A 48 year-old-male goes to his physician with several types of movement disorders that have been developing over time. His bilateral jerking, chorea-like movements of his limbs was getting worse. He was having trouble with gait and balance. His family noticed that he was having trouble focusing and not able to take care of his personal daily needs. His personality had become more aggressive and demanding. The MRI would more likely show cellular degeneration in which of the following?

A 71 year old male presents to the emergency room with complaints of the sudden onset of severe chest pain 2 hours prior. The pain is sharp in nature and radiates into the back.  On a scale of 1-10 he states his pain started as a 7 but has progressed to a 10. The patients thinks that he is able to get mild relief when in the fetal position.  Past history is notable for hypertension, which is being treated with 2 medications.

Vital signs: Temperature: 98.9 F; HR: 102 /min; RR: 16 /min; SpO2: 96% on room air

1. BP (right arm): 92/71 mmHg
2. BP (left arm): 134/93 mmHg

Physical examination: Examination of the thorax is non-contributory with no murmurs, JVD or lung crackles. There is a decrease in the radial pulse.

Chest x-ray (representation)

Based on the findings, transesophageal echocardiogram (TEE) will most likely show (a)

A 64 year old female presents to her physician because she is developing swelling in her feet and ankles that worsens through the day. She has been on medications for her type II diabetes mellitus for 30 years. She is otherwise well.

Vital signs: BP: 126/84 mmHg; HR: 87 /min; RR: 15 /min; Temperature: 99.1 F; SpO2: 95% on room air.

Physical examination: There is 2+ pitting edema to the ankles. There is no murmur, S3 or JVD. No splenomegaly or ascites is found on the abdominal examination. Skin is normal for age, without palmar erythema or spider angiomata.

Laboratory testing:

1. Urinalysis:
   1. Specific gravity: 1.024
   2. Protein: 4+
   3. Hemoglobin: negative
   4. Leukocyte esterase: negative
   5. Nitrites: negative
   6. Sediment: no cell or cast seen

In view of the history and laboratory findings, the most likely pathology would be found at which number?

A 32-year-old racecar driver suffered severe pelvic trauma during a major car accident. Several days later the driver was having difficulty contracting the bladder. Which of the following could have been damaged during the car accident?

A 39-year old female visits her primary care physician because of worsening fatigue and decreased energy. These symptoms have been progressive over the last three months and she also has occasional nausea and vomiting as well as nonspecific abdominal pain.

Vital signs: Blood pressure 79/53 mmHg, RR-19/min, Temper – 98 degrees Fahrenheit.

Physical examination reveals a thin female with little animation. There is darkening of lips and gingiva.

Serum electrolytes:

1. Sodium……….116 mEq/L
2. Potassium……6.8 mEq/L.
3. Chloride………121 mEq/L
4. Bicarbonate….21 mEq/L

Which of the following would be the expected treatment for the most likely diagnosis?

A 57-year-old man comes to the physician for a follow-up examination. Two months ago, his blood pressure was 156/87 mm Hg. His average blood pressures range between 138/83 mm Hg to 159/95 mm Hg. The patient was started on a diuretic. His blood pressure on arrival to the clinic today is 147/85 mm Hg.

The doctor decides to start him on additional pharmacotherapy with captopril. Administration of this drug is most likely to result in decreased activity of which of the following regions of the adrenal gland?

A mother brings her 2-year old son to see his physician for a follow-up visit after his recent hospitalization for Pneumocystis pneumonia. He has had recurrent sinusitis for the past year. When he was 6 months old, he had CMV hepatitis, which required treatment with anti-viral medications.

Laboratory testing shows increased IgM immunoglobulin and deceased IgG, IgA and IgE. T lymphocyte and B lymphocyte levels are normal.

Based on the findings, the most likely defect is a

A 3-year-old boy is evaluated for unexplained recurrent infection. Pregnancy and delivery were both uneventful. His umbilical cord separated on day 35.Within that last 2 months he has had otitis media and multiple skin infections that clear up after antibiotic usage.  Examination of the skin infections revealed bacterial but no pus formation.

1. Hemoglobin: 13.7
2. MCV: 76 fL
3. Platelets: 176 /mm^3
4. Neutrophils: 22,000/mm^3

The patient’s neutrophils most likely lack what protein?

The vessel labeled “3” in the attached radiograph supplies oxygen to which of the following structures?

A 9-year-old boy is brought to the physician by his mother. She explains to the doctor that her son has been bleeding into his right knee joint since he fell off the sidewalk several hours ago. His uncle has some sort of blood disorder, but she does not know the diagnosis.

Laboratory studies:

1. Platelet count: 200,000/mm^3
2. Partial thromboplastin time: 52 seconds
3. Prothrombin time: 13 seconds.

A single-stage clotting assay shows a decrease in factor VIII.

A 65-year-old woman presents to her doctor because she has developed masses in her right axilla and left neck. She feels otherwise well.

Vital signs: normal

A physical exam is unremarkable except for lymphadenopathy in her right axilla (4.5 cm) and left anterior neck (5.2 cm). The nodes are rubbery to palpation.

A lymph node biopsy is performed. The low power lymph node architecture is seen in the image and the immunohistochemical staining results are seen in the table.

The pathophysiology of the neoplasm is due to

A patient has developed progressive movement disorders in his right upper and lower limbs over the recent months.  The gait is affected in the lower limb, tending to fall to the right when walking. The upper limb demonstrated tremor while trying to make planned movements. Which additional observation can be seen in this patient?

A 32 year old female presents to the clinic because of pain in her hands. She works as a secretary, but has had increased difficulty with her because of numbness and pain in her arms and fingers. The symptoms get worse with increased use. She has been feeling generally unwell for 1-2 months, with malaise, unplanned weight loss and occasional mild fevers.

Vital signs: Temperature: 99.6 F; HR: 99 /min; RR: 17 /min; SpO2: 97% on room air

1. BP (right arm): 73/45 mmHg
2. BP (left arm): 89/52 /mmHg

Physical examination: There are bilateral bruits heard over the right supraclavicular region and sternal notch. There are decreased radial pulses.

If tissue became available from an affected region, it would most likely show

A 23-year-old female presents to the clinic because she has an itchy vaginal discharge. She describes discomfort when urinating. She is sexually active with multiple partners and does not use protection.

External genitals are unremarkable. The pelvic exam reveals yellowish purulent discharge from the endocervical canal. Cervical motion tenderness is negative.

If nucleic acid amplification testing suggests a gram negative organism, the most likely infecting organism would be

A 41 year old male presents to his physician’s office because he is getting too short of breath to keep up on group rides with his bicycling club. He has noticed progressive difficulty over the past 6 months. Past medical history is unremarkable, with no history of childhood illnesses or other problems. He drinks in moderation and denies illegal drug use and smoking.

Vitals signs: Temperature: 98.9 F; RR: 16 /min; HR: 84/min; BP: 128/78 mmHg; SaO2: 96% on room air

Physical examination is unremarkable.

Pulmonary function testing:

1. FEV1/FVC ratio (without bronchodilator):   64%
2. FEV1/FVC ratio (with bronchodilator):         63%
3. DLCO:   58% predicted

The most likely underlying pathology is

An 18-year-old female presents to her physician’s office complaining of a fever, headache, muscle aches, and a non-productive cough. Physical examination is unremarkable, but a chest X-ray shows extensive reticular-nodular infiltrates of the right lung. A respiratory panel of a nasopharyngeal swab is positive for M. pneumoniae and she has been prescribed azithromycin.  10 days later, the patient presents again, feeling that her pneumonia is better, but concerned that when she goes outside in the cold weather, she gets pain in her fingertips and nose tip, which both turn blue.

Laboratory testing:

1. Serum LDH: elevated
2. Coombs test: positive

The patient’s late symptoms and findings are most likely mediated by

The CDC recommends routine administration of pneumococcal polysaccharide vaccine (PPSV23) for all adults 65 years or older. The key immune function that is increased by this vaccination is

During the inoculation of a pathogen, the innate immune response increases the granulocyte migration into the tissue through what function?

A newborn male is evaluated 2 hours after birth with an abnormal foreskin on the ventral penile curvature. Several hours later it is noted that urine is leaking from the orifice seen in the image.

The malformation is due to

A 66 year old female presents to her physician for progressive shortness of breath over the past 3 months. She notes that she used to be able to walk her dog through the local park in 45 minutes, but now it takes her one hour and she has to stop to “catch her breath” on the hills. She has been otherwise well, but for a long-standing morning cough of several tablespoons of yellow mucus each morning that she attributes to her smoking. She has a 62 pack-year history of cigarette smoking.

Vital signs: normal

Physical examination: normal

Pulmonary function testing:

1. FEV1: 81%
2. FVC: 84% predicted
3. DLCO: 62% predicted

Chest X-ray: normal

The patient findings suggest an abnormality in

Interruption of the thalamic fibers that project to the superior temporal gyrus would indicate damage to which of the following thalamic nuclei?

A 27-year-old gravida 1 para 1 female presents to her obstetrician’s office 6 months after delivery with complaints of fatigue, anorexia, loss of sexual hair loss and a failure to resume menstruation. She did not try to breastfeed her child. She received adequate prenatal care. During labor, she had a large enough postpartum hemorrhage to require transfusion.

Vital signs: normal

Physical examination: non-diagnostic.

The most likely explanation for this patients’ current complaints is

Cancer causes about 600,000 deaths/year in the United States. What single public health measure would have the biggest effect on decreasing the commonest cause of cancer death?

A young married couple is trying to conceive for 12 months. They are both well and have no known problems. The male is 28 years old; the female is 26 years old. What urine test could they use to optimally time intercourse for the desired pregnancy?

A 32-year-old female presents to her gynecologist’s office with complaints of vaginal burning and itching for the last week. She is experiencing pain when urinating. She is otherwise healthy and takes birth control pills. She has recently become sexually active with a new partner and does not uses condoms.

On physical exam, malodorous yellow-green vaginal discharge is noted. The vaginal pH is 4.9. The cervix and vagina appear inflamed.

The most likely organism causing this patient’s symptoms is

A 34-year old nulliparous female presents to her gynecologist’s office for infertility. She and her husband have had unprotected sex for the past year and have been unable to conceive.  She has regular menses every 28- 30, with bleeding lasting 2-3 days. Her menses are accompanied by pelvic and abdominal pain that starts just before the onset of her period and lasts throughout menses. Her menarche started at age 12. She also notes that she finds intercourse to be uncomfortable with deep penetration.

Physical examination shows normal external genitalia. Bimanual pelvic examination reveals a normal-sized uterus with a 6 cm adnexal mass on the left side.

Ultrasound of the mass shows a  5.7 cm. homogeneous, hypoechoic cyst with diffuse low-level echoes consistent with altered blood.

Confirmation of the most likely diagnosis could best be made by (a)

A 62-year-old man presents to his primary care physician with swelling of his legs for the past month. He notes that his urine has been foamy for a few months now as well. The patient has a 20-year history of type 2 diabetes mellitus and hypertension. Medications include metformin and hydrochlorothiazide.

Vital signs:  blood pressure is 150/92 mm Hg.

Physical examination shows pitting edema to the ankles. Heart and lung auscultation are unremarkable There is no JVD.

Laboratory testing:

1. Serum chemistry:
   1. Glucose: 230 mg/dL
   2. BUN: 60 mg/dL
   3. Creatinine: 2.4 mg/dL
2. HbA1c: 8.5%
3. Urinalysis:
   1. Hemoglobin: negative
   2. Protein: 4+
   3. Leukocyte esterase: negative
   4. Nitrites: negative

A patient is admitted to the ICU due to a thrombotic event that occluded the distal left anterior descending coronary artery. He was not a candidate for fibrinolytic therapy, but percutaneous intervention was available. Five days into recovery the attending physician suspects a recurrent infarction based on new onset of signs and symptoms. What diagnostic test would correlate a second infarction best?

A 34-year-old female is in a motor vehicle accident with significant internal injuries and blood loss. When the EMTs arrive the patient’s vital signs are: heart rate 122 /min; BP 96/44 mmHg.

The tachycardia is due to the sympathetic stimulation of the SA node cells at what level?

B1 receptor antagonist is the mechanism of action for which drug?

A 15-year-old Asian female is brought into the clinic by her parent because she has failed to start menstruation.

Vitals signs: BP: 153/91 mmHg; HR: 91 /min; RR: 16 /min; Temperature: 98.8 F; SpO2: 97%

General examination shows a short, stocky girl with breast development, but little pubic hair (Tanner stage 2).  She is in the 30th percentile in height.  Auscultation of the heart reveals an ejection click best heard at the lower left sternal border followed by a soft ejection murmur. There are strong radial pulses with delayed, smaller pedal pulses.

1. Blood pressure (leg): 109/64 mmHg

The most likely etiology of the cardiovascular findings is

A 78-year-old male presents to his physician because he has had several near syncopal events over the past few months when exerting himself. He has otherwise been well. He does not smoke or take illegal drugs and drinks alcohol in moderation.

Vital signs: BP: 121/78 mmHg; HR: 84 min; RR: 16 min; Temperature: 98.3 F; SpO2: 96% on room air

Physical examination: There is a murmur best heard in the right 2nd intercostal space, represented in the image.

Which of the following findings on the physical examination would help confirm the most likely diagnosis?

A 26-year-old man presents to the emergency department because of sharp back pain. He has experienced this before, but it usually corrects on its own. He notices that he is yellow and his urine appears darker than normal. He immigrated from Sicily 3 years ago. He has recently started on primaquine as he is traveling to Africa.

Vital signs: Temperature is 98.7 degrees Fahrenheit, pulse is 81/min, and blood pressure is 120/80.

Laboratory studies show:

CBC:

1. Hematocrit: 27%
2. MCV: 98 fL
3. Leukocyte count: 8500/mm^3
4. Platelet count: 300,000/mm^3

Chemistry:

1. Serum bilirubin
   1. Total: 5 mg/dL
   2. Direct: 0.4 mg/dL
2. Haptoglobin: 11 mg/dL (N= 41-165 mg/dL)

The most likely cause of the patient’s anemia is

A 19-year-old man visits his physician because he has noticed that his urine is episodically brown in color. He is currently training for a triathlon and is running 20 miles on the weekend. He notices that the urine color change occurs early in the week after weekends with running. He follows a vegan diet and appears well.

Vital signs: Temperature is 98.9°F, blood pressure is 110/79 mm Hg, pulse is 53/min, and respiratory rate is 12/min.

Physical examination shows no abnormalities.

Laboratory testing (on Tuesday):

CBC:

1. Hemoglobin: 14.3 g/dL
2. Mean Corpuscular Volume: 92 fL

Chemistry:

1. Lactate dehydrogenase: 401 U/L
2. Haptoglobin: 22 (N= 41-165 mg/dL)
3. Serum Iron: 91 mg/dL
4. Serum ferritin: 173 ng/mL
5. TIBC: 215 (N= 251-406 mg/dL)

Urinalysis:

1. Dipstick: trace hemoglobin
2. Sediment: normal

The next best test to confirm the likely diagnosis is?

Prions are infectious proteins that cause the production of subacute spongiform encephalopathies. They are variants of normal cellular proteins, which have a predilection for depositing extracellularly in a β-pleated sheet configuration, and then causing changes in normal cellular homologs to deposit with them and build up an impermeable matrix.  Considering the engineering design of the immune response, can you predict the FIRST point at which immunity will be absent from the lesions of such amyloidopathies?

A 7-year-old girl is brought to the Emergency Department with swelling of her right arm and difficulty breathing. She was hiking with her parents, received scratches from brush on her arms, and her parents became alarmed when the swelling of the scratches progressed to shortness of breath. Subcutaneous epinephrine and diphenhydramine are administered with little effect. Which of the following lab results would be expected in her blood work?

A 14-year old adolescent male is admitted to the ER because he becomes weak and confused on a school outing, Friends who are with him state that he was complaining of trouble reading the signs on the trail as his vision was blurry. He has been recently diagnosed with type I diabetes. He is known to skip taking his insulin as he finds it embarrassing to inject himself in front of his classmates.

Vital signs: BP: 110/70 mmHg, HR 110 /min, RR: 24 /min, temp: 99.2 F, SaO2: 98% on room air

During the physical examination, the physician notes a fruity odor to the breath. There is poor skin turgor and tongue is dry.

Laboratory:

1. Glucose ……………..375 mg/dL
2. HCO3:…………………18 mEq/L

The patient’s findings are most likely due to immune damage to the

A 74-year-old male is brought to the ED by his daughter who states her father “may have had a stroke” in the past few days. He has renal failure and missed his dialysis appointment 2 days ago. When he did not answer her phone calls, the daughter went over to his apartment and found him confused and weak on his couch. She shares with the doctor that her father has Type 2 Diabetes mellitus, hypertension, and hyperlipidemia.

Vital signs: BP 154/93 mmHg; temperature 99.1 F, HR 96 /min, RR 14 /min; SpO2 95% on room air

Physical examination reveals a slight, elderly male. He is mildly disoriented by there are no localizing neurologic findings. Skin shows multiple petechiae. There is a mild pericardial friction rub.

What lab values would be expected for this patient?

A 52-year-old man presents to the emergency department with severe right-sided flank pain for the past 2 hours. He states that the pain is 10/10.

Vital signs: Blood pressure 119/78 mmHg, pulse 77 bpm, temperature 98.2 F.

On examination, the patient is diaphoretic and hunched over holding his back. Costovertebral angle tenderness is present.

Urinalysis (dipstick)

1. Blood: 3+
2. Protein: 1+
3. Leukocyte esterase: 1+
4. Nitrites: 0
5. pH: 4.4

Abdominal X-ray (KUB) reveals no abnormalities.

Which of the following would best explain the patient’s findings?

A 40-year-old woman presents to her physician’s office because she was found to have hypertension at a recent health fair. In the doctor’s office, her blood pressure is 158/101 mmHg. Ultrasound in the office shows her right kidney to be smaller than her left kidney. A magnetic resonance angiogram is ordered and seen in the image.

The most likely cause of these findings is

In the pedigree below, the presence of the arrowed individuals suggests which of the following?

A 50-year-old man who raises poultry in rural Ohio presents to his physician complaining of shortness of breath that he began to notice a few days ago.  On questioning, he reports that he began to have a dry cough about 3-months ago associated intermittently with a low-grade fever.   He also admits that he seems to have been losing weight unintentionally over the same period. He denies any recent travel history. On physical examination, the temperature is 38 C (100.4 F), heart rate is 87 beats/minute, respiratory rate is 16 breaths/min and blood pressure is 120/87 mmHg. Chest X-ray reveals a well-circumscribed, dense, calcified nodule in the right lower lobe of the lung.  What is the most likely means by which the patient contracted this infection?

A 37-year-old woman comes to the oncology clinic for evaluation for metastatic adrenal carcinoma. Family history is positive for her mother (breast cancer at 40), first-degree cousin (rhabdomyosarcoma at 6), and grandfather (chronic lymphocyte leukemia at 43 years). All of the members of the family have lived their lives by a pesticide plant.

The most likely explanation for these findings is

A 1-year old girl is brought to her physician for persistent diarrhea. The girl is in the 10th percentile for height and weight. She has been hospitalized twice for lobar pneumonia. She has also had multiple episodes of diaper rash.

Laboratory testing:

1. CBC:
   1. Hgb: 11.2 gm/dL
   2. MCV: 78 fL
   3. Platelets: 442 x 10^3
   4. Neutrophils: 7.8 x 10^3
   5. Lymphocytes: 5599 x 10^3

Dihydrorhodamine flow cytometry is abnormal

What defect is the most likely cause of the patient’s recurrent infections?

Heparin is a commonly used blood thinner and works by increasing antithrombin III activity 1000X, which in turn inhibits thrombin and factor Xa. Heparin is a large molecule with a strong negative charge. Based on these characteristics, match the likely absorption pattern, volume of distribution, and rate of clearance of heparin.

Damage to the neuron cell bodies in the outer lamina of the right dorsal horn of several mid-thoracic spinal cord segments would interrupt projection of fibers to which of the following?

Which of the labeled structures in the attached radiograph receives oxygenated blood via the pulmonary veins?

A 37-year-old female presents to her physician’s office because she has felt unwell for the past day, with nausea and vomiting. She has only urinated a small amount of urine since she started feeling unwell. The patient was last seen in the office last week for acute sinusitis and was prescribed ampicillin with clavulanate at that time.

Vital signs: normal

Physical examination: non-contributory

Urinalysis:

1. Hemoglobin: 1+
2. Protein: 1+
3. Leukocyte esterase: 3+
4. Nitrites: negative
5. Sediment: numerous WBC’s and granular casts

Basic Metabolic Panel

1. Sodium: 134 mEq/L
2. Potassium: 4.2 mEq/L
3. Bicarbonate: 24 mEq/L
4. chloride: 101 mEq/L
5. Glucose: 86 mg/dL
6. BUN: 28 mg/dL
7. creatinine: 2.1 mg/dL
   1. eGFR 29 mL/min
8. Calcium: 9.8 mg/mL

Prions are infectious proteins which cause the production of subacute spongiform encephalopathies. They are variants of normal cellular proteins, which have a predilection for depositing extracellularly in a β-pleated sheet configuration, and then causing changes in normal cellular homologs to deposit with them and build up an impermeable matrix. Considering the engineering design of the immune response, can you predict the FIRST point at which immunity will be absent from the lesions of such amyloidopathies?