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Question 1 of 50
1. Question
A 29-year-old woman develops headache and shortness of breath 10 minutes after a transfusion of packed red blood cells is begun. Her temperature is 37.8°C (100°F), pulse is 100/min, respirations are 20/min, and blood pressure is 90/60 mm Hg. The transfusion is stopped immediately. Laboratory studies show free hemoglobin in urine and plasma. Which of the following erythrocyte blood group antigens is the most likely cause of this patient’s transfusion reaction?
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Question 2 of 50
2. Question
A 62-year-old man with ischemic heart disease is admitted to the hospital because of a 4-day history of increasingly severe chest pain. Physical examination shows no abnormalities. Angiography shows a blockage in the anterior interventricular (left anterior descending) artery. A stent is placed to relieve the obstruction. The stent contains paclitaxel. This drug works to decrease the incidence of restenosis through which of the following mechanisms of action?
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Question 3 of 50
3. Question
A newborn is delivered at 40 weeks’ gestation. Physical examination shows ambiguous genitalia and testes in the inguinal canals. Chromosomal analysis shows a 46,XY karyotype. Serum studies show increased testosterone and decreased dihydrotestosterone concentrations, suggesting a decreased activity of steroid 5α-reductase 2. Hypoplasia of which of the following structures is most likely in this patient?
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Question 4 of 50
4. Question
A 28-year-old woman comes to the physician because of intermittent severe headaches during the past 2 weeks. Her mother and maternal aunt were diagnosed with hypertension at the ages of 23 and 27 years, respectively. The patient’s blood pressure is 220/110 mm Hg in both upper extremities. Abdominal examination shows a periumbilical bruit. Angiography is most likely to show which of the following in this patient?
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Question 5 of 50
5. Question
A 25-year-old man comes to the physician because of a 6-month history of diarrhea, fatigue, and weight loss. Physical examination shows pallor. Laboratory studies show macrocytic anemia, hypercellular bone marrow, and erythrocyte precursors that are abnormally large. Which of the following is the most likely explanation for the hematologic findings in this patient?
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Question 6 of 50
6. Question
A 16-year-old boy is brought to the physician for drainage of his third liver abscess in 3 years. Cultures of fluid obtained from the two prior abscesses grew Staphylococcus aureus and Burkholderia cepacia, respectively. Culture of fluid obtained via needle aspiration of the current lesion grows Aspergillus species. Which of the following is the most likely diagnosis?
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Question 7 of 50
7. Question
A 24-year-old woman has increased range of motion in most of her joints. She is 183 cm (6 ft) tall and weighs 59 kg (130 lb); BMI is 18 kg/m2. Examination shows pectus excavatum. Auscultation of the chest discloses a new diastolic murmur. Which of the following is the most likely cause of the murmur?
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Question 8 of 50
8. Question
A 42-year-old woman with recurring episodes of hypoglycemia comes to the physician for a follow-up examination. She says that the episodes occur regardless of how much or how little she has eaten. The patient is on medical leave from her job as a licensed practical nurse. She recently underwent an exploratory laparotomy to confirm the diagnosis of insulinoma, but no abnormalities were found. She is 173 cm (5 ft 8 in) tall and weighs 55 kg (120 lb); BMI is 18 kg/m2. She appears mildly anxious. Her 2-hour postprandial serum glucose concentration is 70 mg/dL. Which of the following is the most likely diagnosis?
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Question 9 of 50
9. Question
A 35-year-old man has a sinus tachycardia of 120/min. Which of the following best describes the relationship of ventricular contraction and relaxation in this patient?
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Question 10 of 50
10. Question
A 58-year-old man with type 2 diabetes mellitus, a history of renal stones, dyslipidemia, and hypokalemia requires diuretic therapy for hypertension. Thiazide and loop diuretics differ most markedly in which of the following parameters of concern in this man?
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Question 11 of 50
11. Question
A 60-year-old woman is found to have osteoporosis. Her last menstrual period was 10 years ago. She has a history of deep venous thrombosis. The physician wishes to initiate treatment with a medication that will improve the patient’s bone density without increasing her risk for thrombosis or hot flashes. A drug from which of the following classes is most appropriate for this patient?
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Question 12 of 50
12. Question
A 48-year-old man comes to the physician because of an episode of fever, cough, chills, and shortness of breath 5 days ago that began several hours after he helped a friend bale and store hay on a farm. The symptoms resolved within 2 days, but he is concerned about what could have caused the incident. He takes no medications and does not smoke cigarettes. His temperature is 37°C (98.6°F), and respirations are 12/min. The lungs are clear to auscultation of the chest. Which of the following conditions is the most likely cause of this patient’s acute episode of respiratory symptoms?
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Question 13 of 50
13. Question
A 9-month-old boy is brought to the emergency department because of an upper respiratory tract infection and decreased appetite for 2 days and rapid breathing for 6 hours. He is at the 3rd percentile for length and weight. He appears acutely ill. Physical examination shows lethargy and dehydration. Laboratory studies show ketosis, metabolic acidosis, hypoglycemia, anemia, and methylmalonic aciduria. He improves following treatment with intravenous fluids and glucose. Direct sequencing of the patient’s leukocyte DNA fails to show mutations in the methylmalonyl-CoA mutase gene. In addition to dietary protein limitation, administration of which of the following is most appropriate for this patient?
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Question 14 of 50
14. Question
A 56-year-old man comes to the physician because of a 2-month history of cough productive of blood-tinged sputum. He has smoked 1 pack of cigarettes daily for 30 years. A CT scan of the chest shows a 4-cm mass in the right upper lobe that is obstructing the superior vena cava. Blood from this patient’s neck and right upper extremity is most likely returning to his heart through which of the following routes?
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Question 15 of 50
15. Question
A 30-year-old primigravid woman at 18 weeks’ gestation comes to the physician for a prenatal visit. Physical examination shows a uterus consistent in size with an 18-week gestation. Ultrasonography shows several intracranial anomalies, including a single ventricle, small cerebrum, fused thalami, and agenesis of the corpus callosum. These findings were most likely caused by the failure of which of the following structures to differentiate?
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Question 16 of 50
16. Question
A 63-year-old man with a long history of sun exposure develops the skin lesion shown. Which of the following is the most likely diagnosis?
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Question 17 of 50
17. Question
A 32-year-old man comes to the physician for a follow-up examination after he was diagnosed with HIV infection. His CD4+ T-lymphocyte count is 55/mm3 (N≥500) and plasma HIV viral load is greater than 100,000 copies/mL. Results of genotyping show that the patient’s viral strain is broadly resistant to protease inhibitors, non-nucleoside analogs, and nucleotide inhibitors. Which of the following drugs is most likely to be active against the HIV strain in this patient?
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Question 18 of 50
18. Question
A 76-year-old man comes to the emergency department because of a 3-day history of inability to urinate. History includes progressive difficulty urinating, especially initiating the stream, for the past year. Physical examination shows a markedly enlarged prostate and a large, tender suprapubic mass. Catheterization produces 2 L of urine. Ultrasonography shows large kidneys with dilated calyces. Serum studies show a urea nitrogen concentration of 40 mg/dL and a creatinine concentration of 3.6 mg/dL. Arterial Po2 is 90 mm Hg. Which of the following sets of additional arterial blood gas findings is most likely in this patient?
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Question 19 of 50
19. Question
A 22-year-old man is brought to the emergency department 30 minutes after having a generalized tonic-clonic seizure that began in his left leg. He has a 3-year history of intermittent arm stiffening in his left arm followed by spasms of his left thigh. He states that he thinks the episodes may be associated with intense workouts at the gym. He has no personal or family history of seizures. Physical examination shows no abnormalities. An MRI of the brain is most likely to show a lesion at which of the following locations?
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Question 20 of 50
20. Question
A 16-year-old boy who plays high school football comes to the physician because of a painful, pruritic rash on his groin and upper thigh. Physical examination shows a rash with red, scaling margins. Direct microscopic examination of a KOH preparation of a skin scraping shows fungal hyphae and arthrospores. Which of the following is the most likely causal agent?
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Question 21 of 50
21. Question
A 27-year-old woman is admitted to the hospital because of a 1-week history of lower abdominal pain that became more severe 2 days ago. She also has had fever, nausea, and vomiting. Her temperature is 38.4°C (101.2°F), pulse is 110/min, and blood pressure is 135/90 mm Hg. Abdominal examination shows tenderness in the right lower quadrant to light palpation and percussion. A CT scan of the abdomen with oral and intravenous contrast is obtained. Shortly after having the test, she develops audible wheezing in all lung fields and the rash shown in the photograph. Her pulse now is 120/min, and blood pressure is 90/65 mm Hg. Which of the following best describes the mechanism of this patient’s skin reaction?
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Question 22 of 50
22. Question
A 25-year-old nulligravid woman comes to the physician because of a 3-day history of vaginal discharge and suprapubic discomfort. She has not had fever, chills, nausea, or vomiting. She had two episodes of gonococcal cervicitis during the past year. She is sexually active with multiple partners. Her temperature is 37°C (98.6°F). Bimanual examination shows no cervical motion or adnexal tenderness. There is a yellow discharge from the cervical os. Cultures of the discharge are sent to the laboratory to test for Chlamydia trachomatis and Neisseria gonorrhoeae. Urinalysis shows trace WBCs. A urine pregnancy test result is negative. In addition to appropriate antibiotics, which of the following is the most appropriate action by the physician to preserve this patient’s fertility?
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Question 23 of 50
23. Question
A 48-year-old man with a 30-year history of type 1 diabetes mellitus comes to the physician because of the sudden onset of double vision. Ophthalmologic examination shows no abnormalities except for weakness of abduction of the left eye. Which of the following is the most likely cause of the development of double vision in this patient?
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Question 24 of 50
24. Question
A 35-year-old man with chronic hepatitis C comes to the physician because of a 2-week history of weakness and a rash on his legs. Physical examination shows 2+ edema and a purpuric rash over the lower extremities. His serum creatinine concentration is 2.9 mg/dL. Serum C3 and C4 concentrations are markedly decreased. Urinalysis shows numerous dysmorphic RBCs but no RBC casts. Which of the following is the most likely cause of these findings?
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Question 25 of 50
25. Question
A 53-year-old woman having an acute inferior myocardial infarction develops sinus bradycardia and hypotension. Administration of which of the following is the most appropriate next step to increase this patient’s heart rate?
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Question 26 of 50
26. Question
A 24-year-old woman comes to the physician because of a 3-day history of vaginal discharge with itching. She is currently being treated with ciprofloxacin for cystitis. Her vital signs are within normal limits. A photograph of the vaginal area is shown. Which of the following is the most likely causal organism?
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Question 27 of 50
27. Question
A 23-year-old woman comes to the physician because of a 1-month history of chronic sinusitis. She began treatment with broad-spectrum antibiotics 3 weeks ago, but her symptoms have persisted. Nasal endoscopy shows obstruction of the drainage of the left maxillary sinus. Cannulation of the sinus through its normal drainage route to the nasal cavity is scheduled. Which of the following is the most appropriate location for cannula placement in this patient?
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Question 28 of 50
28. Question
A 14-year-old boy is brought to the physician because of a 2-week history of progressively severe pain in his right leg just below the knee. An x-ray of the involved area shows a large, partly calcified mass that erodes the medullary canal of the tibia, infiltrates the cortex, and extends into the adjacent soft tissue. A biopsy of the lesion identifies primitive cells in a lace-like meshwork of bone with numerous mitoses. Which of the following is another common site of origin for this pathologic process?
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Question 29 of 50
29. Question
A 67-year-old man comes to the physician because of numbness in his hands and feet for 3 months. Vitamin B12 (cobalamin) deficiency is suspected. An increased serum concentration of which of the following is most likely to confirm the diagnosis?
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Question 30 of 50
30. Question
A 20-year-old woman (III-1) comes to the physician for cancer risk assessment. She has a family history of breast cancer in her maternal grandfather and maternal aunt. Previous genetic analysis of the aunt showed a mutation in the BRCA2 gene. The patient’s 45-year-old mother does not wish to undergo genetic testing. A pedigree is shown. Which of the following best represents the probability that this patient inherited the gene mutation in this family?
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Question 31 of 50
31. Question
A 28-year-old woman comes to the physician for advice on a weight loss plan. She is 163 cm (5 ft 4 in) tall and weighs 86 kg (190 lb); BMI is 33 kg/m2. Physical examination shows no other abnormalities. She has read an article on the Internet that outlines a balanced diet of 1500 kcal/day. She says, “It’s not as strict of a diet as some of my friends have tried. I think I can follow it for a long time.” At her current level of physical activity, she expends approximately 2500 kcal/day. Based on this information, this patient will most likely lose weight at which of the following rates?
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Question 32 of 50
32. Question
A 56-year-old woman comes to the physician because of shortness of breath over the past several months. She smokes 2 packs of cigarettes daily and is not interested in quitting. Respirations are 24/min. She is barrel-chested. Breath sounds are decreased over all lung fields, and pulmonary function testing shows an obstructive pattern. Oxygen saturation on room air is 91% at rest and 82% with exercise. After telling the patient that her lungs show signs of damage from tobacco, which of the following approaches by the physician is most appropriate in beginning to address advance directives with this patient?
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Question 33 of 50
33. Question
A 48-year-old woman comes to the physician for a routine health maintenance examination. Her husband of 20 years died 2 years ago. Her vital signs are within normal limits. Physical examination shows no abnormalities. During the examination, the patient mentions that she has begun dating again. It is most appropriate for the physician to counsel this patient about which of the following?
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Question 34 of 50
34. Question
A 44-year-old man comes to the physician because of a 2-month history of dry mouth, muscle weakness, constipation, inability to achieve an erection, and progressive fatigue. He has smoked 1 pack of cigarettes daily for 30 years. His temperature is 36.7°C (98°F), pulse is 70/min, respirations are 10/min, and blood pressure is 110/70 mm Hg. Neurologic examination shows weakness of the deltoids, biceps, iliopsoas, and quadriceps, and absence of all muscle stretch reflexes. Sensation to all modalities is normal. A chest x-ray shows a right lung mass. Laboratory studies show antibodies directed against the P/Q-type voltage-gated calcium channel. Which of the following mechanisms is the most likely cause of the neurologic findings in this patient?
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Question 35 of 50
35. Question
A 2-month-old male newborn is brought to the emergency department because of noisy and difficult breathing for 6 hours. Laryngoscopy shows multiple, slender, finger-like excrescences on both vocal cords. The newborn’s condition is most likely caused by maternal infection with which of the following during pregnancy?
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Question 36 of 50
36. Question
A 44-year-old man is brought to the emergency department 30 minutes after he fell off a ladder from a height of 10 feet. His pulse is 70/min, and blood pressure is 125/80 mm Hg. Physical examination shows multiple ecchymoses over the upper extremities and trunk. In response to the injury, activation of the endothelium of this patient’s blood vessels has most likely resulted in which of the following?
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Question 37 of 50
37. Question
During a study of primary human hepatocytes, it is found that these cells dedifferentiate when grown in culture and lose many of the synthetic and metabolic functions unique to in vivo hepatocytes. Coculturing the primary hepatocytes with biliary epithelial cells preserves many aspects of the differentiated state of the hepatocytes. Compared with hepatocytes grown alone, the cocultured hepatocytes most likely produce an increased amount of which of the following?
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Question 38 of 50
38. Question
A male newborn has multiple dysmorphic features suggestive of Down syndrome. Chromosomal analysis is ordered. Which of the following choices is most appropriate regarding what the parents should be told?
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Question 39 of 50
39. Question
A healthy 58-year-old man comes to the physician because of progressive hair loss during the past few years. He says that his father and grandfathers had a similar pattern of baldness. Examination of the scalp shows hair loss in an “M-” shaped pattern over the frontal hairline. Which of the following mechanisms best explains the hair loss in this patient?
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Question 40 of 50
40. Question
A 55-year-old man volunteers as a subject for a cardiac function study. Vital signs and a physical examination are obtained. Echocardiography shows thickening of muscle tissue of the left ventricle. Subsequent testing is most likely to show which of the following underlying conditions in this man?
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Question 41 of 50
41. Question
A 36-year-old man with sarcoidosis comes to the emergency department because of a 3-hour history of severe left flank pain radiating to his groin. He says the pain varies in intensity but never ceases completely. His temperature is 37.5°C (99.5°F), pulse is 100/min, respirations are 16/min, and blood pressure is 144/92 mm Hg. Physical examination shows left flank tenderness. Serum studies show a calcium concentration of 11.2 mg/dL. Urinalysis shows microscopic blood. Which of the following mechanisms is the most likely underlying cause of this patient’s condition?
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Question 42 of 50
42. Question
An investigator is studying a substance abuse problem among school-age children that involves taking large doses of over-the-counter cough medication containing dextromethorphan. The effects range from mild excitement with hallucinations to a sense of complete dissociation from the body. The investigator notes that this substance is an N-methyl-d-aspartate receptor antagonist. The psychological effects of this substance most closely resemble those of which of the following?
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Question 43 of 50
43. Question
A 40-year-old man has a history of cerebellar hemangioblastoma and retinal angiomas. Urinalysis shows microscopic blood. A CT scan of the abdomen shows a renal mass, and a nephrectomy is performed. The cut surface of the resected kidney is shown. Which of the following is the most likely diagnosis?
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Question 44 of 50
44. Question
A 65-year-old man is brought to the emergency department 30 minutes after the sudden onset of tearing chest pain that radiates to his back. He has smoked 1 pack of cigarettes daily for 40 years. His pulse is 115/min, and blood pressure is 170/110 mm Hg. Physical examination and a chest radiograph show no abnormalities. Contrast axial (left) and sagittal (right) CT scans of the chest and abdomen shown confirm thoracoabdominal dissection of the aorta; the arrows indicate the vessel perfused by the false lumen. Occlusion of this vessel will most likely result in compromised blood flow to which of the following organs?
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Question 45 of 50
45. Question
A 32-year-old woman comes to the physician because of intermittent chest pain that is “not severe but rather annoying.” Her mother died of sudden cardiac arrest at age 51 years. A midsystolic click is heard in the fifth intercostal space in the left midclavicular line. Which of the following cardiac abnormalities is most likely in this patient?
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Question 46 of 50
46. Question
A 38-year-old woman comes to the physician because she has not had a menstrual period for 3 months. She also has had increased facial and chest hair growth over the past 2 months. She is 170 cm (5 ft 7 in) tall and weighs 64 kg (141 lb); BMI is 22 kg/m2. Her pulse is 80/min, and blood pressure is 140/78 mm Hg. Physical examination shows hirsutism and vaginal atrophy. Her serum testosterone concentration is 400 ng/dL (N=15–60), and measurement of urine collection of 17-ketosteroids is 10 mg/24 h. Ultrasonography of the pelvis shows a normal-sized left ovary and a right ovarian mass. Which of the following is the most likely diagnosis?
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Question 47 of 50
47. Question
A 60-year-old man comes to the physician because of a 6-month history of increasing hoarseness. He has smoked 2 packs of cigarettes daily for 40 years. Laryngoscopic examination shows a mass consistent with a malignant neoplasm in the larynx, involving the right vestibular fold. This neoplasm is most likely to metastasize initially to which of the following groups of lymph nodes?
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Question 48 of 50
48. Question
A 49-year-old woman with poorly controlled hypertension comes to the emergency department because of a 2-day history of progressive shortness of breath. Current medications are amlodipine, clonidine, enalapril, hydrochlorothiazide, and metoprolol. She has not taken any of her medications for 5 days because she ran out and could not afford to refill her prescriptions. Her pulse is 98/min, respirations are 32/min, and blood pressure is 240/120 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 86%. Physical examination shows no significant ankle edema. Bilateral crackles are heard over all lung fields. Cardiac examination shows a loud S4 . A chest x-ray shows pulmonary edema. An ECG is shown. Which of the following is the most likely mechanism of this patient’s congestive heart failure?
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Question 49 of 50
49. Question
A 6-year-old boy is admitted to the hospital because of an 8-hour history of fever, headache, and nausea. Administration of intravenous (IV) fluids and empiric antibiotics is started pending culture results. A lumbar puncture is done, and a photomicrograph of a Gram stain of cerebrospinal fluid is shown. During the next 24 hours, he develops bleeding from his gums and from all IV puncture sites. He is intubated for respiratory failure, and norepinephrine is administered for blood pressure support. The most likely cause of this patient’s new symptoms is which of the following infection-related complications?
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Question 50 of 50
50. Question
A 43-year-old woman comes to the physician because of a 2-month history of intermittent abdominal pain. The pain occurs after fatty meals and is localized to the right upper quadrant. Ultrasonography of the abdomen shows cholelithiasis. The patient elects to begin a trial of ursodiol therapy before considering operative treatment. Which of the following is the primary mechanism of action of this medication?
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