1.

Block 1 part 1
1. 56-year-old man comes with vague right-sided flank pain and 7-lb weight
loss over past 6 weeks. No recent trauma or back strain. Urine is darker
than usual over 2 weeks. Renal ultrasound shows 1.5-cm solid mass in
upper portion of right kidney. Urine shows 50 erythrocytes, 6 leukocytes, no
bacteria. Dx?
- Renal cell carcinoma
2. 22-year-old man who is a professional cyclist undergoes extensive
physiologic testing as part of his training regimen. His resting pulse is
33/min, and blood pressure is110/62 mm Hg. Echocardiography shows
dilated ventricles with normal function and a left ventricular ejection fraction
of 75%. Which of the following best describes the findings in this patient?
- Eccentric hypertrophy
3. During a clinical study of calcium and phosphorus metabolism, a 50year-old man undergoes series of lab studies. His serum Ca, PO4 and PTH
are normal. He is given infusion 2 g Calcium chloride over 2 hours. His
serum Ca concentration now is 11.5mg/dl. Compared with pre infusion
levels, the serum concentration of which of the following substances is
likely to be increased at this time?
- 24,25-Dihydroxycholecalciferol
4. 70-year-old man comes with skin blistering for 1 week. No oral lesions.
Physical shows tense bullae in joint folds of upper and lower extremities.
Biopsy shows subepidermal blister formation. Immunofluorescence
microscopy shows antibodies against proteins at the dermal-epidermal
junction. Target by antibodies?
- Hemidesmosome
5. 63-year-old man with abnormal blood pressure. 6 months ago, bp was
135/85. Today bp 170/98. Bruit heard over left renal artery. CT angio shows
left arterial stenosis. Labs?
- Total peripheral resistance increased, plasma renin activity increased,
serum aldosterone concentration increased
6. 35-year-old woman with 3-month progressive shortness of breath with
exertion. RR 26. Physical shows jvd and prominent a wave. Lungs clear.
Cardiac exam shows loud pulmonic component of S2 and right-sided S4

gallop. Increased pulmonary expression of what?

- Endothelin-1
7. 30-year-old woman with 2-years of numbness, blanching, and bluish
color to ears, fingers and toes after emotional upset or cold exposure.
Vitals and PE normal. Avoid taking which drug?
- Phenylephrine
8. 35-year-old woman with 2-day history of blistering lesions on sunexposed face, arms and hands. Recurrent episodes of skin lesions over
several years. Taking oral contraceptives for 15y. PE shows fluid-filled
vesicles and bullae. Labs: AST increased, ALT increased, total porphyrin
increased, urine uroporphyrin III increased. Precursor to uroporphyrin?
- Succinyl CoA
9. 65-year-old with sudden onset generalized tonic-clonic seizures.
Personality change last 6 months; used to be mild mannered and now
verbally abusive. CT shows single mass enhances with contrast in right
frontal lobe and crosses to left hemisphere through corpus callosum. Dx?
- High-grade fibrillary astrocytoma
10. 3-week-old male newborn with recurrent vomiting after feeding since
birth, and eager to feed after vomiting. Abdominal exam shows firm, mobile
mass in epigastrum to right of midline. Dx description?
- Single primary development defect
11. 39-year-old man with 1-week of red spots on shins, joint pain and
fatigue. PE shows purpura over lower extremities. Liver palpated 4 cm
below costal margin. Labs: WBC 10,000, AST 142, ALT 154, hepatitis C
virus RNA positive, anti-hepatitis C virus antibody positive, cryoglobulins
positive, C4 120 (N=350-600), urine protein 4+, urine RBC numerous.
Hypersensitivity reaction?
- Type III (immune complex-mediated)
12. 45-year-old man with hypertension not compliant with medications. bp
160/100. Cardiac exam shows apical impulse displaced laterally, loud S2
and S4 gallop. Echo shows thickening of left ventricular wall. Mechanism of
change in cardiac muscle?
- Transcription factor c-Jun: increased, beta-myosin heave chain:
increased, endothelin: increased

13. 70-year-old man with early morning awakening, decreased energy,

difficulty concentrating, anhedonia, psychomotor retardation, depressed
mood for 3 months. He had myocardial infarction and nonsustained
ventricular tachycardia 2 years ago. Tx?
- Paroxetine
14. 5-year-old boy with motion sickness. Planning vacation to Australia, and
wants diphenhydramine for motion sickness. Mechanism of action for
motion sickness?
- Antagonist at muscarinic-3 (M3) receptors
15. Newborn is found to have a cervical rib. Transformation of seventh
cervical segment to thoracic identity. Which is true of HOX gene alteration?
- Expression of a HOX gene normally expressed only caudal to C7
16. 28-year-old man with ulcerative colitis, history of partial colectomy, and
improved rectal bleeding and diarrhea since then. Meds include
mesalamine, hydrocodone and acetaminophen. He says, "I've been taking
so much of my opiate prescription that I ran out and stole some from my
job." Next step?
- Discuss treatment options and a referral for detoxification program
17. 66-year-old man dies 7 days after myocardial infarction. Gross of heart
shown (perforated interventricular wall). Histology?
- Erythrocytes, cellular debris, macrophages, and early granulation tissue
18. 16-year-old boy who frequently thinks about sex, daydreams about girls
before going to sleep, and masturbates one to two times daily. After
counseling about safe sex, best next step?
- Schedule next routine examination
19. 18-year-old man comes with cracked lips and peeling sunburned skin.
Works as lifeguard. PE shows desquamation of sunburned skin. Lips are
dry and cracked. Petrolatum to lips may reduce lip symptoms by which of
following effects of the compound?
- Barrier
20. 29-year-old woman comes to the physician because of irregular
menstrual periods since menarche at the age of 12. She is 5.3Ft and

weighs 86kgs. BMI 34. She is evaluated and a diagnosis of PCOS is made.
After explaining the diagnosis, the physician discusses behavioral changes,
including dietary modification and exercise as part of her treatment. Which
of the following will ensure adherence?
- Provide follow ups to monitor progress in attaining her goal
21. 30-year-old man in bicycle collision and hits right shoulder forcefully.
Unable to flex right elbow with decreased sensation to pinprick over right
lateral forearm. Brachial plexus lesion?
- E (musculocutaneous nerve)
22. 67-year-old man with 1 year progressive difficulty writing and walking.
Pt is stooped and talks slowly. PE shows bland facial expression, fine
resting tremor in both hands, no tremor when moves, walks with difficulty
starting and stopping, cogwheel rigidity. Brain tissue histology shown as
well as gross cross sections of midbrain both normal and diseased.
Substance referred to by arrow?
- Alpha-synuclein
23. 25-year-old woman with polycystic kidneys and 3-month history of
weakness, fatigue, headaches, hypertension, loss of appetite and itching.
Cr 4. Labs?
- bicarb (HCO3-) decreased, inorganic phosphorous (PO4) increased,
parathyroid hormone increased
24. 32-year-old woman brought in after 10-foot fall from ladder. PE
suggests severe hemorrhage and shock. Xray shows fracture of left ninth
and tenth ribs. Organ injured?
- Spleen
25. 26-year-old man comes in 2 hours after injuring arm skiing. Sensation
to pinprick absent over lateral aspect of shoulder. Xray of right shoulder
shown (fracture of surgical neck of humerus). Nerve damaged?
- Axilary nerve

Block 1 Part 2
26. 50-year-old woman with COPD comes with 3 months of progressive

shortness of breath. Physical shows JVD, loud pulmonary component of

S2. Pulmonary function tests show FEV1:FVC ratio of 20% and decreased
diffusing capacity for carbon monoxide. Which is decreased in pulmonary
vascular smooth muscle?
- Endothelial nitric oxide synthase production
27. An experimental animal is created that has a defect in an innate
gastrointestinal defense mechanism. Organism is found to have decreased
HCl prod. After 2 months on biopsy gastric fundus and body show
decreased mucosal thickness and hyperplasia of enterochromaffin like
cells. This closely resembles?
- Chronic gastritis
28. 63-year-old woman with 2-week history of daily episodes of severe,
lancinating, left-sided facial pain. Pain lasts 30 to 60 seconds and shoots
down ear along jawline. Precipitated by chewing or brushing teeth. Dx?
- Trigeminal neuralgia
29. 45-year-old homeless man found unconscious. Breath smells of
alcohol. Vitals stable. PE shows bronzed skin and spider angiomata on
chest. Labs: hemoglobin 10, hematocrit 30%, MCV 110, WBC 9000,
platelets 160,000, ferritin 200, b12 500, folate 20. Blood smear shows
hypersegmented neutrophils and 3+ oval macrocytes. Labs?
- Methylmalonic acid: normal, Homocysteine: increased
30. 68-year-old man with creatinine 2.3 due to chronically increased
hydrostatic pressure in Bowman space. Cause?
- Benign prostatic hyperplasia
31. 70-year-old woman comes to the physician because of increasingly
severe pain in the right knee over the past 3 months. She has fallen
repeatedly. She has a 10 year history of symptomatic osteitis deformans.
She has bowed tibia and tenderness of the proximal right tibia. an X ray
shows a fracture of the proximal tibia with elevated periostium and sunburst
pattern. an xray of lungs shows pulmonary nodules of various sizes. which
of the following findings is most likely on biopsy.
- Pleomorphic neoplastic cells producing new woven bone
32. 30-year-old woman with a long-standing history of pelvic inflammatory
disease has surgical resection of a scarred segment of a fallopian tube.

Which of the following inflammatory cells is most likely to be found in the

resected specimen?
- Macrophages
33. 67-year-old woman with atrial fibrillation with sudden onset severe
abdominal pain. Ex-lap shows embolus in superior mesenteric artery with
complete occlusion of middle colic artery. Ischemic changes where?
- Small intestine, ascending colon, and part of the transverse colon
34. 68-year-old man with alcoholism comes for fever, chills and productive
cough of purulent sputum for 3 days. Blood cultures positive. Gram stain:
gram-positive, lancet-shaped diplococci. Vaccine is against which bacterial
component?
- Capsular polysaccharide
35. Patient making sexual advances towards physician. Appropriate
measure?
- Have a chaperone join them
36. Cholera toxin catalyzes transfer of ADP-ribose to an arginine residue in
stimulatory G protein resulting in inhibition of GTPase activity. Which
increases in cells as a result?
- Concentration of cAMP
37. 8-year-old boy with pain on back and head since he fell off swing.
Tender 2.5cm swollen mass over right occiput. CT shows osteolytic and
soft-tissue mass in skull with inward displacement of dura. Biopsy shows
sheet-like infiltrate of pale eosinophilic cells with bean-shaped nuclei. Cells
positive for CD1a. Electron microscopy of cells shows Birbeck granules.
Abnormal cell type?
- Langerhans cells
38. 60-year-old man 1 day of fever, chills, confusion and memory loss.
Returned from Gulf coast where he walked barefoot. Hx of severe cirrhosis
and portal hypertension. T 39C (102.2 F), RR 22, bp 90/48. Physical shows
early blister formation on right lower extremity. Blood culture: gramnegative, lactose-fermenting organism. Bug?
- Vibrio vulnificus
39. 20-year-old woman at 27 weeks' gestation is admitted to the hospital

because of a 12-hour history of intense uterine contractions occurring every

8 minutes. Her membranes ruptured 32 hours ago. Her temperature is
39.1C(102.4F), and pulse is 115/min. Physical examination shows
tenderness of the uterus. Pelvic examination shows a closed cervix that is
not effaced. The fetal heart rate is 210/min. Which of the following is the
primary stimulus for her uterine muscle contractions?
- Inflamed maternal decidua release of prostaglandin
40. Child with XXY karyotype, genetic studies showed he received the
extra "x" from his father. An error of chromosome segregation occurred
during anaphase at which of the following stages of spermatogenesis in the
patient's father?
- Primary spermatocyte
41. 10-year-old boy with 4 days nosebleeds and easy bruising. Three
weeks ago, upper respiratory tract infection. PE ecchymoses on upper and
lower extremities. Labs shows hemoglobin and leukocyte count normal,
and decreased platelet count. Bone marrow smear shows increased
megakaryocytes. Mechanism of dz?
- Antibodies against glycoprotein (Gp) IIb/IIIa complex
42. 34-year-old man with a 3 month history of a progressive rash on his
feet. Rash is not itchy or painful. A photograph of feet is shown. HIV+. In
addition to HAART, which of the following pharmacotherapy is most
appropriate?
- Antineoplastic
43. 55-year-old man with elevated LDL cholesterol is prescribed lovastatin.
This treatment would result in which adaptive responses at the cellular
level?
- Increased transcription of HMG-CoA reductase
44. A new antiplatelet agent is developed for the prevention of recurrence
of stroke. In a large randomized clinical trial with equal numbers of men
and women, the rates of stroke are lower in patients receiving the new
agent than in patients receiving the standard treatment. Results are shown:
Recurrent Stroke Rates per 1000 Person-Years
Standard Treatment vs. New Antiplatelet Drug
Women .12 .04
Men .24 .08

Overall .18 .06

Based on these results, which of the following is the relative risk reduction
in women?
- 67%
45. 52 yo man is brought to er 30min after the onset of chest pain and
shortness of breath. He had played tennis all day and he does not
remember how much fluid he had consumed. His temperature is 36.7 oC,
pulse 122min, respirations 28min and BP 90/50 mmHg. PE shows dry skin
and decreased capillary refill. An ECG and evaluation of cardiac enzymes
show no abnormalities. Which of the following findings in the nephron best
describes the tubular osmolarity, compared with serum in this patient?
PT //macula densa //medullary collection duct
- Isotonic, hypotonic, hypertonic (?)
46. Persons are at risk of influenza are vaccination every year because of
antigenic variation, which can be drift (minor) or shift (major). Mechanism of
antigenic shift?
- Reassortment
47. 63 yo man with mild emphysema has smoked 1 pack for 45 years
sudden headache, myalgia and rising temperature. A dry cough develops,
with chill and chest pain. Examination of gram stain of sputum disclose
neutrophils, but bacteria are not evident. An X-ray of the chest is consistent
with severe pneumonia. A culture of sputum is negative, but culture of
bronchoscopy specimen on a highly specialized bacteriologic medium
yields gram negative rods. The identity of these bacteria is confirmed by
staining with specific fluoroscent antibodies. The patient respond therapy
with macrolide Ab. Mechanism?
- Inhalation of aerosol from an environmental source (Legionella)
48. A sexually active 32-year-old woman has vaginal pain with urination.
Pelvic examination show bilateral vesicoulcerative lesions of introitus. Tx?
- Acyclovir
49. 4-day-old boy with vomiting after breastfeeding. PE shows lethargy and
dry mucous membranes. Labs: Na 139, Cl 90, K 7, HCO3 17, Glucose 42,
BUN 25, Cr 0.4, 17-hydroxyprogesterone increased. Enzyme deficiency?
- 21-hydroxylase

50. 7-year-old boy is about undergo an appendectomy. An intravenous

catheter needs to be inserted, but the patient is fearful of being stuck with
needle. The most appropriate anesthesia administered by mask to
anesthetize this patient quickly would have which of the following
characteristics?
- Low blood solubility
Block 2 Part 1
1. 23-year-old woman g1p1, not felt well since delivery 2 weeks ago;
ongoing fatigue, inability to breast-feed, light-headedness in upright
position. Pregnancy complicated by preeclampsia and required cesarean
delivery, after she required blood transfusions because of hypotension. PE
appears lethargic. HR 80, BP 100/50, HR standing 85, BP standing 86/44.
Hb 11.6, hct 36%. Serum hormone concentrations?
Prolactin/ACTH/TSH/Aldosterone
- decreased, decreased, decreased, increased
2. 21-year-old woman with 2-days history of urinary frequency and pain
with urination. T 39 C (102.2 F), pulse 125, bp 96/60. Urine grows gramnegative bacteria. Virulence factor for adherence to bladder?
- Fimbriae
3. Man comes to doc for cast removal. Fracture of left humerus that
required open reduction, internal fixation, cast immobilization. Muscle
strength is 2/5 with extension of elbow and 1/5 with extension of wrist and
fingers. Patient most likely sustained a fracture at (which location in
humerus)?
- Radial groove (radial N. is the extensors of arm, wrist and fingers)
4. 36-year-old F with 2 week history of fatigue, bleeding of the gums, and
bone pain. Physical examination shows pallor, hepatosplenomegaly, and
ecchymotic lesions over extremities. Labs:
Hb 8g/dl
Ht 25%
Leukocytes: 36,000
segm neutr 4%
eosinophils 4%
lymph 6%

mono 6%
promyelo 80%
platelets 25,000
Polymerase chain reaction test shows an mRNA corresponding to the
retinoic acid receptor- alfa/promyelocytic leukemia fusion gene resulting
from a reciprocal translocation of chromosomes 15 and 17. Treatment w/
all-trans retinoic acid is started. In response to the therapy, the fusion
protein will most likely attract which of the following proteins to form a pretranscriptional complex?
- Histone acetylase
5. 98-year-old woman who lives with daughter and grandson comes for
routine exam with type 2 diabetes and hypertension but no complaints. She
has had 14-lb weight loss since last visit 3 months ago. BMI 15. PE shows
multiple ecchymoses in various stages of healing upper extremities and
torso. Physician should ask?
- "Are you safe at home?"
6. 18-year-old woman comes 12 hours after ingesting 100 aspirin tablets in
suicide attempt. PE shows tachypnea. Labs?
pH/pCO2/HCO3- 7.32/15/8
7. 10-day-old male newborn 1-day history red eyes with discharge.
Pregnancy uncomplicated but no prenatal care in third trimester. PE
bilateral conjunctival injection with water discharge. Cause?
- Chlamydia trachomatis (gonorrhea occurs earlier and is more purulent)
8. 14-year-old girl with 4 months of heavy menstrual flow. Menarche at 13
with regular intervals. History of frequent nosebleeds and easy bruisability.
Father has problems with nosebleeds and clotting. PE shows mild gum
bleeding and ecchymoses. Labs: hb 8.2, hct 24.6, platelet 250,000,
bleeding time 10, PT 14 (INR 1.5), PTT 60. Dx?
- von Willebrand disease
9. Prevalence of high-grade cervical intraepithelial neoplasia in unscreened
population is 5%. Prevalence in population with negative Pap smear results
is as high 0.2%. Prevalence decreases, which also decreases?
- Predictive value of a positive test result

10. 57-year-old man with alcoholism dies of klebsiella pneumonia. Abscess

cavities filled with purulent exudate on autopsy. Pattern of necrosis in lung
tissue?
- Liquefaction
11. 35-year old man w several episodes of squeezing chest pain gets
angiogram... gets IV NE. Question shows a graph of coronary blood flow
with a drop after the NE and then a rise. Which substance causes
increased total coronary blood flow 1-2 mins after NE?
- Adenosine
12. 24-year-old woman overdose on drug X and has serum concentration
of 32. Drug X follows first-order kinetics. 6 hours later, the serum
concentration is 16. Cannot be moved from intensive care unit until
concentration 1.1 or lower. Which is minimum number of hours from first
blood sample (32) that patient must remain in icu?
- 30 hours (5 half lives)
13. 4-year-old boy with fatigue and irritability for 2 months. Family visited
rural Louisiana 5 months ago and ran around barefoot. Conjunctivae are
pale. Labs shows normal wbc with 15% eosinophils. Stool prep shows
parasite egg (picture). Cause of fatigue?
- Microcytic anemia (strongyloides)
14. 35yo F has congestive cardiomyopathy and pitting edema. Her serum
urea nitrogen concentration is 25mg/dl and serum creatinine is 1.8mg/dl.
Furosemide therapy is started. After 5 days, labs show:
Na 130
K 4.5
Cl 90
HCO 30
BUN 85
Creatinine 2.2
Albumin 3
Urine specific gravity 1.023, rbc 0 wbc0 sediment none
Urinary fractional excretion of sodium is less than 1%. Explanation?
- Prerenal azotemia
15. Investigator studying immune response to fungi. Fungi express betaglucans on cell surface and that triggers innate immune response. Which tx

decreases glucan expression?

- Caspofungin
16. 72-year-old woman comes to the physician because of a 6-month
history of increased bruising on her forearms. She appears alert and well
nourished. Physical examination shows extensive wrinkling, scaly
erythematous patches on the face, and irregularly shaped brown macules
on the face and forearms. There are ecchymoses in various stages of
healing on both forearms; the ecchymoses are more numerous on the right
side. Laboratory studies, including a complete blood count and coagulation
studies, are within the reference ranges. She has noticed no bleeding from
her gums after brushing her teeth. Which of the following is the most likely
cause of the ecchymoses in this patient?
- Extensive solar elastosis
17. Heart of 76-year-old woman shows concentric enlargement of left
ventricle. Micro exam shows enlarged myocardial cells with large nuclei. Dx
that causes this cardiac enlargement?
- Hypertension
18. 45-year-old woman dx with cholelithiasis. She asks why abdominal pain
is intermittent and not constant. Pain is produced when gallbladder
contracts against gallstone obstructing cystic duct. Where is hormone
released from that causes gallbladder contraction?
- Enteroendocrine cells of the small intestine (CCK)
19. 73-year-old man has poor appetite and lost 25 lb over 4 months. Labs
show normochromatic normocytic anemia. Xray of chest shows 2-cm
perihilar mass. Biopsy shows small cell carcinoma of lung. Which is
responsible for weight loss?
- Cytokine effect
20. 34-year-old man burned hands firing pots 3 months ago. He has no
pain during or after burn. PE shows mild atrophy of arms and hands,
absence of deep tendon reflexes in upper extremities, and decreased pain
and temperature sensations in C4 to T1 dermatomes. Touch is preserved.
Dx?
- Syringomyelia
21. 2-year-old girl with febrile seizure. PE shows nuchal rigidity and

bacterial meningitis suspected. LP and immediate abx therapy planned, but

parents unavailable for consent. Next step?
- Initiate the procedure and treatment without consent
22. 51-year-old with Graves disease develops ulcerating pharyngitis after 6
months of propylthiouracil. What's the underlying cause of ulcerative
pharyngeal disease?
- Agranulocytosis
23. 54-year-old man with normal renal functions gets a heart
transplantation. One year later, bp 170/110 and serum creatinine 2.1.
Which drug caused these findings?
- Cyclosporine
24. 44-year-old woman 15 weeks' gestation with uterus consistent size with
gestational age. Amniocentesis shows increased alpha-fetoprotein (AFP).
Fetus at greatest risk for which defect?
- Spina bifida
25. 28-year-old man infertility, weight lifter and takes anabolic steroids.
Mechanism of infertility?
- Suppression of gonadotropins
Block 2 Part 2
26. 34-year-old man with herniated lumbar intervertebral disc.
Laminectomy and removal of hernia scheduled. CT scan of vertebrae
shown, which is surgical entrance location into neural canal?
- D (the lamina - called a laminectomy)
27. 68-year-old man with 3 days of increasingly severe chest pain,
shortness of breath, stridor, hoarseness, difficulty swallowing and
nonproductive cough. Long-standing hx of hypertension. Smokes 2 packs
of cigarettes for 45 years. T 99 F, pulse 80, rr 15, bp 160/94. PE shows
visible pulsation above the manubrium of the sternum and displacement of
the trachea to the right. Murmur second right intercostal space. Dx?
- Aortic aneurysm
28. 35-year-old with Chagas disease and 2-hour history of moderate chest
pain. 4.4 lb weight loss in 2 months. Vitals stable. Barium swallow shows

dilated esophagus with beak-like narrowing at lower esophageal sphincter

(LES). Biopsy shows?
- Loss of neurons in myenteric plexus
29. 62-year-old woman with 3-day hx of fever, shaking chills, and left flank
pain. Dx acute pyelonephritis and treated with ciprofloxacin. Five days after,
sudden onset watery diarrhea and lower abdominal cramps. T 100.9 F,
pulse 80, rr 18, bp 124/88. PE moderate tenderness to palpation in lower
quadrants especially on right and increased bowel sounds. Stool is brown
and occult blood negative. Next step?
- Test of the stool for Clostridium difficile toxin
30. 33-year-old woman who three weeks ago, underwent oophorectomy for
epithelial ovarian cancer. Recommends adjuvant chemotherapy with
paclitaxel. Mechanism?
- Inhibits microtubule disassembly
31. 45-year-old man comes to physician for follow up after appendectomy.
There is mild scleral icterus and well healing surgical incision. Lab values
show
Total bilirubin 3.2
Direct: 0.2
Indirect 3 mg/dL
Dx?
- Gilbert
32. 3-year-old boy 7 days after dx with severe chronic diarrhea due to
Giardia. Immunological studies show peripheral leukocytes that express
both CD3 and CD4 and fail to express CD40 ligand. Based on this, the
immunoglobulin isotype that predominates has which biological properties?
- Complement activation
33. 18-year-old woman get general anesthesia for wisdom teeth extraction.
After 5 minutes, gets hypertonicity of skeletal muscles and increased body
temperature. The treatment is a drug that decreases?
- Sarcoplasmic Ca release
34. 22-year-old nulligravid woman has menses that occur at irregular 26- to
32-day intervals. Height 5 ft 4 in and weighs 187 lb. BMI 32. PE shows mild
hirsutism and velvety brown, thickened skin at the base of the neck and

around axillae. Patient has which condition?

- Hyperinsulinemia
35. 5-year-old girls with severe leg pain 1 day after fell off sled. Immigrate
to USA from Iceland. Has had three bone fractures since birth. Parents are
vegan and don't give diary products. PE shows tenderness, swelling, and
limited range of motion of left lower extremity. Xray shows fracture of fibula.
Pt has vitamin deficiency that affects which of the following?
- Intestinal calcium absorption
36. 36-year-old woman diagnosed with HIV. Two months ago, started
antiretroviral therapy with efavirenz, emtricitabine, and tenofovir. Labs: CD4
352 and undetectable HIV viral load. Two months ago, CD4 count was 158
and plasma HIV viral load was 5500. Next step?
- Continue efavirenz, emtricitabine, and tenofovir with no changes
37. 35-year-old man with several episodes of dizziness and fainting during
the past 2 months. Father and several paternal uncles died suddenly. PE
and lipid studies normal. Angiography shows no coronary artery blockage.
ECG shows prolonged QT. Decreased activity in which of following causes
this?
- Outward (delayed) rectifying potassium channel
38. 4-month-old boy with 1-day respiratory distress. Has progressive
weakness and difficulty feeding for a month. RR 50/min. PE shows
enlarged tongue and generalized hypotonia. Increased lactate, pyruvate,
glucose, and uric acid. CXR shows cardiomegaly. Biopsy of skeletal muscle
shows increased glycogen. Enzyme impaired?
- alpha-1,4-Glucosidase
39. 50-year-old man with pulmonary embolus. Treated with intravenous
heparin. 24 hours later, warfarin added. Day 2, partial thromboplastin time
is 52 seconds (control 26 sec), and prothrombin time is 12 seconds (control
12.1 sec; INR = 1). Best explanation for normal prothrombin time and INR?
- Long half-life of factor II (prothrombin) (?)
40. An investigator conducts a meta-analysis of three genome-wide
association studies of Crohn Disease. The studies encompassed 3200
cases and 4800 controls, all of European descent. The initial studies
identified 11 significant loci with odds ratios above 1.3 and 1.5; the

combined meta-analysis identified an additional 21 loci with odd ratio of 1.1

to 1.3. It is estimated that the 32 loci identified explain about 10% of the
variance in disease risk with 2 loci accounting for 2% of the variance.
Previous studies of twins indicated a 50% heretability rate for Crohn's
disease. Which of the following best explains these results?
- The identified loci account for a relatively small part of the variance
41. 6-year-old boy with 5-day history of intermittent vomiting and 3-month
hx of progressive clumsiness. Can no longer ride bicycle and difficulty
getting out of car. Funduscopic exam shows bilateral papilledema. Neuro
exam shows impaired upward gaze and pupil response to light. Walks
shuffling gait. CT shows enlarged lateral and third ventricles and a 2-cm
mass. Location of mass?
- Pineal gland
42. 67-year-old woman comes to the physician because of a 1-month
history of low back pain. She has hypertension well controlled with a
thiazide diuretic. Her pulse is 140/min, and blood pressure is 140/85 mm
Hg. Physical examination shows tenderness to palpation over the L2-3
vertebrae. Laboratory studies show:
Hemoglobin 13.5 g/dL
Hematocrit 41%
Leukocyte count 10,500/mm3
Segmented neutrophils 65%
Eosinophils 1%
Basophils 1%
Lymphocytes 30%
Monocytes 3%
Platelet count 250,000/mm3
Serum electrophoresis shows a monoclonal spike of IgG kappa. A chest xray shows cardiomegaly with bilateral pleural and pericardial effusions. An
x-ray of the spine shows a lytic lesion. Echocardiography shows an
echodense thickened left ventricle and poor diastolic compliance. A
photomicrograph of a specimen obtained on myocardial biopsy is shown.
Which of the following is the most likely cause of the cardiac findings in this
patient?
- Amyloid infiltration
43. 45-year-old woman with joint pain due to rheumatoid arthritis comes for
infective treatment with over-the-counter agents. Initiate disease-modifying

antirheumatic drug (DMARD). Delayed onset of action of DMARD, so

physician prescribes another until DMARD is effective. Drug?
- Prednisone
44. 8-year-old boy with persistent disruptive behavior. Teacher says he's in
"constant motion" and never completes assignments. Treated in ER several
times because of skateboarding injuries. Tx?
- Methylphenidate
45. A transcription factor that activates expression of HMG coA reductase is
identified, this TF is initially synthetized as a large precursor protein, with 2
membrane spanning domains. The transcriptional domain is released by
proteolysis when the membrane has a decreased cholesterol
concentration. The precursor protein is mot likely initially produced in which
of the following labeled area on this labeled diagram of a hepatocyte?
- F, Rough Endoplasmic Reticulum (ER)
Labeled organelle is the rough endoplasmic reticulum, site of protein
synthesis
46. 3-year-old boy with progressive fever and skin lesions during 24 hours.
T 102.9 F, pulse 120, RR 20, bp 110/60. PE shows large, flaccid, bullous
lesions over trunk and abdomen. Another finding in pt?
- Positive nares culture for toxin-producing Staphylococcus aureus
47. A study is conducted to compare the incidence of myocardial infarction
in patients undergoing two different types of angioplasty or an operative
procedure to manage single-vessel coronary artery disease. A total of 1000
patients are enrolled. Through a chance process, 500 are assigned to
undergo the operative procedure, 250 are assigned to undergo one type of
angioplasty, and 250 are assigned to undergo a second type of angioplasty.
All patients are followed for 3 years to determine the incidence of
myocardial infarction. Which of the following best describes this study
design?
- Randomized clinical trial
48. 48yo man with possible hypertension. based on 20 measurements, his
average diastolic pressure is 94mmHg, SD is 8mmHg. If only four
measurements were made rather than 20, which of the following
statements would best describe the width of the 95% CI with regard the
mean blood pressure?

- Larger
49. 66-year-old man with 1-month hx of nonproductive cough and 6 months
shortness of breath. Bilateral end-inspiratory crackles heard. CT chest
shows diffuse reticular opacities at periphery and bases of lungs. Micro
exam of biopsy shows patchy interstitial fibrosis, several fibroblastic foci
and no granulomas. Dx?
- Idiopathic pulmonary fibrosis
50. 65-year-ld man with cancer of cecum found to have metastatic lesion to
liver. Venous route of mets?
- Ileocolic --> superior mesenteric --> portal --> right hepatic branch of
portal
Block 3 Part 1
1. 60-year-old man for routine health examination. Has had normal blood
pressure measurements. BP today 170/95mmHg. Physical examination
shows no other abnormalities. Serum show hypokalemia and metabolic
alkalosis. Plasma renin activity and serum aldosterone concentrations are
increased. Following the administration of captopril, there is a marked
increase in plasma renin activity. Which of the following is the most likely
cause of the findings in this patient?
- Renal artery stenosis
2. 8-year-old girl is brought to the physician by her mother because of a 3
week history of poor feeding chronic diarrhea and pale foul smelling stools.
Mother says the symptoms began with colicky abdominal pain following
introduction of solid food to the infant's diet. History of gluten sensitivity.
60th percentile for length and 25th percentile for weight. Which cell is
dysfunctional?
- Enterocyte
3. 25-year-old woman comes for counseling prior to conception. Has
seizure disorder on valproic acid. Fetus at greatest risk for drug-related
adverse effect during which pregnancy stage?
- 3 to 8 weeks
4. Study designed to test the effectiveness of a new drug in the treatment
of endometriosis, 100 women randomly assigned to one of two groups. 48

of women receive new drug, 52 receive standard therapy. The primary

purpose of this method of assigning patients to different groups is to create
which of the following ?
- Two groups with similar underlying characteristics
5. 65-year-old woman with 6 hour Hx fever and shaking chills. 4 hours ago,
she took 325 mg aspirine tablets. Temp 39.4 C, pulse 96/m, respiration
18/m and blood pressure 102/60 mmHg. Physical examination shows
marked tenderness bilaterally in the costovertebral areas. Lab studies show
:
Hb 13 g/dl
Ht 39%
Leukocyte count 32.000/mm3
Urine ph 6
Nitrites 4+
Leukocyte esterase 4+
A photograph of wright stained peripheral blood smear, which the most
likely cause this patient leukocytosis ?
- Leukemoid reaction
6. 68-year-old man with a 10-month history of shortness of breath and
swelling of his feet, family history of cardiovascular disease. He smoked 2
packs of cigarettes daily for 50 years. Pulse 80/min, rr 24/min, BP 150/80.
PE: 3+pitting edema of lower extremities. Diffuse, scattered wheezes are
heard bilaterally on auscultation of the chest. Grade 2/6 pansystolic mumur
heard best at lower left sternal border, which increases on inspiration.
Maximal impulse palpated in sub-xiphoid area. S1 and S2 sounds are
distant. Liver span 14 cm. Diagnosis?
- Cor pulmonale
7. 48-year-old woman with gradual onset back pain past 2 weeks. No
trauma. Doesn't smoke cigarettes, drink alcohol or use drugs. Hemogram,
serologic studies and urinalysis unremarkable. Xray of spine shows two
lytic lesions, in T-10 and L-1. Dx?
- Metastatic carcinoma of the breast
8. 17-year-old boy brought by mother with concern that puberty is delayed.
When mother leaves room, patient states, "I'm fine. I don't know what's the
matter with her. She wants me to be tall like my dad." Patient is 175 cm (5 ft

9 in) tall and weighs 70 kg (155 lb); BMI 23. Sex development is Tanner
stage 4. Most appropriate next statement to mother?
- "Tell me more about your concerns about your son's height."
9. 35-year-old from group home comes for worsening behavior for 2 weeks.
He believes CIA is spying on him through television set. Reports hearing
voices in hall outside and that CIA now plans to kill him. Appears
disheveled with unkempt hair and poor hygiene, difficulty answering
questions because listening to internal stimuli. Mental status exam will
show which?
- Flattened affect
10. 17-year-old boy in septic shock unresponsive to ADH (vasopressin).
Treat is discontinued, and high-dose dopamine in started. Which receptors
are stimulated?
- alpha1-adrenoreceptors
11. After operation, 65-year-old patient has lung region that is
underventilated but well perfused. Which increases?
- Physiologic shunt
12. 32-year-old man with X-linked recessive disease has deafness,
hematuria and progressive renal failure. Protein abnormality?
- Type IV collagen
13. 52-year-old with chronic pancreatitis is deficient in which enzymes that
causes inability to digest triglycerides?
- Colipase
14. 47-year-old woman with irregular, raised, multicolored dark lesion on
left forearm with frequent sunlight exposure. Biopsy shows malignant
pigmented cells. Worst prognosis with involvement of which layer?
- Subcutaneous tissue
15. 33-year-old man dx with epilepsy age 10 years. Most recent
generalized tonic-clonic was 5 years ago. Medication was adjusted. Current
meds include carbamazepine. He's never had any collisions while driving
his motor vehicle. Patient's status with respect to driving?
- He is medically qualified to drive

16. 45-year-old woman with 4-month joint pain, muscles aches and fatigue.
Had a renal calculus 6 months ago and had cholecystectomy 1 year ago.
Appears fatigue, depressed, there is mucosal pallor. No masses palpated
in neck. Labs: erythrocyte count 3 million, K+ 4, Cl- 106, Ca2+ 13,
phosphorous 2.7, alk phos 125. Technetium-99m scan shows 1.2 cm
nodule in neck. Mutation?
- MEN1
17. 25-year-old man just returned from work as worker from Africa begins
oral chloroquine therapy for malaria caused by Plasmodium vivax. His
initial therapeutic response is good, but he develops recurrent parasitemia
2 months later. Which of the following best explains the recurrence ?
- Chloroquine is ineffective on the exoerythrocytic malaria tissue stages
18. 32-year-old man with HIV infection follow up examination, has been
treated with HAART for the past 6 years HIV plasma viral load has been
undetectable. HIV viral load now increase, antiretroviral resistance
suspected. HIV genotype analysis confirms that the virus has resistance
mutations, which of the following most likely mutated?
- Reverse transcriptase and protease (the two targets of HAART therapy,
therefore if therapy stopped working, must be these two target proteins of
virus mutated)
19. 58-year-old woman with 6-month shortness of breath and chronic
nonproductive cough. 2-year history difficulty swallowing, joint stiffness,
diffuse tightening of skin on face, neck, shoulders, arms, fingers. Sensitivity
to cold weather, turn white. Hx of esophageal reflux. Biopsy showed
atrophy of epidermis and deposition of collagen throughout dermis with loss
of dermal appendages. PE cutaneous ulceration, clawlike flexion deformity,
decreased joint mobility. At risk for which pulmonary disorder?
- Pulmonary hypertension (dx: systemic sclerosis/CREST)
20. Workbench wiped down with alcohol, successfully inactivates viruses
with which characteristic?
- Enveloped virion
21. 35-year-old woman pain in left leg 2 days. PE shows deep venous
thrombosis. Labs: platelet 200,000, PT 12 (INR 1), PTT 37. Heparin
started. Five days later, platelet 120,000. Reason for decreased platelets?
- Drug-related antibodies

22. 6-year-old girl with 15-minute history of severe shortness of breath.

Diagnosed with throat tumor 3 years ago. RR 32. PE nasal flaring.
Laryngoscopy shows multiple raised, finger-shaped lesions from vocal
cords and epiglottis. Lesions excised and shows finger-shaped
fibrovascular cores lined with benign squamous epithelium. Causal virus?
- Human papillomavirus, type 6
23. A 68-year-old man comes to the physician because of a 1-month history
of light-headedness and tightness in his chest with exertion. He adds that
the pain is worse after arguing with his wife, and the symptoms resolve with
rest. He has a past history of lower gastrointestinal bleeding; evaluation at
that time was negative on upper endoscopy and colonoscopy. His
temperature is 37C (98.6F), pulse is 85/min, respirations are 15/min, and
blood pressure is 110/75 mm Hg. Physical examination shows no
abnormalities. His hemoglobin concentration is 8.2 g/dL, and hematocrit is
24%. Test of the stool for occult blood is positive. An ECG shows no
abnormalities. Repeat colonoscopy shows no abnormalities. Which of the
following is the most likely cause of this patient's gastrointestinal
symptoms?
- Angiodysplasia
24. A 25-year-old woman comes to the physician because of a 2-year
history of intermittent, diffuse, cramping lower abdominal pain. The pain is
usually associated with2 to 6 days of loose, watery stools, and is typically
relieved with defecation. Between these episodes, her stools are normal.
Her vital signs are within normal limits. Physical examination shows no
abnormalities. Laboratory studies, including complete blood count,
metabolic panel, and thyroid function tests show no abnormalities. A drug
targeting which of the following mechanisms of action is most appropriate
for this patient?
- Accentuation of -opioid myenteric plexus receptor
25. 69-year-old woman with 3-week history of muscle cramps, weakness,
abdominal pain, and constipation. Hypertension treated with metoprolol and
hydrochlorothiazide for past 4 months. Labs show hypokalemia. Which
drug should be added?
- Triamterene (potassium-sparing)

Block 3 Part 2
26. A 70-year-old woman comes to the physician for a routine pelvic
examination. During speculum examination of the vagina and cervix, the
Valsalva maneuver causes a bulge of the anterior vaginal wall. Which of
the following is the most likely cause of this finding?
- Cystocele
27. 2-month-old boy well child exam, mother with no concerns. 25th
percentile for length and 30th percentile for weight. Cardiac exam shows
blowing holosystolic murmur best heard at lower left sternal border. Cause?
- Ventricular septal defect
28. 2-year-old boy 2-day history of fever, sore throat, rash. T 101.7 F (38.7
C). Widespread, red, sandpaper-like rash on extremities. Purulent exudate
over tonsils. Dx streptococcus pyogenes (group A) infection. Cause of skin
findings?
- Erythrogenic toxin
29. 1-year-old boy with rash for 2 weeks. 10th percentile for height and
weight. PE scaly, seborrheic eruption over scalp, palms, back, diaper
region and soles of feet. Generalized lymphadenopathy and
hepatosplenomegaly. Xray of skull shows osteolytic lesions. EM biopsy of
skin shows tennis racket-shaped bilamellar granule in cytoplasm. Immuno
studies show CD1a antigen expression. Abnormal cells in patient are
derived from which cell?
- Dendritic cells
30. 21-year-old man loses 15% total blood volume 2 minute after motor
vehicle collision. Finding most likely?
- Increased sympathetic nerve traffic to sinoatrial node
31. 58-year-old man comes to physician for benzodiazepine prescription for
situation at work. Feels anxious and thinks he can complete last 2 years of
work if anxiety decreases. Gives 1-month regimen of benzodiazepine. Wife
calls, "My husband got fired! I know it was because he was taking too much
of that drug you gave him. Didn't you know he had history of alcoholism?"
Initial action?
- Contact the patient to discuss the situation

32. 32-year-old woman has operation for hyperparathyroidism. Three

parathyroid glands found but one does not appear in normal superior
location on right side. Embryologic event that led to this?
- Abnormal migration of endoderm from fourth pharyngeal pouch
33. 52-year-old female with a history of breast cancer who received 4week
course of radiations 6 months ago comes for followup. Exam shows no
cancer recurrence. rr 26/min. CT chest shows b/l atelectasis in upper lung
fields. Primary pathophysiological cause?
- Contraction (secondary to radiation)
34. 4-year-old boy (pedigree shown) has clumsy gait for past year. Exam
calf hypertrophy and proximal muscle weakness. Creatine kinase
increased. Muscle biopsy shows loss of muscle tissue, regenerating
muscles fibers and fibrosis. Maternal uncle had similar findings and died at
15 years. Patient's sister is pregnant. Ultrasound identifies male fetus.
Probability fetus has disorder?
- 1/4
35. 55-year-old man northern European descent with 2-month weakness,
altered skin color, bilateral knee pain. Siblings have type 2 diabetes and
cirrhosis. PE bronzed skin, hepatomegaly, arthritis. Increased saturation of
transferrin and ferritin. Liver biopsy increased iron content and cirrhosis
Greatest risk?
- Hepatocellular carcinoma
36. 35-year-old woman with infertile, receive injection of contrast material
into cervix. On hysterosalpingogram (shown), contrast material (indicated
by arrows) also seen in peritoneal cavity, which explain this finding?
- Spillage of contrast which normal
37. 27-year-old man for psychiatric eval sent by employer because he is
"very odd." Is a computer repair specialist and lives alone. Refuses to
socialize and has no friends. Extremely preoccupied with science fiction,
occult, afterlife. Personality disorder?
- Schizotypal
38. 46-year-old woman with 1-week low-grade fever and joint pain. Has
chronic headaches and takes ibuprofen several times. PE diffuse
maculopapular rash. UA 2+ protein, 10-20 WBC and eosinophils. Renal

biopsy would show what?

- Inflammatory infiltrates in the interstitium
39. 19-year-old woman 2-day history of pain in left index finger. Injured it
when catching a ball. PE shows erythema of left index finger. Unable to flex
the distal phalanx when proximal interphalangeal joint
metacarpophalangeal joints restratined. Xray normal. Injured structure?
- Flexor digitorum profundus tendon
40. 25-year-old-man who has a history of facial flushing and rapid heart
rate each time he consumes a small amount of alcohol participates in study
of alcohol intolerance. Molecular analysis shows presence of a lysine
(K487, oriental variant) for glutamate (E487, native variant) substitution in
aldehyde dehydrogenase. Kinetic characteristics of the enzyme variants
shown:
Enzyme Km (NAD+) microM Kcat (min-1)
E487 37 180
K487 5600 9.5
based on these findings, which of the following is the most likely cause of
this man's condition?
- Decreased catalytic efficiency of K487
41. 45-year-old man bmi 26, total cholesterol 200, HDL 50, triglycerides
550. Which drug to prescribe?
- Fenofibrate
42. 21-year-old woman with 10-days difficulty walking. Two years ago had
loss of vision in left eye which improved. Neuro exam shows decreased
visual acuity in left eye with pallor of optic disc. Has past-pointing on a
finger-nose test. Broad-based gait. MRI shows brain lesions in white matter
of cerebellum. Pathogenesis?
- CD4+ T lymphocytes are activated by myelin basic protein
43. 63-year-old man 2-week sensation of fullness in left upper quadrant.
Has lethargy and shortness of breath. 20-lb weight loss during 3 months.
PE shows pallor. Spleen tip palpated. Labs: hb 9, hct 27%, wbc 4000,
serum uric acid 15. Peripheral blood smear numerous erythrocytes with
abnormal shapes and sizes, nucleated erythrocytes and myelocytes.
Aspiration of bone marrow dry tap. Biopry shows thickened bony
trabeculae with increased reticulum. Dx?

- Myelofibrosis
44. 1-year-old has numerous infection of skin and oral mucosa since birth.
Infections slow to respond to antibiotic therapy. T 100.4F. PE multiple
erythematous lesions of skin some with superficial ulceration. WBC 21,000
77% segmented neutrophils, 6% bands, 14% lymphocytes and 3%
monocytes. Biopsy shows no neutrophils in dermis or epidermis. Culture of
lesion grows Staphylococcus aureus. Defective
- An integrin
45. 45 yr old man with SOB on exertion x 6 months, nosebleeds since
adolescence, 2 pics: clubbing + hemorrhagic lesions in tongue, inhaled
albuterol doesn't improve his symptoms. Cause of symptoms?
- Pulmonary AV shunting
Disease is osler weber rendu
46. 27-year-old primigravid woman at 18 weeks gestation comes to
physician for routine prenatal examination. The uterus consistent in size
with 18 week gestation. Ultrasonography shows a male fetus. The
collecting system and pelvis of the left kidney is dilated and the renal cortex
appears compressed. The left and right ureters are not dilated. The right
kidney appears normal. Amniotic fluid volume is normal. Which causing
renal finding in this fetus ?
- Incomplete recanalization of proximal ureter
47. 24-year-old man with 3-day progressive numbness of both feet
ascended to thighs. Last 24 hours, numbness and tingling of hands. PE
ataxic gait. Deep tendon reflexes diminished in upper extremities and
absent in knees and ankles. Vibration and joint position absent in fingertips
and feet bilaterally. Mild weakness distal upper extremities ad moderate
weakness of lower extremities. Structure involved?
- Myelinated primary afferents
48. 82-year-old woman comes to the physician because of constant severe
lower abdominal pain and fever for 24 hours. Laproscopic examination
shows severe diverticulosis and perforated diverticulitis. In spite of
appropriate therapy she dies 2 days later. Liver autopsy shown. Which of
the following is the primary component of the material shown on the hepatic
surface?
- Fibrin

49. 28-year-old woman comes to the physician because of a 4-day history

of palpitations, severe neck pain, fatigue, and malaise. Her pulse is
120/min and regular. Physical examination shows a diffusely tender, mildly
enlarged thyroid gland. There is no exophthalmos. Serum studies show a
thyroid-stimulating hormone concentration of 0.01 U/mL. Which of the
following is the most likely diagnosis?
- Subacute granulomatous thyroiditis
50. 35-year-old primigravid woman 36 weeks' gestation with 6-hour history
of heavy vaginal bleeding. No prenatal care. Ultrasound shows placenta
over cervical os. Can't stop bleeding and has cesarean. Dx?
- Placenta previa
Block 4 Part 1
1. 39-year-old man with polycystic kidney disease has 6-month history
intermittent blood in urine. T 98.6 F HR 100 RR 24 BP 160/90. Urea
nitrogen 100, creatinine 8. UA shows blood. Arterial blood gas shows?
pH/pCO2/HCO3- 7.22/28/11
2. 48-year-old man 2-month increasing abdominal girth and inability to
achieve erection. Smoked 1 pack cigarettes for 20 years and drug 1 pint of
liquor daily. Vitals normal. PE shows scleral icterus, spider angiomata,
gynecomastia, ascites and prominent umbilical venous pattern. Tests small.
Cause of gynecomastia?
- Failure of liver to degrade estrogen
3. 19-year-old woman is admitted to the hospital for antibiotic treatment of
meningococcal meningitis. She is stabilized. Three days later, her pulse is
120/min, and blood pressure is 60/30 mm Hg. Physical examination shows
bilateral flank tenderness. Serum studies show a sodium concentration
of128 mEq/L, potassium of 5.4 mEq/L, and bicarbonate of 20 mEq/L.
Which of the following is the most appropriate next step to determine the
cause of this patient's hypotension?
- Adrenocorticotropic hormone stimulation test
4. 50-year-old man undergoes operative repair of inguinal hernia. Surgeon

has received written informed consent from patient. After epidural received,
patient decides he does not want to have surgery. Best response?
- "Tell me about your concerns and why you want to cancel the operation."
5. A 25-year-old man is admitted to the hospital because of severe crush
injuries to the chest and extensive burns over 30% of his body surface
area. Three hours later, he develops tachypnea and dyspnea. Arterial blood
gas analysis on room air shows a decreased Po2 and Pco2. A chest x-ray
shows bilateral interstitial and alveolar infiltrates. The patient is intubated
and mechanically ventilated. Damage to which of the following is most
likely to preclude restoration of normal tissue architecture and pulmonary
function in this patient?
- Basement membranes
6. Studying epithelial repair of small intestine in experimental animal. Wants
to identify most active cell division location. Where is this cell activity
found?
- Base of the crypt
7. 16-year-old girl calls the physician on a Friday night 2 hours after a
condom broke during sexual intercourse with her boyfriend. She asks the
physician to prescribe an emergency oral contraceptive. The physician on
call is not the patient's regular physician and does not dispense emergency
contraception for moral reasons. After the physician respectfully informs the
patient that he does not prescribe this contraceptive, it is most appropriate
for the physician to state which of the following?
- "I can have one of my colleagues call you back to further discuss your
concerns."
8. 20-year-old woman with 2-week fever, shaking chills, headaches,
fatigue, and joint and muscle pain. Spent summer workin as lifeguard in
Long Island, New York. Has splenectomy for motor vehicle collision 6 years
ago. T 102.4 F. Peripheral blood smear shows small intraerythrocytic rings.
Polymerase chain reaction for Plasmodium is negative. Causal organism
from bite of?
- Tick
9. 67-year-old man who eight months ago dx with primary lung carcinoma
involving adrenal glands, liver, and bone. Had 17.6-lb weight loss during 3
months. PE shows cachexia and significant muscle wasting. Intracellular

components increased in patient's muscle cells?

- Autophagic vacuoles
10. 2-month-old female with T 102F, vomiting, diarrhea, dehydration. Exam
of stool shows viral particles with wheel-like shape. Properties of virus?
Type of nucleic acid/envelop/capsid symmetry
- Double-stranded RNA, segmented/no/icosahedral
11. 14-year-old girl with type 1 diabetes mellitus and 4-hour history of
lethargy, confusion, disorientation. Symptoms gradually developed and she
did not take her usual insulin dose during a sleepover. HR 110, RR 24 deep
and rapid, bp 95/75. Labs: glucose 450, arterial pH 7.15. ABG?
pCO2/HCO3-/Anion gap
- decreased/decreased/increased
12. Investigator studying vancomycin-resistant strain of Enterococcus
faecalis. Ten generations created. Culture inoculated and resulting bacterial
colonies are screened for vancomycin resistance. Vancomycin-sensitive
colonies observed at frequency of one per 100 cells. Mechanism of
decreased vancomycin resistance?
- Plasmid loss
13. Male newborn delivered at 28 weeks, neonatal respiratory distress
syndrome, ABG shows decreased pH, decreased Po2 increased PCO2. A
deficiency in which of the following most likely caused the disorder?
- Dipalmitoylphosphatidylcholine
14. 65-year-old man with 4-hour history of intermittent severe pain in flank
area radiating to genital region. History of hypercalciuria and renal calculi.
Drug decrease the urinary excretion of calcium?
- Hydrochlorothiazide
15. 45-year-old man comes to the physician because of an enlarging face
shoulders and trunk and thinning of his arms and legs. Physical
examination shows a large plethoric face, fat pad over the upper thoracic
spine and purple striae on the abdomen. Serum studies show undetectable
ACTH and an increased cortisol concentration. Administration of low dose
dexamethasone would most likely result in which of the following sets of
serum findings?
- ACTH no change, cortisol no change

16. 12-year-old boy with mother concerned about enlarged left breast and
family history of breast cancer. Left breast is slightly larger than right, nipple
mildly tender. Penis slightly enlarged and pubic hair curling and beginning
to darken at base. Best next step?
- Reassure the mother that physical findings are not uncommon for his age
17. 55-year-old woman who is a physician has fractured femur during
motor vehicle collision. 2 days after admission, has tachycardia,
restlessness, diaphoresis, anxiety, seeing "vague shapes" on walls. Dx?
- Alcohol withdrawal
18. 35-year-old woman with fever and sharp chest pain for 3 days. T
101.3F. Friction rub heard. All cuases of secondary pericarditis ruled out.
Cause of primary pericarditis?
- Virus
19. 35-year-old man with severe back pain, gained 8 kg in the past 6
months, decreased peripheral vision, compression fracture spine at T10
and L1, healing left rib fracture at T6, imaging shows pituitary
macroadenoma. This tumor produces which?
- ACTH
20. 35-year-old woman passed out while washing dishes. Began to feel
weak and dizzy, husband shares with nursing staff history of bulimia
nervosa, and has been binging more frequently. Suspected she has been
vomiting. Labs of patient?
K+/HCO3-/Anion Gap/pH
- decreased/increased/normal/increased
21. 67-year-old man with 3 months fatigue and shortness of breath. Vitals
HR 90, RR 15, bp 150/98. PE conjunctival pallor. Labs: hb 8.5, hct 26%,
MCV 90, RDW 14.4% (N=13-15%), Cr 2.9, Ferritin 144, Iron 24, Transferrin
saturation 23% (N=20-50%). Besides iron supplementation, most
appropriate tx?
- Erythropoietin
22. 15-year-old girl comes with lack of improvement of facial acne. Tried
topical clindamycin and benzoyl peroxide PE severe acne vulgaris. Says,
"Please help me." She has never been sexually active. Tx?

- Isotretinoin
23. 18-month-old girl with 2 day progressive cough and hoarseness. T
102.2F, HR 88, RR 24, bp 100/70. Oxygen saturation 95%. PE mild
erythema of oropharyngeal and laryngeal mucosa no exudate, harsh,
barking cough heard. Improves within 4 days. Cause?
- Parainfluenza
24. 38-year-old man 1-week shortness of breath with exertion, light
palpation of carotid artery shows upstroke is abnormally brisk and
downstroke falls precipitously. Cause of finding?
- Aortic Regurgitation
25. Retrospective study of incidence and outcome of subarachnoid
hemorrhage. Incidence is 15 per 100,000 people, mortality is 6 per 100,000
people. Incidence remains constant, case fatality rate?
- 40%
Block 4 Part 2
26. 64-year-old with non-Hodgkin lymphoma and 3-day history of
abdominal pain and nausea. T 99.7F, HR 100, bp 130/80. Abdominal exam
tenderness of flanks and lower quadrants. BUN 34 and creatinine 3.8. CT
shows bilateral hydronephrosis and lymphadenopathy compressing
ureters. Tx to improve renal function?
- Bilateral stents in the ureters
27. 71-year old woman with coronary disease and well-controlled
hypertension is brought to the physician 2 hours after sudden onset of
weakness of her left leg. Her BP 145/85 mmHg. Neurologic exam:
weakness and decreased sensation over the left lower extremity. There are
no other sensory or motor deficits. Which labeled structure is site of injury?
- A (Pre/postcentral gyrus; motor/sensory cortex)
28. Girl has chronic cough with thick sputum, abdominal cramps in RLQ,
and frequent resp infections. Clubbing of fingers, hyperresonance on chest
percussion. Diffuse crackles and scattered wheezes. On xray - diffuse
hyperinflation of the right upper lobe. She has a healthy brother. What's the
likelihood he is a carrier for the condition?

- 2/3
29. 4-year-old male with recurrent UTIs, left kidney found small and non
functional; right is normal. Nephrectomy is done, and the picture shown
(dilated ureter and renal calyx). Microscopic exam of kidney will show
which?
- Tubular atrophy
30. Patient with orthostatic hypotension, loose stools for 1 year, and history
of type 1 DM. Stool studies are normal. What is the pathophysiological
mechanism of the diarrhea?
- Motility disorder
31. In a 25-year-old patient who underwent splenectomy, target cells are
seen on peripheral smear. These cells are seen due to loss of function of
which portion of spleen?
- Red pulp
32. 58-year-old man comes to the physician because of a 4-year history of
recurrent cough productive of increased sputum. Use of over-the-counter
cough suppressants has not resolved his symptoms. He has smoked 2
packs of cigarettes daily for 35 years. He has no family history of lung
disease. His temperature is 37C (98.6F), pulse is 72/min, and respirations
are 18/min. Physical examination shows cyanosis. Diffuse wheezing is
heard on auscultation. Which of the following pulmonary cell types is most
likely to be abnormal in this patient?
- Pseudostratified columnar epithelial cells
33. Researching new cancer drug, effective at killing rapidly dividing cells,
in mice caused profound myelosuppression. In patients, most appropriate
to follow which when at risk for infectious complications?
- Neutrophil counts
34. 48-year-old recently diagnosed with lupus and difficulty working as
schoolteacher because of severe pain and swelling of joints. Current meds
include prednisone, hydroxychloroquine, and oxycodone for pain. Best
action to adapt to illness?
- Encourage the patient to participate in a support group for persons with
her condition

35. 19-year-old man with gastrointestinal bleeding. Laparotomy done and

5-cm blind outpouching on antimesenteric side of terminal ileum 15 cm
from ileocecal valve resected. Pathology shows?
- Heterotopic gastric mucosa
36. 17-year-old boy with syncopal episode, fever, nausea, muscle aches,
progressive confusion. T 103.5F, palpable bp 80. PE rash on lower
extremities. WBC 26,000. Blood and CSF cultures grow oxidase positive,
gram negative diplococcus. Brother with similar infection at same age.
Immune disorder?
- Late component of complement deficiency
37. Randomized controlled trial evaluating tx of acute otitis media. No
statistically significant differences found between infants receiving the
antibiotic and those with standard tx. Which aspect results in type II error?
- Number of subjects in the study
38. 17-year-old boy whose mother concerned about physical development.
10th percentile for height and 25th for weight. FSH is 5, testosterone 8
(N=10-35). Physical finding on patient?
- Gynecomastia
39. To decrease risk for cv disease 24 yo man begins diet. 1.53 95 kg BMI
32, Intends to lose 16 kg by limiting caloric intake to 2000 cal. to maintain
the recommended protein intake (56g day); a balanced decreased in carbs
and fat is required (caloric radio of fat and carbs is 30:55). which best
describes number of calories that should be provided by fat in this its diet
each day?
- 630
40. 20-year-old woman with palpable lump in right breast 4 months, no
pain, swelling or nipple discharge. Lump is smooth, firm, round, mobile,
nontender, well delineated. No skin change. Dx?
- Fibroadenoma
41. 65-year-old woman comes to the physician because of a 1-week history
of a swollen, painful left knee. Her temperature is 38C (100.4F), and
blood pressure is 110/65 mm Hg. Examination of the left knee shows
erythema and swelling of the joint and decreased range of motion. A
photomicrograph of synovial fluid obtained by arthrocentesis is shown. This

patient's synovial fluid most likely contains which of the following?

- Uric acid
42. 56-year-old exposed to possible chemical attack. Respirations labored,
diaphoresis, excessive lacrimation, increased salivation, muscle strength
2/5, urinary and fecal incontinence. Besides atropine, another tx?
- Pralidoxime
43. 71-year-old man admitted for prostatic resection. Normal mental status.
2 days after surgery, confused and restless. Cannot sleep and restless,
seeing little men coming through window. Dx?
- Delirium
44. 32-year-old woman has new neuro finding while being tx for acute
infection of sphenoid sinus. Imaging shows cavernous sinus thrombosis on
left. Additional finding most likely?
- Inability to abduct the eye
45. 66-year-old woman is brought to the emergency department by her
daughter because of a 2-day history of fever, flank pain, pain with urination,
and nausea. Ten days ago, she was admitted to the hospital for similar
symptoms and was diagnosed with acute pyelonephritis. She was
discharged with instructions to take oral ciprofloxacin after a 3-day course
of intravenous ciprofloxacin resulted in improvement. She also has
hypertension, hyperlipidemia, and osteoporosis. Current medications also
include alendronate, calcium carbonate, ezetimibe, hydrochlorothiazide,
and simvastatin. Her temperature is 39.1C (102.4F), and blood pressure
is130/80 mm Hg. The most likely cause of this patients current condition is
an interaction between her current oral antibiotic and which of the following
medications?
- Calcium carbonate
46. 34-year old man is brought to the ER semiconscious and combative. In
addition to sedation , a short-acting neuromuscular blocking agent is
administered for intubation to prevent aspiration. Within a few seconds after
admin of the drug, he has transient muscle fasciculations in his face ; he
develops generalized paralysis within 1 minute. Forty five minutes after
completion of the procedure , he is still paralyzed. A genetic abnormality of
which of the following enzymes is the most likely cause of his unusually
slow recovery from paralysis?

- Pseudocholinesterase
47. Full-term newborn in respiratory distress. Imaging shows abdominal
contents in left pleural cavity. Maldevelopment of which structure led to
diaphragm defect?
- Left pleuroperitoneal membrane
48. 83-year-old with arteriosclerosis undergoes repair of infrarenal
abdominal aortic aneurysm. Graft extends just below the renal arteries to
the bifurcation of the aorta. Which organ will lose primary blood supply and
rely on collateral circulation?
- Descending colon
49. 62-year-old with angina pectoris is referred for cardiac catheterization.
Patient worried about hospital-associated infection. Studies show 30% of
patients require admission after procedure, and 2 percent of admitted
patients acquire hospital infection. Patient's risk for infection overall?
- 6/1000
50. 25-year-old woman with fatigue for 3 wks and intermittent fever for 7
days, had teeth cleaned a month ago, no abx for prophylaxis, and had
rheumatic fever as child and endocarditis 4 y ago. PE shows 2/6 murmur,
ultrasound shows abnormal mitral valve. Photo of growth from blood
cultures shown (GP cocci in chains). Characteristic of causal organism?
- Greening reaction on blood agar