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Question 1 of 50
1. Question
A 58-year-old woman comes to the physician because of a 2-month history of intense pain on the right side of her body. She describes the pain as a constant, burning sensation of variable intensity. Over-the-counter medications have not resolved her pain. Six months ago, she sustained a cerebral infarction accompanied by loss of sensation over the right side. Neurologic examination shows loss of sensation to light touch and proprioception on the right side. Light touch of the skin elicits pain. No motor deficits were detected. The most likely cause of this patient’s condition is a lesion in which of the following labeled areas in the MRI of a normal brain?
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Question 2 of 50
2. Question
A 35-year-old man is admitted to the hospital because of confusion, indifference, and lethargy for 3 months. Ophthalmologic examination shows sluggish pupillary responses and horizontal nystagmus; neither eye moves past the midline on lateral gaze. A Romberg test is positive, and his gait is severely ataxic. He develops hemorrhaging from esophageal varices and dies 5 days later. The brain at autopsy is shown in the photograph. Which of the following is the most likely diagnosis?
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Question 3 of 50
3. Question
A 30-year-old woman is brought to the physician because of a 2-day history of double vision and deviation of the eyes. Her symptoms began 24 hours after a motor vehicle collision. Physical examination shows left ptosis, and the left eye has developed a “down and out” location. Which of the following is most likely to occur in this patient when light is shined into the right eye?
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Question 4 of 50
4. Question
A 57-year-old woman with hypertension and hyperlipidemia comes to the physician for a follow-up examination. She has smoked 1 pack of cigarettes daily for the past 40 years. When the physician asks the patient if she is interested in quitting smoking, she replies that she might like to quit sometime in the next 6 months, but she feels ambivalent about giving up her “crutch.” This patient is most likely at which of the following stages of change?
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Question 5 of 50
5. Question
A 9-year-old girl is brought to the physician because of a 6-day history of abnormal movements of the left side of her face and left arm. The movements are involuntary and present only when she is awake. In addition, she has developed spontaneous outbursts of crying. She has received all of the scheduled childhood immunizations. Her temperature is 37.7°C (99.9°F), pulse is 80/min, respirations are 17/min, and blood pressure is 100/70 mm Hg. Physical examination shows intermittent grimacing and tongue fasciculations. When asked to squeeze the physician’s fingers using her left hand, the pressure of the grip fluctuates continuously. A grade 2/6, systolic murmur is heard over the mitral focus. Neurologic examination shows abrupt, nonrhythmic, involuntary movements of the left upper extremity and hand. There is no sensory loss or involvement of the pyramidal tract. Which of the following is the most likely diagnosis?
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Question 6 of 50
6. Question
A 5-year-old boy with a 4-day history of perianal itching is diagnosed with pinworms. Albendazole treatment is initiated. Which of the following best describes the mechanism of action of this drug?
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Question 7 of 50
7. Question
A 27-year-old man comes to the physician because of a 2-month history of difficulty swallowing, and episodes of vomiting and substernal chest pain. He has had a 6.8-kg (15-lb) weight loss during this period. Use of over-the-counter antacids has not relieved his symptoms. He is 183 cm (6 ft) tall and weighs 73 kg (161 lb); BMI is 22 kg/m2. An upper GI barium swallow shows a dilated esophagus with constriction at the gastroesophageal junction. There is no peristalsis in the esophagus; however, there are peristaltic waves in the stomach and small intestine. The most likely cause of his condition is a lesion of which of the following structures that affect the lower esophagus?
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Question 8 of 50
8. Question
A 27-year-old man comes to the physician with his 25-year-old wife because of a 5-year history of inability to conceive. He has no history of major medical illness. Previous examination of his wife showed no abnormalities. Examination of the external male genitalia and testes shows soft lobulated masses bilaterally. Semen analysis shows a sperm count of 0.8 million/mL (N>20 million). Ultrasonography of the scrotum shows bilateral abnormalities that cause increased temperature within the scrotum. Which of the following additional findings is most likely in this patient?
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Question 9 of 50
9. Question
A 27-year-old woman comes to the office because of a 6-month history of progressive numbness and weakness that are more prominent in her legs than in her arms. Vital signs are within normal limits. Neurologic examination shows weakness of hand grasp and dorsiflexion and plantar flexion of the lower extremities. Sensation in all four extremities is diffusely diminished. To avoid motor dysfunction, the most appropriate next step in diagnosis is obtaining a biopsy specimen from which of the following peripheral nerves?
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Question 10 of 50
10. Question
A 31-year-old nulligravid woman comes to the physician because she and her husband have not been able to conceive for the past 3 years. Her husband has been evaluated, and no problems were found. She has an intact hypothalamic-pituitary-ovarian axis, and her serum estrogen concentration is within the reference range. Clomiphene therapy is started. Which of the following effects is most likely to occur in this patient?
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Question 11 of 50
11. Question
During a clinical study of the sickle cell allele, an investigator finds a frequency of 1/20 among African Americans and a frequency of 1/200 among Americans of Hispanic descent. Which of the following genetic mechanisms originally produced this stratification of allele frequency?
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Question 12 of 50
12. Question
A 14-year-old boy is brought to the office for a health maintenance examination. He tells the physician that he is concerned about a small lump that he noticed under his left breast 2 months ago. His vital signs are within normal limits. He is at the 50th percentile for height and 75th percentile for weight. Physical examination shows a 2.5-cm, mildly tender, rubbery mass under the left areola. His sexual maturity rating (SMR) is 2 for genital and pubic hair development. The remainder of the examination shows no other abnormalities. Which of the following is the most likely diagnosis?
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Question 13 of 50
13. Question
An investigator is studying the effects of carnitine depletion in an experimental mouse model. The mice are fed a carnitine-deficient diet, and it is hypothesized that this will result in hepatocytes undergoing either autophagy or apoptosis. Which of the following is the most appropriate marker to identify autophagic cells in this study?
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Question 14 of 50
14. Question
A 45-year-old man with HIV infection comes to the office because of a 6-week history of swelling near the left side of his neck. His most recent CD4+ T-lymphocyte count was 42/mm3 (N≥500), and plasma HIV viral load was 55,000 copies/mL. He currently takes no medications. His temperature is 38.0°C (100.4°F), pulse is 72/min, respirations are 12/min, and blood pressure is 120/81 mm Hg. Physical examination shows a left supraclavicular mass. Immunohistochemical staining of a biopsy specimen of the mass confirms the presence of the causal virus’s DNA and replication within lymphoma cells but not in nearby normal cells. Which of the following is the most likely explanation for the tumor formation?
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Question 15 of 50
15. Question
A 10-month-old girl develops a cough and grunting following a 3-day hospital stay for surgical repair of a cleft palate. Her temperature is 39.2°C (102.6°F), and respirations are 40/min. Crackles are heard over most lung fields, and breath sounds are decreased. There is a mild pleural rub in the right upper thorax. Her leukocyte count is 68,000/mm3 (85% segmented neutrophils, 10% bands, and less than 5% myeloblasts, promyelocytes, and myelocytes). Which of the following mechanisms most likely caused the increased leukocyte count in this patient?
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Question 16 of 50
16. Question
A 6-year-old boy is admitted to the hospital because of fever and cellulitis of his right hand. Examination of the hand shows a 2-cm, erythematous, macular lesion on the dorsum of the right hand. Intravenous treatment with nafcillin is begun. During the next 24 hours, he develops a temperature of 39°C (102.2°F). Blood cultures eventually grow methicillin-resistant Staphylococcus aureus. Production of which of the following most likely caused this organism’s resistance to methicillin?
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Question 17 of 50
17. Question
A 33-year-old man comes to the physician with his wife for a routine health maintenance examination. His medical records show that he has a 10-year history of alcoholism. The patient minimizes the amount and impact of his drinking and says, “I do not have a drinking problem.” However, further questioning suggests a continuing dependence on alcohol. Physical examination shows mild tremulousness, palmar erythema, and a palpable liver edge. Which of the following actions by the physician is most appropriate?
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Question 18 of 50
18. Question
An 85-year-old man develops fever, chills, and a cough productive of thick brownish sputum while in the hospital for treatment of a hip fracture. His temperature is 37.7°C (100°F). A chest x-ray shows bilateral infiltrates in the lower lobe. Serum studies show a creatinine concentration of 0.8 mg/dL. A sputum culture grows Pseudomonas aeruginosa. Combination drug treatment is initiated. Five days later, his serum creatinine concentration is 2 mg/dL. Which of the following drugs is the most likely cause of these laboratory findings?
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Question 19 of 50
19. Question
A 6-month-old boy is brought to the emergency department after being found unresponsive in his crib. He is successfully resuscitated. His serum glucose concentration is 20 mg/dL. Urine contains dicarboxylic acids; there are no ketones. The most likely cause of these symptoms is a defect in which of the following?
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Question 20 of 50
20. Question
A 48-year-old woman comes to the physician for a routine health maintenance examination. She says that she is beginning menopause because she has had irregular menstrual periods over the past year. She asks the physician if “the change of life” will make her irritable, depressed, and lose interest in sexual intercourse. Which of the following responses by the physician is most appropriate?
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Question 21 of 50
21. Question
An obese 45-year-old man comes to the physician because of a 3-week history of nausea, vomiting, abdominal cramps, and diarrhea. He has a 3-week history of flushing and shortness of breath. His temperature is 37.4°C (99.3°F), pulse is 74/min, respirations are 15/min, and blood pressure is 156/90 mm Hg. Bilateral wheezing is heard on auscultation. A grade 3/6 systolic cardiac murmur is heard. Physical examination shows hepatomegaly and a palpable midabdominal nontender mass. A CT scan of the abdomen shows a 3-cm midileal mass and hepatomegaly with a single 5-cm mass. The mass in the ileum is resected. Gross and microscopic appearances of the resected mass are shown. Which of the following is most likely secreted in measurable quantities from this patient’s lesion?
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Question 22 of 50
22. Question
A 25-year-old man is brought to the emergency department by his wife because of confusion for 8 hours. His wife says that he consumed an excessive amount of alcohol at a party the night before, but he does not use illicit drugs. She adds that he had not eaten anything for the preceding 24 hours. Physical examination shows no abnormalities, and neurologic examination shows no focal findings. He is not oriented to person, place, or time. His symptoms are relieved by intravenous administration of 50% glucose. This patient most likely had a limited glucose production because of which of the following changes in hepatic metabolism?
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Question 23 of 50
23. Question
A 55-year-old man comes to the physician because of a rash on his face and body 2 weeks after undergoing allogeneic hematopoietic cell transplantation for multiple myeloma. Physical examination shows a maculopapular rash over the cheeks, upper trunk, and palms. Histologic examination of a section of this patient’s affected skin is most likely to show basal keratinocytes undergoing which of the following processes?
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Question 24 of 50
24. Question
A 30-year-old woman, gravida 2, para 2, with epithelial ovarian cancer comes to the office to begin her first cycle of a planned six cycles of paclitaxel therapy. This treatment is designed to produce drug-induced arrest at which of the following cell cycle checkpoints?
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Question 25 of 50
25. Question
A 70-year-old man comes to the physician because of a 1-month history of heavy, pressing substernal chest pain that occurs when he walks up a flight of stairs. The symptoms are relieved by rest. The physician prescribes a drug to alleviate the symptoms. Within the cell, the drug acts by breaking down into a compound that binds to a protein to increase intracellular concentrations of cGMP, resulting in vasodilation. This binding most likely occurs in which of the following cell locations?
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Question 26 of 50
26. Question
A 30-year-old man comes to the physician for a routine health maintenance examination. Physical examination shows no abnormalities. Laboratory studies show an increased serum creatinine concentration. Renal ultrasonography shows multiple cysts involving both kidneys. Renal ultrasonography of the patient’s father shows cystic kidneys; his serum creatinine concentration is within the reference range. Similar examination of the patient’s mother showed no abnormalities. Which of the following genetic mechanisms best explains the findings in this family?
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Question 27 of 50
27. Question
A 70-year-old man is brought to the emergency department because of a 3-day history of fever and progressive shortness of breath. He also has a history of cough productive of yellow sputum that has recently become thick and green. He has smoked 1 to 2 packs of cigarettes daily for 40 years. His temperature is 40°C (104°F), and respirations are 22/min. Physical examination shows decreased breath sounds. A chest x-ray shows right lower lobe infiltrates surrounding a 3-cm, rounded lesion containing an air-fluid level. Which of the following immune cell activities most likely predominates in the center of this lesion?
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Question 28 of 50
28. Question
A pharmaceutical company develops a new oral medication (Drug X) for the treatment of type 2 diabetes mellitus. Study results have shown that the mechanism of action is mediated by blocking the ATP-dependent potassium channel on pancreatic β cells. Based on these findings, Drug X is most similar to which of the following?
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Question 29 of 50
29. Question
An investigator is conducting a study of the effects of alcohol consumption in young adults. A total of 250 participants between the ages of 21 and 25 years are recruited for the study. Blood alcohol concentrations are measured using a breathalyzer after repeated oral doses of pure (95%) ethanol. Results show that female participants become more intoxicated and have higher blood alcohol concentrations compared with male participants receiving an equivalent dose of ethanol. Which of the following characteristics of the female participants best explains these findings?
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Question 30 of 50
30. Question
A 35-year-old woman has had nervousness and insomnia for 2 weeks. She has asthma that has been successfully treated with a slow-release theophylline preparation for 4 months. Recent use of which of the following is the most likely cause of these symptoms?
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Question 31 of 50
31. Question
A 15-year-old girl with a 7-year history of asthma is brought to the physician for a follow-up examination. She has been taking oral prednisolone for 2 months for exacerbations of her condition. Her respirations are 28/min. Physical examination shows expiratory wheezing. Pulmonary function studies show decreased FEV1 and decreased FEV1 /FVC ratio. A leukotriene receptor antagonist is prescribed and the patient’s clinical condition improves. This drug blocks receptors that belong to which of the following types?
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Question 32 of 50
32. Question
A 52-year-old man who lives in Indiana comes to the physician because of a 1-month history of fever and nonproductive cough. He is a construction worker. His temperature is 38.4°C (101.1°F), pulse is 84/min, respirations are 14/min, and blood pressure is 110/70 mm Hg. Scattered crackles are heard over all lung fields. A chest x-ray shows bilateral interstitial infiltrates. A photomicrograph of a specimen obtained via transbronchial biopsy is shown. The most likely causal organism in this patient has a cell wall composed of which of the following?
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Question 33 of 50
33. Question
An investigator is studying a T-lymphocyte clone that recognizes a peptide from the hemagglutinin glycoprotein of influenza virus. In the context of human leukocyte antigen (HLA)-DR2, this clone most likely recognizes a peptide that was combined with HLA-DR2 in which of the following cellular compartments?
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Question 34 of 50
34. Question
An investigator is studying the effects of complement proteins on acute inflammation in an experimental mouse model. During the study, sections of skin are harvested before and after simultaneous dermal injection of Staphylococcus aureus and a single complement protein. The concentration of several biochemical mediators is measured before and after injection. Compared with baseline measurements, increased concentrations of histamine, leukotriene B4 , and serotonin are found after injection. Which of the following complement proteins was most likely injected during the experiment?
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Question 35 of 50
35. Question
A 62-year-old woman with a 25-year history of type 2 diabetes mellitus comes to the office for a follow-up examination. She is 165 cm (5 ft 5 in) tall and weighs 79 kg (175 lb); BMI is 29 kg/m2. Physical examination shows no other abnormalities. The physician recommends that she receive an influenza virus vaccine at this visit. Administration of this vaccine is most likely to produce protective antibodies against which of the following viral structural proteins?
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Question 36 of 50
36. Question
A 42-year-old man with end-stage renal disease undergoes transplantation with a kidney from a cadaveric donor. During the operation, following anastomosis of the renal vessels, the transplanted kidney becomes cyanotic and mottled. The kidney fails to excrete urine and is removed. Which of the following is the primary cause of nonfunction of the transplanted kidney?
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Question 37 of 50
37. Question
A 30-year-old man comes to the physician because of a 2-month history of episodes of headache, fever, and shaking chills since he returned from a 6-month trip to the Mayan ruins in southern Mexico. His temperature is 39°C (102.2°F). Physical examination shows no other abnormalities. A photomicrograph of a Wright-stained peripheral blood smear is shown. Which of the following vectors is the most likely source of infection in this patient?
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Question 38 of 50
38. Question
A 37-year-old woman has had fatigue and headaches for 1 month. Laboratory studies show a hemoglobin concentration of 9 g/dL, mean corpuscular volume of 82 μm3, platelet count of 75,000/mm3, and leukocyte count of 32,000/mm3, the majority of which are immature granulocytes. Prothrombin and partial thromboplastin times are prolonged. A peripheral blood smear is shown. Which of the following is the most likely diagnosis?
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Question 39 of 50
39. Question
A 65-year-old woman comes to the physician because of a 10-week history of low-grade fever, fatigue, and pain in her right arm. She recalls no trauma to the arm. She has a history of cancer treated with radiation therapy. Her temperature is 37.7°C (99.8°F). Physical examination shows tenderness of the right distal humerus. Laboratory studies show anemia. An x-ray of the right upper extremity is shown. This patient most likely has an abnormality of which of the following cell types?
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Question 40 of 50
40. Question
A 21-year-old college student comes to the physician because of a 3-month history of depressed mood and insomnia. During this period, her school performance has deteriorated, and she has not kept up with stamp collecting, a hobby she used to enjoy. Two years ago, she had a 1-month episode of euphoric mood during which she barely slept and had promiscuous encounters with strangers. Physical examination today shows no abnormalities. Mental status examination shows psychomotor retardation and suicidal ideation. Which of the following is the most likely diagnosis?
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Question 41 of 50
41. Question
An 8-year-old boy is brought to the physician by his mother because of a 6-month history of difficulty reading and impulsive behavior. His full-scale IQ is 103, and his reading and math achievement scores are 101 and 97, respectively. The Conners Rating Scales and Child Behavior Checklist show clinically significant levels of inattention, impulsivity, and hyperactivity. Mood disorder scales and results of a hearing loss test and a vision test are within the reference ranges. The most appropriate therapy for this patient is a drug that affects which of the following neurotransmitters?
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Question 42 of 50
42. Question
A 37-year-old man who is addicted to heroin begins methadone therapy. Which of the following pharmacologic approaches best describes this type of therapy?
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Question 43 of 50
43. Question
A 52-year-old man comes to the physician because of a 2-week history of clumsiness of his left foot when playing soccer. He also has a 2-month history of intermittent tingling in his left leg. Sensation to fine touch, vibration, and position is decreased in the left lower extremity. Muscle strength and deep tendon reflexes are normal throughout. An MRI of the spine is most likely to show a lesion compressing which of the following regions of the spinal cord?
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Question 44 of 50
44. Question
The figure shows the effects of drug X, administered intravenously, on heart rate, atrioventricular (AV) conduction velocity, and force of ventricular contraction. Drug X most likely has which of the following actions?
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Question 45 of 50
45. Question
Drug X is injected intravenously into three subjects (including one control subject). The control subject is not pretreated, whereas the other two subjects are pretreated with either prazosin or cocaine. Blood pressure is recorded directly from the brachial artery (see graph). Drug X is most likely which of the following?
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Question 46 of 50
46. Question
A 54-year-old man with severe hypertension suddenly collapses and loses consciousness while having an argument on the telephone. Physical examination shows pinpoint pupils and decorticate posturing. A CT scan of the head is most likely to show which of the following types of hemorrhage?
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Question 47 of 50
47. Question
A 62-year-old woman is brought to the emergency department 1 hour after she collapsed suddenly at home. A normal AP CT angiogram of a portion of the cerebral arterial circulation is shown; the arrow indicates the area of occlusion. Which of the following neurologic findings would be most likely in this patient?
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Question 48 of 50
48. Question
A 32-year-old man comes to a medical clinic in Santiago, Chile, because of a 6-week history of persistent pain and swelling of his right arm that began after he fell while hiking. Two months ago, he began an extended solo backpacking trip through a remote part of the Andes Mountains. He splinted the arm with a stick. His food supply has been limited to saltine crackers, peanut butter, and processed cheese spread. Today, an x-ray of the right upper extremity shows a poorly formed callus and nonunion of the fracture ends. This patient most likely has decreased function of which of the following proteins?
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Question 49 of 50
49. Question
A 41-year-old man has the acute onset of abdominal pain caused by a calculus at the right ureterovesical junction. The pain is most likely to radiate to which of the following locations on the right?
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Question 50 of 50
50. Question
A homeless 30-year-old man who is living in a shelter is brought to the emergency department because of a 2-day history of cough productive of bloody sputum. A chest x-ray shows a cavitary lesion in the right upper lobe and calcifications in the right hilum. An acid-fast smear of sputum is positive. Sputum is inoculated into mycobacterial culture media. Which of the following best represents the expected time before positive culture results will be available?
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