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usmle-12251 | A 17-year-old teenage boy is brought to the emergency room for severe right upper quadrant (RUQ) pain for the past 5 hours. He denies any precipitating events and reports a sharp, 8/10, constant pain at the RUQ. He denies any past episodes. His past medical history is unremarkable, and he is up to date on his vaccinations. His mother reports a “blood disease” on his father’s side. His temperature is 101.0°F (38.3°C), blood pressure is 118/70 mmHg, pulse is 103/min, respirations are 18/min, and oxygen saturation is 99% on room air. A physical examination demonstrates pale conjunctiva, RUQ tenderness with positive Murphy sign, and splenomegaly. An abdominal ultrasound is shown in Figure A. Which of the following laboratory findings will confirm this patient’s diagnosis? |
usmle-12252 | A 42-year-old woman presents to her primary care physician for fatigue and blurry vision. She is a refugee from Syria who arrived in the United States 1 week ago. She has lived for the last 8 months in a refugee camp. She worked at a grocery store in Syria before being displaced from her home. She has one son who is 9 years old and was seen by a pediatrician the day prior. She reports that while she was in the refugee camp, she ate very little and gave most of her food to her son to ensure that he stayed healthy. She denies any past medical history and takes no medications. She does not smoke or drink alcohol. Her temperature is 97.8°F (36.6°C), blood pressure is 108/68 mmHg, pulse is 102/min, and respirations are 18/min. On exam, she appears fatigued but is fully cooperative with the examination. There are fissures at the corners of her mouth. A funduscopic examination reveals corneal vascularization in both eyes. Her tongue is darkly erythematous. This patient is most likely deficient in a vitamin that has which of the following functions? |
usmle-12253 | A 73-year-old male is brought in by ambulance after he was found to be lethargic and confused. He has not been routinely seeing a physician and is unable to recall how he came to be in the hospital. His temperature is 99°F (37°C), blood pressure is 150/95 mmHg, pulse is 75/min, and respirations are 18/min. His past medical history is significant for poorly controlled diabetes and longstanding hypertension, and he says that he has not been taking his medications recently. Labs are obtained and shown below:
Serum:
Na+: 142 mEq/L
Cl-: 105 mEq/L
K+: 5 mEq/L
HCO3-: 16 mEq/L
Urea nitrogen: 51 mg/dL
Glucose: 224 mg/dL
Creatinine: 2.6 mg/dL
Which of the following changes would most likely improve the abnormal parameter that is responsible for this patient's symptoms? |
usmle-12254 | A 29-year-old female presents to her physician with a small, well-demarcated mass in her left breast. A biopsy of the lesion is taken and shown in Figure A. Which of the following is associated with the patient’s condition? |
usmle-12255 | A 41-year-old woman comes to the clinic complaining of progressive shortness of breath and fatigue for the past 2 years. She reports that “it gets difficult to breathe, especially when I try to exercise at the gym.” According to the patient, she first noticed the symptoms several years ago, but it has worsened to the point that 2 minutes of cardiovascular exercise will leave her dyspneic. Past medical history includes hypertension and 1 miscarriage. She reports smoking 1 pack per day for the past 20 years. Physical examination is significant for a loud S2, jugular venous pulse (JVP) of 10cm H2O, and bilateral lower extremity edema. The patient’s skin findings are shown in Figure A. What systemic disease best explains this patient’s presenting condition? |
usmle-12256 | A 7-year-old patient is brought in by his mother for a routine check-up for school. The child is cooperative throughout the visit and excitedly talks about school. The mother congratulates her son on his behavior, and mentions that when he was being treated for leukemia three years ago, he would start crying in the parking lot even before they arrived at the clinic for his blood checks. The mother notes that since his remission, he has been better tolerating physician visits. She has occasionally been giving him candy before clinic visits to reward his good behavior after she noticed he stopped crying. Since getting these rewards, the patient has sometimes remarked that he enjoys visiting the clinic now. Which of the following best explains why this patient no longer cries at physician visits? |
usmle-12257 | A 52-year-old man presents to his primary care physician because he has been experiencing shortness of breath and cough. He began feeling short of breath when playing recreational soccer with his friends. Over time these episodes have become more severe. They now impair his ability to work as a construction worker. In addition, he has developed a chronic dry cough that has been increasing in intensity. Radiography reveals subpleural cystic enlargement, and biopsy reveals fibroblast proliferation in the affected tissues. Which of the following describes the mechanism of action for a drug that can cause a similar pattern of pulmonary function testing as would be seen in this disease? |
usmle-12258 | An 11-year-old girl presents to her primary care physician because she has been having difficulty hearing her teachers at school. She says that the difficulty hearing started about a year ago, and it has slowly been getting worse. Her past medical history is significant for multiple fractures in both her upper and lower extremities. She also recently had a growth spurt and says that her friends say she is tall and lanky. A mutation in which of the following genes is most likely associated with this patient's condition? |
usmle-12259 | A 45 year old construction worker complains of several weeks of diffuse abdominal pain, constipation, generalized fatigue and irritability. His vital signs are normal. On examination you notice some distal extremity weakness and thin, a grey-blue line visible along the margin of the gums (Figure A). Red blood cells demonstrate microcytosis, hypochromasia and basophilic with visible dots (Figure B). What is the most likely diagnosis? |
usmle-12260 | A 45-year-old woman comes to the clinic for complaints of abdominal pain and repeated watery stools for the past 2 days. She has a history of bowel complaints for the past 2 years consisting of periods of intermittent loose stools followed by the inability to make a bowel movement. Her past medical history is significant for diabetes controlled with metformin. She denies any abnormal oral intake, weight loss, fever, nausea/vomiting, or similar symptoms in her family. When asked to describe her stool, she reports that “it is just very watery and frequent, but no blood.” The physician prescribes a medication aimed to alleviate her symptoms. What is the most likely mechanism of action of this drug? |
usmle-12261 | A 62-year-old male presents to his primary care physician complaining of an unintended 10-pound weight loss over the last 4 months. He also reports vague abdominal discomfort, weakness, and occasional yellowing of his skin and eyes. He has a history of cirrhosis secondary to alcohol abuse and hepatitis C infection. Physical exam demonstrates hepatomegaly and abdominal distention. Which of the following serum markers is most strongly associated with this patient’s condition? |
usmle-12262 | A 25-year-old obese mother with gestational diabetes gives birth at 42 weeks gestation. The delivery is complicated by difficulty pushing the child’s shoulders through the vaginal canal. The child’s birth weight is 4200 grams (normal 2500-4000 grams). A notable physical exam finding is shown in Figure A. Which of the following brachial plexus structures is most likely injured in this patient? |
usmle-12263 | A 8-year-old boy is brought to the clinic by his father for an annual well-check. His dad reports that he has been “difficult to handle” as he would not listen and follow instructions at home. “Telling him to sit still and do something is just so hard,” the father says. His teacher also reports difficulties in the classroom where the child would talk out of turn and interrupt the class intermittently by doing something else. His grades have been suffering as a result. Otherwise, the patient has been healthy and up to date on his immunizations. What is the best course of management for this patient? |
usmle-12264 | A 65-year-old man presents to the clinic for fatigue and malaise for the past 2 weeks. His past medical history is significant for hypertension controlled with lisinopril and hydrochlorothiazide. The patient complains of increasing abdominal pain and decreased bowel movements for the past 3 weeks. Urine dipstick demonstrates 4+ protein. An abdominal ultrasound shows bilaterally enlarged kidneys. A radiographic study of his skull is shown in Figure A.
Urinalysis:
Color: Yellow
Specific gravity: 1.010
pH: 7.0
Epithelial cells: 3-4
Blood: Negative
Protein: 3+
Glucose: Negative
Bacteria: Absent
Leukocyte esterase: Absent
Nitrite: Absent
What histopathological findings of the kidneys would you expect to find? |
usmle-12265 | A 67-year-old male with a history of poorly controlled hypertension, COPD, and diabetes presents to his cardiologist for a routine appointment. He reports that he has no current complaints and has not noticed any significant changes in his health. On exam, the cardiologist hears an extra heart sound in late diastole that immediately precedes S1. This heart sound is most associated with which of the following? |
usmle-12266 | A 29-year-old woman presents to her primary care provider for a normal check-up at the prompting of her mother. When asked how she is doing, she replies that she feels depressed. Upon further questioning, she states that she feels “worthless” now that her ex-boyfriend left her 2 days ago. She has been sitting in his bed all day trying to call him but he is not answering her calls. She says that she will never find another man like him and feels like she should just “disappear” rather than continue living without him. She also reports that she can hear his voice when he’s not around, especially at night before she goes to bed. She denies having any other friends and has some social anxiety, particularly in large groups of people. A review of her medical record indicates that she has endured several episodes of verbal and physical abuse from her prior relationships which she suggested “were all her fault.” She has had 4 prior serious relationships and reports that she has not been single for more than a few days in the last 10 years. On exam, she is unkempt with poor self-care. This patient’s history is most consistent with which of the following conditions? |
usmle-12267 | A 25-year-old man is brought to the emergency department 6 hours after rescuing babies and puppies from a burning daycare center. He says that he has a severe headache, feels nauseous and dizzy. He is tachypneic. An arterial blood gas shows pH 7.3, PaCO2 49 mmHg, PaO2 80 mmHg. Serum lactate level is 6 mmol/L. What biochemical process explains these laboratory values? |
usmle-12268 | A 12-hour-old newborn is urgently transferred to the neonatal intensive care unit because he is found to be cyanotic and appears blue in all four extremities. He was born to a 42-year-old G1P1 mother who underwent no prenatal screening because she did not show up to her prenatal care visits. She has poorly controlled diabetes and hypertension. On physical exam, the infant is found to have slanted eyes, a flattened head, a large tongue, and a single palmar crease bilaterally. Furthermore, a single, loud S2 murmur is appreciated in this patient. Radiography shows a large oblong-shaped heart shadow. Based on this presentation, the neonatologist starts a medication that will temporarily ensure this patient's survival pending definitive fixation of the defect. The substance that was most likely administered in this case also has which of the following effects? |
usmle-12269 | A 63-year-old woman presents to her primary care provider with her spouse for routine follow-up. She has a history of schizophrenia and is currently living at a nursing facility. Her symptoms first started 2 years ago, when she developed auditory hallucinations and her family noticed that her thoughts and speech became more tangential and disorganized. After being referred to a psychiatrist, the patient was started on medication. Currently she reports occasional auditory hallucinations, but her spouse states that her symptoms have improved dramatically with medication. On exam, her temperature is 98.4°F (36.9°C), blood pressure is 110/74 mmHg, pulse is 64/min, and respirations are 12/min. The patient has normal affect with well-formulated, non-pressured speech. She denies any audiovisual hallucinations. Notably, however, the patient has repetitive lip-smacking behavior and occasionally sweeps her tongue across her lips. The spouse is curious about how this developed. Which of the following is the most likely medication this patient was started on? |
usmle-12270 | A 9-year-old boy is brought to the emergency room by his concerned mother after he "urinated blood." The boy reports that, starting this morning, he experienced significant pain with urination and his urine appeared a bright red color. These symptoms were not present before today; however, he reports a cough, runny nose, and sore throat that started approximately 3 days ago. Vital signs are as follows: T 38.4 deg C, HR 101, BP 110/65, RR 14, SpO2 99%. Physical examination is significant for bilateral conjunctivitis, tenderness to suprapubic palpation, and a small amount of clotted blood is noted surrounding the urethral meatus. A urine sample is obtained, and urinalysis shows 3+ blood, and urine microscopy demonstrates gross blood with too many cells to count per high powered field. Which of the following is the most common viral cause of this child's condition? |
usmle-12271 | A 13-year-old girl is evaluated by an orthopedic surgeon for knee pain. She thinks that the pain started after she fell while playing basketball during gym class 4 months ago. At the time she was evaluated and diagnosed with a muscle strain and told to rest and ice the joint. Since then the pain has gotten progressively worse and interferes with her ability to participate in gym. She has otherwise been healthy and does not take any medications. On physical exam, she is found to have mild swelling and erythema over the left knee. The joint is found to have an intact full range of motion as well as tenderness to palpation on both the medial and lateral femoral condyles. Radiograph shows a crescent-shaped radiolucency in the subchondral bone of the femur with the remainder of the radiograph being normal. Which of the following disorders is most likely responsible for this patient's symptoms? |
usmle-12272 | A father brings his 2-year-old son to the pediatrician because he is concerned about his development. He states that his son has been having brief episodes of uncontrollable shaking and has seemed to regress in his motor development. During the subsequent work up, a muscle biopsy is obtained which is demonstrated in figure F and a presumptive diagnosis is made. Which of the following pedigrees correctly demonstrates the inheritance pattern of this disease? |
usmle-12273 | A 54-year-old male presents to his primary care physician complaining of fatigue. He reports that he recently went on a vacation to South America with his family but just wanted to stay in his hotel all day due to fatigue. His past medical history is notable for hyperlipidemia and hypertension. He takes lovastatin and lisinopril. He drinks socially and has a 20 pack-year smoking history. His temperature is 99°F (37.2°C), blood pressure is 130/75 mmHg, pulse is 80/min, and respirations are 16/min. On exam, the patient is appropriately interactive and in no acute distress. Mild splenomegaly is noted. Laboratory analysis reveals the following:
Hemoglobin: 11.0 g/dL
Hematocrit: 36%
Leukocyte count: 3,800/mm^3 with normal differential
Platelet count: 140,000/mm^3
A bone marrow aspiration is ordered but after multiple attempts, they are unable to obtain an adequate bone marrow sample. A peripheral blood smear would likely reveal cells that stain with which of the following stains? |
usmle-12274 | A 14-year-old girl with a BMI of 17 complains of frequent urination, excessive thirst, and abdominal pain. Her parents have noticed that she appears to have lost some weight. Her past medical history is significant for celiac disease. A random plasma blood glucose is 267 mg/dL. Which of the following is a property of the hormone that is deficient in this patient? |
usmle-12275 | A 36-year-old man is brought in by ambulance after being found down on the sidewalk. It is uncertain how long he was down before being found, and he did not have any forms of identification when he was found. On presentation, the man is found to still be unconscious with a disheveled and unkempt appearance. He is also found to be taking slow, shallow breaths that smell of alcohol. His temperature is 98.8°F (37.1°C), blood pressure is 106/67 mmHg, pulse is 119/min, respirations are 5/min, and oxygen saturation is 87% on room air. His pupils are found to be fixed and contracted, and he has multiple bruises and scars on his body. Which of the following sets of findings would most likely be seen in this patient? |
usmle-12276 | A 72-year-old man presents to his primary care provider at an outpatient clinic for ongoing management of his chronic hypertension. His past medical history is significant for diabetes and osteoarthritis though neither are currently being treated with medication. At this visit, his blood pressure is found to be 154/113 mmHg so he is started on lisinopril. After leaving the physician's office, he visits his local pharmacy and fills the prescription for lisinopril before going home. If this patient is insured by medicare with a prescription drug benefit provided by a private company through medicare, which of the following components of medicare are being used during this visit? |
usmle-12277 | A 54-year-old man is newly diagnosed with diabetes. As part of his clinical care, he undergoes testing to determine his kidney function. His glomerular filtration rate is found to be 80 mL/min. He is curious about how glomerular filtration occurs and which molecules are filtered the fastest and slowest. He is told that albumin is filtered less readily than sodium. Aside from size of the 2 molecules, which of the following features of the glomerular basement membrane accounts for this additional finding? |
usmle-12278 | A 29-year-old G1P1 woman presents to her primary care physician with unilateral breast pain. She is currently breastfeeding her healthy 3-month-old baby boy. She has been breastfeeding since her child's birth without any problems. However, 3 days prior to presentation, she developed left breast pain, purulent nipple discharge, and malaise. Her past medical history is notable for obesity and generalized anxiety disorder. She takes sertraline. She does not smoke or drink alcohol. Her temperature is 100.8°F (38.2°C), blood pressure is 128/78 mmHg, pulse is 91/min, and respirations are 17/min. On exam, she appears lethargic but is able to answer questions appropriately. Her right breast appears normal. Her left breast is tender to palpation, warm to the touch, and swollen relative to the right breast. There is a visible fissure in the left nipple that expresses minimal purulent discharge. Which of the following pathogens is the most likely cause of this patient's condition? |
usmle-12279 | A 69-year-old male presents to his primary care physician complaining of fatigue. He reports that over the past four months, he has felt worsening tiredness and generalized weakness. His past medical history is notable for aortic stenosis, hypertension, and diabetes mellitus. Physical examination is notable for conjunctival pallor, delayed capillary refill, and a crescendo-decrescendo murmur at the upper right sternal border. A complete blood count reveals a hemoglobin of 8.9 g/dL and hematocrit of 30%. A stool sample is positive for heme. A colonoscopy is performed and an image from the ascending colon is shown in Figure A. Which of the following mechanisms has most likely contributed to this patient’s condition? |
usmle-12280 | A 14-year-old male is brought to your psychiatric clinic after he was caught stealing his peers’ belongings multiple times by his teacher. He is a straight-A student with many friends and is an outstanding football player. He describes his family as very loving and gets along with his older siblings. He also states that he has no ill will towards anyone he stole from in class. Although never caught, he admits that he would often steal things in stores or locker rooms when no one was looking in order to satisfy an intense impulse. Which of the following is the best diagnosis for this patient? |
usmle-12281 | A 14-year-old previously healthy male presents to your office with complaints of two months of dull, aching pain in his right leg that has recently become worse. While he experiences the pain constantly, he notes that it is sometimes so bad at night that it awakes him from his sleep. Though an avid soccer player, he has been unable to participate this season due to the pain and difficulty running. He cannot think of any particular trauma that might have precipitated this pain. Vitals are all within normal range. Physical examination reveals localized tenderness below the knee with mild swelling and reduced range of motion. You order an X-ray of the painful limb, which is shown in Figure A. What is the most likely diagnosis? |
usmle-12282 | A 64-year-old female with a history of end-stage renal disease presents to her primary care physician complaining of weakness. She reports a six-month history of progressive weakness accompanied by occasional dull aching pain in her arms, legs, and lower back. She has also started to increase her fiber intake because of occasional strained bowel movements. Her past medical history is notable for poorly controlled diabetes, major depressive disorder, and obesity. She takes insulin and sertraline. She has a twenty pack-year smoking history and drinks alcohol socially. Her temperature is 98.5°F (36.9°C), blood pressure is 130/85 mmHg, pulse is 80/min, and respirations are 16/min. Laboratory findings are shown below:
Serum:
Na+: 138 mEq/L
Cl-: 99 mEq/L
K+: 3.9 mEq/L
HCO3-: 26 mEq/L
BUN: 20 mg/dL
Glucose: 140 mg/dL
Creatinine: 2.0 mg/dL
Parathyroid hormone: 720 µU/mL
Ca2+: 11.1 mg/dL
Phosphorus (inorganic): 4.8 mg/dl
A medication with which of the following mechanisms of action is most likely indicated to address this patient’s symptoms? |
usmle-12283 | A 58-year-old homeless man presents to the emergency department after losing consciousness on the street. He appears pale with several bruises. He complains of progressive weakness and fatigue over the last few months. On physical exam he has conjunctival pallor and decreased touch sensation on his lower limbs bilaterally. Lab findings were obtained and are seen as follows:
Hemoglobin: 5.5 g/dL
Mean corpuscular volume: 110 µm^3
Ferritin: 100 ng/mL
Homocysteine: Elevated
Methylmalonic acid: Elevated
A stool smear shows the following as seen in Figure A. What is the most likely cause of this patient’s presentation? |
usmle-12284 | A 44-year-old female presents to her primary care physician complaining of fatigue. She reports a four-month history of increasing fatigue accompanied by occasional constipation. She also reports a 15-pound weight gain over the same time period. She is otherwise healthy and takes no medications. She has never been pregnant. On physical examination, her skin is dry and cracked. Patellar reflexes are 1+ bilaterally. Laboratory analysis reveals an elevated serum TSH and decreased serum and free T4. Her blood is positive for the presence of specific antibodies. A biopsy of this patient’s thyroid gland would most likely reveal which of the following? |
usmle-12285 | A 39-year-old woman presents to the clinic with complaints of constipation for the past 2 weeks. She reports that it has been getting increasingly difficult to pass stool to the point that she would go for 2-3 days without going to the bathroom. Prior to this, she passed stool every day without difficulty. She denies weight changes, headaches, chest pain, or abdominal pain but endorses fatigue. Her past medical history is significant for 2 episodes of kidney stones within the past 3 months. A physical examination is unremarkable. Laboratory studies are done and the results are shown below:
Serum:
Na+: 138 mEq/L
Cl-: 97 mEq/L
K+: 3.9 mEq/L
HCO3-: 24 mEq/L
BUN: 10 mg/dL
Glucose: 103 mg/dL
Creatinine: 1.1 mg/dL
Thyroid-stimulating hormone: 3.1 uU/mL
Ca2+: 12.1 mg/dL
Phosphate: 1.2 mg/dL (Normal: 2.5-4.5 mg/dL)
What is the most likely explanation for this patient’s low phosphate levels? |
usmle-12286 | A 45-year-old female patient presents to her primary care physician 4 years after gastric bypass surgery complaining of numbness and tingling in her feet and fingertips. She has also been feeling fatigued over the last few months and cannot walk far before becoming winded. Physical exam shows conjunctival pallor and pale skin. Lab tests are conducted and demonstrate a hematocrit of 31% (normal range 35%-45%) and Mean Corpuscular Volume (MCV) of 112 fl (normal range 80 fl - 100 fl). A peripheral blood smear is obtained and is shown in Figure A. What is the most likely cause of this patient's clinical syndrome? |
usmle-12287 | A 67-year-old female patient is brought to the emergency department after her daughter noticed she has been having meaningless speech. When assessing the patient, she calls the chair a table, and at times would make up new words. She does not appear to be aware of her deficit, and is carrying on an empty conversation. Her speech is fluent, but with paraphasic errors. Her repetition is impaired. On physical examination, a right upper quadrant field-cut is appreciated, with impairment in comprehension and repetition. Which of the following structures is most likely involved in this patient’s presentation? |
usmle-12288 | An 87-year-old male presents to his neurologist for a follow-up visit. He is being followed for an inoperable tumor near his skull. He reports that he recently noticed that food has started to lose its taste. He also notes increasing difficulty with swallowing. He has a history of myocardial infarction, diabetes mellitus, hyperlipidemia, hypertension, and presbycusis. He takes aspirin, metoprolol, metformin, glyburide, atorvastatin, lisinopril, and hydrochlorothiazide. On examination, the patient is a frail-appearing male sitting in a wheelchair. He is oriented to person, place, and time. Gag reflex is absent on the right side. A taste evaluation is performed which demonstrates a decreased ability to detect sour and bitter substances on the right posterior tongue. The nerve responsible for this patient’s loss of taste sensation also has which of the following functions? |
usmle-12289 | A 2-year-old girl presents to the pediatrician with an itchy rash. Her mother reports that she has had a crusty rash on the face and bilateral upper extremities intermittently for the past 2 months. The child's past medical history is notable for 3 similar episodes of severely itchy rashes since birth. She has also had 2 non-inflamed abscesses on her arms over the past year. Her temperature is 98.9°F (37.2°C), blood pressure is 108/68 mmHg, pulse is 94/min, and respirations are 18/min. On exam, she appears uncomfortable and is constantly itching her face and arms. There is an eczematous rash on the face and bilateral upper extremities. Her face has thickened skin with a wide-set nose. This patient's condition is most likely caused by a mutation in which of the following genes? |
usmle-12290 | A 76-year-old male with a history of chronic uncontrolled hypertension presents to the emergency room following an episode of syncope. He reports that he felt lightheaded and experienced chest pain while walking his dog earlier in the morning. He notes that he has experienced multiple similar episodes over the past year. A trans-esophageal echocardiogram demonstrates a thickened, calcified aortic valve with left ventricular hypertrophy. Which of the following heart sounds would likely be heard on auscultation of this patient? |
usmle-12291 | A 39-year-old man presents to the emergency room for epistaxis. He reports having frequent nosebleeds over the past 48 hours. He also reports a constant pounding headache over the same timeframe. He is accompanied by his wife who reports that he has seemed “off” lately, frequently forgetting recent events and names of his friends. His past medical history is notable for hypertension and rheumatoid arthritis. He takes lisinopril and methotrexate. He has a 10 pack-year smoking history and drinks 2-3 beers per day. His temperature is 101.1°F (37.3°C), blood pressure is 145/90 mmHg, pulse is 110/min, and respirations are 18/min. On exam, he appears pale, diaphoretic, and has mild scleral icterus. His spleen is palpable but non-tender. Laboratory analysis is shown below:
Hemoglobin: 8.9 g/dL
Hematocrit: 26%
Leukocyte count: 4,900/mm^3 with normal differential
Platelet count: 25,000/mm^3
Prothrombin time: 14 seconds
Partial thromboplastin time (activated): 27 seconds
International normalized ratio: 1.1
Bleeding time: 9 minutes
This patient has a condition that is caused by a defect in which of the following processes? |
usmle-12292 | A 25-year-old G1P0 woman at 33 weeks gestation presents to the obstetrician for an episode of postcoital spotting. The patient’s pregnancy is complicated by diet-controlled gestational diabetes. She has no other medical conditions. She takes prenatal vitamins. She denies tobacco, alcohol, or recreational drug use. She is currently sexually active with her boyfriend of 1 year, but prior to her current relationship, she states she had multiple male partners. On physical examination, no vaginal bleeding is appreciated. The cervix is closed, and there is no leakage of fluid or contractions. Fetal movement is normal. Fundal height is 33 cm. Fetal pulse is 138/min. The patient’s temperature is 37.0 °C (98.6°F), blood pressure is 112/75 mm Hg, and pulse is 76/min. A urine dipstick is negative for glucose and protein. Chlamydia trachomatis nucleic acid amplification testing is positive. Which of the following is the mechanism behind the first-line treatment for this patient’s condition? |
usmle-12293 | A 43-year-old woman presents to her primary care provider for follow-up of her glucose levels. At her last visit 3 months ago, her fasting serum glucose was 128 mg/dl. At that time, she was instructed to follow a weight loss regimen consisting of diet and exercise. Her family history is notable for a myocardial infarction in her father and type II diabetes mellitus in her mother. She does not smoke and drinks 2-3 glasses of wine per week. Her temperature is 99°F (37.2°C), blood pressure is 131/78 mmHg, pulse is 80/min, and respirations are 17/min. Her BMI is 31 kg/m^2. On exam, she is well-appearing and appropriately interactive. Today, despite attempting to make the appropriate lifestyle changes, a repeat fasting serum glucose is 133 mg/dl. The patient is prescribed the first-line oral pharmacologic agent for her condition. Which of the following is the correct mechanism of action of this medication? |
usmle-12294 | A 9-year-old boy is brought to his primary care physician after his mom noticed that he was limping. He says that he has been experiencing significant hip and knee pain over the last 2 months but thought he may have just strained a muscle. Radiographs show a collapse of the femoral head, and he is diagnosed with Legg-Calve-Perthes disease. He undergoes surgery and is placed in a Petrie cast from his hips to his toes bilaterally so that he is unable to move his knees or ankles. Eight weeks later, the cast is removed, and he is found to have significantly smaller calves than before the cast was placed. Which process in myocytes is most likely responsible for this finding? |
usmle-12295 | A 23-year-old male presents to the emergency room following a gunshot wound to the leg. On arrival his temperature is 99°F (37.2°C), blood pressure is 90/60 mmHg, pulse is 112/min, respirations are 21/min, and pulse oximetry is 99% on room air. Two large bore IVs are placed and he receives crystalloid fluid replacement followed by 2 units of crossmatched packed red blood cells. Immediately following transfusion, his temperature is 102.2°F (39°C), blood pressure is 93/64 mmHg, pulse is 112/min, respirations are 21/min, and pulse oximetry is 99% on room air. There is oozing from his IV sites. You check the records and realize there was a clerical error with the blood bank. What is the mechanism for his current condition? |
usmle-12296 | A 32-year-old Caucasian woman presents with a three-month history of weight loss, anxiety, and tremors. She recalls frequent heart palpitations and new discomfort while being outside in the heat. Her labs include a TSH level of 0.1 mIU/L. Additionally, the patient’s serum is positive for antibodies that stimulate the TSH receptor. What process is unique to this patient’s diagnosis? |
usmle-12297 | A 73-year-old man presents with sudden onset hemiplegia. He has no known significant medical history. He becomes progressively lethargic. Emergency head CT results are shown in Figure A. Neurosurgery is consulted, but the patient expires. An autopsy is performed; a section from that autopsy is shown in Figure B. Which of the following was the predisposing cause? |
usmle-12298 | A 27-year-old woman presents to her primary care physician’s office complaining of trouble sleeping. She reports that for the past 10 months she has experienced difficulty falling asleep due constant worrying. The content of her worry include items such as whether or not her child will feel lonely in day care and the health of her parents. These worrying episodes typically begin toward the end of the day and last for several hours. She states that she has trouble concentrating at work as well and describes her heart as "racing" during these episodes. She denies any alcohol or illicit drug use. Which of the following neurotransmitters is most likely decreased in this patient? |
usmle-12299 | A 15-year-old boy is brought to the clinic by his father for complaints of “constant irritation.” His father explains that ever since his divorce with the son’s mother last year he has noticed increased irritability in his son. "He has been skipping out on his baseball practices which he has always enjoyed,” his dad complains. After asking the father to step out, the patient reports trouble concentrating at school and has been staying up late “just thinking about stuff.” When probed further, he states that he “feels responsible for his parents' divorce because he was being rebellious.” What is the best treatment for this patient at this time? |
usmle-12300 | A 21-year-old male comes into the physician for a yearly physical. He is a swimmer with no significant past medical history. His baseline cardiac output and venous return curves are shown in Figure A. Assuming that he starts at position 1, which of the following points would most likely represent his cardiac output and venous return curves during one of his swim practices? |
usmle-12301 | A 46-year-old man presents to your primary care office for follow-up. He has hypertension, which has been well-controlled with furosemide. He is a former smoker with a 5 pack-year history and drinks 2 alcoholic drinks twice per week. You saw him 3 months ago for chronic knee pain. At that time, radiographic imaging showed moderate arthritis of the right knee. As a result, the patient started taking an over-the-counter pain reliever with substantial relief. At today's appointment, you note that his blood pressure is elevated. Examination of his feet shows 1+ pitting edema in his bilateral lower extremities (Figure A). You order lab-work, which is notable for: Na 140 mEq/L; K 4.7 mEq/L; Cr 1.2 mg/dL; AST 20 U/L; ALT 20 U/L; Albumin 5.0 g/dL. An echocardiogram shows an ejection fraction of 60%. Which of the following is the most likely cause of his edema? |
usmle-12302 | A 5-year-old male is brought to your office with fever and malaise. Physical exam is significant for a "slapped face" rash on the cheeks (see Figure A). The organism responsible for this patient's presentation targets which of the following cell types? |
usmle-12303 | An 89-year-old woman presents with worsening dyspnea on exertion and generalized fatigue. She has fainted once. Exam reveals a crescendo-decrescendo systolic ejection murmur that radiates to the carotids. What pathological step preceded calcification in her condition? |
usmle-12304 | A 75-year-old man is brought into the emergency department after he was found unconscious in the food court at the hospital. CPR is started and the patient is defibrillated at 200 joules. He is given 1 mg of epinephrine and 300 mg of amiodarone. He currently has a pulse and is intubated. The patient has a past medical history of poorly controlled diabetes. His current medications include metformin, insulin, lisinopril, and atorvastatin. An ECG is ordered as seen in Figure A. A chest radiograph is also ordered, and the patient is transferred to the ICU. A treatment for which of the following conditions is also an appropriate initial treatment for the underlying cause of this patient's presentation? |
usmle-12305 | A 25-year-old woman presents to her primary care physician for her yearly physical exam. She has no past medical history and says that she does not currently have any health concerns. On physical exam, she is found to have hyperactive patellar reflexes but says that she has had this finding since she was a child. She asks her physician why this might be the case. Her physician explains that there are certain cells that are responsible for detecting muscle stretch and responding to restore the length of the muscle. Which of the following is most likely a characteristic of these structures? |
usmle-12306 | A 60-year-old male presents to his primary care physician complaining of fatigue. He reports a six-month history of gradually worsening tiredness. More recently, he has experienced intermittent fevers and night sweats. His temperature is 99.5°F (37.5°C), blood pressure is 115/80 mmHg, pulse is 80/min, and respirations are 18/min. On examination, painless cervical lymphadenopathy is noted. A lymph node biopsy is performed and karyotypic analysis of the biopsy reveals an 11;14 translocation. What is the normal function of the protein that is overexpressed due to the translocation seen in this patient? |
usmle-12307 | An 18-year-old man presents with bloody diarrhea and weight loss. He undergoes endoscopic biopsy which shows pseudopolyps. Biopsies taken during the endoscopy show inflammation only involving the mucosa and submucosa. He is diagnosed with an inflammatory bowel disease. Which of the following was most likely found? |
usmle-12308 | A 37-year-old G2P1 woman presents to the clinic complaining of amenorrhea. She reports that she has not had a period for 2 months. A urine pregnancy test that she performed yesterday was negative. She is sexually active with her husband and uses regular contraception. Her past medical history is significant for diabetes and a dilation and curettage procedure 4 months ago for an unviable pregnancy. She denies any discharge, abnormal odor, abnormal bleeding, dysmenorrhea, or pain but endorses a 10-pound intentional weight loss over the past 3 months. A pelvic examination is unremarkable. What is the most likely explanation for this patient’s presentation? |
usmle-12309 | A 9-year-old boy presents to his orthopedic surgeon for ongoing evaluation of his lower extremity deformities. Specifically, his hips have been dislocating over the last year despite bracing in hip-knee-ankle-foot orthoses. He is paralyzed from below the L2 nerve root and has difficulty with both bladder and bowel incontinence. He has had these abnormalities since birth due to a lower back lesion that required surgical closure during infancy. Which of the following substances was most likely elevated in his mother's serum during her pregnancy? |
usmle-12310 | A 75-year-old male presents to the emergency room complaining of chest pain. He reports a pressure-like “crushing” sensation over his sternum. His past medical history is notable for diabetes, hyperlipidemia, and hypertension. He takes aspirin, metformin, glyburide, rosuvastatin, and enalapril. The patient drinks socially and has a 40 pack-year smoking history. His temperature is 99°F (37.2°C), blood pressure is 150/85 mmHg, pulse is 130/min, and respirations are 24/min. On exam, the patient is diaphoretic and has notably increased work of breathing. An electrocardiogram is shown in Figure A which demonstrates abnormalities in the isoelectric portion of the QT interval in several leads. Which ion channels are normally open during this phase of the cardiac action potential? |
usmle-12311 | A 82-year-old man who is currently being managed by the internal medicine service agrees to be examined by medical students as part of their training in physical examination. He is visited by a small group of medical students under the instruction of a preceptor and allows the students to make observations. They find that he has bibasilar crackles that are most prominent during inspiration as well as some wheezing. Furthermore, he coughs up some sputum during the exam, and this sputum is found to have a rust color. He does not report any pain and no skin findings are seen. Which of the following is most closely associated with the cause of this patient's physical exam findings? |
usmle-12312 | A researcher is investigating whether there is an association between the use of social media in teenagers and bipolar disorder. In order to study this potential relationship, she collects data from people who have bipolar disorder and matched controls without the disorder. She then asks how much on average these individuals used social media in the 3 years prior to their diagnosis. This continuous data is divided into 2 groups: those who used more than 2 hours per day and those who used less than 2 hours per day. She finds that out of 1000 subjects, 500 had bipolar disorder of which 300 used social media more than 2 hours per day. She also finds that 400 subjects who did not have the disorder also did not use social media more than 2 hours per day. Which of the following is the odds ratio for development of bipolar disorder after being exposed to more social media? |
usmle-12313 | A 23-year-old woman presents to the emergency department with a 3-day history of fever and headache. She says that the symptoms started suddenly after she woke up 3 days ago, though she has been feeling increasingly fatigued over the last 5 months. On presentation, her temperature is 102°F (38.9°C), blood pressure is 117/74 mmHg, pulse is 106/min, and respirations are 14/min. Physical exam reveals diffuse petechiae and conjunctival pallor and selected laboratory results are shown as follows:
Bleeding time: 11 minutes
Platelet count: 68,000/mm^3
Lactate dehydrogenase: 105 U/L
Which of the following would also most likely be true for this patient? |
usmle-12314 | A 52-year-old woman presents to her primary care physician because she has been feeling pain in her right leg. Specifically, she says that an area on her right thigh has been feeling tender and swollen over the past few weeks. Her past medical history is significant for obesity, poorly controlled diabetes, and hypertension. She also has been taking estrogen replacement therapy and drinking alcohol to cope with her symptoms of menopause. Her family history is significant for cardiomyopathy. On physical exam, there is erythema and edema along a cord-like lesion in her thigh. This lesion feels thick and hardened on palpation and is tender to the touch. She is started on compression therapy as well as NSAIDs for pain management. Which of the following characteristics of this patient most likely increased her risk for this disorder? |
usmle-12315 | A 75-year-old woman with a history of Hashimoto's disease on thyroid replacement and hypertension presents to your outpatient clinic for fatigue that has progressively worsened over the last year. She has also experienced a fall a few days prior to presentation due to "not knowing where I was stepping when the lights are off." She reports that her husband has noticed she has become more forgetful lately, such as not remember she is expecting visitors or turning the stove off after she finished cooking. She denies fevers, chills, weight loss, and night sweats. She has no chest pain, shortness of breath, constipation, diarrhea, dysuria, heat or cold intolerance. Her temperature is 99.5 deg F (37.5 deg C), blood pressure is 103/72 mmHg, pulse is 76/min, respirations are 12/min. On physical examination, she has a slightly large tongue. She has decreased vibration and proprioception sense in her bilateral lower extremities. She also has a positive Romberg test. Her lab results demonstrate a normal TSH. A peripheral blood smear shows the following: (Figure A). Which of the following lab results would be most consistent with the patient’s clinical presentation? |
usmle-12316 | A 14-year-old male presents to his pediatrician complaining of a sore throat. His mother reports that he developed a fever two days ago that was immediately followed by a sore throat. He denies cough or rhinorrhea. His past medical history is notable for poorly controlled asthma and he currently takes albuterol and budesonide. Of note, the child immigrated to America from Vietnam three months ago. His temperature is 101.6°F (38.7°C), blood pressure is 130/85 mmHg, pulse is 110/min, and respirations are 18/min. Physical examination reveals a malnourished adolescent who is small for his age. No hepatosplenomegaly is noted. A notable physical examination finding is shown in Figure A. Serologic and throat swab studies are pending. Without appropriate treatment, this patient is at greatest risk for which of the following? |
usmle-12317 | A 56-year-old man is brought to the emergency department by his daughter after she noticed her father was confused and behaving abnormally. The daughter states that the patient has been complaining of malaise and headache for the past few days. His temperature is 101.3 °F (38.5 °C). On physical exam, the patient has a decreased level of consciousness and neck stiffness. A magnetic resonance imaging (MRI) of the head is shown in Figure A. Lumbar puncture was performed, and CSF analysis shows a leukocyte cell count of 103/mm^3 (72% lymphocytes), protein of 98 mg/dL, and a glucose of 55 mg/dL. The patient is started on appropriate therapy while awaiting confirmatory results. Which of the following effects is associated with the most likely treatment provided? |
usmle-12318 | A 42-year-old female presents with right upper quadrant pain. On physical exam you note that the patient is jaundiced and has ascites, with an enlarged liver. There is a lack of jugular venous distension in the presence of lower extremity edema. Liver biopsy shows centrilobular congestion, necrosis, and hemorrhage. Her past medical history consists of erythromelalgia, and a constant elevated hematocrit associated with JAK2 mutation; for which she undergoes phlebotomy and takes hydroxyurea. In Figure A, in which of the following anatomical structures is the pathology most likely located? |
usmle-12319 | A 57-year-old man comes to the clinic for diffuse itchiness and headaches for the past month. He reports that the symptoms began shortly after returning from a camping trip in New Hampshire and are especially worse after he showers. He denies any fever, rashes, chest pain, or shortness of breath but reports a 10-lb. weight loss he attributes to exercise intermittent blurred vision, and mild right upper quadrant (RUQ) pain. His past medical history is significant for hepatitis C infection and hypertension for which he was recently started on lisinopril. A physical examination is unremarkable except for mild RUQ tenderness with a negative Murphy test. A computed tomographic (CT) image of the abdomen is obtained and its results are shown in Figure A. What is the most likely explanation for this patient’s presenting symptoms? |
usmle-12320 | A 48-year-old man presents to the ER with a sudden-onset, severe headache. He is vomiting and appears confused. His wife, who accompanied him, says that he has not had any trauma, and that the patient has no relevant family history. He undergoes a non-contrast head CT that shows blood between the arachnoid and pia mater. What is the most likely complication from this condition? |
usmle-12321 | A 43-year-old male comes to his primary care physician for a routine checkup. He has a history of type II diabetes, hypertension, and obstructive sleep apnea. He has no complaints at this time. An EKG during the visit is shown in Figure A. Which of the following therapies can cause this phenomenon? |
usmle-12322 | A 62-year-old man presents to his primary care physician because he is unhappy about his inability to tan this summer. He has been going to the beach with his family and friends, but he has remained pale. He has no other complaints except that he has been getting tired more easily, which he attributes to normal aging. Based on clinical suspicion a panel of tests are performed with the following results:
Hemoglobin: 11 g/dL
Leukocyte count: 5,370/mm^3
Platelet count: 168,000/mm^3
Mean corpuscular volume: 95 µm^3
Haptoglobin level: Decreased
Reticulocytes: 3%
Peripheral blood smear is also obtained and shown in the figure provided. Which of the following patient characteristics is consistent with the most likely cause of this patient's disease? |
usmle-12323 | A 45-year-old male is worried because he has been experiencing uncontrolled writhing movements. He admits that over the past year he has been more forgetful while performing basic tasks (i.e., balancing the checkbook), and his wife complains that his not been acting like himself. He is afraid that he may be getting depressed from these symptoms and from the fact that he is experiencing frontal balding. His past medical history includes diabetes and mild intellectual disability. A brain section from a patient with the same disease is shown (Figure A). The affected gene in this patient would most likely have an increased number of which of the following sequences? |
usmle-12324 | An 82-year-old man is brought to the emergency department after he was found down by his daughter. On presentation, he is alert and oriented with no obvious signs of trauma. He says that he felt lightheaded shortly before passing out and that he has been feeling extremely fatigued over the last few weeks. He has a known diagnosis of colorectal adenocarcinoma and had it surgically removed 2 months ago; however, recently he has been feeling increasingly short of breath. He has a 60-pack-year smoking history and drinks 2-3 beers a night. He worked as an insulation technician and shipyard laborer for 40 years prior to retiring at age 65. Radiographs reveal approximately a dozen new nodules scattered throughout his lungs bilaterally. Biopsy of these lesions would most likely reveal which of the following? |
usmle-12325 | A G1P0 34-year-old woman presents to the clinic complaining of difficulty breathing and coughing up blood for 2 days. Past medical history is significant for molar pregnancy 6 months ago. The patient was lost to follow up as she was abruptly laid off and had to stay at a homeless shelter for the past few months. She endorses nausea and vomiting, abdominal discomfort, and “feeling hot all the time.” The patient is a past smoker of 1 pack per day for 10 years. Vital signs are within normal limits except for tachycardia. What is the disease process that most likely explains this patient’s symptoms? |
usmle-12326 | An 85-year-old man presents to his primary care provider after feeling "lightheaded." He said he helped his wife in the garden for the first time, but that while moving some bags of soil he felt like he was going to faint. He had a big breakfast of oatmeal and eggs prior to working in the garden. He has no significant past medical history and takes a baby aspirin daily. Physical exam reveals an elderly, well-nourished, well-built man with no evidence of cyanosis or tachypnea. Vital signs show normal temperature, BP 150/70, HR 80, RR 18. Cardiac exam reveals crescendo-decrescendo systolic murmur. What is the most likely cause of this patient's diagnosis? |
usmle-12327 | A 57-year-old male presents to his primary care physician with upper abdominal pain. He reports a 3-month history of mild epigastric pain that improves with meals. He has lost 15 pounds since his symptoms started. His past medical history is notable for gynecomastia in the setting of a prolactinoma for which he underwent surgical resection over 10 years prior. He has a 15-pack-year smoking history, a history of heroin abuse, and is on methadone. His family history is notable for parathyroid adenoma in his father. His temperature is 98.8°F (37.1°C), blood pressure is 125/80 mmHg, pulse is 78/min, and respirations are 18/min. This patient’s symptoms are most likely due to elevations in a substance with which of the following functions? |
usmle-12328 | A 5-year-old boy is brought to the emergency room by his parents due to worsening cough, fever, and difficulty breathing in the past 2 days. Physical exam reveals a barking cough and use of accessory muscles for breathing. After a full clinical workup, he is diagnosed with an upper respiratory infection caused by a parainfluenza virus. Which of the following findings in the clinical workup of this patient supported the diagnosis? |
usmle-12329 | An 87-year-old man with glioblastoma multiforme is informed that the size and location of the tumor make operative resection impossible, and he has a prognosis of between 3-6 months. The patient then asks whether it would be possible to get a prescription for lethal medications so that he would be able to end his life if his situation deteriorated further. The physician says that he is unable to prescribe such drugs because assisted suicide is not legal in their state. Refusing to help a patient commit suicide is most consistent with which of the following ethical principles? |
usmle-12330 | A 31-year-old woman presents to her primary care physician with a 2-week history of diarrhea. She says that she has also noticed that she is losing weight, which makes her feel anxious since she has relatives who have suffered from anorexia. Finally, she says that she is worried she has a fever because she feels warm and has been sweating profusely. On physical examination she is found to have proptosis, fine tremor of her hands, and symmetrical, non-tender thyroid enlargement. Which of the following types of enzymes is targeted by a treatment for this disease? |
usmle-12331 | A 16-year-old boy presents to his pediatrician’s office after noticing right leg pain for the past 2 weeks. The patient first noticed the pain 2 weeks prior after a soccer game. He did not report any significant injuries at the time. He states that the pain is intermittent, but he tends to notice it while he is in bed at night. Recently, the pain has been getting worse and is a gnawing pain mainly localized to his right lower thigh. On exam, his temperature is 98.2°F (36.8°C), blood pressure is 114/76 mmHg, pulse is 68/min, and respirations are 12/min. There is no gross deformity of his extremities, but he does cite some tenderness to palpation on his anterior thigh immediately superior to his right knee. Motor and sensory function are intact. After imaging is obtained, a bone biopsy is performed and is found to contain pleomorphic cells with osteoid production (Figure A). Which of the following is also associated with this type of lesion? |
usmle-12332 | A 3-year-old boy is brought to the emergency department by his mother. His mother reports that she found him playing under the sink yesterday. She was concerned because she keeps some poisons for pest control under the sink but did not believe that he came in contact with the poisons. However, this morning the boy awoke with abdominal pain and epistaxis, causing her to rush him to the emergency department.
You obtain stat lab-work with the following results:
WBC: 6,000/microliter;
Hgb: 11.2 g/dL;
Platelets: 200,000/microliter;
PTT: 35 seconds;
INR: 6.5;
Na: 140 mEq/L;
K: 4 mEq/L;
Cr: 0.7 mg/dL.
Which of the following is likely to be the most appropriate treatment? |
usmle-12333 | A 42-year-old woman presents to her primary care physician with fatigue. She reports that over the past 2 months, she has felt increasingly tired despite no changes in her diet or exercise. Her past medical history is notable for obesity, seasonal allergies, and hypertension. She takes ranitidine as needed and hydrochlorothiazide daily. Her family history is notable for colorectal cancer in her mother and maternal uncle, endometrial cancer in her maternal aunt, and ovarian cancer in her maternal grandmother. Her temperature is 98.8°F (37.1°C), blood pressure is 132/71 mmHg, pulse is 89/min, and respirations are 17/min. On exam, she has conjunctival pallor. A stool sample is hemoccult positive. A colonoscopy reveals a fungating hemorrhagic mass in the ascending colon. Which of the following processes is likely impaired in this patient? |
usmle-12334 | You are evaluating a 72-year-old lady who presents to your office with fatigue and lower extremity edema. On exam you notice a distended, pulsating jugular vein. A jugular venous pressure tracing is shown in Figure A. In a healthy individual, the majority of the right ventricular filling occurs between which two points on the curve? |
usmle-12335 | A 49-year-old woman presents to her primary care physician with fatigue. She reports that she has recently been sleeping more than usual and says her “arms and legs feel like lead” for most of the day. She has gained 10 pounds over the past 3 months which she attributes to eating out at restaurants frequently, particularly French cuisine. Her past medical history is notable for social anxiety disorder. She took paroxetine and escitalopram in the past but had severe nausea and headache while taking both. She has a 10 pack-year smoking history and has several glasses of wine per day. Her temperature is 98.6°F (37°C), blood pressure is 130/65 mmHg, pulse is 78/min, and respirations are 16/min. Physical examination reveals an obese woman with a dysphoric affect. She states that her mood is sad but she does experience moments of happiness when she is with her children. The physician starts the patient on a medication to help with her symptoms. Three weeks after the initiation of the medication, the patient presents to the emergency room with a severe headache and agitation. Her temperature is 102.1°F (38.9°C), blood pressure is 180/115 mmHg, pulse is 115/min, and respirations are 24/min. Which of the following is the mechanism of action of the medication that is most likely responsible for this patient’s symptoms? |
usmle-12336 | A 14-year-old female is brought to the emergency department by her parents for altered mental status and lethargy. Her past medical history is notable for type I diabetes, and her parents report that she recently came down with the flu over the past two days. Her blood pressure is 100/75 mmHg, pulse is 100/min, and respirations are 24/min. Her breath smells sweet. Plasma glucose is 600 mg/dL. The subcutaneous injection of which form of insulin will most rapidly correct this patient's blood glucose has which of the following concentration profiles shown in Figure A? |
usmle-12337 | A 23-year-old woman presents to her primary care physician because she has been having difficulty seeing despite previously having perfect vision all her life. Specifically, she notes that reading, driving, and recognizing faces has become difficult, and she feels that her vision has become fuzzy. She is worried because both of her older brothers have had visual loss with a similar presentation. Visual exam reveals bilateral loss of central vision with decreased visual acuity and color perception. Pathological examination of this patient's retinas reveals degeneration of retinal ganglion cells bilaterally. She is then referred to a geneticist because she wants to know the probability that her son and daughter will also be affected by this disorder. Her husband's family has no history of this disease. Ignoring the effects of incomplete penetrance, which of the following are the chances that this patient's children will be affected by this disease? |
usmle-12338 | A 55-year-old male presents to his primary care physician complaining of right hip pain for the past eight months. He also reports progressive loss of hearing over the same time period. Radiographic imaging reveals multiple areas of expanded bony cortices and coarsened trabeculae in his right hip and skull. Laboratory analysis reveals an isolated elevation in alkaline phosphatase with normal levels of serum calcium and phosphate. Which of the following histologic findings is most likely to be seen if one of the lesions were biopsied? |
usmle-12339 | A 65-year-old patient with a history of COPD and open-angle glaucoma in the left eye has had uncontrolled intraocular pressure (IOP) for the last few months. She is currently using latanoprost eye drops. Her ophthalmologist adds another eye drop to her regimen to further decrease her IOP. A week later, the patient returns because of persistent dim vision. On exam, she has a small fixed pupil in her left eye as well as a visual acuity of 20/40 in her left eye compared to 20/20 in her right eye. Which of the following is the mechanism of action of the medication most likely prescribed in this case? |
usmle-12340 | A 23-year-old woman on prednisone for lupus presents to her primary care physician because she experiences a burning sensation with urination. She has also been urinating more frequently than normal. The patient denies fever, chills, nausea/vomiting, abdominal or back pain, or other changes with urination. Her vital signs and physical exam are unremarkable, and her urine analysis is positive for leukocyte esterase and nitrites. The patient receives a diagnosis and is then prescribed an antimicrobial that acts by inhibiting DNA gyrase. Which adverse effect should the patient be counseled about? |
usmle-12341 | A 57-year-old African American woman is seen in your office for her annual visit. In addition to her history of hypertension and hyperlipidemia, she has a 50 pack-year smoking history. Since her last visit, she has been hospitalized twice for right upper lobe pneumonia, both which resolved uneventfully with antibiotic therapy. Although she feels otherwise well, she is concerned because she has developed a chronic cough and experienced an unintentional 15-pound weight loss since her last visit. Her temperature is 98.6°F (37°C), blood pressure is 148/92 mmHg, pulse is 90/min and regular, and respirations are 20/min. Physical examination is significant for wheezing over the right upper lung field. A radiograph of the chest is obtained and displayed in Figure A. An interferon-gamma release assay is negative. Which of the following sets of laboratory studies is most likely to be seen in this patient? |
usmle-12342 | A 67-year-old man presents to his primary care provider with difficulty breathing. He reports a 7-month history of progressively worsening exertional dyspnea. He has also developed a mild nonproductive cough. His past medical history is notable for major depressive disorder, hypertension, and diabetes mellitus. He takes fluoxetine, enalapril, metformin, and glyburide. He has a 15-pack-year smoking history and quit 20 years ago. He drinks a 6-pack of beer a week. His temperature is 99.1°F (37.3°C), blood pressure is 140/80 mmHg, pulse is 82/min, and respirations are 22/min. On exam, fine bibasilar inspiratory crackles are noted along with digital clubbing. Antinuclear antibody and rheumatoid factor titers are low. Results of a high-resolution computed tomography (CT) scan are shown in Figure A. Which of the following is the underlying cause of this patient's condition? |
usmle-12343 | A 13-year-old African American boy with no past medical history goes out to dinner with his family at a local Mexican restaurant. He eats a traditional Central-Mexican dish made with fava beans. Two days later, he becomes pale and begins to complain of back pain. His mother accompanies him to the pediatrician where a peripheral blood smear is obtained. Which of the following figures best demonstrates the likely appearance of this patient's red blood cells? |
usmle-12344 | A 3-year-old boy is taken to the ER by his parents due to his elevated temperature. He has had a fever (>101.1 deg F) for a little over a week, and over that time, his parents noticed his eyes had gotten a little pink, and his palms and soles were red and swollen. His lips and tongue are also peeling. His parents note he has not taken any new medications, and they did not notice any runny nose, sore throat, cough, or changes in his bowel or bladder habits. In the ER, his vitals are as follows: temperature is 101.3 deg F (38.5 deg C), blood pressure is 90/60 mmHg, pulse is 125/min, and respirations are 20/min. His exam is notable for bilateral injected conjunctivae, right-sided cervical lymphadenopathy, erythematous and edematous palms and soles, and erythema multiforme-like rash over his trunk. Appropriate lab tests and imaging were performed. Which of the following is the most worrisome complication of this boy's disease process? |
usmle-12345 | A 21-year-old woman presents for a routine check-up with a new primary care physician. She is concerned about a needle-stick that occurred 2 days ago while volunteering to clean a public park. She notes that she had about 8 drinks last night while celebrating her best friend's engagement. Otherwise she has been healthy and has no past medical history. She does not smoke and drinks socially. On physical exam, she is found to have scleral icterus and mild jaundice. Lab results are shown below:
Alanine aminotransferase (ALT): 9 U/L (normal range: 8-20 U/L)
Aspartate aminotransferase (AST): 11 U/L (normal range: 8-20 U/L)
Total bilirubin: 3.5 mg/dL (normal range: 0.1-1.0 mg/dL)
Direct bilirubin: 0.2 mg/dL (normal range: 0.0-0.3 mg/dL)
Hematocrit: 41% (normal range: 36%-46%)
Which of the following processes is most likely responsible for this patient's jaundice? |
usmle-12346 | A 17-year-old girl presents to an urgent care clinic after waking up in the morning with a left-sided facial droop and an inability to fully close her left eye. Of note, she is currently on oral contraceptives and escitalopram and smokes half a pack of cigarettes per day. Her temperature is 98.2°F (36.8°C), blood pressure is 110/68 mmHg, pulse is 82/min, and respirations are 12/min. On exam, she has generalized, unilateral left-sided drooping of her upper and lower face, and an inability to move the left side of her mouth or close her left eye. Her extraocular movements and swallow are intact. She has no other neurologic deficits. Which of the following interventions would most likely address the most likely cause of this patient's symptoms? |
usmle-12347 | A 63-year-old man undergoes workup for nocturnal dyspnea and what he describes as a "choking" sensation while sleeping. He also endorses fatigue and dyspnea on exertion. Physical exam reveals a normal S1, loud P2, and a neck circumference of 17 inches (43 cm) (normal < 14 inches (< 35 cm)). His temperature is 98.8°F (37°C), blood pressure is 128/82 mmHg, pulse is 86/min, and respirations are 19/min. He undergoes spirometry, which is unrevealing, and polysomnography, which shows 16 hypopneic and apneic events per hour. Mean pulmonary arterial pressure is 30 mmHg. Which of the following complications is this patient most at risk for? |
usmle-12348 | A 17-year-old man is brought by his mother to his pediatrician in order to complete medical clearance forms prior to attending college. During the visit, his mother asks about what health risks he should be aware of in college. Specifically, she recently saw on the news that some college students were killed by a fatal car crash. She therefore asks about causes of death in this population. Which of the following is true about the causes of death in college age individuals? |
usmle-12349 | A mother brings her 5-year-old son to the pediatrician because she is concerned about recent changes in his appearance. She states that over the past day her son's face has become swollen and now his arms and legs appear swollen as well. She reports that he has always been in good health with the exception of a honey colored rash which resolved 2 weeks ago. In the course of the work up, the pediatrician obtains a urinalysis which demonstrates hematuria and red blood cell casts. Concerned for a renal pathology, she obtains a renal biopsy. Which of the following light microscopy images is most likely to be seen on this patient's biopsy? |
usmle-12350 | A 38-year-old African American female presents to her primary care provider complaining of shortness of breath. She has noticed gradually worsening shortness of breath over the past six months. She initially attributed her symptoms to stress associated with her divorce. Her past medical history is also notable for obesity and major depressive disorder for which she takes fluoxetine. She has a 5 pack-year smoking history and drinks alcohol socially. Her temperature is 99.0°F (37.1°C), blood pressure is 130/85 mmHg, pulse is 95/min, and respirations are 20/min. Physical examination is notable for bilateral rales. A chest radiograph is shown in Figure A. Which of the following dermatologic conditions is this patient at increased risk of developing? |