Exam 10: Pathology

Gentamicin is being administered to a 65-year-old woman for an abdominal infection complicated by multidrug-resistant organisms. The patient's urine output decreases noticeably after a week of treatment, and serum creatinine rises to 2.3 mg/dL. She has no history of kidney disease, and her baseline kidney function was normal prior to starting therapy. For the past 24 hours, the patient has been afebrile. The blood pressure is 130/80 mm Hg, and the pulse rate is 80 bpm. The examination reveals moist mucous membranes. There is nothing rash. Urinalysis results are as follows: Fractional excretion of sodium is >2%.  Histologic examination of the patient's kidneys would most likely show which of the following?

A 59-year-old man comes to the office due to progressive weakness for the past several weeks.  The patient has had difficulty getting out of bed and climbing stairs in the morning, which improves gradually as he "warms up the muscles" with continued use.  He has also had to drink water more frequently due to dry mouth and has had episodic double vision.  The patient also reports difficulty achieving erections despite having a good libido.  Neurologic examination shows decreased strength of the hip flexors and diminished knee reflexes.  Repeat examination after lower extremity isometric exercise shows normalization of the muscle strength and deep tendon reflexes.  Which of the following conditions is most closely associated with this patient's current disease process?

A 67-year-old man comes to the physician because of a worsening tremor that began 1 year ago. The tremor affects his left hand and improves when he uses his hand to complete a task. He also reports feeling stiffer throughout the day, and he has fallen twice in the past year. He has not noticed any changes in his cognition or mood. She is interested in discussing surgical options.  This patient would most likely benefit from high-frequency deep brain stimulation targeted at suppressing neuronal activity in which of the following brain structures?

A 5-year-old girl is brought to the physician because her mother has found her to be inattentive at home and has received multiple complaints from her teachers at school. She does not complete her assignments and does not listen to her teachers' instructions. She refuses to talk to her parents or peers. Her mother says, "She ignores everything I say to her!" She prefers playing alone, and her mother reports that she likes playing with 5 red toy cars, repeatedly arranging them in a straight line. She avoids eye contact with her mother and the physician throughout the visit. Physical and neurological examination shows no abnormalities. Which of the following is the most likely diagnosis?

A 74-year-old man presented to the emergency department due to an episode of bloody vomiting. The patient is known to have alcohol use disorder, he consumes 5 cans of beer daily. Temperature is 36.7 C (98 F), blood pressure is 90/60 mm Hg, the pulse is 120/min, and respirations are 23/min. On examination, the patient has yellowish skin and scleral discoloration. Abdominal examination shows an enlarged spleen. Upper gastrointestinal endoscopy shows bleeding in dilated tortuous veins found in the esophagus. This patient's presentation is due to shunting of blood through which of the following structures?

A 72-year-old woman is brought to the emergency department for right hip pain 1 hour after she fell while walking around in her house. She has been unable to stand or walk since the fall. She has hypertension and gout. Her sister died of multiple myeloma at the age of 55 years. Current medications include amlodipine and febuxostat. She does not smoke cigarettes. She drinks a glass of wine daily. Her temperature is 37.3°C (99.1°F), pulse is 101/min, and blood pressure is 128/86 mm Hg. Examination shows right groin tenderness. Range of motion of the right hip is limited by pain. The remainder of the examination shows no abnormalities. A complete blood count and serum creatinine concentration are within the reference range. An x-ray of the hip shows a linear fracture of the right femoral neck. Which of the following changes in bone structure is most likely responsible for this patient's condition?

The office is visited by a 43-year-old guy with a history of HIV infection who is not adhering to highly active antiretroviral medication as a result of years of memory loss and cognitive impairment. The patient struggles with speaking, concentration, and attention. He has been more indifferent and sluggish during the past few months. He has fallen several times in the recent past due to balance issues. The patient hasn't had a headache, tremor, blurred vision, fever, nausea, or incontinence. His brother has a history of severe intellectual disability and epilepsy. The patient has an 18/30 Mini-Mental State Examination score and is emotionally dulled. He also struggles with fine motor skills and postural instability. Noncontrast head CT scan reveals diffuse cortical atrophy with some enlargement of the ventricles, as shown in the exhibits.  This patient's condition can be best described as which of the following?

A 12-year-old girl is brought to the office by her mother due to unusual nighttime behavior.  The mother reports that once or twice a month over the past year she has found her daughter walking around the house between the hours of midnight and 2 AM.  The mother says, "Although her eyes are open, she appears to be in a daze and doesn't respond to me.  I guide her back to bed and she goes back to sleep, but I worry that she could get hurt or fall down the stairs if I'm not there."  The girl has no recollection of the events.  Which of the following EEG patterns is characteristic of the sleep stage associated with this behavior?

In young and otherwise healthy patients who have fatigue, progressive dyspnea, atypical chest pain, or unexplained syncope, pulmonary hypertension should be suspected. Long-term pulmonary hypertension causes right ventricle hypertrophy and/or dilation (cor pulmonale). Which of the following is the most likely cause of this patient's dyspnea?

A 52-year-old woman comes to the emergency department because of a 2-day history of worsening fever, chills, malaise, productive cough, and difficulty breathing. She has type 2 diabetes mellitus, hypertension, and varicose veins. Her current medications include metformin, lisinopril, and atorvastatin. Her temperature is 39.4°C (102.9°F), pulse is 102/min, respirations are 31/min, and blood pressure is 88/59 mm Hg. Pulse oximetry on 2 L of oxygen via nasal cannula shows an oxygen saturation of 94%.   A central venous catheter terminating in the superior vena cava is placed.  Blood aspirated from the catheter appears red.  Blood gas analysis of this venous sample reveals an oxygen saturation of 87% (normal: 65%-70%), and lactate is moderately elevated.  Which of the following is the most likely cause of this patient's abnormal blood gas findings?

A 22-year-old man comes to the emergency department because of the onset of facial swelling, difficulty breathing 20 minutes after eating some trail mix. He has never had a similar episode before. Blood pressure is 80/40 mm Hg, pulse is 130/min, and respirations are 32/min. Examination shows generalized hives, swelling of his tongue and lips, and labored breathing with intercostal retractions.   Intravenous fluids are begun, and intramuscular epinephrine is administered immediately.  In addition to its effect on airway and circulation, this medication is most likely to improve this patient's condition through which of the following mechanisms?

A 55-year-old man is found unresponsive on the street during a cold winter night.  He is hypothermic and does not follow commands.  Medical history is unavailable.  Despite rewarming efforts, the patient dies in the emergency department.  An autopsy is performed.  Light microscopy of a section of the patient's kidney is shown on the slide below. This individual's renal condition could most likely have been prevented by use of which of the following types of medication?

A 42-year-old woman comes to the physician with a 6-month history of breast tenderness and menstrual irregularities. She also reports hot flashes and unintentional weight loss for the past few months. Physical examination shows no abnormalities. An ultrasound of the pelvis shows a right adnexal mass. TSH is low and a urine pregnancy test is negative.  Pelvic ultrasound reveals a 6-cm right ovarian mass.  The mass is surgically removed, and gross examination of the specimen shows a cystic lesion with an oily substance.  Which of the following cell types is the most likely source of the neoplasm in this patient?

A 66-year-old man comes to the emergency department due to increasing shortness of breath over the past 5 days.  He has had a nonproductive cough for 4 days.  The patient appears ill.  Neck veins are nondistended.  There is decreased chest expansion on the right side.  Auscultation reveals decreased breath sounds over the right lung base and dullness to percussion.  Chest imaging shows a right lower lobe infiltrate and a mild pleural effusion on the right side.  Thoracentesis is performed. Pleural fluid and serum findings are as follows: Which of the following is contributing most to the pathogenesis of this patient's pleural effusion?

A 26-year-old women comes to the offfice due to worsening fatigue and weight loss. She has a history of primary hypothyroidism and she takes levothyroxine. Physical examination is normal. Blood pressure is 115/75 mmHg supine and 92/61 mmHg on standing. Laboratory results are as follows: Which of the following changes in circulating hormone levels are expected in this patient?

A 37-year-old woman, gravida 4, para 3, at 35 weeks' gestation is admitted to the hospital in active labor. She has had no prenatal care. Two years ago, she delivered her 3rd child by uncomplicated cesarean delivery. The patient appears in acute distress. Her pulse is 98/min, respirations are 15/min, and blood pressure is 130/80 mm Hg. The abdomen is nontender and contractions are felt. One hour following vaginal delivery, the placenta is not delivered. Manual separation of the placenta leads to profuse vaginal bleeding. A firm, nontender uterine fundus is palpated at the level of the umbilicus. Which of the following is the most likely cause of this patient's ongoing vaginal bleeding?

A 4-hour-old male newborn has perioral discoloration for the past several minutes. Oxygen by nasal cannula does not improve the cyanosis. He was delivered by cesarean delivery at 37 weeks' gestation to a 38-year-old woman, gravida 3, para 2. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. Pulse oximetry shows an oxygen saturation of 85%. Cardiopulmonary examination shows a 2/6 holosystolic murmur along the lower left sternal border. The abdomen is soft and non-tender. Echocardiography shows pulmonary arteries arising from the posterior left ventricle, and the aorta rising anteriorly from the right ventricle. Definitive surgical correction of the main congenital abnormality is planned.  Pending definitive repair, which of the following temporary measures would be most likely to improve this patient's condition?

A 32-year-old man comes to the emergency department because of sharp chest pain for 3 days. The pain is retrosternal, 8 out of 10 in intensity, increases with respiration, and decreases while sitting upright and leaning forward. He has nausea and myalgia. He has not had fever or a cough. He has asthma and was treated for bronchitis 6 months ago with azithromycin. His mother has hypertension. He uses an over-the-counter inhaler. His temperature is 37.3°C (99.1°F), pulse is 110/min, and blood pressure is 130/84 mm Hg. Breath sounds are normal, but the jugular veins are distended. His pulse becomes undetectable to palpation during inspiration.An ECG shows diffuse ST elevations in all leads. The patient is at increased risk for which of the following conditions?

A 35-year-old man visits the clinic for an assessment of red skin lesions beneath his breast, which his wife initially observed. The sores are not itchy or unpleasant, and no one else in the family has skin problems. He hasn't experimented with any new soaps, lotions, or detergents. The patient has no known medical issues and does not use any drugs. Every night, he consumes 4-6 beers. He does not smoke or use illegal substances. The BMI is 32kg/m2, and vital signs are normal. The skin findings are depicted below. Which of the following is the most likely diagnosis in this patient?

A 46-year-old woman comes to the physician because of a 5-month history of severe muscle and joint pain. The pain varies in location and intensity. She also has joint stiffness in the morning and reports fatigue throughout the day that she attributes to not sleeping well. She reports a tingling sensation in the lower limbs. Her bowel habits are unchanged, but she often feels bloated. She has hypertension and occasional tension headaches. She does not smoke cigarettes or drink alcohol. Her medications are hydrochlorothiazide and naproxen. She appears healthy. Vital signs are within normal limits. Examination shows symmetric muscular tenderness at the base of the neck, over the shoulders, and in the lumbosacral area. Strength and deep tendon reflexes are normal. Laboratory studies show no abnormalities. Which of the following is the most likely diagnosis?