Nbme 19 Block y6e6y

Exam Section 1: Item 1 of 50 • Mark

National Board of Medical I xaminers Comprehensive Basic Science Self-Assessment

lime Remaining: 1 hr 13 min 27 sec

1. A 30-year-old woma n is brought to the physician because of a 1-week history of visual difficulty She has a 3-year history ofllfuilliRie sClerosis Vital signs are within normal limits. When the examination room lights are off, both pupils are 6 mm in diameter; they are 4 mm in ambient lig ht. When light is shined in the left eye, both eyes constrict to 2 mm. When light is then shined quickly in the right eye, both eyes d ilate to 4 mm. Which of the following is the most likely location of the lesion in this patient?

0 A) B) C) D) E) • F)

Left Edinger-Westphal nucleus Left oculomotor nerve Left optic nerve Right Edinger-Westphal nucleus Right oculomotor nerve Right optic nerve



2. A case-control study examining the rela tionship of a risk factor and disease generated th e following data: Disease Present Absent Risk Factor Present Absent

50 50 100

30 70 100

80 120 200

Which of the following is the estimated odds ratio of the presence of the risk factor and development of disease?

A) B) C) D)

(50 (50 (50 (50

X X X

X

30) I (50 X 70) = 0 .4 50) I (30 X 70) = 1 .2 70) I (50 X 30) = 2 .3 50 X 30 X 70) I (1003) = 5.25

0 E) Cannot be determined





3. A 45-year-old patient with chronic alcohol dependence comes to the emergency department because of foul-smelling brownish sputum for the past 3 days. The patient has had several episodes of unconsciousness following bouts of heavy drinking over the past month. Which of the following X-rays of the chest shown most likely represents this patient?

A

B

A

8

c

D

0 A)

0 B)

C)

D)




4. During an experiment, an isolated skeletal muscle is placed in a bath with a high concentra tion of glucose for 2 hours. The muscle is then contracted with electrical stimulation. An intracell ular decrease in which of the following most likely indicates the onset of muscle fatigue? A) B) C) D) E)

ADP Inorganic phosphate Inosine monophosphate Lactate pH




5. A premenopausal 49-year-o ld woman asks her physician about her risk for osteoporosis. Her mother had osteoporosis and disabling bone fractures after menopause. The patient works as a gardener for a landscape service and plays tennis 3 times a week. She does not smoke, drinks 1 glass of wine a week, and takes no medications. Her weight is 55 kg (121 lb). Which of the following additional information is needed to evaluate her risk for osteoporosis? 0 A) B) C) D) E) F)

Age at first sexual intercourse Dietary history Exposure to ionizing radiation Exposure to organophosphate Family history of rheumatic diseases Socioeconomic history




6. A 26-year-old woman comes to th e physician because of pain and stiffness of the fingers of both hands for 3 months. Physical examination shows swelling and red ness of the proximal interphalangeal ts of the affected fingers. X-rays of both hands show t space narrowing and marginal erosions of the proximal interphalangeal ts; the distal interphalangeal ts are spared. If a biopsy specimen of ti ssue from the affected j oint were taken, it wou ld most likely show which of the following? 0 A) B) C) D) E)

Necrotizing granulomas Neutrophilic infiltrates Pigmented villonodular synovitis Synovial pannus formation Urate crystals



7. A 24-year-old man is evaluated because of sharp left-sided chest pain and dyspnea tha t occurred suddenly 4 hours ago. An x-ray of the chest is shown. Which of the following is the most likely cause of the x-ray find ings?

A) Bronchoconstriction B) Diaphragmatic paralysis C) Loss of negative intrapleural pressure D) Mucus obstruction of the left main bronchus E) Respiratory muscle fatigue


(])




8. A healthy 23-year-old woman engages in strenuous aerobic exercise for 30 minutes. Which of the following best describes the total cross-sectional area of the pulmonary microcirculation in this woman during exercise? A) B) C) D) E)

Decreased, as a result of increased carbon dioxide levels in blood Decreased, in proportion to the increased resistance Increased, as a result of distention and recruitment of microvessels Increased, as a result of myogenic reflexes Unchanged

Exam Section 1: Item 9 of 50

• Mark


lime Remaining: 59 min 3 sec

9. A 48-year-old man is itted to the hospital for treatment of idiopathic pulmonary hypertension. The patien t has experienced progressive dyspnea over the past 6 months. Cardiac catheterization shows a decrease in cardiac function. The most likely cause of t'he decreased cardiac function is an increase in which of the following? A) B) C) D)

Left ventricular preload Right ventricular preload Left ventricular afterload Right ventricular aftertoad




10. A 19-year-old woman has her first prenatal visit. She feels well but has experienced some spotting. She is at 10 weeks' gestation by dates. Her uterus is enlarged to the level of the umbilicus. Quantitative serum ~-human chorionic gonadotropin concentration i s 350,000 miU/mL. Which of the following is the most likely diagnosis? A) B) C) D)

Ectopic pregnancy Fetal demise Hydatidiform mole Normal pregnancy


• Mark


11 . A 13-year-old girl grew 7.5 em (3 in) over the summer. Which of the following most likely s for increased intestinal absorption of calcium during this period? 0 A) B) 0 C) D) E)

Calcitonin-mediated hypercalcemia Calcium-binding proteins in goblet cells Cortisol-induced transcription of calcium transport ers Cyclic AMP generated in the enterocytes in response to parathyroid hormone Hormones derived from 7-dehydrocholesterol



• Mark



12. An 80-year-old woman has had progressive shortness of breath and fatigue during the past 6 months. A diagnosis of severe aortic stenosis is made, and she undergoes an aortic valve replacement. After the operation, dicumarol is istered, resulting in !Prolongation of the prothrombin time. The beneficial effect of this drug most likely results from which of the following mechanisms?

0 A) B) C) D) E)

Activates antithrombin Il l Induces fibrinolysis Induces a vitamin K deficiency-like state Inhibits platelet thromboxane A 2 production Inhibits protein C production


• Mark



13. A 24-year-old woman has severe vomiting, flush ing, and a headache after drinking a glass of wine. She is taking an antimicrobial drug for Trichomonas vagina/is infection. Which of the following is the most likely antimicrobial drug?

A) Clindamycin B) Ketoconazole C) Mebendazole D) Metronidazole E) Tetracycline




14. A 52-year-old man is brought to the emergency department because of a 4-hour history of a severe headache, anxiety, sweating, and palpitations. He has a 2-year history of hypertension well controlled with clonidine and hydrochlorothiazide, but he ran out of his prescriptions 3 days ago. His pulse is 120/min, and blood pressure is 1701110 mm Hg. Physical examination shows diaphoresis. Which of the following effects is most likely to follow an injection of propranolol in this patient? 0 A) B) C) D) E)

Decreased total peripheral resistance and decreased cardiac output Decreased total peripheral resistance and increased cardiac output Increased total peripheral resistance and decreased cardiac output Increased total peripheral resistance and increased cardiac output No change in total peripheral resistance or cardiac output




15. A 43-year-old woman has a 3-day history of black tarry stools. She has been taking aspirin for 1 week for a sprained ankle. At which of the following labeled steps in the diagram shown is protection of gastric mucosa most likely inhibited in this woman? Ce11 membrane phospholipids

!A

Arachidonic acid

!e !c

Prostaglandin G2

Prostaglandin H2

D Thromboxane

Prostacyclin

Prostag land in 0 2

Prostaglandin F2

Prostag Iandin E2

0 A)

0 B)

0 C)

D)

(.) E)




16. A previously healthy 25-year-old man is brought to the emergency department because of severe pain on the left side of his chest after falling from a ladder. The pain is sharp and stabbing and becomes more intense when the patient coughs or takes a deep breath. An x-ray of the chest shows fractures of four consecutive ribs on the left. There is no pneumothorax. Which of the following patterns represents the most likely changes in respiratory status caused by his injury? A) B)

C)

D) E) F)

G)

Respiratory Rate

Tidal Volume

Airway Resistance (1 sec)

1 •r •I

,_,

l l

I

. r

I

I

.'

+-+ +-+

1 +-+

1


• Mark



17. An investiga tor studying spermatogenesis introduces a chemical that disrupts tight junctions between adjacent cells into the testes of experimental animals. The animals later develop an autoimmune response to products of germ cell division that have entered the circulation. Tight junctions have been disrupted between which of the following cells in these animals?

El A) B) C) D) E)

Capillary endothelium Early spermatids Fibroblasts Leydig Sertoli


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lime Remaining:

18. A 19-year-old man is brought to the emergency department after being stabbed in the abdomen during a fight. He adamantly denies starting the fight and intends to "get even" at his fi rst opportunity. He has been incarcerated for the past 3 years for committing an armed robbery but says that he was "set up. " Which of the following is 1he most likely d iagnosis? Antisocial personality disorder Avoida nt personality disorder Bipolar disorder, manic Borderline personality disorder Conduct disorder Dependent personality disorder Narcissistic personality disorder H) Paranoid personality disorder I) Schizoid personality disorder

0 A) B) C) D) • E) F) G)




19. The graph shows the rate of breakdown of skeletal muscle glycogen by phosphorylase in the presence and absence of AMP. Based on the data, which of the following best describes the action of AMP?

A) Allosteric activator B) Allosteric inhibitor C) Catabolite activator D) Catabolite repressor E) Covalent modifier of the enzyme F) Covalent modifier of phosphorylase kinase

No ttftctor

(S)


• Mark

National Board of Medical I xarniners Comprehensive Basic Science Self-Assessment

I irne Remaining: 38 min 48 sec

20. A 23-year-old woma n who is 6 months pregnan t develops deep venous thrombosis. Intravenous istration of heparin is started. Seven days later, platelet cou nt is 44,000/mm 3. Whic h of the following is most likely responsible for the decreased platelet cou nt in this patient? A) B) C) D) E)

Antimegakaryocyte antibodies Antiplatelet antibodies Heparin-induced hemodilution Hypersplenism Stem cell antibodies


• Mark



21. A 25-yea r-old woman requests prenatal diagnosis at 12 weeks' gestation because her sister recently de~ivered an infa nt with Down syndrome. The woman's karyotype is 45,XX,t(14q21 q). Which of the following prenatal tests is most appropriate?

EJ A) B) C) D) E)

Amniotic fluid phospholipid analysis Chorionic villi sampling Fetal biopsy Fetal echocardiogram Fetal ultrasonography



lime Remaining:

22. A 65-year-old man with prostate cancer comes to the physician because of a 2-week history of severe fa tigue and bone pain. Metastasis to bone is suspected. The physician recommends symptomatic relief via androgen ablation therapy using intramuscular depot leuprolide monthly and daily oral flutamide. Which of the following is the most likely rationale for using these drugs together in this patient? 0 A) B) C) D) E)

Flutamide and leuprolide both directly stimulate estrogen synthesis Flutamide antagonizes photosensitivity associated with the use of leuprolide Flutamide blocks the initial androgenic action of leuprolide Flutamide specifically in1erferes with plasma protein binding of leuprolide, increasing the free drug concentrations The need for radiation therapy is eliminated when this combination of drugs is used




23. A 35-year-old man with HIV infection comes to the physic ian for a routine examination. He has been receiving highly active antiretroviral therapy for 2 years. Physica l examination shows th in extremities, wid e abdominal girth, and a buffalo hump on the upper back. Laboratory studies show: CD4+ T-lymphocyte count Plasma HIV viral load Serum Glucose Total cholesterol Triglycerides

43/mm3 ( N~500) 1190 copieslml 110 mg/dl 225 mg/dl 260 mg/dl

Results of a glucose tolerance test are abnormal. A drug from which of the following classes is the most likely cause of these laboratory findings? A) B) C) D) E)

Fusion inhibitor Non-nucleoside reverse transcriptase inhibitor Nucleoside reverse transcriptase inhibitor Nucleotide reverse transcriptase inhibitor Protease inhibitor



24. A 44-year-old man has the following findings on pulmonary fu nction testing: Functional residual capaci1y (L) Residual volume (L) Total lung capacity (L) Forced expiratory volume in 1 sec (FEY 1) (L) F EY { forced vital capac ity Forced expiratory now (25-75%)(FEF 2s.75.,J (L)

Predicted 3.2

Patient Values 4.0

1.5

3.0

5.9

6.8 2.0

3.5 75% 4.4

53% 1.2

This pattern of pulmonary function represents which of the following? A) B) C) D)

Normal pulmonary function Obstructive and restrictive pulmonary diseases Obstructive pulmonary disease only Restrictive pulmonary disease only



• Mark



25. A 74-year-old man comes to the physician for a routine follow-up examination. He had a myocardial infarction 5 years ago and has been receiving thyroid-replacement therapy for 25 years for hypothyroidism. His blood pressure has been normal at previous visits. His blood pressure today is 200/115 mm Hg Physical examination shows a continuous systolic/diastolic bruit over the right posterior Hank. Laboratory studies show no abnormalities. Which of the following is the most likely diagnosis? 0 A) B) C) D) E)

Abdominal aortic aneurysm Pheochromocytoma Renal artery stenosis Renal failure Thyrotoxicosis




26. A 56-year-old man is brought to the hospital because of lethargy for the past month. He is not taking any medications. He does not have postural hypotension or edema. Laboratory studies show: Serum

Na• Creatinine Thyroxine (T J Cortisol (AM) Plasma osmolality Urine osmolality Urine Na• T hese findings are most likely associated with which of the following neoplasms? A) B) C) 0 D) E)

Adrenocortical carcinoma Renal cell carcinoma Small cell carcinoma of the lung Tra nsitional cell carcinoma of the bladder Villous adenoma of the colon

125 mEqJL 1 mg/dL 10 ~g/dL 20 ~g/dL 275 mOsmoVkg 450 mOsmoVkg 30 mEq/L


• Mark



27. A 43-year-old man is brought to the emergency department because of severe hip pain after a fall. He has a 15-year history of severe rheumatoid arthritis. X-ray of the hip shows a fracture and marked osteopenia. Which of the following drugs is most likely responsible for these find ings? A) B) C) D) E) F) G)

Acetaminophen Aspirin Azathioprine Gold-containing compounds Methotrexate Penicillamine Prednisone


National Board of Medical Examiners Comprehensive Basic Science Self-Assessment

Time Remaining: 24 min 2 sec

28. A 52-year-old man is brought to the emergency department 30 minutes after the sudden onset of substernal chest pain The pain has persisted despite self-istration of three doses of sublingual nitroglycerin His pulse is 90/min, and blood pressure is 114/70 mm Hg. Physical examination shows diaphoresis The lungs are cl ear to auscultation. Cardiac examination shows an S 4 An ECG shows ST-segment elevation in the inferior leads. Intravenous morph ine is istered, and he devel ops generalized pruritus and warmth 1 minute later. His pulse now is 120/min, and blood pressure is 90/50 mm Hg Physical examination shows facial flushing Which of the following substances is the most likely cause of the new symptoms and findings in this patient?

0 0 0 0 0

A) B) C) D) E)

Epinephrine Histamine Nitric oxide Serotonin Throm boxane A 2


• Mark



29. An investiga tor does an experimen t in which the third pharyngeal pouches are prevented from forming in a mouse embryo. As a result, whic h of the following organs will fail to develop?

A) Lungs B) C) D) E)

Salivary glands Thymus Thyroid gland Tonsils




30. During an experiment, a researc her blocks th e production of microtubule-associated (MAP-1 C) ATPase (dynein) in the neuronal cell body. This is most likely to cause a reduction of which of the following neuronal processes? A) B) C) D) E)

Fast anterograde axonal transport Neurotransmitter reuptake Retrograde axonal transport Slow anterograde axonal transport Vesicle release


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31. A 65-year-old man has low back pain. X-rays show multiple osteoblastic lesions within vertebrae. The most likely laboratory fi nding is increased serum concentration of which of the following? A) B) C) D) E)

Ery1hropoietin a-Fetoprotein Monoclonal immunoglobulin Parathyroid hormone Prostate-specific antigen


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32. Skin from a male mouse is grafted onto the back of a female mouse. Within 2 weeks , this graft becomes necrotic and must be removed. Which of the following cells is most likely responsible for graft rejecti on? A) B) C) D) E)

B lymphocytes Eosinophils Macrophages Neutrophils T lymphocytes




33. In a study to assess whether neck irradiation is a risk factor for thyroid cancer, the researchers identify a group of patients with thyroid cancer and a similar group of patients without thyroid cancer. History of prior neck irrad iation is obtained from each group based on stric t criteria for exposure. This type of study is best described as which of the following? A) B) C) D) E)

Case-control Case series Cohort Cross-sectional Randomized clinical tria l


• Mark



34. A newborn is delivered at term to a 40-year-old primigravid woman. Chorionic villus sampling at 15 weeks' gestation was done, and results of chromosomal analysis showed a male fetus. Physical examination shows female external genitalia and absent internal genitalia. Further tests are most likely to determine that this child has a mutation preventing responses to which of the following hormones?

0 A) B) C) D) E)

Estrogen Follicle-stimulating hormone Luteinizing hormone MOIIerian-inhibiting hormone Testosterone


• Mark



35. A 45-year-old man receives a diagnosis of major depressive disorder. Fluoxetine therapy is initiated. Th is patient is at increased risk for serotonin syndrome with use of which of the following substances found in food and drugs? A) B) C) D) E)

Leucovorin Methionine Niacin Tryptophan Vitamin B 1 (thiamine)



• Mark


36. A 33-year-old woman has had weakness of the right lower two thirds of the face for the past 2 months. Which of the following labeled regions in the normal brain shown is the most likely site of the lesion causing this symptom?

Central sulcus

A}

() B)

0 C)

0 D)

0 E)

0 F)

0 G)

(.) H)

0 I}

0 J}



• Mark

5'


3'

mRNA

~ =tRNA 37. A schematic representation of eukaryotic translation is shown in the diagram. Only a portion of the mRNA is shown, and each separately colored segment represents a sense codon. Which of the following processes is the most likely next step in this reaction? 0 0 0 0 0

A) B) C) D) E)

Binding of aminoacyl-tRNA to the A site Hyd rolysis of the peptide cha in from the P site Interaction of eiF-4e with the A site Peptidyl transfer to the E site Translocation of the peptidyl-tRNA from the P site to the A site




In

0 t<- ---·-'I.-

Airflow

Out Phrenic nerve activity

-

Abdomnal

pressure 0

~-==~--==========-

Tim e 38. A study is conducted to determine the effects of drug X on respiratory function. The respiratory tracing of an experimental animal is shown. Drug X was inistered at the arrow. Drug X is most likely which of the following? 0 0 0 0 0 0

A) B) C) D) E) F)

lidocaine Morphine sulfate Pentobarbital Potassium chloride Tetrodotoxin Tubocurarine


• Mark



39. O ne year ago, a 15-year-old girl received a bone marrow transplant following a relapse of acute myelogenous leukemia. She now has a karyotype of 46,XY. The resu lts of the karyotyping are most likely due to which of the following? A) B) C) D) E)

Male pseudohermaphroditism Nonautologous donor Relapse of acute myelogenous leukemia Total body irradiation-induced aberration Underlying myelodysplasia


• Mark



40. A 25-year-old woman with AIDS is itted to the in1ensive care unit for treatment of sepsis caused by Cryptococcus neoformans. Appropriate treatment includes istration of which of the following drugs? A) B) C) D) E)

Amphotericin B Ketoconazole Pentamidine Saquinavir Zidovudine (AZT)


• Mark



41. A 45-year-old man is brought to the emergency department after being lost outdoors in the Roc ky Mountains for 10 days. He has had a 5-kg (11-lb) weight loss during this period. His serum glucose concentration is 92 mg/dl . A serum glucose concentration within the reference range was most likely maintained in this patient via glucose synthesis in the liver and in which of the following organs?

0 A) B) C) D) E) F)

Adrenal glands Kidney Large intestine Pancreas Small intestine Spleen




42. A 41-year-old woman at 34 weeks' gestation undergoes an amniocentesis because of uncontrolled hypertension. Amniotic fluid shows a decreased lecithin-to-sphingomyelin ratio of 1 .5:1 (N=3:1 ). If the newborn is born at this ti me, which of the following pulmonary findings is most likely to develop in the newborn during the first 48 hours after delivery? A) B) C) D) E)

Decreased airway resistance Decreased functional residual capacity Decreased respiratory rate Increased static lung com pliance Increased total lung capacity


• Mark



43. A previously healthy 27-year-old man comes to the physician because he has had a cough productive of blood-tinged sputum for 4 days. His blood pressure is 160/100 mm Hg. His serum creatinine concentration is 4.8 mg/dl . Urinalysis shows erythrocyte cast s. Immunofluorescence microscopy of a renal biopsy specimen shows linear deposits of lgG in the glomeruli. Whic h of the following histologic abnormalities in the glomerulus is most likely?

0 A) B) C) D) E) F)

Crescent formation Focal segmental change Global sclerosis Membranoproliferative changes Minimal change Nodular glomerulosclerosis




44. A 30-year-old man and a 24-year-old woman (indicated by the arrows) request preconceptional counseling because the man's brother has type I oculocutaneous albinism. This is an autosomal recessive, single gene disorder thought to occur about once in every 40,000 persons in the general population. Assume that the alleles are in equilibrium in the population, that the woman's family history is negative for this disorder, and that the two probands have neither shared relatives nor common ethnicity. A pedigree is shown. Which of the following is the best estimate that their child will be affected with oculocutaneous albinism? A ) 1 in 4 B) 1 in 100 C) 1 in 200 D) 1 in 600 E) 1 in 40,000

?


National Board of Medical I xarniners Comprehensive Basic Science Self-Assessment

Please Wall

45. A 40-year-old man comes to the physician because of a 1-month history of increasing malaise, nausea, and abdominal pain and a 1-week history of light-colored stools. Abdominal examination shows tenderness of the right upper quadrant. Laboratory studies show: Leukocyte count Serum Bilirubin, total Alkaline phosphatase AST ALT Serology Hepatitis Be antigen (HBeAg) Hepatitis B su rface antigen (HBsAg) Hepatitis B virus-DNA

10,000/mmJ 4 mg/dL 180 U/L 1500 U/L 1700 U/L positive positive positive

lgG anti-HBsAg

negative

lgM anti-hepatitis A virus lgM anti-hepatitis B core antigen lgM anti-HBeAg

negative positive negative

Further observation shows that CD8+ T lymphocytes bind to antigens, resulting in liver injury. These antigens are most likely to occur in which of the following locations? A) B) C) D) E)

Bile duct epithelium Hepatocytes Ito cells Kupffer cells Stellate cells


X


46. A 76-year-old man is brought to the emergency department by his brother 30 minutes after the onset of severe substernal chest pain that began while they w ere having an argument. istration of three sublingual nitroglycerin tablets has not relieved the pain. He has a 5-year history of ischemic heart disease. His pulse is 110/min, respirations are 20/ min, and blood pressure is 120/80 mm Hg . Cardiac examination shows an S 1 and S 2 w ithout murmurs, gallops, or rubs. An ECG shows ST-segment elevations in leads I, aVL, and V 4 through V 6. Which of the following best describes the role of the argument in the development of this patient's chest pain?

LABORATORY VALUES ~I nc luded

in the Biochemical Profile (SMA-12)

BL OOD, PLASMA, SERUM

REFERENCE RANGE

SI REFERENCE INTERVAL S

!Alanine aminotransferase (ALT, GPT at 30 C)

8· 20 U/L

8· 20 U/L

!Amylase, serum

?5·12.5 U/L

?5·12.5 U/L

!Aspartate aminotransferase (AST, GOT at 30 C) 8· 20 U/L

8· 20 U/L

Bilirubin, serum (adult) Total // Direct

0.1-1.0 mg/dl II 0.0· 0.3 mg/dl

?.17 ~moVL // 0· 5 ~moVL

Calc ium, serum ( ca2"")

8.4·10.2 mg/dl

?.1 ·2.8 mmoVL

Cholesterol, seru:m

Rec :<200 mg/dl

<5.2 mmoVL

Cortisol, serum

~ h: 5· 23 ~g/dl

138·6:35 nmov L

A) Coronary vasosJPasm due to a 1-adrenergic stimulation

1600 h: 3·15 ~g/dl

82· 41 3 nmoVL

B) Coronary vasosJPasm due to 13 1-adrenergic stimulation C) Decreased preload for the left ventricle due to a 1-adrenergic stimulation D) Increased afterload for the left ventricle due to 13 1-adrenergic stimulation E) Negative chronotropic effect of a 1-adrenergic stimulation

2000 h: < 50% o f 0800 h

Frac tton of 0800 h: < 0.50

Male: 25· 90 U/L

j25· 90 U/L

Female: 10· 70 U/L

10· 70 U/L

0.6·1.2 mg/dl

53·106 ~moVL

Sodium (Na•)

136-1·45 mEq/L

136-145 mmoVL

Chloride (Cr)

95·10.5 mEq/L

~5·1 0.5 mmoVL

Potassium (K+-)

3.5· 5.0 mEq/L

3.5· 5.0 mmoVL

Bicarbonate (H C03')

~· 28 mEq,IL

!22·28 mmolfl

Magnesium (Mg2+)

1.5-2.0 mEq/L

F) Positive inotropic effect of ~ 7adrenerg i c stimulation

Creatine kinase, :serum

Creatinine, serum Electrolytes, serum

1.5-2.0 mmoVL

Estriol, total, serum (in pregnancy)

24· 28 wks 11 32· 36 wks

30·170 ng/ml // 60· 280 ng/ml

....

1, ____

.. ..

. .. ... -.

104· 590 // 208· 970 nmoVL 1, , ____ , _,_ · - · -



47. A 39-year-old man who is a police officer comes to the physician with his wife because of a 6-month history of headache, muscle aches, and fatigue. He has a 1-month history of intermittent crampy epigastric pain, w hich he attributes to work stress. He has become increasingly irritable and distractible while instructing people at the firing range and was asked to t ake a leave of absence 1 week ago. His wife notes that he has also been uncharacteristically irritable and forgetful at home. Vital signs are normal. Neurologic examination shows bilateral distal motor weakness of the extremities and moderate impairment of concentration. Recent and remote memory functions are intact. Laboratory studies show : Hemoglobin Hematocrit Mean corpuscular hemoglobin concentration Mean corpuscular volume Leukocyte count A peripheral blood smear is most likely to show which of the following? A) B) C) D) E) F) G)

Auer rods Basophilic stippling Oval macrocytes Pleomorphic lymphocytes Ringed sideroblasts Schistocytes Target cells

11 g/dL 36% 31% Hb/cell 78 J.1m3 9300/mm3




48. The following blood gas values are measured in a resting patient Arterial Po 2 Arterial Pco, Arterial 0 2 content Mixed venous Po 2 Mixed venous 0 2 content

96 mm Hg 40 mm Hg 12.0 vol% (N=20) 36 mm Hg (N=40) 8.0 vol% (N=15)

These values are most consistent with which of the following? I!J A) B) C) D) 0 E)

Anemia Drug-induced alveolar hypoventilation Residence at high altitude Severe regional mismatching of alveolar ventilation and pulmonary capillary perfusion Voluntary hyperventilation

...i.!l! J 't,JI x . ~~ \V >oL>,:,o ;~_,;.ll&- ->'-"~>'

0000


X


49. A previously healthy 20-month-old girl dev·elops temperatures to 38.3°C (101 °F) and symptoms of an upper respiratory infection. Over the next few days, her condition worsens and she is brought to the emergency departm ent because of dyspnea and cyanosis. Crackl es are heard on auscultation of the chest. An x-ray of the chest show s cardiac enlargemen t. Hemoglobin, hematocrit, and peripheral leukocyte count are within the reference ranges. She goes into cardiac arrest the day after ission and dies in spite of aggressive resuscitation efforts. The predominant find ing at autopsy is a diffuse lymphocytic infiltrate in the myocardium without evidence of inclusion bodies or microorganisms. Which of the fo llowing viruses was the most likely cause of her illness? A) Coxsackievirus B) Cytomegalovirus C) Epstein-Barr virus D) Herpes simplex virus E) Measles virus

LABORATORY VALUES ~I nc luded

in the Biochemical Profile (SMA-12)

BL OOD, PLASMA, SERUM

REFERENCE RANGE

SI REFERENCE INTERVAL S

JAianine aminotransferase (ALT, GPT at 30 C)

8· 20 U/L

8· 20 U/L

jAmylase, serum

?5·12.5 U/L

?5·12.5 U/L

JAspartate aminotransferase (AST, GOT at 30 C ) 8· 20 U/L

8· 20 U/L

Bilirubin, serum (adult) Total // Direct

~.1-1.0 mg/dl II 0.0· 0.3 mg/dl

?.17 ~moVL // 0· 5 ~moVL

Calc ium, serum ( ca2"")

8.4·10.2 mg/dl

?.1·2.8 mmoVL

Cholesterol, seru:m

Rec :<200 mg/dl

<5.2 mmoVL

Cortisol, serum

Psoo h: 5· 23 ~g/dl

138·6:35 nmov L

1600 h: 3·15 ~g/dl

82· 41 3 nmoVL

2000 h: < 50% o f 0800 h

Fractton of 0800 h: < 0.50

Male: 25· 90 U/L

j25· 90 U/L

Female: 10· 70 U/L

10· 70 U/L

~.6·1 .2 mg/dl

53·106 ~moVL

Sodium (Na• )

136-1·45 mEq/L

136-145 mmoVL

Chloride (Cr)

95·10.5 mEq/L

j95·10.5 mmoVL

Potassium (K+-)

3.5· 5.0 mEq/L

3.5· 5.0 mmoVL

Bicarbonate (H C03')

~· 28 mEq,IL

!22·28 mmolfl

Magnesium (Mg2+)

1.5-2.0 mEq/L

Creatine kinase, :serum

Creatinine, serum Electrolytes, serum

1.5-2.0 mmoVL

Estriol, total, serum (in pregnancy)

24· 28 wks 11 32· 36 wks

30·170 ng/ml // 60· 280 ng/ml

.. ..

1, _ __ _

.. . .

. .. ... -.

104· 590 // 208· 970 nmoVL I .. • - • • .. • .• . • . •



Time Remaining: 52 sec

50. A 48-year-old man comes to the physician for a follow-up examination. Three years ago, he underwent operative removal of his right kidney and adrenal gland for wellencapsulated renal cell carcinoma. His two previous annual examinations since then showed no abnormalities. He does not drink alcohol or smoke cigarettes. His pulse is 75/min, and blood pressure is 130/ 88 mm Hg Physical examination shows no abnorm alities. Serum studies show mildly increased total bilirubin concentration and alkaline phosphatase, AST, and ALT activities. ACT scan of the abdomen shows widening of hepatic venules. Catheters guided by radiographic fl uorography to measure pressures across the liver show Location

Right atria Hepatic vein Hepatic wedge Further evaluation is most likely to show which of the following? 0 0 0 0 0

A) B) C) D) E)

Acute cholecystitis Acute hepatitis Acute pancreatitis Budd-Chiari syndrome Cirrhosis

Pressure (mm Hg)

5

25 30



Time Remaining: 1 hr 14 min 45 sec

1. An 11-year-old boy has had pain in his right m id-thigh for 2 weeks. Physical examination shows an area of warmth and tenderness around an ill-defined mass. X-ray of the femur shows a solitary mid-diaphyseal osteolytic lesion with permeative margins The lesion is surrounded by concentric layers of reactive bon e. Tissue obtained on biopsy of the mass is composed of poorly differentiated sheets of sm all, uniform, hyperc hromatic cells with a very high nuclear cytoplasmic ratio, scant stroma, and no visible matrix. Which of the following is the most likely diagnosis? 0 0 0 0 0 0 0

A) B) C) D) E) F) G)

Chondrosarcoma Eosinophilic granuloma Ewing sarcoma Multiple myeloma Nephroblastoma (Wilms tu mor) Osteosarcoma Small lymphocytic lymphoma




2. A 53-year-old man w ith angina pectoris is treated with nitroglycerin Which of the following actions of nitroglycerin is most likely to be responsible for symptomatic improvement? 0 A) Impaired transmembrane calcium flux 0 B) Increased concentration of cyclic GMP in smooth muscle

o C) Induction of the release of acetylcholine by endothelial cells 0 D) Induction of th e release of interleukin-1 (IL-1) by endothelial cells 0 E) Stimulation of autonomic nervous system tone




3. A previously healthy 16-year-old girl is brought to the physician by her 18-year-old sister because of a 2-day history of a thick, yellow vaginal discharge and burning with urinatiion. She does not want her parents to know that she is sexually active. Her temperature is 3rC (98 6°F), pulse is 80/min, and blood pressure is 11 0/70 mm Hg Examination shows a mucopurulent discharge at the cervical os and friability of the cervix. The uterus is small, firm, and nontender. There are no adnexal masses or external vaginal lesions. A Gram stain of the discharge shows gram-negative diplococci in pairs and greater than 30 leukocytes/hpf Urinalysis is within normal limits. Testing for Neisseria gonorr!Joeae and Chlamydia tractwmatis is ordered. Which of the following is the most appropriate course of action? 0 0 0 0 0

A) B) C) D) E)

Do not prescribe antibiotics until testing results are available Obtain written consent from a parent before prescribing antibiotics Obtain written consent from her sister before prescribing antibiotics Prescribe antibiotics and notify her parents Prescribe antibiotics without notifying her parents



5. A 25-year-old man is brought to the emergency department by his wife because of fever and swelling of his left calf since cutting his leg 2 days ago while mountain biking He is awake but somewhat confused. Physical examination shows an exquisitely tender, edematous left calf. Palpation of the swollen area produces crepitus There is a foul-smelling, watery discharge from the edge of the wound. A photomicrograph of a Gram stain of the discharge is shown. Which of th e following is the most likely causal organism? 0 0 0 0 0

A) B) C) D) E)

Clostridium botulinum C. difficile C. perfringens C. septicum C. tetani





6. A 52-year-old man w ith hypercholesterolemia is treated with lovastatin w ith some benefit Gemfibm zil is added to th e regimen. After 2 weeks, he develops renal failure. Which of the following is the most likely drug-related ca use? 0 0 0 0

A) B) C) D)

Glomerulonephritis Hemoglobinuria Myoglobinuria Obstructive uropathy




7. A 65-year-old woman in the terminal stage of breast cancer needs an analgesic for severe pain Dose-response curves of Drugs A-E are shown in the graph. Which of the following labeled analgesics would be most efficacious in alleviating this patient's pain?

<1> (/)

c 0 a. (/)

<1>

~ ~~~~~~--~---'--------Log dose

0 A)

0 B)

0 C)

0 D)

0 E)




8. A 47-year-old man with a history of rheumatic va lvular disease comes 1o the physician because of chest pain and diffic ulty breathing for the past 2 days _An ECG shows an acute myocardial infarction. Examination shows a systolic murmu r. Pressure tracings from the aorta, left ventricle (LV), and left atrium (LA) a re shown. Which of the following is the most likely diagnosis? 0 0 0 0 0

A) B) C) D) E)

Aortic obstructfion Aortic regurgitation Left ventricular aneurysm Mitral obstruction Rupture of th e chordae tendineae

C) Aortic I

E E

m ....

LV

::J 1/) 1/)

(J) .... c..

Time




9. A 3-day-old female newborn is brought to the physician by her mother after she noticed an unusually sweet odor when changing the newborn's diaper She has not been feeding well for 1 day Laboratory studies show hypoglycem ia, metabolic acidosis, ketonemia, and hyperammonemia Isoleuci ne is increased in urine. Which of the following metabolic pathways is most likely impaired in this patient? 0 0 0 0 0

A) B) C) D) E)

Branched -chain amino acid degradation Fatty acid oxidation Glycogenolysis Purine degradati on Urea cycle




10. A 32-year-old woman has absent tactile fremitus, hyperresonance on percussion, and absent breath sounds at the left lung base. Which of the following is the most likely diagnosis?

0 A) 0 B) 0 C) 0 D) 0 E)

Atelectasis Emphysema Pleural effusion o n the left Pneumonia, left lower lobe Pneumothorax o n the left




11. While scuba diving, a 46-year-old man ascends without appropriate decompression. As part of the developing decompression sickn ess, small gas bubbles form in the spinal vessels supplying the dorsal white matter of th e upper thoracic spinal cord. The most likely neurologic outcome is loss of which of the following? 0 A) Discriminative sensation in the lower extremities

0 B) Motor and reflex activity and all sensation in the lower extremities 0 C) Motor and reflex activity in the lower extrem ities 0 D) Motor and reflex activity in the upper extrem ities 0 E) Pain and tem perature sensation in th e upper extremities




12. A 26-year-old woman has lost 95 kg (209 lb) since undergoing a jejunoileal by for treatment of morbid obesity Fecal fat excretion is excessive. This patient most likely has a deficiency in which of the following nutrients?

0 A) Iron 0 B) Magnesium 0 C) Niacin 0 D) Protein ~ E) Vitamin A 0 F) Vitamin B 1 (thiamine)




13. Naive mouse thymocyte precursors are obtained from normal active bone marrow genetically altered to constitutively express the gene, bcl-2, and combined with normal marrow cells for injection into mice whose active marrow has been destroyed by rad iation. Control irradiated mice are injected with norm al marrow alone. After recovery from the procedure, which of th e following differences is most likely to be observed in animals receiving the genetically altered cells as compa red with the control animals? 0 0 0 0 0 0

A) B) C) D) E) F)

Decreased cell death in the thymic cortex Decreased naive B-lymphocyte production by the reconstituted marrow Decreased number of circulating lymph ocytes Decreased overall risk of autoimmunity Increased formation of lymphoid nodules in the thymic cortex Increased number of circulating plasma cells




14. A 31-year-old man comes to the emergency department because of a 4-hour history of severe cramping pain in his right fl ank that radiates to his groin He rates the pain as 10 on a 10-point scale. The pain is not relieved by position His temperature is 37.2oC (99°F), pulse is 90/min, respirations are 20/min, and blood pressure is 130/88 mm Hg. Physical examination shows tenderness on percussion of the right flank. The appropriate treatment is istered, and the patient is stabilized. Which of the following dietary changes is most likely to decrease this patient's risk for recurrence of similar symptoms? 0 0 0 0 0

A) B) C) D) E)

Decreased caffeine Decreased calcium Decreased fat Increased fluids Increased protein




15. A 23-year-old wom an comes to the student health center because of a 2-week history of a vaginal sore. She has been sexually active with a new partner, and they use condoms inconsistently. Pelvic examination shows a nontender ulcer on the vulva. Dark-field examination of a scraping of the lesion is positive for spiroc hetes Which of th e following histologic changes is most likely to be seen o n a biopsy specimen of this lesion? 0 0 0 0 0

A) B) C) D) E)

Acute inflammation with abscess formation Granulomas with caseation and plasma cell infiltration Granulomas with suppuration Obliterative endarteritis with lymphocytes a nd plasma cells Pyogranulomato us inflammation with edema




16. An 8-year-old girl is brought to the emergency department by her parents 15 minutes after she became unconscious. They had been traveling in their truck overn ight and had made a bed for their daughter in the truck bed, which was enclosed in a cabin, to allow her to sleep during the journey. When they arrived home, they had difficulty arousing her. When she did awaken, she said that she had a severe headache and nausea. She then began to vomit during ambulance transport to the hospital Her pUJise is 150/min. Physical examination shows cherry red skin around th e mouth. The most appropriate immediate therapy should include which of th e following? 0 0 0 0 0

A) B) C) D) E)

Amyl nitrite Dextrose Fomepizole Naloxone Oxygen




17. A 2-week-old full-term female newborn develops pale stools and jaundice The jaundice progresses; nuclear scans show no exc retion of bile. Serum assay rules out a 1-antitrypsin deficiency Examination of tissue obtained on biopsy of the liver shows inflammation and proliferation of small bile ducts and increased portal fibrosis . If not appropriately treated, this newborn is most likely to develop which of the following? 0 0 0 0

A) B) C) D)

Budd -Chiari syndrome End -stage cirrhosis Hepatocellular carcinoma Rec urrent episodes of hepatitis



l1 st

:2nd

:

:

:

Norma/ --~rjVI> ~---·~----~~ I'll' rw·. ~"Normal

•

Diastole

: Systole

Patient ----'N/NIINNIININitYNNifJ!IIr'ilf'-'--------+11~ I

DiasNJie : I

I

Systole

: I

I

I

18. A 40-year-old man has the cardiac phonogram shown. A normal tracing is also shown. Which of the following is the most liikely diagnosis?

0 0 0 0 0

A) B) C) D) E)

Aortic reg urgitation Aortic stenosis Mitral regurgitation Mitral stenosis Patent ductus arteriosus





19. A 52-year-old woman begins treatment with cisplatin for non-small cell carcinoma of the lung. Concomitant istration of which of the fol lowing drugs is most appropriate for this patient?

0 A) Dronabinol 0 B) Metoclopramide 0 C) Ondansetron 0 D) Prochlorperazine 0 E) Scopolamine




20. A 54-year-old man comes to the physician for a routine health maintenance examination. His pulse is 80/min, respirations are 14/min, and blood pressure is 140/95 mm Hg Physical examination shows no other abnormalities. An angiotensin !-converting enzyme inhibitor is prescribed. Which of the following labeled regions in the illustration of the kidney shown will be most affected by the adlministration of this drug?

0 A)

0 B)

0 C)

0 D)

0 E)

0 F)




21. A man with a fair co mplexion develops an ulcerated nodule on his face after prolonged exposure to sunlight Examination of tissue obtained on excision of the nodule shows invasive squamous cell carcinoma. Which of the following types of DNA damage is most likely responsible for this lesion? 0 A) Base sequence rearrangements 0 0 0 0

B) C) D) E)

Double-strand breaks lnterstrand cross-links Pyrimidine dimers Single-strand breaks

Exam Section 2: Item l l of 50 • Mark



22. A 30-year-old woman undergoes a cervical biopsy because of a Pap sm ear showing a high-grade intraepitheliallesion. Wlhich of the following locatio ns of the neoplastic cells in the tissue sample is most consistent with in situ cervical carcinoma?

0 A) 0 B) 0 C) 0 D) 0 E)

In the cervical stroma In the cervical venules In the iliac lymph nodes In the myometriu m Superficial to the basement membrane




23. Blood drawn from a 1-day-old newborn is tested for anti-HIV antibodies. The Western blot confirms the presence of lgG antibodies that react with envelope glycoproteins and the core proteins of the virus. Based on th ese data, which of the following conclusions ca n be made? 0 0 0 0 0

A) B) C) D) E)

Both the newborn and the mother are infected The mother is infected; the status of the newborn is uncertain The newborn is infected; infection occurred at birth The newborn is infected; infection occurred in utero The newborn is infected; the status of the mother is uncertain




24. A 22-year-old man is involved in an automobile collision. On arrival in the emergency department 1 hour after the accident, his blood pressure is unobtainable. Blood pressure returns to normal with intravenous istration of flu ids and blood transfusions. Laparotomy shows a lacerated spleen and liver. The spleen is removed and the liver bleeding is stopped During the next 24 hours, renal output is 350 ml . Which of the fol lowing is the most likely cause of the decreased urine output?

0 A) Acute pyelonephritis 0 0 0 0

B) C) D) E)

Acute tubular necrosis Disseminated intravascular coag ulation Rapidly progressive glomerulonephritis Renal artery obstruction




25. A 30-year-old woman with Marfan syndrome is brought to the emergency department 30 minutes after the onset of tearing chest pain An echocardiogram obtained 1 year ago showed the aortic root to be 5.5 em {N<4 0) She stopped taking her prescribed propranolol 1 year ago because of fatigue Her pulse is 120/min, and blood pressure is 80/40 mm Hg Physical examinati on shows jugular venous distention 6 em above the sternal angle that does not decrease with inspiration. The point of maximum impulse is not palpable, and the heart sounds cannot be distinguished Wh ich of the following sets of findings is most likely on cardiac catheterization of th is patient?

0 0 0 0 0 0

A) B) C) D) E) F)

Cardiac Index {Liminfm2) {N=2.5- 4.2) 2.0 2.0 2.0 4.0 4.0 4.0

Right Atria l Pressure {mm Hg) {N=0- 8) 2 5 18 2 5 18

Pulmonary Capillary Wedge Pressure {mm Hg) (N=:S-16) 5 15 18 5 15 18

Pullmonary Diastolic Aterial Pressure {mm Hg) {N=12- 30) 6 15 20 6 15 20

Systemic Vascular Res istance (dyn • stem s) {N=770- 1500) 600 1200 2000 600 1200 2000




26. A 17-year-old boy is brought to the emergency department on a hot summer day after he collapses while working as a trafrfic controller for a road construction crew. When he was 4 years old, he was treated with numerous skin grafts after sustaining full-thickness burns involving 30% of his body surface area. Examination shows hyperthermia Which of the following is the most likely explanation for this occurrence?

0 A) The burn scars and skin grafts lack eccrine glands, limiting his ability to sweat 0 B) Central thermoregulation is inadequate 0 C) Injured skin is more likely to release endogenous pyrogens increasing core temperature 0 D) Skin grafts and scars are more sensitive to heat and sunlight




27. A 36-year-old wom an with type 2 diabetes mellitus comes to the physic ian for a follow-up examination. Current medications include a sulfonylurea. She is 173 em (5 ft 8 in) tall and weighs 95 kg (210 lb); BMI is 32 kgfm2 Physical examination shows acanthosis nigrica ns Treatment with metform in is most likely to produce which of the following effects in this patient?

0 A) Decrease intestinal carbohyd rate digestion 0 0 0 0

B) C) D) E)

Increase beta-cell insulin secretion Increase deposition of adipocyte fat Increase hepatic triglyceride synthesis Inhibit hepatic gluconeogenesis



28. Rifampin interferes with the bacterial synth esis of which of the following? 0 0 0 0 0

A) B) C) D) E)

Cell membrane DNA Glycolipids Protein RNA





29. A 60-year-old man with a 20-year history of hypertension comes to the physician because of shortness of breath and fatigue for 3 months. The shortness of breath is exacerbated by climbing stairs. IHis pulse is 80/min, and blood pressure is 100/70 mm Hg Physical examination shows peripheral cyanosis Crackles are heard bilaterally on auscultation of the chest Cardiac examination shows an S3 There is 2+ pitting ankle edema. Which of the following is the most likely set of cardiac output and central venous pressure (CVP) fi ndings in this patient? 0 0 0 0 0 0 0 0 0

A) B) C) D) E) F) G) H) I)

Cardiac Output

CVP

Decreased Decreased Decreased Increased Increased Increased No change No change No change

decreased increased no change decreased increased no change decreased increased no change




30. A 52-year-old wom an with coronary artery disease is found to have a heart with a right-dominant coronary circulation. After angioplasty of the circumflex artery, which of the following structures supplied by it would receive increased blood flow?

0 0 0 0 0

A) Atrioventricular node

B) Left ventricle C) Right atrium D) Right ventricle E) Sinoatrial node




31. A 35-year-old woman comes to the physician because of fatigue for the past 3 months. She has followed a vegetarian diet for the past 12 years She eats no meat, dairy products, fish, or chicken. Exa mination shows a loss of vibratory sensation in her lower distal extremities. Laboratory studies show Hemoglobin Leukocyte count Mean corpuscular volume Platelet count Which of the following nutritional deficiencies is most likely?

0 0 0 0

A) B) C) D)

Folic acid Iron Vitamin B 12 (cob alamin) Vitamin C 0 E) Vitamin D 0 F) Zinc

9.1 g/dL 4900/mm 3 11 4 11m3 155,000/mm 3




32. A 6-week-old boy has a 2-week history of projectile vomiting after feed ing Several changes in fo rmula do not change his symptoms Vomitus is free of bile. He is dehydrated, and stools are decreased. Serum electrolyte and pH fi ndings show metabo lic alkalosis. Which of the following is the most likely diagnosis? 0 0 0 0 0 0

A) B) C) D) E) F)

Achalasia Congenital megacolon (Hirschsprung disease) Meconium ileus Necrotizing enterocolitis Paralytic ileus Pyloric stenosis




33. A 22-year-old man gets separated from a gro up of friends while hiking .. He becomes lost, and it is several days before he is rescued. He survives by eating plants; however, one of the plants causes him to develop nausea and vomiting The mechanism that precipitates his vomiting most likely involves signaling in which of the fol lowing structures? 0 A) Area postrema 0 0 0 0

B) C) D) E)

Median eminence Organum vasculosum of the lamina terminalis Pineal gland Subcommissural organ




34. A 69-year-old woman comes to the physician because she has had a tremor in her hands for the past month. Her muscle 1one is increased, and she has difficulty stopping abruptly when moving forward. She has a short, shuffling gait. Her affect is blank. The neurotransmitter system most likely to be involved with these symptoms has cell bodies at which of th e following labeled structures on the normal MRI of the head?

0 A)

0 B)

0 C)

0 D)

0 E)

0 F)




35. A 24-year-old woman participates in a study of renal function. Her renal oxygen consumption is 20 ml /min. Which of the following processes uses tlhe most oxygen consumption in the kidneys of th is woman?

0 A) 0 B) 0 C) 0 D) 0 E)

Acid-base homeostasis Glomerular filtration Metabolism of tubular toxins Production of renal hormones Tubular reabsorption




36. Oral fluid therapy is commonly used in developing countries to treat diarrhea ca used by Vibrio cholerae. These fluids benefit patients with cholera primari ly by stimulating the activity of w hich of the following labeled membrane transport mechanisms?

L---__..J

Lumen

A

K+

B

Na+

~

""\ "

Na+ Na+

c

()

D

...()"" H• ~ I Cl" ...()"

E

Glucose

I

HCO" 3

...

F

Cl"

~

G

Na+ H20

Blood

K+

~

Na+

Cl"

. r--2-./

Na+H 0

)

0 A)

0 B)

0 C)

0 D)

0 E)

0 F)

0 G)




37. A 2-yea r-old boy is brought to the physician because of fever and cough for 2 days. He has had two episodes of Streptococcus pneumoniae bacteremia and multiple ear and sinus infections since birth. His temperature is 38 4 °C (101 .1°F) Physical examination shows no tonsillar tissue. Crackles are heard in the right lower lobe of the lung Which of the following is the most likely immunodeficiency syndrome in this patient?

0 A) Bruton agammaglobulinemia 0 0 0 0 0

B) C) D) E) F)

Chediak-Higashi syndrome Chronic granulomatous disease DiGeorge syndrome lgG2 deficiency Isolated lgA deficiency



Time Remaining:

38. of the same family have a progressive dementia associated with major depressive disorder and a movement disorder. The disease is thought to be an autosomal dominant trait There is great variability in the symptom severity and age at onset Which of the following is the best explanation for this variability? 0 0 0 0 0

A) B) C) D) E)

Alteration of the codon for a specific amino acid Compen sation for the defect by other genes Differential genomic imprinting Maternal inherita nce through mitoc hondria The number of tr iplet repeat sequences




39. A 20-year-old man is brought to the emergency department 30 minutes after being involved in a motorcycle collision. Physical examination shows severe contusions on th e chest and abdomen. He lhas an unsteady gait and slurred speech. Th e patient is itted to the hospital for observation for possible damage to the spleen. By the third night, he becomes restless and begins having generalized tonic-clonic seizures .. The diagnosis of substance withdrawal is made. Which of the following best describes the patient's substance withdrawal and the immediate treatment required? 0 0 0 0 0

A) B) C) D) E)

Withd rawal

Medication

Buspirone Cocaine Ethanol Heroin ll.9-THC

lorazepam haloperidol diazepam naloxone phenytoin



40. Which of the following best explains the induction of galactorrhea by metoc lopramide?

0 A) Increased affinity of mammary gland prolactin receptors for prolactin 0 B) Stimulation of re lease of estrogen from developing ovarian follicles 0 C) Stimulation of re lease of growth hormone from the adenohypophysis 0 D) Stimulation of re lease of oxytocin from the neurohypophysis 0 E) Stimulation of re lease of prolactin from the adenohypophysis



• Mark



41. A 45-year-old woman comes to the physician because of a 24-hour history of fever, cough, runny nose, sore throat, and muscle aches. She appears moderately ill. Her temperature is 38.7"C (1 01.r F) Cardiopulmonary examination shows no abnormalities. A test result for influenza virus antigen is positive Which of the following types of medications is the most appropriate treatment for this patient?

0 A) Aminoglycoside antibiotic 0 0 0 0 0

B) C) D) E) F)

13-Lactam antibiotic Macrolide antibiotic Neuraminidase inhibitor Protease inhibitor Thymidine kinase inhibitor




42. A 59-year-old woman comes to the physician because of a 5-day history of yellow skin and dark urine. She returned from a business trip to Asia 3 weeks ago. Physical examination shows jaundice Serologic examination shows lgM anti-hepatitis E anti bodies. The patient says that she is unfamiliar with hepatitis E but that she has read articles about hepatitis A Which of the following aspects of hepatitis E illustrates a primary difference from hepatitis A? 0 0 0 0 0

A) B) C) D) E)

Chance of chronicity Incubation ti me Mode of transmission Mortality among preg nant women Prognosis




43. An autopsy is performed on a previously healthy 20-year-old woman who died immediately follow ing a motor vehicle collision 8 hours ago Microscopic examination of the lungs is most likely to show that the greatest amount of alveolar endothelial surface area is covered by w hich of the following cells?

0 A) 0 B) 0 C) 0 D) ~ E)

Brush cells Fibroblasts Lymphatic capillary cells Macrophages Type I pneumocytes




44. A 60-year-old wom an comes to the physician because of a 1-year history of episodes of involuntary rhythmic jerking of her right leg and foot These episodes last approximately 3 minutes. Neurol ogic examination shows an increased right ankle jerk reflex. A Babinski sign is present on the right An M RI of the brain shows a 2.-cm, round, enhancing lesion within the interhem ispheri c fissure in the region of the central sulcus. W hich of the following is the most likely diagnosis?

0 A) Astrocytoma 0 0 0 0

B) C) D) E)

Lymph oma Meningioma Metastatic ca rcinoma Oligodendrogliom a




45. In immunocompromised patients, the case definition of a positive PPD skin test was changed from 10 mm of induration to 5 mm of induration. This change in case definition has which of th e following effects on incidence and prevalence of a positive PPD skin test? Incidence

0 A) 0 0 0 0

B) C) D) E)

l l

Prevalence

T

No change

! no change

! !

!

T




46. A 6-month-old male infant has a history of frequent severe viral and bacterial infections. A tentative diagnosis of severe combined immunodeficiency is made. A deficiency of which of the fol lowing enzymes would this diagnosis? 0 A) Adenosine deaminase

0 B) Glucose 6-phosphatase 0 C) Hypoxa nthine-guanine phosphoribosyltransferase 0 D) Myeloperoxidase 0 E) NADPH oxidase




47. A 35-year-old man comes to the physician to discuss donating a kidney to his 39-year-old sister who has type 1 diabetes mellitus and chronic renal failure. He has no history ,of major medical illness, and physical examination shows no abnormalities. Which of the following best describes the likelihood that this donor's human leukocyte antigen type will match that of his sister?

0 0 0 0 0

A) B) C) D) E)

11 12 14 16 18




48. A 67 -year-old man comes to the physician for a follow-up examination.. Eight months ago, he received a diagnosis of primary lung carcinoma involving the adrenal glands, liver, and bone. He has had an 8-kg (17.6-lb) weight loss during the past 3 months. Physica l examination shows cac hexia and signifrica nt muscle wasting The breakdown of muscle proteins in this patient was most likely preceded by conjugation of the proteins with which of the following! substances?

0 A) Bcl-2 0 0 0 0 0 0

B) C) D) E) F) G)

Catalase Copper Cytochrome c Lysozyme Phospholipase A 2 Ubiquitin




49. A 30-year-old man develops urinary incontinence 2 weeks after successful treatment of a fracture of the left pelvis that was sustained at work. He was pinned against a loading dock by a truck moving in reverse. Physical examination shows a distended bladder. Cystometrography shows absence of micturition reflexes. After the bladder fills to capacity, overflow of urine occurs through the urethra a few drops at a time. This patient most likely sustained additional injury to which of th e following during his initial accident?

0 A) External urinary sphincter 0 B) 1tJ C) 0 D) 0 E)

Hypogastric nerve Pelvic nerves Pudendal nerves Skeletal motor fi bers



50. An 18-year-old woman has severe, painful blistering following a day at the beach. She is ta king an antibiotic. Which of the following drugs is the most likely cause?

0 A) Cephalosporin 0 B) Ciprofloxacin 0 C) Erythromycin 0 D) Penicillin 0 E) Tetracyc line


Exam Section 3: Item 1 of ~0

• Mark

National Board of Medic:all xamim•rs

linw l~emaininy:

Comprehensive Basic Science Self-Assessment

1 hr 14 min 49 sec

1. A 48-year-old woman comes to the physician because of a 2-month history of urinary frequency and urgency. Physical examination shows no abnormalities. The physician prescribes a medication that will affect the normal stimulation of bladder contraction. Wh ich of the following is the most likely effect of this drug? 0 A) Blockade of parasympathetic innervation of the detrusor muscle 0 B) Blockade of postganglionic sympathetic innervation of the bladder trigone .:> C) Blockade of preganglionic parasympathetic transmission D) Enhancement of afferent from the bladder stretch receptors E) Enhancement of peristalsis of the ureters F) Enhancement of sympathetic preganglionic transmission



Time Remaining: 1 hr 10 min 35 s

2. A 75-year-old man with dementia, Alzheimer type, is brought to the hospital by his wife because of cough, difficulty breathing, and agitation th at began after he ate breakfast 2 hours ago. He has been a resident of a skilled nursing care facility for 7 years His wife visits the facility daily to feed him his midday meals. His two adult children visit him several times weekly. His wife mentions that the patient has been coughing during his meals for several weeks. He also has been taking longer to finish even smaller portions of food. Results of imaging studies are consistent with aspiration pneumonia with a developing compromised swallowing function. His medical records show no advance directives. In speaking with the patient's family, it is most appropriate for the physician to address th.e issue of a feeding tube in which of the following manners? 0 0 0 0

A) B) C) D) !!] E)

Encourage the family to come to a consensus based on their perception of the patient's wishes Explain that a feeding tube is diffic ult to monitor and may not prevent aspiration Follow only the wishes of the wife Help the adult children encourage the wife to start a gradual withdrawal from the patient Recommend a tube, because feeding will be more efficient and prevent starvation



Time Remainin 1 hr 9 min 42 s

3. A 12-year-old boy with asthma is brought to the physician because of wheezing for 2 hours. Treatment with an inhaled bronchodilator has not completely resolved his symptom s Which of the following portions of the aiiWay is most suscepti ble to flow limitation due to smooth muscle contraction in this patient? 0 A) Alveolar duct 0 B) Alveolus !!] C) Bronchiole 0 D) Nasal age 0 E) Trac hea




4 . A previously h.ealthy 18-year-old man develops pain in multiple ts and fatigue Two months ago, he had a rash and flu-like illness while working as a counselor at a camp on the

New England coast Which of the following is the most likely diagnosis? 0 0 0 0 0

A) B) C) D) E)

Acute rheumatic fever Brucellosis Lyme disease Palindromic rheumatism Roc ky Mountain spotted fever




5. A 62-year-old woman comes to the physician for follow-up care of cramping abdominal pain and constipation for 3 months. Treatment with simethicone has provided some relief of symptoms She also has had a 9-kg (20-0b) weight loss, increasing fatigability, and a need for more sleep Endoscopy, colonoscopy, and aCT scan of the abdomen showed no abnormalities 1 month ago She believes. her difficulty sleeping is due to worries about her son who has been using drugs. during the past few months. Over the past 3 weeks, she began to worry that she has cancer and will never get better. Vital signs are stable. Physical examination shows mild, diffuse abdominal tenderness. She is not anemic, and all other laboratory findings are within reference ranges Which of the following initial actions by the physician is most appropriate? 0 0 0 0 0

A) B) C) D) E)

Evaluation of the patient for major depressive disorder Increase in the amount of dietary fiber Barium enema Repeat CT scan Repeat colonoscopy



6. A 3-month-old girl with congenital HIV infection is brought to the physician by her mother because of a 2-week history of a diaper rash that spread to her abdomen and th ighs. Physical examination shows clusters of erythematous papules and pu stules distributed over the abdomen, gr·oin, and thighs A photom icrograph of a scraping from one of the lesions is shown. Which of the following is the most likely source of the causal organism? A) B) C) D) E)

Bird droppings Contaminated soil Infected fecal material Infected urine Normal skin flora

Ple.ase Wait




7. A 29-year-old man has a left testicular mass. A frozen section obtained during a planned orchiectomy shows a seminoma. Which of the following provides the greatest risk factor

associated with this condition? 0 0 0 0 0

A) B) C) D) E)

Alcohol abuse Cryptorchidism Mumps orchitis Varicocele Vasectomy



I irne Remaining: 1 hr 3 min 34 sec

8. A 32-year-old woman has had fecal incontinence since giving birth to her first child 1 year ago. Wh ich of the following is the most likely cause of the fecal incontinence in this patient? A) C B) 0 C) D) E)

Achalasia of the internal anal sphinc ter Damage to the anal sphinc ter Increased pressure of the anal sphincter Spastic contraction of the puborectalis muscle Spastic external anal sphincter


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1 hr 2 min 23 sec

9 A 10-year-old girl has a slightly painful 2-mm subcutaneous nodule on her chin. Ten weeks ago, she required sutures after she lacerated her chin playing basketball. A photomicrograph of tissue obtained on biopsy of the nodule is shown. Which of the following best describes the pathologic features?

0 A) B) C) D) E)

Amyloid Granulation tissue Granuloma Lymphocytic infiltrate Neutrophilic infiltrate


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National Board of Mecfic:al l xam iners Comprehensive Basic Science Self-Assessment

I irne f~ernaining:

1 hr 1 min 10 sec

10. A 24-year-old man is brought to the emergency department 1 hour after a motor vehicle collision. He has lost an estimated 2 L of blood from the trauma associated with a left femoral fracture. His !blood pressure is 70/40 mm Hg. Following immediate operative repair, physical examination shows multiple ecchymoses over the medial aspects of the upper arms. There is bleeding from venipuncture sites. Laboratory studies show:

Platelet count

75,000/mmJ

Prothrombin time Partial thromboplastin time Plasma fibrinogen

21 sec (INR=1 .7) 56 sec <100 mg/dl (N=200-400)

Which of the following coagulation abnormalities is most likely in this patient? A) Consumption coagulopathy B) Hemophilia A C) Hemophilia B D) Henoch-SchOnlein purpura 0 E) Vitamin K deficiency


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linw I~Pmaininy:

58 min 14 sec

11. A 30-year-old man is brought to the emergency department 30 minutes after being stung by several wasps. He is confused and has diffic ulty breathing. His temperature is 3s•c (1004.F), pulse is 122/min, respirations are 34/min, and blood pressure is 80/40 mm Hg. Physical examination shows dry slkin and decreased capillary refill. There are multiple erythematous, inflamed marks on the back and 1+ pitting edema of the ankles. In addition to the istration of 0.9% saline, the most appropriate next step in management is istration of which of the following?

v

A) B) C) D) E) F) G)

ACE inhibitor Angiotensin II receptor blocker Parasympathetic blocker Parasympathomimetic agent Sympathetic blocker Sympathomimetic agent Whole blood


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55 min 55 sec

12. A 7-year-old boy who emigrated with his family from Africa 4 days ago is brought to the physician by his mother bec au se of a 2-day history of headache and recurrent fever accompanied by back pain. The mother reports that a child in the village where they used to live had a similar condition 10 days ago The patient's temperature is 39•c (102.2.F). Physical examination shows weakness of the left lower extremity; the knee reflex is weaker on the left. Neurologic examination shows fasciculations o f the lower extremities. Whic h of the following is the most likely diagnosis? A) B) C) D) E) F) G)

Amyotrophic lateral sclerosis Coxsackievirus infection Herpes encephalitis HIV infection Poliomyelitis Rabies West Nile encephalitis



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I irne Remaining: 53 min 3 1 sec

13. A 73-year-old man comes to the physician because of a 4-month history of localized mid-back pain. He has hypertension and type 2 diabetes mellitus. He is in mild discomfort but is able to walk without problems. There is pain with percussion over the lower thoracic spine. Neurologic examination shows no focal fi ndings X-rays of the spine show vertebral cortical thickening of the end-plates, creating "picture frame" vertebrae. Which of the following sets of serum studies is most likely in this patient? Calcium

Phosphorus

Alkaline Phosphatase

Parathyroid Hormone

A) B) C)

• •

no change

no change no change no change

no change •

D)

No change No change

E)

• no change no change no change

T T

no change


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14. A 42-year-old woman develops hearing loss while being treated for pyelonephritis. She is most likely taki ng a drug from which of the following classes? A) C B) 0 C) D) E)

Aminog lycosides Quinolones Semisynthetic penicillins Sulfonamides Third-generation cephalosporins



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National Board of Medical! xaminers Comprehensive Basic Science Self-Assessment


15. A 61-year-old man has erectile dysfunction due to spinal cord injury at L-2. Sildenafil is likely to markedly correct the dysfunction by acting at which of the following labeled structures in the transverse sec tion of the penis?

e> A)

0 B)

0 C)

D)


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16. A 45-year-old man comes to the physician because of gradually worsening heartburn over the past 3 months. Physical examination is unremarkable. Endoscopic examination of his stomach shows a thickened, nodular mucosa with no discrete ulcerations. A representative Steiner silver-stained gastric biopsy (400x) is shown. The abnormality shown is most commo nly

associated with the development of which of the following diseases? A) B) C) D) E) F)

Autoimmune gastritis Celiac disease Crohn disease Giardiasis Peptic ulcer disease Reflux esophagitis



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4!> min 3 1 sec

17. A previously healthy 24-year-old man is itted to the hospital after having a generalized tonic-clonic seizure. He is somnolent. Serum studies show a sodium concentration of 118 mEq/L and a potassium concentration of 4.0 mEq/L. Urinalysis shows a specific gravity of 1.005. The sodium concentration slowly returns to the reference range over the next 36 hours after treatment. The patient remains somewhat somnolent and stays in bed. On the third hospital day, serum osmolality is 280 mOsmollkg, and two random measurements of urine osmolality are 260 and 272 mOsmol/kg, respectively. The patient is more alert and active. He is observed drinking a large amount of water (more than 6 liters in 1 day), and his serum sodium concentration begins to decrease. When water restrictions are imposed, he drinks from water fountains on other floors. He says he does not have excessive thirst. Which of the following is the most likely cause of this patient's condition? A) B) C) D) E)

Adrenal insufficiency Central diabetes insipidus Nephrogenic diabetes insipidus Psychogenic polydipsia Syndrome of inappropriate secretion of ADH (vasopressin)


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42 min 49 sec

18. During a study of pulmonary artery pressure, subjects with hypertension experience a decrease in this pressure after receiv ing a phosphodiesterase inhibitor. This improvement in pulmonary artery pressure is most likely media1ed by an increase in the intracellular concentration of which of the following? () A) Adenosine 0 B) Calcium .:> C) cGMP D) Endothelin E) Nitric oxide




19. A 70-year-old man develops a progressive disinhibition syndrome characterized by episodes of emotional outbursts, inappropriate use of language, and socially inappropriate behavior. Which of th e following labeled structures is most likely damaged?

A

L

A)

0 B)

0 C)

0 D)

0 E)

0 F)

G)

H)

I}

0 J)


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39 min 27 sec

20. A new humanized monoclonal antibody is being investigated for the treatment of a clinical condition. This monoclonal antibody is monomeric, crosses the placenta, and has a serum half-life of about 21 days. Which of the following is the most likely isotype of this antibody? () A) lgA 0 B) lgD .:> C) lgE D) lgG E) lgM


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38 min 41 sec

21. In a case control study, 100 men who have bladder cancer were compared with 100 controls. Cases and controls were asked about their alcohol consumption. The investigators calculated an odds ratio of 3.0; the 95% confid ence interval was 1.8 to 6.6 for the association of bladder cancer and alcohol consumption. Which of the following is the most appropriate interpretation of this result? 0 A) B) C) D) E) F)

At least 5% of the bladder cancers can be attributed to consumption of alcohol At least 5% of consumers of alcohol will develop cancer of the bladder The likelihood is 95% that the true value for the odds ratio is between 1.8 and 6.6 There is at least a 5% increased risk for bladder cancer among consumers of alcohol Men who drink alcohol are 5 times more likely to develop bladder cancer than those who do not drink alcohol There is a 95% chance that the true odds ratio is 3.0


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36 min 13 sec

22. A 48-year-old woman comes to the physician because of a 3-month history of fatigue, weakness, loss of appetite, and weight loss. Her serum parathyroid hormone concentrations are increased. X-rays of the skeletal system show generalized osteopenia, with subperiosteal resorption of bone within the phalanges. Which of the following mechanisms is the most likely cause of the skeletal changes observed in this patient? 0 A) B) C) D) E)

Impaired calcification of preformed osteoid Paracrine stimulation of osteoclasis by osteoblasts Parathyroid hormone-mediated induction of calcitonin Parathyroid hormone-mediated induction of interleukin-1 (IL-1) Parathyroid hormone-mediated production of transforming growth factor-13 1


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23. A 2-day-old full-term newborn develops jaundice. The most likely cau se of the jaundice is a reduction in the rate of which of the following? A) C B) 0 C) D) E) F)

Bilirubin syn thesis Conjugation of bilirubin to glucuronic acid Glucuronic acid synthesis Release of bilirubin into the circulation by the spleen Release of iron into the circulation by the spleen Removal of old erythrocytes from circulation by the spleen





24. A 30-year-old woman is brough t to the emergency department because of a 6-hour history of nausea and vomiting. She has had type 1 diabetes mellitus for the past 10 years. She is confused and sleepy. Pulse is 130/min, respirations are 30/min, and blood pressure is 80/60 mm Hg. laboratory studies show: Serum

Na•

K•

HC0 3Giucose Urea nitrogen (BUN) Arterial blood pH Pco 2

134 mEqJL

6.2 mEq/l 7 mEq/l 900 mg/dl 40 mg/dl

7.14 23mm Hg

Urine output is scant and urine is dark. She is given insulin and an infusion of isotonic saline. Which of the following changes in laboratory findings are most likely 4 hours after the istration of insulin and saline?

<:)

0 0 0 0 0

A) B) C) D) E) F)

K•

Serum HCO 3-

l l

r

!

l

T T

r r r

!

T

!

No cha nge No cha nge

r r

BUN

l

r

r

A rterial Blood pH Pco 2

l

!

r

!

T ! !

T T


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31 min 44 sec

25. A 24-year-old woman comes to the gynecologist because of a 6-month history of painful menstrual periods. She misses 2 to 3 days of work each month because of the pain. There is no pain during the midpoint of her menstrual cyc le. She has had two episodes of rectal bleeding associated with menses. Which of the following is the most likely diagnosis? 0 A) Cervical cancer 0 B) Ectopic pregnancy .:> C) Endometriosis D) Ovarian cancer E) Uterine leiomyoma


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26. The action poten tial causes current to flow deep within the skeletal muscle fiber by wh ich of the following? A) C B) 0 C) D) E)

Electrogenic Na•-K•pump activity at the sarcoplasmic reticulum Elec trotonic spread of the potential from one myofibril to the next Release of sodium from the sarcoplasmic reticulum Synchronous contraction of the myofibrils Transmission along T tubules



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29 min 14 sec

27. A 25-year-old man has significant blood loss after he sustains a fracture of his right tibia during a soccer match. Prior to emergency treatment, wh ich of the following is most likely to compensate for his decreased blood volume? 0 A) Decreased secretion of renin 0 B) Filtration of nuid from systemic capillaries .:> C) Increased secretion of atrial natriuretic peptide D) Reabsorption of Huid into systemic capillaries E) Relaxation of systemic arterioles F) Relaxation of venous smooth muscle



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28. In the diagram of proximal renal tubular epithelium, the labeled arrows denote pathways and mechanisms of net movement of water or solutes. Which of the following letters of the pathway best describes the transepithelial transport of water?

c

A

0

E

B Carrier reQuiring

energy

Basement

membrane

Peritubular capillary

6 A)

B)

C)

D)

E)


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26 min 5 1 sec

29. A 25-year-old woman has recently developed nervousness and emotional lability. Her pulse is 110/min and blood pressure is 135/70 mm Hg She has a wide-eyed, staring gaze; her skin is warm and moist; and the fi ngers of both hands show a fine tremor when extended. Her thyroid gland is diffusely enlarged. Whic h of the following is the most likely cause of the thyroid changes?

0 A) ~,., B) C) D) E)

Antithyroid cytotoxic T lymphocytes Thyroid antithyroglobulin autoantibodies Thyroid peroxidase (antimicrosomal) autoantibodies Thyrotropin receptor autoantibodies Thyroxine (T.J autoantibodies


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25 min 10 sec

30. A 25-year-old man with eczematous dermatitis comes to the physician for evaluation. A biopsy specimen of the skin shows Langerhans cells infiltrating the dermis. Which of the following is highly characteristic of the cell of origin of this condition? () A) 0 B) .:> C) D) E) F) G) H)

Birbeck granules Desmosomes (maculae adherentes) Keratohyaline granules Melanofilaments Melanosomes Neurosecretory granules Odland bodies Tonofibrils


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24 min 3 sec

31. During a study, it is found that characteristic malformations of embryos exposed to retinoic acid involve reproducible changes in homeobox (HOX) gene expression. Both reti noic acid receptors and HOX gene products recognize and bind to specific DNA sequences at numerous sites on multiple chromosomes. Which of the following best describes the function of these molecules? 0 A) B) C) D) E)

Adapter proteins Initiation factors Ligands Polymerases Primers

F) G) H) I) J)

Promoters Signal recognition particles Signal sequences Transcription factors Transducers


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32. The symptoms associated with scurvy are most likely to be caused by decreased activity of which of the following? A) C B) 0 C) D) E)

Glucosyltransferase Lysyl oxidase Procollagen peptidase Prolyl hydroxylase Transglutaminase



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21 min 48 sec

33. A 38-year-old woman has a 6-month history of depressed mood, t pain, muscle weakness, memory problems, insomnia, palpitations, and blurred vision. The symptoms vary in duration and severity. She has a history of erythema migrans Which of the following is the most likely diagnosis? 0 A) Cryptococcosis 0 B) Cytomegalovirus infection .:> C) Herpes encephalitis D) Histoplasmosis E) Lyme disease


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20 min 27 sec

34. A 32-year-old woman comes to th e physician because her sister recently died of melanoma. Other fi rst-degree family have been similarly affected, and other family also have large pigmented skin lesions. Whic h of the following lesions is most likely on both sun-exposed and nonsun-exposed areas of this patient's skin? 0 A) Acanthosis nigricans 0 B) Basal cell carcinoma .:> C) Blue nevi D) Dysplastic nevi E) Pigmented seborrheic keratosis


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19 min 36 sec

35. A 42-year-old man comes to the physician because of progressive weakness of his hands during the past 10 months. Physical examination shows atrophy of the hand muscles with fasciculations. There are also fasciculations of the tongue and trapezius muscles. Electromyography con fi rms the diagnosis of amyotrophic lateral sclerosis. Which of the following initial statements by the physician is most appropriate?

o

A) "You have amyotrophic lateral sclerosis, also called Lou Gehrig disease, which is a terminal illness. You will eventually need to go on a respirator Have you thought about advance directives?" B) "You have an incurable illness. I'm sorry to say there is nothing I can do for you. Are you religious?" C) "You have Lou Gehrig disease. Have you ever heard anything about this disease before?" D) "You have a mild case of amyotrophic lateral sclerosis, also called Lou Gehrig disease. We'll check it every few months just to see if it is progressing." E) "You may have amyotrophic lateral sclerosis. We'll check every few months and if it progresses, then we'll know for sure."


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I irne f~ernaining: 17 min 33 sec

36. During a study of the digestion of protein following a meal, a substance that is produced in the gastrointestinal tract is isolated and examined. This substance causes the ac tiva tion of pancreatic trypsinogen to trypsin, as well as the subsequent activation of other proteolytic zymogens. This substance most closely resembles whic h of the following? 0 A) Carboxypeptidase A 0 B) .:> C) EJ D) E)

Elastase Enteropeptidase Pepsin Secretin




37. Serum cholesterol concentrations are measured as part of a community study. The mean and standard deviation are given for women by age group Age (years) 45-49 50-54 55-59 60-62

Cholester ol (mg/dl) 229 ± 47 246 ± 50 255 ± 48 244 ± 36

Assuming serum cholesterol concentrations follow a normal (gaussian) d istribution, which of the following is the probability that a woman between the ages of 50 and 54 years has a serum cholesterol concentration greater than 296 mg/dl?

A) B) C) D)

1% 2.5% 5% 16% E) 95%


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16 min 12 sec

38. During an experiment, it is found that instillation of lipid into the duodenum leads to the release of a hormonal substance from endocrine cells in the duodenal mucosa. Which of the following best describes the major physiologic action of this substance? 0 A) Gallbladder contraction 0 B) Increased gastric contractility .:> C) Pancreatic endocrine stimulation D) Salivary gland stimulation E) Splanchnic vasoconstriction


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1!> min 18 sec

39. Histone acetyltra nsferases cata lyze the acetylation of lysine residues in the amino-terminal tails of histones. Whic h of the following is the most likely effect of th is covalent modification on chromatin structure? 0 A) Decreases the affinity of histones for DNA 0 B) Decreases the nucleosome content of the nucleus .:> C) Increases the affinity of histones for DNA D) Increases the nucleosome content of the nucleus E) Removes histone H1 from DNA F) Removes histone H4 from DNA


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13 min 50 sec

40. A 29-year-old woman comes to th e physician because of inability to conceive children. She has had 10 menstrual periods in the past year, but her menstrual pattern is very erratic and unpredic table. She has been advised that she may not be ovulating. She had some right pelvic pain 4 days ago, and she suspects that this pain is an indication that she has ovulated. Which of th e following changes in serum hormone concentration is the best evidence that ovulation has occurred?

0 A) B) C) D) 0 E) F)

Decrease in estradiol Decrease in follicle-stimulating hormone Decrease in progesterone Increase in estradiol Increase in follicle-stimulating hormone Increase in progesterone


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13 min 1 7 sec

41. Immunization of a 3-month-old infan t with tetanus toxoid results initially in an lgM anti-tetanus antibody response followed by anti-tetanus lgG antibody response. Which of the following B- to T-lymphocyte interactions is essential for this immunologic phenomenon? () A) CD40 - CD40 ligand 0 B) CD44 - hyaluronic acid .:> C) CD64 - lgG D) CD88- complement component GSa E) CD95- Fas ligand


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12 min 11 sec

42. A 45-year-old woman with cancer is undergoing an intensive 2-week course of chemotherapy with vinblastine. Whic h of the following changes is mos11ikely to occur by the end of this treatment? 0 A) Decreased number of neutrophils 0 B) Decreased transferrin saturation .:> C) Increased activated partial thromboplastin time D) Increased hematocrit E) Increased serum glucose concentration


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10 min 52 sec

43. A 40-year-old woman undergoes chorionic villus sampling at 11 weeks' gestation because of her age-related increased risk for having a child with aneuploidy. Chromosome analysis shows 46,XY in 14 cells studied and 47,XY+15 in an additional 25 cells studied. Subsequent chromosome studies of amniotic fluid show 46,XY in 50 cells. Which of the following best explains this difference?

0 A) B) C) D) E)

Confined placental mosaicism Cross-patient contamination Fetal mosaicism Laboratory error Pseudomosaicism


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9 min 29 sec

44. During a period of 24 hours, a 25-year-old man has an upper respiratory infection with fea tu res of the common cold. Which o f the following viral or host factors is most critical in the initial establishmen t of the infec tion? 0 A) Activation of latent virus within epithelial cells 0 B) Inhibition of inflammatory mediators .:> C) Inhibition of synthesis of lgA antibodies D) Lysis of CDS+ T lymphocytes E) Presence of viral receptor molecules on epithelial cells


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I irne Remaining:

45. A sexually active 20-year-old woman has had painful, erythematous, vesicular lesions on the vulva for 2 days. Examination by speculum also shows lesions in the vaginal vault and on the cervix. A photomicrograph of a scraping of the base of an unroofed vesicle is shown. Wh ich of the following is the most likely diagnosis?

0 0 0 0 0

A) B) C) D) E)

Candida! vag initis Condylomata acuminata Genital herpes Syphilis Trichomonas vagina/is vag initis


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7 min 3 sec

46. A 3-day-old male newborn has progressive abdominal distention and inc reasing distress. One of three siblings has cystic fibrosis. He has had no bowel movements since birth. Xrays of the abdomen suggest small-bowel obstruction. Which of the following is the most likely diagnosis? 0 A) Abetalipoproteinennia 0 B) Congenital megacolon (Hirschsprung disease) .:> C) Hypertrophic pyloric stenosis D) Meckel diverticulum E) Meconium ileus


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6 min 0 sec

47. Two of a hi'king club that recently returned from a 5-day hike in Arizona develop an infection and require hospitalization The infection is characterized by the sudden onset of fever, chills, weakness, and headache , followed by the development of unilateral, intensely tender lymphadenopathy in the groin A Gram stain of fluid taken from a lymph node shows gram-negative coccobacilli. Which of the following is the most likely causal organism? 0 A) Cryptococcus neoformans B) Flavivirus C) Plasmodium falciparum D) Vibrio cholerae E) Yersinia pestis




48. A healthy 25-year-old man undergoes an exercise stress test Which of the following sets of physiologic changes is most likely to occur in this man's exercising skeletal muscles?

Arteri olar Diameter A) 0 B)

C) D) E) F)

G) H)

Tissue Adenosine Concentration Vascu lar Conductance

T

l

l

1

l l l T T ! !

! l ! T ! T l

•r •j

I I

r

I



49. A 60-year-old woman is brought to the physician because of increasingly severe t pain and swelling during th e past 8 years. She says that she is now almost incapac itated because of her condition. Physical examination shows irregular, asymmetric enlargements of multiple ts of the fi ngers and toes, left elbow, and ri ght knee , with focal ulceration of the overlying skin. A photograph of the left hand is shown. Serum studies show

K• Ca2• Urea nitrogen (BUN) Glucose Creatinine Phosphorus P rotein, total Cholesterol A lkaline phosphatase AST ALT U ric acid Whic h of the followirng is the most likely diagnosis?

0 0 ® 0 0

A) B) C) D) E)

Gout Hyperparathyroidism Osteoarthritis Pseudogout Rheu matoid arth ritis

4.8 mEq/L 10.1 mg/dl 24 mg/dl 120 mg/dl 1.5 mg/dl 3.3 mg/dl 6.1 g/dl 220 mg/dl

68 UIL 17 U/L 15 U/L 9.1 mg/dl

I irne Remaining:


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1 min 25 sec

50. A 10-year-old girl is brought to the physician because of a 1-day history of pain and swelling of her right index finger. Her temperature is 37.s·c (99 s~F) . Examination of the right hand shows a tender, erythematous, edematous index finger with an intact wooden splinter embedded in the soft tissue. A white exudate is found in tlhe lesion during removal of the splinter. This material is predominantly composed of which of the following types of cells? 0 A) B) C) D) E)

Basophils Eosinophils Lymphocytes Monocytes Neutrophils




1. A 29-year-old man with a 9-year history of untreated HIV infecti on comes to the physician because of fever, severe diarrhea, and fatigue for 3 weeks. His temperature is 38.3•c (101•F) Physical examination shows oral thrush and enlargement of the cervical and axillary lymph nodes. His CD4+ T-lymphocyte count is 190/mm3(N
A) B) C) D) E)

CD8+ T-lymphocyte-mediated killing Dendritic cell engulfment Destruction by reactive oxygen rad icals Histamine-induced apoptosis Man nose-binding lectin activation of complement

2. A parasagittal MRI of the brain of a 54-year-old man shows tlhe brain lesions indicated by the arrows. Laboratory findings include an abnormally decreased serum gonadotropin concentration. A transbronchial biopsy shows granulomas indicative of sarcoidosis. The MRI shows the sarcoidosis localized to which of the following?

o A)

e e e e

B) C) D) E)

Corpus callosum Hypothalamus Optic tracts Pituitary gland Pons




3. A 22-year-old woman comes to the physician because of a 6-month history of frequent headaches and fatigue She tells the physician that she often overeats when she is anxious and has been making herself vomit and using laxatives for the past 2 years She is 168 em (5 ft 6 in) tall and weig hs 59 kg (130 lb); BMI is 21 kg/m 2 Physical examination will most likely show which of the following conditions?

0 0 0 0 0 0 0

A) B) C) D) E) F) G)

Arthr itis Decreased body hair Dental caries Galactorrhea Pituitary adenoma Tachycardia Thyroid gland enlargement




4. A 12-year-old girl is referred to the emergency department by her physician because slhe has been unable to walk for 5 days. Her parents appear very anxious, but s he seems (98 6•F), pulse is 70/min, and blood pressure is 115/70 mm Hg Deep tendon reflexes in the lower extremities are unconcerned about her symptoms . Her temperature is 37 equal bilaterally Sensation to pain and to light touch is va riable. Which of the following is the most likely diagnosis?

o·c

0 0 0 0 0

A) B) C) D) E)

Brief psychotic disorder Conversion disorder Depersonalization/derealization disorder Illness anxiety disorder (hypoc hondriasis) Post-traumatic stress disorder



5. Which of the fol lowing pathophysiologic processes is involved in Niemann-Pick disease? 0 0 0 0 0

A) B) C) D) E)

Decreased lysosomal hydrolase activity Decreased synthesis of ceramide Decreased synthesis of phosphatidylcholine Increased amounts of glycosphingolipids in the diet Increased synthesis of glycosphingolipids





6. An investigator is developing a new drug that is designed to stimulate epithelial cell tunnover in the small intestine . To be successful, this drug must target which of th e following structures? 0 0 0 0 0

A) B) C) D) E)

Crypt cells Folds of Kerckring Goblet cells Mature enterocytes Microvilli




7. A 3-month-old boy is brought to the physician by his mother because of a 1-week history of difficulty breast-feeding. The mother reports that her son frequently stops. breast-feeding and seems to be gasping for breath. The amount of time he spends feeding seems less than th at of her other children. He is at the 50th percentile for length and 5th percentile for weight The lungs are clear to auscultation. A grade 3/6 holosystolic murmur is heard. Subsequent cardiac test results show normal oxygen (O z) tension in the right atrium, increased 0 2 tension in the right ventricle, and normal systemic 0 2 tension. Which of the following is th e most likely diagnosis? 0 0 0 0 0

A) B) C) D) E)

Atrial septal defect Coarctation of the aorta Tetralogy of Fallot Transposition of the great arteries Ventricular septal defect



8. An 18-year-old woman comes to the physician to request screening for colon cancer. Her father and grandfather died of colon cancer at the ages of 36 and 45 years, respectively Physical examination shows no abnormalities. Colonoscopy shows approximately 200 lesions throughout t he colon. A colectomy is done, and a section of the colon removed is shown in the photograph. Which of the following is the chance that this patient's offspring will eventually develop adenocarcinoma of the colon? 0 0 0 0 0

A) B) C) D) E)

0% 25% 50% 75% 100%





9. A 40-year-old man has pain in the buttocks that extends down the posterior left lower extremity to the heeL Pain is elicited with ive flexion of the hip beyond 30 degrees with the knee straight Power is decreased on plantar flexion. The left Achilles tendon reflex is absent; all other reflexes in the upper and lower extremities are 2+. There is a decrease in pinprick sensation over the lateral left foot and fourth and fifth toes. The most likely explanation is a lesion involving which of the following nerve roots? 0 0 0 0

A) B) C) D)

T-12 L-2 L-4 S-1

0 E) S-3




10. A 60-year-old man comes to the physician because of a 2-week history of flank pain and blood in his urine. He a lso has had weakness and a 4.5-kg (10-lb) weight loss over the past 2 months. Laboratory studies show hypercalcemia and polycythemia ACT scan of the chest shows multiple nodules in both lungs. ACT scan of the abdomen shows an 8-cm mass in the upper pole of the right kidney A biopsy specimen of the lung nodule is most likely to show which of the following?

0 0 0 0 0

A) B) C) D) E)

Bronchogenic squamous cell carcinoma Metastatic ren al cell carcinoma Metastatic transitional cell carcinoma Mult iple myeloma Undifferentiated carcinoma




11. A 28-year-old man has had urinary frequency and discomfort for 3 days Findings on urologic examination are unremarkable. Urinalysis shows pyuria but no other abnorm alities. A clean-catch urine culture yields no growth (<103 organismsfml ) The patient most likely has an infection caused by which of the following o rganisms?

0 0 0 0 0

A) B) C) D) E)

Chlamydia trachomatis Escf1eric!Jia coli Gardnerella vagina/is Human papillomavirus

Trichomonas vagina/is




12. A 4-yea r-old boy has fever and acute renal failure. A stool specimen grows Esc!Jeric/Jia coli 0157 H7. Which of the following find ings is most likely in a peripheral bl!ood smear? 0 0 0 0 0

A) B) C) D) E)

Hypersegmentation of neutrophils Normal cell counts Reactive lymphocytosis Schistocytes and throm bocyto[penia Severe pancytopenia




13. A 73-year-old man is brought to the physician by his wife because of a change in behavior, decreased appetite, and intermittent constipaHon during the past 4 months. He also has had a 4-kg (10-lb) weight gain during this period. His wife says, "He takes forever to get out of bed each day, and he talks so slowly these days. He is always forgetting things like where he put his keys." The patient says, "I don't think I have a memory problem, but I feel apathetic all the time." Physical examination shows an enlarged tongue He has slowed speech and difficulty following complex commands. He recalls only one of three objects after 5 minutes. Which of the following is most likely to establish the diagnosis? 0 0 0 0 0

A) B) C) D) E)

Measurement of fasting serum glucose concentrati on Measurement of serum thyroid-stimulating hormone concentration Serologic testing for syphilis EEG Lumbar puncture




14. An investigator studying the fu nction of a voltage-gated sodium channel develops a mutant form of the channel th at inactivates more rapidly than normaL Which of the following is the most likely effect of this mutation on the electrical properties of the neuron? 0 0 0 0 0

A) B) C) D) E)

Decreases the amplitude of the action potential Decreases the maximum frequency of action potential production Increases the conduction velocity of the axon Increases the input resistance of the axon Increases the rate of depolarization of th e action potential



15. A 62-year-old woman has an abdominal aortic aneurysm repaired Forty-eight hours after surgery, her right distal leg is dusky and cool, a nd there are dark purple-to-black necrotic lesions on several toes as shown. A biopsy of one of the lesions would most likely show occluded small arteries with needle-shaped clefts. Which of the following is the most likely cause of the lesions? 0 0 0 0 0

A) B) C) D) E)

Arteriolar narrowing Cholesterol emboli Septic emboli Vasospasm Venous thrombosis





16. Immediately after a cerebral infarction, a 62-year-old right-handed man has decreased fluency of spontaneous speech, with phrase lengths of less than four to five words. His comprehension is normal. Neurologic examination shows weakness of the lower two thirds of the face on th e right This patient most likely has a lesion in which of the following labeled areas in the drawing of the brain?

0 A)

0 B)

0 C)

0 D)

0 E)

0 F)

0 G)



17. A 6-year-old girl has the recent onset of difficulty hearing bilaterally. She has a history of multiple fractures. Her teeth have a yellowish brown discoloration. A ph otograph of part of her face is shown. The abnormality that is the most likely cause of these clinical findings is a gene coding a defect in which of the following? 0 0 0 0 0

A) B) C) D) E)

Elastase Fibrillin Neurofibromin Osteonectin Procollagen, type I





18. A 64-year-old man comes to the physician because of a 3-day history of fever and co ugh productive of purulent sputum. He has smoked 2 packs of cigarettes daily for 30 years. His temperature is 39.4•c (103. F). Physical examination shows erythematous tym panic m embranes. Rhonchi are heard on auscultation of the chest A chest x-ray shows consolidation in the right middle lobe. The physician wants to prescribe a drug that inhibits protein synthesis by binding to the 50S subunit of bacterial ribosomes. Which of the following drugs should be prescribed for this purpose?

0 0 0 0 0

A) B) C) D) E)

Azithromycin Cefdinir Cefepime Levofloxac in Trim ethopri m-sulfamethoxazole




19. A 65-year-old man has a radica l prostatectomy and lymph node dissection for adenocarcinoma of the prostate Which of the following features is involved in the grading of this neoplasm? 0 0 0 0 0

A) B) C) D) E)

Capsular penetration Lymph node involvement Metastatic spread Tum or cell appearance and arrangement Tum or size




20. A 60-year-old man with congestive heart failure develops bacterial bronchopneumonia while in the intensive care unit He responds to appropriate antibiotic therapy, but 3 days after the initiation of treatment, he develops a maculopapular rash over the extremities, with central vesicles and bullae having a targetoid appearance. A biopsy specimen of the rash shows subepidermal blisters and degeneration of the basal cell layer, keratinocyte necrosis, and lymphocytic infiltration at the dermal/epidermal junction. Which of the following is the most likely diagnosis? 0 0 0 0 0

A) B) C) D) E)

dermatitis Erythema multiforme Impetigo Stapflylococcus aureus infection Urticaria




21. An 11-year-old boy has repeated episodes of staphylococcal pneumonia When incubated in vitro with Stap!Jy/ococcus aureus, his peripheral blood neutrophils fail to demonstrate a respiratory burst and do not kill the microorganisms, even though electron microscopy of the neutrophils shows bacterial cells within phagosomes. This failure to killl phagocytosed organisms is due to a deficiency of which of the following? 0 0 0 0 0

A) B) C) D) E)

Lactoferrin Lysosomal proteases Lysozyme NADPH oxidase Superoxide dismutase

Exam Section 4: Item l l of 50 • Mark



22. A 22-year-old woman is itted 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 istration of desmopressin, urine output and osmolality do not change. The most likely cause of the polyuria in this. patient is a defect in which of the following sites in tihe nephron? 0 0 0 0 0

A) B) C) D) E)

Collecting duct Glomerular capillary Juxtaglomerular apparatus Loop of Henle Proximal tubule




23. An investigator is studying the efficacy of autoclave sterilization commonly used by hospitals to disinfect surgical instruments. One of the autoclaves studied generates pressures of 15 to 20 psi and temperatures of 121 octo 126°C. Which of the following infectious agents is most likely to retain infectivity after this method of sterilization? 0 0 0 0 0

A) B) C) D) E)

Bacteria Fungi Parasites Prions Viruses




24. A newborn has cyanosis, tachypn ea, and retractions of the muscles of the chest wall during inspiration She weighs 2500 g (5 lb 8 oz) Arterial blood values w hile she breathes room air are:

pH Pco, Po, HC0 3Which of the following best describes her acid-base balance?

0 A) Metabolic acidosis, uncompensated 0 B) Metabolic alkalosis, uncompen sated

o C)

Respiratory acidosis, uncompensated

0 D) Respiratory alkalosis, uncompensated 0 E) Respiratory acidosis and metabolic acidosis 0 F) Respiratory acidosis and metabolic alkalosis

7.04 65 mm Hg 35 mm Hg 15 mEq/L




25. A 2-yea r-old girl who is exposed to the sun has progressive development of dryness of the skin, excessive freckl ing, and keratoses. Skin fibroblasts cultured from this child are most likely to be defective in which of the following? 0 0 0 0 0

A) B) C) D) E)

Alky ltransferases required to repair alkylated nucleotides Excision repair catalyzed by e111donuclease Ill Excision repair of uracil that occurs in DNA Nuclear excision repair of pyrimidine dimers Recombination repair mechanisms




26. A 32-year-old man who is an international health worker is given primaquine as prophylaxis against malaria. He becomes jaundiced Laboratory findings are consistent with hemolytic anemia. The mechanism most likely to be responsible for this blood disorder is hemolysis due to which of the following? 0 0 0 0 0

A) B) C) D) E)

Antibody directed against the drug bound to a protein of the erythrocyte membrane Antibody directed against the drug in th e plasma with complement binding to the erythrocyte membrane Autoantibody induced by the dlrug Direct injury to the erythrocyte membrane Enzyme deficiency in the erythrocytes




27. A 48-year-old woman comes to the physician because of fever and frequent slimy stools for 2 weeks. She recently emigrated from Uganda Her temperature is 38.4•c (1 01. 1•F) Abdominal examination shows mild tenderness of the right upper quadrant Examination of the stool shows mucus. Colonoscopy shows multiple ulcers that have undermined and destroyed large areas of the intestinal epithelium Which of the fol lowing is th e most likely causal organism? 0 0 0 0 0

A) B) C) D) E)

Cryptosporidium parvum Entamoeba !Jistolytica Giardia Iamblia Leishmania donovani Trichomonas vagina/is



28. Which of the following mechanisms of action disting uishes tumor-suppressor genes from proto-oncogenes? 0 0 0 0 0

A) B) C) D) E)

Inhibition of cell-cyc le regulation Mutations of G protein Mutations of gene activation Phosphorylation of gene product Trans factor binding to regulatory DNA sequences





29. A 48-year-old man is brought to the emergency department 2 hours after injuring his left leg when he slipped and fell on an icy sidewalk. Physical examination shows an obvious lateral swing of th e left lower extrem ity when he walks. X-rays of the left lower extrem ity show no fractures. An injury to the left obturator nerve as it es through the obturator foramen is suspected, and physical therapy is initiated. This patient's gait abnormality is most likely to be corrected by strengthening the muscles that control which of the following movements of the left proximal lower extremity? 0 0 0 0 0 0

A) B) C) D) E) F)

Abduction Add uction Extension Flexion Lateral rotation Med ial rotation




30. A 66-year-old man comes to the physician because of a 2-month history of the inability to maintain an erection. He also has had fatigue and difficulty sleeping and concentrating during this period. Three months ago, he had a cerebral infarction with right hemiparesis that has gradually resolved. Physical examination shows no abnormalities. Which of the following additional pairs of findings in this patient is most likely on history taking? Libido

0 0 0 0

A) B) C) D)

Normal Normal Decreased Decreased

Nocturnal Erections

normal decreased normal decreased



Time Remaining:

31. The eDNA clone of ovalbumin contains 1872 base pairs, while a genomic clone of the gene contains 7700 base pairs Which of the following sequences present in t he genomic clone primarily s for this d ifference in size?

0 0 0 0 0

A) B) C) D) E)

Exons lntrons Long terminal repeats Polyadenylation signals Promoters




32. A 5-yea r-old boy is brought to the physician because of pain in the right eye at night fo r the past week. There is no family history of neoplasia Examination shows strabismus and tenderness in the eye The left eye is norm al. Examination of the retina shows the presence of a mass. The physician explains to the parents that the boy is unlikely to develop any other neoplasms The fi rst mutation leading to this neoplasm most likely occurred in w hich of the following? 0 0 0 0 0

A) B) C) D) E)

Germ cells Retinal cells Somatic cells of the child Somatic cells of the parents Zygote




33. A 2-yea r-old boy with cerebral palsy is scheduled for surg ical correction of early adduction contracture and subluxation of the right hip. He had difficulty sitting up at the age of 8 months and learned to crawl by dragging his lower extrem ities. Section of which of the following nerves is most likely to relieve the addl!lction contracture in this patient? 0 0 0 0 0

A) B) C) D) E)

Common fibular (peroneal) Femoral Obturator Superior gluteal Tibial




34. A 36-year-old woman comes to the emergency department because she thinks she had a heart attack when she was grocery shopping this morning She had the sudden onset of palpitations, shortness of breath, dizziness, numbness and tingling of her hands and feet, and shaking The symptoms lasted about 30 miinutes and resolved spontaneously. She has a history of two similar episodes in the past month; one occurred while she was at home and the other while she was at work. She is otherwise healthy. Physical examination, ECG, and laboratory studies show no abnormalities. Which of the following is the most likely diagnosis? 0 0 0 0 0

A) B) C) D) E)

Acute stress disorder Generalized anxiety disorder Panic disorder Social phobia Specific phobia




35. A 13-year-old girl is brought to the physician by her mother for a routine well-child examination. Neither the child nor the mother has any particular health concerns. The patient is doing well in school and participates in soccer and lacrosse in a local recreation league The physician wants to ask the pati ent about sexuality and sexual activity. Which of the following actions by the physician is most appropriate? 0 0 0 0 0

A) B) C) D) E)

Ask the mother to leave the room before asking the patient any questions Ask the patient to leave the room and then ask the mother about her daughter Ask the questions with both the moth er and the patient present Give the patient a questionnaire that she can fill out at home Tell the patient that some sens itive questions are next and that only she can ask her mother to leave the room


• Mark


36. A patient in the early stages of hemorrhagic shock is most likely to have which of the following? 0 0 0 0 0

A) B) C) D) E)

Decreased ventilatory rate due to inhibition of the respiratory center Flus hing due to cutaneous vasodilation that occurs seco ndary to sweating Increased renal blood flow due to sympathetic activation Sweating due to parasympathetic stimulation of sweat glands A weak pulse due to decreased stroke volume

Time Remaining:

17 min 0 sec




37. A 50-year-old man comes to the physician because of a 2-month history of chronic abdominal pain He also has had intermittent mild knee pain since playing college football 30 years ago; the pain has become more constant during th e past 5 weeks. Physical examination shows mild epigastric tenderness and decreased range of motion of both knees. End oscopy shows an antral ulcer. Which of the following drugs is most appropriate fo r this patient's knee pain?

0 0 0 0 0

A) B) C) D) E)

Acetaminophen Aspirin Ibuprofen Indomethacin Naproxen




38. A 14-year-old boy has had tremo rs of the extrem ities and greenish rings at the margin of the cornea near the lim bus for 1 year Laboratory studies show a plasma ceruloplasmin concentration below the 95% confidence limits of normal and a 12-fold increase in sew m ALT activity. Which of the following treatments is most likely to be effective? 0 0 0 0 0

A) B) C) D) E)

Calcium supplementation Mult ivitamins Oral istration of calcium disodium ed etate (EDTA) Oral istration of ferrous salts Periodic intramuscular injections of penicillamine



39. A 53-year-old man comes to the physician because of ma laise and increased fatigue during the past 2 months; he has had a 9-kg (20-lb) weight loss during tlhis period Physical examination shows splenomegaly His leukocyte count is 75,000/mm3. A bone

marrow biopsy specimen shows hypercellularity with maturing granulocytes, increased numbers of megakaryocytes, and normal erythroid elements. A peri pheran blood smear is shown. This patient is treated with imatinib mesylate for his condition. This drug is most likely 1o block which of the fol lowing enzyme activities associated with the chromosomal abnormality that causes this disease? A) B) C) D) • E)

MAP kinase Phosphofructokinase Phosphorylase kinase Protein kinase A Tyrosine kinase

Please Wait




40. A 53-year-old woman with gastroesophageal reflux disease comes to the physician for a follow-up examination. Dietary changes and stress reduction have had no ·effect on th e frequency or intensity of her symptoms. Physical examination shows mild epigastric tenderness. Which of the following drugs is most likeliy to be effective in both relieving this patient's symptoms and promoting healing of her esophageal mucosa? 0 0 0 0 0

A) B) C) D) E)

Bethanechol Famotidine Metoclopramide Misoprostol Omeprazole



41. Adhesion of pl atelets to the subendothelial surface requires the interaction of platelet membrane glycoprotei n with which of the following? 0 0 0 0 0

A) B) C) D) E)

Fibrinogen Spectrin Throm bomodulin Throm boplastin von Willebrand factor



42.


Test (1)

Sensitivity

Specificity

70

100

(2)

90

95

(3)

95

70


Three inexpensive tests are available to evaluate children w ith diarrhea for rotavirus. The sensitivity and specificity of each test are summarized in th e ta ble. If it is important to treat only those who actually have the disease because of the toxicity of the treatment, which of th e following testing strategies is most appropr iate? 0 A) I!] B) 0 C) 0 D) 0 E)

Test Test Test Test Test

1 followed 3 followed 2 only 2 followed 2 followed

by test 3 if test 1 is positive by test 1 if test 3 is positive by test 3 if test 2 is negative by test 3 if test 2 is positive




43. A 40-year-old woman comes to the physician because of a lump in her neck. She says the lump has been present for decades but has become larger over the past month. Physical examination shows an 8x10-mm mass that is located just lateral to the midline over the thyroid cartilage It is soft, mobile, and moves upward when th e patient protr udes her tongue maximally Th e mass most likely represents which of the fol lowing structures?

0 0 0 0 0 0

A) B) C) D) E) F)

Carotid body tu mor Dermoid cyst Hygroma Inno minate artery Lymph node Thyroglossal cyst




44. A 40-year-old woman who had pneumonia due to Streptococcus pneumoniae 6 months ago comes to the physician for a follow-up examination. X-rays of the chest show no abnormalities. Which of the following is produced by the ceal type most likely respon sible for the restitution of near-n ormallung structure?

0 0 0 0 0

A) B) C) D) E)

Factor VIII (antihemophilic factor) Histamine P-selectin Surfactant Type I collagen




45. To determ ine whether angiotensin-converting enzyme (ACE ) inhibitors are superior to ca lcium channel blockers in preventing renal disease progression in patients with newly diagnosed type 1 diabetes mellitus, which of the following is the major advantage of a randomized controlled trial versus a prospective co hort study? 0 0 0 0 0

A) B) C) D) E)

Better control for confounding variables Less likely to show regression to the mean Lower risk for a Type I error Lower risk for a Type II error Req uirement of fewer patients to achieve statistical significance



46. A 35-year-old man has nephrotic syndrome. Examination of tissue obtained on a renal biopsy shows uniformly thickened glomerular capillary basement membranes . Immunofluorescent studies show granular deposits of lgG and C3. Which of the follow ing is the most likely diag nosis? 0 0 0 0 0 0

A) B) C) D) E) F)

Amyloidosis Diabetes mellitus Focal segmental glomerulosclerosis Membranous nephropathy Minimal change disease Systemic lupus erythematosus




47. A 2070-g (4 1b 9 oz) stillborn male newborn is delivered by cesarea n secti on at 36 weeks' gestation At autopsy, examination shows cyclopia and a cleft lip and palate. Chromosomal analysis shows a 47,XY+13 karyotype Which of the following congenital central nervous system malformations is most likely in this newborn?

0 0 0 0 0 0

A) B) C) D) E) F)

Anencephaly Cranial meningocele Encephalocele Holoprosencephaly Neuronal heterotopia Polymicrogyria





48. A 62-year-old woman is brought to the physician 1 day after the sudden onset of weakness of her left leg. She has smoked 111, packs of cigarettes daily for 40 years. She is 157 em (5 ft 2 in) tall and weighs 68 kg (150 Ib); BMI is 27 kgfm2 H·er pulse is 85/min, and blood pressure is 140/ 100 mm Hg Examination of the Deft lower extremity shows a muscle strength of 1/5 and deep tendon reflexes of 3+. When her eyes are closed, she cannot tell whether her left great toe is raised or depressed. The remainder of the examination shows no abnormalities. The most likely cause of her condition is an embolism of which of the following arteries? 0 0 0 0 0

A) B) C) D) E)

Left anterior cerebral Left middle cerebral Left posterior cerebral Left radicular branches of the anterior spinal Left radicular branches of the posterior spinal

0 0 0 0 0

F) G) H) I)

Right anterior cerebral Right middle cerebral Right posterior cerebral Right radicular branches of the anterior spinal J) Right radicular branches of the posterior spinal




49. Examination of tissue obtained on biopsy of a neoplasm on the scalp of a 45-year-old man shows early invasive squamous cell carcinoma. The site of incision for the biopsy is not sutured . One week later, the mass is widely excised. In the excised specimen, the biopsy site is most likely to show which of the following? 0 0 0 0 0

A) B) C) D) E)

Granulation tissue Granulomatous inflammation Intense eosinophilic infiltration Perifolliculitis Regeneration of elastic fibers



Time Remaining: 44 sec

50. A sedentary 50-year-old woman comes to the physician because of decreased energy for several months. She states that she has not seen a physician in years because she does not trust doctors. She says, "But, I just turned 50, so I thought I'd get myself checked out" She has smoked one-half pack of cigarettes daily for 33 years She is 163 em (5 ft 4 in) tall and weighs 86 kg (189 lb); BMI is 33 kg/m2 Her blood pressure is 148/92 mm Hg. Breath sounds are decreased and mildly tubular on auscultation. Cardiac examination shows a laterally displaced point of maxfimal impulse There is trace pedal edema. Serum studies show a fasting glucose concentration of 122 mg/dl, total cholesterol concentration of 238 mg/dl, and HDL-cholesterol concentration of 31 mg/dl. An ECG suggests left ventricular hypertrophy. It is most appropriate for the physician to primarily focus on which of the following for the first several visits? 0 0 0 0 0

A) B) C) D) E)

Control of her hypertension Establishing a therapeutic alliance with the patient Evaluation and treatment of chronic obstructive pulmonary disease Recommendation of smoking cessation Treatment of her hyperlipidemia

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