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1. A 36 year old, sexually active woman sho is immunocompromised presents with a milky white vaginal discharge which she described as odourless.

She also complains of a burning sensation while passing urine.

She has been with her current partner for 10 years. She is otherwise fit and well.

A vaginal swab and culture is peformed , this showed brown inclusion bodies in a McCoy cell culture.

What is the likely causative organism ?

2. A six month old irritable infant has a CSF sample taken.

You suspect bacterial meningitis clinically.

Which of the CSF readings shown would most be consistent with the diagnosis of bacterial meningitis ?

3. A 75-year-old English lady was referred to the emergency department by her general practitioner with a presumed chest infection which gave her symptoms of dyspnoea and cough.

She also complained of pink blood-stained sputum .

A high resolution computed tomography scan report stated ‘There are multiple patchy areas of consolidation throughout both upper lobes suggestive of alveolar haemorrhage .

An arterial blood gas taken during the arrest showed a serum hyperkalemia. Her calculated estimated glomerular filtration rate was 58 ml/min.

A renal biopsy later showed autoantibodies directed against the basement membrane.

What diagnosis would fit in with the finding of autoantibodies directed against the basement membrane. ?

4. Name the arrowed structure

5. Gastric secretion is the process by which gastric juices are secreted into the stomach.

What percentage of gastric secretion occurs when food is in the duodenum?

6. A 20-year-old female patient with no history of heart disease presented to the hospital with high fever, cough and sputum. On the third day of hospitalisation, left facial paralysis developed and cranial revealed an infarct in the right frontoparietotemporal lobe. Transthoracic echocardiography revealed 1.5×2 cm-sized vegetation on the mitral valve and severe mitral regurgitation. On examination, small, tender nodules are found on the finger and toe pads, along with small hemorrhages on the palms and soles. Three sets of blood cultures were obtained from different veins.

Which organism is most likely to be cultured?

7. A young man is involved in a traffic accident in which he sustained severe comminuted fractures of the right femur.

Three days following the accident he develops seizures.

What best explains this occurrence ?

8. A scientist is carrying out studies on different samples of the basal ganglia in patients with memory loss and reports to his superior that he has found that there is a particular part of the basal ganglia that shows a lower number of dopamine containing cells than expected.

His colleague explains that the loss of cells in this part of the basal ganglia could be causing memory loss.

When examining this same tissue they notice that the black-coloured cells are decreased in number.

What is most likely to have caused this patient's memory loss?

9. A man in his late fifties presents to a general check up. The man said that initially he was not going to attend as he felt he was in good health. However, his sister had urged him to attend as she was concerned due to a recent cancer scare in the family. On examination, you find that the patient has severely high blood pressure, fatigue and muscle weakness.

You suspect that this patient may have primary aldosteronism

Tests confirm this.

As well as a drug treatment, you also know that it is important to give a supplement in the case of this condition.

Which supplement would be beneficial for this man with primary aldosteronism ?

10. A 58-year-old woman was referred with a painful tooth .

A draining sinus tract was noted leading from the gingiva of the involved tooth.

What is the most appropriate description of this lesion ?

11. A 40-year-old male presented with a chronic cough and a 2-month history of intermittent afternoon fever. Associated symptoms included general malaise, anorexia, and the loss of 6 kg body weight within the previous 2 months. On admission, the vital signs were shown as blood pressure: 124/68 mmHg; pulse rate: 80/min; respiratory rate: 22/min; body temperature: 38.5°C.

An abscess in a molar cavity that required debridement was found, although the patient had not complained of dental pain. Laboratory tests revealed a WBC count of 9250/μL with elevated neutrophils (82.7%); normocytic anemia with a hemoglobin level of 10.4 g/dL; an elevated ESR level (123 mm/1 hr); and abnormal liver function with AST/ALT of 49/79 IU/L. A chest x-ray film revealed increased infiltration over the right upper and lower lobes, and abdominal sonography showed mild splenomegaly

He was noted to have a swelling in the ring finger as shown:
On fundoscopy the following abnormality was observed in the retina:

What is the likely diagnosis ?

12. A patient suspected of having megaloblastic anemia complains of smooth and tender tongue, tingling in hands and feet and numbness in extremities. Blood tests marked the appearance of very large red blood cells.

Blood tests marked the appearance of very large red blood cells.

What supplement may alleviate these signs and symptoms of megaloblastic anemia ?

13. Name this structure:

14. A female infant was born by vaginal delivery at 33 weeks and 5 days of gestational age with respiratory distress and severe abdominal distension and bilious vomiting.

The plain radiograph is shown below .

What is the likely diagnosis?

15. A man in his mid-60s was seen in the emergency department with a 4-day history of fever (up to 40.5uC), occipital headache, runny nose, chills, confusion, and lethargy. He was released from the emergency department to his home.

Later that day, he was admitted with altered mental status.

Previous medical history was unremarkable except for a diagnosis of Crohn’s disease, for which he was currently receiving a monoclonal antibody treatment directed against tumor necrosis factor alpha .

The patient recently had ingested raw foods including raw meat and vegetables and he is suspected of having a meningitis by a food-borne bacterial pathogen .

A CSF culture was performed and this showed gram positive cocco-rods as shown below :

The antimicrobial susceptibility test showed that the organisms were sensitive to vancomycin, ampicillin, and aminoglycosides.

What is the likely diagnosis?

16. In the WHO algorithm for diagnosis of Dengue fever a blood pressure cuff is applied and inflated to the midpoint between the systolic and diastolic blood pressures for five minutes.

The result is shown below

What is the purpose of this test?

17. Gastric secretion is the process by which gastric juices are secreted into the stomach.

Which phase of gastric secretion is regulated by sensory and mental inputs?

18. A 36 yr old female surfer from California presented with mental status changes. Seven days prior to admission she developed an erythematous rash on back and chest confined to right side of thorax. The next day she was noted to be disoriented by family and brought to ER. Physical exam revealed an erythematous vesicular rash on her chest and back confined to the T2–T3 dermatome on right side. Neurological exam was within normal limits except that she had difficulty finding words.

CT scan of the head on admission was normal and her labs were significant for hyponatremia (123 mmol/l). Urine osmolality was 708 mosm/kg and serum osmolality was 267 mosm/kg consistent with SIADH. Cerebrospinal fluid (CSF) analysis revealed an elevated white blood cell count (321/cmm) with lymphocytic predominanace (90%) and elevated protein level (115 mg/dL). The patient was noted to become increasingly confused.

Polymerase chain reaction test on the cerebrospinal fluid revealed DNA of an organism that has the following structure .

What is the organism responsible for this patient's ?

19. Your patient, a 30-year-old woman, is explaining to you that her cousin and grandmother both had breast cancer, but they are on her father's side.

Clarification of her family history reveals that her paternal grandmother had breast cancer at age 50.

A first cousin (daughter of her father's sister) was diagnosed with breast cancer a year ago at age 42. Her father is in good health at 62. She has two older sisters, aged 33 and 35 years, who are also worried about their risk.

What is the next step of choice?

20. A 48 years female presented with weight loss, and nausea for 2 months.
She had a history of exertional dyspnea, dry cough off and on and antitubercular treatment 2 years ago.

She also had history of low backache . She admits to polyuria and polydipsia.

Her laboratory findings showed :

a Serum alkaline phosphatase 918 IU/L (raised)
serum total calcium 14.6mg/dl (raised)
serum phosphate 4.1mg/dl , urea 63.5 mg/dl
creatinine 3.8 mg/dl
serum Na + 141.3meq/L, K + 4meq/L
24 hour urinary calcium 990 mg/day
serum iPTH- 14.3pg/ml ( reference value 15-65)
Serum angiotensin converting enzyme (SACE) level was 158 U/L (Reference value 8- 65).
QTc interval in electrocardiogram was 0.40sec. Ultrasound of the abdomen showed hepatosplenomegaly.

Her CT thorax is shown below

Image description

What is the most likely diagnosis?

21. A 62-year-old woman complained of pain, rapid weight gain, and shortness of breath. Biventricular cardiomegaly with pulmonary venous hypertension was evident on chest radiographs. She is found to be hypertensive.

What is the antihypertensive drug of choice in this case?

22. A 29-year-old woman was admitted to the hospital with abdominal pain and bloody diarrhea On hospital day 2, her urine volume decreased, and generalized edema developed Laboratory tests showed a serum creatinine of 4.2 mg/dL, blood urea nitrogen of 35.4 mg/dL, hemoglobin 9.2 g/dL, platelet count 19,000/mm3, corrected reticulocyte count 5.4%, lactate dehydrogenase 3150 IU/L, haptoglobin 7.69 mg/dL, total bilirubin 1.31 mg/dL, and direct bilirubin 0.19 mg/dL.

Peripheral blood smear showed abnormal red blood cells shown below:

23. A patient with diarrhea is found to have the following organisms in her fecal specimen.



What is the likely diagnosis ?

24. A 56-year-old heterosexual man presented to the emergency department with a 10-day history of abdominal pain, nausea and vomiting, and diarrhea. The patient denied taking any medication and had no history of recent travel. His medical history was also unremarkable and he denied having any previous homosexual partners. On physical examination, the patient had a temperature of 38.4°C, a heart rate of 110 beats/min and a blood pressure of 95/55 mmHg. Head and neck, respiratory and cardiovascular, and musculoskeletal examinations were all normal. The patient had a distended abdomen and identified marked right lower quadrant tenderness with guarding.

Laboratory results revealed a hemoglobin level of 127 g/L (normal 127 g/L to 165 g/L), an increased white blood cell count of 18.2×109/L (normal 4.0×109/L to 11.0×109/L), lactate level of 8.2 mmol/L (normal 0.5 mmol/L to 2.2 mmol/L) and increased levels of alkaline phosphatase (232 U/L [normal 30 U/L to 145 U/L]) and gamma glutamyl-transferase (176 U/L [normal 11 U/L to 63 U/L]).

Computed tomography images of the abdomen demonstrate liver abnormalities (black arrows) and colonic wall abnormalities (yellow arrows.

What is the likely organism responsible ?

25. A 35-year-old woman presents to her gynecologist with complaints of burning on urination for the past 2 days.

Dipstick test of her urine demonstrates marked positivity for leukocyte esterase, but no reactivity for nitrite. Urine culture later grows out large numbers of organisms.

Which of the following bacteria are most likely to be responsible for this patient's infection?

26.
A 33-year-old white male presented to our hospital with a two-week history of subjective fevers, chills, and rigors. He had history of intravenous drug abuse and a habit of licking the needle to the dorsum of the tongue before injection into his arm.

CT of the thorax showed multiple cavitary lesions in both lungs and echocardiogram showed vegetations on the tricuspid valve.
The patient was treated with a six-week course of penicillin G He responded well with complete resolution of symptoms.

What is the likely cause of the vegetations on the tricuspid valve ?

27. The ELN gene encodes a protein that is one of the two components of elastic fibers.

Which of the following conditions is likely to be associated with a defect in this ELN gene ?

28. A patient suspected of having osteoporosis presents with a fractured wrist as a result of a relatively minor trauma and a stooped posture that resembles a hump.

What supplement may alleviate these signs and symptoms of osteoporosis ?

29. When a protein is being synthesized by a ribosome an elongating length of protein is produced in a process called translation . These ribosomes are attached to an extensive intracellular membrane system .

What is this membrane system called ?

30. A child with sickle cell anemia is develops severe anemia.

A bone marrow aspirate contains pronormoblasts .

The girl was probably infected with which of the following viruses?

31. A 36 year old, sexually active woman presents with an offensib=ve vaginal discharge

She has been with her current partner for 10 years. She is otherwise fit and well.

A vaginal swab and culture is peformed ,

What is the likely causative organism ?

32. An 85-year-old white male presented to our Emergency Department complaining of a 1-day history of right upper quadrant and right flank pain. He stated that the pain started suddenly and seemed to originate deep within his right upper quadrant. It extended laterally into his flank. He graded the pain as “severe” and described it as sharp and constant .

On physical examination, he had a temperature of 35.5°C. Blood pressure was 126/88 mmHg, with a heart rate of 86 beats per minute. Respiratory rate was 22 per minute, with an oxygen saturation of 92% on room air.

You order a CT abdomen/pelvis with IV contrast shown below:

What underlying medical condition is likely in this patient?

33. A patient suspected of having scurvy complains of dry mouth and eyes, small red and purple spots on thighs and legs, gum disease and teeth loss.

Blood tests marked the appearance of very large red blood cells.

What supplement may alleviate these signs and symptoms of scurvy ?

34. A 32 year old woman complains of a yellow vaginal discharge and minor dysuria during menstruation. An indicator paper shows the vaginal discharge to have a pH of 7 .

On examination a purulent, foul-smelling vaginal discharge is noted.

The cervix is characterized by punctate hemorrhagic lesions, is shown below. :

Treatment with oral metronidazole is successful in treating this discharge and it does not recur.

A sample of the discharge is taken from the cervix and examined under a microscope.

What is the likely seen under the microscope ?

35.  

A 29-year-old woman was admitted to the hospital with abdominal pain and bloody diarrhea On hospital day 2, her urine volume decreased, and generalized edema developed Laboratory tests showed a serum creatinine of 4.2 mg/dL, blood urea nitrogen of 35.4 mg/dL, hemoglobin 9.2 g/dL, platelet count 19,000/mm3, corrected reticulocyte count 5.4%, lactate dehydrogenase 3150 IU/L, haptoglobin 7.69 mg/dL, total bilirubin 1.31 mg/dL, and direct bilirubin 0.19 mg/dL.

Peripheral blood smear showed abnormal red blood cells shown below:

 

What is the likely diagnosis ?

 

36. A 37-year-old woman presents with 3 days of progressive joint pain in her ankles, knees, and wrists. She recalls three similar episodes over the past several years. On examination, she has a temperature of 38.7 C, her blood pressure is 110/70 mm Hg, and her heart rate is 90/min. She has a diffuse petechial rash over her trunk and extensor surfaces. Her ankles and knees are swollen, red, and tender with decreased range of motion, and there is tenderness over the tendon sheaths of her hands and forearms. Blood cultures are negative. Aspiration of joint fluid reveals a white cell count of 22,000/mm3 with no visible organisms, but culture on chocolate agar is positive.

Which of the following is an attribute of the causative organism that allows it to produce recurrent infections?

37. A 37-year-old female is diagnosed with acute bacterial endocarditis of the tricuspid valve.

Staph aureus is cultured from the blood stream.

Which of the following is the most probable etiology?