A 55-year-old woman is scheduled to undergo transvaginal hysterectomy and oophorectomy for dysfunctional uterine bleeding. During the procedure, the uterus must be separated from all surrounding pelvic structures. Identification and incision of which of the following structures that attaches to the cervical region and extends posteriorly is most appropriate in this patient?

A 28-year-old woman comes to the physician because of a 2-week history of generalized swelling. She has autoimmune (Hashimoto) thyroiditis and chronic hepatitis C. Her temperature is 37.1°C (98.7°F), pulse is 74/min, and blood pressure is 142/88 mm Hg. Physical examination shows 2+ peripheral pitting edema. Laboratory studies show a serum albumin concentration of 2.1 g/dL, serum cholesterol concentration of 324 mg/dL, and 3+ protein in urine. A renal biopsy specimen shows diffuse thickening of the glomerular capillary wall, granular immunofluorescent deposits of IgG along the glomerular basement membrane, and irregular subepithelial electron-dense deposits. This patient most likely has which of the following types of glomerulonephritis?

A 63-year-old woman comes to the physician because of vaginal bleeding for 2 weeks. Menopause occurred at the age of 49 years, and she received hormone replacement therapy for 4 years. She has osteoarthritis of the hands and knees, but she has been otherwise healthy. Pelvic examination shows a mildly enlarged uterus and a 10-cm right adnexal mass. An endometrial biopsy specimen shows simple hyperplasia without atypia. This patient most likely has which of the following types of adnexal masses?

Assuming the positive predictive value of a test is 50% and the negative predictive value is 75%, which of the following tables are consistent with these values?

A 62-year-old man comes to the physician for a follow-up examination. Two weeks ago, he was discharged from the hospital after sustaining an acute myocardial infarction. He smokes 2 packs of cigarettes and drinks four 12-oz beers daily. His diet mostly consists of cured meats and fast food. He does not exercise. The patient tells the physician, “I know that I need to make some changes in how I live so that my heart can be healthier. I just don’t have the willpower to quit smoking and drinking and all that stuff right now.” Which of the following best describes this patient’s stage of behavioral change?

A 45-year-old woman has had progressive fatigue and mild shortness of breath with exertion during the past 3 months. She thinks she had rheumatic fever at the age of 10 years. A grade 2/6, rumbling, diastolic murmur is heard at the fifth left intercostal space in the midclavicular line. A lateral x-ray of the chest shows mild posterior displacement of the esophagus. Which of the following cardiovascular structures is most likely responsible for the esophageal displacement?

A 20-year-old woman comes to the physician because of a 1-year history of intermittent low-grade fever, fatigue, and joint pains. One week ago, she had a severe exacerbation of these symptoms after a trip to the beach; she also developed a red rash, even on areas that were not exposed to sun. Her temperature is 38.3°C (101°F). Physical examination shows an erythematous rash over the malar areas, trunk, and upper extremities; oral ulcerations; 1-cm axillary lymph nodes bilaterally; and mild swelling and tenderness of the joints of the hands. Serologic studies show an antinuclear antibody titer of 1:200. Further studies are most likely to show a mutation of a gene encoding which of the following proteins?

A 57-year-old man is brought to the emergency department because of a 6-hour history of acute lower abdominal and flank pain. He also has a 6-week history of fatigue and generalized muscle and bone pain. He appears ill and changes positions to relieve the pain when it occurs. Physical examination shows a 0.5-cm, nontender, movable mass in the left side of the neck. Abdominal examination shows decreased bowel sounds; there is no rebound tenderness. Laboratory studies show:

An x-ray of the abdomen shows a calculus in the proximal left ureter. Which of the following is the most likely underlying cause of this patient’s condition?

An 85-year-old man comes to the physician because of a 4-month history of headaches, shortness of breath, and leg swelling. He has a 15-year history of well-controlled hypertension. His pulse is 80/min, respirations are 18/min, and blood pressure is 210/110 mm Hg. Crackles are heard at the lung bases. There is a bruit in the left flank and edema in both lower extremities. Urinalysis shows:

He dies the next day. Which of the following findings is most likely on autopsy?

 A 46-year-old man with type 2 diabetes mellitus is brought to the emergency department by his wife 30 minutes after he developed chest pain and then lost consciousness. He has a 2-year history of exercise-induced angina pectoris that is well controlled with isosorbide dinitrate, atenolol, and diltiazem. Current medications also include metformin and glipizide. His wife is tearful and says, “He took one of his friend’s Viagra pills about 4 hours ago.” On arrival, he is alert. His blood pressure is 60/30 mm Hg. Physical examination shows pallor and diaphoresis. This patient is most likely having which of the following effects of a drug interaction?

An investigator is designing a study to compare a new behavioral program for attention-deficit/hyperactivity disorder (ADHD) with the standard behavioral modification program for this disorder. Because ADHD is more common among boys, girls and boys are randomized into the two treatment groups separately. Which of the following types of treatment allocation is most likely being used in this study?

A 63-year-old man has had this gradually enlarging lesion on his right forearm for the past 3 years. Which of the following is the most likely diagnosis?

An 18-year-old man with acute lymphoblastic leukemia comes to the physician because of a 3-day history of intermittent fever and left-sided chest pain. He is in the fifth week of induction chemotherapy consisting of asparaginase, daunorubicin, prednisone, and vincristine. His absolute neutrophil count has been less than 500/mm3 for the past month. His temperature is 39.2°C (102.6°F). Physical examination shows dullness to percussion and decreased breath sounds on the left side. A chest x- ray shows a left lower lobe infiltrate and a moderate pleural effusion on the left. A photomicrograph of a periodic acid-Schiff stain of pleural fluid obtained via thoracentesis is shown. Which of the following is the most appropriate pharmacotherapy for this patient?

A 30-year-old woman, gravida 2, para 1, who is Rh-negative delivers a male stillborn at 24 weeks’ gestation. She had no prenatal care. The stillborn is Rh-positive. Autopsy findings are consistent with erythroblastosis fetalis. The mechanism of this reaction is most similar to that found in which of the following conditions?

A 79-year-old woman with osteoarthritis comes to the physician for an initial examination. She is otherwise healthy and lives alone. When the physician enters the examination room, he detects a slight odor suggestive of urine. It is most appropriate for the physician to approach the topic of urinary incontinence with this patient in which of the following ways?

A 77-year-old woman dies in the hospital after a long illness. Her vertebral column, obtained at autopsy, is shown in the photograph. The process shown is most likely associated with an increase in which of the following?

A 34-year-old woman is brought to the emergency department by her husband because of an inability to see objects in the peripheral visual fields in both eyes for 1 day. Her temperature is 37.2°C (99°F), pulse is 68/min, respirations are 16/min, and blood pressure is 124/78 mm Hg. Automated computerized perimetry examination shows a loss of the temporal visual field in both eyes. Neurologic examination shows no other abnormalities. This patient is most likely to have which of the following additional findings?

A 66-year-old man has a surgical excision of a brain mass; a photomicrograph of excised tissue is shown. He has smoked 1 pack of cigarettes daily for the past 50 years. His blood pressure is 130/90 mm Hg. Laboratory studies show polycythemia, hypercalcemia, and microscopic hematuria. Immunostaining of the tissue is positive for epithelial membrane antigen and negative for carcinoembryonic antigen. Which of the following is the most likely site of the primary neoplasm?

A 22-year-old woman is admitted to the hospital because of a 10-day history of polydipsia and polyuria. She says that the urge to urinate often awakens her at night. She has been taking lithium carbonate for 2 years for bipolar disorder; her dosage was increased 6 months ago because of recurrent severe manic episodes. Her vital signs are within normal limits. Physical examination shows no abnormalities. Over the next 24 hours, urine excretion totals 6.5 L. Laboratory studies at this time show a serum sodium concentration of 148 mEq/L, serum osmolality of 315 mOsmol/kg, and urine osmolality of 75 mOsmol/kg. After administration of desmopressin, urine output and osmolality do not change. Which of the following mechanisms is the most likely cause of the polyuria in this patient?

A 48-year-old woman comes to the physician because of a 1-year history of progressive ringing in her right ear. She also has felt dizzy while exercising. Neurologic examination shows dysmetria of the right upper and lower extremities. Muscle strength and somatosensory function testing of all extremities shows no abnormalities. Audiometry shows moderate hearing loss in the right ear. An MRI of the brain is most likely to show a mass compressing which of the following labeled structures in the photograph of a cross section of the brain stem?

During a study on exercise, a 45-year-old woman runs on a treadmill for 30 minutes. An increase in which of the following is most likely to change gastrocnemius muscle blood flow in this woman?

This graph best depicts the natural history of which of the following human disorders?

A 53-year-old man comes to the physician for a health maintenance examination. He does not smoke. He is 180 cm (5 ft 11 in) tall and weighs 95 kg (210 lb); BMI is 29 kg/m2. His blood pressure is 140/92 mm Hg. Physical examination shows no other abnormalities. Serum studies show:

In addition to appropriate pharmacotherapy, it is most appropriate for this patient to decrease his dietary intake of which of the following types of fatty acids?

A 35-year-old man comes to the physician because of a 2-year history of slowly progressive muscle weakness of his thighs. His father and paternal uncle have a disorder involving proximal muscle weakness of the lower extremities. Physical examination shows no other abnormalities. A muscle biopsy specimen shows ragged red fibers. Electron-microscopic examination of this specimen is most likely to show which of the following inclusions?

A 75-year-old man has decreased exercise tolerance and occasional syncopal episodes related to exertion. Left- heart catheterization discloses this pressure tracing (Ao -aorta; LV -left ventricle; LA-left atrium). The most frequently encountered mechanism underlying this disorder is which of the following?

A 38-year-old woman who is undergoing intensive chemotherapy for acute myelogenous leukemia develops pancytopenia. She also has pain, tingling, and itching of the skin of the right lower lip. One day later, a group of vesicles containing clear fluid appears on the lower lip. The most appropriate pharmacotherapy for this patient is a drug that inhibits which of the following?

A 50-year-old man with type 2 diabetes mellitus comes to the physician for a follow-up examination. Current medications include long-acting insulin and metformin. His vital signs are within normal limits. Physical examination shows no abnormalities. His hemoglobin A1c is 7.9%. Treatment with a third drug that promotes release of endogenous insulin is initiated to improve glucose control. This drug is most likely which of the following?

A 50-year-old woman comes to the physician with her husband because of a 6-month history of progressive weakness of her arms and legs. Neurologic examination shows mild spasticity, weakness, and hyperreflexia of the upper and lower extremities. A Babinski sign is present bilaterally. An MRI of the spine shows a 1.5-cm, well-defined spherical lesion indenting the cervical spinal cord on the left at the C1 level. Which of the following is the most likely diagnosis?

A 69-year-old man with hepatic disease and increased prothrombin time is scheduled to undergo a left hip replacement operation. Preoperatively, the patient receives a transfusion of 1000 ml_ of fresh frozen plasma. Two hours later he develops chills, abdominal cramps, dyspnea, vomiting, and diarrhea. The most likely cause of this patient’s reaction is a genetic deficiency in which of the following immune mediators?

The biological effects of thyroid hormone and retinoic acid are mediated through similar mechanisms. Which of the following properties is common to the receptors for these two compounds?

A clinical study compares patients with HIV infection with an age-matched control group of persons without HIV infection. Men and women in both the study and control groups have a history of unprotected sexual intercourse with both male and female partners. The CD4+ T-lymphocyte counts of persons in both groups are greater than 500/mm3 (N>500). The histories of any infection are obtained from persons in both groups. A history of infection with which of the following organisms most likely increased the risk for developing HIV infection in the study group?

A 17-year-old girl who is a gymnast is brought to the emergency department 30 minutes after fainting during a competition. Her mother says that the patient eats so little food that her teeth are decaying and that she has stopped menstruating. She is 165 cm (5 ft 5 in) tall and weighs 37 kg (82 lb); BMI is 14 kg/m2. Sexual development is Tanner stage 2. Her pulse is 130/min and blood pressure is 80/50 mm Hg. Physical examination shows pale, cool skin. There are scars across her knuckles that she says are cat scratches. Serum studies show a potassium concentration of 2.9 mEq/L and a chloride concentration of 92 mEq/L. Which of the following is the most likely diagnosis?

A 57-year-old man comes to the physician because of an intermittent cough and a 9-kg (20-lb) weight loss over the past 6 months. He has smoked 1 pack of cigarettes daily for 42 years. His serum calcium concentration is 13.3 mg/dL. An x-ray of the chest shows a 4-cm central mass in the left lung. Which of the following is the most likely diagnosis?

A 16-year-old boy is brought to the physician because of a 3-day history of difficulty walking because his right foot drops when he lifts it. He is a member of a wrestling team at his high school. Physical examination shows weakness of the right ankle dorsiflexor muscles. The right ankle evertor muscles have full power. Sensation to pinprick is decreased between the great and second toes of the right foot. Sensation over the rest of the foot is normal. Which of the following nerves is most likely damaged in this patient?

A 9-year-old boy has had alopecia and hypocalcemia since birth. His serum 1,25-dihydroxycholecalciferol concentration is within the reference range, serum 24,25-dihydroxycholecalciferol is undetectable. Serum parathyroid hormone concentration is above the upper limit of the laboratory assay and needs to be reassayed at a dilution. The results are pending. Which of the following is the most likely cause of his condition?

A 43-year-old woman comes to the physician because of vague discomfort, the increased prothrombin time is damage to which of the following cells?

A 24-year-old man comes to the physician because of fever, muscle aches, runny nose, cough, and chills for 1 day. His temperature is 39.9°C (103.8°F), pulse is 92/min, respirations are 24/min, and blood pressure is 124/78 mm Hg. Physical examination shows erythema of the throat but no pus. The lungs are clear to auscultation. Which of the following is the most likely cause of the chills in this patient?

New reagents are being designed to treat graft-versus-host disease in HLA-unrelated bone marrow transplant recipients. Reagents should be designed that selectively deplete which of the following donor cells?

A fetus exposed to an infection at 22 weeks’ gestation appears normal at birth but later develops a persistent mucopurulent nasal discharge, malformed teeth, skin cracks and fissures around oral, anal, and vulvar orifices, splenomegaly, and lymphadenopathy. Which of the following best explains these findings?

In a study designed to test the effectiveness of a new drug in the treatment of endometriosis, 100 women are randomly assigned to one of two groups: 48 of the women receive the new drug and 52 receive standard therapy. Which of the following is the major benefit of assigning patients in this manner?

A 53-year-old woman comes to the physician because of a 6-month history of increasingly severe abdominal discomfort. She is 170 cm (5 ft 7 in) tall and weighs 104 kg (230 lb); BMI is 36 kg/m2. Abdominal examination shows fullness and tenderness of the right lower quadrant that increases with coughing. A CT scan of the abdomen is shown; the arrow indicates an abnormality. Which of the following structures forms the medial border of this abnormality?

A 2-month-old boy is brought to the physician by his mother for a well-child examination. The mother tells the physician that her son has been gazing at her more directly. He also indicates delight with gestures when he sees her and shows signs of distress when he cannot see her. Which of the following best describes this patient’s recent behavior?

A 52-year-old woman with breast cancer comes to the physician for a follow-up examination. She had a 4-week course of radiation treatment 6 months ago. Her respirations are 26/min. Physical examination shows no recurrence of the cancer. ACT scan of the chest shows bilateral patches of atelectasis in the upper lung fields. The atelectasis in this patient most likely developed because of which of the following primary pathophysiologic processes?

A 1 -month-old male newborn is brought to the emergency department by his mother because of a 5-day history of vomiting after feedings. His mother says the vomiting is forceful, and appears to contain only formula. She says he seems eager to feed after each episode. He appears irritable. He is at the 25th percentile for length and weight. His temperature is 37.6°C (99.7°F), pulse is 140/min, respirations are 24/min, and blood pressure is 80/40 mm Hg. Physical examination shows decreased skin turgor. Which of the following sets of serum findings (in mEq/L) is most likely in this newborn at this time?

A 32-year-old man is being evaluated for increased jugular venous pressure, a systolic murmur, hepatomegaly, ascites, and 2+ pitting edema of the ankles. He is an intravenous drug user. Which of the following is the most likely diagnosis?

A 1-day-old male newborn has bilious vomiting and reluctance to feed. Physical examination shows dehydration and mild abdominal distention. Abdominal x-rays show a volvulus of the small bowel between the third and fourth segments of the duodenum. Which of the following blood vessels is most likely constricted by the volvulus in this patient?

A 33-year-old woman with HIV infection is brought to the emergency department 30 minutes after she had a generalized tonic-clonic seizure. She also has a 2-month history of daily headaches. Physical examination shows no signs of meningismus. Muscle strength is 3/5 in the left upper extremity and 5/5 in the right upper extremity. Her CD4+ T- lymphocyte count is 22/mm3 (N>500), and plasma HIV viral load is 50,000 copies/mL. A CT scan of the head shows a 3-cm lesion in the right cerebral cortex. Serologic studies show a positive IgG antibody titer to Toxoplasma gondii. Treatment with pyrimethamine and sulfadiazine is initiated. During the next 2 weeks, she has three additional seizures. Two weeks after starting antibiotic therapy, a CT scan of the head shows that the lesion has increased to 3.5 cm. Which of the following is the most likely cause of this mass?

A 67-year-old man is brought to the physician because of a 2-day history of double vision and drooping of his left eyelid. He has no history of trauma to the eye. His vital signs are within normal limits. Physical examination shows ptosis of the left eyelid. When the eyelid is raised manually, the eye is fixed in the out position and the pupil is dilated. The visual acuity of the left eye is within normal limits. Which of the following is the most likely cause of these findings?

A 49-year-old woman comes to the emergency department because of a 3-day history of fever, shortness of breath, and confusion. She is a postal worker. Her temperature is 38.4°C (101.2°F), respirations are 28/min, and blood pressure is 100/60 mm Hg. Physical examination shows nuchal rigidity. Breath sounds are decreased on the right side of the chest. A lumbar puncture is done. Analysis of cerebrospinal fluid (CSF) shows:

A Gram stain of CSF shows large, gram-positive, spore-forming bacilli. A chest x-ray shows marked widening of the mediastinum. Which of the following extracellular virulence factors most likely enables the causal organism to evade phagocytosis?