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A 36-year-old man presents to the emergency department for right upper quadrant abdominal pain and jaundice. His temperature is 38.5 °C (101.3 °F), heart rate is 96/min, and a blood pressure is 118/78 mmHg. Following initial work-up, the diagnosis of acute cholangitis is made. During endoscopic retrograde cholangiopancreatography (ERCP), the patient is found to have 2 distinct pancreatic duct openings. Which of the following embryologic processes likely failed to occur in this patient? +
A 52-year-old construction worker with no significant past medical history presents to the physician's office with complaints of right inguinal pain. The patient reports that his pain gradually worsens during the day and is worst at night. It is relieved almost completely when he lies down. Physical examination is remarkable for a bulge in the right inguinal region. The patient is diagnosed with a direct inguinal hernia bulging from the Hasselbach's triangle. Which anatomic structure most likely defines the medial aspect of the patient's hernia? +
A 42-year-old patient presents to the emergency department with painful episodes bright red blood-tinged vomiting. Upon questioning, the patient denies any past medical or surgical history, intake of any medications, or any allergies. He explains that his symptoms began after an initial episode of violent retching he attributed to recent binge drinking. The patient's vital signs are stable and his physical examination is unremarkable. Following initial work-up, the patient undergoes endoscopy. Which of the following best characterizes the pathological process responsible for this patient's hematemesis? +
A 36 week newborn is delivered vaginally. The specialist in charge notices the infant has blue hands and toes immediately after delivery. He is actively crying, has a heart rate of 145 bpm, has active withdrawal and grimaces to stimulation. Which of the following is this infant's APGAR score? +
A 36 week newborn is delivered vaginally. The specialist in charge notices the infant is blue throughout her body immediately after delivery. She has shallow gasps, her pulse is 75 bpm, has no reflexes and a weak tone. Which of the following is this infant's APGAR score? +
A 45-year-old man is referred by the primary care physician to the nephrologist's office. The patient is found to have elevated levels of anti-phospholipase A2 receptor (PLA2R) antibodies. The patient then undergoes a kidney biopsy that demonstrates subepithelial deposits and capillary wall thickening with normal cellularity. Anti-PLA2R IgG antibodies and C3 deposits are also observed on immunofluorescence. What is the most likely clinical presentation associated with this patient's condition? +
A 67-year-old man presents to the physician's office for high blood pressure. Physical examination is remarkable for elevated blood pressures and faintly audible abdominal bruits bilaterally. The physician orders a Doppler ultrasound and the diagnosis of high-grade bilateral atherosclerotic renal artery stenosis is made. The physician decides to initiate anti-hypertensive therapy. Which of following medications should be avoided in this patient? +
A 65 year old male comes to the ER with complaints of acute sharp and cramping right upper abdominal pain, 8/10 in severity, spreading to his right shoulder blade and worsening over the past six hours. The pain is accompanied by nausea and vomiting. He is a known alcoholic cirrhotic patient. His vital signs are heart rate 112 beats/min, respiratory rate 20/minute, blood pressure 100/60 mm Hg and oral temperature 39.2 C. On physical examination yellowing of his skin and sclera are obvious, and abdominal examination elicits guarding and tenderness without rigidity. Emergency serum biochemistry tests were ordered and it revealed the following results<br>
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RBC count: 4.2 million/mm3<br>
WBC count: 16,000/ mm3<br>
Platelet count: 140,000/mL<br>
Aspartate aminotrasferace (AST): 100 IU/L<br>
Alanine aminotrasferace (ALT): 70 IU/L<br>
Total bilirubin: >4 mg/dL<br>
Serum albumin: 2 g/dL<br>
Prothrombin time: 22 seconds<br>
Partial thromboplastin time: 80 seconds<br>
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An emergency ultrasound was also performed and it revealed a calculous cholecystitis. The patient requires an emergency laparoscopic cholecystectomy. A transfusion of fresh frozen plasma is planned to minimize the risk of bleeding due to surgery. The transfusion should be started +
A 52 year old woman has come to her primary care physician’s office for a routine annual examination. She has no complaints. She has no known family history of breast or cervical or colorectal cancer. She is a non-smoker. She drinks a glass of wine once in a month for the past 15 years and does not use illicit drugs. Her vital signs are heart rate 82 beats/min, respiratory rate 16/minute, blood pressure 110/70 mm Hg and oral temperature 37.2 C. On physical examination she looks well nourished. A routine pelvic examination with Pap test and a mammography were done. As a part of the routine preventive care, the physician advices her regarding screening for colorectal cancer. Which will be the most effective method of screening for colorectal cancer in this patient? +
A 25 year old woman has come to her primary care physician’s office for a routine annual examination. She has no complaints. She has no known family history of breast or cervical cancer. But the physician is made aware of the patient's 40 year old elder sister who recently underwent surgery for colon cancer found as a result of routine colorectal cancer screening and surgeries for colon cancer in her mother and her aunt at the ages of 60 years and 70 years respectively. She is a non-smoker. She drinks a glass of wine once in a month for the past 2 years and does not use illicit drugs. She lives with her boyfriend and has no history of multiple sexual partners. Her vital signs are heart rate 82 beats/min, respiratory rate 16/minute, blood pressure 110/70 mm Hg and oral temperature 37.2 C. On physical examination she looks well nourished. A routine pelvic examination with Pap test and a clinical breast examination were done. She is concerned about her family history of colon cancer. Which will be the most effective targeted method of preventive care in this patient? +
A 38 years old Caucasian male is admitted following complaints for 2 months history of diarrhea. It is associated with abdominal pain, progressing from the upper to the lower abdomen, and weight loss. The patient has no previous history of similar illness or surgery. He denies alcohol or tobacco use. His vital signs are heart rate 82 beats/min, respiratory rate 16/minute, blood pressure 110/70 mm Hg and oral temperature 37.2 C. Physical examination revealed a distended abdomen with increased bowel sounds and a palpable mass at the left lower quadrant of the abdomen. Routine laboratory tests revealed no alterations in the principal biochemical parameters, except for the levels of the following tumoral markers:<br>
<br>
CA 19-9 = 85.7 U/ml (normal value: up to 37 U/ml)<br>
CEA = 13.7 ng/ml (normal value: up to 3 ng/ml)<br>
CA 50 = 51.3 U/ml (normal value: up to 19 U/ml)<br>
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Abdominal USG revealed a mass of 9 × 5 cm of mixed echogenicity in the proximity of the sigmoid colon with some hypoechoic lymph nodes of increased volume in the adipose adjacent tissue. It was followed by colonscopy with biopsy, where a polypoid vegetating mass, involving the 2/3 of the intestinal circumference was found in the caecum. Histopathological examination of the mass showed microscopic aspects of adenocarcinoma. The abdominal CT with intravenous contrast showed the mass with an increase in the volume of mesenteric lymph nodes. What will be the line of management in this patient? +
A 28 year old African-American male presented to the emergency department with complaints of lethargy and vomiting for the past one day. He is a known type 1 diabetes mellitus patient. He had a gastrointestinal disturbance before two days following which he restricted his food intake and skipped his insulin doses. He also revealed playing soccer with his friends last evening. Physical examination revealed a confused, dehydrated, tachypneic male with vital signs like heart rate of 120 beats/min, blood pressure of 98/58 mmHg, respiratory rate of 35/minute and oral temperature of 37.2 C. Pulseoximetry read as 94%. Which is the next best step in the management of this patient? +
A 28 year old African-American male presented to the emergency department with complaints of lethargy and vomiting for the past one day. He is a known type 1 diabetes mellitus patient. He had a gastrointestinal disturbance before two days following which he restricted his food intake and skipped his insulin doses. He also played soccer with his friends last evening. Physical examination revealed a confused, dehydrated, tachypneic male with vital signs like heart rate of 120 beats/min, blood pressure of 98/58 mmHg, respiratory rate of 35/minute and oral temperature of 37.2 C. A rapid finger glucose test revealed plasma glucose of 638 mg/dL, thus confirming diabetic ketoacidosis. He was started on 0.9% normal saline while waiting for the following laboratory tests<br>
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Serum sodium: 130 mEq/L<br>
Serum potassium: 5.2 mEq/L<br>
Serum chloride: 87 mEq/L<br>
Serum bicarbonate: 12 mEq/L<br>
Serum BUN: 32 mg/dL<br>
Serum creatinine: 1.5 mg/dL<br>
Blood glucose: 700 mg/dL<br>
Blood pH: 7.08<br>
PaCO2: 25 mmHg<br>
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Urinary Ketones turned out to be positive. Meanwhile he was transferred to the intensive care unit. What is the next best step in line of management of this patient? +
A pathologist is studying the process of healing in rats. Following acute injury, he demonstrates that inflammatory cells produce growth factors that help in wound healing. Growth factors are capable of stimulating specific cells to migrate to the site of the wound. During the proliferation stage of wound healing, which immunohistochemical stain will most likely be strongly positive? +
A 60-year-old male presents to the physician for several episodes of fainting in the last 4 weeks. His past medical history is significant for hypertension and diabetes mellitus. His current medications are glibenclamide , atorvastatin , losartan and multivitamins. On physical examination, his vital signs show a heart rate of 75 bpm with weak peripheral pulses, and a blood pressure measuring 110/80 mmHg. Cardiac auscultation reveals a crescendo decrescendo systolic ejection murmur that increase in intensity with elevation of the legs. What is the most likely diagnosis? +
A 32-year-old female presents to the physician for concern over several “scary” episodes over the past two months. During these episodes she reports feeling her heart race, nausea, difficulty breathing and numbness throughout her body. Her pulse rate is 76/min, blood pressure is 110/70 mm hg and respiratory rate is 16/minute. Cardiac auscultation reveals a mid-systolic click with a murmur that decreases in intensity on hand grip. What is the best initial treatment for this patient’s symptoms? +
A 40 year old male presents to the emergency department for difficulty breathing that started an hour prior and lasted for 15 minutes. Over the past 2 months he has experienced 3-4 similar episodes, which were brought on by exertion and relieved by rest. Other complaints include swelling of both feet and difficulty in swallowing. His past medical history is significant for hypertension and gout. He is an immigrant from Brazil and works as a security officer in the mall. His pulse rate is 72/min, and blood pressure is 100/70 mm hg. Cardiac auscultation reveals an S4 gallop. Electrocardiogram and cardiac enzymes are normal and echocardiography shows an ejection fraction of 50 percent. What is the most likely cause of this patient’s condition? +
A 25-year-old male presents to the physician complaining difficulty in breathing on exertion for the last 2 days. He has had fever, sore throat, diarrhea and vomiting for the last week. He took Tylenol for fever. He has smoked one pack a day for the past year and consumes alcohol occasionally. He is married and lives with his wife and one son. His wife had diarrhea and fever as well during the past week but has recovered. Physical examination reveals jugular venous distension and chest auscultation is significant for an S4 heart sound and rales in the lung bases. +
A 38-year-old female presents to the office with complaints of intermittent chest pain for the last 3 months. The pain is severe while lying down and subsides upon sitting. She also complains of on and off knee pain. Vitals signs include blood pressure 120/70, respiratory rate 20/minute and pulse rate 78 bpm. On physical examination there is a purplish rash on face. Electrocardiogram shows diffuse ST segment elevation. What is the most specific test to diagnose the underlying cause of this chest pain? +
A 50-year-old male presents to the office for pain in the right leg on walking for the last 6 months. The pain is present when walking both uphill and downhill but he gives no history of pain while resting and denies pain in the left leg. He has history of diabetes mellitus and hypertension and is on medication. 6 months ago he injured his right leg while moving some heavy boxes, he went to doctor and an X-ray of the right leg was normal. He has consumed 2 glasses of wine every day for the last 20 years and has smoked a pack of cigarettes every day for the last 15 years. What is the best initial test towards diagnosing the patient’s condition? +