Set 7

Item: 1 of 46
QID: 2609
Mark
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118639 : DR. JITENDRA
A.Closure of the rostral neural tube
B.Development of the ureteric buds
C.Formation of the tracheoesophageal septum
D.Migration of neural crest cells to the distal colon
E.Recanalization of the duodenum
The correct answer is B. 83% chose this.
The presentation described here is consistent with Potter's syndrome, one cause of which is bilateral renal agenesis. The renal parenchyma (except for the nephrons) is derived from the ureteric bud (recall
that the nephrons arise from mesoderm surrounding the ureteric bud). A failure of ureteric bud maturation would result in a fetus without kidneys. An absence of kidneys would lead to oligohydramnios, as
the fetus would be unable to excrete urine into the amniotic sac. This, in turn, would lead to compression of the fetus by the uterine wall, causing limb deformities, abnormal facies, and wrinkly skin. Death
would occur shortly after birth unless an appropriate kidney donor could be found.
A is not correct. 5% chose this.
Anencephaly may result from a failure of the rostral neural tube to close. Anencephalic infants are born with a marked reduction in fetal brain tissue and usually an absence of the overlying skull. These
infants are unable to swallow amniotic fluid in utero, so their mothers' pregnancies are usually marked by polyhydramnios (too much amniotic fluid) rather than oligohydramnios (too little).
C is not correct. 6% chose this.
Failure of development of the tracheoesophageal (TE) septum is the cause of a TE fistula. There are several variants of TE fistula, the most common of which is a blind upper esophagus with the lower
esophagus having an anomalous connection to the trachea. TE fistulas commonly result in polyhydramnios rather than oligohydramnios, and they are unlikely to cause the other findings in this infant.
D is not correct. 2% chose this.
This describes the defect in Hirschsprung's disease, which manifests as severe constipation and an inability to pass meconium. Hirschsprung's disease would not account for the symptoms described in this
scenario.
E is not correct. 4% chose this.
A baby boy dies several hours after his birth despite several attempts to save his life. He was born with wrinkled skin, deformed limbs, and abnormal facies. Prenatal ultrasonography at 15 weeks
indicated that the mother's pregnancy was complicated by oligohydramnios.
Which of the following embryologic processes most likely failed in this child?
Lock End Block Pause Suspend
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Item: 2 of 46
QID: 3112
Mark
A.Androgen supplementation
B.Binding to G proteins to stimulate adenylyl cyclase
C.Inhibition of cAMP
D.Inhibition of cGMP
E.Inhibition of phosphoinositide 3-kinase
The correct answer is D. 76% chose this.
The absence of rapid eye movement, or REM, erections and morning tumescence in this patient indicates that his symptoms are pathological, not psychological, and he requires pharmacologic treatment.
Sildenafil is a first-line treatment for erectile dysfunction. Sildenafil acts by inhibiting cGMP phosphodiesterase, which increases cGMP levels via direct release of nitric oxide, thus leading to smooth muscle
relaxation in the corpus cavernosum. The smooth muscle relaxation allows increased blood flow to the corpus vascularity. Some of sildenafil???s adverse effects include headache, flushing, and disturbances
in color vision. Sildenafil is contraindication in patients taking nitroglycerin or other such drugs, because sildenafil enhances the effect of nitric oxide.
Testosterone cannot be given orally because of hepatotoxicity. It can be administered intramuscularly, topically, or buccally, but it is rarely effective in the setting of erectile dysfunction, because most
patients with erectile dysfunction have normal testosterone levels. Testosterone is discouraged in this setting because of the adverse effects of decreased spermatogenesis, gynecomastia, and possible
impotence.
B is not correct. 9% chose this.
Alprostadil is an intraurethral prostaglandin pellet that increases arterial inflow and decreases venous outflow, thereby increasing erection by binding G proteins and stimulating adenylyl cyclase. It also is
available as an intracavernous injection, but this form is associated with a higher risk of priapism.
Sildenafil works via inhibition of cGMP, not cAMP.
A 45-year-old man complains of erectile dysfunction. The physician investigates the etiology of the patient's complaint and rules out a psychological cause for the patient's symptoms. The patient lacks
erections during episodes of rapid eye movement on sleep studies and denies morning penile tumescence. The physician decides to prescribe an oral therapeutic agent to treat the patient's erectile
dysfunction.
Which of the following is the mechanism of action of the first-line oral agents approved for treating erectile dysfunction?
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Item: 3 of 46
QID: 3917
Mark
A.Decreasing calcium availability in smooth muscle cells
B.Decreasing proton secretion into the stomach lumen
C.Enhancing the phosphorylation of myosin light chains
D.Inhibiting the degradation of acetylcholine
The correct answer is A. 50% chose this.
The patient's dysphagia for both solids and liquids suggest a motility problem. Due to loss of the myenteric (Auerbach's) plexus, the lower esophageal sphincter (LES) fails to relax. The majority of patients
with achalasia have difficulty swallowing both solids and liquids for >6 months, as well as an increased risk of esophageal cancer. Esophageal manometry is the gold standard of diagnosing achalasia by
documenting loss of coordinated peristalsis along the esophagus and abnormally high lower esophageal sphincter tone. Upper endoscopy is also performed to rule out cancer. Surgical corrections include
pneumatic dilation and esophageal myotomy. Medical approaches to treating achalasia include using a calcium channel blocker, nitroglycerin, or botulinum toxin . Calcium channel blockers such as
nifedipine decrease the availability of calcium to the myosin-actin complex, leading to smooth muscle relaxation. Nitroglycerin works through a cGMP-mediated mechanism to dephosphorylate and
inactivate myosin light chains . Botulinum toxin causes muscle paralysis by inhibiting the exocytosis of acetylcholine from presynpatic neurons.
Decreasing proton secretion into the stomach lumen is the mechanism of action of proton pump inhibitors (eg, omeprazole), which are used to treat gastroesophageal reflux disease and dyspepsia as well
as peptic ulcer disease. This patient has achalasia, which is unrelated to acid secretion. This mechanism would not relieve the patient's symptoms.
Enhancing phosphorylation of myosin light chains would enhance muscle contraction, which is the opposite of the mechanism of action of nitroglycerin, and would worsen this patient's symptoms.
Inhibiting the degradation of acetylcholine is the mechanism of action of acetylcholinesterase inhibitors (eg, physostigmine), which are used to treat organophosphate poisoning and to reverse the effects of
neuromuscular junction blockers (eg, pancuronium). This mechanism would lead to increased availability of acetylcholine at the neuromuscular junction, leading to more active muscle contraction, and
would actually worsen this patient's symptoms.
A 29-year-old woman presents to her primary care physician complaining of "trouble eating." She says she has had pain when swallowing both solids and liquids for the past 9 months and regurgitation.
She states that it has been difficult to maintain an appetite over this time and reports a weight loss of 2.3 kg (5 lb). Symptoms have remained constant since they appeared 9 months ago. The patient
does not exhibit tightening of the facial skin, claw-like hands, or any other systemic symptoms.
Which of the following drug mechanisms of action is most likely to improve the patient's symptoms?
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Item: 4 of 46
QID: 3123
Mark
A.Alkylation of DNA
B.Formation of superoxide or hydroxide radicals
C.Inhibition of microtubule polymerization
D.Intercalation into DNA
E.Stabilization of microtubules against depolymerization
This man likely has a stage II testicular seminoma, given his testicular nodule, normal serum tumor marker levels, and spread of his cancer to the retroperitoneal nodes. His symptoms of pulmonary toxicity
and fibrosis are common with bleomycin, a chemotherapeutic agent used as first-line treatment for stage II seminomas. Bleomycin is a mixture of glycopeptides that have the unique feature of forming
complexes with Fe
2+
while also bound to DNA. Oxidation of Fe
2+
gives rise to superoxide and hydroxyl radicals that attack the DNA bonds, causing fragmentation and cessation in the G
2
phase.
Although its main adverse effect is pulmonary toxicity, bleomycin can also cause skin changes and alopecia.
Mitomycin C is a broadly active anti-neoplastic agent that alkylates DNA. Although it can cause delayed bronchospasm 12-14 hours after dosing , it rarely produces a pulmonary fibrosis syndrome like that
caused by bleomycin.
Vincristine binds to the tubulin dimer to prevent microtubule polymerization. It is used to treat acute lymphoblastic leukemia, Wilms' tumor, and lymphomas, not testicular carcinoma. Some adverse effects
of vincristine include cellulitis and peripheral neuropathies, not pulmonary fibrosis.
A 24-year-old man presents for a routine physical examination before beginning a new job. The physician notes a small, firm nodule on the man's left testicle, and the patient is subsequently diagnosed
with a testicular neoplasm. Notably, -human chorionic gonadotropin and -fetoprotein are normal, but a CT taken at the time of diagnosis reveals spread of his disease to the retroperitoneal nodes.
Soon after beginning high-dose chemotherapy, the patient returns to his primary care physician complaining of a 1-week history of dry cough, poor inspiratory effort, and shortness of breath. He denies
orthopnea, paroxysmal nocturnal dyspnea, or peripheral edema. A CT scan of the chest shows diffuse, bilateral interstitial infiltrates.
What is the mechanism of one of the chemotherapeutic agents most likely used to treat his seminoma?
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Item: 5 of 46
QID: 3219
Mark
A.Decrease platelet activation in response to injury
B.Decreases afterload, decreases myocardial oxygen demands
C.Decreases plaque formation on coronary arteries
D.Decreases preload, decreases myocardial oxygen demands
E.Increases afterload and decreases myocardial oxygen demands
F. Increases preload, decreases myocardial oxygen demands
This patient's symptoms are consistent with stable angina pectoris: transient chest pain that is brought on by situations that increase myocardial oxygen demands, such as exercise, cold, or emotional
stress, and is relieved by rest. Her stable angina is most likely due to a fixed atheromatous plaque in one or more of her coronary vessels. In stable angina, the coronary blood flow through atherosclerotic
vessels is sufficient to meet the demands of the heart at rest; however, during exertion blood flow through the coronary vessel(s) is not able to increase enough to meet the increased myocardial oxygen
demands in the areas of the heart supplied by these vessel(s), leading to ischemia and chest pain. Sublingual nitroglycerin tablets are a mainstay of both the diagnosis and treatment of angina pectoris.
They work through the action of nitric oxide on the vascular smooth muscle to cause vasodilation via a cGMP-dependent mechanism. At low doses the organic nitrates affect veins more than arterioles , and
the increased compliance of the veins decreases the venous return to the heart, causing a decrease in preload, thus decreasing the myocardial oxygen demands to a level that can be met by the narrowed
coronary vessel(s). Nitroglycerin also dilates the coronary arterioles directly, and this increased coronary blood flow may be of particular importance in cases of angina due to coronary vasospasm. At higher
doses the organic nitrates cause widespread arteriolar dilation in addition to venous dilation, which can decrease afterload by decreasing blood pressure, but can also lead to hypotension and reflex
tachycardia. Dilation of the facial and meningeal arterioles causes the adverse effects of flushing and headache.
Nitroglycerin has no effect on platelet activation and clumping; however, aspirin and other anticoagulants do. This action decreases the possibility of thrombus formation and serves to decrease the risk of
myocardial infarction.
A 48-year-old woman with a history of hypercholesterolemia and smoking presents to the cardiologist complaining of activity-induced chest pain. She describes the pain as a chest tightness that
develops after walking several blocks and goes away after several minutes of rest. In addition to arranging further testing, the physician gives the patient a tablet and tells her to put it under her tongue
when she has any similar episodes.
At low doses, which of the following is the primary mechanism by which this medication alleviates the patient's symptoms?
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Item: 6 of 46
QID: 1931
Mark
A.0.0007 L/min
B.0.007 L/min
C.0.01 L/min
D.0.07 L/min
E.0.10 L/min
The first step is to calculate the volume of distribution (V
d
): V
d
= (amount of drug in the body) / (plasma drug concentration) = (50 mg) / (5.0 mg/L) = 10 L. With the volume of distribution calculated, and
knowing the half-life (t
1/2
), clearance (CL) can be calculated as: t
1/2
= (0.7 V
d
) / CL; then CL = (0.7 V
d
) / t
1/2
= (0.7 10 L) / 100 min = 0.07 L/min.
Calculation error.
Calculation error.
Calculation error.
Calculation error.
Fifty milligrams of drug X is administered to a patient intravenously, yielding a steady-state plasma concentration of 5.0 mg/L.
If the half-life of drug X is 100 min, which of the following is the clearance of drug X?
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Item: 7 of 46
QID: 2042
Mark
A.Crepitus
B.Flaccid paralysis
C.Tenesmus
D.Trismus
E.Watery diarrhea
Assuming that this man received an initial course of immunizations against tetanus, he must receive a tetanus booster shot following this puncture wound (tetanus booster shots are good for only 10
years). Tetanus is a disease caused by an exotoxin (tetanospasmin) released by Clostridium tetani. This toxin causes sustained contraction of skeletal muscles (tetany). When this occurs in the muscles of
the jaw, a condition called trismus (or lockjaw) results.
Crepitus is a grinding or crunching noise that can be associated with Clostridium perfringens infection (also known as "gas gangrene"). The organism creates pockets of gas in skin, muscle, and
subcutaneous tissues that can be released when the skin is palpated.
Flaccid paralysis is characteristic of infection with Clostridium botulinum. Botulinum toxin prevents the release of acetylcholine from motor end plates, causing a flaccid paralysis.
Tenesmus is the sensation of the need to empty the bowel accompanied by pain and cramping, although there is little stool to pass. It is usually associated with inflammatory (either infectious or
noninfectious) diseases of the bowel.
Pseudomembranous colitis is caused by Clostridium difficile, usually after a patient has been treated with broad-spectrum antibiotics for several days. This organism causes diarrhea, abdominal cramping,
A 35-year-old man comes to the emergency department after stepping on a rusty nail in his backyard. He has not received any immunizations since he was 12 years old, but he states that he "had all
the regular childhood shots."
If left untreated, which of the following is the patient most likely to develop?
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Item: 8 of 46
QID: 4136
Mark
A.Altered fetal development due to disruption of cellular differentiation and growth; DNA and protein synthesis and inhibition of cell migration
B.Defective primary and/or secondary neurulation
C.Full or partial trisomy 18
D.Nondisjunction in maternal gametes
E.Splitting of the fertilized ovum 2-12 days after fertilization
An elevated -fetoprotein level is indicative of a neural tube defect (NTD) such as spina bifida; levels of estriol and -human chorionic gonadotropin usually are normal. Open NTDs usually result from
defective primary neurulation, whereas closed NTDs are the result of defective secondary neurulation. The exact etiology of NTD is unknown and is likely multi-factorial, including radiation, drugs,
malnutrition, and genetics. The major NTDs include spina bifida occulta, meningocele, myelomeningocele, encephalocele, and anencephaly. Maternal folic acid supplementation reduces the risk of NTDs.
Although the precise mechanism remains unknown, ethanol and its metabolite acetylaldehyde have a wide spectrum of adverse effects on virtually every organ system as a result of disruption of a
multitude of cellular processes. Fetal alcohol syndrome is associated most often with mental retardation, smooth philtrum, and a short palpebral fissure. Fetal alcohol syndrome is not associated with any
abnormalities of the triple test.
Trisomy 18, or Edwards' syndrome, is the second most common trisomy among live-born children (after trisomy 21). It is characterized by a decreased -fetoprotein, decreased estriol, and decreased
-human chorionic gonadotropin. Characteristic findings include "rocker bottom" feet, micrognathia, and clenched fists. Multiple organ systems are involved.
This describes trisomy 21, or Down's syndrome. Most cases are the result of nondisjunction in maternal gamete; mosaicism and robertsonian translocation are rarer causes of trisomy 21. It is characterized
by a decreased -fetoprotein, decreased estriol, and increased -human chorionic gonadotropin. Characteristic signs and symptoms present at birth include, but are not limited to, hypotonia (virtually
pathognomonic for trisomy 21), flat nasal bridge, single palmar crease, and congenital heart defects.
A 32-year-old mother of two presents at 16 weeks' gestation for a routine prenatal check-up. A triple test of the maternal serum is done and shows an elevated -fetoprotein level but normal estriol and
-human chorionic gonadotropin levels.
What is the pathophysiology of the condition the baby is most likely to have?
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Item: 9 of 46
QID: 1950
Mark
A.Acts as an insulin sensitizer
B.Decreases glucagon release
C.Directly binds insulin receptors
D.Inhibits intestinal -glucosidases
E.Triggers insulin release
Metformin is a biguanide used to help control hyperglycemia in patients with diabetes. Its mechanism of action is poorly understood, but it likely stimulates glycolysis in peripheral tissues, decreases hepatic
gluconeogenesis, and increases insulin sensitivity in the periphery. It does not act on islet cells and has no effect on insulin secretion, so it is less likely than other drugs, such as the sulfonylureas, to cause
hypoglycemia. The most life-threatening adverse effect of metformin is lactic acidosis. This patient has an anion gap metabolic acidosis, likely lactic acidosis from metformin use. This potentially fatal
complication of metformin treatment is far more likely in patients with renal insufficiency, because they cannot efficiently clear lactate from the body.
A 57-year-old man with diabetes, hypertension, osteoarthritis, and chronic renal insufficiency comes to the emergency department complaining of malaise, abdominal pain, and shortness of breath. Soon
after arrival, he becomes difficult to arouse. He is afebrile with a respiratory rate of 28/min and heart rate of 60/min. Laboratory tests show:
Na
+
: 140 mEq/L
K
+
: 5.5 mEq/L
Cl
-
: 100 mEq/L
HCO
3
-
: 18 mEq/L
Blood urea nitrogen: 30 mg/dL
Creatinine: 2.2 mg/dL
Arterial blood gas analysis reveals a pH of 7.20, partial oxygen pressure of 100 mm Hg, and partial carbon dioxide pressure of 33 mm Hg.
The drug most likely contributing to this patient's condition has which of the following mechanisms?
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Item: 10 of 46
QID: 3004
Mark
A.Acts as a H
2
-receptor agonist
B.Acts as a H
2
-receptor antagonist
C.Acts as a prostaglandin agonist
D.Acts as a prostaglandin antagonist
E.Acts as a proton pump inhibitor
The correct answer is C. 58% chose this.
Misoprostol is the medication that was most likely prescribed. It is a prostaglandin E
1
analog and acts as an agonist at the prostaglandin receptors on parietal cells. This, in turn, results in increased mucus
production and decreased acid secretion. Misoprostol may be used in patients with gastric ulcers induced by nonsteroidal anti-inflammatory (NSAID) use (this patient was likely taking chronic NSAIDs given
her history of rheumatoid arthritis) when the patient needs to continue NSAID use despite the gastrointestinal adverse effects. Another clinical use for misoprostol is in medically induced abortions, where it
is used in combination with mifepristone, a progesterone antagonist.
H
2
-receptor agonists would not help reflux but in fact would worsen the symptoms.
H
2
-receptor antagonists such as ranitidine, cimetidine, and famotidine will inhibit acid secretion at the histamine receptor. Misoprostol is not an H
2
blocker.
Misoprostol is a prostaglandin E
1
analog and acts as an agonist at prostaglandin receptors on parietal cells. It does not act as a prostaglandin antagonist.
Proton pump inhibitors such as omeprazole and lansoprazole work to inhibit acid secretion. These drugs may also be used to treat NSAID-induced ulcers. However, misoprostol is a prostaglandin agonist
A 35-year-old woman with a history of rheumatoid arthritis is diagnosed with peptic ulcer disease. The doctor confirms that the patient is not pregnant and that she will not try to become pregnant while
being treated, and then prescribes a medication.
What is the mechanism of action of the drug the doctor most likely prescribed?
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Item: 11 of 46
QID: 4740
Mark
A.Antiepithelial cell
B.Antihistone
C.Antimicrosomal
D.Antimitochondrial
E.Antineutrophil
The correct answer is E. 51% chose this.
This patient has symptoms of microscopic polyangiitis (MPA, also called microscopic polyarteritis), a small-artery vasculitis that is most common in white individuals. Activation of neutrophils and monocytes
by perinuclear antineutrophil cytoplasmic antibodies (MPO-ANCAs/p-ANCAs) leads to inflammation and subsequent symptoms. Until recently, MPA was believed to be part of "classic" polyarteritis nodosa, a
small- or medium-vessel vasculitis. It is now believed that MPA, Wegener's granulomatosis, and Churg-Strauss syndrome all comprise a category of small-vessel vasculitides related to ANCA and
characterized by a paucity of immune deposits (hence, the term "pauci-immune," which suggests that there is a 2+ or less staining when immunofluorescence is used to test for the presence of antibodies).
In late stages, MPA can cause rapidly progressive glomerulonephritis and pulmonary capillaritis.
Antiepithelial cell antibodies might be found in a patient with pemphigus vulgaris. Patients with this potentially fatal disease present with acantholysis and intraepidermal bullae. Antiepithelial cell antibodies
would not be found in a patient with polyarteritis nodosa.
Antihistone antibodies might be found in a patient with drug-induced lupus, a form of lupus that can be an adverse effect of hydralazine and procainamide. These antibodies would not be found in a patient
with polyarteritis nodosa.
Antimicrosomal antibodies might be found in a patient with Hashimoto's thyroiditis. This patient would present with symptoms of hypothyroidism, not with the symptoms seen in this patient.
A 56-year-old white man presents to his physician with complaints of fatigue, muscle pain, and a 9.1-kg (20-lb) unintentional weight loss over the past 3 months. He also mentions that his stools have
been unusually dark brown for the past few weeks. The patient is febrile, and physical examination reveals palpable purpura along his extremities. He also mentions that he has coughed up reddish-
looking sputum in the past few weeks.
The physician would expect to find antibodies to which cellular component in this patient?
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Item: 12 of 46
QID: 4099
Mark
A.Anterior communicating artery
B.Anterior spinal artery
C.Left posterior inferior cerebellar artery
D.Right anterior cerebral artery
E.Right middle cerebral artery
The constellation of this patient's deficits is consistent with medial medullary syndrome. An infarct of the medial medulla produces contralateral weakness in an upper motor neuron pattern (due to damage
to the corticospinal tract in the medullary pyramids) and loss of proprioception and vibratory sensation (due to damage to the medial lemniscus) below the neck, while sparing the face. Damage to the
hypoglossal nucleus causes the tongue to deviate to the side of the lesion. Occlusion of the anterior spinal artery is responsible for the ischemic damage in medial medullary syndrome.
Occlusion of the anterior communicating artery would cause visual field defects.
The posterior inferior cerebellar artery supplies the lateral medulla. Occlusion of this artery produces the symptoms of lateral medullary syndrome: ipsilateral ataxia, vertigo, hoarseness, loss of pain and
temperature sensation in the ipsilateral face and contralateral trunk and extremities, and an ipsilateral Horner's syndrome. None of the deficits mentioned in the vignette would be present.
The anterior cerebral artery supplies the anterior medial surface of the brain, along the interhemispheric fissure. Occlusion of the right anterior cerebral artery would produce weakness and sensory loss
limited to the left side of the body, rather than the right side as with this patient, because the descending motor fibers cross over to the contralateral side in the medulla and the ascending sensory fibers
cross over in the spinal cord. Pinprick and temperature sensation would not be selectively spared.
A 74-year-old woman presents with weakness and hyperreflexia of the right arm and leg. Vibratory sensation and proprioception are lost in these areas as well, whereas pinprick and temperature
sensation are spared. She does not have facial weakness, but her tongue deviates to the left. Infarction-induced medial medullary syndrome is suspected.
Which of the following vessels is most likely involved?
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Item: 13 of 46
QID: 4201
Mark
A.
2
-Agonist
B.Dopamine receptor blocker
C.Monoamine oxidase inhibitor
D.Serotonin receptor agonist
E.Serotonin receptor antagonist
Sumatriptan is an agonist of the 5HT
1B/1D
receptor that is used in the treatment of acute migraine and cluster headaches. Action on these receptors causes vasoconstriction of cerebral and meningeal
vessels. Other "triptans" work on the 5HT
1B/1D
receptor and include almotriptan, eletriptan, rizatriptan, and zolmitriptan. A rare adverse effect of 5HT
1B/1D
agonism is coronary vasoconstriction.
2
-Agonists such as albuterol cause bronchodilation and are used in the treatment of asthma.
Haloperidol is an antipsychotic drug that blocks dopamine receptors. It is used in the treatment of schizophrenia and psychosis.
Selegiline is an antiparkinsonian drug that selectively inhibits MAO-B and increases the availability of dopamine.
Ondansetron is a 5HT
3
receptor antagonist and is used in the treatment of nausea and vomiting associated with chemotherapy.
A 20-year-old woman sees her physician, reporting that she has been experiencing severe, unilateral, throbbing headaches several times each month. The headaches are associated with nausea and
occasional vomiting. She has used ibuprofen in the past but finds it does not control the headaches well. The physician recommends another drug that the patient should take at the immediate onset of
her symptoms.
What is the mechanism of action of her new medication?
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Item: 14 of 46
QID: 5279
Mark
A.Atenolol
B.Meropenem
C.Selegiline
D.Sumatriptan
E.Valproic acid
A 35-year-old woman presents to her primary care physician complaining of lower back pain. The physician completes a full neurological examination, which reveals a normal patellar deep tendon reflex.
X-ray of the lumbar/sacral spine is shown in the image. The physician asks the patient if her mother took a certain medication during her pregnancy, and the patient confirms his suspicion.
Which of the following drugs did the patient's mother most likely take during the pregnancy?
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Item: 16 of 46
QID: 1797
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A.10-15:1 with low urine output
B.<15:1 with normal urine output
C.15-20:1 with normal urine output
D.>15:1 with low urine output
E.>20:1 with normal urine output
The important point of this question is that this patient died in renal failure, which is indicated by the diffuse tubular necrosis seen on autopsy. Tubular necrosis indicates acute renal failure, which can be
secondary to ischemia, crush injuries (causing myoglobinuria), or a variety of toxins (in this case ethylene glycol, which results in a profound metabolic anion-gap acidosis). If the rest of the organ systems
can be supported, individuals with acute tubular necrosis (ATN) usually recover in 2-3 weeks with supportive dialysis. To calculate this patient's blood urea nitrogen:creatinine (BUN:Cr) ratio and urine
output before his death, one has to figure out what type of renal failure he had: prerenal, intrarenal, or postrenal. ATN is an intrarenal process, and intrarenal damage is marked by a decline in glomerular
filtration rate. BUN and plasma Cr concentrations increase in proportion to one another, so the ratio remains below 15:1. Because the kidney is damaged in ATN, it is unlikely that it will be able to reabsorb
sodium and concentrate the urine. Thus, the fraction of excreted sodium is usually >2%. Renal failure is also associated with low urine output. Therefore, this patient's renal function prior to death most
likely showed a BUN:Cr ratio of <15:1 and low urine output.
A BUN:Cr ratio of <15:1 is consistent with intrarenal disease, as this patient had; however, the patient would not have normal urine output, so this answer is incorrect.
A BUN:Cr ratio of 15-20:1 is consistent with postrenal, not intrarenal, disease. Additionally, renal failure is not associated with normal urine output.
A BUN:Cr ratio above 15:1 with low urine output is consistent with postrenal causes of renal failure. Prostatic disease and urethral stones can cause urinary obstruction, leading to acute renal failure.
Postrenal disease is manifested by low urine output and a fractional excretion of sodium of >4%.
A 49-year-old alcoholic consumes antifreeze and is subsequently found unconscious on the sidewalk. He is taken to a nearby hospital, where he is found to be in florid renal failure. Despite emergency
dialysis, he ultimately goes into torsade de pointes and dies. Postmortem renal biopsy shows diffuse tubular necrosis.
Which of the following blood urea nitrogen to creatinine ratios would be consistent with this patient's data prior to his death?
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Item: 15 of 46
QID: 3476
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A.G
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phase
B.G
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C.G
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D.M phase
E.S phase
Vincristine and other vinca alkaloids block the polymerization of microtubules, thereby preventing the formation of a mitotic spindle. The mitotic spindle is necessary for mitosis; thus, vincristine is specific
to the M phase.
The G
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phase of the cell cycle is characteristic of permanent cell types that are not actively dividing, such as neurons, skeletal muscles, and RBCs. Cancer cells typically do not enter the G
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phase, and
vincristine is not specific for this phase.
G
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phase.
Podophyllotoxins and bleomycin are specific to the G
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phase of the cell cycle, but vincristine does not target this phase.
Antimetabolites and podophyllotoxins are S-phase specific, but vincristine is not.
Vinca alkaloids such as vincristine are chemotherapeutic agents that are used for the treatment of choriocarcinoma as a part of the mechlorethamine/Oncovin/procarbazine/prednisone regimen.
Vincristine's mechanism of action makes the drug specific for which phase of the cell cycle?
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Item: 17 of 46
QID: 5145
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A.Decreased plasma osmolarity
B.Decreased total body potassium
C.Hyperchloremia
D.Hypoglycemia
E.Metabolic alkalosis
The patient is experiencing diabetic ketoacidosis (DKA), an acute and potentially fatal complication of type 1 diabetes mellitus. In DKA, a combination of insulin deficiency and an excess of counterregulatory
hormones, including glucagon and epinephrine, leads to a state of hyperglycemia. The body turns to ketogenesis for an alternative source of energy, leading to ketonuria and metabolic acidosis from the
build-up of acidic components. In DKA, even though serum levels of potassium may be low, normal, or even increased due to the exchange of intracellular potassium for extracellular hydrogen ion, total
body potassium is decreased from osmotic diuresis. The patient is experiencing nausea and vomiting from the increase in ketones such as -hydroxybutyrate. His Kussmaul's breathing is typical of severe
metabolic acidosis. Additionally, his breath would have a fruity odor secondary to acetone. His physical exam is notable for dehydration due to osmotic diuresis. DKA needs to be treated promptly with
administration of fluids and insulin, correction of electrolytes, and perhaps the administration of glucose.
In DKA, there is an increase in plasma osmolarity, not a decrease, as the body loses fluids via osmotic diuresis from hyperglycemia.
In DKA, hypochloremia, not hyperchloremia, is seen. Osmotic diuresis leads to a loss of sodium chloride in the urine.
In DKA, hyperglycemia from deficiency of insulin is seen, not hypoglycemia.
A 17-year-old boy is brought to the emergency department because of nausea, vomiting, diffuse abdominal pain, and lethargy since the previous night. This morning when he woke up, his parents
noticed that he seemed very confused. The patient has had episodes of polyuria and polydipsia in the preceding weeks. Physical examination is notable for rapid deep breathing. Mucous membranes are
dry and lips appear cracked.
Which of the following is most likely to exist in this patient?
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Item: 18 of 46
QID: 1758
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A.HIV has not yet developed resistance to reverse transcriptase inhibitors
B.Many of the reverse transcriptase inhibitors function as amino acid analogs
C.Peripheral neuropathy is an adverse effect associated with the use of certain reverse transcriptase inhibitors
D.Reverse transcriptase inhibitors have not been shown to decrease vertical (mother-fetus) transmission of HIV
E.Reverse transcriptase inhibitors prevent the assembly of new viral particles from viral precursor proteins
Peripheral neuropathy has been associated with didanosine (ddI), zalcitabine (ddC), and stavudine (d4T) . In addition to retroviral reverse transcriptase, these drugs also inhibit an enzyme that
mitochondria use to reproduce, resulting in the production of fewer mitochondria and an increase in mitochondrial mutations.
Resistance to the reverse transcriptase inhibitors is due to mutations at several sites on the pol gene of HIV. Resistance occurs rapidly in monotherapy, which is one of the reasons why combination therapy
with multiple drugs and drug classes (highly active antiretroviral therapy) has been so successful.
The majority of reverse transcriptase inhibitors are nucleoside analogs: didanosine is an analog of deoxyadenosine ; zalcitabine is a pyrimidine analog; stavudine is a thymidine analog; and abacavir is a
guanosine analog.
Zidovudine (AZT), a nucleoside reverse transcriptase inhibitor, has been shown to reduce the mother-to-fetus/child transmission rate during pregnancy. When given antepartum, intrapartum, and
postpartum, the transmission rate is reduced from 22.6% to 7.6%.
Reverse transcriptase inhibitors function by blocking the retroviral enzyme reverse transcriptase. The nucleoside reverse transcriptase inhibitors (zidovudine, didanosine, zalcitabine, lamivudine, stavudine,
With the advent of antiretroviral therapy, the morbidity and mortality of HIV-positive individuals have been improved tremendously. Many of these antiretroviral drugs fall into the category of reverse
transcriptase inhibitors.
Which of the following statements regarding reverse transcriptase inhibitors is true?
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Item: 19 of 46
QID: 4565
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A.Anemia
B.Atherosclerosis
C.Cardiac arrest
D.Congestive heart failure
E.Dementia
A 36-year-old man who works at an explosives factory comes to the clinic for an annual check-up. He is concerned about long-term exposure to industrial chemicals. He reports that although he is in
excellent health otherwise, he experiences headaches, dizziness, and palpitations every Monday. Laboratory studies show:
WBC count: 8000/mm
Hematocrit: 46%
Hemoglobin: 15 g/dL
Platelet count: 310,000/mm
Na
+
: 137 mEq/L
K
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Cl
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HCO
3
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: 24 mEq/L
Blood urea nitrogen: 12 mg/dL
Creatinine: 1.0 mg/dL
An ECG shows normal sinus rhythm with no Q wave changes.
Which of the following is the most likely serious complication that can occur as a result of his exposure?
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Item: 20 of 46
QID: 10003
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A.-Synuclein aggregates
B.Aggregated tau proteins
C.Areas of decreased myelin with increased GFAP
D.Misfolded protein aggregates
E.Neurofibrillary tangles
The patient is suffering from dementia with Lewy bodies (DLB). She has had a fairly rapidly progressive dementia with early loss of executive function. She also has marked psychotic symptoms including
paranoia and visual hallucinations (which are commonly seen with this condition). Physical exam is significant for some parkinsonian features such as bradykinesia, but there is no evidence of a tremor.
Brain biopsy specimens of patients with DLB show Lewy bodies (aggregates of -synuclein).
Aggregated tau proteins are found primarily in Pick's disease. Pick's disease is a progressive degenerative disorder characterized by selective involvement of the anterior frontal and temporal neocortex.
Pathologically, patients with Pick's disease have intracellular inclusions called Pick bodies. Clinical features include gradual onset of confusion of place and time, difficulties with comprehension, inability to
cope with new problems, loss of tact, deterioration of work habits, neglect of personal hygiene, and alterations of personality and behavior. Visual hallucinations are not a prominent finding in this disorder.
Multiple sclerosis (MS) is characterized by relapsing and remitting episodes of demyelinization followed by remyelinization. GFAP is a marker of astrocytes, cells that are involved in the repair process of
nerve myelin layers. Diagnosis of MS at age 65 would be very rare, and this patient is not suffering from the motor or visual symptoms often seen with the disease.
The following vignette applies to the next 2 items. The items in the set must be answered in sequential order. Once you click Proceed to Next Item, you will not be able to add or change an answer.
A 65-year-old woman with no significant medical history is seen by her primary care physician for recent changes in behavior. The son who brought her to the appointment states that just 6 months ago,
the patient was living independently and was active in her community. However, over the past few months, she has become increasingly reclusive and mistrustful of others. Her son recently convinced
her live with him, because she was unable to prepare meals for herself and failed to keep track of her bills. He noticed her staring into space for lengthy periods of time and occasionally mumbling to
herself and swatting at the air, especially at night. The patient reluctantly admits to visual hallucinations. Physical examination is significant for an expressionless face, disorganized speech, and bradykinesia.
If a biopsy of her brain were done, what would be the primary pathologic finding?
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Item: 21 of 46
QID: 10004
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A.Acetaminophen
B.Dantrolene
C.Diazepam
D.Levodopa
E.Norepinephrine
The patient has neuroleptic malignant syndrome (NMS) as demonstrated by her muscle rigidity, altered mental status, and autonomic instability. Patients with DLB are very sensitive to neuroleptic agents,
and it is thought that NMS is a result of acute dopaminergic blockade. Patients with DLB have been known to respond to neuroleptics with worsening psychosis and NMS. The primary pharmacologic
intervention in NMS is dantrolene, which blocks excitation-contraction coupling in muscle cells and allows for muscle relaxation. Prolonged muscle rigidity can lead to rhabdomyolysis and renal failure.
Dantrolene is also useful for related conditions like serotonin syndrome and malignant hyperthermia.
Acetaminophen is a powerful antipyretic. However, it is not recommended for the treatment of fever in NMS.
Diazepam is a useful antiepileptic as well as a muscle relaxant. It is often one of the first-line agents used for treating stiffness in tetanus. However, it is not the primary agent for treatment of NMS.
Levadopa can often be an adjunctive therapy for NMS in addition to dantrolene. However, it is not the primary intervention.
Three days later, the patient is brought to the emergency department by ambulance because she could not be aroused from sleep. The son also noticed that she was "as stiff as a board." Yesterday she
had accidentally ingested one of her son's medications used to treat schizophrenia. Her vital signs in the emergency department include a temperature of 41.0C, pulse of 130/min, and blood pressure of
170/85 mm Hg. She was diaphoretic and shouting incoherent phrases. Physical examination revealed extreme muscle rigidity. Twenty minutes later, she became unresponsive and a repeat blood
pressure showed a reading of 82/40 mm Hg.
Which of the following should be the primary treatment?
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Item: 22 of 46
QID: 10005
Mark
A.Hypercalcemia
B.Hyperkalemia
C.Hypernatremia
D.Hypophosphatemia
E.Hypouricemia
Rhabdomyolysis is a condition defined by the breakdown of muscle cells. Electrolyte abnormalities that exist in this condition include hyperkalemia, hyperuricemia, hyperphosphatemia, and hypocalcemia.
Hyperkalemia exists because the breakdown of cells leads to the release of intracellular potassium. The condition is exacerbated by the acute renal failure, which prevents the body from effectively
excreting the excess potassium.
There is a transient hypocalcemia associated with rhabdomyolysis, but it is usually self-resolving.
Hypernatremia is a documented cause for rhabdomyolysis, but it would not be a consequence of this condition.
Rhabdomyolysis leads to hyperphosphatemia, not hypophosphatemia.
There is a massive release of uric acid with muscle breakdown. The uric acid can get trapped in the renal tubules and precipitate crystals. This can further exacerbate renal failure.
With proper diagnosis and treatment, the patient has resolution of her muscle rigidity but she remains obtunded. The resident realizes that the patient has had a decreasing urine output. A serum
creatine kinase and serum creatinine are ordered and found to be elevated.
What electrolyte abnormality is most likely to be present?
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Item: 23 of 46
QID: 10116
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A.Amitryptiline
B.Bupropion
C.Fluoxetine
D.Phenelzine
E.Trazodone
Selective serotonin reuptake inhibitors (SSRIs) (eg, fluoxetine, paroxetine, citalopram, and sertraline) are first-line agents for the treatment of depression, and the preferred choice in patients who express
suicidal ideation. They work by increasing the level of serotonin (5-HT) in the synaptic cleft by blocking the reuptake transporter. Adverse effects include sexual dysfunction, agitation, and possibly the
serotonin syndrome (muscle rigidity, hyperthermia, and vascular instability) when taken with other serotonergic medications (particularly monoamine oxidase inhibitors).
The tricyclic antidepressants (eg, nortriptyline and amitryptiline) work by inhibiting the reuptake mechanism that terminates the actions of norepinephrine (NE) and 5-HT. They have anticholinergic
properties and should not be used in patients with glaucoma because mydriasis may reduce the caliber of the aqueous humor outflow tract.
Bupropion is a little understood antidepressant that works via weak dopaminergic and noradrenergic mechanisms. It is contraindicated in patients with a history of seizures, bulimia, or anorexia nervosa. Of
the antidepressants, it is the least likely to cause sexual adverse effects.
Phenelzine is a monoamine oxidase inhibitor that works by inhibiting the metabolism of NE and 5-HT in nerve terminals. They are less frequently used in current practice due to their relatively dangerous
A 70-year-old widower presents to his primary care physician with a chief complaint of fatigue. He is found to be severely depressed and has intermittent suicidal ideation. He denies having a formal plan
to commit suicide. His past medical history is notable for glaucoma and epilepsy. He does not smoke but does consume 1-2 beers per day. The patient agrees to start psychotherapy and return if he
feels unable to cope with his suicidal thoughts.
Which of the following drugs would be most appropriate to treat this patient's condition?
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Item: 24 of 46
QID: 10117
Mark
A.Change medications to a tricyclic antidepressant
B.Discontinue the selective serotonin reuptake inhibitor
C.Hospitalize the patient
D.Increase the dose of the selective serotonin reuptake inhibitor
E.Observation for 4 weeks
Offering voluntary admission for this patient who is adherent to medications and likely to cooperate in the milieu setting is the best first step. Involuntary hospitalization is indicated for the acutely suicidal
patient or the acutely homicidal patient, especially when there is a plan of action. The problem with involuntary inpatient hospitalization is that this can always be challenged in court, thus delaying
treatment further.
Sometimes in treating major depressive disorder, it is necessary to switch to a different class of medication. This may be due to inefficacy or unfavorable adverse effects. However, a particular drug should
be given a trial of 6 weeks if possible, as some unfavorable adverse effects (gastrointestinal disturbances with SSRIs, for instance) tend to wane with continued use of the medication.
A normal trial of an SSRI takes 4-6 weeks. The underlying condition that is contributing to the suicidality is the patient's depression. The best course of action would be to continue treating the depression.
In this case, the patient should also be closely monitored in the inpatient setting and receive social and familial support.
Inadequate dosage may be the cause of treatment-resistant depression; however, this patient needs emergent hospitalization to prevent him from harming himself.
The same patient returns 1 week later without any improvement in his depressive symptoms. The physician had prescribed a selective serotonin reuptake inhibitor, but explained to the patient that it
may take several weeks before the drug is able to exert its full effect. The patient now states that his thoughts about committing suicide are more intense and intrusive. He has thought about overdosing
on his "depression pills."
Which of the following is the most appropriate action?
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Item: 25 of 46
QID: 10113
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A.Alprazolam
B.Ethylene glycol
C.Fluoxetine
D.Heroin
E.Nortriptyline
A 45-year-old woman presents by ambulance to the emergency department after the housekeeping staff at her hotel found her lying on her bed unconscious. She had a seizure on the way to the
hospital. Physical examination reveals dry mucous membranes and dilated pupils. Her temperature is 39.2C (102.6F), pulse is 123/min, respiratory rate is 8/min, and blood pressure is 95/60 mm Hg.
An ECG, obtained upon arrival in the emergency department, is shown in the image.
Which of the following substances, if taken alone, would account for her condition?
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Item: 26 of 46
QID: 10114
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A
B
C
D
E
When respiratory depression is present, TCA overdose produces a mixed acidosis with both a metabolic and a respiratory component . Hence the pH will be reduced (acidosis), the bicarbonate will be
decreased (metabolic acidosis), and the partial arterial carbon dioxide pressure would be expected to increase (hypoventilation). TCAs block norepinephrine reuptake and can cause hypokalemia by
increasing catecholamine stimulation.
Laboratory tests, including arterial blood gas, are obtained.
Which of the following would be expected in this woman's condition?
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Item: 27 of 46
QID: 10115
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A.Bicarbonate
B.Diphenhydramine
C.Ethanol
D.Flumazenil
E.Hemodialysis
Pharmacologic management of TCA poisoning involves plasma alkalinization, which increases the binding of the TCA to plasma proteins, thus reducing the amount of free, active TCA. Alkalinization also
treats the hypotension and stabilizes ventricular arrhythmias by decreasing the duration of the QRS interval. This is accomplished because alkalinization reduces the amount of TCA bound to myocardial
calcium channels. Sodium bicarbonate administration also alkalinizes the urine and promotes TCA excretion. Acute management may also involve activated charcoal. Seizures should be treated with
benzodiazepines.
Diphenhydramine is an histamine antagonist and has been used to treat serotonin syndrome.
Ethanol is used in the management of toxic alcohol ingestion. Ethanol is a competitive inhibitor of both methanol and ethylene glycol for alcohol dehydrogenase. The presence of ethanol prevents alcohol
dehydrogenase from producing harmful metabolites (eg, formic acid and oxalic acid) that are formed when toxic alcohols are processed by this enzyme.
Flumazenil is a competitive antagonist of benzodiazepine and is used to treat benzodiazepine overdose.
Dialysis is not effective at treating TCA overdose because the drug has a large volume of distribution with relatively low concentrations in the blood.
From their conversation with the hotel staff, the paramedics estimate that the patient has been in a comatose state for at least 2 hours.
Which of the following could be used to treat this woman's condition at this time?
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Item: 28 of 46
QID: 3195
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A.Complete infarction of the optic chiasm
B.Infarction of the lower division of the middle cerebral artery
C.Left retinal artery occlusion with sparing of the vessels supplying the macula
D.Right posterior cerebral artery infarction with sparing of Meyer's loop
E.Right posterior cerebral artery infarction with sparing of the occipital pole
The right posterior cerebral artery (PCA) supplies the right occipital lobe, which is responsible for perceiving the left lateral visual field in both eyes. The occipital pole is the extreme posterior end of the
occipital lobe, which houses the fibers that originate from the macula. The macula is responsible for central vision. Thus PCA infarcts that spare the occipital pole cause hemianopia (in this case, left
homonymous hemianopia) with sparing of central vision.
A lesion in the optic chiasm would cause bitemporal hemianopia, not left homonymous hemianopia. The most common cause of optic chiasm lesions is a pituitary adenoma.
Infarction of the lower division of the middle cerebral artery would cause defects of the temporal lobe, including the lower optic radiations (Meyer's loop). Such lesions would cause contralateral superior
quadrantanopia, or "pie in the sky" defects.
A left retinal artery occlusion with sparing of the vessels supplying the macula could cause a hemianopia of the left eye, with macular sparing, but "left homonymous hemianopia" means that the left visual
field of both eyes is defective.
Meyer's loop refers to the inferior division of optic radiations as they pass through the temporal lobe. Meyer's loop lesions are caused by middle cerebral artery infarcts. All PCA lesions should spare Meyer's
A 64-year-old man with a history of hypertension, coronary artery disease, and type 2 diabetes presents to his physician because he "has trouble seeing." Visual field testing reveals a defect in the left
half of the visual field for both eyes, with sparing of central acuity.
Which of the following is the most likely cause of the patient's symptoms?
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Item: 29 of 46
QID: 2998
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A.Binds to the gastrin receptor on parietal cells
B.Binds to the H
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-receptor on parietal cells to block its interaction with histamine
C.Binds to the M
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-receptor
D.Binds to the prostaglandin receptor
E.Binds to the somatostatin receptor
Ranitidine belongs to the class of drugs termed H
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-receptor antagonists include famotidine and cimetidine. They bind to H
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-receptors on parietal cells to block the receptors'
interaction with histamine, and thereby decrease acid secretion.
There is no known inhibitor for the gastrin receptor.
Anticholinergics such as atropine bind to the M
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-receptor to block its interaction with acetylcholine, which stimulates acid secretion.
Prostaglandins bind to the prostaglandin receptor on parietal cells and decrease acid secretion.
There are no known inhibitors of the somatostatin receptor.
A 34-year-old man comes to his physician complaining of worsening heartburn and reflux. He has been taking over-the-counter ranitidine but feels he needs a stronger prescription.
What is the mechanism of action of ranitidine?
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Item: 30 of 46
QID: 10108
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A.Hyperresponsiveness of cells with bound antibody
B.Hypertrophy of mucus-secreting glands of bronchioles
C.Misfolding of a protease inhibitor protein
D.Point mutation in an ion transporter
E.Release of inflammatory substances that result in alveolar damage
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-Antitrypsin (AAT) deficiency is a genetic disorder that leads to both cirrhosis and emphysema. This enzyme is normally responsible for inactivating elastase (a protease) present in lung parenchyma. The
molecular basis is a mutation that causes misfolding of AAT. Consequently, AAT cannot be effectively released from hepatocytes, and thus it is deficient in the rest of the body. This results in overactive
elastase within the lung which destroys alveoli, resulting in emphysema. Although smokers also develop emphysema from destruction of alveoli, in them it tends to be centroacinar, while AAT deficiency
produces a panacinar emphysema.
The molecular basis of asthma and respiratory allergies is hyperresponsiveness to an antigen, which leads to inappropriate activation of IgE-bound mast cells. Consequently, bronchioles constrict and mucus
is oversecreted in response to histamine released from the mast cells. This is not the basis of this patient's disease, as his picture is consistent with emphysema, not asthma. His radiologic findings indicate
chronic obstructive pulmonary disease (COPD).
Hypertrophy of mucus-secreting glands of the bronchioles is seen in patients with chronic bronchitis, a form of COPD. The patient's lack of productive cough or sputum production weighs against this
diagnosis. Moreover, this form of COPD is strongly associated with smokers, and this patient does not have a smoking history.
A 35-year-old man comes to the clinic complaining of increasing exertional dyspnea. The patient denies productive cough or fever. On examination, a nodular liver edge is palpated. X-ray of the chest
reveals increased anterior-posterior diameter, a flattened diaphragm, and increased lung field lucency. The patient is a nonsmoker and has no occupational hazards.
What mechanism is responsible for this disease?
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Item: 31 of 46
QID: 10109
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A.Intracellular periodic acid-Schiff-positive globules
B.Intracytoplasmic eosinophilic inclusions
C.Lymphocytic invasion of parenchyma
D.Positive Prussian blue-stained hepatocytes
E.Sclerotic intrahepatic biliary ducts
The accumulation of misfolded AAT within hepatocytes is seen histologically as intracellular periodic acid-Schiff (PAS)-positive globules. The excessive protein in these cells leads to liver cirrhosis. Many of
the common signs and symptoms of hepatic failure such as elevated bilirubin, uremia-induced nausea, and decreased platelet function and coagulopathy are present in this patient. There is no effective
treatment for hepatic AAT deficiency other than a liver transplant for end-stage hepatic failure.
Intracytoplasmic eosinophilic inclusions, also known as Mallory bodies, are seen in alcohol-induced hepatitis. This patient does not have a history of alcohol use. Moreover, the patient is suffering from a
cirrhotic picture, and Mallory bodies are not seen in end-stage liver failure.
Autoimmune hepatitis is an uncommon cause of cirrhosis. Histologically, this disease presents with portal lymphocyte infiltration, fibrosis, and occasionally piecemeal necrosis. In advanced disease, fibrosis
is extensive and cirrhosis ensues. The typical patient is a middle-aged woman with other autoimmune diseases.
Hemochromatosis is a multiorgan disease in which deposits of iron build up within tissue parenchyma, leading to its destruction. Hemochromatosis often affects the liver, leading to cirrhosis. Histologically,
iron deposits within hepatocytes can be appreciated with Prussian blue stain. The patient's gender and age make him a prime candidate for hemochromatosis. However, his history of emphysema, and the
The patient returns to his physician several months later complaining of yellow skin, fatigue, nausea, and excessive bruising. The physician is suspicious for advanced disease and performs a CT scan of
his abdomen, which confirms a shrunken, nodular liver. A biopsy is then performed.
What are the likely histologic findings on liver biopsy?
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Item: 32 of 46
QID: 3815
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A.Left ventricular free-wall rupture
B.Papillary muscle rupture
C.Pulmonary embolus
D.Re-infarction
E.Right ventricular free-wall rupture
Five to ten days after myocardial infarction, mechanical weakening of the necrotic and inflamed myocardium can result in rupture of the ventricular free wall, resulting in hemopericardium and cardiac
tamponade. The physical manifestations of cardiac tamponade include distended neck veins, Kussmaul's sign, muffled or distant heart sounds, and pulsus paradoxus. As a result of this cardiac emergency
the patient becomes severely hypotensive, because the blood in the pericardium restricts diastolic filling and subsequently compromises overall cardiac function (cardiogenic shock).
As with ventricular wall rupture, papillary muscle rupture most frequently occurs 4 to 7 days after acute MI. Rupture of papillary muscles, specifically at the mitral valve, leads to acute mitral regurgitation
and sudden pulmonary edema. The typical presentation includes tachypnea, tachycardia, and hypotension accompanied by diffuse pulmonary rales and respiratory distress. The classic murmur of mitral
A 53-year-old man with diabetes presents to the emergency department complaining of crushing substernal chest pain. He is diaphoretic and has lateral ST elevations on ECG. He is rushed to the cardiac
catheterization laboratory, where two coronary artery stents are placed in the circumflex artery and warfarin therapy is started. Six days later, when preparing for discharge, the patient suddenly
experiences intense chest pain and lightheadedness. The following values are obtained:
Temperature: 37.5C (99.5F)
Pulse: 125/min
Blood pressure: 85/40 mm Hg
Respiratory rate: 18/min
Oxygen saturation: 97% on room air
Auscultation of distinct heart sounds is difficult. The patient's neck veins are prominent. No other physical findings are appreciated. After a few minutes the patient loses consciousness.
What is the most likely mechanism behind this patient's sudden symptoms?
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Item: 33 of 46
QID: 2452
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A.5- to 10-mm oval, tan-brown patches that do not darken with sunlight
B.Raised, pearly borders surrounded by fine telangiectasias
C.Sharply defined red, scaling plaques
D.Tan-brown, rough lesion <1 cm in diameter
E.Thickened, hyperpigmented skin with velvet-like texture
The classic gross signs of pearly borders and fine telangiectasias lead one to suspect basal cell carcinoma. The photomicrograph confirms this, as the nuclei are arranged in palisades, and there are islands
of tumor cells. These histologic characteristics are hallmarks of basal cell carcinoma. Also note that the lesion is on the face of a farmer, someone who presumably has extensive sun exposure.
The image shows a section of biopsied tissue from a skin lesion on the forehead of a 60-year-old farmer.
Which of the following is the most likely gross description of the skin lesion?
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Item: 34 of 46
QID: 2382
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A.CD16
B.CD19
C.CD28
D.CD3
E.CD8
CD16 (also called Fc-g RIII) is an important cell surface receptor found on natural killer (NK) cells and sometimes on macrophages. The Fc receptor CD16 can bind to the Fc portion of antibodies coating
virally infected cells. CD16 recognizes the Fc of certain IgG subclasses and, after binding intracellular signaling, results in the release of perforin and granzymes, thereby killing the virally infected cells. This
mechanism of NK Fc receptor-mediated destruction is called antibody-dependent cell-mediated cytotoxicity.
CD19 is a cell surface marker for B cells. B cells produce the antibodies that opsonize bacteria and neutralize viruses, among other functions. In this case, however, we are looking for a cell receptor that
could utilize antibodies already attached to the virus, such as CD16, an Fc receptor, found on NK cells and macrophages.
CD28, found on T lymphocytes, receives a costimulatory signal that allows full activation of T lymphocytes by antigen-presenting cells. The ligand for CD28, B7, is found on antigen-presenting cells
(dendritic cells and macrophages). They do not recognize antibodies.
CD3 is expressed by T lymphocytes and is a key component of signal transduction for the T lymphocyte-receptor complex.
High-affinity antibodies in the body protect against infection by neutralizing foreign antigens such as toxins or those accompanying bacteria or viruses. However, accessory effector pathways are also
needed, because many pathogens cannot be neutralized directly. A new virus is discovered that is not cleared by neutralization. However, antibodies are found to be necessary mediator to destroy the
pathogen.
Which of the following CD (cluster of differentiation) proteins is associated with an immune cell that could play a key role in destroying this pathogen?
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Item: 35 of 46
QID: 3470
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A.t(8;14)
B.t(9;22)
C.t(11;14)
D.t(11;22)
E.t(14;18)
This patient has follicular lymphoma, which is the most common type of non-Hodgkin's lymphoma (NHL). Follicular lymphoma is recognizable by its attempt to recapitulate lymph node architecture by
forming follicles. Ninety percent of follicular lymphomas have a translocation between chromosomes 14 and 18, which leads to the overexpression of the antiapoptotic bcl-2 gene.
Burkitt's lymphoma is a rare cancer of young adults that is associated with Epstein-Barr virus infection. Translocation between chromosome 8 and the heavy arm of the Ig gene is highly prevalent, leading
to the classic overexpression of c-myc.
Philadelphia chromosome is considered a hallmark for chronic myelogenous leukemia (CML). The t(9;22) translocation generates a fused bcr-abl hybrid (not to be confused with bcl) that leads to a
A 49-year-old woman presents to her primary care physician for a lower abdominal pain that has worsened over the course of several weeks. A CT scan shows a drastically enlarged spleen. The spleen is
surgically removed and pathologic sections show a lymph node-like appearance with abnormal germinal centers. The results of immunohistochemical staining are:
CD20: High
CD15: Low
bcl-2: High
c-Myc: Low
Tartrate-resistant acid phosphatase: Low
Which gene translocation has occurred in this cancer cell?
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Item: 36 of 46
QID: 1348
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A. Receptors utilize the inositol triphosphate mechanism
B.
-Blockers cause a decrease in Na
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C.-Blockers cause a decrease in protein kinase C
D.-Blockers cause an increase in cyclic adenosine monophosphate
E.-Blockers cause an increase in protein kinase A
-Blockers work by inhibiting -receptors and thus inhibiting the G-protein/cyclic adenosine monophosphate (cAMP) mechanism. By decreasing the amount of cAMP and protein kinase A produced,
-blockers work to decrease the Na
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and Ca
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current within the atrioventricular node and thus decrease the slope of phase 4 and phase 0. As a result, abnormal pacemakers can be suppressed.
Receptors do not utilize the inositol triphosphate mechanism and thus are not involved with protein kinase C.
Receptors do not utilize the inositol triphosphate mechanism and thus are not involved with protein kinase C.
-Blockers cause a decrease in cyclic adenosine monophosphate.
-Blockers cause a decrease in protein kinase A.
In a clinical study examining the properties of -blockers, it is found that the atrioventricular node is targeted and that the PR interval on ECG is lengthened.
Which of the following is true about -blockers and receptors?
Bottom Line:
The receptor is a G-protein coupled receptor linked to cAMP. -Blockers act to inhibit these receptors, thereby decreasing cAMP production and reducing the slope of phase 4 and phase 0.
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Item: 37 of 46
QID: 2708
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A.Bethanechol
B.Erythromycin
C.Metoclopramide
D.Ondansetron
E.Scopolamine
The gastrointestinal (GI) tract has an extensive neuronal network that regulates its function, including motility. Stimulation of cholinergic and serotonin receptors promotes GI motility; activation of
dopaminergic D
2
receptors in the GI tract decreases GI motility. Metoclopramide is a prokinetic agent that promotes GI motility by antagonizing D
2
receptors. It is also able to enter and act on dopamine
receptors in the central nervous system, which is thought to be responsible for its significant antiemetic properties as well as the parkinsonism-like adverse effects described in this vignette. Other adverse
effects of metoclopramide include restlessness, drowsiness, and diarrhea.
Bethanechol is useful as a GI prokinetic agent because of its cholinomimetic action. Adverse effects are similar to other cholinomimetic drugs and may include diarrhea, urination, bradycardia, and
bronchospasm (rare).
Erythromycin belongs to the macrolide class of antibiotics. In the GI tract, erythromycin promotes motility by directly stimulating motilin receptors on smooth muscle. This additional site of action has
resulted in a secondary use for the antibiotic as a GI prokinetic agent. Other adverse effects include QTc prolongation, increased incidence of pyloric stenosis when used in infants, and inhibition of
cytochrome P450 enzymes.
A 48-year-old woman with insulin-dependent type 2 diabetes mellitus is hospitalized for intractable nausea and vomiting. Endoscopy of the upper gastrointestinal tract shows residual food in the
stomach, and gastric emptying scintigraphy study shows a delay in the passage of food from the stomach to the small bowel, confirming the diagnosis of diabetic gastroparesis. She is started on a
prokinetic agent and is warned about possible adverse effects, including the development of muscle rigidity, shuffling gait, and tremor.
What drug was she most likely prescribed?
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QID: 3058
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A.Imatanib
B.Raloxifene
C.Trastuzumab
D.Valacyclovir
E.Vincristine
A young woman comes to her primary care physician complaining of 8 weeks of fevers, chills, night sweats, fatigue, and weight loss. About 3 weeks ago she noticed a large bump around her clavicle.
The mass is surgically removed and biopsied (see the image).
What is the best treatment for this patient's most likely illness?
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Item: 39 of 46
QID: 2222
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A.Bone marrow transplant
B.C-kit ligand
C.Erythropoietin
D.Granulocyte colony-stimulating factor
E.Interleukin-11
F. Monocyte colony-stimulating factor
Clozapine, an atypical anti-psychotic agent, is effective in patients with schizophrenia who do not respond to standard anti-psychotic agents. However, agranulocytosis is a serious and potentially
life-threatening complication seen in some patients receiving clozapine. Thus patients taking clozapine must undergo weekly WBC and absolute neutrophil counts for the first 24 weeks of treatment. The
correct treatment strategy in clozapine-induced neutropenia is to discontinue the clozapine and administer granulocyte colony-stimulating factor (GCSF). GCSF acts by promoting the proliferation and
maturation of granulocytes. Alternatively, granulocyte macrophage colony-stimulating factor can be used, but it has more severe adverse effects, including capillary leak syndrome and peripheral edema.
Neutropenia caused by clozapine is both transient and reversible following withdrawal of the drug. A bone marrow transplant would be too invasive at this point.
C-kit ligand plays a role in pluri-potent stem cell development prior to lineage differentiation.
Erythropoietin, a glycoprotein growth factor that stimulates RBC production, is used to treat anemia in renal failure. It is not indicated in the treatment of neutropenia.
A 45-year-old woman with a 15-year history of schizophrenia and six previous psychiatric admissions begins taking clozapine to treat refractory schizophrenia. Six months later the patient's WBC count
is <500/mm.
Which of the following treatments is most appropriate for this patient's neutropenia?
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Item: 40 of 46
QID: 3720
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A.Bruton's agammaglobulinemia
B.Chronic granulomatous disease
C.Hyper-IgM syndrome
D.Leukocyte adhesion deficiency syndrome
E.Severe combined immunodeficiency
X-linked hyper-IgM syndrome is due to a deficiency of the CD40 ligand . There is a selective deficiency of IgG with normal or elevated serum concentrations of IgM. It can be the result of one of many gene
defects, which causes an inability for the immunoglobulin to class switch (from IgM to IgG) and form functional antibodies . Clinical manifestations include recurrent pyogenic infections and P. jiroveci
pneumonia. Patients generally respond well to intravenous immunoglobulin replacement therapy. Definitive diagnosis can be made with special laboratories confirming CD40 ligand deficiency. Gene
sequencing can be used as well.
Bruton's agammaglobulinemia is an X-linked recessive disease like hyper-IgM, but it is due to a defect in a tyrosine kinase gene and is associated with low levels of all classes of immunoglobulins, not just
IgG. The disease usually does not manifest until about age 6 months, when maternal IgG is depleted. Patients have recurrent bacterial infections of the respiratory tract such as acute and chronic
pharyngitis, sinusitis, otitis media, bronchitis, and pneumonia. The causative organisms are usually Haemophilus influenzae, Streptococcus pneumoniae, or Staphylococcus aureus. These organisms are
normally opsonized and cleared by phagocytosis. These patients are also susceptible to viral infections, especially those caused by enteroviruses such as echovirus, poliovirus, and coxsackievirus.
Chronic granulomatous disease is not a result of CD40 ligand deficiency, but a defect in phagocytosis of neutrophils due to deficiency in reduced nicotinamide adenine dinucleotide phosphate oxidase
activity.
A 3-year-old boy has been hospitalized multiple times with recurrent infections including otitis media, sinusitis, and pneumonia. He has also suffered from opportunistic infections, including Pneumocystis
jiroveci (formerly carinii) and Cryptosporidium. Doctors determine that his recurrent infections are a result of a deficiency of the CD40 ligand, which is normally expressed on activated CD4+ T
lymphocytes.
What is the most likely diagnosis?
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Item: 41 of 46
QID: 3385
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A.Esophageal adenocarcinoma
B.Hepatocellular carcinoma
C.Mesothelioma
D.Nasopharyngeal carcinoma
E.Transitional cell carcinoma of the bladder
Aniline dyes such as naphthalene increase the risk of transitional cell carcinoma of the bladder. Clinical symptoms of bladder cancer include hematuria, dysuria, and incontinence.
Exposure to nitrosamines (compounds often found in smoked foods) increases one's risk of esophageal and gastric cancer.
Infection with hepatitis B and hepatitis C viruses, as well as exposure to carbon tetrachloride, aflatoxins, and vinyl chloride, increase one's risk of hepatocellular carcinoma.
Asbestos exposure increases the risk of mesothelioma and lung cancer.
Infection with Epstein-Barr virus increases the risk of nasopharyngeal carcinoma.
A 55-year-old man comes to his physician for a routine health maintenance examination. He has never smoked and does not drink alcohol. Toward the end of the visit, he tells his physician that he has
worked in the textiles industry for 30 years. He knows that he has been exposed to aniline dyes and is concerned about how this may affect his health.
This patient's occupational exposure increases his risk for which of the following neoplasms?
Bottom Line:
Aniline dyes such as naphthalene increase the risk of transitional cell carcinoma of the bladder.
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Item: 42 of 46
QID: 1419
Mark
A.Decreased sympathetic outflow
B.Decreased venous pressure
C.Increased aldosterone secretion
D.Increased effective arterial blood volume
E.Increased glomerular filtration rate
This individual is presenting with signs typical of congestive heart failure (CHF). In CHF, there is a decrease in effective arterial blood volume due to the inability of the heart to effectively pump blood,
which stimulates the renin-angiotensin-aldosterone axis to increase the tubular absorption of Na
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to help increase intravascular volume.
Sympathetic outflow would be increased to counteract the diminished cardiac output of the failing heart. Norepinephrine stimulates
1
-receptors on myocardial cells to raise the heart rate and increase
contractility so more blood is ejected with each beat.
The venous pressure would actually be increased due to the inability of the heart to effectively pump blood into the arterial system. The blood backs up and leads to passive congestion of the venous
circulation. Increased venous pressure leads to increased intracapillary pressure causing fluid to leak out into the interstitial tissue space. The transudate collects in dependent areas and manifests clinically
as pitting ankle edema.
The effective arterial blood volume would be decreased due to the decreased ability of the heart to pump blood into the high-pressure arterial circulation.
Glomerular filtration rate would be decreased because the ineffective pump leads to lowered effective arterial blood volume, resulting in a reduction in renal blood flow.
A 57-year-old white man presents to his primary care physician with dyspnea. He says that he likes to maintain his garden, but recently has had trouble doing the work. He reports shortness of breath
when walking up even one flight of stairs. On further questioning, he reports waking up in the middle of the night with shortness of breath. Physical examination demonstrates pitting ankle edema.
Which of the following findings would also be expected in this patient?
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QID: 3175
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A.Branchial cleft cyst
B.Dermoid cyst
C.Ectopic thyroid gland
D.Enlarged pyramidal lobe of the thyroid
E.Lipoma
F. Thyroglossal duct cyst
The correct answer is F. 67% chose this.
The thyroid gland originates as the thyroid diverticulum on the floor of the pharynx. It descends into the neck during development, but remains connected to the tongue by the thyroglossal duct. The
thyroglossal duct eventually disappears, leaving a small cavity (the foramen cecum) at the base of the tongue. The pyramidal lobe of the thyroid can be thought of as the caudal part of the duct.
Occasionally, part of the duct epithelium persists in the neck and may form cysts. Thyroglossal duct cysts are usually painless or slightly tender and appear in the midline of the neck. They often appear
over or just below the hyoid, but may appear anywhere between the base of the tongue and the thyroid. If a normal thyroid gland is present, surgery to remove the thyroglossal duct cyst is recommended
to prevent infection. In this case, the presence of a normal thyroid is demonstrated by normal triiodothyronine, thyroxine, and thyroid-stimulating hormone levels and is confirmed by CT scan.
Branchial cleft cysts can also occur in the neck but are not always in the midline. Unlike thyroglossal duct cysts, they are often associated with fistulas or sinus tracts.
Dermoid cysts are the second most common cause of midline neck masses, after thyroglossal duct cysts. They tend to be more superficial than thyroglossal duct cysts and more mobile relative to
underlying structures.
A physician is asked to evaluate a 5-year-old girl who has developed a mass in her neck. During the interview, he learns that the mass appeared within the past few months and has been enlarging;
however, it causes no pain or discomfort. The mass is in the midline of the neck just inferior to the hyoid bone. Laboratory tests reveal a triiodothyronine level of 150 ng/dL, a thyroxine level of 8.0
g/dL, and a thyroid-stimulating hormone level of 1 U/mL. A CT scan of the neck is performed and the doctor recommends surgery.
Which of the following is the most likely diagnosis?
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Item: 44 of 46
QID: 2680
Mark
A.Ascaris lumbricoides
B.Cigarette smoking
C.Gallstones
D.Schistosoma haematobium
E.Tuberculosis
The patient's clinical presentation is consistent with adenocarcinoma of the gallbladder. Gallbladder adenocarcinoma is associated with chronic gallbladder inflammation, typically from a history of
gallstones, which can be seen with the thickening of the gallbladder wall on CT. Gallbladder polyps, the polypoid lesion, are also associated with an increased risk of gallbladder adenocarcinoma. The
enlarged lymph nodes point to local invasion and spread, which is unfortunately common on initial presentation. Gallbladder cancer is a disease of the elderly and is more common in women than men.
Most (90%) patients with gallbladder cancer have concomitant stones . In general, the treatment for adenocarcinoma of the gallbladder is surgical excision but prognosis is generally poor if not found
incidentally.
Ascaris lumbricoides is associated with gastrointestinal irritation, cough, and eosinophilia.
Cigarette smoking is associated with many malignancies, particularly of the lung, pancreas, and esophagus; it has not been linked to adenocarcinoma of the gallbladder.
Schistosoma haematobium infection is associated with the development of squamous cell carcinoma of the bladder.
Tuberculosis is associated with hemoptysis, cough, and weight loss.
A 65-year-old white woman presents to the emergency department with persistent right upper quadrant pain with nausea and vomiting. CT of the abdomen reveals a polypoid mass of the gallbladder
protruding into the lumen, diffuse thickening of the gallbladder wall, and enlarged lymph nodes.
This patient most likely has a history of which of the following?
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Item: 45 of 46
QID: 2104
Mark
A.Amphotericin B
B.Fluconazole
C.Potassium iodide
D.Selenium sulfide
E.Sodium stibogluconate
This patient likely has been infected by Blastomyces dermatitidis, the fungus that causes blastomycosis. It is endemic in many parts North America, including the parts of the United States and Canada that
surround the Great Lakes. Blastomycosis usually presents with flu-like symptoms: fevers, chills, productive cough, myalgia, arthralgia, and pleuritic chest pain. Patients commonly progress to develop
chronic pulmonary infection or widespread disseminated infection. Mild pulmonary infections are treated with fluconazole or ketoconazole. Amphotericin B is used to treat systemic infections .
Fluconazole or ketoconazole are effective treatments for local mild pulmonary blastomycosis infections but are ineffective if the infection is systemic .
Potassium iodide and itraconazole are used to treat Sporothrix schenckii. S. schenckii is the cause of sporotrichosis. When S. schenckiiis introduced into the skin, usually by a thorn prick, it causes a local
pustule or ulcer with nodules along draining lymphatics (ascending lymphangitis). S. schenckii is a dimorphic fungus that has cigar-shaped, budding yeast visible in pus.
Selenium sulfide (Selsun) is used to treat Malassezia furfur. M. furfur is the cause of tinea versicolor. Symptoms of this infection include hypopigmented skin lesions that occur in hot and humid conditions.
Sodium stibogluconate is used to treat Leishmania donovani infection. L. donovani presents with hepatomegaly and splenomegaly, malaise, anemia, and weight loss. L. donovani is transmitted via the
sandfly. Microscopically, macrophages containing amastigotes are observed.
A 43-year-old man presents with flu-like symptoms, fevers, chills, and a productive cough. Physical examination is remarkable for pleuritic chest pain. On questioning, the patient says that he spent the
past week on a hiking trip in Canada. Cultures taken from the patient's blood grow a broad-based, budding organism.
Which of the following agents is the most appropriate treatment for this patient?
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Item: 46 of 46
QID: 1003
Mark
A.Arteriosclerosis
B.Atherosclerosis
C.Mnckeberg's arteriosclerosis
D.Medial calcific sclerosis
E.Takayasu's arteritis
Atherosclerosis begins with the formation of a fatty streak, a deposition of cholesterol and cholesterol esters, lipid-laden macrophages (foam cells), calcium, and necrotic debris in the intima of the coronary
arteries. Over time, the fatty streak becomes an inflammatory, proliferative plaque that progresses to a complex atheroma under the influence of risk factors such as smoking, hypertension, diabetes,
hyperlipidemia, and family history. The most common arteries affected are the abdominal aorta, and the coronary, popliteal, carotid, renal, and mesenteric arteries.
Arteriosclerosis is a general term for vascular disease characterized by rigidity caused by calcification and thickening of medium to large arteries. Atherosclerosis is the most common form of
arteriosclerosis.
Mnckeberg's arteriosclerosis is an eponymic term for medial calcific sclerosis.
Medial calcific sclerosis, also known as Mnckeberg's arteriosclerosis, involves calcification of the media of medium-sized muscular arteries without intimal thickening or obstruction of flow.
Takayasu's arteritis, also known as "pulseless disease," involves the thickening of the aortic arch or proximal great vessels, which leads to weak pulses in the upper extremities. Patients may also have
ocular disturbances due to involvement of the carotid arteries.
A 53-year-old man presents to his physician with a chief complaint of chest pain that worsens on exertion and at times of stress. An angiogram reveals fibrous plaques in the intima of the proximal
portions of his coronary arteries.
Fibrous plaques are indicative of which of the following pathologic processes?
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