Pathology Question Set 2

An 18-years-old young girl presents to the emergency department with a history of severe pain in right iliac fossa, anorexia, nausea and 2 episodes of vomiting since last night. She also stated that the pain was initially started in the epigastrium and then migrated to the right iliac fossa. On abdominal examination, there is superficial tenderness in right iliac fossa, rebound tenderness, rigidity, and guarding are also positive. The Rovsing and Psoas signs are also positive. A complete blood count result shows leukocytosis and shift to the left. Laparoscopic surgery is performed, and the swollen and erythematous appendix which is partly covered by a yellowish exudate is removed. A microscopic examination of a removed appendix demonstrates neutrophil infiltrate of the mucosal and muscular layers extending into the lumen. Which of the following chemical mediators is responsible for the pain in this patient?

A 5-year-old female child was presented to the emergency department with seizures. On investigations, her blood sugar is 94 mg/dl, Serum calcium is 5.3 mg/dl. PTH levels are low. On inquiry, her past history includes a delay in achieving developmental milestones. Her mother also says she needs frequent hospital visits due to recurrent flu. The cardiovascular examination is within normal limits. The most likely cause for this presentation is?

A 48 year old male presents with chronic uncontrolled hypertension for the past 12 years. He is smoking around 3 packs per day for and drinking 2-packs of alcohol per day for past 10 years. Which of the following pathological change could be seen in his bronchial epithelium?

A 46 year old homeless male was found wandering in the supermarket. On examination, he is confused and told that the president appointed some men to kill him as he is disclosing state secrets to extraterrestrial organisms. Also, there is horizontal nystagmus and ataxic gait. The most likely cause is due to presence of?

A 25 year African-American women brought to the clinic with complaints of chest pain on right side which is more during inspiration. She has also reported fever for past 3 months intermittently. Other findings on patient history and examination are, 6 lbs (3 kg) weight loss in past 2 months, and joint pain in knee for past 1 month. On further examination, BP - 110/84 mm of Hg, PR- 86/min, a red rash is seen on face covering nose and adjacent cheeks. Lab finding show Hb - 9 gm/dl and TLC - 1500/cmm. Which of following would be most specific helping in the diagnosis?

A 34-year old primigravida woman was brought came to the clinic with a chief complaint of painless vaginal bleeding. She was diagnosed with placenta praevia and was transfused with one unit of whole blood. She was resuscitated with one unit of whole blood transfusion. Five hours after the transfusion, she developed fever and chills. The current situation could have been prevented by?

A 27-year male met with a road traffic accident and sustained multiple fractures on left femur, and left tibia. His fractures are stabilized by surgery. On the second day of hospital stay, he suddenly develops severe dyspnea. Spo2 is 82%. What is the most likely mechanism of the respiratory insufficiency?

A 28-year-old male presents for a pre-placement health checkup. Auscultation reveals a mid-systolic click. An echocardiogram reveals a floppy mitral valve and a dilated aortic root. Ocular examination finds a subluxated lens superior and laterally. The most likely genetic defect in the above individual is?

A 5-year old boy is presented to you because of learning difficulties at school. He has short stature, flat face, low set ears, large tongue and single line on palm. His parents are very much concerned about him as he was born after 20 years of their marriage. You ordered for Karyotyping, which most probably will reveal:

A 60-year old man received an intradermal injection of PPD (Purified Protein Derivative) on his left forearm. After 48 hours, a 14 mm oval induration was noticed. The type of cells most likely present and responsible for the indurated area will have the following characteristic feature:

A 21 year old medical student is studying different types of necrosis and tissue injuries for his assignment. In the pathology laboratory, he observes microscopically different dead tissues and notices the changes that are occurring in them with time. After serial observations, he deduced that coagulation necrosis is:

A 70-year old African male presented to your clinic for routine follow up. He is hypertensive for last 20 years and is currently on multiple antihypertensive medicines. On examination, his BP was 150/100 mmHg. The rest of the examinations were within normal limits. Echocardiography showed some changes in his left ventricle. What is the most likely reason for the change?

A 28-year-old female presents with respiratory distress. Auscultation shows bilateral crepitations and friction rub. Lab findings show pancytopenia, proteinuria, and a false positive test for syphilis. Chest x-ray shows bilateral pleural effusion. Which of the following findings are most likely to be seen?

A pulmonary autopsy specimen of 58-year-old female who died of severe respiratory distress was examined. She had recently had surgery for fractured femur 3 months ago. Fibrous connective tissues around the lumen were observed. The most likely pathogenesis beyond the present findings is:

A newborn male child shows increased serum bilirubin in the first 24 hrs of delivery. The delivery was uneventful. The pathogenesis involved for the present findings is?

A 75-year-old woman is being treated for atrial fibrillation. She presents to the clinic with nausea, vomiting, photophobia, and yellow-green vision with yellow halos around the lights. Liver function tests and respiratory system are normal. Toxicity of which of the following anti-arrhythmic drugs would best fit this clinical picture?

A 3-month-old infant boy presents to his pediatrician with persistent diarrhea, oral candidiasis, signs and symptoms of respiratory syncytial virus (RSV) pneumonia. He is very lean with weight in the 10th percentile. He is being evaluated for an immunodeficiency disease. Laboratory results for HIV are negative by PCR. The most likely cause of these findings is:

A previously healthy 7-month-old boy presents with fever, chills, cough, runny nose, and watery eyes. His elder brother is having the similar symptoms. He is diagnosed with influenza virus infection. Assuming that this is the child's first exposure to influenza virus, which of the following immune mechanisms will most likely function to combat the viral infection?

A 1-year-old immigrant girl has not received any recommended vaccines since birth. She attends day care and remains healthy despite her daily association with several other children for the past 3 months at a home day care facility. Which of the following phenomenon explains why she has not contracted any vaccine-preventable diseases such as measles, diphtheria, or pertussis?

A 4-month-old neonate girl is brought to the pediatrician because of feeding problems and recurrent infections. On evaluation, she has a cleft palate, malformed jaw,structural cardiac abnormalities and diminished cell mediated responses. Laboratory investigations reveal hypocalcaemia. Which of the following is the most likely diagnosis?

A 31-year-old female with a characteristic butterfly rash on her face and history of photosensitivity presents with decreased renal function, hypertension, edema, and anemia. Laboratory findings reveal decreased serum C3 levels. Her urine sediment contains proteins, WBCs and red blood cell casts. Her renal biopsy is consistent with acute inflammation and immune deposits. These findings suggest which type of hypersensitivity?

A 2-year-old boy presents to you with multiple skin abscesses caused by Staphylococcus aureus. He has past history of recurrent infections by the same organism. The nitroblue tetrazolium test demonstrates his inability to kill microbes. Which of the following key pathophysiologic events relate to the condition that is most likely responsible for the findings in this patient?

An 18-year-old male is known to be allergic to peanuts. He mistakenly eats biscuits containing some traces of peanuts. Within 15 minutes, he develops generalized redness of the skin and urticaria, associated with shortness of breath and diffuse wheezing. These findings are an example of which of the following hypersensitivity reactions?

A 4-year-old boy presents with history of recurrent bacterial infections, including several episodes of pneumococcal sepsis. His two maternal uncles died having the similar complaints. Lab investigations reveal an undetectable level of all serum immunoglobulins. Which of the following disorders should be included in the differential diagnosis of this patient?

A 9-month-old infant girl is brought to the pediatrician by her worried parents, due to repetitive severe fungal infections, persistent diarrhea, and skin rashes. She is also not gaining weight. On evaluation, she is found to be deficient in both T- and B-cell function. The thymus is of normal size. While discussing the treatment options, the concerned pediatrician told them that the most likely option for the permanent restoration of their daughter’s normal immunity would be?

A 6-month-old male presents to his pediatrician for the evaluation of recurrent bacterial infections. Physical examination reveals light colored skin and silver hair. On further evaluation, large cytoplasmic vacuoles containing microbes were found within the neutrophils. These findings suggest patient is having:

A 5-year-old girl is brought in for a routine checkup. Upon examination, pallor and petechiae are visible and hepatosplenomegaly is found. Liver enzymes are mildly elevated and complete blood count shows slight anemia and thrombocytopenia. Mother also reported that the child had several bones broken without a strong trauma. Bone marrow examination shows cells with wrinkled paper appearance, without the presence of blasts. What is a most likely diagnosis in the present case?

An 8-year-old boy is brought in for a routine checkup. His father said that the boy has been hurting himself more than usually. He had several of his bones broken; he bruises easily and is pale. Upon examination, hepatosplenomegaly is found. Liver enzymes are mildly elevated and complete blood count shows slight anemia and thrombocytopenia. Bone marrow examination showed cells with wrinkled paper appearance, without the presence of blasts. What test should be used to prove the expected diagnosis?

A 4-month-old male infant is brought in because he rejects food and is losing weight. He had several upper respiratory tract infections during the last two months. Upon examination, hepatosplenomegaly is noted, as well as mild hypotonia. During the next few weeks hepatosplenomegaly progresses, the boy fails to thrive and continues to reject food. Blood reports showed pancytopenia, elevated levels of transaminases. Chest X-ray shows a reticulonodular pattern and calcified nodules. Biopsy of the liver shows foamy histiocytes. What is the most likely diagnosis?

A 2-day-old male newborn is brought in because of apnea, cyanosis, and seizures. He is severely hypoglycemic and doesn’t react to glucagon administration. Blood reports showed high lactate levels. On examination, an enlarged liver is palpable. What enzyme is expected to be deficient in this baby?

An 8-year-old boy presents to the physician with complaints that he is persistently facing sickness and clumsiness with multiple episodes of pneumonia and diarrhea. Other symptoms include white patches (keratinized epithelium) on sclerotic coat (protection and covering of the eyeball) and conjunctival dryness. Can you suggest the cause of these symptoms in this particular child?

A 55-years-old diabetic woman comes to the emergency department due to swelling of her left leg, fever, and chills for 2 days. The maximum recorded temperature was 101℉ at home. Her left leg is red and swollen from her ankle to the calf with an ill-defined edge. Her vitals include a blood pressure of 120/78 mmHg, a pulse of 94/min, a temperature of 101℉ and respiratory rate of 16/min. On physical examination, there is tenderness and warmth compared to her normal leg. The left inguinal lymph node is enlarged to a size of 3 x 3 cm. Which of the following chemical mediators is the most likely cause of her fever?

A 20-year-old girl comes to the emergency department with painful swelling in the middle of the neck for past 3 days. She denies any pain during swallowing, difficulty in breathing or change in her voice. On examination, a red 5 x 5 cm, exquisitely tender, non-pulsatile, fluctuating mass is present in the midline on the anterior aspect of the neck. The patient is being prepared for an incision and drainage for the neck abscess. Which of the following is the mechanism responsible for the presence of pus in the tissue space in this case?

A 7-month-old infant is brought to the hospital by her mother with the complaint of a labial lesion for 5 days. The lesion is 2 X 2cm in size, red in color with serosanguinous fluid oozing out of it on her right labia. The parents state that the infant has a history of recurrent bacterial skin infections lacking pus with delayed healing since birth. She also had delayed sloughing of the umbilical cord at birth. Complete blood count results are as follows: Neutrophils: on admission Leukocytes: 19,000 / mm^3 Neutrophils: 83 % Lymphocytes: 10% Esinophils: 1 % Basophils: 1% Monocytes: 5% Hemoglobin: 14 gm/dL Which of the following compounds is most likely to be deficient in this patient?

A 6-year-old boy is brought to a pediatric clinic by his mother with the complaints of fever, malaise, and cough for the past 2 days. The mother mentions that initially the fever was low-grade and intermittent in nature but later became high-grade and continuous.The patient is also anorexic. Physical examination reveals a pulse of 130/min, temperature of 101 °F and respiratory rate of 32/min. Oropharyngeal examination shows his palatine tonsils covered with pus and erythema of the surrounding mucosa. Which of the following mediators is responsible for this patient’s abnormal temperature?

A 4-year-old girl is brought to the clinic by her parents with the complaints of discharge from her nose for the past two weeks. The discharge is foul smelling and unilateral with occasional blood clots. There is no history of trauma and she was completely fine during her well child visit last month. Her vital signs are within normal limits. Examination of the nose reveals a mucoid discharge with thick consistency oozing out from left nostril. The girl panics when the physician tries to use a nasal speculum. Palpation over the facial bones does not reveal any tenderness. An X-Ray image of the paranasal sinuses shows no abnormality. Which of the following is the most likely cause of this condition?

A 40-year-old male is rushed to the Emergency Room (ER) after being involved in a motor vehicle accident. He has lacerations on his right arm and some minor abrasions on lower limbs and his face. The resident on call quickly manages the patient with proper care of his open wounds in the ER. The patient is admitted to the surgery unit for daily care of his wounds. His lacerations get better with proper dressing and occasional debridement. Which of the following best describes the healing process in this patient?

A 38-year-old nursing home worker presents to the clinic with the complaints of fever, loss of appetite, fatigue, and productive cough for a couple of months. His fever is low grade and sputum is often blood-tinged. He also lost 15 lbs during this period and complains of profound night sweats. A plain radiograph of chest shows consolidation in the apical part of the right lung. Baseline investigations show: Complete Blood Count: Hemoglobin: 11gm/dl White blood cells: Total count: 16,000/mm^3 Differential count: Neutrophils: 35% Lymphocytes: 54% Eosinophils: 11% Erythrocyte sedimentation rate: 84 mm You suspect that he is suffering from a chronic lung infection. Which of the following statements best describes this particular type of lung inflammation in this patient?

A 6-year-old boy is rushed to the ER after being involved in a motor vehicle accident. He has abrasions on his left knee and elbow. All of his wounds are cleaned and a pressure bandage is applied. Typically, neutrophils and macrophages are attracted toward the site of injury by various chemical mediators. Which of the following cells releases these mediators?

A 12-year-old girl is brought to an oncologist as she was recently diagnosed with a rare form of cancer. Cytogenetic studies reveal that the tumor is responsive to Vinblastine which is a cell-cycle specific anticancer agent. It acts on M-Phase of the cell cycle and inhibits the growth of cells. Which of the following statements best describes the regulation of cell cycle?

A 35-year-old male visits the outpatient clinic with the complaints of numbness and tingling in his fingers and toes for a month. He also complains of pain in his calf muscles while sleeping which is sever enough to wake him up in the middle of the night. He is a software engineer and spends most of his time indoors. He has been smoking one pack of cigarettes daily for the past 10 years and occasionally drinks wine with dinner. His current medication included regular vitamin and calcium supplements. On examination, he has a pulse rate of 74/min, Blood pressure of 128/67 mmHg, respiratory rate of 16/min and temperature of 37.6 °C. He has tenderness in the proximal muscles of his upper and lower limbs. Remaining of the physical examination is normal. X-ray imaging of his lower limbs show features of demoralization. Which one of the following set of abnormalities will most likely belongs to this patient?

A 40-year-old women at her 18th week of pregnancy based on her Last Menstrual Period (LMP) visits her obstetrician for her antenatal checkup. All of her antenatal investigations are normal except her quad screen test results which is given below: Maternal Serum Alpha-Fetoprotein (MS-AFP): low; Unconjugated estriol: low; Human chorionic gonadotropin: high; Inhibin A: high. Which of the following conditions is most likely cause of this patient's abnormal quad screen?

A 21-year-old male comes to the physician with the complaints of visual disturbance in both eyes for a month and an episode of abnormal seizure-like activity last week. He was doing well in his last doctor’s visit a couple of months back and does not have any significant past medical history. His mother has intermittent muscle weakness and his maternal uncle developed hemiplegia at the age of 35. Neuroimaging shows bilateral occipital lobe infarcts and a skeletal muscle biopsy reveals ragged appearing muscle fibers. The physician suspect a maternally inherited genetic disorder. The difference in the level of severity of this disorder among family members in best explained by which of the following?

A 2-month-old boy is brought to the clinic for a well child visit by his parents. His parents complain of poor cry and difficulty in feeding the baby. Physical examination reveals a malnourished appearing boy with a small narrow forehead and small jaw. His mouth is small and he has comparatively small genitals. He has a poor muscle tone. Birth history reveals that the boy was born at 37th week of gestation by cesarean section due to poor fetal movement and fetal distress. His Apgar score was 3 and 5 at first and fifth minute respectively and birth weight was 6 lbs. After repeated follow up, he gains weight rapidly but his height fails to increase. Developmental milestones are delayed at the age of 3 years. Genetic testing reveals Prader-Willi syndrome. Which of the following is the most common mechanism for the development of this patient’s condition?

A graduate student at the biochemistry laboratory decides to research the different effects of vitamin deficiencies in mice. By completely depriving the mice of one vitamin, in particular, he observes that they develop symptoms of posterior column and spinocerebellar tract demyelination, as well as hemolytic anemia. The work up from the mice reveals no megaloblastic anemia, hypersegmented neutrophils or elevated serum methylmalonic acid. What is characteristic of the vitamin causing the symptoms in the mice?

An 85-year-old woman was brought in by her neighbor, who had noted several bruises on her arms and legs when she came by for a regular visit. The woman's medical history is remarkable for pneumonia that was successfully treated three weeks ago with ceftriaxone. The patient complains of muscle pain. There is no history of poor nutrition or dehydration. She had a prolonged prothrombin time, normal liver function tests, and occult blood in her stool. Her doctor decides to give her an injection and informs the patient and the neighbor that the symptoms will regress in two days. What is the behind the mechanism of action of the medication received by the patient?

A 15-year-old girl is brought to the physician by her mother because she has not started menstruating yet. Her elder sister started menstruating at the age of 13 and her mother, at the age of 14. The patient is more concerned about her poor performance in sports. She says she can not participate in sports like before and gets tired very soon. During her last training session she had to walk out while performing a squatting exercise due to severe pain in her legs. She does not have a significant past medical or surgical history. Physical examination reveals pulsatile blood vessels within the intercostal spaces and diminished femoral pulses relative to brachial pulses. She also has a short neck with excessive skin in the lateral neck. This patient's symptoms are most likely associated with which of the following conditions?

A 45-year-old woman comes to clinic with a variety of complaints on certain parts of his body. She is a smoker and works at a factory that produces silica. After evaluation, an anti-centromere antibodies test is ordered and comes back positive. All of the symptoms below are expected to be seen in this patient, except for:

A 13-year-old girl is admitted to the hospital due to muscle weakness, pain and arthralgia in her wrist joints, the patient says "I am having trouble walking home after school, specifically climbing a steep hill". She also complains of malaise. A heliotrope rash is observed around her eyes and multiple hyperkeratotic, flat, red papules with central atrophy were present on the backs of the patient's metacarpophalangeal and interphalangeal joints. Serum creatine kinase levels are elevated. Which of the following antibody is most likely found in this patient?

A 17-year-old teenage girl is brought in by her mother due to a rapid weight loss over one month, her current BMI is 16.8 kg/m2. The mother reports that she has not had her period yet and she has been underperforming at school and acting very strangely at home. The girl reports she has been having episodes of diarrhea, which she attributes to laxatives she takes regularly. On evaluation, the skin over her limbs and around her neck appears to be red and inflamed. Her tongue is bright red and smooth. She states that over the last two weeks she has been eating nothing but small portions of fruit. She is recommended for a follow-up with a psychiatrist and is given oral niacin. Everything about niacin below is true, except:

A 25-year old woman first presented to the clinic due to morning stiffness, symmetrical arthralgia in her wrist joints and fatigue. Anti-citrullinated protein antibodies were positive and ESR was above normal ranges. She was started on methotrexate therapy. After two months, she developed a megaloblastic anemia. What is the action of methotrexate?

An HIV-positive mother has given birth to a healthy boy two days ago. She takes her antiretroviral medication regularly and is compliant with the therapy. Before being discharged, her doctor explains why she can't breastfeed the child since there is a risk of infection through breastmilk and stresses that the child can benefit from formula. The physician stresses the importance of not overheating the formula since vitamin C may be inactivated by overheating. Which process could be impaired if the mother boiled the formula longer than needed?

A 40-year-old African American female has complaints of dyspnea, cough, arthritis in her ankle joints. A CT scan reveals multiples granulomas in both lungs, as well as bilateral hilar lymphadenopathy. On examination, cutaneous nodules over the trunk are found. Erythrocyte sedimentation rate, angiotensin-converting enzyme, and serum calcium levels are elevated. She is treated with steroids. What is the most likely diagnosis?

Researchers are investigating oncogenes, specifically the KRAS gene that is associated with colon, lung and pancreatic cancer. They have established that the gain of function of this gene increases the chance of the development of cancers. They want to pursue the research further and study tumor suppressor genes. Which of the genes below is a tumor suppressor gene?

A 27-year-old woman was referred to a dermatology clinic due to changing discoloration of her fingers from white to red to blue. She also complains of increasing fatigue, muscle weakness, and weight loss, although she has not had any changes in her routines lately. Anti-U1 RNP antibodies and increased creatinine kinase were found in her serum. What is the most likely diagnosis in this patient?

A 29 year old female comes to the office with chief complaints of shortness of breath and chest pain for 1 week. The chest pain is aggravated on deep breathing. She becomes short of breath while walking upstairs at her home. She has lost 10 pounds over 1 month and feels feverish and fatigued. She also complains of pain in her wrists, hands and knee. Past history consists of two spontaneous abortions, both occurred in first trimesters. On physical examination there is a pink rash over her face which aggravates on sunlight. On chest auscultation decreased breath sound on right chest are heard. CXR reveals pleural effusion on the right chest. Serum ANA and anti-dsDNA are positive. Urinalysis shows no proteinuria, casts nor hematuria. What is the most likely cause of her disease?

A 50 year old man is brought to emergency department due to chest pain and shortness of breath for 2 hours. He explains the chest pain as squeezing in nature radiating towards left arm. It is associated with nausea and sweating. He has similar history in the past which mostly aggravated on doing strenuous activity which got relief after taking sublingual Nitroglycerin. He has a history of uncontrolled diabetes and hypercholesterolemia for 10 years. His last Hba1c was 8.0. his vitals are as follows BP=150/90, Pulse=90/min, RR=20/min, Temp=98.3 °F. Oxygen saturation in room air is 98 %. ECG shows ST segment elevation in leads I, II and aVF. He is being prepared for coronary angioplasty. Elevation of which of the following enzyme is most significant in diagnosis of this patient?

A 60 years old asian man presented to the hospital with abdominal pain for 2 days. He has a history of Hepatitis B in the past. He underwent a Computed Tomography which revealed a large mass (11.3 cm X 7.2 cm in diameter) with metastatic retroperitoneal lymph node. He was diagnosed with Hepatocellular carcinoma received liver transplantation. He received radiotherapy afterwards. Three months after radiotherapy, the patient had hematemesis and melena. He was admitted to the emergency room with vitals of blood pressure 84/56mm Hg; heart rate was 92 beats/min and respiratory rate was 20 breaths/min. Laboratory evaluation revealed severe anemia with hemoglobin level of 3.7 gm/dL, PT of 11.4s, apTT was 27.5 seconds, INR was 0.98 and platelets of 68,000 cells/mm^3. Blood transfusion was administered. The endoscopic examination showed diffuse edematous hyperemic mucosa, multiple hemorrhagic patches with active oozing were visible over the antrum. What is the most likely diagnosis for the lesions seen in endoscopy?

A 69-year-old diabetic woman comes to the emergency department due to right flank pain for 10 days. Her right flank pain is radiating towards her groin and is associated with fever and chills. Pain is exacerbated with hip extension. She feels fatigued and is lying on her left side with right hip flexed. CT guided percutaneous drainage reveals 900 ml of greenish pus. Her vitals include a blood pressure of 145/75 mmHg, a pulse of 96/min, a temperature of 36.9 ℃, respiratory rate of 16/min and oxygen saturation of 95. Her complete blood count shows following readings: On admission: Leukocytes: 16,600/mm^3 Neutrophils: 80 % Lymphocytes: 16 % Esinophils: 1 % Basophils: 1 % Monocytes: 2 % Hemoglobin: 7.6 gm/dL Creatinine: 0.8 mg/dL BUN: 15 mg/dL Which of the following process most likely could have occurred?

A 9 year old girl comes to the clinic with chief complaint of swollen eye and sinus infection for 4 days. She complained of left nasal pain prior to that. Her left eye was swollen and red and progressively worsening. It has been difficult to open her eyelids and complains of diplopia and pain in ocular movement. Visual acuity is 20/20 in both eyes. Intraocular pressure measurement shows values of 23 and 14 mm of Hg in right and left eye respectively. Her complete blood count shows following readings: On admission: Leukocytes: 11,600/mm^3 Neutrophils: 80 % Lymphocytes: 14% Esinophils: 1 % Basophils: 0 % Monocytes: 5 % Hemoglobin: 12 gm/dL ESR: 65 CRP: 4.6 The organism causing the above condition is destroyed by which one of the following process?

A 25 year old man was admitted to neurosurgery department after sustaining a closed head injury in a motor vehicle accident. He had been in good health except use of anabolic steroids for 6 months. Empirical therapy with ceftriaxone was started in hospital for the closed head injury. After 10 days of treatment in the hospital, he became acutely tachypneic and had decreased loss of consciousness. His temp was 105.4 °F and his WBC count of 19,000/mm^3. He developed generalized pustular eruption. Gram stain of an aspirate showed many budding yeasts and neutrophils. Culture of skin specimens were positive for Candida albicans. The nitroblue tetrazolium test is positive. What is the most likely cause condition related to his signs and symptoms?

A 10 month old boy is referred to hospital because of severe pneumonia. During the first month of his life, the patient developed upper airway infections, bronchitis and diarrhea. He has received all the immunizations according to his age. He had developed failure to thrive since the age of 3 months. One month before he had severe lung infection with cough, dyspnea and diarrhoea, unresponsive to an empiric oral macrolide. Upon admission to his local hospital he had fever of 39.5C. Now he has mild respiratory distress, and crackles on auscultation. Oxygen saturation is 95 % in room air. Quantitative immunoglobulin tests shows increase in IgG, lgM, IgA. Peripheral blood smear shows leukocytosis and normochromic normocytic anemia. Chloride sweat test and tuberculin test were negative. CXR revealed bilateral pneumonia. Bronchoalveolar lavage and gram stain reported gram negative bacteria that grew Burkholderia cepacia. His complete blood count shows: On admission: Leukocytes: 36,600/mm^3 Neutrophils: 80 % Lymphocytes: 16 % Esinophils: 1 % Basophils: 1 % Monocytes: 2 % Hemoglobin: 7.6 gm/dL Creatinine: 0.8 mg/dL BUN: 15 mg/dL Which of the following defects of neutrophil function is most likely responsible?

A 28-year-old woman presents to a clinic with the complaints of occasional low-grade fever and joint pain since last month. She also complains of morning stiffness in her bilateral proximal interphalangeal joints of hands which lasts only for 5-10 minutes. Recently, she noticed a pink rash on her nose and cheekbones. Her family history is significant for similar complaints in her mother. On examination, her temperature is 99.6 ºF, the pulse is 74 beats per minute, blood pressure is 110/70 mm Hg, and respirations are 18 per minute. Which of the following tests is most appropriate to confirm her diagnosis?

A critically ill 83-year-old woman with a past medical history of poorly controlled diabetes, hyperlipidemia, hypertension, obesity and recurrent urinary tract infections is brought to the Emergency Room by her husband due to confusion, generalized malaise and weakness, nausea, and mild lower abdominal pain. Her medications include metformin and glyburide, atorvastatin, lisinopril, and hydrochlorothiazide. On presentation, her oral temperature is 102.2 °F (38.9 °C), heart rate is 122 beats per minute, blood pressure is 93/40 mmHg, and oxygen saturation is 96 % on room air. She is breathing rapid shallow breaths, but does not have any rales or crackles on pulmonary auscultation. No murmurs are appreciated on cardiac auscultation and femoral pulses are bounding. Her skin is warm and flushed in the face, dry to touch, and she does not have any mottling or rashes on her extremities or core. She has trace bilateral pedal edema. Her abdomen is soft and nondistended, but she has some involuntary guarding on palpation of the suprapubic lower abdominal region. EKG shows normal amplitude sinus tachycardia without evidence of ST segment changes or T-wave inversions. Based on this presenting history and exam, what would pulmonary artery catheterization likely show in measurements of Pulmonary Capillary Wedge Pressure (PCWP), mixed venous oxygen saturation (SaO2), and calculated Cardiac Output (CO) and Systemic Vascular Resistance (SVR)?

A 71-year-old woman with a past medical history of type 2 diabetes, hypercholesteremia, and hypertension was admitted to the hospital 8 hours ago with substernal chest pain for management of acute non-ST elevated myocardial infarction (NSTEMI) noted by ST depressions and T-wave inversions on anterolateral leads on initial EKG and elevated cardiac enzymes. Upon diagnosis, management with inhaled oxygen therapy, beta-blocker, and aspirin and low-molecular-weight heparin therapy was initiated and she was placed on bed rest with continuous electrocardiographic monitoring. Since admission she required two doses of sublingual nitric oxide for recurrent angina, and troponin levels continued to rise from the 0 hour, 3 hour to 6 hour values. Given her risk factors, plans were made for early coronary angiography. Now, the telemetry nurse calls the on-call physician due to concern over the patient’s mild confusion and increasing need for supplemental oxygen. At bedside evaluation, her vital signs are a heart rate of 122 beats per minute, blood pressure of 89/40 mmHg, and pulse oximetry of 91 % on 6L oxygen by nasal canula. Telemetry and a repeat EKG show sinus tachycardia. She is breathing rapidly, appears confused, and complains of shortness of breath. On exam, her skin is cool and clammy and appears pale and dull. She has diffuse bilateral pulmonary crackles and an S3 gallop on chest auscultation with no new murmurs appreciated. She has jugular venous distention to the jaw-line, rapid and faint radial pulses, and 1+ dependent edema. She is immediately transferred to the intensive care unit for respiratory support and precautions for airway security. Bedside sonography shows abnormal hypodynamic anterior wall movement and an ejection fraction of 20 %, but no evidence of mitral regurgitation or ventricular shunt, and chest x-ray demonstrates cephalization of pulmonary veins and pulmonary edema. What is the most appropriate next step in stabilization of this patient?

A 56-year-old man suffered seizure like activity followed by loss of consciousness within minutes after surfacing from a recreational 55-foot dive with some friends. His friends laid him on his side and called emergency services. He has a known history of paroxysmal atrial fibrillation status post failed catheter ablation and no other known medical problems. He takes low-dose metoprolol, a daily baby aspirin and a multivitamin. When the emergency response team arrived they found the patient with altered consciousness, a blood pressure of 92/54 mmHg, and a heart rate of 115 beats per minute. His skin appears mottled and his breath sounds are shallow. What is the best next step in management of this patient?

A 37-year-old patient who was being evaluated for involuntary movements, difficulty swallowing food and personality change. He has entered a clinical trial that is studying the interaction of certain neuromediators in patients with similar (CAG)n trinucleotide repeat disorders. The laboratory work of one of the candidates for the clinical trial is presented. Acetylcholine ↓ Dopamine ↑ GABA ↓ Norepinephrine unchanged Serotonin unchanged Which trinucleotide disorder can the patient be diagnosed with?

A 12-year-old boy develops muscle weakness and pain, vomiting, seizures and severe headache. Additionally, he presents with hemiparesis on one side of the body. A muscle biopsy showes "ragged red fibers". What is true about the mode of inheritance of the disease described?

A 17-year-old girl is being evaluated for primary amenorrhea. A pelvic ultrasound shows no uterus, fallopian tubes, or ovaries, her external sexual organs are normal. There is some armpit and pubic hair. Breast development is normal. Laboratory tests show an evidence of increased serum testosterone with normal conversion to dihydrotestosterone (DHT) and increased Luteinizing Hormone (LH). What is the karyotype of this patient?

A 10 weeks and 5 days primigravida has come to the clinic for prenatal care. She has noted the appearance of a rash that looks rough, with reddish-brown spots on her palms. The patient is screened with a rapid plasma regain test (RPR) that comes back positive. The diagnosis is confirmed by dark-field microscopy. What can the fetus develop secondary to the mother's condition?

A 57-year-old man with a history of coronary artery disease has been brought to the emergency department due to the sudden onset of chest pain. He has been diagnosed with arterial hypertension 12 years ago and takes enalapril regularly. The patient is hypotensive on further examination and his skin is cold and clammy. He is diagnosed with a life-threatening condition that resulted from inadequate circulation of blood, with decreased cardiac output and high pulmonary capillary wedge pressure. Which of the conditions below can cause the same disorder?

A patient in the intensive care unit was admitted with hypovolemia due to extensive burns after an arson incident. He is a 57-year-old man with no relevant other medical problems. Currently, his blood pressure is 75/40 mm Hg, the pulse is 140/min, and respirations are 17/min. Currently he is undergoing aggressive fluid resuscitation. You suspect he is in shock. You decide to place a Swan Ganz catheter to clarify his volume status. The most likely finding to support your suspicion that he is a hypovolemic shock would be:

A 37-year-old 11-week primigravida will soon undergo a prenatal evaluation. The doctor wants to exclude chromosomal abnormalities with a test. He tells her that the test consists of a blood sample, that will determine if there is an increased or decreased chance of certain genetic conditions by analyzing placental DNA in her blood. What conditions can the given test predict? I. Trisomy 21 II. Trisomy 13 III. Spina Bifida IV. Fetal sex V. Ebstein anomaly

A 55-year old male living in Midwest USA comes in complaining of painless hematuria for the past week. He denies dysuria, but does note fatigue and loss of energy at work. His vitals are stable but he has lost about 20 pounds in the past 6 months. He drinks 1-2 beers on the weekends over the past 10 years but denies smoking. He has worked at a plastics chemical plant for the past 30 years and has never been out of the country. He has family history of pancreatic cancer. Urinary Analysis (UA) is positive for RBCs. A cystoscopy is performed and finds a pedunculated mass projecting into the bladder lumen. A biopsy shows malignant cells. Which of the following is a risk factor in this patient’s condition?

A 40-year old woman is admitted to the emergency department (ED) with severe, constant epigastric pain radiating to her back for the past 2 hours and severe shortness of breath. She is nauseous and has vomited twice on the way to the ED. Upon further inquiry, the patient had been hiking in the Arizona desert national park for the past 3 days. An hour prior to the onset of pain, she had been bitten by a scorpion. She has a remote history of gallstones and takes hydrochlorothiazide (HCTZ) for high blood pressure which has been well-controlled for the past 5 years; she is otherwise healthy. Upon examination she has bilateral rales in her lungs and breath sounds are barely audible. Her vitals are as follows: heart rate 95/min, blood pressure 90/55 mmHg, respiratory rate 24/min. Radial pulses are weak but symmetric bilaterally. No murmur is heard upon heart auscultation. Which of the following processes is responsible for her symptoms?

A 35-year old male is pulled out of a burning building. He is unconscious and severely injured. He is assessed on site to have 40% of his his body area burned and is transferred to a burn unit where an intravenous peripheral line is in place and a Foley catheter inserted. Upon evaluation of his burns, it is noted that the patient has lost the sensation to pain in the areas burned and there is minimal blanching when pressure is applied to the affected areas. He is given IV fluids and his urinary output is 30 ml/hr. In the next 48 hours his urinary output decreases to 10 ml/hr, blood pressure is 90/60 mmHg, respiratory rate is 25/min, temperature 39.5 C, SaO2 is 60%. There are rales and decreased breath sounds bilaterally upon lung auscultation. What kind of burns are most likely affecting the patient?

A 20-year-old male army recruit collapses during an especially hot day at basic training. At the hospital the patient appears to have altered mental status. Two weeks ago he had an upper respiratory infection (URI) but has since recovered. His father has chronic kidney disease (CKD), bilateral hearing loss and vision problems. He is otherwise healthy. He has severe diaphoresis, his skin is flushed and he is complaining of severe bilateral flank pain and generalized myalgia. His vitals are as follows: temperature 104.5 °F, blood pressure 85/55 mmHg, respiratory rate 24/min, his breaths are shallow. A Foley catheter is inserted and 200 ml of tea-colored urine is excreted. Urine dipstick is positive for blood, but urinalysis is negative for RBCs or WBCs. Which of the following is responsible for his condition?

A 60-year-old retired teacher comes to the dermatologist with a lesion on her lower eyelid. It appeared a month ago and looked like an acne bump. She says it has been bleeding of late with minimal trauma which raised the alarm and made her visit the clinic today. The lesion has not grown in size and is not associated with pain or pruritus. Past medical history is negative. Physical examination reveals a 0.5 cm lesion that has a pearly appearance with telangiectasia and a central ulceration and curled borders. The lesion is biopsied. Histopathology reveals peripheral palisading cells with large, hyperchromatic nuclei and high nuclear: cytoplasmic ratio. Which of the following mechanism explains the most common mode of spread of this neoplasm?

A 58-year-old man visits the physician with complaints of lower back pain. He was diagnosed with aggressive squamous cell carcinoma of the right lung and underwent surgical resection followed by adjunct chemotherapy and radiation therapy that completed 6 months ago. The back pain started a couple of weeks ago and is increasing in severity gradually. At present, the intensity is 6/10. There is no radiation or associated paresthesias. There is no history of trauma. Investigations including a technetium bone scan reveal metastatic lesions in the lumbar vertebrae L2- L4. The physician explains to the patient that these are likely metastatic lesions from his lung cancer. Which of the following is the most appropriate mechanism for development of these metastatic lesions?

A 20-year-old boy is brought to the emergency department by his friends with complaints of abdominal pain and vomiting for the past couple of hours. He describes the pain to be 8/10 in intensity, colicky and associated with nausea. There has been one episode of vomiting. He says there have been a couple of similar but not so severe episodes in the past but he did not seek medical care then. There is no history of bleeding per rectum or black colored stools. He is a law student at the state university, lives in the students’ dorm, does not smoke or drink, and exercises regularly. There is no history of recent travel. His father was diagnosed with colorectal cancer at the age of 45 but he does not know more about it. On physical exam, hyperpigmented macules are noted around his mouth. Other findings raise the suspicion for intestinal obstruction and further investigations confirm the diagnosis of intussusception. Colonoscopy reveals hamartomatous polyps. Which of the following is the mode of transmission of the condition seen in this patient?

A 27-year-old woman comes to the gynecologist for a routine annual examination. She has a 3-year-old child born via normal vaginal delivery. She had a Pap smear during her last pregnancy which was normal. She has no complaints. Her remaining past medical history is insignificant. Recently, one of her close friends was diagnosed with breast cancer at the age of 36 and wants to be checked for all types of cancer. Her family history is negative for cancers. What would be the gynecologist’s best advice to this patient?

A 46-year-old lawyer presents with complaints of increasing fatigue and weakness for the past three months. He was handling a complicated criminal case which was stressful and he thought he was fatigued because of that. He has lost 5 pounds during this span. His history is positive for chronic constipation and infrequent episodes of bloody stools. His father and paternal uncle died of colon cancer. They were both known to possess a genetic mutation for the disease. He was also advised to get tested for the same but owing to work pressure he never had the time to do it. He has never had a colonoscopy and past medical history is otherwise insignificant. Physical examination is normal except for pallor. Colonoscopy reveals multiple adenomatous polyps. They are removed and sent for histopathology examination and show high grade dysplasia. Genetic testing reveals the same genetic mutation as his father and uncle. The patient is concerned for his 20-year-old son. Which of the following is the most appropriate physician’s advice regarding his son?

A Biology graduate student is performing an experiment at the Immunology Laboratory. He is researching the recombination activation genes RAG1 and RAG2 in order to verify the function of these genes. He then decides to carry out the experiment on knock-out mice by turning these genes off. What changes is he expected to see?

A 52-year-old woman scheduled an appointment with her family doctor due to fatigue and pain of the proximal interphalangeal and metacarpophalangeal joints over the last 6 months and knee and wrists pain for the past 2 months and morning stiffness that improves over the course of the day. During a physical exam, the physician notes subcutaneous nodules. Laboratory tests are run: Hgb: 12.5 g/dL; RBC: 4.9 x 106/µL; WBC: 5000/mm^3; PLT: 180,000/mm^3; Coombs test — negative; C reactive peptide (CRP) – elevated; Erythrocyte Sedimentation Rate (ESR) - normal; Anti-citrullinated protein antibody (ACPA) - moderately positive; Anti-nuclear antibody - negative; Rheumatoid factor (RF) - negative. What is the HLA subtype associated with this disease?

A 22-year-old woman is admitted from the emergency department due to increasing in severity neurologic symptoms. During physical examination the patient seems pale, visible mucosa is pale and peripheral paresthesias and ataxia are remarkable. The patient denies alcohol or cigarette abuse. Laboratory tests are run: Hemoglobin: 10.1 g/dL; Red Blood Cells: 3.1 x 106/µL; White Blood Cells: 4000/mm^3; Platelets: 170,000/mm^3; Serum homocysteine: 8.8 µmol/L (Reference Range: 4.6 – 8.1 µmol/L); Serum vitamin B12: 90 ng/L (Reference Range: 180 – 914 ng/L); Methylmalonic acid: 0.09 µmol/L (Reference Range: 0-0.4 µmol/L): Intrinsic factor antibody: positive. Which of the following can cause a deficiency of the same nutrient as in this patient? I. Chron’s Disease II. Blood loss III. X-linked disorder IV. Autoantibodies to intrinsic factor V. Pancreatic insufficiency

A 24 year old male is running a marathon (42.2 km) on a hot summer day and collapses about halfway through the run. Emergency personnel rush to his aid. They arrive to find him seizing. As the seizure subsides the runner presents confusion, dry lips and decreased skin turgor. On the way to the Emergency Department he denies taking medication or having a history of epilepsies. However, he did admit to drinking a gallon of water before the run and several cups of water during the run. Which therapy should the patient receive initially?

A new substance X is being tested for it effect on renal function. During the experiments, the researchers find that urinary concentration of sodium decreases, while the urine potassium concentration increase. Substance X seems to affect the kidneys in the same way as which of the following substances?

A 38-year-old man with complaints of fatigue, enlarged lymph nodes, a mild fever for over three weeks and night sweats presents to his doctor. He also complains about a persistent cough. He has been to a country in South Asia on a business trip some months ago. The physician decides to run a Mantoux test. Which cells or mediators are responsible for this reaction? I. Th1 II. Th17 III. Eosinophils IV. Cytotoxic T-cells V. Macrophages VI. Autoantibodies VII. Immune complexes

A 30-year-old woman has an appointment with her physician, she suffers from arterial hypertension and plans to get pregnant. She is currently taking enalapril and tolerates the medication well. The physician explains that this medication can be teratogenic, which is will they need to change her antihypertensive medication to methyldopa, which has no contraindications for pregnant women. A few days later, she is admitted to the emergency department with jaundice and dark urine. Laboratory tests are as follows: Hemoglobin: 0.9 g/dL; Red blood cells: 3.2 x 106/µL; White blood cells: 5000/mm^3; Platelets: 180,000/mm^3; Direct Coombs test — positive. The patient is diagnosed with autoimmune hemolytic anemia. Which of the statements below is true about autoimmune hemolytic anemia in this patient?

A 2-year-old boy is brought to the clinic because of a swollen face and irritability. His mother reports his urine was red this morning. Three weeks ago, he presented to this same clinic with a ‘sandpaper’ rash and a red tongue with patchy hyperplastic fungiform papillae. He was then treated with broad spectrum antibiotics. Laboratory tests reveal proteinuria, elevated antistreptolysin O and decreased serum C3. Which conditions mentioned below are triggered by a similar mechanism? I. Arthus reaction II. Myasthenia gravis III. Acute rheumatic fever IV. Polyarteritis nodosa V. Rheumatoid arthritis

A 25-year-old Hispanic American female comes into the clinic complaining of worsening malaise, hair loss and a rash on her face. The patient states she has been avoiding daylight because the rash becomes painful and she has not been able to go to classes because of a debilitating arthralgia in her fingers and ankles. She is currently taking no medication. At the time of the consult, she has a fever of 39 °C (102.2 °F). The presence of which of the following is the most useful in diagnosing this patient’s condition?

A 37-year-old man comes to the emergency department due to acute loss of vision, slurred speech, and agitation. He is accompanied by the police. An MRI shows asymmetric, hypointense white matter lesions. A social worker, who helped identify the patient, explains to the physician that he has had HIV and Hepatitis C for approximately 10 years but was not always compliant to his prescribed medication. Which pathogen is responsible for the opportunistic infection that the patient is most likely to have?

A 27-year-old patient visits the clinic for a consultation. He complains of a long-lasting fever, malaise, and occasional diarrhea over the last 2 weeks. During the examination, the physician notes enlarged lymph nodes in the patient. An HIV screening test is positive. Laboratory studies show a CD4+ count of 350 /mm^3. What stage of the disease is correct in relation to this patient?

A 45-year-old patient arrives to a scheduled visit with complaints of night sweats, cough and a fever that started two weeks ago. Past medical history includes HIV infection from 10 years ago, treated with HAART. He says he hasn’t been taking his antiretroviral therapy as prescribed because it is too expensive and he is currently unemployed and without insurance. A chest x-ray is performed and revels a cavity in the right upper lobe of his lung. What is lung infection most likely to be causing this patient’s symptoms?

A 36-year-old patient presents to the clinic with a 3 week of history fever, enlarged lymph nodes, a dry cough that started three weeks ago and complaints of fatigue. His wife noticed that he lost a lot of weight over the last six months and seems very pale. Recently, he developed a non-productive cough and night sweats. His blood count shows anemia and low lymphocyte count. He tells the physician that he has had unprotected sexual relationships with someone other than his wife about one year ago and is fearful this may be related to his current health concerns. The physician needs to run a test for initial screening. What will this test detect?

A 34-year-old Caucasian male is being evaluated for dizziness and headache after a stressful event at work. He was taken to an emergency clinic and evaluated. On physical exam, the patient appears well and his blood pressure is 170/80 mm Hg. He reports that his face often becomes swollen and he occasionally has difficulty breathing during these spells. The patient informs the physician that his father died of a stroke and his mother often suffers from similar facial swelling events. Taking into account the patient’s family history, what medications are likely contraindicated in this patient?

A 28-year-old woman that immigrated recently from Kenya reports she has been experiencing fatigue, shortness of breath and palpitations. Her voice seems hoarse, although her pharynx does not show signs of an inflammatory process. She adds that she had a painful swollen knee. During auscultation, a loud first heart sound with a split second heart sound and a mid-diastolic rumbling murmur with an opening snap can be best heard over the cardiac apex. During echocardiography, the mitral valve looks calcified and with an opening area of 1.5 cm^2 (normal: 3.0-3.5 cm^2). The patient is recommended for a valve replacement because of the risk for systemic complications, such as atrial fibrillation, which may lead to the formation of life-threatening thrombi that can spread to other parts of the body. All sites below can be affected, except for:

A 15-year-old boy is admitted to the emergency department with neck stiffness, maculopapular rash after an onset of persistent headache and fever. He is admitted to the hospital after a blood culture shows encapsulated gram-negative diplococci. He has had this infection before. Which protein is likely to be deficient in the boy?

A 70-year-old male is on the transplant list for a kidney, he has a long history of diabetes mellitus and hypertension. Currently, the patient undergoes hemodialysis two to three times a week. He presents to his primary physician with complaints of constant wrist and shoulder pain. The patient denies any recent traumas. Taking his history into account, what kind of abnormal protein is likely to be found in his urine, causing the patient’s late complaints?

A 72-year-old man is diagnosed with multiple myeloma. His blood work shows mild anemia and urine analysis detects proteinuria of 670 mg/24 h. A kidney biopsy is performed. What deposits are most likely to be detected by the biopsy?