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usmle-12551

A 65-year-old African-American man presents to your office with dysphagia. He reports that he has found it progressively more difficult to swallow food over the past year. At the time of presentation, he is able to eat only soup. Social history is significant for asbestos exposure, multiple daily drinks of hard alcohol, and a 70 pack-year smoking history. What would you most expect to see on an esophageal biopsy of this patient?

usmle-12552

A 63-year-old man presents to his primary care physician for follow-up. He reports a slow and steady weight gain of 6 pounds over the past 6 months, despite attempts to control his diet and increase his level of exercise. His medications include pravastatin, lisinopril, and hydrochlorothiazide. On exam, his vital signs are stable. He is obese (BMI 32), and his waist circumference is 43 inches. His physician is concerned about an abnormal fasting blood glucose and dyslipidemia. On further work-up with oral glucose tolerance test, the patient is diagnosed with diabetes. Which of the following associations is consistent with this patient’s most likely form of diabetes?

usmle-12553

A 31-year-old man is referred to an otolaryngologist for ringing in his ears. He reports a 4-month history of intermittent tinnitus and deafness in his right ear. He has also experienced multiple episodes of nausea, vomiting, and vertigo with no clear etiology. He is otherwise healthy and takes no medications. He does not smoke and does not drink alcohol. He works in a loud automobile factory and rarely uses ear protection. His temperature is 99.0°F (37.2°C), blood pressure is 120/85 mmHg, pulse is 90/min, and respirations are 16/min. On exam, he is a healthy well-appearing male in no acute distress. He has a mildly ataxic gait. Audiologic examination reveals decreased hearing in his right ear. Results of a magnetic resonance imaging (MRI) scan are shown in Figure A. A biopsy of this mass would most likely stain for which of the following?

usmle-12554

A 23-year-old man presents to the emergency room following a stab wound to the back. He was in a bar when he got into an argument with another man who proceeded to stab him slightly right of the midline of his back. He is otherwise healthy and does not take any medications. He has one previous admission to the hospital for a stab wound to the leg from another bar fight 2 years ago. His temperature is 99°F (37.2°C), blood pressure is 115/80 mmHg, pulse is 100/min, and pulse oximetry is 99% on room air. Cardiopulmonary and abdominal exams are unremarkable; however, he has an abnormal neurologic exam. If this wound entered his spinal cord but did not cross the midline, which of the following would most likely be seen in this patient?

usmle-12555

A 22-year-old Caucasian male is stabbed in his left flank, injuring his left kidney. As the surgeon undertakes operative repair, she reviews relevant renal anatomy. All of the following are correct regarding the left kidney EXCEPT?

usmle-12556

A 49-year-old female with a long history of poorly controlled diabetes mellitus visits her primary care physician with 2+ non-pitting edema in her legs. The patient has a serum creatinine of 2.9 mg/dL and a blood urea nitrogen of 61 mg/dL. A 24-hour urine collection reveals 8.5 grams of protein. A renal biopsy is obtained. Which of the following histologic findings is most likely to be seen upon tissue analysis:

usmle-12557

A 44-year-old woman is brought to the emergency department for confusion and lethargy for the past 2 hours. Per the husband, the patient was behaving weirdly and forgot how to get to the bathroom at her house. She was also difficult to wake up from her nap. The husband denies any fever, weight loss, headaches, dizziness, chest pain, or gastrointestinal changes. He reports that she had frequent diarrhea over the past 3 days but attributed it to food poisoning. In the emergency room, the patient had a 1-minute episode of seizure activity. Following initial resuscitation and stabilization, laboratory studies were performed and the results are shown below. Hemoglobin: 13 g/dL Hematocrit: 38% Leukocyte count: 7,600/mm^3 with normal differential Platelet count: 170,000/mm^3 Serum: Na+: 125 mEq/L Cl-: 90 mEq/L K+: 3.2 mEq/L HCO3-: 20 mEq/L BUN: 22 mg/dL Glucose: 101 mg/dL Creatinine: 1.0 mg/dL Thyroid-stimulating hormone: 3.2 µU/mL Ca2+: 9.3 mg/dL AST: 19 U/L ALT: 22 U/L What is the most appropriate treatment for this patient?

usmle-12558

A 25-year-old woman presents to her primary care physician with 3 weeks of palpitations and shortness of breath while exercising. She says that these symptoms have been limiting her ability to play recreational sports with her friends. Her past medical history is significant for pharyngitis treated with antibiotics and her family history reveals a grandfather who needed aortic valve replacements early due to an anatomic abnormality. She admits to illicit drug use in college, but says that she stopped using drugs 4 years ago. Physical exam reveals a clicking sound best heard in the left 6th intercostal space. This sound occurs between S1 and S2 and is followed by a flow murmur. Which of the following is most likely associated with the cause of this patient's disorder?

usmle-12559

A 68-year-old man presents to the emergency department with a 3 day history of periorbital and leg swelling. He says that he has also been experiencing fatigue and shortness of breath. On physical examination he is found to have ascites and pitting edema. Laboratory tests reveal 4+ protein in his urine and a kidney biopsy is obtained for further evaluation. The results of this biopsy are shown in Figure A. If the vessel shown in the slide is an efferent arteriole, which of the following is most likely responsible for the vascular changes observed in this patient?

usmle-12560

A 54-year-old woman presents to her primary care physician complaining of watery diarrhea for the last 3 weeks. She reports now having over 10 bowel movements per day. She denies abdominal pain or rash. A basic metabolic profile is notable for the following: Na: 127 mEq/L; K 2.1 mEq/L; Glucose 98 mg/dL. Following additional work-up, octreotide was started with significant improvement in symptoms and laboratory values. Which of the following is the most likely diagnosis?

usmle-12561

A 37-year-old-man presents to the clinic for a 2-month follow-up. He is relatively healthy except for a 5-year history of hypertension. He is currently on lisinopril, amlodipine, and hydrochlorothiazide. The patient has no concerns and denies headaches, weight changes, fever, chest pain, palpitations, vision changes, or abdominal pain. His temperature is 98.9°F (37.2°C), blood pressure is 157/108 mmHg, pulse is 87/min, respirations are 15/min, and oxygen saturation is 98% on room air. Laboratory testing demonstrates elevated plasma aldosterone concentration and low renin concentration. What is the most likely explanation for this patient’s presentation?

usmle-12562

A 16-year-old female presents to the dermatologist with non-pruritic, hypopigmented areas on her back, abdomen, and extremities that fail to tan (Figure A). The dermatologist prescribes a topical ointment that acts by inhibiting the conversion of lanosterol to ergosterol. Which of the antifungals was prescribed?

usmle-12563

A 45-year-old woman with a history of alcoholic hepatitis returns to clinic for follow-up after being diagnosed with rheumatoid arthritis and started on NSAIDs. She complains of continued joint effusions and increasing morning stiffness. Given this patient's presentation and history, which of the following drugs presents the greatest risk when started for the management of her condition?

usmle-12564

A 28-year-old male intern is currently on a trauma surgery service. After a busy overnight shift, the intern did not have enough time to prepare to present all of the patients on the team’s list. At morning rounds, the chief resident made a sarcastic comment that the intern “really put a lot of effort into preparing for rounds.” After rounds, while managing the floor with the third year medical student, the intern berates the student that she “needs to step up her game and do a better job helping with pre-rounding in the morning.” What type of ego defense is most relevant in this situation?

usmle-12565

A 57-year-old man presents to his primary care physician with a 2-month history of right upper and lower extremity weakness. He noticed the weakness when he started falling far more frequently while running errands. Since then, he has had increasing difficulty with walking and lifting objects. His past medical history is significant only for well-controlled hypertension, but he says that some members of his family have had musculoskeletal problems. His right upper extremity shows forearm atrophy and depressed reflexes while his right lower extremity is hypertonic with a positive Babinski sign. Which of the following is most likely associated with the cause of this patient's symptoms?

usmle-12566

A 60-year-old female presents to her gynecologist with concerns about a mass she felt in her right breast on self-examination. She denies pain, redness, or nipple discharge in the affected breast. She denies a family history of breast cancer. Physical examination is notable for a firm, immobile mass in the superolateral quadrant of the right breast. No skin changes or axillary lymphadenopathy are noted. Her left breast has no significant findings. A biopsy of the lesion is performed and an H&E stained slide is shown in Figure A. Which of the following is the most likely explanation for the histologic appearance of the specimen?

usmle-12567

A 51-year-old woman presents to the emergency department with a 2-day history of bilateral lower extremity swelling. She says that her legs do not hurt, but she noticed she was gaining weight and her legs were becoming larger. Her past medical history is significant for morbid obesity, hypertension, and hypercholesterolemia. She says the swelling started after she was recently started on a new medication to help her blood pressure, but she does not remember the name of the medication. Which of the following is the most likely the mechanism of action for the drug that was prescribed to this patient?

usmle-12568

A 6-year-old boy is brought to the pediatrician by his mother for diarrhea and a skin rash. His mother reports that he had a cough, sore throat, and runny nose 1 week ago. Although his upper respiratory symptoms improved after two days, he started having multiple watery bowel movements 3 days ago. He also developed a red pruritic rash on his arms, legs, and neck at that time. His mother also reports that he has had similar symptoms in the past that have occurred after the boy gets sick. His temperature is 98.8°F (37.1°C), blood pressure is 109/68 mmHg, pulse is 92/min, and respirations are 19/min. The child is alert and oriented to person but not place or time. He is unable to count to 10 even though his mother says he can normally count to 100 easily. He walks with a wide-based gait. An erythematous patchy rash is noted on his upper and lower extremities bilaterally. A complete blood count and basic metabolic panel are within normal limits. A urinalysis reveals elevated levels of neutral amino acids. Which of the following is the most appropriate acute treatment for this patient?

usmle-12569

A 45-year-old gentleman comes to his primary care physician complaining of redness and foul-smelling discharge from his penis. The patient is not married and denies sexual activity. Upon further questioning, he denies trauma or any associated fevers or chills. After the initial work-up was found to be negative for sexually-transmitted diseases, a biopsy and imaging were ordered. The biopsy shows squamous cell carcinoma (SCC). Which of the following is associated with a reduced risk of developing penile SCC?

usmle-12570

A 12-year-old boy presents to the emergency room with difficulty breathing after several days of severe sore throat. Further history reveals that his family immigrated recently from Eastern Europe and he has never previously seen a doctor. Physical exam shows cervical lymphadenopathy with extensive neck edema as well as the finding shown in the image provided. You suspect a bacteria that causes the disease by producing an AB type exotoxin. Which of the following is the proper medium to culture the most likely cause of this infection?

usmle-12571

A 25-year-old female presents to her geneticist due to the fear that she may have inherited her father's disease. He was diagnosed at the age of 41 when his symptoms of chorea, coordination problems, and cognitive decline begin to occur. He was diagnosed with a disease resulting from the expansion of CAG repeats on chromosome 4 and later developed severe dementia and died at the age of 56. The daughter was found to have double the amount of CAG repeats and was told by the geneticist that she may have an earlier onset with increased severity of disease. What phenomenon describes this?

usmle-12572

A 12-year-old boy is brought to the emergency department after he vomited and said he was having double vision in school. He also says that he has been experiencing morning headaches, nausea, and dizziness over the last month. He has no past medical history and is not taking any medications. Physical exam reveals a broad-based gait, dysmetria on finger-to-nose testing, and nystagmus. Both serum and urine toxicology are negative, and radiography reveals a solid mass in the midline cerebellum that enhances after contrast administration. Biopsy of this lesion reveals cells of primitive neuroectodermal origin. Which of the following would most likely be seen on histology of this lesion?

usmle-12573

A 39-year-old man presents to a primary care clinic for a routine physical exam. He denies any complaints. He has a long beard and hair, wears several copper bracelets, and a crystal amulet. When asked about his diet, he discloses eating mostly canned foods, which he has stockpiled in his cabin in case there is a natural disaster or "apocalypse" (though he admits that this is highly unlikely). He has a few close friends, but feels awkward when meeting new people. He seems happy overall and has many long-standing interests, including hiking and astrology. He has been steadily employed as a data scientist and a paranormal investigator. He has never been diagnosed with a mental illness, though he has a family history of schizophrenia. Review of systems is negative for depressed mood, anxiety, or hallucinations. Thought process is linear and reality testing is intact. Which of the following is the most likely diagnosis for this patient?

usmle-12574

A 25-year-old male armadillo enthusiast visits his primary care doctor because he is concerned about recent changes in his skin. He states that he has noticed a number of light appearing areas on his back. The areas are not painful and he has not had any other associated symptoms. On exam, the physician notes a number of hypoesthetic, hairless skin plaques as demonstrated in Figure A. Which of the following correctly describe the immune response to this patient's condition?

usmle-12575

A 48-year-old woman presents to the emergency room because of severe back pain after a fall. She says that she was walking home from work when she slipped on a patch of ice on the sidewalk. Since she did not have anything to hold onto, she fell backwards and landed on her posterior iliac crests bilaterally. Immediately after the fall, she started experiencing back pain and tenderness that concerned her enough to call for an ambulance. Her past medical history is significant for arthritis, diabetes, and hypertension. On arrival, her temperature is 99°F (37.2°C), blood pressure is 129/86 mmHg, pulse is 112/min, respirations are 19/min. Physical exam reveals tenderness to palpation over the middle of her lower back. A drug that may have predisposed this patient to this outcome most likely has which of the following mechanisms?

usmle-12576

A 24-year-old G1P0 woman gives birth to a male infant at 33 weeks gestation. The mother had intermittent prenatal care and did not take prenatal vitamins. Her history is notable for poorly controlled epilepsy. The child’s temperature is 98.6°F (37°C), blood pressure is 85/55 mmHg, pulse is 100/min, and respirations are 28/min. The child’s height, weight, and head circumference are in the 20th, 25th, and 50th percentiles, respectively. The infant moves his arms spontaneously but his legs appear flaccid. A brain MRI of the patient is shown in Figure A. Which of the following is most strongly associated with this patient’s condition?

usmle-12577

A 26-year-old woman at 30 weeks 2 days of gestational age is brought into the emergency room following a seizure episode. Her medical records demonstrate poorly controlled gestational hypertension. Following administration of magnesium, she is taken to the operating room for emergency cesarean section. Her newborn daughter’s APGAR scores are 7 and 9 at 1 and 5 minutes, respectively. The newborn is subsequently taken to the NICU for further management and monitoring. Ten days following birth, the baby begins to refuse formula feedings and starts having several episodes of bloody diarrhea despite normal stool patterns previously. Her temperature is 102.2°F (39°C), blood pressure is 84/53 mmHg, pulse is 210/min, respirations are 53/min, and oxygen saturation is 96% on room air. A physical examination demonstrates a baby in mild respiratory distress and moderate abdominal distention. What do you expect to find in this patient?

usmle-12578

A 46-year-old man comes to the clinic complaining of abdominal pain for the past month. The pain comes and goes and is the most prominent after meals. He reports 1-2 episodes of black stools in the past month, a 10-lbs weight loss, fevers, and a skin rash on his left arm. A review of systems is negative for any recent travel, abnormal ingestion, palpitations, nausea/vomiting, diarrhea, or constipation. Family history is significant for a cousin who had liver failure in his forties. His past medical history is unremarkable. He is sexually active with multiple partners and uses condoms intermittently. He admits to 1-2 drinks every month and used to smoke socially during his teenage years. His laboratory values are shown below: Serum: Na+: 138 mEq/L Cl-: 98 mEq/L K+: 3.8 mEq/L HCO3-: 26 mEq/L BUN: 10 mg/dL Glucose: 140 mg/dL Creatinine: 2.1 mg/dL Thyroid-stimulating hormone: 3.5 µU/mL Ca2+: 10 mg/dL AST: 53 U/L ALT: 35 U/L HBsAg: Positive Anti-HBc: Positive IgM anti-HBc: Positive Anti-HBs: Negative What findings would you expect to find in this patient?

usmle-12579

A 23-year-old man comes to his primary care provider after having severe abdominal cramping and diarrhea beginning the previous night. He denies any fevers or vomiting. Of note, he reports that he works in a nursing home and that several residents of the nursing home exhibited similar symptoms this morning. On exam, his temperature is 99.7°F (37.6°C), blood pressure is 116/80 mmHg, pulse is 88/min, and respirations are 13/min. His stool is cultured on blood agar and it is notable for a double zone of hemolysis. Which of the following organisms is the most likely cause?

usmle-12580

A 64-year-old female presents with acute right wrist pain after she lost her balance while reaching overhead and fell from standing height. Her right wrist radiographs shows a fracture of her right distal radius. A follow-up DEXA bone density scan is performed and demonstrates a T-score of -3.5 at the femoral neck and spine. Her medical history is significant for hypertension, for which she is not currently taking any medication. She has not had a previous fracture. Which of the following antihypertensive agents would be preferred in this patient?

usmle-12581

A 31-year-old man presents to neurology clinic for one month of new onset generalized seizures and occasional headaches and nausea. He is well appearing, and has no significant past medical history. He takes no medications. He emigrated from Central America ten months ago where he worked as a pig farmer. Figure A demonstrates a brain MRI with multifocal lesions. Which organism is mostly likely responsible?

usmle-12582

A 50-year-old male presents to the emergency room complaining of fever, shortness of breath, and diarrhea. He returned from a spa in the Rocky Mountains five days prior. He reports that over the past two days, he developed a fever, cough, dyspnea, and multiple watery stools. His past medical history is notable for major depressive disorder and peptic ulcer disease. He takes omeprazole and paroxetine. He does not smoke and drinks alcohol on social occasions. His temperature is 102.8°F (39.3°C), blood pressure is 120/70 mmHg, pulse is 65/min, and respirations are 20/min. Physical examination reveals dry mucus membranes, delayed capillary refill, and rales at the bilateral lung bases. A basic metabolic panel is shown below: Serum: Na+: 126 mEq/L Cl-: 100 mEq/L K+: 4.1 mEq/L HCO3-: 23 mEq/L Ca2+: 10.1 mg/dL Mg2+: 2.0 mEq/L Urea nitrogen: 14 mg/dL Glucose: 90 mg/dL Creatinine: 1.1 mg/dL Which of the following is the most appropriate growth medium to culture the pathogen responsible for this patient’s condition?

usmle-12583

A 5-year-old boy is brought to the pediatrician for anal pain. He and his mother immigrated to the United States from Trinidad and Tobago 3 months ago. The boy reports severe pain with defecation. He is frequently constipated and has approximately 1-2 bowel movements per week. He has seen blood on the toilet paper after wiping multiple times and sometimes feels a need to "push" his anus back inside. More recently, he has been unable to hold his bowel movements and has had 2 episodes of fecal incontinence. His temperature is 99°F (37.2°C), blood pressure is 110/70 mmHg, pulse is 82/min, and respirations are 18/min. On exam, his anus appears normal. However, when asked to strain slightly, a notable finding is shown in Figure A. This patient's condition is associated with which of the following infections?

usmle-12584

A 72-year-old presents to the Emergency Room with hemoptysis. He has smoked 1 pack of cigarettes a day for the past 30 years. Physical examination of the face is shown in Image A and is accompanied by left upper extremity edema. Of the following, which is the most likely cause of the patient’s symptoms:

usmle-12585

A 38-year-old woman presents to her primary care physician after she felt dizzy during a hike at the Grand Canyon with her family. She says that the feeling of dizziness came on suddenly, though she had felt dehydrated and tired for about an hour prior to the event. She has no past medical history and does not take any drugs. She doesn't smoke and drinks sparingly. Physical exam is unrevealing, and both the basic metabolic panel and the complete blood count are unremarkable. EKG is obtained and the results are shown in Figure A. Which of the following coronary arteries supplies the structure that is most likely abnormal in this patient?

usmle-12586

Your test subject is a stout 52-year-old gentleman participating in a study on digestion. After eating a platter of meat riblets and beef strips a test subjects digestive tract undergoes vast hormonal changes. Which of the following changes likely occurred in this patient as a result of the meal?

usmle-12587

A 51-year-old man presents to his primary care provider for recurrent epigastric pain. He reports a 3-month history of gnawing epigastric and chest pain that is worse after meals and after lying down. His past medical history is notable for obesity, hypertension, and hyperlipidemia. He takes lisinopril and rosuvastatin. He has a 30 pack-year smoking history and drinks 4-5 beers per day. On exam, he is well-appearing and in no acute distress. He has no epigastric tenderness. He is prescribed an appropriate medication for his symptoms and is told to follow up in 2 weeks. He returns 2 weeks later with improvement in his symptoms, and a decision is made to continue the medication. However, he returns to clinic 3 months later complaining of decreased libido and enlarged breast tissue. Which of the following medications was this patient most likely taking?

usmle-12588

A 59-year-old woman is scheduled to undergo a right hip total arthroplasty for severe hip osteoarthritis that has failed conservative management. She has never had surgery before. She has a history of major depressive disorder and takes sertraline daily and ibuprofen occasionally for pain. Her mother died of breast cancer and her father died from a myocardial infarction. She has a brother who had an adverse reaction following anesthesia, but she does not know details of the event. In the operating room, the anesthesiologist administers isoflurane and succinylcholine. Two minutes later, the patient develops hypercarbia and hypertonicity of his bilateral upper and lower extremities. Her temperature is 103.7°F (39.8°C), blood pressure is 155/95 mmHg, pulse is 115/min, and respirations are 20/min. A medication with which of the following mechanisms of action is most strongly indicated for this patient?

usmle-12589

A 70-year-old male comes to the emergency department complaining of severe back pain. The pain started 20 minutes ago when he was sitting and watching TV. He describes the pain as intense, epigastric, and radiating to his back. His vitals on presentation to the emergency department are blood pressure is 150/75 mmHg, pulse is 110/min, and respirations are 24/min with an oxygen saturation of 98% on room air. His body mass index is 35 kg/m^2 and he appears pale and in visible pain. On abdominal exam, his abdomen is tender and a pulsatile mass is felt in the midline during deep palpation. His past medical history includes diabetes, hypertension well-controlled on medications, and a history of benign prostatic hyperplasia. His social history is notable for consuming 2-3 beers per night and a smoking history of ½ pack per day. Which of the following is considered the greastest risk factor for this patient’s condition?

usmle-12590

A 55-year-old female with a history of poorly controlled hyperlipidemia and obesity presents to her primary care physician for a follow-up visit. She reports that she feels well and has no complaints. She currently takes atorvastatin. Her temperature is 99°F (37.2°C), blood pressure is 135/80 mmHg, pulse is 80/min, and respirations are 16/min. Her BMI is 31 kg/m2. Her total cholesterol is 290 mg/dl, triglycerides are 120 mg/dl, and LDL cholesterol is 215 mg/dl. Her physician considers starting her on a medication that forces the liver to consume cholesterol to make more bile salts. Which of the following adverse effects is this patient at highest risk of developing following initiation of the medication?

usmle-12591

A 25-year-old woman presents to the clinic with complaints of dysuria and increased urinary frequency. Her urinalysis results are negative for nitrites. Urine microscopy shows the findings in figure A. What is the most likely cause underlying her symptoms?

usmle-12592

An 8-year-old boy presents to the emergency department with intermittent muscle spasms that have been getting worse over the last two days. He is under the growth curve for his age and has had dental problems throughout childhood but is otherwise healthy. Physical exam reveals wrist spasms when a blood pressure is taken as well as shortened 4th and 5th digits. Tapping over the facial nerve elicits contraction of facial muscles. Based on clinical suspicion a panel of calcium tests are obtained. Which of the following combinations of serum calcium and parathyroid hormone (PTH) levels would be most likely in this patient (choices seen in Figure A)?

usmle-12593

A 36-year-old woman is seen in your emergency department complaining of two days of headache, sensitivity to light, and a mildly stiff neck. Her vitals are T 101.4F, P 85, RR 18, and BP 140/80. On examination of the external genitalia, the lesion in Figure A is noted and you decide to perform a lumbar puncture to analyze cerebral spinal fluid (CSF). Which of the following best describes the CSF findings you would expect in this patient?

usmle-12594

A 25-year-old male rugby player presents to the emergency room complaining of a severe headache. He is accompanied by his teammate who reports that he had a head-to-head collision with another player and briefly passed out before regaining consciousness. His past medical history is significant for a pilocytic astrocytoma as a child treated successfully with surgery. His family history is notable for stroke in his father. His temperature is 98.9°F (37.2°C), blood pressure is 160/90 mmHg, pulse is 60/min, and respirations are 20/min. On examination, he is lethargic but oriented to person, place, and time. The affected vessel in this patient directly branches from which of the following vessels?

usmle-12595

A 38-year-old woman is referred to a cardiologist for evaluation of syncope. Over the past year she has experienced 2 syncopal events. The first event occurred while she was standing, and the second when she laid down on her side. She denies bowel or bladder incontinence during the episodes or palpitations. However, she reports the presence of a low-grade fever over the past 3 months and a recent visit to the emergency department for a transient ischemic attack. She has a history of intravenous drug use but reports not having used in over 5 years. Temperature is 100.0°F (37.8°C), pressure is 115/72 mmHg, pulse is 90/min, and respirations are 20/min and regular. A detailed neurologic examination reveals no focal deficits. Cardiac auscultation demonstrates a diastolic "plop" at the cardiac apex. Which of the following findings will most likely be demonstrated on transthoracic echocardiography?

usmle-12596

A 56-year-old woman comes to the emergency room for recurring chest pain lasting 1 day. The pain is described as sharp, 8/10, and concentrated at the left mid-chest region. Her past medical history is significant for hypertension controlled with lisinopril. Her father passed at the age of 59 from a heart attack, and she is worried that she might be having one right now. She denies fever, weight loss, diaphoresis, palpitations, dyspnea, or nausea, but endorses cough, rhinorrhea, and headache for the past week. A physical examination demonstrates a well-appearing woman with an unremarkable exam except for some tenderness upon palpation at the left chest. An electrocardiograph (ECG) is obtained and is shown in Figure A. What is the most likely explanation for this patient’s symptoms?

usmle-12597

A 32-year-old man presents to a mission hospital in Cambodia because he has had difficulty walking from his village to the market. He says that he has always been healthy other than occasional infections; however, over the last year he has been having numbness in his hands and feet. Furthermore, he has noticed weakness, muscle wasting, and pain in his lower extremities. The only change he can remember is that after having a poor harvest last year, he and his family have been subsisting on white rice. Physical exam reveals normal skin color and decreased deep tendon reflexes. The most likely cause of this patient's symptoms is associated with which of the following enzymatic reactions?

usmle-12598

After a year of trying to conceive, a young couple in their early twenties decided to try in vitro fertilization. During preliminary testing of fertility, it was found that the male partner had dysfunctional sperm. Past medical history revealed that he had frequent sinus and lung infections throughout his life. The physician noted an abnormal exam finding on palpation of the right fifth intercostal space at the midclavicular line. What would be the most likely diagnosis responsible for this patient's infertility?

usmle-12599

A 47-year-old female presents to her primary care physician complaining of diarrhea and fatigue. She reports an eight-month history of increasingly frequent diarrhea, fatigue, and muscle weakness. She currently has over 15 episodes of watery diarrhea per day despite fasting. Her past medical history is notable for diabetes that is well controlled with metformin. Her temperature is 98.6°F (37°C), blood pressure is 100/70 mmHg, pulse is 95/min, and respirations are 18/min. Physical examination is notable for mild diffuse abdominal pain and facial flushing. An upper endoscopy is performed and the stomach is found to be less acidic than normal. In addition to correcting this patient’s dehydration, which of the following medications is most appropriate in the management of this patient?

usmle-12600

A 63-year-old male is accompanied by his wife to his primary care doctor complaining of shortness of breath. He reports a seven-month history of progressively worsening dyspnea and a dry non-productive cough. He has also lost 15 pounds over the same time despite no change in diet. Additionally, over the past week, his wife has noticed that the patient appears confused and disoriented. His past medical history is notable for stable angina, hypertension, hyperlipidemia, and diabetes mellitus. He currently takes aspirin, metoprolol, lisinopril, atorvastatin, metformin, and glyburide. He has smoked 1 pack of cigarettes per day for 30 years and previously worked as a mechanic at a shipyard. Physical examination reveals no wheezes, rales, or rhonchi with slightly decreased aeration in the left lower lung field. Mucus membranes are moist with normal skin turgor and capillary refill. Laboratory analysis reveals the following: Na 121 mEq/L K 3.4 mEq/L Cl 96 mEq/L HCO3 23 mEq/L Cr 1.1 mg/dl BUN 17 mg/dl A biopsy of the responsible lesions will most likely demonstrate which of the following findings?

usmle-12601

A 34-year-old woman comes to the fertility clinic with her husband for infertility treatment. The couple has been having unprotected intercourse for the past 2 years without any pregnancies. This is their first time seeking fertility treatment. The patient’s past medical history includes asthma. She denies any menstrual irregularities, menstrual pain, abnormal bleeding or past sexually transmitted infections. The husband reports that “he would get sick easily and would always have some upper respiratory infections.” Physical examination of the wife demonstrates nasal polyps bilaterally; vaginal examination is unremarkable. Physical examination of the husband is unremarkable. Semen analysis results are shown below: Semen analysis: Volume: 1.9 mL (Normal > 1.5 mL) pH: 7.4 (Normal: > 7.2) Sperm concentration: 0 mil/mL (Normal: > 15 mil/mL) Total sperm count: 0 mil/mL (Normal: > 39 mil/mL) Total motility: N/A (Normal: > 40%) Morphology: N/A (Normal: > 4% normal forms) What is the most likely explanation for this couple’s infertility?

usmle-12602

A 3-year-old boy is brought in by his parents to the emergency department for lethargy and vomiting. The patient was fine until this afternoon, when his parents found him in the garage with an unlabeled open bottle containing an odorless liquid. On exam, the patient is not alert or oriented, but is responsive to touch and pain. The patient is afebrile and pulse is 90/min, blood pressure is 100/60 mmHg, and respirations are 20/min. Which of the following is an antidote for the most likely cause of this patient’s presentation?

usmle-12603

A 24-year-old male is brought in by ambulance to the emergency department after he was found unresponsive at home for an unknown length of time. Upon arrival, he is found to be severely altered and unable to answer questions about his medical history. Based on clinical suspicion, a panel of basic blood tests are obtained including an arterial blood gas, which shows a pH of 7.32, a pCO2 of 70, and a sodium bicarbonate level of 30 mg/dl. Which of the following is most likely the primary disturbance leading to the values found in the ABG?

usmle-12604

A forty-five-year-old farmer with past medical history of diabetes, hypertension, and glaucoma comes into your emergency room confused, diaphoretic, salivating, vomiting and shedding tears. He has pinpoint pupils. You conclude that he is showing effects of acute organophosphate poisoning. While administering the antidote, you should carefully monitor for which of the following side effects?

usmle-12605

A 15-year-old female presents to your office for evaluation of a painful neck mass. The family reports the patient has had a midline neck mass for many years, but had become painful over the past week with erythema at the overlying skin. The patient denies subjective fevers at home. The patient has an otherwise unremarkable past medical history. Her temperature is 100.1 deg F (37.8 deg C), blood pressure is 110/70 mmHg, pulse is 90/min, and respirations are 15/min. Clinical exam is seen in Figure A. The mass is noted to rise with deglutition and tongue protrusion. What is the most likely diagnosis?

usmle-12606

A 2-year-old male presents to the emergency department for fatigue and lethargy. Upon presentation, the patient is found to be severely dehydrated. The patient's mother says that he has been having non-bloody diarrhea for a day. She also says that the patient has not received any vaccinations after 6 months and currently attends a daycare center. The responsible microbe is isolated and its structure is analyzed. Which of the following organisms is most likely responsible for the symptoms seen in this child.

usmle-12607

A 65-year-old female patient comes to the physician’s office for her annual check-up. The patient’s only complaint is that she feels her vision has been getting more blurry over the past year. The patient has a past medical history of diabetes diagnosed 20 years ago and osteoarthritis. Her medications include metformin, glimepiride, and ibuprofen as needed for pain. Fundoscopic examination of this patient reveals narrowing of retinal arteries and microaneurysms. This patient’s symptoms are likely caused by tissue specific differences in expression of which of the following enzymes?

usmle-12608

A 78-year-old woman with a history of breast cancer, status-post bilateral mastectomy, presents to the emergency department with progressive difficulty breathing, worsening fatigue, and 5 pounds of unintended weight loss over the past month. A portable chest x-ray reveals a massive right pleural effusion. The ED resident performs thoracentesis with chest tube placement and admits her to the floor. Overnight, the patient requests multiple pain medications for right upper abdominal pain and is found to have increasingly sanguinous drainage. Where was the thoracentesis needle most likely placed?

usmle-12609

A 19-year-old man presents to an orthopedic surgeon to discuss repair of his torn anterior cruciate ligament. He suffered the injury during a college basketball game 1 week ago and has been using a knee immobilizer since the accident. His past medical history is significant for an emergency appendectomy when he was 12 years of age. At that time, he said that he never wanted to have surgery again. At this visit, the physician explains the procedure to him in detail including potential risks and complications. The patient acknowledges and communicates his understanding of both the diagnosis as well as the surgery and decides to proceed with the surgery in 3 weeks. Afterward, he signs a form giving consent for the operation. Which of the following statements is true about this patient?

usmle-12610

A 76-year-old man is brought to the emergency department by his daughter because he has been feeling lightheaded and almost passed out during dinner. Furthermore, over the past few days he has been experiencing heart palpitations. His medical history is significant for well-controlled hypertension and diabetes. Given this presentation, an electrocardiogram is performed showing an irregularly irregular tachyarrhythmia with narrow QRS complexes. The patient is prescribed a drug that decreases the slope of phase 0 of the ventricular action potential but does not change the overall duration of the action potential. Which of the following drugs is consistent with this mechanism of action?

usmle-12611

A 14-year-old boy is brought to his pediatrician complaining of a fever he has had for several days. In addition, he says that he has been getting painful sores in his mouth. He is otherwise healthy though there is a family history of immunodeficiency. He reports that he walked through the woods and drank from a mountain stream on a school field trip a few days before he started developing symptoms. On presentation, his temperature is 101.1°F (38.4°C), blood pressure is 118/73 mmHg, pulse is 87/min, and respirations are 14/min. On physical exam, the boy appears fatigued. He is alert and able to follow instructions. A rash is seen that is shown in Figure A. Which of the following is most consistent with the cause of this patient's disease?

usmle-12612

A 56-year-old man is seen in the hospital for a chief complaint of intense thirst and polyuria. His history is significant for recent transsphenoidal resection of a pituitary adenoma. With regard to the man's fluid balance, which of the following would be expected?

usmle-12613

An 83-year-old male presents to the emergency department with altered mental status. The patient’s vitals signs are as follows: temperature is 100.7 deg F (38.2 deg C), blood pressure is 143/68 mmHg, heart rate is 102/min, and respirations are 22/min. The caretaker states that the patient is usually incontinent of urine, but she has not seen any soiled adult diapers in the past 48 hours. A foley catheter is placed with immediate return of a large volume of cloudy, pink urine. Which of the following correctly explains the expected findings from this patient’s dipstick urinalysis?

usmle-12614

A 27-year-old man presents to his primary care provider with low back pain. He has not been to the physician in 6 years. He reports the gradual onset of non-radiating low back pain that started 2 years ago and has progressively worsened over that time. He denies any inciting injury. His pain is worse in the morning and is accompanied by stiffness that improves throughout the day. He has been taking ibuprofen intermittently to treat his pain. He drinks alcohol socially and has a 5 pack-year smoking history. On exam, he is well-appearing and in no acute distress. Palpation of his lumbar vertebral spines elicits no pain. Spine flexion and extension are slightly limited. A radiograph of the patient’s pelvis is shown in Figure A. This patient is at an increased risk of developing which of the following?

usmle-12615

A healthy 36-year-old Caucasian man takes part in an experimental drug trial. The drug is designed to lower glomerular filtration rate (GFR) while simultaneously raising the filtration fraction. Which of the following effects on the glomerulus would you expect the drug to have?

usmle-12616

A 46-year-old man presents to the clinic complaining of fatigue and difficulty breathing for the past month. He reports that it is particularly worse when he exercises as he becomes out of breath at 1 mile when he used to routinely run 3 miles. He is frustrated as he was recently diagnosed with diabetes despite a good diet and regular exercise. He denies any weight changes, chest pain, or gastrointestinal symptoms. When asked about other concerns, his wife complains that he is getting darker despite regular sunscreen application. A physical examination demonstrates a tanned man with an extra heart sound just before S1, mild bilateral pitting edema, and mild bibasilar rales bilaterally. An echocardiogram is ordered and shows a left ventricular ejection fraction (LVEF) of 65% with reduced filling. What is the most likely explanation for this patient’s condition?

usmle-12617

A 28-year-old woman with a history of migraines presents to your office due to sudden loss of vision in her left eye and difficulty speaking. Two weeks ago she experienced muscle aches, fever, and cough. Her muscle aches are improving but she continues to have a cough. She also feels as though she has been more tired than usual. She had a similar episode of vision loss 2 years ago and had an MRI at that time. She has a family history of migraines and takes propranolol daily. On swinging light test there is decreased constriction of the left pupil relative to the right pupil. You repeat the MRI and note enhancing lesions in the left optic nerve. Which of the following is used to prevent progression of this condition?

usmle-12618

A 32-year-old previously healthy female presents to her primary care physician with double vision. She first noted the double vision yesterday and saw no improvement this morning. She does not think it is worsening. She has not had any changes in her normal routine though she recalls one episode of right arm weakness 2 months ago. She did not seek treatment and the weakness subsided after several days. She does not have a history of head trauma. She denies headache, fever, chills, nausea, vomiting, paresthesias, extremity pain, or weakness. On exam she has right adduction palsy on leftward gaze. She has no focal weakness. Which of the following additional physical exam findings is associated with the lesion responsible for her ocular findings?

usmle-12619

A 21-year-old woman makes an appointment with a geneticist for counseling after finding out that she is pregnant with her first child. Specifically, she is worried because she has a 13-year-old brother who has been experiencing progressive muscle weakness since childhood. He is now attending middle school and uses a power wheelchair to get around. He also requires bilateral leg braces as well as a thoracolumbar brace because he is unable to hold his body upright in the wheelchair without restraints. She says that she remembers her brother using the method shown in Figure A to stand up when he was still able to walk. Though she is very close to her brother, she is worried that her child will also have the same disorder. She does not yet know the sex of the child, and her husband does not have the mutated gene. What is the probability that her child will be affected by this disorder?

usmle-12620

A 40-year-old male is brought into the emergency department as the unrestrained passenger in a motor vehicle collision. On presentation he is obtunded with multiple ecchymoses on his chest and abdomen. There is marked distortion of his left lower extremity. His blood pressure is 90/64 mmHg, pulse is 130/min, and respirations are 24/min. Physical exam is limited by the patient’s mental state. The patient appears to be in pain while breathing and has tenderness to palpation of the abdomen. Neck veins are distended. Auscultation of the lungs reveals absent breath sounds on the left and hyperresonance to percussion. An emergent procedure is done and the patient improves. Had a chest radiograph of the patient been obtained on presentation to the ED, which of the following findings would most likely have been seen?

usmle-12621

A 48-year-old female with hypertension and diabetes presents with severe chest pain. She describes the pain as sharp at the mid-sternum without radiation. The chest pain has occurred three times in the past week, each time while at rest. She does note episodes of chest discomfort while eating and drinking. The patient's vital signs are as follows: T 98.7, P 89, BP 132/78, RR 14, SpO2 98% RA. Cardiac markers are within normal limits. Electrocardiogram is as follows (Figure A). Stress test is normal. Which of the following would most likely yield the diagnosis of this patient's chest pain?

usmle-12622

A 1-year-old African American boy is brought to urgent care by his mother. The boy has been inconsolably crying all day. His mother noticed that his hands appeared swollen (Figure A). The family recently moved to the area and now live in a house built in 1981. The boy's older brother has had repeated salmonella osteomyelitis. Which of the following is the most likely underlying defect?

usmle-12623

A 21-year-old female presents to her psychiatrist for ongoing management of major depressive disorder. She has previously tried cognitive behavioral therapy as well as selective serotonin reuptake inhibitors, but neither treatment has been very effective. She also states that she has been smoking two packs per day for the last three months and would like to stop smoking. Based on these concerns, her psychiatrist prescribes a medication that addresses both depression and smoking cessation. Which of the following if present, would be a contraindication for the drug that was most likely prescribed in this case?

usmle-12624

A 45 year-old gentleman presents to his primary care physician complaining of wrist pain and is diagnosed with carpal tunnel syndrome. Upon further questioning, the patient admits that he has recently been outgrowing his gloves and shoes and has had to purchase a new hat as well due to increased head size. Upon exam, he is found to have new mild hypertension and on basic labs he is found to be hyperglycemic. Which of the following is the best blood test to diagnose his suspected disorder?

usmle-12625

A 55-year-old man presents to the emergency department for chest pain. He states that the pain started last night and has persisted until this morning. He describes the pain as in his chest and radiating into his back between his scapulae. The patient has a past medical history of alcohol abuse and cocaine abuse. He recently returned from vacation on a transatlantic flight. The patient has smoked 1 pack of cigarettes per day for the past 20 years. His temperature is 99.5°F (37.5°C), blood pressure is 167/118 mmHg, pulse is 120/min, and respirations are 22/min. Physical exam reveals tachycardia and clear air movement bilaterally on cardiopulmonary exam. Which of the following is also likely to be found in this patient?

usmle-12626

A 33-year-old woman presents to her primary care provider for a normal check-up. She reports she has been feeling intermittently fatigued over the past 3 months, but she attributes it to her work as a corporate lawyer and balancing family life. She is otherwise healthy and takes no medications. She was adopted and has no information about her biological family. She has 2 children and has been married for 7 years. She drinks 4-5 glasses of wine per week and does not smoke. Her temperature is 99.2°F (37.3°C), blood pressure is 125/65 mmHg, pulse is 78/min, and respirations are 18/min. On exam, she is well-appearing and in no acute distress. A complete blood count is within normal limits. Additional workup is shown below: Serum: Na+: 139 mEq/L Cl-: 99 mEq/L K+: 3.9 mEq/L HCO3-: 23 mEq/L BUN: 18 mg/dL Glucose: 110 mg/dL Creatinine: 1.1 mg/dL Ca2+: 11.1 mg/dL Parathyroid hormone: 700 pg/mL Urine: Na+: 100 mEq/L/24h Ca2+: 100 mg/24h Osmolality: 400 mOsmol/kg H2O Which of the following is the most likely underlying cause of this patient's condition?

usmle-12627

A 48-year-old homeless male presents to the ED because he hasn’t felt well recently. He states that he has been feeling nauseous and extremely weak over the past few days. He has several previous admissions for alcohol intoxication and uses heroin occasionally. His temperature is 100.9°F (38.3°C), blood pressure is 127/89 mmHg, and pulse is 101/min. His physical examination is notable for palmar erythema, tender hepatomegaly, and gynecomastia. His laboratory findings are notable for: AST: 170 U/L ALT: 60 U/L GGT: 400 (normal range: 0-45 U/L) Alkaline phosphatase: 150 IU/L Direct bilirubin: 0.2 mg/dL Total bilirubin: 0.8 mg/dL WBC: 10,500 Serum iron: 100 µg/dL TIBC: 300 µg/dL (normal range: 250–370 µg/dL) Serum acetaminophen screen: Negative Serum AFP: 6 ng/mL (normal range: < 10ng/mL) Which of the following is the most likely cause of this patient’s symptoms?

usmle-12628

A 42-year-old male presents to his primary care physician complaining of fatigue. He has not been to the doctor since he was 22 years of age. He reports that over the past three months, he has felt tired and weak despite no changes in diet or exercise. He is otherwise healthy and takes no medications. Family history is notable for colorectal cancer in his father and paternal uncle, ovarian cancer in his paternal grandmother, and pancreatic cancer in his paternal uncle. Physical examination is notable for conjunctival pallor. A complete blood count reveals a hemoglobin of 9.1 g/dL and hematocrit of 31%. A stool sample is hemoccult positive and a colonoscopy reveals a fungating hemorrhagic mass in the ascending colon. Which of the following processes is most likely impaired in this patient?

usmle-12629

A 67-year-old man comes to the clinic for establishment of care. He recently retired and moved to Florida with his wife. His past medical history includes hypertension, diabetes, chronic back pain, and hyperlipidemia. According to the patient, he takes lisinopril, metformin, atorvastatin, acetaminophen, and methadone. His previous doctor prescribed methadone for breakthrough pain as he has been having more severe pain episodes due to the recent move. He is currently out of his methadone and asks for a refill on the prescription. A physical examination is unremarkable except for mild lower extremity edema bilaterally and diffuse lower back pain upon palpation. What is the best initial step in the management of this patient?

usmle-12630

A 74-year-old man comes to the attention of the inpatient hospital team because he started experiencing shortness of breath and left-sided back pain 3 days after suffering a right hip fracture that was treated with hip arthroplasty. He says that the pain is sharp and occurs with deep breathing. His past medical history is significant for diabetes and hypertension for which he takes metformin and lisinopril. On physical exam, he is found to have a friction rub best heard in the left lung base. His right calf is also swollen with erythema and induration. Given this presentation, which of the following most likely describes the status of the patient's lungs?

usmle-12631

A 46-year-old male with a history of recurrent deep venous thromboses on warfarin presents to his hematologist for a follow-up visit. He reports that he feels well and has no complaints. His INR at his last visit was 2.5 while his current INR is 4.0. His past medical history is also notable for recent diagnoses of hypertension, hyperlipidemia, and gastroesophageal reflux disease. He also has severe seasonal allergies. He reports that since his last visit, he started multiple new medications at the recommendation of his primary care physician. Which of the following medications was this patient likely started on?

usmle-12632

A 59-year-old man presents to the emergency department with a 6 day history of persistent fevers. In addition, he has noticed that he feels weak and sometimes short of breath. His past medical history is significant for congenital heart disease though he doesn't remember the specific details. He has been unemployed for the last 3 years and has been occasionally homeless. Physical exam reveals nailbed splinter hemorrhages and painful nodes on his fingers and toes. Blood cultures taken 12 hours apart grow out Streptococcus gallolyticus. Which of the following is most likely associated with this patient's disease?

usmle-12633

An 8-year-old boy is brought to the pediatric emergency department by his parents with a complaint of abdominal pain and diarrhea for the past week. He states that for the past two days, he has noticed blood in his stool. His parents note that they attended a neighbor’s barbecue last weekend, but otherwise have not eaten any new foods or changed their usual diet. The patient is admitted to the hospital unit for further work-up. The provider team finds that the patient’s blood is positive for Shiga-like toxin and notes the following lab values: creatinine of 4.2 mg/dL, platelet count of 50,000/mm^3, and hemoglobin of 6.0 g/dL. Which of the following additional lab findings would be consistent with the diagnosis?

usmle-12634

A 35-year-old female presents to her primary care physician complaining of right upper quadrant pain over the last 6 months. Pain is worst after eating and feels like intermittent squeezing. She also admits to lighter colored stools and a feeling of itchiness on her skin. Physical exam demonstrates a positive Murphy's sign. The vitamin level least likely to be affected by this condition is associated with which of the following deficiency syndromes?

usmle-12635

A 25-year-old woman comes to the office complaining of pelvic pain and feeling “off” for the past few weeks. She has not had any changes in diet or lifestyle but reports weight loss despite an increase in appetite. In addition, she has been experiencing chest palpitations, increased frequency of diarrhea, and heat intolerance. Physical exam of her thyroid is unremarkable but her TSH was found to be 0.21 mIU/L. A complex structure in her right ovary was detected on ultrasound. Her symptoms can be explained by which of the following?

usmle-12636

A 15-year-old male comes to the clinic with complaints of intermittent episodes of jaundice. The episodes self-resolve within a few days, and he can’t seem to find any triggering events. The patient is otherwise healthy with no past medical history and no other symptoms. He does not use tobacco, alcohol, or other illicit drugs. Preliminary work-up reveals the complete blood count below: Leukocyte count: 5,000/mm^3 Hemoglobin 14.3 g/dL Erythrocyte count 4.8 million/mm^3 Platelets 150,000/mm^3 Routine blood work does not lead to a diagnosis so the patient undergoes a liver biopsy. His liver biopsy is shown in Figure A. Which of the following laboratory abnormalities would be expected in this patient?

usmle-12637

A 41-year-old African American woman presents to her primary care physician with a 3-week history of lower extremity edema and shortness of breath. She says that she has also noticed that she gets fatigued more easily and has been gaining weight. Her past medical history is significant for sickle cell disease and HIV infection for which she is currently taking combination therapy. Physical exam is significant for periorbital and lower extremity edema. Laboratory testing is significant for hypoalbuminemia, and urinalysis demonstrates 4+ protein. Which of the following would most likely be seen on kidney biopsy in this patient?

usmle-12638

A 2-year-old, previously healthy female presents to the emergency department complaining of 7 hours of 10/10 intermittent abdominal pain, vomiting, and dark red stools. On exam, there is tenderness to palpation in the right lower quadrant and high-pitched bowel sounds. Technetium-99m pertechnetate scan was performed (Image A). Which of the following is true about this patient's condition?

usmle-12639

A 26-year-old man with HIV and a recent CD4+ count of 800 presents to his PCP with fever, cough, and dyspnea. He notes that he recently lost his job as a construction worker and has not been able to afford his HAART medication. His temperature is 102.6°F (39.2°C), pulse is 75/min, respirations are 24/min, and blood pressure is 135/92 mmHg. Physical exam reveals a tachypneic patient with scattered crackles in both lungs, and labs show a CD4+ count of 145 and an elevated LDH. The chest radiography is notable for bilateral diffuse interstitial infiltrates. For definitive diagnosis, the physician obtains a sputum sample. Which stain should he use to visualize the most likely responsible organism?

usmle-12640

A 54-year-old man is brought to the emergency department after being found wandering the streets during a snowstorm. This patient is well known to the emergency department for being a “frequent flyer” due to his history of alcohol abuse. When asked why he was outside, he claims that he was trying to find his mother. However, his medical records show that his mother passed away 5 years ago from a myocardial infarction. His blood alcohol content is measured at 0.05%. Physical examination reveals a flat affect, and skin findings on his abdomen are shown in Figure A. What other findings would you expect in this patient?

usmle-12641

A 36-year-old G1P0 woman presents to the emergency department in labor. She is an immigrant from Romania and did not receive any prenatal care. She reports that her pregnancy has been uneventful and denies any family history of illnesses. After 8 hours of active labor, her child was delivered vaginally. Figure A shows her baby. What is most likely mechanism of her child’s condition?

usmle-12642

An 86-year-old male with a history of hypertension and hyperlipidemia is sent to the hospital from the skilled nursing facility due to fever, confusion, and decreased urine output. Urinalysis shows 12-18 WBC/hpf with occasional lymphocytes. Urine and blood cultures grow out gram-negative, motile, urease positive rods. What component in the identified bacteria is primarily responsible for causing the innate immune response seen in this patient?

usmle-12643

A 44-year-old man presents to his primary care physician due to a shock-like pain in his left leg. He describes the pain as sharp and lasting a few minutes at a time. He has noticed being "clumsy" when walking in a dark room. Approximately 2 weeks ago, he was helping his daughter move and this required him to lift heavy boxes. He denies any trauma to the back or lower back pain. Medical history is significant for hypertension, hyperlipidemia, and type 2 diabetes mellitus. He is currently sexually active and is in a monogamous relationship with his wife. Approximately 15 years ago, he noted a painless genital lesion. On physical exam, there is a miotic pupil that does not constrict with light but constricts with convergence and accommodation. Strength, reflex, and sensory exam of the lower extremity is unremarkable. The patient has a positive Romberg test. Which of the following is most likely the cause of this patient's symptoms?

usmle-12644

A 46-year-old man presents to his primary care provider for an ulcerating skin lesion on his leg for the past week. He says that the week prior he slipped while hiking and scraped his left leg. Over the course of the next week, he noticed redness and swelling of the scraped area and the development of a nodule that eventually ulcerated. On exam, his temperature is 99.5°F (37.5°C), blood pressure is 136/92 mmHg, pulse is 88/min, and respirations are 12/min. Over his left lateral leg is an erythematous patch with a 2-cm nodule with central ulceration. Staining of a sample from the nodule demonstrates gram-positive organisms that are also weakly acid-fast. Morphologically, the organism appears as branching filaments. Which of the following should be used to treat this infection?

usmle-12645

A 50-year-old woman returns from a family trip to the Caribbean with three days of fever, watery diarrhea, and vomiting. She states that she tried to avoid uncooked food and unpeeled fruits on her vacation. Of note, her grandson had caught a cold from daycare prior to the trip, and she had been in close contact with the infant throughout the trip. She denies rhinorrhea or coughing. On exam, her temperature is 99.1°F (37.3°C), blood pressure is 110/68 mmHg, pulse is 113/min, and respirations are 12/min. Her stool culture is negative for bacteria. Which of the following describes the most likely cause?

usmle-12646

A 35-year-old man is transferred to the intensive care unit after a motorcycle accident. He does not open his eyes with painful stimuli. He makes no sounds. He assumes decerebrate posture with sternal rub. His right eye is abnormally positioned downward and outward and has a dilated pupil which is not responsive to light. In contrast to this patient's findings, one would expect a patient with a diabetic mononeuropathy of the oculomotor nerve to present in which fashion?

usmle-12647

A 34-year-old woman comes to the clinic complaining of numbness and tingling of her right arm for 2 days. She reports that she was washing dishes when she felt a burning sensation along her right forearm. The patient has been relatively healthy except for an episode of right eye pain and vision loss 4 years ago. She does not recall specific details but claims that “it just went away on its own after a couple of days.” The patient denies any recent travel, trauma, loss of consciousness, speech changes, weakness, or vision change but does endorse gastroenteritis about 1 week ago. She is sexually active with multiple partners and rarely uses contraception. Her last HIV testing 2 weeks ago was negative. A magnetic resonance image (MRI) of her brain is shown in Figure A. What is the most likely explanation for this patient’s symptoms?

usmle-12648

A 12-year-old female with no past medical history is found to have an abnormal cardiovascular exam during routine physical examination at her pediatrician’s office. All other components of her physical exam are normal. During evaluation for potential causes for her abnormal exam, an echocardiogram with doppler is done that shows flow between the atria. Which of the following would would have most likely been auscultated as a result of the pathology on her echocardiogram?

usmle-12649

A 7-year-old boy is brought to the emergency room by his father for fever and sore throat lasting 2 days. The patient reports that “my throats hurts as if I am swallowing glass.” He feels “hot” and reports that he sweats through his pajamas at night. His father gave him some acetaminophen yesterday, but it did not seem to help. During his shower yesterday, the patient noticed some “red dots” on his arms that do not itch or hurt. His past medical history is unremarkable and he is up to date on all his vaccinations. Physical examination reveals a soft, musical murmur at the left lower sternal border that is louder in the supine position. His arms and torso show a fine, erythematous rash that blanches with pressure. A picture of his tongue is shown in Figure A. What is the most likely pathophysiology of this patient’s condition?

usmle-12650

A 65-year-old alcoholic male had been taken to the emergency room after he was found unconscious covered in vomitus. After regaining consciousness, he complained of a constant productive cough with foul-smelling sputum for the past few weeks. A chest x-ray(Image A) was taken and the patient was treated accordingly. The patient comes to you today complaining of watery diarrhea. Which best describes the pathogen causing diarrhea?