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usmle-11851 | A 4-month-old girl is seen for ongoing lethargy and vomiting. She was born to a 31-year-old G2P2 mother with a history of hypertension. She has had 7 episodes of non-bloody, non-bilious vomiting and 3 wet diapers over the last 24 hours. Laboratory results are shown below.
Serum:
Na+: 132 mEq/L
Cl-: 100 mEq/L
K+: 3.2 mEq/L
HCO3-: 27 mEq/L
BUN: 13 mg/dL
Glucose: 30 mg/dL
Lactate: 2 mmol/L
Urine ketones: < 20 mg/dL
Which of the following is the most likely diagnosis? |
usmle-11852 | A 78-year-old right-handed man is brought to the emergency department by his daughter for sudden onset speech changes. The patient lives with his daughter and was chatting with her when suddenly his speech became distorted with random and disconnected words that made no sense. He seems to be physically frustrated that no one understands him. Physical examination demonstrates weakness of the right arm. Damage to which location would best explain this patient’s symptoms? |
usmle-11853 | A 27-year-old male presents to urgent care complaining of pain with urination. He reports that the pain started 3 days ago. He has never experienced these symptoms before. He denies gross hematuria or pelvic pain. He is sexually active with his girlfriend, and they consistently use condoms. When asked about recent travel, he admits to recently returning from a “boys' trip" in Cancun where he had unprotected sex 1 night with a girl he met at a bar. The patient’s medical history includes type I diabetes that is controlled with an insulin pump. His mother has rheumatoid arthritis. The patient’s temperature is 99°F (37.2°C), blood pressure is 112/74 mmHg, and pulse is 81/min. On physical examination, there are no lesions of the penis or other body rashes. No costovertebral tenderness is appreciated. A urinalysis reveals no blood, glucose, ketones, or proteins but is positive for leukocyte esterase. A urine microscopic evaluation shows a moderate number of white blood cells but no casts or crystals. A urine culture is negative. Which of the following is the most likely cause for the patient’s symptoms? |
usmle-11854 | A 65-year-old man is brought to your office by his wife. He has not seen a doctor in decades. The patient has a longstanding history of “heartburn” following meals, for which he takes over-the-counter antacids. He is now having difficulty swallowing food. He has lost 15 pounds in the last three months. On further review, he has a 5 pack-year smoking history. He enjoys a beer with dinner several nights a week. An upper endoscopy is performed, with the finding shown in Figure A found just proximal to the gastroesophageal junction. Which of the following was the most important predisposing risk factor for his disease? |
usmle-11855 | A 67-year-old man presents to his primary care physician because he has been feeling increasingly short of breath. Specifically, after retirement he has been going on daily morning walks with his wife; however, over the last year he feels that his endurance has decreased. His medical history is significant for well-controlled hypertension but is otherwise unremarkable. When asked, he reveals that he worked in a variety of industries throughout his life. Testing demonstrates decreased forced vital capacity (FVC) and a normal forced expiratory volume (FEV) to FVC ratio. Pathology demonstrates changes primarily in the upper lobes where macrophages can be seen with dark round ingested particles. Which of the following is most likely associated with the cause of this patient's symptoms? |
usmle-11856 | A 19-year-old collegiate football player sustains an injury to his left knee during a game. He was running with the ball when he dodged a defensive player and fell, twisting his left knee. He felt a “pop” as he fell. When he attempts to bear weight on his left knee, it feels unstable, and "gives way." He needs assistance to walk off the field. The pain is localized diffusely over the knee and is non-radiating. His past medical history is notable for asthma. He uses an albuterol inhaler as needed. He does not smoke or drink alcohol. On exam, he has a notable suprapatellar effusion. Range of motion is limited in the extremes of flexion. When the proximal tibia is pulled anteriorly while the knee is flexed and the patient is supine, there is 1.5 centimeter of anterior translation. The contralateral knee translates 0.5 centimeters with a similar force. The injured structure in this patient originates on which of the following bony landmarks? |
usmle-11857 | A 81-year-old man is brought to the emergency department after he fell asleep at the dinner table and was not able to be roused by his family. His past medical history is significant for Alzheimer disease though he is still relatively functional at baseline. He has also been taking warfarin over the last 3 months after he suffered a deep venous thrombosis. After he was transported to the ED, his family found that the pills his grandson takes for seizures were missing. On presentation, he is found to be somnolent and physical exam reveals ataxia and nystagmus. After determining the cause of this patient's symptoms, his physicians begin monitoring his international normalized ratio, because they are concerned that it will start trending down. Which of the following treatments would most improve the urinary excretion of the substance likely responsible for these symptoms? |
usmle-11858 | A 31-year-old male presents to the emergency room following an altercation with patrons at a local grocery store. He is acting aggressively toward hospital staff and appears to be speaking to non-existent individuals. On examination he is tachycardic and diaphoretic. Horizontal and vertical nystagmus is noted. The patient eventually admits to taking an illegal substance earlier in the evening. Which of the following mechanisms of action is most consistent with the substance this patient took? |
usmle-11859 | A 25-year-old female is diagnosed with hypertension by her primary care physician after being found to have persistently elevated blood pressure measurements. She also has a history of intermittent headaches and also complains of leg cramps after walking. On physical exam she is found to have a systolic heart murmur as well as cold feet with a poor capillary refill time. In addition, a blood pressure from her lower extremity is found to be significantly lower than in her upper extremities. Based on clinical suspicion, a chest radiograph is obtained and the result is shown in the radiograph provided (Figure A). Which of the following clinical conditions is associated with this patient’s most likely disorder? |
usmle-11860 | A 76-year-old African American man presents to his primary care provider complaining of urinary frequency. He wakes up 3-4 times per night to urinate while he previously only had to wake up once per night. He also complains of post-void dribbling and difficulty initiating a stream of urine. He denies any difficulty maintaining an erection. His past medical history is notable for non-alcoholic fatty liver disease, hypertension, hyperlipidemia, and gout. He takes aspirin, atorvastatin, enalapril, and allopurinol. His family history is notable for prostate cancer in his father and lung cancer in his mother. He has a 15-pack-year smoking history and drinks alcohol socially. On digital rectal exam, his prostate is enlarged, smooth, and non-tender. Which of the following medications is indicated in this patient? |
usmle-11861 | A 17-year-old woman presents to your office concerned that she has not had her menstrual period in 4 months. She states that menses began at age of 13 and has been regular until two months ago. She denies sexual activity, and urine pregnancy test is negative. On exam, she appears well-nourished with a BMI of 21 kg/m^2, but you note that she has enlarged cheeks bilaterally and has calluses on the dorsum of her hands. She says that she has been very stressed with school and has recently been binge eating. What other finding do you expect to see in this patient? |
usmle-11862 | A 57-year-old woman presents to the emergency department with acute onset vomiting, vertigo, throbbing headache, and weakness. She says that the symptoms started when she went to dinner with friends and had a drink of alcohol. Her past medical history is significant for type 2 diabetes, and she was recently started on a new medication for this disease. She says that she was warned that she might experiences these symptoms as a side effect of a new medication, but she did not realize how severe they would be. Which of the following describes the mechanism of action for the most likely diabetes drug that this patient started taking? |
usmle-11863 | A 28-year-old man is brought to the emergency department after he was found half dressed and incoherent in the middle of the road. In the emergency department he states that he has not slept for 36 hours and that he has incredible ideas that will make him a billionaire within a few months. He also states that secret agents from Russia are pursuing him and that he heard one of them speaking through the hospital intercom. His past medical history is significant only for a broken arm at age 13. On presentation, his temperature is 102.2°F (39°C), blood pressure is 139/88 mmHg, pulse is 112/min, and respirations are 17/min. Physical exam reveals pupillary dilation and psychomotor agitation. Which of the following mechanisms is most likely responsible for this patient's symptoms? |
usmle-11864 | A 10-year-old boy presents to the pediatrician with a three day history of sore throat and fever of 101°F (38.3°C). On physical exam, his oral mucosa is shown in Figure A. He also has tender anterior cervical lymph nodes. A rapid strep test returns negative. Three weeks later, the boy presents with painful joints and nodular swelling on his skin. Erythrocyte sedimentation rate (ESR) is obtained and found to be 76 mm/hr. A reaction to which of the following compounds is most likely responsible for the patient’s return presentation? |
usmle-11865 | A 61-year-old man presents to his primary care doctor with shortness of breath. He reports a 6-month history of progressive dyspnea and a dry cough. He has also lost 10 pounds despite no change in his diet or exercise routine. His past medical history is notable for psoriatic arthritis and gastroesophageal reflux disease. He currently takes methotrexate and omeprazole. He has a 45-pack-year smoking history and drinks 8-10 beers per week. He previously worked as a deckhand on a large shipping vessel. Physical examination reveals minimal wheezes with decreased aeration in the left lower lung field. Mucus membranes are moist with normal skin turgor and capillary refill. A chest radiograph and computerized tomography (CT) scan demonstrate a mass in the left lower lung field. A biopsy of the mass is performed. On examination of the biopsy, the pathologist notes an area of normal lung tissue shown in Figure A. Which of the following is one of the main functions of the labeled cells? |
usmle-11866 | A 27-year-old breastfeeding woman presents to her primary care physician complaining of breast pain and malaise. She has been breastfeeding her newborn for the past six weeks without problems. However, three days ago she developed breast pain, purulent nipple discharge, and fatigue. Her current temperature is 101.2°F (38.4°C). Her breast is shown in Figure A. Laboratory examination reveals a leukocyte count of 14,000/mm^3. Which of the following pathogens is the most likely cause of this patient’s condition? |
usmle-11867 | A 34-year-old man was brought into the emergency room after he was found running in the streets. Upon arrival to the emergency room, he keeps screaming, “they are eating me alive," and swatting his hands. He reports that there are spiders crawling all over him. His girlfriend, who arrives shortly after, claims that he has been forgetful and would forget his keys from time to time. He denies weight loss, fever, shortness of breath, abdominal pain, or urinary changes but endorses chest pain. His temperature is 98.9°F (37.2°C), blood pressure is 160/110 mmHg, pulse is 112/min, respirations are 15/min, and oxygen saturation is 98%. He becomes increasingly agitated as he believes the healthcare providers are trying to sacrifice him to the “spider gods.” What is the most likely explanation for this patient’s symptoms? |
usmle-11868 | A 29-year-old patient presents to her primary care physician with persistent amenorrhea and inability to breastfeed over the last 5 months. She says that she has also been very tired since her baby was born and this fatigue was accompanied by an inability to deal with cold weather despite having no problem with cold prior to becoming pregnant. She has gained an additional 5 pounds since delivery. Review of her hospital records reveals that she had a vaginal delivery that was complicated by severe hemorrhage and episodes of hypotension. Which of the following hormone levels is most likely to be normal in this patient? |
usmle-11869 | A 42-year-old male is brought by ambulance to the emergency room following a syncopal episode. He is unresponsive. A review of the patient’s medical record reveals that he was recently treated for a bacterial respiratory tract infection; however, the specific antibiotic was not recorded. He has a complicated past medical history notable for severe diabetes mellitus and chronic kidney disease. On examination, he is pale and diaphoretic with a rapid but weak pulse. An electrocardiogram is obtained and the results are shown in Figure A. A basic metabolic panel is pending. Which of the following medications was this patient most likely treated with? |
usmle-11870 | A 10-year-old girl is brought to the physician by her parents due to 2 months of a progressively worsening headache. The headaches were initially infrequent and her parents attributed them to stress from a recent move. However, over the last week the headaches have gotten significantly worse and she had one episode of vomiting this morning when she woke up. Her medical history is remarkable for a hospitalization during infancy for bacterial meningitis. On physical exam, the patient has difficulty looking up. The lower portion of her pupil is covered by the lower eyelid and there is sclera visible below the upper eyelid. A magnetic resonance imaging (MRI) of the brain is shown. Which of the following is the most likely diagnosis? |
usmle-11871 | A 33-year-old G0 woman presents to reproductive counseling because she has tried to conceive with her husband for over 2 years without success. She has not used any form of birth control and her husband has two biological children from a previous marriage. Her past medical history is significant for migraines, obesity, and type 2 diabetes mellitus well-controlled on metformin. Past surgical history is notable for a childhood accident requiring hip surgery. Physical exam reveals some acne, extra hair on the lip, and the sign seen in Figure A. Which of the following findings would most likely also be seen in this patient? |
usmle-11872 | A 45-year-old African American woman presents to the clinic for complaints of intermittent diarrhea and mouth sores for the past 3 months. The symptoms began shortly after a trip to Kenya where she volunteered at a medical clinic. The diarrhea is described as intense, explosive, and refractory to conventional anti-diarrheal medications. She reports intermittent flushing, abdominal pain, and forgetfulness but denies fevers, chills, shortness of breath, palpitations, or nausea/vomiting. Her past medical history is unremarkable. A physical examination demonstrates significant skin changes shown in Figure A but is otherwise unremarkable. What is the most appropriate treatment for this patient? |
usmle-11873 | A 33-year-old female presents to her primary care physician complaining of heat intolerance and difficulty sleeping over a one month period. She also reports that she has lost 10 pounds despite no changes in her diet or exercise pattern. More recently, she has developed occasional unprovoked chest pain and palpitations. Physical examination reveals a nontender, mildly enlarged thyroid gland. Her patellar reflexes are 3+ bilaterally. Her temperature is 99°F (37.2°C), blood pressure is 135/85 mmHg, pulse is 105/min, and respirations are 18/min. Laboratory analysis is notable for decreased TSH. Which of the following pathophysiologic mechanisms contributed to the cardiovascular symptoms seen in this patient? |
usmle-11874 | A 61-year-old male comes to his physician for a routine health maintenance visit. He states that he has no health concerns and attributes his good health to the large amounts of time he spends working outside. On exam, his physician finds a scaly plaque on his forehead as demonstrated in Figure A. The physician is concerned because this lesion is a precursor to what? |
usmle-11875 | A rheumatologist is interested in studying the association between osteoporosis and the risk of sustaining a distal radius fracture. To explore this association, she develops a retrospective study design in which she identifies patients in a large institutional database over the age of 55 with and without osteoporosis, then follows them over a 10-year period to identify cases of distal radius fracture. She matches patients on age, sex, and body mass index to control for known confounding. After completing the study, she finds that patients with osteoporosis were at an increased risk of developing distal radius fractures. Which of the following study designs did this investigator use in this case? |
usmle-11876 | A 25-year-old previously healthy woman presents to her PCP reporting cessation of menses for the past 6 months. Previously, her period occurred regularly, every 30 days. She also complains of decreased peripheral vision, most noticeably when she is driving her car. She denies any recent sexual activity and a pregnancy test is negative. Upon further work-up, what other physical findings may be discovered? |
usmle-11877 | A 26-year-old female undergoes a stem cell transplant for the treatment of non-Hodgkin's lymphoma after several rounds of failed chemotherapy and radiation. One month after undergoing the transplantation, she develops voluminous diarrhea and reports abdominal pain. She describes the stool as green, mucoid, and watery. The patient also complains of recent development of a painful and itchy rash on her forearms, as shown in Figure A. Physical examination is significant for jaundice and hepatosplenomegaly on abdominal palpation. Which of the following best describes the pathogenesis of her current complication? |
usmle-11878 | A 63-year-old man presents to the emergency room with severe upper abdominal pain. His symptoms started 2 days prior to presentation and have progressed rapidly. He has been seen in the emergency room 3 times in the past year for acute alcohol intoxication. His past medical history is notable for multiple deep venous thromboses, hypertension, diabetes mellitus, gout, and a transient ischemic attack one year prior. He takes warfarin, lisinopril, metformin, glyburide, and allopurinol. His temperature is 100.0°F (37.8°C), blood pressure is 100/55 mmHg, pulse is 130/min, and respirations are 26/min. On exam, he is in acute distress but is able to answer questions appropriately. Hepatomegaly, splenomegaly, and scleral icterus are noted. There is a positive fluid wave. Laboratory analysis reveals an INR of 1.3. An abdominal ultrasound is ordered, and the patient is started on the appropriate management. However, before the ultrasound can begin, he rapidly loses consciousness and becomes unresponsive. He expires despite appropriate management. An autopsy the following day determines the cause of death to be a massive cerebrovascular accident. A liver biopsy demonstrates darkly erythematous congested areas in the centrilobular regions. This patient’s presenting symptoms are most likely caused by obstructive blood flow in which of the following vessels? |
usmle-11879 | A 37-year-old man is brought to the emergency department because he was found down on a city sidewalk. Upon presentation he is found to be disheveled with multiple poorly healed wounds on his hands and feet. He has had dozens of previous presentations for alcohol intoxication and is currently known to be homeless. Physical examination reveals multiple minor wounds, alopecia, and decreased axillary hair. Upon being aroused, the patient reveals that he has had difficulty with taste and smell and has also had severe diarrhea over the last week. The deficient substance most likely responsible for this patient's symptoms is associated with which of the following proteins? |
usmle-11880 | A 5-year-old African-American male with no previous medical history is taken to the ED by his mother because his urine was darker than normal. She notes that, for the past week, he has had a cough, runny nose, and fever. A few days ago, she gave him a small dose of acetaminophen, which seemed to help. This morning, he complained of worsening fatigue and back pain. When he went to the bathroom, his urine was the color of tea, prompting his mother to bring him to the hospital. In the ED, his vitals are as follows: temperature is 101.6 deg F (38.7 deg C), blood pressure is 120/80 mmHg, pulse is 99/min, respirations are 15/min. His exam is noteworthy for mild scleral icterus and mild splenomegaly. His labs are consistent with acute hemolytic anemia. Peripheral smear is shown in Figure A. What is the underlying cause of the patient's anemia? |
usmle-11881 | A 74-year-old male presents to his primary care physician complaining of left lower back pain. He reports a four-month history of worsening left flank pain. More recently, he has started to notice that his urine appears brown. His past medical history is notable for gout, hypertension, hyperlipidemia, and myocardial infarction status-post stent placement. He has a 45 pack-year smoking history and drinks 2-3 alcoholic beverages per day. His temperature is 100.9°F (38.3°C), blood pressure is 145/80 mmHg, pulse is 105/min, and respirations are 20/min. Physical examination is notable for left costovertebral angle tenderness. A CT of this patient’s abdomen is shown in figure A. This lesion most likely arose from which of the following cells? |
usmle-11882 | A 40-year-old woman presents to clinic with multiple complaints. She complains of swelling around her eyes (Image A) and generalized weakness. A complete blood count reveals eosinophilia. She recently returned from a trip to Asia where she reports having eaten street food, including pork. If this patient's disease is explained by a parasite that causes inflammation of skeletal muscle, what would be the appropriate treatment? |
usmle-11883 | A 31-year-old woman presents to your office with one week of recurrent fevers. The highest temperature she recorded was 101°F (38.3°C). She recently returned from a trip to Nigeria to visit family and recalls a painful bite on her right forearm at that time. Her medical history is significant for two malarial infections as a child. She is not taking any medications. On physical examination, her temperature is 102.2°F (39°C), blood pressure is 122/80 mmHg, pulse is 80/min, respirations are 18/min, and pulse oximetry is 99% on room air. She has bilateral cervical lymphadenopathy and a visible, enlarged, mobile posterior cervical node. Cardiopulmonary and abdominal examinations are unremarkable. She has an erythematous induration on her right forearm. The most likely cause of this patient's symptoms can be treated with which of the following medications? |
usmle-11884 | A 22-year-old man presents to clinic with a chief concern about a painless ulcer on his penis that he noticed 4 weeks ago and resolved one week ago. He denies any pain on urination or changes in urinary patterns. He admits to having multiple sexual partners in the past 3 months and inconsistent use of barrier protection. His vitals are within normal limits and his physical exam is unremarkable. He is given the appropriate antibiotic for this condition and sent home. What molecular structure is mimicked by the antibiotic most likely prescribed in this case? |
usmle-11885 | A 9-year-old boy is brought to the psychiatrist due to unusual behavior over the past several months. His mother reports that he has started to blink more frequently than usual. His parents initially attributed this behavior to attention-seeking but he has not stopped despite multiple disciplinary efforts and behavioral therapy from a clinical psychologist. He previously performed well in school but has recently become more disruptive and inattentive in class. He has not been sick recently and denies any drug use. His parents report multiple episodes in the past in which the child seemed overly elated and hyperactive for several days followed by periods in which he felt sad and withdrawn. On examination, he is a well-appearing boy in no acute distress. He is alert and oriented with a normal affect but gets distracted easily throughout the exam. He blinks both eyes several times throughout the examination. Strength, sensation, and gait are all normal. Which of the following medications is most appropriate for this patient? |
usmle-11886 | A 30-year-old man presents to his primary care physician for a routine check-up. During the appointment, he remarks that he has started noticing some thinning and hair loss without other symptoms. The physician reassures him that he is likely experiencing male-pattern baldness and explains that the condition is largely inherited. Specifically he notes that there are multiple genes that are responsible for the condition so it is difficult to predict the timing and development of hair loss. What genetic principle is being illustrated by this scenario? |
usmle-11887 | A 40-year-old man presents to his primary care provider complaining of abdominal pain. The patient reports a dull pain that has been present for 4 weeks now. The patient states that the pain is located to his right upper quadrant and does not change with eating. The patient denies any alcohol or illicit substance use, stating that he is meticulous about eating healthy since he is a professional bodybuilder. The patient reports no history of malignancy. On exam, the patient's temperature is 98.2°F (36.8°C), blood pressure is 130/86 mmHg, pulse is 60/min, and respirations are 12/min. The patient has an athletic build, and his exam is unremarkable for any palpable mass or abdominal tenderness. On further questioning, the patient does endorse a 5-year history of using anabolic steroids for bodybuilding. Imaging demonstrates an enhancing liver nodule. Which of the following is the most likely histopathologic finding of this patient’s disease? |
usmle-11888 | A 58-year-old man is rushed to the ER in the middle of the night with severe chest pain. He arrives in the ER short of breath, sweating, and looking terrified. His blood pressure is noted to be 250/140, and he is immediately administered nitroprusside. His blood pressure is controlled, but he soon develops confusion and lactic acidosis. Which of the following are potential side effects of nitroprusside administration? |
usmle-11889 | A 59-year-old man presents to the emergency room for a fever that has persisted for over 4 days. In addition, he has been experiencing weakness and malaise. His past medical history is significant for a bicuspid aortic valve that was replaced 2 years ago. Physical exam reveals nailbed splinter hemorrhages, tender nodules on his fingers, and retinal hemorrhages. An echocardiogram shows aortic valve vegetations and culture reveals a gram-positive alpha-hemolytic organism that grows as cocci in chains. The organism is then exposed to optochin and found to be resistant. Finally, they are seen to ferment sorbitol. The most likely cause of this patient's symptoms is associated with which of the following? |
usmle-11890 | An 18-year-old man comes to the clinic with his mom for “pins and needles” of both of his arms. He denies any past medical history besides a recent anterior cruciate ligament (ACL) tear that was repaired 1 week ago. The patient reports that the paresthesias are mostly located along the posterior forearms, left more than the right. What physical examination finding would you expect from this patient? |
usmle-11891 | A 78-year-old woman is brought to the emergency department after she fell while gardening and experienced severe pain in her right arm. She has a history of well controlled hypertension and has been found to have osteoporosis. On presentation she is found to have a closed midshaft humerus fracture. No other major findings are discovered on a trauma survey. She is placed in a coaptation splint. The complication that is most associated with this injury has which of the following presentations? |
usmle-11892 | A 3-year-old boy presents with progressive lethargy and confusion over the last 5 days. He lives with his parents in a home that was built in the early 1900s. His parents report that "his tummy has been hurting" for the last 3 weeks and that he is constipated. He eats and drinks normally, but occasionally tries things that are not food. Abdominal exam shows no focal tenderness. Hemoglobin is 8 g/dL and hematocrit is 24%. Venous lead level is 55 ug/dL. Which therapy is most appropriate for this boy's condition? |
usmle-11893 | A 36-year-old woman presents to the emergency department with chest discomfort and fatigue. She reports that her symptoms began approximately 1 week ago and are associated with shortness of breath, swelling of her legs, and worsening weakness. She’s been having transitory fevers for about 1 month and denies having similar symptoms in the past. Medical history is significant for systemic lupus erythematosus (SLE) treated with hydroxychloroquine. She had a SLE flare approximately 2 weeks prior to presentation, requiring a short course of prednisone. Physical exam was significant for a pericardial friction rub. An electrocardiogram showed widespread ST-segment elevation and PR depression. After extensive work-up, she was admitted for further evaluation, treatment, and observation. Approximately 2 days after admission she became unresponsive. Her temperature is 100°F (37.8°C), blood pressure is 75/52 mmHg, pulse is 120/min, and respirations are 22/min. Heart sounds are muffled. Which of the following is a clinical finding that will most likely be found in this patient? |
usmle-11894 | A 34-year-old female visits her primary care physician because recently she has started to have painful, numb, and discolored toes. She is otherwise healthy and has no family history of similar conditions that she can recall. Occasionally during these episodes, her fingers and nose will also have similar symptoms. On examination, the patient's appearance is completely normal with warm and well perfused extremities. No evidence of discoloration is found. On closer questioning, she reveals that several months ago during the summer, she succumbed to a viral illness that caused her to feel fatigued and have a long bout of cold symptoms with sore throat and swollen lymph nodes. The bacterial species that is also associated with this patient's most likely condition has which of the following characteristics? |
usmle-11895 | A 14-year-old boy is brought to the clinic by his mother for temper tantrums for the past year. She is concerned as he gets abnormally irritated and angry towards the smallest things. After asking the mother to leave the room, the patient reports that he is simply annoyed by his mother’s constant nagging. He denies any violent tendencies, suicidal ideations, depressive symptoms, or intention to hurt others. The patient states he finds the physician irritating and that he reminds her of his mother in his mannerisms and demeanor. Without provocation, the patient shouts at the physician saying that he does not understand or really care about him and he never would. What is the likely explanation for this patient’s behavior toward the physician? |
usmle-11896 | A 72-year-old male presents to a cardiac surgeon for evaluation of severe aortic stenosis. He has experienced worsening dyspnea with exertion over the past year. The patient also has a history of poorly controlled hypertension, diabetes mellitus, and hyperlipidemia. An echocardiogram revealed a thickened calcified aortic valve. The surgeon is worried that the patient will be a poor candidate for open heart surgery and decides to perform a less invasive transcatheter aortic valve replacement. In order to perform this procedure, the surgeon must first identify the femoral pulse just inferior to the inguinal ligament and insert a catheter into the vessel in order to gain access to the arterial system. Which of the following structures is immediately lateral to this structure? |
usmle-11897 | A tall, 25-year-old man is brought to the ED by his friend after sudden difficulty breathing while smoking a cigarette. In the trauma bay he is tachypneic, but able to talk to you. Vital signs show that he is afebrile and tachycardic with blood pressure of 115/60. Physical exam reveals hyperresonance and absent breath sounds over the left upper lung. A chest x-ray is obtained and shown below. What is the most likely diagnosis? |
usmle-11898 | A 35-year-old woman presents to the emergency department with severe nausea and diarrhea. One day prior to presentation, she went to a new seafood restaurant known for serving exotic fish. For the past day she experienced nausea, diarrhea, weakness, and a tingling sensation in her extremities. In the emergency department, her temperature is 100.3°F (37.9°C), blood pressure is 95/60 mmHg, pulse is 105/min, and respirations are 20/min. On physical examination, she appears fatigued and has 1+ Achilles and patellar reflexes. Which of the following is the mechanism of action of the compound most likely responsible for this patient's clinical presentation? |
usmle-11899 | A 48-year-old woman presents to the emergency department with a 1-day history of severe left back pain. She says that the pain is squeezing in character, occurs in waves, and radiates to her left groin. She has no past medical history, drinks socially, and does not smoke. Physical exam reveals left costovertebral tenderness, and urine sediment analysis reveals the finding shown in Figure A. Which of the following would most likely present with the same urine sediment findings as seen in this patient? |
usmle-11900 | A 22-year-old male presents to his primary care physician complaining of several instances of postprandial right upper quadrant pain that he describes as being "squeezing" in nature. He also says that he also has general fatigue and was easily winded in gym when he was in school. Physical exam reveals conjunctival pallor and generally pale skin. Based on clinical suspicion blood work is obtained showing a hematocrit of 34% (normal range 41%-50%). Mean corpuscular volume is found to be 87 fl (normal range 80 fl - 100 fl). A peripheral blood smear is also obtained and the results are shown in Figure A. Which of the following is the most likely cause of this patient's syndrome? |
usmle-11901 | A medical student is spending his research year studying the physiology of cholesterol transport within the body. Specifically, he wants to examine how high density lipoprotein (HDL) particles are able to give other lipoproteins the ability to hydrolyse triglycerides into free fatty acids. He labels all the proteins on HDL particles with a tracer dye and finds that some of them are transferred onto very low density lipoprotein (VLDL) particles after the 2 are incubated together. Furthermore, he finds that only VLDL particles with transferred proteins are able to catalyze triglyceride hydrolysis. Which of the following components were most likely transferred from HDL to VLDL particles to enable this reaction? |
usmle-11902 | A 70-year-old woman presents to her primary care doctor complaining of left knee pain. She states that she has noticed this more during the past several months after a fall at home. Previously, she was without pain and has no history of trauma to her knees. The patient states that the majority of her pain starts in the afternoon after she has been active for some time, and that the pain resolves with rest and over-the-counter analgesics. Aside from the left knee, she has no other symptoms and no other joint findings. On exam, her temperature is 98.8°F (37.1°C), blood pressure is 124/76 mmHg, pulse is 70/min, and respirations are 12/min. The patient has no limitations in her range of motion and no changes in strength on motor testing. However, there is tenderness along the medial joint line. What finding is most likely seen in this patient? |
usmle-11903 | A 45-year-old man with a history of hypertension, IV drug use, and type 1 diabetes is brought to the emergency room due to nausea, vomiting, and altered consciousness. He was brought in by his sister who found him asleep on her couch. He is difficult to arouse and does not respond to questions. His sister does not know his medications; however, he has a known history of medication noncompliance. On physical exam his temperature is 99°F (37.2°C), blood pressure is 100/70 mmHg, pulse is 112/min, respirations are 26/min, and pulse oximetry is 99% on room air. He is arousable but is not cooperative with the exam. His breaths are deep and you notice a fruity-smell coming from his mouth. Exam is otherwise unremarkable. Which of the following findings would you also expect to see in this patient? |
usmle-11904 | A 72-year-old woman is brought to the emergency department by her son after he noticed that she was slurring her speech. He also noticed that she appeared to have difficulty using her fork about halfway through dinner when the speech problems started. He brought her to the emergency department immediately and he estimates that only 1 hour has passed since the beginning of the symptoms. An immediate exam is conducted. A medication is administered to ameliorate the effects of this patient's condition that would not be available for use if the patient had presented significantly later. An hour later the patient's condition becomes significantly worse and new deficits are found. Which of the following agents should be used at this point? |
usmle-11905 | A 12-year-old boy presents to the emergency department after breaking his right leg secondary to a low energy fall. He says that he has had bone pain in his right leg and hips over the last year. He also notes that he has been feeling hot all the time and his mom adds that he has been unable to concentrate with flight of ideas. Physical exam shows the skin findings in Figure A. Radiograph shows multiple bony lesions in his pelvis and right femur. Which of the following molecular changes is most likely present in the cells of this patient? |
usmle-11906 | A 75-year-old female patient comes to the emergency department with altered mental status. She is brought in by her daughter with whom the patient lives. The patient’s daughter said they were watching TV when her mother became unresponsive. On exam the patient withdraws to pain but does not open her eyes or speak. An emergent head CT is done and shows an intracranial bleed. The patient is moved to the ICU and intubated. Further history is obtained from the daughter. The patient has a past medical history of diabetes and a previous stroke. Her medications are metformin and warfarin. The patient is compliant with all of her medications. The daughter says that the patient changed her diet about 1 month ago in response to a diet she saw on a talk show. Which of the following foods is most likely to cause the pathology seen in this patient? |
usmle-11907 | A 31-year-old, G1P0 woman at 35 weeks of gestation comes to the emergency room for a severe headache. She reports that she was washing the dishes 2 hours ago when a dull headache came on and progressively worsened. She also reports 2 episodes of intermittent blurred vision over the past hour that has since cleared. Nothing similar has ever happened before. She denies any precipitating events, trauma, mental status changes, abdominal pain, lightheadedness, fever, ulcers, or urinary changes. Her temperature is 98.9°F (37.1°C), blood pressure is 160/110 mmHg, pulse is 98/min, respirations are 12/min, and oxygen saturation is 98%. A physical examination demonstrates a rash on her face that she attributes to a recent change in cosmetics. A urine test demonstrates the presence of protein. What is the most likely explanation for this patient’s symptoms? |
usmle-11908 | A 34-year-old female presents to the clinic for tingling of her feet over the past 2 months. She reports that ever since her vacation to the Rocky Mountains 3 months ago, she began feeling “pins and needles” at her feet. She denies weight loss, fever, palpitations, chest pain, gastrointestinal symptoms, or rashes, but endorses lightheadedness and fatigue. Her past medical history is significant for gastric bypass surgery 4 year agos for weight loss. A physical examination demonstrates decreased vibration and pinprick sensation at the toes bilaterally. A peripheral blood smear is shown in Figure A. What is the most appropriate treatment for this patient? |
usmle-11909 | A 33-year-old man presents to the emergency department with a rash. The patient is homeless and is a known IV drug abuser. His temperature is 99.5°F (37.5°C), blood pressure is 127/68 mm Hg, pulse is 100/min, respiratory rate is 24/min, and oxygen saturation is 98% on room air. Physical exam reveals the finding in Figure A and a red rash on the skin. Which of the following is the best initial treatment for this patient's chief complaint? |
usmle-11910 | A 1-year-old girl is brought to the clinic for an annual wellness exam. The mother reports that she is beginning to walk and can say 4-5 words. She is eating well and is overall very healthy. The mother denies any significant concerns. A physical examination demonstrates a well-developed child with closed fontanelles, positive tracking, and normal reflexes. The child has several flat, hyperpigmented macules throughout her body as shown in Figure A. What other findings would you expect in the patient as she grows older? |
usmle-11911 | A 23-year-old woman comes to the clinic complaining of a rash on her legs for the past week. She reports that 2 weeks ago she had an episode of congestion, runny nose, and cough. Shortly afterwards, she began noticing purplish-red dots appearing on her legs, as shown in Figure A. The patient reports that the rash is not painful, itchy, and is not warm upon palpation. She denies joint pain, weight changes, nausea, diarrhea, or palpitations. Physical examination demonstrates an oral ulcer at the right cheek and flat, red, non-blanching lesions on her legs bilaterally. Laboratory findings are shown below.
Hemoglobin: 13.7 g/dL
Hematocrit: 41 %
Leukocyte count: 7,600/mm^3 with normal differential
Platelet count: 90,000/mm^3
Serum:
Na+: 137 mEq/L
Cl-: 97 mEq/L
K+: 4.6 mEq/L
HCO3-: 25 mEq/L
Glucose: 120 mg/dL
Creatinine: 1.1 mg/dL
Anti-nuclear antibodies: negative
What is the most likely explanation for this patient’s symptoms? |
usmle-11912 | A 68-year-old man presents to his primary care provider after noticing that his urine has been pink for the last week. He does not have any pain with urination, nor has he had any associated fevers or infections. On his review of systems, the patient notes that he thinks he has lost some weight since his belt is looser, and he has also had occasional dull pressure in his back for the past two months. His temperature is 98.8°F (37.1°C), blood pressure is 132/90 mmHg, pulse is 64/min, and respirations are 12/min. The patient weighs 210 lbs (95.3 kg, BMI 31.9 kg/m^2), compared to his weight of 228 lbs (103.4 kg, BMI 34.7 kg/m^2) at his last visit 2 years prior. On exam, the patient does not have any back or costovertebral angle tenderness. On abdominal palpation, a firm mass can be appreciated deep in the left abdomen. The clinical workup should also assess for which of the following conditions? |
usmle-11913 | A 55-year-old gentleman has been working in a sand blasting factory for over 25 years. He presents to his primary care physician with what he describes as increasing shortness of breath. PFTs are performed describing a restrictive lung process. Which of the following has most likely been the long-term mechanism of his disease development? |
usmle-11914 | A 57-year-old male presents to his primary care physician for an annual check-up. His medical history is significant for hypertension, controlled with lisinopril, and hyperlipidemia, managed with atorvastatin. He reports that, for the past nine months, he has experienced occasional substernal chest pain. The patient relates that the chest pain is very predictable, occurring when he is about halfway through mowing his lawn and nearly every time he picks up the newspaper from the driveway and has to return uphill to his house. The pain has never lasted for longer than "a couple minutes" and has always resolved quickly with rest. An electrocardiogram is obtained in the office and is shown in Figure A. The physician recommends obtaining an exercise stress test and provides medication to help relieve the chest pain when it occurs. Which of the following dietary supplements may aid in improving this patient's symptoms? |
usmle-11915 | A 71-year-old African American man with a history of prostatic adenocarcinoma presents to his oncologist with low back pain. He was diagnosed with non-resectable prostatic adenocarcinoma 4 years ago. He has undergone radiation therapy and chemotherapy. Over the past 3 months, he has developed constant mild non-radiating low back pain that occasionally wakes him up from sleep. He denies any recent falls or trauma. His past medical history is notable for hypertension, diabetes mellitus, coronary artery disease, and gout. He also has a history of thyroid cancer and underwent thyroidectomy 5 years ago. He takes lisinopril, metoprolol, aspirin, metformin, and allopurinol. He has a 40-pack-year smoking history and drinks alcohol socially. His temperature is 99.2°F (37.3°C), blood pressure is 150/85 mmHg, pulse is 84/min, and respirations are 18/min. On exam, he is well-appearing and in no acute distress. He is mildly tender to palpation along the lumbar vertebral spinous processes. A computerized tomography (CT) scan of the lumbar spine demonstrates a blastic and sclerotic lesion in the L5 vertebral body. Which of the following findings would most likely be seen on a serum study of this patient? |
usmle-11916 | An 8-year-old boy is referred to your office by his school for kyphoscoliosis. His mother recently noticed a change in the way he walks but thought it was a normal part of his growth. She notes that he has always been clumsy and has frequent falls. He has a history of type 1 diabetes mellitus for which he receives insulin. He has no other health problems and has been doing well in school. On physical exam his temperature is 99°F (37.2°C), blood pressure is 110/75 mmHg, pulse is 80/min, and respirations are 19/min. Cardiopulmonary exam is unremarkable. On neurologic exam you notice nystagmus. Patellar reflex is absent and the patient has a staggering gait. The disorder most likely responsible for this patient’s presentation is due to an abnormality in which of the following? |
usmle-11917 | A 63-year-old woman presents to the emergency department after being found unresponsive by her family. Upon presentation she is confused and does not answer questions that are addressed to her. An EKG is obtained and the result is provided here. Which of the following processes would be consistent with the findings seen on this patient's EKG? |
usmle-11918 | A 53-year-old woman presents to your office with several months of fatigue and abdominal pain. The pain is dull in character and unrelated to meals. She has a history of type 2 diabetes mellitus and rheumatic arthritis for which she is taking ibuprofen, methotrexate, and metformin. She has 2-3 drinks on the weekends and does not use tobacco products. On physical examination, there is mild tenderness to palpation in the right upper quadrant. The liver span is 15 cm at the midclavicular line. Laboratory results are as follows:
Serum:
Na+: 135 mEq/L
Cl-: 100 mEq/L
K+: 3.7 mEq/L
HCO3-: 24 mEq/L
BUN: 13 mg/dL
Creatinine: 1.0 mg/dL
Alkaline phosphatase: 100 U/L
AST: 70 U/L
ALT: 120 U/L
Bilirubin (total): 0.5 mg/dL
Bilirubin (conjugated): 0.1 mg/dL
Amylase: 76 U/L
What is the most likely cause of her clinical presentation? |
usmle-11919 | A 37-year-old male presents to general medical clinic reporting sleeping difficulties. He states that he has daytime sleepiness, having fallen asleep several times while driving his car recently. He sometimes experiences very vivid dreams just before awakening. You ask the patient's wife if she has witnessed any episodes where her husband lost all muscle tone and fell to the ground, and she confirms that he has not had this symptom. The patient notes that this condition runs in his family, and he desperately asks for treatment. You begin him on a first-line medication for this illness, which works by which mechanism of action? |
usmle-11920 | A 33-year-old man comes into the ED after getting into a fight at a bar. He tells the physician that he was punched in the face for no reason. In the ED, he declares multiple times that he is incredibly angry and upset that he was beaten up. The patient's mood rapidly shifts between anger and sadness. He is wearing a multi-colored top with bright yellow pants, and he makes broad gestures while speaking. Before the paramedics left, they told the doctor that multiple bystanders at the bar reported the patient was flirting with numerous women. He began to touch one of them inappropriately, and she shoved him away. Upset, he demanded to be taken to the ED. The doctor begins to suspect the patient has a personality disorder. Which one is most likely? |
usmle-11921 | A 26-year-old woman presents to her primary care physician for 5 days of increasing pelvic pain. She says that the pain has been present for the last 2 months; however, it has become increasingly severe recently. She also says that the pain has been accompanied by unusually heavy menstrual periods in the last few months. Physical exam reveals a mass in the right adnexa, and ultrasonography reveals a 9 cm right ovarian mass. If this mass is surgically removed, which of the following structures must be diligently protected? |
usmle-11922 | A 30-year-old G1P1 woman gives birth to a healthy infant at 39 weeks gestation. The mother attended all her prenatal visits and took all her appropriate prenatal vitamins. Her past medical history is notable for diabetes mellitus, for which she takes metformin. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. The infant's temperature is 99.2°F (37.3°C), blood pressure is 65/40 mmHg, pulse is 110/min, and respirations are 22/min. On exam, the child has ambiguous genitalia. A karyotype analysis demonstrates the presence of a Y chromosome. Further workup reveals internal testes with normal levels of serum luteinizing hormone and testosterone. Which of the following additional findings would most likely be seen in this patient? |
usmle-11923 | A 78-year-old male presents to the emergency room with crampy abdominal pain and bloating. His last bowel movement was three days ago and he has not passed gas over the same time period. His past medical history is notable for Alzheimer's disease, hypertension, and stable angina. He takes donezepil, aspirin, enalapril, and metoprolol. His temperature is 100.8°F (38.2°C), blood pressure is 90/60 mmHg, pulse is 110/min, and respirations are 24/min. On examination, his abdomen is notably distended and tender to palpation. A frontal abdominal radiograph is shown in Figure A. Which of the following is the most likely diagnosis in this patient? |
usmle-11924 | A 25-year-old man presents to his primary care provider complaining of several weeks of intense itching, particularly localized around his anus. Of note, the patient denies any recent travel, sexual contacts, fever, dysuria, or diarrhea. His temperature is 98.1°F (36.7°C), blood pressure is 110/70 mmHg, pulse is 65/min, and respirations are 12/min. On exam, the patient demonstrates severe excoriations in his perianal region with slight erythema over the areas that are torn. He does not have any other dermatologic findings. The scotch tape test is positive. The patient has a previous documented allergy to albendazole. Which of the following is an alternative medication that can be used? |
usmle-11925 | A 62-year-old man presents to the emergency department with a tender swollen right knee. He bumped this knee against his chair at dinner and was unable to stand. His past medical history is significant for a pulmonary embolism 3 months ago. Since then, he has been taking a medication to prevent recurrence of pulmonary embolisms. He is otherwise healthy but recently went on a vacation to Florida where he consumed large amounts of citrus fruits. Which set of lab findings shown in Figure A would be seen 1 day after starting the medication most likely taken by this patient? |
usmle-11926 | A 46-year-old woman presents to her primary care physician with one week of intermittent nausea and vomiting. She does not have any sick contacts, and her medical history is significant only for diabetes well-controlled on metformin. She also complains of some weakness and back/leg pain. She says that she recently returned from traveling abroad and had been administered an antibiotic during her travels for an unknown infection. On presentation, her temperature is 98.6°F (37°C), blood pressure is 119/78 mmHg, pulse is 62/min, and respirations are 25/min. An EKG is obtained showing flattening of the T wave. After further testing, the physician prescribes a thiazide for this patient. Which of the following diseases is also associated with this patient's most likely diagnosis? |
usmle-11927 | A 4-year-old male is brought to the pediatrician for a low-grade fever. His mother states that he has had a waxing and waning fever for the past 6 days with temperatures ranging from 99.8°F (37.7°C) to 101.0°F (38.3°C). She reports that he had a similar episode three months ago. She also reports symmetric joint swelling in the child’s knees and wrists that has become increasingly noticeable over the past 8 weeks. He has not had a cough, difficulty breathing, or change in his bowel movements. The child was born at 40 weeks gestation. His height and weight are in the 45th and 40th percentiles, respectively. He takes no medications. His temperature is 100.1°F (37.8°C), blood pressure is 100/65 mmHg, pulse is 105/min, and respirations are 18/min. On examination, there is a non-pruritic, macular, salmon-colored truncal rash. Serological examination reveals the following:
Serum:
Rheumatoid factor: Negative
Anti-nuclear antibody: Negative
Anti-double stranded DNA: Negative
Anti-SSA: Negative
Anti-SSB: Negative
Human leukocyte antigen B27: Positive
Erythrocyte sedimentation rate: 30 mm/h
This patient is most likely at increased risk of developing which of the following? |
usmle-11928 | A scientist is studying the characteristics of a newly discovered infectious disease in order to determine its features. He calculates the number of patients that develop the disease over several months and finds that on average 75 new patients become infected per month. Furthermore, he knows that the disease lasts on average 2 years before patients are either cured or die from the disease. If the population being studied consists of 7500 individuals, which of the following is the prevalence of the disease? |
usmle-11929 | A 47-year-old patient returns to his primary care physician after starting aspirin two weeks ago for primary prevention of coronary artery disease. He complains that he wakes up short of breath in the middle of the night and has had coughing "attacks" three times. After discontinuing aspirin, what medication is most appropriate for prevention of similar symptoms in this patient? |
usmle-11930 | A 26-year-old G1P0 woman presents to her primary care physician’s office with feelings of anxiety and trouble with sleep. She finds it difficult initiating sleep, occasionally has palpitations, and feels fatigued. She denies having similar symptoms in the past or starting any new medications or illicit drugs. She is currently 10 weeks pregnant and is closely followed by her obstetrician. Her temperature is 98.6°F (37°C), blood pressure is 125/70 mmHg, pulse is 105/min, and respirations are 18/min. On physical exam, the patient is mildly diaphoretic. The skin is warm and the thyroid gland is diffusely enlarged with thyroid bruits. Laboratory studies are significant for a thyroid-stimulating hormone level of 0.01 µU/mL (normal is 0.5-5.0 µU/mL) and an elevated free thyroxine (FT4) that is inappropriate for her pregnancy. Which of the following is the best treatment option for this patient? |
usmle-11931 | A 45-year-old woman presents to her primary care provider for wrist pain. She reports a 4-month history of gradually worsening pain localized to the radial side of her right wrist. The pain is dull, non-radiating, and intermittent. Her past medical history is notable for rheumatoid arthritis and von Willebrand disease. She does not smoke and drinks alcohol socially. She is active in her neighborhood’s local badminton league. Her temperature is 98.6°F (37°C), blood pressure is 125/75 mmHg, pulse is 80/min, and respirations are 18/min. On exam, she has mild tenderness to palpation in her thenar snuffbox. Nodules are located on the proximal interphalangeal joints of both hands. Ulnar deviation of the hand with her thumb clenched in her palm produces pain. Which of the following muscles in most likely affected in this patient? |
usmle-11932 | A 67-year-old female is brought to the emergency room by her son for unusual behavior. She moved into her son’s house three years ago after her husband passed away. The son reports that when he returned home from work earlier in the day, he found his mother minimally responsive. She regained consciousness soon after his arrival and did not recall the event. The son also reports that for the past two years, his mother has had trouble remembering names and addresses. She still goes shopping on her own and cooks regularly. Her past medical history is notable for major depressive disorder, diabetes mellitus, and hypertension. She takes clomipramine, glyburide, lisinopril, and hydrochlorothiazide. She recently saw her primary care provider who adjusted some of her medication dosages. Her temperature is 99°F (37.2°C), blood pressure is 135/75 mmHg, pulse is 80/min, and respirations are 18/min. On examination, she is easily distractible with disorganized speech. She does not recognize her son and thinks that her intravenous line is a rope. She says she feels fine and would like to go home. Brain imaging would likely reveal which of the following? |
usmle-11933 | A 58-year-old man comes to the emergency department for cough and fever for the past week. The cough is described as wet and productive of a yellow/greenish colored sputum with no blood. His past medical history is significant for diabetes, end-stage renal disease secondary to reflux nephropathy, and mild asthma. The patient is currently on tacrolimus and mycophenolate mofetil for a right kidney transplant 3 months ago. He just returned from Indiana and denies any sick contacts. A physical examination demonstrates diffuse crackles at the bibasilar lung fields, tachycardia, and verrucous lesions of the skin shown in Figure A. A chest radiograph is obtained and demonstrates diffuse alveolar infiltrates. What is the most appropriate treatment for this patient? |
usmle-11934 | A 52-year-old man comes to the clinic complaining of a transient loss of vision in his left eye that lasted for several minutes. He reports watching TV last night when he covered his right eye and noticed that his vision had “become black.” Several minutes later, his vision returned. The patient reports no precipitating event. Family history is significant for myocardial infarction in his father at age 58 and brother at age 47. His medications include hydrochlorothiazide and aspirin. Physical examination demonstrates AV nicking of retinal vessels bilaterally and a harsh murmur heard at the left abdomen. Which of the following laboratory findings (shown in Figure A) would you expect to find this patient? |
usmle-11935 | A 25-year-old female comes to the clinic complaining of fatigue and palpitations. She has been undergoing immense stress from her thesis defense and has been extremely tired. The patient denies any weight loss, diarrhea, cold/heat intolerance. TSH was within normal limits. She reports a family history of "blood disease" and was later confirmed positive for B-thalassemia minor. It is believed that abnormal splicing of the beta globin gene results in B-thalassemia. What is removed during this process that allows RNA to be significantly shorter than DNA? |
usmle-11936 | A 1-day-old male infant is evaluated in the neonatal intensive care unit (NICU) for dyspnea. He was born at 34 weeks gestation. Apgar scores were 6 and 8 at 1 and 5 minutes, respectively. The pregnancy was complicated by polyhydramnios. His mother is a healthy 33-year-old G1P1 woman who received adequate prenatal care. The nurse in the NICU noted increased oral secretions and intermittent desaturations. His temperature is 100.8°F (38.2°C), blood pressure is 100/55 mmHg, pulse is 130/min, and respirations are 28/min. On exam, the child appears to be in respiratory distress. Intercostal retractions are noted. Auscultation of the lungs reveals rales bilaterally. The patient’s abdomen is moderately distended. A chest radiograph is performed and demonstrates coiling of the nasogastric (NG) tube in the esophagus. This patient should be evaluated for which of the following conditions? |
usmle-11937 | A 32-year-old woman presents with a three-month history of difficulty swallowing. She says that it occurs with both solids and liquids with the sensation that food is getting stuck in her throat. Additionally, the patient reports that while shoveling snow this past winter, she had noticed that her hands would lose their color and become numb. She denies any cough, regurgitation, joint pains, shortness of breath, fever, or changes in weight. She does not smoke or drink alcohol. The patient’s physical exam is within normal limits, although she does appear to have thickened, tight skin on her fingers. She does not have any other skin findings. Which antibody will most likely be found on serological study in this patient? |
usmle-11938 | A 35-year-old woman with a one-year history of auditory hallucinations and periods of anhedonia and amotivation is being seen by her psychiatrist. She was started on haloperidol at her last visit, but she was told to stop taking the medication since she developed muscle stiffness and spasms soon after taking the drug. Today, her temperature is 97.7°F (36.5°C), blood pressure is 132/76 mmHg, pulse is 98/min, and respirations are 12/min. The patient is now started on a new medication that will seek to avoid the same side effects as her previous one; however, she will need to come in for weekly testing. Which of the following should be tested weekly? |
usmle-11939 | A 52-year-old fisherman presents to the clinic for an evaluation of a pigmented lesion on his neck. He states that he first noticed the lesion last year, but he believes that it has been slowly growing in size. Dermatopathology determines that the lesion contains neoplastic cells of melanocytic origin. Which of the following characteristics of the lesion would likely be found on physical examination? |
usmle-11940 | A 72-year-old female is brought in by ambulance after being found down in her home. Her daughter discovered her after returning from work and does not know how long she has been down. Physical exam reveals right sided paralysis with a positive babinski sign. She is also found to produce strained stuttering speech with no perceivable meaning. She is unable to follow any instructions and cannot repeat speech. An MRI is obtained showing a left MCA infarct. Damage to which of the following structures is most likely to be responsible for her language deficits? |
usmle-11941 | A 15-year-old African-American male with a BMI of 22 is brought to his physician by his mother to address concerns about a change in his dietary habits. The patient's mother notes that he is constantly hungry and thirsty, despite his eating and drinking water in excess. She also reports an increase in his use of the bathroom. The physician begins explaining that her son's symptoms are likely due to which of the following? |
usmle-11942 | A 39-year-old woman presents to her primary care physician because she has been experiencing intermittent abdominal pain for the last 2 weeks. She says that the pain is squeezing in nature, is located in the right upper quadrant, and is particularly severe after eating a meal. After a diagnosis is made, the patient asks why the pain gets worse after eating. The physician explains that food is detected by the gastrointestinal tract through numerous receptors and that this information is transmitted to other parts of the body to cause compensatory changes. The neurons responsible for transmitting this information are most likely located in a layer of the intestine that has which of the following characteristics? |
usmle-11943 | A 65-year-old male presents to the emergency room complaining of a severe headache. He developed a sudden-onset severe throbbing headache while watching a football game on television. His past medical history is significant for migraines and hypertension; however, he states that this headache is different from his normal migraine headaches. He has a 30 pack-year smoking history. His family history is notable for stroke in his mother and father. His temperature is 98.9°F (37.2°C), blood pressure is 150/90 mmHg, pulse is 100/min, and respirations are 14/min. On examination, he is oriented to person, place, and time. Neck motion is limited due to pain. Strength is 5/5 bilaterally in both the upper and the lower extremities and sensation is grossly intact across all the dermatomal distributions. Patellar, brachioradialis, and Achilles reflexes are 2+ bilaterally. The vessel that is most likely responsible for this patient’s condition directly branches off which of the following vessels? |
usmle-11944 | A morbidly obese 43-year-old man presents for elective bariatric surgery after previously failing several non-surgical weight loss plans. After discussing the risks and benefits of several different procedures, a sleeve gastrectomy is performed. During the surgery, the surgeon begins by incising into the right half of the greater curvature of the stomach. Which of the following arteries most likely directly provides the blood supply to this region of the stomach? |
usmle-11945 | A 38-year-old woman was brought to the emergency department after she experienced dizziness and shortness of breath while walking with her friend. She recently immigrated to the United States and is unable to report her previous medical history. Physical exam reveals pallor underneath her eyelids. Labs are obtained with the following results:
Hemoglobin: 8.4 g/dL
Platelet count: 62,000/mm^3
Mean corpuscular volume: 89 µm^3
Reticulocyte count: 0.1%
Lactate dehydrogenase: 175 U/L
Which of the following is associated with the most likely cause of this patient's symptoms? |
usmle-11946 | A 65-year-old male presents to his pulmonologist for a follow-up visit. He has a history of chronic progressive dyspnea over the past five years. He uses oxygen at home and was seen in the emergency room two months prior for an exacerbation of his dyspnea. He was discharged following stabilization. His past medical history is notable for hyperlipidemia and hypertension. He drinks alcohol socially and has a 45 pack-year smoking history. His temperature is 98.6°F (37°C), blood pressure is 140/75 mmHg, pulse is 110/min, and respirations are 22/min. On examination, increased work of breathing is noted. The physician decides to start the patient on an additional medication that has both mucoactive and anti-oxidative properties. What is the primary mechanism of action of this medication in the lungs? |
usmle-11947 | A 67-year-old African American male presents to his primary care physician for routine follow-up. He has a history of poorly controlled hypertension, despite being on lisinopril, hydrochlorothiazide, amlodipine and metoprolol, which he takes regularly. His blood pressure during the visit is 170/80. He does not have kidney disease. His primary care physician decides to start him on methyldopa. What is the mechanism of action of methyldopa? |
usmle-11948 | A 27-year-old man and his wife present to an infertility clinic for evaluation after they tried unsuccessfully to conceive for 2 years. He has no prior medical history and does not currently take any medications. On evaluation, he is found to have long extremities and gynecomastia. In addition, he has testicular atrophy and very little body hair, which is distributed primarily in the pubic region. Further analysis reveals azoospermia, and appropriate tests confirming the diagnosis are performed. The couple is told about the cause of their inability to conceive and given further options to pursue. Which of the following is associated with the pathophysiology underlying this patient's disorder? |
usmle-11949 | A 60-year-old man comes to the physician’s office with jaundice. Liver ultrasound reveals a shrunken liver and biopsy reveals cirrhosis. Hepatitis serologies are below:
Anti-HAV: negative
HBsAg: negative
HBsAb: positive
HBeAg: negative
Anti-HBe: negative
Anti-HBc: negative
Anti-HCV: positive
The hepatitis C viral load is 1,000,000 copies/mL. The patient is started on an antiviral regimen including sofosbuvir. What is the mechanism of action of this drug? |
usmle-11950 | A 68-year-old right hand-dominant man presents to the emergency room complaining of severe right arm pain after falling down a flight of stairs. He landed on his shoulder and developed immediate severe upper arm pain. Physical examination reveals a 2-cm laceration in the patient’s anterior right upper arm. Bone is visible through the laceration. An arm radiograph demonstrates a displaced comminuted fracture of the surgical neck of the humerus. Irrigation and debridement is performed immediately and the patient is scheduled to undergo definitive operative management of his fracture. In the operating room on the following day, the operation is more complicated than expected and the surgeon accidentally nicks a neurovascular structure piercing the coracobrachialis muscle. This patient would most likely develop a defect in which of the following? |