Anatomy Question Set 2

A 31-year-old female presents with high-grade fever with chills, abdominal pain, and malaise for the past 5 days. Severe costovertebral angle tenderness is noted. The patient is admitted and blood is drawn. Lab reports reveal leukocytosis with predominant neutrophilia, increased C-reactive protein and ferritin levels. She is suspected to have a retroperitoneal organ infection with subsequent abscess formation. Which of the following best describes the involved organ?

A 41-year-old truck driver presents with pain and swelling in his right leg. He has just returned from Mexico after a shipment delivery and was on road for 2 days with small breaks. Physical exam reveals erythema, warmth, and tenderness of the leg posteriorly. Homans sign is positive. Doppler ultrasound reveals a thrombus in the right popliteal vein. Which of the following veins will have reduced blood flow due to the thrombus?

A 53-year-old businessman is rushed to the ER with a complaint of sudden onset severe crushing central chest pain radiating to his left arm and jaw. He has a history of episodic chest pain on exertion for which he uses glyceryl trinitrate sublingually but today his medication did not relieve the pain. An electrocardiogram showed ST-segment elevation in leads II, III, and aVF. Blood was drawn and sent to the lab which was positive for cardiac troponins. A diagnosis of acute inferior myocardial infarction was made and necessary treatment was started immediately which included coronary artery catheterization and angioplasty with stent placement. The coronary catheterization will most likely reveal blockage of which of the following arteries in this patient?

A 28-year-old man presents to the ER with difficulty in vision and diplopia. On eye exam, he cannot look outwards and, when trying to look straight ahead, the eye is turned in. He was involved in a bar fight and suffered a penetrating wound that severed the cranial nerve proximal to its entrance into the orbit. Which of the following nerves is most likely injured?

A 31-year-old female presents with shortness of breath, palpitations, and fatigue. She has a past history of infective endocarditis. The physical examination reveals a displaced hyperdynamic apex, soft S1, S3 present, and a pan-systolic murmur that radiates to the axilla. Echocardiography reveals one of the cardiac valves is not functioning properly and causing regurgitation. In normal individuals, this valve can be best heard by placing the stethoscope over the:

A 24-year-old professional soccer player presents with discomfort and pain while walking, and unstable knee joint following an injury during the match. The patient heard a popping sound at the time of injury. Physical examination reveals swelling of the knee joint and tibia could be moved excessively forwards on the femur. Which of the following knee structures is most likely damaged?

A 47-year-old man presents to you with gradual loss of voice and difficulty swallowing. Physical exam also reveals loss of taste on the posterior one-third of his tongue and palate; weakness in shrugging his shoulders, absent gag reflex, and uvula deviates away from the midline. MRI scan was suggested which revealed a meningioma that was compressing some cranial nerves leaving the skull. Which of the following openings in the skull transmit the affected cranial nerves?

A 31-year-old male presents to the emergency department with sudden shortness of breath and chest pain. Physical exam revealed stony dullness on percussion and absent breath sounds on one side. Chest x-ray shows opacification of one of his lungs. Thoracentesis revealed chylothorax that probably resulted from rupture of the thoracic duct. Which of the following areas will have normal lymphatic drainage?

A 24-days-old neonate boy is brought to the pediatrician with high-grade fever, inability to feed, and lethargy. The baby looks floppy, unresponsive, and difficult to wake. Physical exam reveals bulging fontanelles. He is admitted to the Neonatal ICU to rule out meningitis, and lumbar puncture is performed. During the lumbar puncture, the needle may penetrate which of the following pairs of structures to withdraw the cerebrospinal fluid (CSF)?

A 47-year-old woman presents to the office with the complaints of difficulty in speaking and swallowing for the past 2 weeks. She has difficulty in swallowing solid food but not liquids. She also complains of blurry vision for the same duration. She does not have any significant past medical history and claims to have been healthy before these symptoms appeared. Physical examination is significant for fullness of the suprasternal notch and a slurred speech. Routine blood tests reveal no abnormal lab values but a chest Xray shows a widened mediastinum. A CT scan of the chest reveals a mass in anterior mediastinum with irregular borders and coarse calcification. A CT guided biopsy is performed. Which of the following cell surface markers would this patient’s mass be positive if an immunophenotyping of the biopsy sample is performed?

A 7-year-old girl is brought to the pediatrician by her mother with the complaint of a lump at the base of her neck which they noticed a few days back. The mother adds that her daughter's left eyelid seems to be drooping making the left eye look small. There is no significant past medical history. On neurological examination, the patient has a normal bilateral pupillary reflex but a miotic left pupil. A lateral X Ray of the chest reveals a mass in the posterior mediastinum with no evidence of bone erosion. An MRI is done and the result is given below. An imaging guided biopsy of the is performed which reveals spindle-shaped cells arranged chaotically, with moderate cytoplasm and spindle shaped nuclei. Scattered mature ganglion cells are also present with abundant cytoplasm and round to oval nuclei. The specimen is also treated with immunohistochemical stains and is found to be positive for S-100, synaptophysin, chromogranin, and leucocyte common antigen (LCA). Which of the following prognostic factors is associated with poor prognosis of the tumor in this patient? (Image: by Fatimi et al; licensee BioMed Central Ltd. 2011, http://media.springernature.com/full/springer-static/image/art%3A10.1186%2F1752-1947-5-322/MediaObjects/13256_2010_Article_1679_Fig1_HTML.jpg, License: CC BY 2.0, https://creativecommons.org/licenses/by/2.0/)

A 43-year-old Asian American woman presents to the Emergency Department with the complaints of palpitation, dry cough and shortness of breath for one week. She immigrated to the US at the age of 20. She says that her heart is racing and she has never felt these symptoms before. Her cough is dry and is associated with shortness of breath that occurs with minimal exertion. Her past medical history is otherwise unremarkable. She has no allergies and is not taking any medications currently. She is a nonsmoker and an occasional drinker. She denies use of any drug abuse. Vital signs are as follows: Temperature: 98.2 °F, Pulse: 76/min irregularly irregular, Blood pressure: 100/65 mmHg, Respiratory Rate: 23/min. Her physical exam is significant for bibasilar lung crackles and a low-pitch, mid-diastolic rumbling murmur best heard at the apical region without radiation. In addition, she has jugular vein distention and bilateral pitting edema in her lower extremities. Which of the following best describes the infectious agent that led to this patient’s condition?

A 53-year-old African American woman visits her physician with the complaints of shortness of breath and fatigue for a couple of weeks. She was diagnosed with hypertension 20 years back and is on hydrochlorothiazide and losartan. Her family history is positive for hypertension. Her mother died at 54 from a stroke and both her grandparents suffered from cardiovascular disease. She has a 13 pack year smoking history and drinks alcohol occasionally. Her vital signs are as follows: Temperature: 98.1 °F, Heart Rate: 95 /min, Blood Pressure: 140/100 mmHg, Respiratory rate: 28 /min. On physical examination, there are bibasilar rales, distended jugular veins, and pitting edema in both lower extremities. Her pulses are irregularly irregular and her apical pulse is displaced laterally. Fundoscopy reveals presence of copper wiring and cotton wool spots. Which of the following echocardiographic findings most likely will be found in this patient?

A 17-year-old girl while playing volleyball at her school’s court grabs her chest and collapses on the ground. A nurse who was present at the site rushes towards the girl to evaluate the situation realizes that she has no pulse and wasn’t breathing. Chest compressions are started immediately and an Automated External Defibrillator is brought to the scene within three minutes. A shock is advised and delivered. The patient recovers and attains a regular sinus rhythm and regains consciousness. The patient was rushed to the emergency room. Her pulse in the ER is 65/min and regular, and her BP is 122/77 mmHg. ECG shows a shortened PR interval, a wide QRS complex, a delta wave and an inverted T wave. Which of the following is the most likely pathology in the conduction system of this patient's heart?

A 68-year-old woman visits her family physician with the complaints of shortness of breath and left-sided chest pain for a week. She says that her breathlessness is getting worse and the chest pain is more when she takes a deep breath. She has never had similar symptoms in the past. Her past medical history is insignificant except for occasional heart burns. She currently does not take any medication. She is a non-smoker and drinks alcohol occasionally. She denies use of any illicit drugs including marijuana. Vital signs include: Blood pressure of 122/78 mmHg, pulse of 67/min, respiratory rate of 20/min and a temperature of 99 °F. Her physical examination is remarkable for diminished chest expansion on the left side, an absence of breath sounds at the left lung base and dullness to percussion and decreased tactile fremitus on the same side. A plain radiograph of the chest reveals a large left sided pleural effusion occupying almost two-thirds of the left lung field. 2L of fluid is drained from the thorax under ultrasound guidance.. Which of the following positions with location is the safest for this procedure?

A 24-year-old man is rushed to the emergency room after he had a motor vehicle accident on a highway. He was driving alone and lost control of his vehicle as he was hitting a speed of 160 mph. In the ER, the patient is alert and oriented but is having difficulty breathing. He has a severe right sided chest pain which he rates 8/10. His vitals are Blood pressure: 90/65 mmHg, respiratory rate: 30/min, pulse: 120/min and temperature: 99F. The primary survey shows bruise over the anterior chest, distended neck veins, left sided tracheal shift with a subcutaneous emphysema in the base of his neck. Respiratory movements are diminished on the right side and the area is hyperresonant on percussion. Which of the following findings is indicative of cardiogenic shock in this patient?

A 12-year-old boy is brought to the pediatric clinic by his mother with a two-day history of fever and generalized weakness. She further adds that her son was involved in a school fight with some other kids four days ago and sustained minor injuries to the face but was otherwise well until this morning when he complained of pain in his right eye. Physical examination reveals erythema around the right eye along with ophthalmoplegia and proptosis. Which of the following findings will most likely be present in this patient on the affected side as a sequela of the condition he currently has?

A 65-year-old female presents to her physician with the complaint of a ringing in her right ear. She says it started about 3 months ago and has noticed a progressive difficulty in hearing on the same side. Past medical history is significant for a hysterectomy 5 years back for dysfunctional uterine bleeding. She is currently not taking any medications. She is a non-smoker and drinks socially. She denies any other complaints. Vital signs reveal a blood pressure of 130/78 mmHg, a pulse of 76/min, a temperature of 37 °C and respiratory rate of 14/min. On otoscopic examination, a red-blue pulsatile mass is observed behind the right tympanic membrane. A noncontrast CT scan of the head shows significant bone destruction resulting a larger jugular foramen highly suggestive of a tumor derived from neural crest cells. Which of the cranial nerves are most likely to be involved in this type of lesion?

A 65-year-old male presents to the emergency department with facial weakness. The patient states that he noticed that his face appeared twisted while he looked at the bathroom mirror this morning. He is otherwise well and does not have any other complaints. He does not have facial pain or paresthesia. Neurological examination reveals that the patient has difficulty shutting the right eye tight and bringing up the right corner of his mouth when asked to smile. There are no other neurological findings besides those on the right side of the face. What is the most likely diagnosis?

An 85-year-old previously healthy female is brought to the emergency department by her niece with the complaint of left sided weakness. Her symptoms started 4 hours ago while she was on the phone with her niece. The patient recalls dropping the phone and not being able to pick it up with her left hand when she tried. The niece drove over to check on her and brought her to the hospital. Physical examination reveals left-sided sensory and motor loss of the upper limb and face. Ophthalmic examination reveals conjugate eye deviation to the right. Non-contrast CT scan is negative for any evidence of hemorrhagic stroke and the patient is started on aspirin. A repeat contrast CT scan a few days later reveals a right-sided ischemic stroke involving the lateral convexity of the cerebral cortex. What other finding is most likely to be found in this patient?

A 75-year-old female is brought into the emergency department by her niece with the complaint of sudden loss of vision. The patient recalls reading when suddenly she was not able to see the print on half of the page. The symptoms started 4 hours ago and are accompanied by a severe headache at the back of her head. Physical examination reveals a blood pressure of 119/76 mm/Hg, the pulse of 89 per minute and SpO2 of 98 % on room air. An urgent non-contrast CT scan of the head shows no evidence of hemorrhagic. Later during the rounds with the attending physician, the patient did not recognize her niece. What is the most likely diagnosis?

A 25-year-old female student presents to the physician with the complaint of several episodes of headache in the past 4 weeks that are affecting his school performance. The episodes are getting progressively worse, and over-the-counter headache and migraine medication do not seem to help. She also mentions about having to raise her head each time to look at the board when taking notes; she cannot simply glance up with just her eyes while facing her notes. She has no significant past medical or family history and was otherwise well prior to this visit. Ophthalmic examination shows an upward gaze palsy, convergence-retraction nystagmus, and papilledema. What structure is most likely to be affected by this patient's condition?

An 86-year-old female is brought to the emergency department by her niece because the patient felt like she was spinning and about to topple over. This occurred around 4 hours ago, and although symptoms have improved, she still feels like she is being pulled to the right side. Vital signs show a blood pressure of 116/75 mm/Hg, the pulse of 90 per minute and SpO2 of 99 % on room air. Physical examination reveals right-sided limb ataxia along with hypoalgesia and decreased temperature sensation on the right side of the face and left-side of the body. An urgent non-contrast CT scan of the head shows no evidence of hemorrhage. What other finding is most likely to be present in this patient?

A 28-year-old man presents to the physician with the complaint of a four-week history of headaches that is affecting his academic performance. Over the counter medication does not seem to help. He also mentions he has to raise his head each time to look at the board when taking notes as he cannot simply glance up with just his eyes when facing his notes. Ophthalmic examination shows an upward gaze palsy, convergence-retraction nystagmus, and papilledema. CT scan of the head reveals a 1.5 x 1.2 cm heterogeneous mass in the epithalamus with dilated lateral and third ventricles. What other finding is most likely to be associated with this patient’s condition?

A 56-year-old male with a significant past medical history of diabetes mellitus, hypertension and hypercholesterolemia is brought to the emergency department by his wife. The wife states the symptoms started an hour ago when she noticed he was having difficulty swallowing his breakfast and his voice became hoarser. The patient had a recent admission for a transient ischemic attack but was not compliant with his discharge instructions and medication. Examination of the eye shows a left-sided partial ptosis and miosis along with diplopia and nystagmus. During the examination, it is noted that the right side of the face had markedly more sweat than the left. A later MRI of the brain revealed an ischemic infarct at the level of the left lateral medulla. Which of the following most likely accounts for the associated pathology?

A 35-year-old woman who was recently ill with a cold presents to the emergency department with the weakness in her lower limbs. She is unable to get up from the chair without some assistance. The symptoms began with a burning sensation in her toes along with numbness. She claims that the weakness has been getting worse over the last few days and now involving her arms and face. Physical examination shows a blood pressure of 145/89 mmHg, pulse of 99/min, respiratory rate of 22 breaths/min and SpO2 of 93 % on room air. She has diminished breath sounds on auscultation of bilateral lung fields with noticeably poor inspiratory effort. Palpation of the lower abdomen reveals a palpable bladder. Neurological examination is consistent with the complaints above. What is the most likely diagnosis?

A 50-year-old male with no significant past medical history comes to the physician with a complaint of difficulty grabbing things off the table - he seems to misjudge how far they are from his reach. He also reports a mild difficulty walking down the stairs or reading his morning paper. His wife has also noted he has been keeping one almost completely shut during the week. Physical examination of the eye reveals a dilated left pupil (mydriasis) that is positioned down and out. A digital subtraction angiogram (DSA) reveals a left-sided 1cm berry's aneurysm at the junction of the posterior communicating and distal posterior cerebral artery. Which of the following statements is most correct regarding the H-test of his affected eye?

A 63-year-old male is brought to the emergency department by his wife because she is concerned he is having another stroke. He was diagnosed with a stroke 10 years ago and since then has recovered and led a healthy lifestyle and is compliant with his medication. Additionally, he recently developed shingles and is being treated with acyclovir. He has had right-sided facial weakness and droop since waking up this morning. The symptoms are limited to the face, affecting the entire right side. Physical examination shows normal vital signs and otherwise normal examination. Which of the following is most likely another finding for this patient?

A 25-year-old male is admitted to the hospital after a severe motor vehicle accident as a unrestrained front seat passenger. Appropriate lifesaving measures are given, and the patient is now hemodynamically stable. Physical examination shows a complete loss of consciousness. There are no motor or ocular movements with painful stimuli. The patient has bilaterally intact pupillary light reflexes. Vestibulo-ocular reflex testing is performed. The patient is placed in a 30° semi-recumbent position and stimulated. The results are recorded. What is the most likely finding on this patient's right ear examination?

A 65-year-old male is brought into the emergency department by his wife for slurred speech and right sided weakness. The patient has a significant past medical history of hypertension and hyperlipidemia. The wife reports her husband went to bed last night normally but woke up this morning with the above symptoms. Physical examination shows right-sided hemiparesis along with the loss of vibration and proprioception. Cranial nerve examination shows a deviated tongue to the left. What is the most likely diagnosis?

A 75-year-old man is brought to the Emergency Department by his son. He is suffering from left sided weakness. The symptoms started 2 hours ago with sudden left sided weakness. The patient is a known hypertensive, who is inconsistently compliant with his two anti-hypertensive medication and a heavy smoker, with 40 pack-years. Physical examination shows an elderly male in mild distress with a blood pressure of 140/95 mmHg, a pulse of 89 per minute and SpO2 of 98% on room air. Neurological examination shows left-sided hemiparesis, with no sensory, cognitive or brain stem abnormalities. A CT scan of the head without IV contrast shows a left-sided ischemic infarct. What other finding is most likely to develop in this patient as his condition progresses?

A 56-year-old female present to the Emergency Department with severe pain in her legs. She has had these pains in the past, but access to a doctor was not readily available in her remote village back home. She and her family have recently moved to the United States. She is seen walking to her stretcher with a broad-based gait. She has a non-itchy maculopapular rash on her hands and feet. Ophthalmic examination shows an absent pupillary light reflex, but pupillary constriction with accommodation and convergence. She is given a stat dose of IV penicillin G benzathine. What other sign or symptom is most likely in this patient?

A 40-year-old businessman who was previously well is brought into the Emergency Department by his assistant with a complaint of left-sided weakness after chiropractic neck manipulation. A T2-weighted MRI shows a left C5 hemicord lesion. The patient is treated with cervical immobilization, a course of steroids and physical therapy. What other finding is most likely in this patient?

A previously well 25-year-old female was brought to the emergency department by her boyfriend because of progressively blurred vision. Examination of the eyes reveals loss of horizontal gaze, intact convergence, and nystagmus. A clinical diagnosis of multiple sclerosis is made, and the patient is started on a course of corticosteroids. What is the most likely etiology for her eye examination findings?

A 21-year-old motorcyclist was involved in a motor vehicle accident and died. His corpse was brought to the Medical Examiner’s where they performed a forensic autopsy. On exam, they noticed increased mobility at the neck. A section of cervical spine at C6 was removed and processed into slides. What histopathological features are most likely true for this spinal cord level?

A 63-year-old male presents to the physician with the complaint of back pain for the past 2 months. The pain is present throughout the day, even at night when he lies down on his bed. He also complains of difficulty walking upstairs and says he recently started to wear adult diapers because he seems to have difficulty controlling his bowel movements. His vitals are within normal limits. Neurological examination reveals bilateral lower limb weakness as well as diminished temperature and vibratory sensation. Rectal examination reveals a hard nodular mass and weak rectal sphincter tone. Which of the following is the most likely cause of his symptoms?

A 45-year-old male with a very promiscuous sexual history as a travel writer from the age of 19, presents to the physician with a complaint of long standing ulcers on the bottom of his feet. He recalls having ulcers before in his genital area back when he was 19 and writing about the South American rain forest. The ulcers had healed on their own before he got to the main city to see a doctor. Rapid plasma reagin (RPR) is positive, and the result of Treponema pallidum particle agglutination (TP-PA) is pending. What other finding is most likely to be present in the physical exam of this patient?

A 25-year-old man from India visits the clinic with the complaints of feeling tired all the time and lack of energy for the past couple of weeks. He also complains of weakness and numbness of his lower limbs. He came to the US two years back and continues to follow his Indian diet which consists of only plant products. He says he has not eaten anything a non-vegetarian diet since the age of 18, not even eggs and milk products. He does not take any vitamin or dietary supplements. Physical examination reveals a smooth red beefy tongue along with lower extremity sensory and motor deficits. What other finding is most likely to accompany this patient's condition?

A 35-year-old baseball player with no significant past medical history presents to his physician with the complaint of stiffness in his hands. He is unable to bat as he would like to and feels like he lacks power in his swings. His wife also noted that he sometimes appears to be dragging his feet while walking and that his voice seems to have changed. Neurological examination reveals significant decrease in muscle power in the extensor and flexor group of muscles in both upper and lower limbs. There are no sensory deficits but fasciculations are noted. What is the most likely diagnosis for this patient?

A 56-year-old male is rushed to the Emergency Department by his son due to severe back pain for the past one hour. The pain started about 1 hour ago, with no relief of symptoms. The patient describes the pain as sharp, 10/10 pain located between his scapula. He is a known hypertensive but is noncompliant with his medications. His blood pressure 180/95 mmHg and pulse is 108/min. Neurological examination reveals loss of pain and temperature sensation in the lower trunk along with bilateral lower limb weakness. CT scan of the chest reveals a Type-B aortic dissection. Which of the following is the most likely cause of his neurological findings?

A 45-year-old chronic smoker presents to the physician with the complaint of worsening left shoulder pain for several months but has become steadily worse over the past two weeks and is now radiates down his left arm. Physical examination reveals a palpable 2 x 1.5cm supraclavicular lymph node along with decreased grip strength in his left hand. Examination of the face reveals partial ptosis of the left eyelid and miosis of the same eye. Laboratory testing offers the following values: Sodium (Na+): 135 mEq/L Potassium (K+): 3.6 mEq/L Chloride (Cl-): 100 mEq/L BUN: 12 mg/dL Creatinine (Cr): 0.6 mg/dL Magnesium (Mg2+): 1.5 mg/dL Phosphate: 3 mg/dL Calcium (Ca2+): 8.5 mg/dL An X-ray of the chest reveals a soft tissue mass at the apex of the left lung with possible involvement of the first rib. What is the most likely diagnosis?

A 45-year-old man presents to the physician with the complaints of increased urinary frequency and decreasing volumes for the past 2 months. He does not complain of any pain during urination. He is frustrated that he has to wake up 2 or 3 times to urinate even though he tried reducing the amount of water he consumes before bed and made some other dietary changes without any improvement. He has no family history of prostate disease. Physical examination is negative for any suprapubic mass or tenderness and there is no costovertebral angle tenderness. Which of the following is the best next step in the management of this patient?

A 25-year-old female student presents to the physician with the complaint of several episodes of headache in the past 4 weeks that are affecting his school performance. The episodes are getting progressively worse, and over-the-counter headache and migraine medication do not seem to help. She also mentions about having to raise her head each time to look at the board when taking notes; she cannot simply glance up with just her eyes while facing her notes. She has no significant past medical or family history and was otherwise well prior to this visit. Ophthalmic examination shows an upward gaze palsy, convergence-retraction nystagmus, and papilledema. What structure is most likely to be affected by this patient's condition?

A professional musician visits his physician after a morning concert. He is concerned that his right cheek swells up when he plays his tuba. The swelling only lasts a short while and is not painful. On extra-oral examination, the patient has slight facial asymmetry due to minor swelling on the right side of his face. The skin over the swelling is smooth. There are no secondary changes. Palpation reveals a soft, non-tender swelling. Intra-orally, the mouth opening is normal and there is no trismus. A swelling is present in the left buccal mucosa extending from first to the third molar. The physician visualizes the swelling with the office ultrasound machine and diagnosis this patient with pneumoparotid. What nerve supplies motor function to prevent air from entering the affected duct in this patient?

A 50 year old man presents to the Emergency Department complaining of retrosternal pain and drooling that started immediately after eating a steak. His past medical history is significant for lye ingestion 5 years ago during a suicide attempt. On physical exam, the patient is drooling, but there is no airway compromise or evidence of aspiration. The patient’s heart rate is 96 bpm, his Temperature is 98 F degrees and there is no subcutaneous crepitus or swelling of the neck or chest. Endoscopy confirms the presence of a retained bolus of meat 24 cm from the incisors where a stricture is identified. The bolus is removed and the stricture is dilated during an endoscopic procedure. Where is the stricture located? What area contains the structure that creates a physiological narrowing of the esophagus most likely involved in the development of this patient’s stricture from caustic ingestion?

A 48 year old woman comes to the doctor’s office complaining of severe, frequent heartburn and chest pain. It feels like food is getting stuck in her throat somewhere. She wakes up at night in fits of cough and in excruciating pain. Lately, the pain does not resolve even after taking a cocktail of Tums, Gas-ex, and Motrin. The physician feels she has acid reflux and recommends upper endoscopy and a trial of omeprazole. Several biopsies are taken: one from the distal esophagus, one from the EG junction, and one from the body of the stomach. Which histological finding would place her at the highest risk of developing esophageal adenocarcinoma in the near future?

A 58 year old Department store manager comes to his doctor’s office complaining that he had recently been waking up in the middle of the night with abdominal pain. This was happening several nights a week. He was also experiencing occasional discomfort in the middle of the afternoon. The patient's appetite had suffered as a result of the pain he was experiencing. His clothes hang around him loosely. The remaining of the patient’s history and physical exam was completely normal. The patient does not take any prescription or over the counter medications. The doctor referred the patient for a stomach acid test and an upper endoscopy The stomach acid test revealed that this patient is a heavy acid producer and the upper endoscopy revealed a gastric peptic ulcer. This ulcer was likely found in which part of the stomach?

A 45 year old bank manager presents to the Emergency Department with epigastric abdominal pain for two weeks. He describes the pain as 10/10 in intensity, stabbing and relentless. The ingestion of food makes it better, as does the consumption of milk, but now the patient is vomiting, and in the last hour he vomited blood. He appears pale, feels dizzy and is tachycardia with a heart rate of 115 bpm. His blood pressure is 85/66 mm Hg standing, and 96/83 mm Hg lying down. An intravenous line is started and a bolus of fluids is administered, which improves his vital signs. After stabilization of the patient’s vital signs, an esophagogastroduodenoscopy (EGD) is performed. There is a fair amount of blood in the stomach, but after it’s washed away, there are no abnormalities. However, the blood appears to be welling up from the pylorus and, upon crossing the pyloric channel and entering the duodenum, a bleeding duodenal ulcer is seen, located on the postero-medial wall of the duodenal bulb. What artery is at most risk of damage from a penetrating duodenal ulcer in this location, a damage that may result in a massive upper intestinal hemorrhage?

A 45 year old bank manager presents to the Emergency Department with upper abdominal pain over the last two weeks. He describes the pain as 10/10 in intensity, stabbing and relentless. The ingestion of food makes it better, as does the consumption of milk, but now the patient is vomiting, and in the last hour he vomited frank blood. He appears pale, feels dizzy and is tachycardia with a heart rate of 115 ppm. His blood pressure is 85/66 standing, and 96/83 lying down. An intravenous line is started and a bolus of fluids is administered, which improves his vital signs. After stabilization an esophagogastroduodenoscopy (EGD) is performed. There is a fair amount of blood in the stomach but no abnormalities are noted. However, a bleeding duodenal ulcer is found on the postero-medial wall of the second portion of the duodenum. Which artery supplies this portion of the bowel?

A 16-year-old male patient presented to the emergency room with abdominal pain and tenderness. According to the patient, the pain began approximately two days prior in the area just above his umbilicus and was crampy in nature. Earlier this morning the pain moved laterally to the patient’s RLQ. At that time, the pain in the right lower quadrant became severe and constant, and awoke him from a disturbed sleep. He decided to come to the hospital. The patient was nauseous and had a low grade fever of 100.1 F. His vital signs showed a mild tachycardia at 100 bpm, but the rest of his vital signs were normal. Upon physical examination, the patient had a positive Rovsing's sign and a negative psoas sign, but the remaining areas of his abdomen were non-tender. His rectal exam was benign. His laboratory values showed a WBC of 15,000/ mm3 but his urinalysis and other laboratory findings were negative. Based upon this patient’s history and physical exam, what conclusion can be drawn about the nerves involved in the transmission of this young man’s pain?

A 78 year old woman presents to the Emergency Department with a one week history of weakness and abdominal discomfort an hour after her second syncopal episode. This was accompanied by passage of bright red blood per rectum followed by black tarry stools. She denies nausea, vomiting, hematemesis, or weight loss. She has no recent history of travel or antibiotic and NSAID use. She is an ex-smoker and drinks two glasses of wine four times a week. She has no family history of autoimmune disease, inflammatory bowel disease, or gastrointestinal malignancy. On examination, she is afebrile, but has orthostatic hypotension and left lower quadrant abdominal tenderness. Laboratory investigations revealed anemia with a hemoglobin of 11.7 g/dL (N=12.0-16.0). Her other blood test results are normal including complete blood counts, coagulation profile, creatinine and liver enzymes. Her C-reactive protein (CRP) is elevated at 117 mg/L (normal <3.1), and an autoimmune screen including anti-neutrophil cytoplasmic antibody (ANCA), anti-nuclear antibody (ANA), and double-stranded DNA are all negative. Stool cultures are pending but C. difficile toxin is also negative. An esophagogastroduodenoscopy after fluid resuscitation and the transfusion of 2 Units of packed red blood cells is normal. Her colonoscopy, however, reveals an isolated segment of bowel 40 cm from the anal verge with an edematous and friable mucosa and loss of vascular margins. Biopsies show pseudomembranous luminal inflammatory exudate, crypt atrophy, and laminal propria fibrosis highly suspicious for ischemic colitis with a differential diagnosis of pseudomembranous colitis. Which vessel contributes the most in its delivery of blood flow to the affected area and, if insufficient, could cause this patient’s disease?

A 59 year old truck driver returns from his usual week-long trucking trip with excruciating pain around his anus. He is seen in the Emergency Department and found to have a 1-cm tender lump on the right side of his anus in the supine position with the legs up in stirrups. The lump is bluish and surrounded by swelling, and is visible without the aid of an anoscope. It is exquisitely tender to touch of the gloved finger, and soft. The rest of his history and physical exam is unremarkable. The patient drinks beer when not working and his meals consist of fast food. He has no allergies, takes no medications and his vital signs are normal. Which vein drains the vessel responsible for the formation of this lump?

A 32 year old woman comes to her doctor’s office with abdominal distention, diffuse ab-dominal pain, and a history of 10-12 bowel movements a day for the last week. Three years ago she presented with a 6-week history of 5 loose, non-bloody stools daily, right lower quadrant abdominal pain (especially after eating), a twenty pounds weight loss and bilateral knee and ankle pains. Her physical examination showed a moderately tender 5-cm mass in the right lower quadrant of her abdomen. Radiographic findings demonstrated a 10-cm narrowing in the terminal ileum (string sign) with a separation of bowel loops around the terminal ileum. After a colonoscopy, she was given the diagnosis of Crohn’s disease and was started on a combination of steroids and anti-metabolites. She responded initially, but then her symptoms returned. Now she has a distended, diffusely tender abdomen. A CT scan shows evidence of several small bowel fistulas and strictures located in the last 30 cm of her ileum. Because of the severity of the disease, a resection of the af-fected portion of the bowel is necessary. What changes in bile metabolism are expected in this patient?

A 55 year old female comes to see her doctor for a rapidly enlarged abdomen and lower extremity edema. She was hospitalized 2 weeks prior for an UGI bleed. On that occasion, her EGD showed grade 1 esophageal varices and a 1cm clean-based antral ulcer. The patient was discharged on omeprazole 20 mg BID. Review of symptoms shows that the patient is forgetful, does not sleep well, is drowsy and fatigued during the day which prevents her from working full-time. No abdominal pain. The patient has a 10 yr history of type 2 diabetes mellitus, hypertension and hypercholesterolemia. She has no history of angina or coronary heart disease. She drank alcohol moderately heavy in her twenties. and currently drinks less than 3 drinks per week and does not smoke. Her family history is unremarkable. On physical exam, her blood pressure is 132/82 mm Hg, pulse is 88 ppm, her temperature is 37.0 C. She weighs 235 lbs and her BMI is 33. She is alert, oriented to person, place, year and month but not to the day. Her sclerae are not icteric. Her pulmonary and cardiovascular exam are normal, but her abdomen is distended with a fluid wave, and mild tenderness to palpation. There is no hepatosplenomegaly. There is a 2+ edema to mid-calf and pedal pulses are barely palpable. Her neurological exam is without motor or sensory deficits, but she demonstrates asterixis and her skin exam shows a few spider telangietasias on her face and upper chest. After initial evaluation, lab tests were obtained: Serum sodium: 133 mEq/ml Serum potassium: 3.8 mEq/ml BUN: 8 mg/dl Serum creatinine: 1.0 mg/dl Serum albumin: 2.5 gm/dl AST: 68 IU/ml ALT: 46 IU/ml Alkaline phosphatase: 130 IU/ml Total bilirubin: 1.8 mg/dl WBC: 4200/mm^3 Platelets: 94,000/mm^3 Hct: 35.5% Prothrombin time (INR): 1.5. A liver biopsy shows changes typically associated with alcoholic liver disease (ALD). These hepatocytes are predominantly located in which area of the hepatic lobule?

A 53-year-old man was admitted to the hospital because of huge ascites and general wasting. He had a history of alcohol consumption about 3 – 5 oz per day for 20 years and smoked about 20 cigarettes per day for 20 years. The patient had suffered from cirrhosis of the liver for 5 years. Serology for viral hepatitis B and C were negative. Examination revealed significant ascites and a network of varicose veins radiating from a single, large umbilical varix. Laboratory values were: Total bilirubin: 4.0 mg/dL AST: 40 U/L ALT: 18 U/L. GGT: 735 U/L Platelet count: 11.000/mm^3 White blood cells: 4.300/mm^3 An abdominal Doppler ultrasound was performed and showed enlarged superficial epigastric veins, large ascites and a hepatopetal flow of the portal vein. Within a few days, the patient had ultrasound-guided drainage of his ascites, in total ten liters of straw-colored fluid. For this patient, which portacaval anastomosis site is likely to rupture and bleed first?

A 42 year old woman presents to the emergency department complaining of abdominal pain, nausea and vomiting for the last four hours after she had two generous portions of pizza. She notes she has had prior similar episodes which resolved spontaneously however the pain today has persisted for five hours and is much more severe. She appears uncomfortable and is clutching her abdomen. The pain is located in the right upper quadrant of her abdomen and radiates to her upper back. She describes the pain as dull and cramping. The patient's vital signs are blood pressure 148/96 mm Hg, pulse108 bpm, respirations 18 per minute, temperature 99.9 °F. She has a history of hypertension and her BMI is 28. On physical exam, the patient has right upper quadrant abdominal tenderness and guarding. Murphy's Sign is positive. She describes her pain as dull, continuous and sharp at the tip of her right shoulder. Her CBC is mildly elevated but her chemistry including amylase, lipase, bilirubin and liver function tests is normal, as is urinalysis and urine hCG. Her RUQ ultrasound is positive for a large stone lodged in the neck of the gallbladder. What is the mechanism of referred pain in this patient?

A 56 year old woman presents to the Emergency Department with an episode of nausea and severe, unrelenting right upper quadrant pain. She had a cholecystectomy for gallstones a year ear-lier and has since experienced frequent reoccurrences of right upper abdominal pain, most often after a meal. Her past medical history is otherwise unremarkable and she only takes medications for her pain when it becomes intolerable. Her physical exam is normal except for exquisite abdominal pain to deep palpation of her right upper quadrant. Her laboratory values are unremarkable with the exception of a mildly elevated alkaline phosphatase, amylase and lipase. Her RUQ ultrasound shows a slightly enlarged common bile duct at 8mm (N=up to 6mm) in diameter and a normal pancreatic duct. The patient is referred to a gastroenterology service for evaluation of her common bile and pancreatic ducts. During the procedure, the pressure in the distal common bile duct is elevated at 45 mmHg (N<40 mmHg), but the pancreatic duct cannot be cannulated. Which statement about the regulation of function of the sphincter of Oddi is correct?

A 73-year-old female previously treated for a MRSA-infected sacral decubitus ulser was readmitted from a nursing home with a fever of 101F, swelling in front of her left ear and dehydration. There was no evidence of a well-formed parotid abscess and no stones were palpable in the duct. She was edentulous and there was pus visible at the parotid duct opening. A clinical diagnosis of parotitis was made. She had a past medical history of type II diabetes mellitus, dementia and a left below knee amputation for gangrene of the foot. She lived in a nursing home and had four previous admissions to hospital in the preceding 12 months. Her white cell count (31000/mm3) and C-reactive protein (17.7 mg/L) were elevated. Vancomycin was started empirically because of her MRSA history, and was continued when blood cultures taken on admission grew MRSA within 24 hours. A mouth swab taken on admission grew mixed oral flora. No other source for the bacteremia was found. She was discharged 19 days after admission and was well at follow up 12 months later. What physical finding would suggest involvement of the nerve in its course through the inflamed and swollen area?

A 38-year-old man is brought in to the Emergency Department after suffering a motor vehicle accident as the passenger. He had no obvious injuries, but he complained of excruciating right hip pain. Clinically the right leg was externally rotated, abducted, and extended at the hip and the femoral head could be palpated anterior to the pelvis. Plain radiographs of the pelvis revealed a right anterior right hip dislocation and femoral head fracture. Which sensory and motor deficits are most likely in this patient’s right lower extremity?

A 95 year old woman resident of a long term care facility got up from her chair, tripped on a rug and fell on her right knee. She could not get up without assistance and complained of severe pain in her right hip and buttock. The nurse who evaluated her tried to stand her up, but when the patient tried to stand on her right leg, she dropped her left hip and lost her balance. The nurse then recognized that her patient had a foreshortened right leg fixed in the adducted position and a large swelling in her right buttock. At the receiving hospital, the patient was confused and, though she knew her name, she couldn’t remember the date and insists to leave the hospital immediately to see her family. Past medical history includes diabetes, congestive heart failure, and incontinence. She is currently taking metformin, lisinopril, hydrochlorothiazide, metoprolol, and oxybutynin. Physical exam confirmed the nurse’s findings. Radiology proved the presence of a right posterior hip dislocation without fractures. What medication is most likely associated with this patient’s confusion?

A 23-year-old woman backpacker presented to the Emergency Department with an acute exacerbation of her three-month history of low back pain and more recently right leg pain. This was the seventh presentation, each time with the same symptoms, but this time the pain was so excruciating, it took her breath away. The patient couldn't recall a single event relating to the onset of her back pain. In the weeks prior to its onset she had been working casually as a waitress and did find bending over tables a strain. The pain began in her lower back and with time started radiating straight down the back of her right thigh and into her calf, stopping at the ankle. The patient’s pain was worse in the morning, making getting out of bed a chore. The patient woke up at night with severe buttock and posterior thigh pain, but walking actually made the pain subside, though it never abated completely. The most important findings on physical examination were that her left straight leg raise test was severely limited and reproduced her buttock pain at 20 degrees hip flexion. It was worsened by the addition of ankle dorsiflexion. Her lumbar neurological conduction examination revealed no sensory abnormalities. Her L4 and L5 reflexes were normal, but her S1 reflex was absent on the right side. The patient was referred to an orthopedic specialist after a Lumbar spine CT was obtained, that showed an L5-S1 disc protrusion with right S1 nerve root compression. What muscle-nerve complex is involved in producing an S1 reflex?

A 72-year-old African American woman presented to the emergency department complaining of left gluteal pain over the last 3-month. The pain was gradual and she doesn’t recall any trauma or previous infection. The patient described the pain as sharp and progressive, with radiation down the posterior left thigh to the level of the knee. The patient was a nonsmoker without record of anticoagulant therapy and with a past medical history of peripheral vascular disease, hypertension, and hyperlipidemia. Physical examination of the left gluteal region reveals some atrophy and muscle weakness. Vital signs, cell counts, and blood chemistries were within normal limits. The suspicion of embolus was confirmed with pelvic computed tomography demonstrating a heterogeneously enhanced blockage in the deep branch of the superior gluteal artery. The patient underwent an uneventful superselective embolization and recovered. Complete occlusion of this artery may cause muscle ischemia and atrophy that would compromise the ability of this patient to perform which daily activity?

A 32 year old man jumped from a 10-story building in a suicide attempt. He was rescued and taken to the hospital where was found to have several stable lumbar fractures and a shattered right calcaneus. He was taken to surgery and his calcaneus was repaired with 11 screws. Which of the following statements is most consistent with what he may have been told after surgery?

A 42 year old overweight restaurant waiter develops excruciating pain in the heel of his right foot. Symptoms are most intense after getting out of bed but get better after walking. On physical examination, both feet have a flat medial arch. There is tenderness to palpation along the inner aspect of the right heel bone, minimal active dorsiflexion, and pain at passive dorsiflexion. X-ray films reveal a bone spur at the level of the attachment of the right plantar fascia. The spur is also present in the comparison film of the left foot. He is diagnosed with plantar fasciitis and is told to lose weight, rest, ice and anti-inflammatory medications. What is the most likely scenario?

A 76 year old hypertensive man who used to smoke 20 cigarettes a day for 40 years but quit five years ago presents to his family physician with a painless ulcer in the sole of his left foot, located at the base of his first toe. He has a history of pain in his left leg that awakens him at night and is relieved by dangling his foot off the side of the bed. His wife discovered the ulcer last week while doing his usual monthly toe nail trimming. On physical exam palpation of the patient’s pulses revealed the following: Right foot: Femoral: 4+; Popliteal: 3+ Dorsalis Pedis: 2+; Tibialis Posterior: 1+. Left foot: Femoral: 4+; Popliteal: 2+; Dorsalis Pedis: 0; Tibialis Posterior: 0. Pulse detection by Doppler revealed decreased flow in the left tibialis posterior artery, but no flow could be detected in the dorsalis pedis. What is the most likely principal cause of this patient’s toe ulcer?