NBME 18

April 2, 2018 | Author: Dilawar Jan | Category: Management Of Hiv/Aids, Kidney, Blood Pressure, Lung, Hypertension


Comments



Description

NBME 18Block 1 part 1 1. 56-year-old man comes with vague right-sided flank pain and 7-lb weight loss over past 6 weeks. No recent trauma or back strain. Urine is darker than usual over 2 weeks. Renal ultrasound shows 1.5-cm solid mass in upper portion of right kidney. Urine shows 50 erythrocytes, 6 leukocytes, no bacteria. Dx? - Renal cell carcinoma 2. 22-year-old man who is a professional cyclist undergoes extensive physiologic testing as part of his training regimen. His resting pulse is 33/min, and blood pressure is110/62 mm Hg. Echocardiography shows dilated ventricles with normal function and a left ventricular ejection fraction of 75%. Which of the following best describes the findings in this patient? - Eccentric hypertrophy 3. During a clinical study of calcium and phosphorus metabolism, a 50-year-old man undergoes series of lab studies. His serum Ca, PO4 and PTH are normal. He is given infusion 2 g Calcium chloride over 2 hours. His serum Ca concentration now is 11.5mg/dl. Compared with pre infusion levels, the serum concentration of which of the following substances is likely to be increased at this time? - 24,25-Dihydroxycholecalciferol 4. 70-year-old man comes with skin blistering for 1 week. No oral lesions. Physical shows tense bullae in joint folds of upper and lower extremities. Biopsy shows subepidermal blister formation. Immunofluorescence microscopy shows antibodies against proteins at the dermal-epidermal junction. Target by antibodies? - Hemidesmosome 5. 63-year-old man with abnormal blood pressure. 6 months ago, bp was 135/85. Today bp 170/98. Bruit heard over left renal artery. CT angio shows left arterial stenosis. Labs? - Total peripheral resistance increased, plasma renin activity increased, serum aldosterone concentration increased 6. 35-year-old woman with 3-month progressive shortness of breath with exertion. RR 26. Physical shows jvd and prominent a wave. Lungs clear. Cardiac exam shows loud pulmonic component of S2 and right-sided S4 gallop. Increased pulmonary expression of what? - Endothelin-1 7. 30-year-old woman with 2-years of numbness, blanching, and bluish color to ears, fingers and toes after emotional upset or cold exposure. Vitals and PE normal. Avoid taking which drug? - Phenylephrine 8. 35-year-old woman with 2-day history of blistering lesions on sun-exposed face, arms and hands. Recurrent episodes of skin lesions over several years. Taking oral contraceptives for 15y. PE shows fluid-filled vesicles and bullae. Labs: AST increased, ALT increased, total porphyrin increased, urine uroporphyrin III increased. Precursor to uroporphyrin? - Succinyl CoA 9. 65-year-old with sudden onset generalized tonic-clonic seizures. Personality change last 6 months; used to be mild mannered and now verbally abusive. CT shows single mass enhances with contrast in right frontal lobe and crosses to left hemisphere through corpus callosum. Dx? - High-grade fibrillary astrocytoma 10. 3-week-old male newborn with recurrent vomiting after feeding since birth, and eager to feed after vomiting. Abdominal exam shows firm, mobile mass in epigastrum to right of midline. Dx description? - Single primary development defect 11. 39-year-old man with 1-week of red spots on shins, joint pain and fatigue. PE shows purpura over lower extremities. Liver palpated 4 cm below costal margin. Labs: WBC 10,000, AST 142, ALT 154, hepatitis C virus RNA positive, anti-hepatitis C virus antibody positive, cryoglobulins positive, C4 120 (N=350-600), urine protein 4+, urine RBC numerous. Hypersensitivity reaction? - Type III (immune complex-mediated) 12. 45-year-old man with hypertension not compliant with medications. bp 160/100. Cardiac exam shows apical impulse displaced laterally, loud S2 and S4 gallop. Echo shows thickening of left ventricular wall. Mechanism of change in cardiac muscle? - Transcription factor c-Jun: increased, beta-myosin heave chain: increased, endothelin: increased 13. 70-year-old man with early morning awakening, decreased energy, difficulty concentrating, anhedonia, psychomotor retardation, depressed mood for 3 months. He had myocardial infarction and nonsustained ventricular tachycardia 2 years ago. Tx? - Paroxetine 14. 5-year-old boy with motion sickness. Planning vacation to Australia, and wants diphenhydramine for motion sickness. Mechanism of action for motion sickness? - Antagonist at muscarinic-3 (M3) receptors 15. Newborn is found to have a cervical rib. Transformation of seventh cervical segment to thoracic identity. Which is true of HOX gene alteration? - Expression of a HOX gene normally expressed only caudal to C7 16. 28-year-old man with ulcerative colitis, history of partial colectomy, and improved rectal bleeding and diarrhea since then. Meds include mesalamine, hydrocodone and acetaminophen. He says, "I've been taking so much of my opiate prescription that I ran out and stole some from my job." Next step? - Discuss treatment options and a referral for detoxification program 17. 66-year-old man dies 7 days after myocardial infarction. Gross of heart shown (perforated interventricular wall). Histology? - Erythrocytes, cellular debris, macrophages, and early granulation tissue 18. 16-year-old boy who frequently thinks about sex, daydreams about girls before going to sleep, and masturbates one to two times daily. After counseling about safe sex, best next step? - Schedule next routine examination 19. 18-year-old man comes with cracked lips and peeling sunburned skin. Works as lifeguard. PE shows desquamation of sunburned skin. Lips are dry and cracked. Petrolatum to lips may reduce lip symptoms by which of following effects of the compound? - Barrier 20. 29-year-old woman comes to the physician because of irregular menstrual periods since menarche at the age of 12. She is 5.3Ft and weighs 86kgs. BMI 34. She is evaluated and a diagnosis of PCOS is made. After explaining the diagnosis, the physician discusses behavioral changes, including dietary modification and exercise as part of her treatment. Which of the following will ensure adherence? - Provide follow ups to monitor progress in attaining her goal 21. 30-year-old man in bicycle collision and hits right shoulder forcefully. Unable to flex right elbow with decreased sensation to pinprick over right lateral forearm. Brachial plexus lesion? - E (musculocutaneous nerve) 22. 67-year-old man with 1 year progressive difficulty writing and walking. Pt is stooped and talks slowly. PE shows bland facial expression, fine resting tremor in both hands, no tremor when moves, walks with difficulty starting and stopping, cogwheel rigidity. Brain tissue histology shown as well as gross cross sections of midbrain both normal and diseased. Substance referred to by arrow? Spleen 25. After 2 months on biopsy gastric fundus and body show decreased mucosal thickness and hyperplasia of enterochromaffin like cells. Which is decreased in pulmonary vascular smooth muscle? . Nerve damaged? .Alpha-synuclein 23. Xray shows fracture of left ninth and tenth ribs. 50-year-old woman with COPD comes with 3 months of progressive shortness of breath. Labs? . 26-year-old man comes in 2 hours after injuring arm skiing. Pulmonary function tests show FEV1:FVC ratio of 20% and decreased diffusing capacity for carbon monoxide. Sensation to pinprick absent over lateral aspect of shoulder.Axillary Block 1 Part 2 26.bicarb (HCO3-) decreased. This closely resembles? . Organ injured? . Physical shows JVD. Organism is found to have decreased HCl prod.Chronic gastritis . An experimental animal is created that has a defect in an innate gastrointestinal defense mechanism. loss of appetite and itching. 25-year-old woman with polycystic kidneys and 3-month history of weakness. headaches. inorganic phosphorous (PO4) increased. PE suggests severe hemorrhage and shock.Endothelial nitric oxide synthase production 27. 32-year-old woman brought in after 10-foot fall from ladder. Xray of right shoulder shown (fracture of surgical neck of humerus). Cr 4. loud pulmonary component of S2.. fatigue. hypertension. parathyroid hormone increased 24. b12 500. 67-year-old woman with atrial fibrillation with sudden onset severe abdominal pain.Benign prostatic hyperplasia 31. 63-year-old woman with 2-week history of daily episodes of severe. Labs: hemoglobin 10. Precipitated by chewing or brushing teeth. MCV 110. She has fallen repeatedly.Small intestine. 70-year-old woman comes to the physician because of increasingly severe pain in the right knee over the past 3 months. Ischemic changes where? . folate 20. lancinating.Methylmalonic acid: normal.28. platelets 160. ascending colon. She has bowed tibia and tenderness of the proximal right tibia. Homocysteine: increased 30.Pleomorphic neoplastic cells producing new woven bone 32.3 due to chronically increased hydrostatic pressure in Bowman space. Dx? . Cause? . PE shows bronzed skin and spider angiomata on chest. hematocrit 30%. Vitals stable. 45-year-old homeless man found unconscious. which of the following findings is most likely on biopsy. Pain lasts 30 to 60 seconds and shoots down ear along jawline. and part of the transverse colon . an xray of lungs shows pulmonary nodules of various sizes. an X ray shows a fracture of the proximal tibia with elevated periostium and sunburst pattern. . Blood smear shows hypersegmented neutrophils and 3+ oval macrocytes. WBC 9000.Trigeminal neuralgia 29. Breath smells of alcohol. Which of the following inflammatory cells is most likely to be found in the resected specimen? . Labs? . She has a 10 year history of symptomatic osteitis deformans. left-sided facial pain. 68-year-old man with creatinine 2.000. 30-year-old woman with a long-standing history of pelvic inflammatory disease has surgical resection of a scarred segment of a fallopian tube. Ex-lap shows embolus in superior mesenteric artery with complete occlusion of middle colic artery.Macrophages 33. ferritin 200. and pulse is 115/min. Biopsy shows sheet-like infiltrate of pale eosinophilic cells with bean-shaped nuclei. Pelvic examination shows a closed cervix that is not effaced. T 39C (102. CT shows osteolytic and soft-tissue mass in skull with inward displacement of dura. Patient making sexual advances towards physician. confusion and memory loss. The fetal heart rate is . Bug? . Blood cultures positive. Abnormal cell type? .Vibrio vulnificus 39.5cm swollen mass over right occiput. lactose-fermenting organism. RR 22. Gram stain: gram-positive. Electron microscopy of cells shows Birbeck granules.Capsular polysaccharide 35. Physical examination shows tenderness of the uterus. 60-year-old man 1 day of fever. Tender 2. Her temperature is 39. Her membranes ruptured 32 hours ago.Langerhans cells 38. chills and productive cough of purulent sputum for 3 days. Cells positive for CD1a. Appropriate measure? .1°C(102.Concentration of cAMP 37. chills.Have a chaperone join them 36.34.2 F). Vaccine is against which bacterial component? . Hx of severe cirrhosis and portal hypertension. lancet-shaped diplococci. bp 90/48. Cholera toxin catalyzes transfer of ADP-ribose to an arginine residue in stimulatory G protein resulting in inhibition of GTPase activity. Which increases in cells as a result? .4°F). 68-year-old man with alcoholism comes for fever. Physical shows early blister formation on right lower extremity. 20-year-old woman at 27 weeks' gestation is admitted to the hospital because of a 12-hour history of intense uterine contractions occurring every 8 minutes. Returned from Gulf coast where he walked barefoot. Blood culture: gram-negative. 8-year-old boy with pain on back and head since he fell off swing. 10-year-old boy with 4 days nosebleeds and easy bruising.12 . PE ecchymoses on upper and lower extremities. Mechanism of dz? . New Antiplatelet Drug Women . Three weeks ago. 55-year-old man with elevated LDL cholesterol is prescribed lovastatin. HIV+. which of the following pharmacotherapy is most appropriate? . In addition to HAART.Primary spermatocyte 41. Child with XXY karyotype.Antineoplastic 43. Bone marrow smear shows increased megakaryocytes. upper respiratory tract infection.Inflamed maternal decidua release of prostaglandin 40.04 . genetic studies showed he received the extra "x" from his father. This treatment would result in which adaptive responses at the cellular level? .210/min. Results are shown: Recurrent Stroke Rates per 1000 Person-Years Standard Treatment vs. Which of the following is the primary stimulus for her uterine muscle contractions? . Labs shows hemoglobin and leukocyte count normal. the rates of stroke are lower in patients receiving the new agent than in patients receiving the standard treatment. In a large randomized clinical trial with equal numbers of men and women. A new antiplatelet agent is developed for the prevention of recurrence of stroke.Antibodies against glycoprotein (Gp) IIb/IIIa complex 42. An error of chromosome segregation occurred during anaphase at which of the following stages of spermatogenesis in the patient's father? . Rash is not itchy or painful. 34-year-old man with a 3 month history of a progressive rash on his feet. A photograph of feet is shown. and decreased platelet count.Increased transcription of HMG-CoA reductase 44. which of the following is the relative risk reduction in women? . Persons are at risk of influenza are vaccination every year because of antigenic variation. Mechanism? . respirations 28min and BP 90/50 mmHg.06 Based on these results. An X-ray of the chest is consistent with severe pneumonia. 52 yo man is brought to er 30min after the onset of chest pain and shortness of breath. with chill and chest pain.Men . pulse 122min. which can be drift (minor) or shift (major). but culture of bronchoscopy specimen on a highly specialized bacteriologic medium yields gram negative rods. PE shows dry skin and decreased capillary refill. Tx? . 63 yo man with mild emphysema has smoked 1 pack for 45 years sudden headache. A sexually active 32-year-old woman has vaginal pain with urination. compared with serum in this patient? PT //macula densa //medullary collection duct . hypertonic (?) 46.7 oC. An ECG and evaluation of cardiac enzymes show no abnormalities. The identity of these bacteria is confirmed by staining with specific fluoroscent antibodies. A culture of sputum is negative.Inhalation of aerosol from an environmental source (Legionella) 48. Mechanism of antigenic shift? .Isotonic.Reassortment 47.67% 45.24 . A dry cough develops. Which of the following findings in the nephron best describes the tubular osmolarity.08 Overall . He had played tennis all day and he does not remember how much fluid he had consumed. hypotonic. but bacteria are not evident. Examination of gram stain of sputum disclose neutrophils.18 . The patient respond therapy with macrolide Ab.Acyclovir . His temperature is 36. myalgia and rising temperature. Pelvic examination show bilateral vesicoulcerative lesions of introitus. Patient most likely sustained a fracture at (which location in humerus)? . The most appropriate anesthesia administered by mask to anesthetize this patient quickly would have which of the following characteristics? . Cl 90. BP standing 86/44. K 7. ongoing fatigue. Muscle strength is 2/5 with extension of elbow and 1/5 with extension of wrist and fingers.Fimbriae 3. Serum hormone concentrations? Prolactin/ACTH/TSH/Aldosterone . decreased. bp 96/60. inability to breast-feed.Low blood solubility Block 2 Part 1 1. PE shows lethargy and dry mucous membranes. hct 36%. Glucose 42. An intravenous catheter needs to be inserted. T 39 C (102. decreased. 17-hydroxyprogesterone increased. Pregnancy complicated by preeclampsia and required cesarean delivery. HCO3 17. 7-year-old boy is about undergo an appendectomy. after she required blood transfusions because of hypotension.6. increased 2.4.decreased. Virulence factor for adherence to bladder? . Cr 0. but the patient is fearful of being stuck with needle. pulse 125. BUN 25.49. not felt well since delivery 2 weeks ago. Urine grows gram-negative bacteria. HR standing 85. internal fixation. BP 100/50.21-hydroxylase 50. Enzyme deficiency? . Man comes to doc for cast removal. light-headedness in upright position. Labs: Na 139. PE appears lethargic.2 F). cast immobilization. 4-day-old boy with vomiting after breastfeeding. HR 80. 23-year-old woman g1p1. Fracture of left humerus that required open reduction. Hb 11. 21-year-old woman with 2-days history of urinary frequency and pain with urination. hepatosplenomegaly. and ecchymotic lesions over extremities.Radial groove (radial N.Histone acetylase 5. and bone pain. Treatment w/ all-trans retinoic acid is started. Labs: Hb 8g/dl Ht 25% Leukocytes: 36. wrist and fingers) 4. 36-year-old F with 2 week history of fatigue. In response to the therapy. the fusion protein will most likely attract which of the following proteins to form a pre-transcriptional complex? .000 Polymerase chain reaction test shows an mRNA corresponding to the retinoic acid receptor. Labs? pH/pCO2/HCO3- . PE shows multiple ecchymoses in various stages of healing upper extremities and torso. is the extensors of arm.000 segm neutr 4% eosinophils 4% lymph 6% mono 6% promyelo 80% platelets 25. BMI 15.. Physician should ask? ."Are you safe at home?" 6. 18-year-old woman comes 12 hours after ingesting 100 aspirin tablets in suicide attempt. Physical examination shows pallor. bleeding of the gums.alfa/promyelocytic leukemia fusion gene resulting from a reciprocal translocation of chromosomes 15 and 17. 98-year-old woman who lives with daughter and grandson comes for routine exam with type 2 diabetes and hypertension but no complaints. PE shows tachypnea. She has had 14-lb weight loss since last visit 3 months ago. 10-day-old male newborn 1-day history red eyes with discharge. Father has problems with nosebleeds and clotting. Menarche at 13 with regular intervals. PTT 60. Which substance causes increased total coronary blood flow 1-2 mins after NE? . Drug X follows first-order kinetics. Pattern of necrosis in lung tissue? . 35-year old man w several episodes of squeezing chest pain gets angiogram. History of frequent nosebleeds and easy bruisability.. Prevalence in population with negative Pap smear results is as high 0. 24-year-old woman overdose on drug X and has serum concentration of 32. Prevalence of high-grade cervical intraepithelial neoplasia in unscreened population is 5%.1 or lower.von Willebrand disease 9.6. PE shows mild gum bleeding and ecchymoses. Labs: hb 8. PT 14 (INR 1.2. bleeding time 10.7.Liquefaction 11. Cannot be moved from intensive care unit until concentration 1. the serum concentration is 16. Prevalence decreases..Adenosine 12.2%.000.32/15/8 7.. 6 hours later. hct 24. Question shows a graph of coronary blood flow with a drop after the NE and then a rise. Cause? . gets IV NE. which also decreases? . 14-year-old girl with 4 months of heavy menstrual flow. platelet 250. 57-year-old man with alcoholism dies of klebsiella pneumonia.Chlamydia trachomatis (gonorrhea occurs earlier and is more purulent) 8. Pregnancy uncomplicated but no prenatal care in third trimester.Predictive value of a positive test result 10. PE bilateral conjunctival injection with water discharge. Dx? .5). Abscess cavities filled with purulent exudate on autopsy. Which is . 2 Albumin 3 Urine specific gravity 1. Which tx decreases glucan expression? . Stool prep shows parasite egg (picture). 35yo F has congestive cardiomyopathy and pitting edema. After 5 days.30 hours (5 half lives) 13. Fungi express beta-glucans on cell surface and that triggers innate immune response. rbc 0 wbc0 sediment none Urinary fractional excretion of sodium is less than 1%. Family visited rural Louisiana 5 months ago and ran around barefoot.Microcytic anemia (strongyloides) 14. Furosemide therapy is started.minimum number of hours from first blood sample (32) that patient must remain in icu? . Labs shows normal wbc with 15% eosinophils.023.Caspofungin .8mg/dl. Her serum urea nitrogen concentration is 25mg/dl and serum creatinine is 1. Explanation? .Prerenal azotemia 15. labs show: Na 130 K 4. 4-year-old boy with fatigue and irritability for 2 months. Cause of fatigue? . Investigator studying immune response to fungi.5 Cl 90 HCO 30 BUN 85 Creatinine 2. Conjunctivae are pale. Micro exam shows enlarged myocardial cells with large nuclei.Hypertension 18. She appears alert and well nourished.Cytokine effect 20. scaly erythematous patches on the face. are within the reference ranges. There are ecchymoses in various stages of healing on both forearms. Which of the following is the most likely cause of the ecchymoses in this patient? . Pain is produced when gallbladder contracts against gallstone obstructing cystic duct. Where is hormone released from that causes gallbladder contraction? . 34-year-old man burned hands firing pots 3 months ago. Laboratory studies. Heart of 76-year-old woman shows concentric enlargement of left ventricle. She asks why abdominal pain is intermittent and not constant. and irregularly shaped brown macules on the face and forearms. 45-year-old woman dx with cholelithiasis. Dx that causes this cardiac enlargement? . absence of deep tendon reflexes in upper extremities. Labs show normochromatic normocytic anemia. Physical examination shows extensive wrinkling.16. including a complete blood count and coagulation studies. Touch is preserved. and decreased pain and temperature sensations in C4 to T1 dermatomes. Dx? . He has no pain during or after burn. Which is responsible for weight loss? . Xray of chest shows 2-cm perihilar mass.Enteroendocrine cells of the small intestine (CCK) 19. 72-year-old woman comes to the physician because of a 6-month history of increased bruising on her forearms. Biopsy shows small cell carcinoma of lung. She has noticed no bleeding from her gums after brushing her teeth.Syringomyelia .Extensive solar elastosis 17. PE shows mild atrophy of arms and hands. 73-year-old man has poor appetite and lost 25 lb over 4 months. the ecchymoses are more numerous on the right side. Which drug caused these findings? . 54-year-old man with normal renal functions gets a heart transplantation.Initiate the procedure and treatment without consent 22. LP and immediate abx therapy planned.Agranulocytosis 23.called a laminectomy) . CT scan of vertebrae shown. 28-year-old man infertility. One year later. bp 170/110 and serum creatinine 2.Suppression of gonadotropins Block 2 Part 2 26.Spina bifida 25. weight lifter and takes anabolic steroids. but parents unavailable for consent. 34-year-old man with herniated lumbar intervertebral disc. Mechanism of infertility? .Cyclosporine 24.1. What's the underlying cause of ulcerative pharyngeal disease? . Fetus at greatest risk for which defect? . Laminectomy and removal of hernia scheduled. PE shows nuchal rigidity and bacterial meningitis suspected. 44-year-old woman 15 weeks' gestation with uterus consistent size with gestational age.D (the lamina . Next step? . 2-year-old girl with febrile seizure. Amniocentesis shows increased alpha-fetoprotein (AFP). which is surgical entrance location into neural canal? .21. 51-year-old with Graves disease develops ulcerating pharyngitis after 6 months of propylthiouracil. 62-year-old woman with 3-day hx of fever. Lab values show Total bilirubin 3. Dx acute pyelonephritis and treated with ciprofloxacin. 35-year-old with Chagas disease and 2-hour history of moderate chest pain. Smokes 2 packs of cigarettes for 45 years. and left flank pain.Aortic aneurysm 28.27.Inhibits microtubule disassembly 31. T 99 F. bp 160/94. 4. 33-year-old woman who three weeks ago. Barium swallow shows dilated esophagus with beak-like narrowing at lower esophageal sphincter (LES). Stool is brown and occult blood negative. stridor.2 Direct: 0. 45-year-old man comes to physician for follow up after appendectomy. Vitals stable. hoarseness. pulse 80. 68-year-old man with 3 days of increasingly severe chest pain. sudden onset watery diarrhea and lower abdominal cramps.Test of the stool for Clostridium difficile toxin 30. Longstanding hx of hypertension. Mechanism? . Murmur second right intercostal space. pulse 80. difficulty swallowing and nonproductive cough. Five days after. T 100. Recommends adjuvant chemotherapy with paclitaxel.9 F. bp 124/88. underwent oophorectomy for epithelial ovarian cancer. rr 18. shortness of breath. Next step? . rr 15. shaking chills. PE moderate tenderness to palpation in lower quadrants especially on right and increased bowel sounds.Gilbert .4 lb weight loss in 2 months. PE shows visible pulsation above the manubrium of the sternum and displacement of the trachea to the right. Biopsy shows? . There is mild scleral icterus and well healing surgical incision.Loss of neurons in myenteric plexus 29.2 Indirect 3 mg/dL Dx? . Dx? . Immigrate to USA from Iceland. 5-year-old girls with severe leg pain 1 day after fell off sled. 35-year-old man with several episodes of dizziness and fainting during the past 2 months. CD4 count was 158 and plasma HIV viral load was 5500. swelling. Based on this. PE shows tenderness.Sarcoplasmic Ca release 34. PE and lipid studies . and tenofovir with no changes 37.Hyperinsulinemia 35. emtricitabine. Has had three bone fractures since birth. Xray shows fracture of fibula. Labs: CD4 352 and undetectable HIV viral load. BMI 32. started antiretroviral therapy with efavirenz. Two months ago. and limited range of motion of left lower extremity.Continue efavirenz.Intestinal calcium absorption 36. After 5 minutes.to 32-day intervals. PE shows mild hirsutism and velvety brown.32. Father and several paternal uncles died suddenly. Patient has which condition? . 36-year-old woman diagnosed with HIV. 18-year-old woman get general anesthesia for wisdom teeth extraction.Complement activation 33. thickened skin at the base of the neck and around axillae. the immunoglobulin isotype that predominates has which biological properties? . 22-year-old nulligravid woman has menses that occur at irregular 26. emtricitabine. and tenofovir. Pt has vitamin deficiency that affects which of the following? . Next step? . Two months ago. Immunological studies show peripheral leukocytes that express both CD3 and CD4 and fail to express CD40 ligand. 3-year-old boy 7 days after dx with severe chronic diarrhea due to Giardia. gets hypertonicity of skeletal muscles and increased body temperature. The treatment is a drug that decreases? . Height 5 ft 4 in and weighs 187 lb. Parents are vegan and don't give diary products. 4-month-old boy with 1-day respiratory distress. all of European descent. It is estimated that the 32 loci identified explain about 10% of the variance in disease risk with 2 loci accounting for 2% of the variance. 24 hours later. partial thromboplastin time is 52 seconds (control 26 sec). Day 2. Enzyme impaired? . RR 50/min.1 sec.4-Glucosidase 39. warfarin added.Outward (delayed) rectifying potassium channel 38. pyruvate. and prothrombin time is 12 seconds (control 12.3 and 1. Which of the following best explains these results? .Pineal gland . Has progressive weakness and difficulty feeding for a month.normal. Funduscopic exam shows bilateral papilledema. ECG shows prolonged QT. Can no longer ride bicycle and difficulty getting out of car. Walks shuffling gait.The identified loci account for a relatively small part of the variance 41. glucose. An investigator conducts a meta-analysis of three genome-wide association studies of Crohn Disease. CT shows enlarged lateral and third ventricles and a 2-cm mass. the combined meta-analysis identified an additional 21 loci with odd ratio of 1. Best explanation for normal prothrombin time and INR? .Long half-life of factor II (prothrombin) (?) 40. CXR shows cardiomegaly.3. PE shows enlarged tongue and generalized hypotonia. Neuro exam shows impaired upward gaze and pupil response to light. Biopsy of skeletal muscle shows increased glycogen. The initial studies identified 11 significant loci with odds ratios above 1. Angiography shows no coronary artery blockage. Increased lactate. and uric acid. Location of mass? . INR = 1).alpha-1. The studies encompassed 3200 cases and 4800 controls.5. 6-year-old boy with 5-day history of intermittent vomiting and 3-month hx of progressive clumsiness. Treated with intravenous heparin. Previous studies of twins indicated a 50% heretability rate for Crohn's disease.1 to 1. 50-year-old man with pulmonary embolus. Decreased activity in which of following causes this? . Echocardiography shows an echodense thickened left ventricle and poor diastolic compliance. 45-year-old woman with joint pain due to rheumatoid arthritis comes for infective treatment with over-the-counter agents. Tx? .Methylphenidate . Delayed onset of action of DMARD. Initiate disease-modifying antirheumatic drug (DMARD). An x-ray of the spine shows a lytic lesion. A photomicrograph of a specimen obtained on myocardial biopsy is shown.500/mm3 Segmented neutrophils 65% Eosinophils 1% Basophils 1% Lymphocytes 30% Monocytes 3% Platelet count 250.Prednisone 44.000/mm3 Serum electrophoresis shows a monoclonal spike of IgG kappa.5 g/dL Hematocrit 41% Leukocyte count 10. A chest x-ray shows cardiomegaly with bilateral pleural and pericardial effusions. Which of the following is the most likely cause of the cardiac findings in this patient? . Her pulse is 140/min. so physician prescribes another until DMARD is effective. Treated in ER several times because of skateboarding injuries. and blood pressure is 140/85 mm Hg. Teacher says he's in "constant motion" and never completes assignments.42. Laboratory studies show: Hemoglobin 13. Physical examination shows tenderness to palpation over the L2-3 vertebrae. 67-year-old woman comes to the physician because of a 1-month history of low back pain. Drug? . She has hypertension well controlled with a thiazide diuretic.Amyloid infiltration 43. 8-year-old boy with persistent disruptive behavior. Positive nares culture for toxin-producing Staphylococcus aureus 47. Which of the following best describes this study design? . All patients are followed for 3 years to determine the incidence of myocardial infarction. flaccid. and 250 are assigned to undergo a second type of angioplasty. SD is 8mmHg. A transcription factor that activates expression of HMG coA reductase is identified. A total of 1000 patients are enrolled. his average diastolic pressure is 94mmHg. RR 20. The transcriptional domain is released by proteolysis when the membrane has a decreased cholesterol concentration. 250 are assigned to undergo one type of angioplasty. The precursor protein is mot likely initially produced in which of the following labeled area on this labeled diagram of a hepatocyte? . A study is conducted to compare the incidence of myocardial infarction in patients undergoing two different types of angioplasty or an operative procedure to manage single-vessel coronary artery disease. 48yo man with possible hypertension. CT chest shows diffuse . bp 110/60. 3-year-old boy with progressive fever and skin lesions during 24 hours.Randomized clinical trial 48. 66-year-old man with 1-month hx of nonproductive cough and 6 months shortness of breath. pulse 120. Rough Endoplasmic Reticulum (ER) Labeled organelle is the rough endoplasmic reticulum.Larger 49.45. T 102. PE shows large. this TF is initially synthetized as a large precursor protein. with 2 membrane spanning domains.9 F. 500 are assigned to undergo the operative procedure. Through a chance process. which of the following statements would best describe the width of the 95% CI with regard the mean blood pressure? .F. bullous lesions over trunk and abdomen. Bilateral end-inspiratory crackles heard. Another finding in pt? . based on 20 measurements. site of protein synthesis 46. If only four measurements were made rather than 20. 100 women randomly assigned to one of two groups. Venous route of mets? . 8-year-old girl is brought to the physician by her mother because of a 3 week history of poor feeding chronic diarrhea and pale foul smelling stools. 25-year-old woman comes for counseling prior to conception.3 to 8 weeks 4.Renal artery stenosis 2.Ileocolic --> superior mesenteric --> portal --> right hepatic branch of portal Block 3 Part 1 1. several fibroblastic foci and no granulomas. Micro exam of biopsy shows patchy interstitial fibrosis. 65-year-ld man with cancer of cecum found to have metastatic lesion to liver. Dx? . there is a marked increase in plasma renin activity. Physical examination shows no other abnormalities. Has seizure disorder on valproic acid. Which of the following is the most likely cause of the findings in this patient? . Following the administration of captopril. 48 of women . Mother says the symptoms began with colicky abdominal pain following introduction of solid food to the infant's diet. 60th percentile for length and 25th percentile for weight. BP today 170/95mmHg. Has had normal blood pressure measurements. Fetus at greatest risk for drug-related adverse effect during which pregnancy stage? .reticular opacities at periphery and bases of lungs. Plasma renin activity and serum aldosterone concentrations are increased. Serum show hypokalemia and metabolic alkalosis.Idiopathic pulmonary fibrosis 50. 60-year-old man for routine health examination. Which cell is dysfunctional? . History of gluten sensitivity.Enterocyte 3. Study designed to test the effectiveness of a new drug in the treatment of endometriosis. 48-year-old woman with gradual onset back pain past 2 weeks.Two groups with similar underlying characteristics 5. He smoked 2 packs of cigarettes daily for 50 years. Temp 39. Pulse 80/min. Diffuse. Dx? . in T-10 and L-1. Xray of spine shows two lytic lesions. The primary purpose of this method of assigning patients to different groups is to create which of the following ? .Leukemoid reaction 6. PE: 3+pitting edema of lower extremities. Grade 2/6 pansystolic mumur heard best at lower left sternal border. Maximal impulse palpated in sub-xiphoid area. Doesn't smoke cigarettes. rr 24/min. family history of cardiovascular disease. 52 receive standard therapy. which increases on inspiration. Lab studies show : Hb 13 g/dl Ht 39% Leukocyte count 32. 68-year-old man with a 10-month history of shortness of breath and swelling of his feet. S1 and S2 sounds are distant. 65-year-old woman with 6 hour Hx fever and shaking chills. Liver span 14 cm. Diagnosis? . scattered wheezes are heard bilaterally on auscultation of the chest. which the most likely cause this patient leukocytosis ? . pulse 96/m. 4 hours ago. BP 150/80. she took 325 mg aspirine tablets. respiration 18/m and blood pressure 102/60 mmHg.Cor pulmonale 7. Physical examination shows marked tenderness bilaterally in the costovertebral areas.4 C.000/mm3 Urine ph 6 Nitrites 4+ Leukocyte esterase 4+ A photograph of wright stained peripheral blood smear.receive new drug. drink alcohol or use drugs. serologic studies and urinalysis unremarkable. Hemogram. No trauma. " 9. Sex development is Tanner stage 4."Tell me more about your concerns about your son's height. 17-year-old boy brought by mother with concern that puberty is delayed. 32-year-old man with X-linked recessive disease has deafness.Colipase ." Patient is 175 cm (5 ft 9 in) tall and weighs 70 kg (155 lb). I don't know what's the matter with her. 35-year-old from group home comes for worsening behavior for 2 weeks. 52-year-old with chronic pancreatitis is deficient in which enzymes that causes inability to digest triglycerides? . and high-dose dopamine in started.. Reports hearing voices in hall outside and that CIA now plans to kill him. BMI 23. difficulty answering questions because listening to internal stimuli. "I'm fine. Appears disheveled with unkempt hair and poor hygiene. hematuria and progressive renal failure. 65-year-old patient has lung region that is underventilated but well perfused.Flattened affect 10. patient states. Mental status exam will show which? . Which increases? .alpha1-adrenoreceptors 11. When mother leaves room. Treat is discontinued.Physiologic shunt 12. Protein abnormality? . Most appropriate next statement to mother? .Metastatic carcinoma of the breast 8. After operation. He believes CIA is spying on him through television set. 17-year-old boy in septic shock unresponsive to ADH (vasopressin). She wants me to be tall like my dad. Which receptors are stimulated? .Type IV collagen 13. 7. 47-year-old woman with irregular.Reverse transcriptase and protease (the two targets of HAART therapy.He is medically qualified to drive 16. HIV viral load now increase. Patient's status with respect to driving? .Subcutaneous tissue 15.14. Most recent generalized tonicclonic was 5 years ago. which of the following most likely mutated? . Had a renal calculus 6 months ago and had cholecystectomy 1 year ago. He's never had any collisions while driving his motor vehicle.MEN1 17. alk phos 125. Current meds include carbamazepine. depressed. His initial therapeutic response is good. there is mucosal pallor. phosphorous 2. antiretroviral resistance suspected. Ca2+ 13. raised. 32-year-old man with HIV infection follow up examination.106. No masses palpated in neck. Worst prognosis with involvement of which layer? . but he develops recurrent parasitemia 2 months later. 45-year-old woman with 4-month joint pain. Labs: erythrocyte count 3 million. 33-year-old man dx with epilepsy age 10 years. Biopsy shows malignant pigmented cells. Medication was adjusted. muscles aches and fatigue. Cl. Which of the following best explains the recurrence ? . Technetium99m scan shows 1. has been treated with HAART for the past 6 years HIV plasma viral load has been undetectable. 25-year-old man just returned from work as worker from Africa begins oral chloroquine therapy for malaria caused by Plasmodium vivax. therefore if therapy stopped working. multicolored dark lesion on left forearm with frequent sunlight exposure.2 cm nodule in neck. Mutation? . HIV genotype analysis confirms that the virus has resistance mutations. must be these two target proteins of virus mutated) . K+ 4.Chloroquine is ineffective on the exoerythrocytic malaria tissue stages 18. Appears fatigue. finger-shaped lesions from vocal cords and epiglottis. Biopsy showed atrophy of epidermis and deposition of collagen throughout dermis with loss of dermal appendages. Five days later. PE nasal flaring. Physical examination shows no abnormalities. PE shows deep venous thrombosis.000. PTT 37. An ECG shows no abnormalities. pulse is 85/min. evaluation at that time was negative on upper endoscopy and colonoscopy. A 68-year-old man comes to the physician because of a 1-month history of lightheadedness and tightness in his chest with exertion. Which of the following is the most likely cause of this patient's gastrointestinal symptoms? .Pulmonary hypertension (dx: systemic sclerosis/CREST) 20. type 6 23. PE cutaneous ulceration. 6-year-old girl with 15-minute history of severe shortness of breath. respirations are 15/min. Workbench wiped down with alcohol.000. PT 12 (INR 1). Sensitivity to cold weather. arms. Heparin started.Human papillomavirus. Labs: platelet 200. 58-year-old woman with 6-month shortness of breath and chronic nonproductive cough. and the symptoms resolve with rest. clawlike flexion deformity. joint stiffness.19. His temperature is 37°C (98. 35-year-old woman pain in left leg 2 days. Reason for decreased platelets? . RR 32. He adds that the pain is worse after arguing with his wife.2 g/dL. Causal virus? . Repeat colonoscopy shows no abnormalities. and hematocrit is 24%. He has a past history of lower gastrointestinal bleeding. fingers. diffuse tightening of skin on face.Drug-related antibodies 22. Diagnosed with throat tumor 3 years ago. neck. and blood pressure is 110/75 mm Hg. turn white. His hemoglobin concentration is 8. Lesions excised and shows finger-shaped fibrovascular cores lined with benign squamous epithelium. shoulders. 2-year history difficulty swallowing. Test of the stool for occult blood is positive.Enveloped virion 21. decreased joint mobility. platelet 120. At risk for which pulmonary disorder? .6°F). Laryngoscopy shows multiple raised. Hx of esophageal reflux. successfully inactivates viruses with which characteristic? . Cystocele 27. Laboratory studies. A drug targeting which of the following mechanisms of action is most appropriate for this patient? . Between these episodes. 25th percentile for length and 30th percentile for weight. A 70-year-old woman comes to the physician for a routine pelvic examination. the Valsalva maneuver causes a bulge of the anterior vaginal wall. weakness. During speculum examination of the vagina and cervix. Which drug should be added? . A 25-year-old woman comes to the physician because of a 2-year history of intermittent. Which of the following is the most likely cause of this finding? . 69-year-old woman with 3-week history of muscle cramps.Angiodysplasia 24. abdominal pain.Triamterene (potassium-sparing) Block 3 Part 2 26. cramping lower abdominal pain. and thyroid function tests show no abnormalities. and is typically relieved with defecation. Cause? . metabolic panel. watery stools. The pain is usually associated with2 to 6 days of loose. 2-month-old boy well child exam. including complete blood count. diffuse. Hypertension treated with metoprolol and hydrochlorothiazide for past 4 months.Accentuation of μ-opioid myenteric plexus receptor 25. Labs show hypokalemia. and constipation. Physical examination shows no abnormalities. Her vital signs are within normal limits. Cardiac exam shows blowing holosystolic murmur best heard at lower left sternal border. mother with no concerns. her stools are normal.Ventricular septal defect .. sore throat. sandpaper-like rash on extremities. Gives 1-month regimen of benzodiazepine. Finding most likely? . CT chest shows b/l atelectasis in upper lung fields. Immuno studies show CD1a antigen expression.7 F (38. Widespread.Erythrogenic toxin 29.28. Feels anxious and thinks he can complete last 2 years of work if anxiety decreases. red. 21-year-old man loses 15% total blood volume 2 minute after motor vehicle collision. rr 26/min. Exam shows no cancer recurrence. Generalized lymphadenopathy and hepatosplenomegaly. 58-year-old man comes to physician for benzodiazepine prescription for situation at work. 52-year-old female with a history of breast cancer who received 4week course of radiations 6 months ago comes for followup. diaper region and soles of feet.Increased sympathetic nerve traffic to sinoatrial node 31. EM biopsy of skin shows tennis racket-shaped bilamellar granule in cytoplasm. T 101.Dendritic cells 30. Embryologic event that led to this? .Contact the patient to discuss the situation 32. Wife calls. "My husband got fired! I know it was because he was taking too much of that drug you gave him. PE scaly. Purulent exudate over tonsils. Primary pathophysiological cause? . Xray of skull shows osteolytic lesions. seborrheic eruption over scalp. 2-year-old boy 2-day history of fever. Didn't you know he had history of alcoholism?" Initial action? . rash. 32-year-old woman has operation for hyperparathyroidism. 1-year-old boy with rash for 2 weeks. Three parathyroid glands found but one does not appear in normal superior location on right side. Cause of skin findings? . palms.Abnormal migration of endoderm from fourth pharyngeal pouch 33. Abnormal cells in patient are derived from which cell? . back.7 C). 10th percentile for height and weight. Dx streptococcus pyogenes (group A) infection. 27-year-old man for psychiatric eval sent by employer because he is "very odd.. Renal biopsy would show what? .Contraction (secondary to radiation) 34. On hysterosalpingogram (shown).1/4 35. Ultrasound identifies male fetus. 10-20 WBC and eosinophils. Patient's sister is pregnant. regenerating muscles fibers and fibrosis. Exam calf hypertrophy and proximal muscle weakness. Maternal uncle had similar findings and died at 15 years.Schizotypal 38. Probability fetus has disorder? . altered skin color. PE diffuse maculopapular rash. 35-year-old woman with infertile. Extremely preoccupied with science fiction. which explain this finding? . bilateral knee pain. 55-year-old man northern European descent with 2-month weakness. 4-year-old boy (pedigree shown) has clumsy gait for past year. Has chronic headaches and takes ibuprofen several times. 46-year-old woman with 1-week low-grade fever and joint pain.Spillage of contrast which normal 37. hepatomegaly. contrast material (indicated by arrows) also seen in peritoneal cavity. Refuses to socialize and has no friends. Muscle biopsy shows loss of muscle tissue. arthritis. Siblings have type 2 diabetes and cirrhosis. afterlife. receive injection of contrast material into cervix. Liver biopsy increased iron content and cirrhosis Greatest risk? . occult. Personality disorder? . UA 2+ protein. Creatine kinase increased." Is a computer repair specialist and lives alone.Inflammatory infiltrates in the interstitium . Increased saturation of transferrin and ferritin.Hepatocellular carcinoma 36. PE bronzed skin. 39. PE shows erythema of left index finger. which of the following is the most likely cause of this man's condition? . PE shows pallor. 21-year-old woman with 10-days difficulty walking. Injured structure? .5 based on these findings. Injured it when catching a ball. Pathogenesis? . 19-year-old woman 2-day history of pain in left index finger. Has lethargy and shortness of breath. Spleen tip palpated. 25-year-old-man who has a history of facial flushing and rapid heart rate each time he consumes a small amount of alcohol participates in study of alcohol intolerance. Unable to flex the distal phalanx when proximal interphalangeal joint metacarpophalangeal joints restratined. Which drug to prescribe? . Molecular analysis shows presence of a lysine (K487. total cholesterol 200. Peripheral blood smear numerous erythrocytes with abnormal shapes and sizes. wbc 4000. Xray normal. . hct 27%. Neuro exam shows decreased visual acuity in left eye with pallor of optic disc. Has past-pointing on a finger-nose test. Labs: hb 9. 63-year-old man 2-week sensation of fullness in left upper quadrant. Broad-based gait. 45-year-old man bmi 26.CD4+ T lymphocytes are activated by myelin basic protein 43. Two years ago had loss of vision in left eye which improved. serum uric acid 15. MRI shows brain lesions in white matter of cerebellum. HDL 50. Kinetic characteristics of the enzyme variants shown: Enzyme Km (NAD+) microM Kcat (min-1) E487 37 180 K487 5600 9. native variant) substitution in aldehyde dehydrogenase.Flexor digitorum profundus tendon 40. oriental variant) for glutamate (E487. triglycerides 550.Fenofibrate 42.Decreased catalytic efficiency of K487 41. 20-lb weight loss during 3 months. Ultrasonography shows a male fetus. Last 24 hours. 2 pics: clubbing + hemorrhagic lesions in tongue. 6% bands.Myelofibrosis 44. Infections slow to respond to antibiotic therapy. 45 yr old man with SOB on exertion x 6 months. PE ataxic gait. Deep tendon reflexes diminished in upper extremities and absent in knees and ankles. WBC 21.Pulmonary AV shunting Disease is osler weber rendu 46. numbness and tingling of hands. Aspiration of bone marrow dry tap. 27-year-old primigravid woman at 18 weeks gestation comes to physician for routine prenatal examination. 1-year-old has numerous infection of skin and oral mucosa since birth. Culture of lesion grows Staphylococcus aureus.Myelinated primary afferents . T 100. The left and right ureters are not dilated. inhaled albuterol doesn't improve his symptoms. 24-year-old man with 3-day progressive numbness of both feet ascended to thighs.An integrin 45. Mild weakness distal upper extremities ad moderate weakness of lower extremities. nosebleeds since adolescence. Vibration and joint position absent in fingertips and feet bilaterally. The uterus consistent in size with 18 week gestation. PE multiple erythematous lesions of skin some with superficial ulceration.nucleated erythrocytes and myelocytes. The collecting system and pelvis of the left kidney is dilated and the renal cortex appears compressed.4F. Cause of symptoms? . Amniotic fluid volume is normal. Structure involved? .000 77% segmented neutrophils. Biopsy shows no neutrophils in dermis or epidermis. 14% lymphocytes and 3% monocytes. The right kidney appears normal.Incomplete recanalization of proximal ureter 47. Defective . Which causing renal finding in this fetus ? . Dx? . Biopry shows thickened bony trabeculae with increased reticulum. T 98. ascites and prominent umbilical venous pattern. Dx? . 82-year-old woman comes to the physician because of constant severe lower abdominal pain and fever for 24 hours. and malaise. severe neck pain.22/28/11 2.Failure of liver to degrade estrogen . Urea nitrogen 100. Vitals normal.Placenta previa Block 4 Part 1 1. Laproscopic examination shows severe diverticulosis and perforated diverticulitis. There is no exophthalmos.Fibrin 49. Ultrasound shows placenta over cervical os. creatinine 8. Her pulse is 120/min and regular.6 F HR 100 RR 24 BP 160/90.01 μU/mL. In spite of appropriate therapy she dies 2 days later. Tests small. Which of the following is the most likely diagnosis? . PE shows scleral icterus. fatigue. spider angiomata. UA shows blood.Subacute granulomatous thyroiditis 50. gynecomastia. 39-year-old man with polycystic kidney disease has 6-month history intermittent blood in urine. Cause of gynecomastia? . Can't stop bleeding and has cesarean. 48-year-old man 2-month increasing abdominal girth and inability to achieve erection. No prenatal care.7. Arterial blood gas shows? pH/pCO2/HCO3. 28-year-old woman comes to the physician because of a 4-day history of palpitations. Liver autopsy shown. Which of the following is the primary component of the material shown on the hepatic surface? . Physical examination shows a diffusely tender. Serum studies show a thyroid-stimulating hormone concentration of 0. mildly enlarged thyroid gland. Smoked 1 pack cigarettes for 20 years and drug 1 pint of liquor daily.48. 35-year-old primigravid woman 36 weeks' gestation with 6-hour history of heavy vaginal bleeding. Three days later.4 mEq/L. potassium of 5. Studying epithelial repair of small intestine in experimental animal. Serum studies show a sodium concentration of128 mEq/L. 50-year-old man undergoes operative repair of inguinal hernia. The patient is intubated and mechanically ventilated. After the physician respectfully informs the patient that he does not prescribe this contraceptive. After epidural received. Surgeon has received written informed consent from patient. A chest x-ray shows bilateral interstitial and alveolar infiltrates.Base of the crypt 7. Damage to which of the following is most likely to preclude restoration of normal tissue architecture and pulmonary function in this patient? ." 5. and blood pressure is 60/30 mm Hg. A 25-year-old man is admitted to the hospital because of severe crush injuries to the chest and extensive burns over 30% of his body surface area. he develops tachypnea and dyspnea. 16-year-old girl calls the physician on a Friday night 2 hours after a condom broke during sexual intercourse with her boyfriend. Physical examination shows bilateral flank tenderness. Which of the following is the most appropriate next step to determine the cause of this patient's hypotension? . Wants to identify most active cell division location. and bicarbonate of 20 mEq/L."Tell me about your concerns and why you want to cancel the operation. it is most appropriate for the physician to state which of the following? . Best response? . patient decides he does not want to have surgery. Arterial blood gas analysis on room air shows a decreased Po2 and Pco2.Adrenocorticotropic hormone stimulation test 4.3.Basement membranes 6. her pulse is 120/min. She is stabilized. Three hours later. 19-year-old woman is admitted to the hospital for antibiotic treatment of meningococcal meningitis. She asks the physician to prescribe an emergency oral contraceptive. Where is this cell activity found? . The physician on call is not the patient's regular physician and does not dispense emergency contraception for moral reasons. Ten generations created. HR 110. 2-month-old female with T 102F. Polymerase chain reaction for Plasmodium is negative. T 102. Mechanism of decreased vancomycin resistance? . Vancomycin-sensitive colonies observed at frequency of one per 100 cells. bp 95/75. and joint and muscle pain. Intracellular components increased in patient's muscle cells? . confusion."I can have one of my colleagues call you back to further discuss your concerns. PE shows cachexia and significant muscle wasting. dehydration. disorientation.6-lb weight loss during 3 months. Had 17. Peripheral blood smear shows small intraerythrocytic rings.15. liver." 8. Causal organism from bite of? . vomiting.decreased/decreased/increased 12. Has splenectomy for motor vehicle collision 6 years ago. Symptoms gradually developed and she did not take her usual insulin dose during a sleepover. diarrhea. shaking chills.Autophagic vacuoles 10. ABG? pCO2/HCO3-/Anion gap . Culture inoculated and resulting bacterial colonies are screened for vancomycin resistance. 67-year-old man who eight months ago dx with primary lung carcinoma involving adrenal glands. and bone. 14-year-old girl with type 1 diabetes mellitus and 4-hour history of lethargy. Spent summer workin as lifeguard in Long Island. segmented/no/icosahedral 11. Investigator studying vancomycin-resistant strain of Enterococcus faecalis.Plasmid loss .. Properties of virus? Type of nucleic acid/envelop/capsid symmetry . Exam of stool shows viral particles with wheel-like shape.Tick 9. fatigue. arterial pH 7. New York. RR 24 deep and rapid. Labs: glucose 450.4 F. headaches.Double-stranded RNA. 20-year-old woman with 2-week fever. Best next step? . 2 days after admission. ABG shows decreased pH. nipple mildly tender. A deficiency in which of the following most likely caused the disorder? .13. 65-year-old man with 4-hour history of intermittent severe pain in flank area radiating to genital region. Physical examination shows a large plethoric face. 35-year-old woman with fever and sharp chest pain for 3 days. Cause of primary pericarditis? .3F. Male newborn delivered at 28 weeks. History of hypercalciuria and renal calculi.Hydrochlorothiazide 15.ACTH no change. Dx? . T 101.Alcohol withdrawal 18. decreased Po2 increased PCO2. fat pad over the upper thoracic spine and purple striae on the abdomen. diaphoresis. Penis slightly enlarged and pubic hair curling and beginning to darken at base. has tachycardia. neonatal respiratory distress syndrome. 12-year-old boy with mother concerned about enlarged left breast and family history of breast cancer. Friction rub heard. All cuases of secondary pericarditis ruled out. restlessness. Administration of low dose dexamethasone would most likely result in which of the following sets of serum findings? . Left breast is slightly larger than right. 55-year-old woman who is a physician has fractured femur during motor vehicle collision.Dipalmitoylphosphatidylcholine 14.Reassure the mother that physical findings are not uncommon for his age 17. seeing "vague shapes" on walls. Drug decrease the urinary excretion of calcium? . Serum studies show undetectable ACTH and an increased cortisol concentration. anxiety. 45-year-old man comes to the physician because of an enlarging face shoulders and trunk and thinning of his arms and legs. cortisol no change 16. " She has never been sexually active. Improves within 4 days. 67-year-old man with 3 months fatigue and shortness of breath. PE conjunctival pallor. Tried topical clindamycin and benzoyl peroxide PE severe acne vulgaris. Labs of patient? K+/HCO3-/Anion Gap/pH . bp 150/98. Suspected she has been vomiting. healing left rib fracture at T6. most appropriate tx? . barking cough heard. 15-year-old girl comes with lack of improvement of facial acne. and has been binging more frequently. Besides iron supplementation. Labs: hb 8. Transferrin saturation 23% (N=20-50%). hct 26%.Virus 19. RR 15. Vitals HR 90. 35-year-old woman passed out while washing dishes. compression fracture spine at T10 and L1. Tx? . MCV 90.Isotretinoin 23. imaging shows pituitary macroadenoma. bp 100/70.Parainfluenza . Iron 24..2F. husband shares with nursing staff history of bulimia nervosa. Says.decreased/increased/normal/increased 21.5. RDW 14. Ferritin 144. Cr 2. Oxygen saturation 95%. HR 88. RR 24.9.ACTH 20. 18-month-old girl with 2 day progressive cough and hoarseness. "Please help me. PE mild erythema of oropharyngeal and laryngeal mucosa no exudate. gained 8 kg in the past 6 months. This tumor produces which? . harsh. decreased peripheral vision. Began to feel weak and dizzy.4% (N=13-15%). Cause? . 35-year-old man with severe back pain.Erythropoietin 22. T 102. motor/sensory cortex) 28. Tx to improve renal function? . hyperresonance on chest percussion. and frequent resp infections.A (Pre/postcentral gyrus. Girl has chronic cough with thick sputum. What's the likelihood he is a carrier for the condition? . Retrospective study of incidence and outcome of subarachnoid hemorrhage.2/3 . abdominal cramps in RLQ. mortality is 6 per 100. BUN 34 and creatinine 3. 64-year-old with non-Hodgkin lymphoma and 3-day history of abdominal pain and nausea.Aortic Regurgitation 25.8. Abdominal exam tenderness of flanks and lower quadrants. Incidence remains constant.24. There are no other sensory or motor deficits. bp 130/80.Bilateral stents in the ureters 27.000 people. case fatality rate? . light palpation of carotid artery shows upstroke is abnormally brisk and downstroke falls precipitously. 71-year old woman with coronary disease and well-controlled hypertension is brought to the physician 2 hours after sudden onset of weakness of her left leg. Which labeled structure is site of injury? . 38-year-old man 1-week shortness of breath with exertion. Her BP 145/85 mmHg. Neurologic exam: weakness and decreased sensation over the left lower extremity. She has a healthy brother. CT shows bilateral hydronephrosis and lymphadenopathy compressing ureters.40% Block 4 Part 2 26. Cause of finding? . Incidence is 15 per 100. On xray . Diffuse crackles and scattered wheezes.7F.diffuse hyperinflation of the right upper lobe. Clubbing of fingers. T 99. HR 100.000 people. Microscopic exam of kidney will show which? . Stool studies are normal. Diffuse wheezing is heard on auscultation. In a 25-year-old patient who underwent splenectomy. pulse is 72/min. target cells are seen on peripheral smear. What is the pathophysiological mechanism of the diarrhea? . right is normal. 48-year-old recently diagnosed with lupus and difficulty working as schoolteacher because of severe pain and swelling of joints.Red pulp 32. effective at killing rapidly dividing cells. left kidney found small and non functional. 4-year-old male with recurrent UTIs. Which of the following pulmonary cell types is most likely to be abnormal in this patient? . Current meds include prednisone. Use of over-the-counter cough suppressants has not resolved his symptoms. and history of type 1 DM. He has no family history of lung disease.Neutrophil counts 34. 58-year-old man comes to the physician because of a 4-year history of recurrent cough productive of increased sputum. Best action to adapt to illness? . loose stools for 1 year. in mice caused profound myelosuppression. hydroxychloroquine. Nephrectomy is done. Physical examination shows cyanosis.Motility disorder 31. His temperature is 37°C (98.Pseudostratified columnar epithelial cells 33.6°F). These cells are seen due to loss of function of which portion of spleen? . Patient with orthostatic hypotension. and the picture shown (dilated ureter and renal calyx). Researching new cancer drug. He has smoked 2 packs of cigarettes daily for 35 years.Tubular atrophy 30. and respirations are 18/min.29. In patients. most appropriate to follow which when at risk for infectious complications? . and oxycodone for pain. 17-year-old boy whose mother concerned about physical development. a balanced decreased in carbs and fat is required (caloric radio of fat and carbs is 30:55). Immune disorder? . 1. WBC 26. Blood and CSF cultures grow oxidase positive. FSH is 5.Late component of complement deficiency 37. No statistically significant differences found between infants receiving the antibiotic and those with standard tx. Physical finding on patient? . gram negative diplococcus. To decrease risk for cv disease 24 yo man begins diet. to maintain the recommended protein intake (56g day). 10th percentile for height and 25th for weight.000.Number of subjects in the study 38. PE rash on lower extremities. 17-year-old boy with syncopal episode.Heterotopic gastric mucosa 36. progressive confusion.53 95 kg BMI 32.5F. Brother with similar infection at same age.Gynecomastia 39. Laparotomy done and 5-cm blind outpouching on antimesenteric side of terminal ileum 15 cm from ileocecal valve resected. muscle aches. Randomized controlled trial evaluating tx of acute otitis media. which best describes number of calories that should be provided by fat in this its diet each day? .630 . 19-year-old man with gastrointestinal bleeding. palpable bp 80. fever. testosterone 8 (N=10-35). T 103. Pathology shows? . Intends to lose 16 kg by limiting caloric intake to 2000 cal.Encourage the patient to participate in a support group for persons with her condition 35.. Which aspect results in type II error? . nausea. muscle strength 2/5. Normal mental status. excessive lacrimation. Respirations labored. Current . swelling or nipple discharge. Imaging shows cavernous sinus thrombosis on left. round. No skin change.4°F). and blood pressure is 110/65 mm Hg. She also has hypertension. She was discharged with instructions to take oral ciprofloxacin after a 3-day course of intravenous ciprofloxacin resulted in improvement. Dx? . Dx? . mobile. Cannot sleep and restless. diaphoresis. Lump is smooth. pain with urination.Fibroadenoma 41. 65-year-old woman comes to the physician because of a 1-week history of a swollen. 56-year-old exposed to possible chemical attack. 32-year-old woman has new neuro finding while being tx for acute infection of sphenoid sinus. she was admitted to the hospital for similar symptoms and was diagnosed with acute pyelonephritis.Pralidoxime 43. Examination of the left knee shows erythema and swelling of the joint and decreased range of motion. 2 days after surgery. no pain. 66-year-old woman is brought to the emergency department by her daughter because of a 2-day history of fever. This patient's synovial fluid most likely contains which of the following? .Inability to abduct the eye 45. well delineated. Her temperature is 38°C (100. flank pain. firm. and nausea. seeing little men coming through window. A photomicrograph of synovial fluid obtained by arthrocentesis is shown.Uric acid 42. confused and restless. nontender. and osteoporosis. 20-year-old woman with palpable lump in right breast 4 months.Delirium 44. Additional finding most likely? . Besides atropine. hyperlipidemia. another tx? . painful left knee.40. Ten days ago. urinary and fecal incontinence. increased salivation. 71-year-old man admitted for prostatic resection. 1°C (102.medications also include alendronate. Patient's risk for infection overall? . PE shows 2/6 murmur. hydrochlorothiazide. and 2 percent of admitted patients acquire hospital infection. Imaging shows abdominal contents in left pleural cavity. 34-year old man is brought to the ER semiconscious and combative. Patient worried about hospital-associated infection. he has transient muscle fasciculations in his face . Full-term newborn in respiratory distress. ezetimibe. Forty five minutes after completion of the procedure .Descending colon 49. Maldevelopment of which structure led to diaphragm defect? . Graft extends just below the renal arteries to the bifurcation of the aorta. he develops generalized paralysis within 1 minute. had teeth cleaned a month ago. and blood pressure is130/80 mm Hg. and simvastatin. Studies show 30% of patients require admission after procedure. 83-year-old with arteriosclerosis undergoes repair of infrarenal abdominal aortic aneurysm. 62-year-old with angina pectoris is referred for cardiac catheterization. no abx for prophylaxis. Which organ will lose primary blood supply and rely on collateral circulation? . and had rheumatic fever as child and endocarditis 4 y ago. a short-acting neuromuscular blocking agent is administered for intubation to prevent aspiration.Pseudocholinesterase 47. Within a few seconds after admin of the drug.4°F). Her temperature is 39.Left pleuroperitoneal membrane 48. he is still paralyzed.Calcium carbonate 46.6/1000 50. calcium carbonate. The most likely cause of this patient’s current condition is an interaction between her current oral antibiotic and which of the following medications? . 25-year-old woman with fatigue for 3 wks and intermittent fever for 7 days. In addition to sedation . ultrasound shows abnormal . A genetic abnormality of which of the following enzymes is the most likely cause of his unusually slow recovery from paralysis? . is 100% renal cell carcinoma (RCC) until proven otherwise. Urine is darker than usual over 2 weeks. which at his age. fluid. but a combination of cysts. located either in the ureter or in the inner portion of the kidney (the pelvis). no bacteria. The cancer described is not only typical of RCC but also is located on the upper portion of the kidney.Renal cell carcinoma Why it’s right: This is a patient with recent weight loss. Characteristic of causal organism? . 6 leukocytes. The typical triad is the latter two symptoms (flank pain. Cystic mass is more favorable for a benign process. An abscess is less likely to be a solid mass – similarly. Why the others are wrong: Metastasis from another cancer wound not have such prominent urinary findings. 56-year-old man comes with vague right-sided flank pain and 7-lb weight loss over past 6 weeks. flank pain and hematuria.5-cm solid mass in upper portion of right kidney. Finally. But the triad doesn’t always need to be completed. which is borderline normal) in the urine. and here the word “solid” directs the test-taker towards malignancy. and therefore must derive from the renal cortex parenchyma itself. An abscess would also present with fever and have an acute onset with bacteria and WBCs (more than just 6. a hematoma would also not be a solid mass.mitral valve. Dx? .Greening reaction on blood agar Block 1 Part 1 1. etc. or in the cortex. and they even further support the dx of RCC by sharing the ultrasound results – a solid mass. hematuria) plus palpable mass. Photo of growth from blood cultures shown (GP cocci in chains). transitional cell carcinoma is referring to cancer of the ureter or pelvis. . Urine shows 50 erythrocytes. Renal ultrasound shows 1. and they would have to give other signs/symptoms (s/s) of another malignancy elsewhere in the body. No recent trauma or back strain. Why the others are wrong: All of the other choices are suggestive of a pathological process. This is a key concept for the boards that is repeatedly tested. Diastolic dysfunction is incorrect because although in diastolic dysfunction there is preserved EF with impaired relaxation. . 2. and flank pain is RCC until proven otherwise. since his EF is still preserved and actually more than it should be at 75% (normal is ~55-65%). He is a professional athlete and works his heart to the max. His resting pulse is 33/min. so much so that it has become big. hematuria. the ventricles are not dilated but usually hypertrophied and thicker. Echocardiography shows dilated ventricles with normal function and a left ventricular ejection fraction of 75%. the same reason why also hypertrophic cardiomyopathy and increased myocardial stiffness are incorrect – both may have a normal to increased EF.Eccentric hypertrophy Why it’s the right answer: “Dilated ventricles” is the key phrase in the stem. or in-line (or in-series) building and enlargements of muscle cells/fibers. A dilated heart is built from eccentric hypertrophy. or parallel building and enlargement of muscle cells. Which of the following best describes the findings in this patient? . this patient doesn’t necessarily have anything wrong with him. In contrast. a thick heart of normal size (not dilated) is built from concentric hypertrophy. Furthermore. and blood pressure is110/62 mm Hg. Congestive cardiomyopathy would have a decreased EF. 22-year-old man who is a professional cyclist undergoes extensive physiologic testing as part of his training regimen. and not in a pathological way. but the ventricles would be thick not dilated.Take home point: Patient >50 YO with weight loss. crohn’s colitis (issue with vitD absorption). the serum concentration of which of the following substances is likely to be increased at this time? . a 50-year-old man undergoes series of lab studies.24. So lets take a look: 1) So we start with Vitamin D3 (AKA cholecalciferol.25-Dihydroxycholecalciferol Why it’s the right answer: First off.25-dihydroxyvitamin D3 (by enzyme 24-alph-hydroxylase also in the kidney) . concentric hypertrophy results in thickening.25-dihydroxyvitamin D3 (by enzyme 1-alpha-hydroxylase located in the kidney and gets positive feedback from PTH) (b) 24. from diet like fortified dairy products and fish oils. 3.Take home point: Eccentric hypertrophy results in dilation. PO4 and PTH are normal. biochemistry. He is given infusion 2 g Calcium chloride over 2 hours.5mg/dl. His serum Ca concentration now is 11. or synthesized from 7-dehydrocholesterol in the skin when exposed to UV rays) à (via the liver) à 2) 25-hydroxyvitamin D3à (via the kidney) à 3) (a) 1. and nutrition. Compared with pre infusion levels. and sarcoidosis (elevated Ca++). but also high-yield diseases like kidney disease (problem with alpha-1-hydroxylase). His serum Ca. it is important to know the sequence of vitamin D metabolism for step 1 because this concept incorporates not only physiology. During a clinical study of calcium and phosphorus metabolism. which is the dx presented in the vignette. the active form of vitamin D that increases Ca++ absorption from the gut.Now. an enzymes that converts 25-Vitamin D3 to 1. Biopsy shows subepidermal blister formation. When there is a high level of calcium. Conversely.25-Vitamin D and shunted to the other pathway.nih. Take home point: PTH gets positive feedback from low Ca++ and negative feedback from high Ca+.25-Vitamin D. antibodies . there is negative feedback on the amount of PTH released (because PTH leads to increased calcium).nlm. and a great schematic on what I said above in words regarding vit D metabolism. PTH increases Ca++. For more information. low PTH does not activate 1-alphahydroxylase when calcium levels are high (such as in the clinical scenario above). which converts vitamin D3 to 1.gov/pmc/articles/PMC2879391/ 4. No oral lesions. PTH increases the enzymatic activity of 1-alphahydroxylase. In this autoimmune disease. 70-year-old man comes with skin blistering for 1 week.25Dihydroxylase (by another enzyme that is not important for purposes of the boards). positive and negative feedback. Target by antibodies? . the question is asking about negative feedback. This is one of the most difficult questions on NBME 18 because it requires that you not only know the metabolism of vitamin D as well as the back of your hand. Physical shows tense bullae in joint folds of upper and lower extremities. Immunofluorescence microscopy shows antibodies against proteins at the dermal-epidermal junction.ncbi. The other choices are ruled out based on the above explanation. but it also requires that you know the concept of enzyme kinetics.25-Vitamin D. and does so in part by increasing the activity of enzyme 1-alpha-hydroxylase. it’s being shunted to its other pathway that forms 24. and specifically where Vitamin D3 goes if its not being converted to 1. follow this link: http://www. When vitamin D3 isn’t being converted to 1.25-Vitamin D. So 25-Vitamin D3 is shunted to the other pathway and converted to 24.Hemidesmosome Why it’s the right answer: This is a pretty basic question on bullous pemphigoid.25Dihydroxycholecalciferol. target antigen .common.hemidesmosome. You either know this one or you don’t. blisters flaccid. Bruit heard over left renal artery. the kidney(s) are starved by blood. well-controlled blood pressure 6 months ago. serum aldosterone concentration increased Why it’s the right answer: The board examiners love these up and down arrow questions.desmosome. blister content .are directed against the hemidesmosomes. so they release factors to increase the pressure in the form of the RAAS cascade (silly little . Labs? .positive. the other high-yield autoimmune skin disease that’s tested on the boards.superficial. oral lesions . but now has very high blood pressure that is a result of gradual onset renal artery stenosis. Immunofluorescence .negative. Bullous pemphigoid: Layer . there’s a guy that had good. plasma renin activity increased. Nikolsky's sign .middle-age (not always). basically.tense/firm.Basement membrane. Immunofluorescence . 63-year-old man with abnormal blood pressure. pemphigus vulgaris. age . age . CT angioshows left arterial stenosis.hemorrhagic Pemphigus vulgaris: Layer . and they are not something to be intimidated by because they are usually pretty straight forward as long as you’re able to break down the clinical vignette. target antigen . Take home point: Bullous pemphigoid is a disease of the hemidesmosomes and characterized by a linear immunofluorescent pattern that highlights the dermal and epidermal junction.elderly. 6 months ago. oral lesions rare. Conversely. Nikolsky's sign . bp was 135/85. Here. easily rupture. Today bp 170/98. blister content . When there is a blockage of one or two renal arteries. In reaction the kidneys think blood pressure is low. which link the dermis to the overlying epidermis. creating a circular immunofluorescence pattern INTRAdermally.Total peripheral resistance increased. is a disease in which autoantibodies target desmosomes.intraepidermal.fluid-filled 5. circular. blisters .deep. This clinical vignette is still pretty obvious sans the demographics of the patient based on physical exam alone. know the drug to treat this condition. Physical shows jvd and prominent a wave. However. which increases aldosterone. that when starved for blood. don’t be tripped up. Finally. RR 26. the board examiners know that everyone is going to get the answers right if they put that there. One factor/hormone they release is renin (from the juxtaglomerular cells) Renin then causes a cascade of other hormones to be released. which . a middle-aged woman is the classic demographic category for idiopathic pulmonary fibrosis. including aldosterone. total peripheral resistance (TPR) is increased. Vasodilation is a normal response to decreased blood flow à to let more blood flow in!! However. Another KEY point is that the lungs is the ONLY organ system. so they try to make the question harder (sometimes) by changing it up and maybe giving you a 40-50-year-old MAN with pulmonary fibrosis.e. So again.kidneys). 35-year-old woman with 3-month progressive shortness of breath with exertion. Cardiac exam shows loud pulmonic component of S2 and right-sided S4 gallop. In other words. which increases blood pressure so the kidneys are happy and no longer starved. Take home point: Low kidney perfusion (from things like renal artery stenosis or fibromuscular dysplasia) leads to activation of the RAAS cascade and an overall increase in BP/TPR. And one of the factors that is upregulated in pulmonary fibrosis is endothelin-1. An important point I want to bring up here is that the boards don’t always follow the demographic rules we know and love – i. Increased pulmonary expression of what? . the vessels in the lungs CONSTRICT and mainly do so through endothelin-1. And the reason they constrict? To not promote further deoxygenation through a V/Q or shunt defect. The other important thing to remember is the columns do not go in order necessarily– they should really in fact be reversed to show first increases renin. vasoconstricts instead of vasodilating. 6. which increases TPR à so don’t be fooled by that. Lungs clear.Endothelin-1 Why it’s the right answer: Dx is pulmonary hypertension secondary to pulmonary fibrosis. The mechanism of vasoconstriction is alpha agonism. Taking oral contraceptives for 15y. PAH is a consequent of pulmonary fibrosis. fingers and toes after emotional upset or cold exposure. total porphyrin increased. blanching.Succinyl CoA . 30-year-old woman with 2-years of numbness. arms and hands. The only drug listed that is an alpha agonist is phenylephrine. which is vasospasm of arteries and arterioles. Take home point: Avoid alpha agonists in Raynaud’s phenomenon. Vitals and PE normal. 35-year-old woman with 2-day history of blistering lesions on sun-exposed face. Bosentan is a medication frequently used to treat PAH through antagonization of the endothelin receptor. Labs: AST increased. It could be on your test (wink wink). Precursor to uroporphyrin? . so you would absolutely at all costs avoid drugs that act as agonists on alpha receptors. specifically a selective alpha1-adrenergic receptor agonist. PE shows fluid-filled vesicles and bullae. Recurrent episodes of skin lesions over several years. and bluish color to ears. commonly the hands. ALT increased. urine uroporphyrin III increased. Avoid taking which drug? . 8. impairing circulation and resulting in color changes in extremities.Phenylephrine Why it’s the right answer: Dx is Raynaud’s phenomenon. 7. Take home point: Pulmonary artery hypertension (PAH) results from increase in release of endothelin-1.decreases pulmonary hypertension by antagonizing the endothelin receptor: Bosentan. Why the others are wrong: A meningioma usually presents with localized neurological deficits since it normally has a mass effect and pushes on the cerebral hemispheres. specifically the frontal lobe. Take home point: Porphyria is a group of disorders that result in defective heme synthesis and the buildup of uroporphyrin. Personality change last 6 months. CT shows single mass enhances with contrast in right frontal lobe and crosses to left hemisphere through corpus callosum. Dx? . 65-year-old with sudden onset generalized tonic-clonic seizures.High-grade fibrillary astrocytoma Why it’s the right answer: It is pretty clear from the question that this is cancer. the very start of heme synthesis. At the start of heme synthesis. The most common type of porphyria is porphyria cutanea tarda. resulting in defective heme synthesis. succinyl CoA and glycine combine to form ALA (via ALA synthase). the classic ‘butterfly lesion’ that goes from one hemisphere to the other is also characteristic of astrocytomas. It also is described on imaging as a mass with a tail. used to be mild mannered and now verbally abusive. The key tip-offs to knowing this is an astrocytoma are the location and characteristic crossover from one hemisphere to the other.Why it’s the right answer: Dx is porphyria. Furthermore. and therefore present with personality changes. Astrocytomas love the supretentorial region. and that is why the rest of the answer choices are also all cancers. since it is . The deficient or defective enzyme is uroporphyrinogen decarboxylase. and we need to figure out which type of cancer this patient has. which describes a group of disorders. 9. an intermediate compound. The very beginning of heme synthesis starts with succinyl CoA and glycine. tinnitus. . and also will come with other s/s of hearing loss. and therefore intratentorial. but this could have easily been mets as well. Take home point: Astrocytomas are single lesions that are often in the frontal lobe. ect. Metastasis is typically 2+ lesions. presenting with personality changes therefore. A schwannoma is classically located in the cerebellar-pontine junction (know where this is on imaging).“sprouting” from the meninges (or at least that’s how I remember it). its just that astrocytoma is a better fit for the clinical picture presented. and “butterfly” from lobe to the other through the corpus callosum. not just the one.
Copyright © 2022 DOKUMEN.SITE Inc.