals that he has not had care from a physician since he graduated from college. In the interim he has been largely unemployed and admits that he has recently been homeless. When asked directly, the patient admits to alcohol and marijuana use but denies illicit drug use. Which of the following best describes the mechanism of action of the agent most likely responsible for this patient's presentation?

usmle-11501

A 42-year-old woman presents complaining of pain in her hands. She reports that the pain is in both hands, and that it is usually worse in the morning. She reports that her hands are also stiff in the morning, but that this gradually improves throughout the morning. She notes, however, that her symptoms seem to be getting worse over the last three months. What is the most likely pathogenesis of her disease process?

usmle-11502

A 4-year-old presents to his pediatrician because over the past 3 months he has experienced recurrent itchy red rashes located in the folds of his elbows. His mother is worried because they are causing him serious discomfort and have not abated in spite of her trying a number of different creams and lotions. On exam, the physician notes a pruritic, raised, erythematous raised lesion in both antecubital fossae as demonstrated in Figure A. This child's dermatologic condition is most closely associated with which of the following?

usmle-11503

A 71-year-old man presents to his oncologist with nausea. He recently underwent chemotherapy for pancreatic cancer and has developed severe intractable nausea over the past week. He vomits several times a day. His past medical history is notable for gout, osteoarthritis, and major depressive disorder. He takes allopurinol and sertraline. He has a 15-pack-year smoking history and drinks 1 glass of wine per day. His temperature is 98.6°F (37°C), blood pressure is 148/88 mmHg, pulse is 106/min, and respirations are 22/min. On exam, he is lethargic but able to answer questions appropriately. He has decreased skin turgor and dry mucous membranes. He is started on a medication to treat nausea. However, 3 days later he presents to the emergency room with fever, agitation, hypertonia, and clonus. What is the most likely mechanism of action of the drug this patient was prescribed?

usmle-11504

A 23-year-old man comes to clinic with a three-day history of a pruritic rash in both antecubital fossae. He states that he just returned from a family hiking trip in Maine and that he has had no fevers or other symptoms. His vitals signs are within normal limits. On exam, both antecubital fossae are notable for erythematous patches with linear excoriations and scale, as shown in Figure A. Which of the following is his condition most likely associated with?

usmle-11505

A 65-year-old man with a history of diabetes, hypertension, hyperlipidemia, and obesity is transferred from the cardiac catheterization lab to the cardiac critical care unit after sustaining a massive myocardial infarction. He received a bare metal stent and has now stabilized. However, shortly after being transferred, he reports palpitations. EKG reveals ventricular tachycardia. Your attending wishes to start an anti-arrhythmic drug with a high selectivity for ischemic cardiac myocytes. You call the nurse and ask her to begin intravenous:

usmle-11506

A 79-year-old man with a long-standing history of hypertension and diabetes presents to the emergency department with sudden-onset of loss of motor function on the left side of his body. Neurologic exam shows normal sensation throughout the body. MRI of the brain is obtained and shows a small sub-cortical infarct involving a perforating vessel. Which of the following is the most likely underlying pathogenesis?

usmle-11507

An 8-year-old girl presents to her primary care provider with several months of headaches and impaired vision. Physical exam reveals a female in the 10th percentile for height and 43rd percentile for weight; cranial nerve testing demonstrates bitemporal hemianopsia. She undergoes a head CT, which shows suprasellar calcifications (Figure A). Given her likely diagnosis, which of the following are also derived from the same germ cell layer?

usmle-11508

A 67-year-old male with a past medical history of diabetes and hypertension, and a 40-pack-year smoking history, presents to the emergency room with right-sided weakness. He is unable to move the right side of his face and his right arm. You ask him to repeat a sentence and he is unable to do so. He speaks gibberish and cannot follow your commands. This patient's clinical presentation is most likely related to occlusion of which of the following in Figure A?

usmle-11509

A 36-year-old man comes to the clinical for “bumps under his nipples.” He is anxious that this could be breast cancer as his sister was just recently diagnosed. Past medical history is unremarkable except for an appendectomy at age 13. He currently works as a personal trainer and reports a diet that consists mainly of lean meat. The patient reports drinking 1-2 beers over the weekends. Physical examination demonstrates a muscular physique with mobile smooth masses below the areola bilaterally with no discharge. What other physical exam finding is most likely to be seen in this individual?

usmle-11510

A 52-year-old man presents to his primary care physician to discuss laboratory results that were obtained during his annual checkup. He has no symptoms or concerns and denies changes in eating or urination patterns. Specifically, the physician ordered a panel of metabolic laboratory tests to look for signs of diabetes, hyperlipidemia, or other chronic disorders. A spot glucose check from a random blood sample showed a glucose level of 211 mg/dL. A hemoglobin A1c level was obtained at the same time that showed a level of 6.3%. A fasting blood glucose was obtained that showed a blood glucose level of 125 mg/dL. Finally, a 2-hour glucose level was obtained after an oral glucose tolerance test that showed a glucose level of 201 mg/dL. Which of the following statements is most accurate for this patient?

usmle-11511

A 28-year-old man is brought to the emergency department after his girlfriend found him twitching and jerking in the yard while gardening. Shortly after he became obtunded, emergency medical services reported 1 episode of emesis during transport. His blood pressure is 85/50 mmHg, pulse is 55/min, and respirations are irregular. Physical examination demonstrates marks on his left forearm, pinpoint pupils, diaphoresis, and fasciculations of his left calf. Following initial stabilization and respiratory support, what is the best next step?

usmle-11512

A 52-year-old man presents to the his primary care physician complaining of an ongoing cough. He reports that the cough started 1 year ago after a “bad cold” and then never resolved. He feels the cough is getting worse, sometimes the cough is dry, but often the cough will bring up a clear to white mucus, especially in the morning. The patient has hypertension and peripheral artery disease. He takes aspirin and lisinopril. He started smoking at age 16, and now smokes 2 packs of cigarettes a day. He has 1-2 beers a couple nights of the week with dinner. He denies illicit drug use. Which of the following cell types within the lung is most likely to undergo metaplasia caused by smoking?

usmle-11513

A 55-year-old African American male presents to his primary care provider complaining of shortness of breath. He has noticed progressively worsening difficulty running, walking up the stairs, and working out. His past medical history is notable for well-controlled asthma and osteoarthritis. He had a previous spinal surgery. He drinks alcohol socially and has never smoked. His family history is notable for emphysema in his father and myocardial infarction in his mother. He works as an investment banker, recently inherited some land, and is working on restoring a barn on the property. His temperature is 98.6°F (37°C), blood pressure is 135/85 mmHg, pulse is 100/min, and respirations are 24/min. Physical examination reveals bilateral rales at the lung bases. A chest radiograph is shown in Figure A. Which of the following is most likely responsible for this patient’s symptoms?

usmle-11514

A 72-year-old man presents to the emergency department with a 1 hour history of bruising and bleeding. He says that he fell and scraped his knee on the ground. Since then, he has been unable to stop the bleeding and has developed extensive bruising around the area. He has a history of gastroesophageal reflux disease, hypertension, and atrial fibrillation for which he is taking an oral medication. He says that he recently started taking omeprazole for reflux. Which of the following processes is most likely inhibited in this patient?

usmle-11515

A 12-year-old boy is brought to the emergency department because of acute onset abdominal pain. On arrival, he also complains of nausea and shortness of breath in addition to epigastric pain. He has previously been admitted to the hospital several times for respiratory infections with Pseudomonas species and uses a nebulizer and a chest wall oscillation vest at home. The patient's acute condition is found to be due to premature activation of an enzyme that normally interacts with the brush border. Which of the following describes the activity of this enzyme?

usmle-11516

A 53-year-old woman presented to her PCP with one week of difficulty falling asleep, despite having good sleep hygiene. She denies changes in her mood, weight loss, and anhedonia. She has had difficulty concentrating and feels tired throughout the day. Recently, she was fired from her previous job. What medication would be most helpful for this patient?

usmle-11517

A 42-year-old woman comes to the clinic for a routine annual exam. She recently moved from New Jersey, and her medical records show a total colectomy. The patient reports that she has had annual colonoscopies since she was 10 years of age because her father had “a condition with his colon.” What is the genetic inheritance pattern of the patient’s disease?

usmle-11518

A 25-year-old woman presents to the ED with nausea, vomiting, diarrhea, abdominal pain, and hematemesis after ingesting large quantities of a drug. Which of the following pairs a drug overdose with the correct antidote for this scenario?

usmle-11519

A 37-year-old woman presents to the general medical clinic with a chief complaint of anxiety. She has been having severe anxiety and fatigue for the past seven months. She has difficulty concentrating and her work has suffered, and she has also developed diarrhea from the stress. She doesn't understand why she feels so anxious and is unable to attribute it to anything specific aspect of her life right now. You decide to begin pharmacotherapy. All of the following are suitable mechanisms of drugs that can treat this illness EXCEPT:

usmle-11520

A 37-year-old female presents to her primary care physician because of persistent joint pain. She notes that she has also experienced chest pain that worsens with inhalation several times over the last 6 months. She feels fatigued at times and has noticed ulcers in her mouth. Physical exam reveals a skin rash (Figure A) and conjunctival pallor. Based on clinical suspicion, an antibody panel is sent and returns positive for anti-nuclear antibodies (ANAs) and anti-small nuclear ribonucleoproteins (snRNPs). The patient asks whether there is a genetic predisposition to this disease and is informed that specific human leukocyte antigen (HLA) subtypes are associated with her condition. Which of the following diseases is also linked to one of the same HLA subtypes as this patient's disease?

usmle-11521

A 72-year-old man presents to his primary care physician due to worsening headache and double vision. His headache began several months ago, and he describes them as sharp and localized to the left side of the head. His double vision began one week prior to presentation. Medical history is significant for hypertension and type II diabetes mellitus, which is treated with lisinopril and metformin. He smokes a pack of cigarettes a day for the last 40 years. His temperature is 98.3°F (37°C), blood pressure is 148/84 mmHg, pulse is 60/min, and respirations are 14/min. On physical exam, a mild head turning towards the left is appreciated. Pupils are equal, round, and reactive to light, with a more pronounced esotropia on left-lateral gaze. The rest of the neurologic exam is otherwise normal. Magnetic resonance imaging (MRI) of the head and MR angiography shows a left-sided intracavernous carotid aneurysm. Which of the following nerves is most likely compressed by the aneurysm in this patient?

usmle-11522

A 5-year-old boy is brought to his pediatrician due to sore throat and fever. He was in his usual state of health until 3 days ago when he began to complain of a sore throat as well as general malaise. The patient's past medical history reveals recurrent upper respiratory infections but no skin or soft tissue infections. The child had cardiac surgery as an infant but has otherwise been healthy. On presentation, his temperature is 100°F (37.8 °C), blood pressure is 115/72 mmHg, pulse is 65/min, and respirations are 22/min. Physical exam shows white plaques on the tongue and mouth. A scraping of this material reveals a characteristic morphology after being treated with KOH. Serum protein electrophoresis shows a normal distribution of bands from this patient. Which of the following findings would most likely be found in this patient?

usmle-11523

A 12-year-old boy is brought by his mother to the emergency room because of a swollen, hot, and tender knee that he sustained after falling on his way home. He has never had a swollen joint before; however, he has had frequent nosebleeds throughout his life. His mother is worried because they live with her parents who are currently on blood thinners. Every morning she puts the blood thinner pill in the boy's grandfather's milk and was concerned that she may have switched it this morning. Family history reveals a number of uncles who have had bleeding disorders; however, the mother does not know the exact disorder suffered by these relatives. A hematologic panel reveals the following findings: Bleeding time: Increased Prothrombin time: 12 seconds Partial thromboplastin time (PTT): 55 seconds PTT after factor mixing study: 37 seconds Which of the following most likely explains the abnormal partial thromboplastin time in this patient?

usmle-11524

A 44-year-old man presents to his primary care physician for muscle pain and weakness. He says that his muscle pain mainly affects his legs. He also experiences difficulty with chewing gum and has poor finger dexterity. Medical history is significant for infertility and cataracts. On physical exam, the patient's face is long and narrow with a high arched palate and mild frontal balding. There is bilateral ptosis and temporalis muscle and sternocleidomastoid muscle wasting. Creatine kinase level is mildly elevated. Which of the following is most likely to be found on genetic testing?

usmle-11525

A 34-year-old female with HIV presents to her physician for a routine health maintenance visit. During the visit, she admits that she has been poorly compliant with her HAART regimen, as she has not had the money to afford her medications. Her CD4 count at this visit is found to be 159. On exam, the findings in Figure F are appreciated and are able to be scraped off. Which of the following histologic images most closely corresponds to the finding in Figure F?

usmle-11526

A 62-year-old woman presents to her primary care provider with anal bleeding. She reports a 4-month history of intermittent anal bleeding that was initially mild but has increased in severity over the past 2 weeks. She also reports having intermittent mucoid discharge from her anus. She denies any pain with defecation but does experience occasional constipation that has been increasing in frequency over the past month. Her past medical history is notable for hypertension and breast cancer status-post-mastectomy and radiation therapy. She takes enalapril. She has a 15-pack-year smoking history and drinks 3-4 glasses of wine per week. Her temperature is 98.4°F (36.9°C), blood pressure is 135/85 mmHg, pulse is 85/min, and respirations are 18/min. On exam, she appears pale but is pleasant and conversational. Digital rectal examination reveals a small mass within the anal canal. Anoscopy demonstrates an erythematous irregular mass arising from the mucosa proximal to the dentate line. Which of the following histologic findings is most likely to be seen in this patient’s lesion?

usmle-11527

A 24 year-old male presented to his physician with a homogenous, painless testicular swelling that he noticed for the past two weeks. After ultrasound and blood tests, he subsequently underwent a radical inguinal orchiectomy and pathology was consistent with seminoma. Which of the following would you expect to see in a tissue sample from the patient’s orchiectomy?

usmle-11528

A 59-year-old male presents to his primary care physician complaining of a tremor. He developed a tremor in his left hand approximately three months ago. It appears to be worse at rest and diminishes if he points to something or uses the hand to hold an object. His past medical history is notable for emphysema and myasthenia gravis. He has a 40 pack-year smoking history. Physical examination reveals slowed movements. The patient takes several seconds to rise from his chair for a gait analysis which reveals a shuffling gait. The physician decides to start the patient on a medication that prevents the degradation of a neurotransmitter. This medication is also indicated for use in which of the following conditions?

usmle-11529

A healthy 29-year-old HIV-positive G1P0 gives birth to a newborn infant at 34 weeks gestation. The child was born before antenatal betamethasone was able to be given. The mother has a history of alcohol abuse and a 5-pack-year smoking history. She had no prenatal care and took no medications during her pregnancy. Immediately after birth, the child’s temperature is 99.2°F (37.4°C), blood pressure is 90/50 mmHg, pulse is 140/min, and respirations are 35/min. The infant has notable dyspnea and perioral cyanosis. A chest radiograph is shown in Figure A. What is the most likely cause of this patient’s current symptoms?

usmle-11530

A 75-year-old male presents to his primary care physician complaining of epigastric pain. He has developed progressively worsening epigastric pain, heartburn, and nausea over the past five months. The pain does not change with meals and is not positional. He also reports that he is rarely hungry and has lost ten pounds. The patient immigrated from Japan two years ago to live with his son in the United States. He worked as a fisherman and dock worker for most of his life. His past medical history is notable for gout and gastroesophageal reflux disease. He takes allopurinol and cimetidine. He has a 30 pack-year smoking history and drinks 1-2 alcoholic beverages per day. Physical examination reveals mild epigastric tenderness to palpation and a hard lymph node near his left shoulder. Which of the following substances is most strongly associated with this patient’s condition?

usmle-11531

A 25-year-old female presents to the emergency room with a heart rate of 32 BPM and a blood pressure of 80/40. She was found by emergency medical services with an empty bottle of propanolol that was taken from her grandmother. Her vital signs do not improve despite IV fluids and oxygen. Which of the following is a first line treatment for overdose?

usmle-11532

A 27-year-old woman presents to the dermatologist with complaints of facial flushing. She says that the redness seems to be exacerbated by being in the sun on a hot day as well as by consumption of spicy foods or alcohol. Physical exam of her skin reveals erythematous papules and pustules across her forehead, cheeks, and nose but no comedones. A photo of her facial skin findings is shown in Figure A. In addition to recommending lifestyle modifications of avoiding sun exposure, alcohol, and spicy foods, what pharmacologic treatment could be prescribed for this patient’s condition?

usmle-11533

A 30-year-old woman is undergoing work up for progressive weakness. She reports that at the end of the work day, her "eyelids droop" and her "eyes cross," but in the morning she feels "ok." She reports that her legs feel heavy when she climbs the stairs of her house to go to sleep at night. As part of her work up, the physician has her hold her gaze toward the ceiling, and after a minute, her lids become ptotic. She is given an IV medication and her symptoms resolve, but return 10 minutes later. Which of the following medications was used in the diagnostic test performed for this patient?

usmle-11534

A 35-year-old African American female presents to the emergency department with a three day history of cough, chest pain, and fever. Upon presenting to the emergency department, her temperature is 101.4 °F (38.5 °C), blood pressure is 110/80 mmHg, pulse is 95/min, and respirations are 24/min. Lung auscultation reveals crackles over the left lung base. Chest radiograph reveals a dense consolidation in the left lower lung. The patient undergoes lab tests in the emergency department that demonstrate an elevated level of C-reactive protein. This abnormal lab finding was most likely caused by increased activity of which of the following mediators?

usmle-11535

A 51-year-old African American man presents to his primary care physician’s office for an annual visit. He has no major concerns and says that he has been healthy for the last year. His past medical history is significant for diabetes as well as long standing hypertension that has developed gradually since his 30's; however, he has refused to take any medications. Physical exam shows no abnormal findings. Routine laboratory testing reveals the following: Serum creatinine concentration: 1.5 mg/dL Blood urea nitrogen: 31 mg/dL Based on these results, urine studies are conducted that reveal mild proteinuria of less than 1 g/day and no casts. Which of the following is most likely associated with the cause of this patient's elevated creatinine?

usmle-11536

A 9-year-old boy with cerebral palsy is about to undergo a femoral osteotomy. An intravenous catheter needs to be placed; however, given prior experience the boy is extremely anxious and does not want to be stuck with a needle while awake. The decision is made to administer appropriate anesthesia by mask first before any other procedures are performed. An inhalation agent that would anesthetize most quickly has which of the following characteristics?

usmle-11537

You are consulted for a 68-year-old woman, who is post-operative day 4 from an open cholecystectomy. She currently has a fever of 102.5 F. A urine culture grows the following organism seen on gram stain in Figure A. Which drug would have been ineffective in the treatment of this patient?

usmle-11538

A 28-year-old woman comes to the clinic complaining of recurrent blisters on her hands and face. She has always had these blisters, which eventually scar and heal, but decided to come in for further evaluation as there is an increased number this time. The patient just returned from a vacation in Greece where she sunbathed, visited tourist attractions, and ate the local food. She denies any fever, weight loss, chills, or joint pains but endorses some dark urine from time to time. Her hands are shown in Figure A. What is the pathophysiologic explanation of this patient’s symptoms?

usmle-11539

A 26-year-old man presents to the emergency department with complaints of intractable, 10/10 abdominal pain without nausea or vomiting. His CT is unremarkable, and other aspects of his history and physical examination suggest that his complaints may not be organic in etiology. His medical record is notable for previous ED visits with similar complaints that had resolved on one occasion with narcotic agents. A previous psychiatric evaluation reports a long history of migraines, depression, and characteristics of antisocial personality disorder. Which of the following best explains his abdominal symptoms?

usmle-11540

A 75-year-old man with a 35-pack-year history of smoking is found to be lethargic three days being admitted with a femur fracture following a motor vehicle accident. His recovery has been progressing well thus far, though pain continued to be present. On exam, the patient minimally responsive with pinpoint pupils. Vital signs are blood pressure of 115/65 mmHg, HR 80/min, respiratory rate 6/min, and oxygen saturation of 87% on room air. Arterial blood gas (ABG) shows a pH of 7.24 (Normal: 7.35-7.45), PaCO2 of 60mm Hg (normal 35-45mm Hg), a HCO3 of 23 mEq/L (normal 21-28 mEq/L) and a Pa02 of 60 mmHg (normal 80-100 mmHg). Which of the following is the most appropriate therapy at this time?

usmle-11541

A 10-year-old boy is brought by his mother to his pediatrician for “skin growths.” His mother reports that she started noticing small lumps arising from the patient’s lips and eyelids several months ago. She also notes that he seems to suffer from frequent constipation and appears “weaker” than many of his peers. The boy’s past medical history is unremarkable. His maternal aunt, maternal uncle, and maternal grandmother have a history of colorectal cancer and his father and paternal grandmother have a history of thyroid cancer. His height and weight are in the 85th and 45th percentiles, respectively. His temperature is 99°F (37.1°C), blood pressure is 110/65 mmHg, pulse is 90/min, and respirations are 18/min. On examination, he has an elongated face with protruding lips. There are numerous sessile painless nodules on the patient’s lips, tongue, and eyelids. This patient’s condition is most strongly associated with a mutation in which of the following genes?

usmle-11542

A 32-year-old man presents to the emergency department because he coughed up copious amounts of bloody sputum at work. He also says that he has had multiple lung infections over the last 2 years. Furthermore, he says that during the episodes, he coughs up a lot of foul smelling sputum. Past medical history is significant for childhood allergies and absence seizures. He has smoked 1 pack per day for 10 years and drinks socially. A computed tomography scan of this patient shows the section seen in Figure A. Which of the following diseases would most likely also cause the same symptoms as seen in this patient?

usmle-11543

A 5-year-old boy is brought to the emergency department for blood in his urine. The patient reports having painless hematuria today for the first time. He denies any trauma, abnormal discharge, dysuria, frequency, conjunctivitis, or recent upper respiratory infections. His father is worried as he seems more lethargic than usual. His past medical history is unremarkable expect for an episode of diarrhea and abdominal pain 5 days ago. A physical examination is unremarkable except for skin findings shown in Figure A. Laboratory findings are shown below: Hemoglobin: 7.9 g/dL Hematocrit: 36% Leukocyte count: 7,400/mm^3 with normal differential Platelet count: 10,000/mm^3 Serum: Na+: 137 mEq/L Cl-: 97 mEq/L K+: 3.8 mEq/L HCO3-: 25 mEq/L BUN: 8 mg/dL Glucose: 117 mg/dL Creatinine: 1.5 mg/dL Thyroid-stimulating hormone: 4.1 µU/mL Ca2+: 9.2 mg/dL AST: 16 U/L ALT: 15 U/L What is the most likely explanation for this patient’s symptoms?

usmle-11544

A 57-year-old African American woman presents complaining of a "rash" on her breast. She has had some pain and itching in the affected area (Figure A). She also noted that the area feels warm. She says the texture of the area feels differently now as well. Which of the following is most likely to appear on histology?

usmle-11545

A 44-year-old woman presents to her primary care physician because she has been experiencing shortness of breath and fatigue over the past week. In addition, she has noticed that her eyelids appear puffy and her lower extremities have become swollen. Laboratory tests reveal protein and fatty casts in her urine. Based on these findings, a kidney biopsy is obtained and has a granular appearance on immunofluorescence with subepithelial deposits on electron microscopy. Which of the following is associated with the most likely cause of this patient's symptoms?

usmle-11546

A 67-year old man presents to his primary care physician for his yearly checkup. He has not noticed any major changes in his health over the last year but says that unfortunately, he stopped exercising because he has been stressed by work. His past medical history is significant for obesity, hypertension, diabetes, hypercholesterolemia, and hyperlipidemia. He is taking a number of drugs but does not remember what they are. A panel of metabolic and lipid tests are ordered and show worsening of his metabolic parameters. Based on these findings, his physician prescribes a drug that leads to a large decrease in triglycerides with a much smaller increase in high-density lipoproteins and decrease in low-density lipoproteins. The drug that was most likely prescribed in this case is associated with which of the following side effects?

usmle-11547

A 67-year-old woman is referred to a gastroenterologist for a history of intermittent bloody stools over the past 4 months. She says that she has had these episodes a few times a month, and occasionally notes mild amounts of dark red blood in the toilet bowl. She denies recent weight loss or weight gain, changes in the caliber of her stools, fatigue, or palpatations. Fecal occult blood test in office is positive, and complete blood count is consistent with a hypochromic, microcytic anemia. A decision is made to undergo colonoscopy. A lesion is identified, and is pictured in Figure A. Electrocautery during colonoscopic evaluation causes cessation of the bleeding. Which of the following findings is most likely on cardiac auscultation?

usmle-11548

A 29-year-old woman is brought to the emergency room for seizure-like activity. Her husband reports that they were in bed sleeping when his wife began complaining of “hot flashes.” Several minutes later, her right arm began to twitch, and she did not respond to his calls. The whole episode lasted for about 5 minutes. She denies any prior similar episodes, tongue biting, loss of bowel or urinary control, new medications, or recent illness. She reports a family history of epilepsy and is concerned that she might have the same condition. Urine pregnancy test is positive. If this patient is prescribed phenytoin, during which of the following weeks is the fetus most sensitive to its side effects?

usmle-11549

A 64-year-old man presents to the emergency department because he has been experiencing increased shortness of breath for the last 2 weeks. Specifically, he says that he can barely walk up the stairs to his apartment before he feels winded. In addition, he has been waking up at night gasping for breath and has only been able to sleep propped up on 2 more pillows than usual. Physical exam reveals jugular venous distention as well as pitting lower extremity edema. Which of the following abnormal sounds will most likely be heard in this patient?

usmle-11550

A 48-year-old male presents to his primary care provider with a two-week history of low back pain and left leg pain. He reports that his symptoms started while he was working at his job as a construction worker. He has since experienced intermittent achy pain over his lumbar spine. He has also noticed pain radiating into his left leg and weakness in left ankle dorsiflexion. On exam, he demonstrates the following findings on strength testing of the left leg: 5/5 in knee extension, 4/5 in ankle dorsiflexion, 4/5 in great toe extension, 5/5 in ankle plantarflexion, and 5/5 in great toe flexion. The patellar reflexes are 5/5 bilaterally. He is able to toe walk but has difficulty with heel walking. Weakness in which of the following compartments of the leg is most likely causing this patient’s foot drop?