64

3
ii
()

iii
64
1. A.Purine
Uric acid is the final breakdown product of dietary or endogenous purines and is generated by xanthine
dehydrogenase (xanthine oxidase), primarily in the liver and intestine. Exogenous purines also represent an
important source of uric acid, and approximately 50% of RNA purines and 25% of DNA purines are absorbed in
the intestine and subsequently excreted in urine.

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 http://www.medscape.com/viewarticle/472684_2
2. E.Alpha-tocopherol

Alpha-tocopherol terminal chain reaction

2
(tocopheryl quinine) (tocopheryl radical)

3. C.Mitochondria
( heme synthesis human )

Heme is synthesized in all human nucleated cells. It involves a series of enzymatic reactions taking place partly in
the mitochondrion and partly in the cytoplasm (Fig. 2). Heme requirements vary significantly among various cells
and tissues. The most rapid rates of heme synthesis occur in the erythroid cells in the bone marrow [75% of total
body heme and the hepatocytes in the liver.
http://pharmrev.aspetjournals.org/content/55/3/551.full#F2
4. D.Single base deletion

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A frameshift mutation is a type of mutation involving the insertion or deletion of a nucleotide in which the
number of deleted base pairs is not divisible by three. "Divisible by three" is important because the cell reads a
gene in groups of three bases. Each group of three bases corresponds to one of 20 different amino acids used to
build a protein. If a mutation disrupts this read
5. E. (
)
X=linked dominant
A B C D X
Y X
6. A.Testis
( (Parotid gland)
)
1)
2) 1 6,000
3)
4)
:
7. A.Osteoporosis
estrogen in CVS total cholesterol and LDL HDL bone resorption
( menopause = ovarion tissue gradually ceases to respond to stimulation by anterior pituitary
gland ) osteoporosis CVS ex
hypertension dyslipidemia
8. E.Cobalamin
Terminal ileum vitamin B12 Terminal ileum vitamin
B12 deficiency megaloblastic anemia
ileum bile salt entero-hepatic circulation

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9. A. 135,3.5,32
Congenital hypertrophy pyloric stenosis
Nonbilious projectile vomiting
electrolyte abnormalities hyponatremic,
hypokalemic, hypochloremic metabolic alkalosis

Potassium level: 3.55 mmol/L

Bicarbonate level: 2226 mmol/L
Sodium level: 135 - 145 mmol/L
10.
26C 37C

Decreased glycogenolysis
Decreased oxegen consumption
Increased gluconeogenesis
Increased thyroid hormone secretion
Increased lipolysis of brown adipose tissue
BROWN ADIPOSE TISSUE
The main function of the multilocular adipose cells is to produce heat by nonshivering thermogenesis. In newborn
mammals (including humans) that are exposed to an environment colder than the mother's uterus, nerve impulses
liberate norepinephrine into brown adipose tissue. As in white fat, this neurotransmitter activates the hormonesensitive lipase present in adipose cells, promoting hydrolysis of triglycerides to fatty acids and glycerol.
However, unlike white fat, liberated fatty acids of multilocular adipocytes are quickly metabolized, with a
consequent increase in oxygen consumption and heat production, elevating the temperature of the tissue and
warming the blood passing through it.
REF: Junqueira's Basic Histology: Text & Atlas, 12e
11. 55 10 Decreased
deep tendon reflexes and light touch vitamin
Retinol :
Thiamine
Ascorbic acid
Calciferol
Tocopherol
Patients with chronic alcoholism may have poor dietary intakes of thiamine and impaired thiamine absorption,
metabolism, and storage.
Dry beriberi involves both the peripheral and the central nervous systems. Peripheral nerve involvement is
typically a symmetric motor and sensory neuropathy with pain, paresthesias, and loss of reflexes.
Retinol (Vit A) : Night-blindness, Hyperkeratosis,dry skin
Thiamine (Vit B1) : Wet beriberi, dry beriberi

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Ascorbic acid (Vit C) : Scurvy

Calciferol (Vit D) : Rickets, Osteomalacia, hypocalcemic tetany
Tocopherol (Vit E) : hemolytic anemia
12. Adrenergic agonist
dilated pupil sympathetic
sympathomimetic Adrenergic agonist
13. b.depression SSRIs antidepressant
14 B. Acinetobacter baumannii gram neg-coccobacilli
(pneumonia) ventilator-associated (Intensive Care Unit, ICU)
Klebsella pneumoniae rods alcoholism UTI

Pseudomonas aeruginosa rods pneumonia in cystic fibrosis

Haemophilus influenzae pediatric infection
15 A. Anaerobes anaerobes
16. D. Aspergillus fumigates branching septate hyphae hyaline mold
brain abscess
Fusarium filamentous fungi species opportunistic infections
fusarium (onychomycosis) cornea (keratomycosis or mycotic keratitis)
Rhizopus non-septate mold order Mucorales mucormycosis
Penicillium marneffei dimorphic fungi
25
mold hyphae conidia
37
intracellular fission yeasts clinic umbilication molluscum like lesion skin
Histoplasma capsulatum dimorphic fungi intracellular budding yeast cell
capsule yeast cell
17.
A.Epidermophyton floccosum -- often causes tinea pedis, tinea cruris, tinea corporis and onychomycosis
--slow growing, greenish-brown or khaki coloured with a suede-like surface, raised
and folded in the centre
-- Microscopic morphology shows characteristic smooth, thin-walled macroconidia
B. Candida albicans-- Microscopic morphology shows spherical to subspherical budding yeast-like cells or
blastoconidia
-- occurs naturally as a commensal of mucous membranes and in the digestive tract
c. Malassezia furfur -- Malassezia furfur in skin scale from a patient with tinea versicolor

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-- yeast cells and short pseudohyphal

d.Microsporum canis -- Macroconidia are typically spindle-shaped with 5-15

cells, verrucose, thick-walled and often have a terminal knob
-- zoophilic dermatophyte of world-wide distribution which is a frequent cause of
ringworm in humans, especially children. Invades hair, skin and rarely nails.
E. Trichophyton rubrum -- Typical slender clavate microconidia downy type. Typical cigar shaped macroconidia
of T. rubrum granular type.
-- anthropophilic dermatophyte, causes chronic infections of skin, nails and rarely scalp

18. B
A. Clostridium botulinum : Food Poisoning
B. Clostridium tetani : usually enters a host through a wound.
C. Clostridium difficile : competing bacteria are wiped out by antibiotics. > Diarrhea
D. Clostridium perfringens : Food Poisoning > Gas gangrene
E. Clostridium septicum : Hematogenous spread from the GI tract > Gas gangrene
spore Clostidium spore ?
19. C. Ancylostoma spp.
Reasons : iron deficiency anemia, eosinophilia,

Ancylostomiasis Necator americanus Ancylostoma duodenale

6000-20000 1-2
rhabditiform larvae
5-10
filariform 5-10

1-2

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 24

rhabditiform
20. B
(Trichuris trichiura)
- Size 50-54 x 22-23 micron
- Shape (barrel shape)
- Color
- Egg shell 2 bipolar mucous plug
- Content yolk sac
21. A
- (Paragonimus westernmani)
- 2nd IH

22. E. Taenia solium

A. Diphyllobothrium latum ()

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B. Hymenolepis nana(dwarf tapeworm) / autoinfection/

, day-care
C. Hymenolepis diminuta

23. E. T lymphocyte
Digeorge Syndrome ( deletion 22q11.2 )
- absence of thymus => T cell defect
- parathyroid hypoplasia => hypocalcemia
- birth defect congenital heart disease , cleft palate
- hypertelorism(), micrognathia(), short philtrum with fish-mouth
appearance, antimongoloid slant(), telecanthus with short palpebral fissures

24. D (IgE- mediated)

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IgE

Cytotoxic(Anti
body): IgM,
IgG

Immune
Complex

Delayed (Tcell mediated)

USMLE 2010 209

25. D.T lymphocyte thymus gland T lymphocyte
thymus gland T lymphocyte

tonsil Mature B cell tonsil

B lymphocyte B lymphocyte
B lymphocyte T lymphocyte Severe combined
immunodeficiency (SCID)

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26. D Antigen-antibody complex deposition

abnormal urinalysis
BUN creatinine > "" renal blood flow GFR
hematuria, hypertension, edema > "glomerulonephritis"
Hx infection (pharyngitis)
dx : "Acute poststreptococcal glomerulonephritis" (APSGN)
"Acute poststreptococcal glomerulonephritis" (APSGN)
- Acute proliferative glomerulonephritis
- group A beta hemolytic streptococci
- antigen antigen M T antigen
nephritogenic
- M-type 1, 3, 4, 12, 25 49 APSGN
streptococcal pharyngitis M-type 2, 49, 55, 57 60 APSGN

- circulating immune complex
- = delayed-type hypersensitivity , superantigens M proteins and pyrogenic exotoxins
..
- Acute glomerulonephritis bacteria, virus parasite
Staphylococcus aureus, Staphylococcus epidermidis, Mycoplasma sp., Leptospira sp., Ebstein-Barr virus, Human
immunodeficiency virus Toxoplasma
-
- 2-6 Streptococci
- pharyngitis 1-3
3-6
- APSGN acute nephritis 4-7

references :
- ,, Acute proliferative glomerulonephritis >> http://qsnichpediatrics.com/node/175
- eMedicine ,, Acute poststreptococcal glomerulonephritis >> http://emedicine.medscape.com/article/980685overview
27. A. IgA
IgA mucosal antibody
secretory IgA (sIgA), subclass IgA2 dimer
J chain

10

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28
E
Deep vein thrombosis
Rate of flow ->
The consistency (thickness) of the blood
Qualities of the vessel wall
Rate of flow stasis


29
A
(Pb) sulfhydryl groups enzyme
delta-aminolevulinic acid dehydratase <ALAD>

39. A. Midbrain
: Parkinsons disease bradykinesia, resting tremor, hypertonia,
shuffling gait, cogwheel rigidity, postural instability, poker face(slow facial expression, showing no emotions),
micrographia dopaminergic neuron in substantia nigra located in midbrain
40. C. Carbamazepine
: Diabetic neuropathy (most common of all the late complications of diabetes,
Symmetric sensory diabetic neuropathy is the most common form of diabetic neuropathy
2 ) painful sensation
Medications(Uptodate)
- Duloxetine(SNRIs), Pregabalin(Analgesic/Anticonvulsant) are only drugs approved by FDA to
control pain from DM neuropathy ( choice)

11

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- TCA
Nortriptyline, Amitryptyline, Fluoxetine
- Anticonvulsant Pregabalin, Gabapentin, Carbamazepine, Lamotrigine
- Capsaicin
- Other anesthetic drugs
41. B. Acetylcholine
Delirium (Disturbance of consciousness and cognition + hallucination from medical condition
or substance toxicity) acetylcholine sedative agent
( anticholinergic effect)
42. B. Dopamine
Schizophrenia neurotransmitter
Dopamine imbalance positive symptoms(increased dopamine in mesolibic) + negative
symptoms(decreased dopamine in mesocortex)
43. A. Folic acid
Valproic acid neural tube defect folic acid
neural tube defect
44. A. enhanced GABA activity
Diazepam Benzodiazipine enhanced GABA activity
45. B. Tyrosinase
Albinism melanin eyes, skin, hair follicle +
(occulocutaneous albinsim) (squamous cell CA)
Tyrosinase oxidation phenol (tyrosine)
melanin
46. B
sweat gland
choice
A. Micrococcus luteus
B. Staphylococcus aureus
C. Streptococcus pyogenes
D. Propiobacterium acnes
E. Staphylococcus epidermidis

12

normal flora skin

infect
involve sebaceous gland
normal flora skin Prosthetic device

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47. E
free nerve endings nociceptor
free nerve endings epidermis dermis subcutaneous tissue
48. A
Triamcinolone - corticosteroid 387 First aid USMLE 2010

Phospholipase inhibitor: Corticosteroid (ex Benclomethasone, Prednisolone)

Cyclooxygenase inhibitor: NSAIDs, acetaminophen, COX-2 inhibitor(-coxib), Aspirin
Lipoxygenase inhibitor: Zileuton
Leukotriene antagonist: -lukast: zafirlukast, montelukast
Mast cell stablizer: Cromolyn
49. E
Gnathostomiasis
second intermediate host

13

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* (Gnathostoma spinigerum) Accidental Host

(encysted advanced third stage larvae) Second intermediate host *
intermediate host 2
cyst common Subcutaneous, ,
Definite host
First intermediate host (Cyclops)
Second intermediate host
choice
A. Filariasis Lymphatic Filariasis Subcutaneous Filariasis Loa loa, M
ozzardi, M perstans, M streptocerca

B. Toxocariasis Toxocara visceral larva migrans

C. Trichinellosis tissue fever,muscle edema,myalgias
,
D. Strongyloidiasis (Strongyloides stercolaris)
(Strongyloides papillosus)

Lung migration
filaria form
( first aid)
Filariasis: Wuchereria Bancrofti
Toxocariasis: Toxocara canis
Transmission - > Female mosquito
Transmission - > Food contaminated with egg
Disease -> lymphatic blockage(elephantiasis) 9mo-1yr Disease -> Granuloma ( retina -> blindness), visceral

larva migrans
Trichinellosis: Trichinella spiralis
Strongyloidiasis: Strongyloides stercoralis
Transmission - > Undercooked meat, usaually pork
Transmission - > larvae in soil penetrate to skin
Disease - > Muscular inflammation(larvae encysts in
Disease - > intestinal infection, vomiting, anemia,
muscle), Periorbital edema
diarrhea
Gnathostomiasis - > Gnathostoma spinigerum
Transmission - > larvae (advance 3rd stage larvae) in
, ,
Disease - > (Subcutaneous
migratory swelling)

50. -E epithelium basement membrane

connective tissue squamous cell carcimoma
Stratum germinativum (stratum basale) epidermis epithelium cell

14

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51. -A KOH preperation septate hyphae C,D E Tinea versicolor

Budding yeasts&Short hyphae candida Budding yeasts & pseudohyphae
Tinea cruris Tinea corporis Dermatophyte
forming irregular rings with inflammatory borders & clearing in the central area
Tinea cruris Tinea corporis
52. -Bcelecoxib selective COX-2 inhibitor side effect NSAIDS
COX-1 NSAIDs Non-selective side effect Non-selective COX-1
( PGE2, PGI2 cytoprotective )
53 B.
-Acinetobacter spp.: Gram-negative coccobacilli, non-motile, oxidase negative, strictly aerobic ; A. baumannii
nonfermenting bacteria nosocomial infection lateonset VAP

A. baumannii http://www.buddycom.com/bacteria/gnr/gnrfastid.html)
-Neisseria gonorrhoeae: Gram-negative coffee-bean shaped diplococci bacteria, facultative intracellular with
fastidious growth requirements chocolate agar with carbondioxide Thayer-Martin agar,
oxidase & catalase positive; Outer surface with multiple antigens: pili protein; Por proteins; Opa proteins; Rmp
protein; protein receptors for transferrin, lactoferrin, and hemoglobin; lipooligosaccharide; immunoglobulin
protease; -lactamase
Neisseria gonorrhoeae
Gonorrhea: characterized by purulent discharge for involved site (e.g., urethra, cervix, epididymis, prostate,
anus) after 2- to 5-day incubation period
Disseminated infections: spread of infection from genitourinary tract through blood to skin or joints; characterized
by pustular rash with erythematous base and suppurative arthritis in involved joints
Ophthalmia neonatorum: purulent ocular infection acquired by neonate at birth

15

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(N. gonorrhoeae http://archive.microbelibrary.org/ASMOnly/details_print.asp?id=2965&lang=)

-Haemophilus influenzae: Hib (encapsulated type b), small, pleomorphic, gram-negative rods or
coccobacilli, facultative anaerobes, fermentative, most species require X and/or V factor for growth
Haemophilus influenza
Meningitis: primarily a disease of unimmunized children; characterized by fever, severe headache, and
systemic signs
Epiglottitis: primarily a disease of unimmunized children; characterized by initial pharyngitis, fever, and
difficulty breathing, and progressing to cellulitis and swelling of the supraglottic tissues, with obstruction of the
airways possible
Pneumonia: inflammation and consolidation of the lungs observed primarily in the elderly with
underlying chronic pulmonary disease; typically caused by nontypeable strains

(Gram stains of Haemophilus influenzae. A, Small coccobacilli forms seen in sputum from patient with
pneumonia. B, Thin, pleomorphic forms seen in 1-year-old, unvaccinated child in Africa with overwhelming
meningitis Murray Medical Microbiology, 6th edition)
-Salmonella enteric (nonthyphoidal salmonella): Gram-negative rod-shaped, flagellated, facultative anaerobe,
fermenter, oxidase negative poultry, pork, egg

16

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(S. enteric http://bioweb.uwlax.edu/bio203/s2009/meinhard_jaso/Phylogenetic%20Tree.htm)

-Burkholderia pseudomallei: Gram-negative, bipolar, aerobic, molite, rod-shaped bacteria, "safety pin"
appearance melioidosis Ashdowns medium

(Burkholderia pseudomallei http://www.nature.com/nrurol/journal/v4/n2/fig_tab/ncpuro0713_F3.html)

54 B C

table 348-1 (from Harrison Online)) 40

SLE prednisolone 3 Choice
A B C E
estrogen 3 early menopause
A
Uptodate online Musculoskeletal manifestations of systemic lupus erythematosus
OSTEOPOROSIS

17

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Loss of trabecular bone density is a significant problem in patients with SLE. Trabecular bones (eg, ribs,
vertebrae) are more likely to be involved than long cortical bones. There are no symptoms unless fractures occur.
Thus prevention, recognition, and treatment of bone mineral loss are important for the prevention of fractures.
calcium 3 bone mineral loss
fracture D E
Prednisolone
Prednisolone Corticosteroid chronic glucocorticoid therapy serious side effects
Osteoporosis glucocorticoid-induced osteoporosis C
( Harrison online Chapter 348. Osteoporosis Glucocorticoid-Induced Osteoporosis)
B (Low exercise) C (Corticosteroids)
55. B asbestos
56. E
57. D
58. A beta-2 adrenegic agonist
59. A surfactant
60. D Squamous cell carcinomas are more likely to be associated with hypercalcemia due to parathyroid like
hormone production.
61. B
62. B tetralogy of fallot = right ventricular hypertrophy + overriding aorta + pulmonary stenosis + VSD
63. C
64 E. CAD
MAJOR risk factors from NCEP: CAD
1. Age (e.g., >45yo for men, >55yo for women unless premature menopause w/o HRT)
2. Family history (e.g., MI or sudden death at <55yo in father or other 1st-degree male relative, or <65yo in
mother or other 1st-degree female relative)
3. Smoking
4. Hypertension
5. Dyslipidemias BMI 28 (high LDL, low HDL,
high TC/HDL or LDL/HDL ratio)
6. Diabetes Mellitus
- Unknown whether glycemic control affects risk
- Raises risk more for women than for men
7. Sedentary lifestyle
5 CAD sure
65 B. Mitral valve
Pulmonary valve second intercostal space left upper sternal border
Aortic valve

18

second intercostal space right upper sternal border

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Mitral valve

fifth intercostal space

medial to left midclavicular line

Tricuspid valve fourth intercostal space lower left sternal border

murmur mitral incompetence

66
66. e. ACEI

AGEI
: captopril(prototype), Enalapril ,perindopril
Mechanism of action : Inhibit converting enzyme peptidyl dipeptidase that hydrolyse AgI to AgII and inactivate
bradykinin , apotent vasodilator
Toxicity : AGEI severe first dose hypotension, Acute renal failure, ( esp. in bilateral renal atery
stenosis or the renal artery of a solitary kidney), Hyperkalemia, Dry cough
67. a. Aortic regurgitation
anatomy intercostal space 2 Aortic area
ventricle aortic valve flow aorta aorta
flow aorta pressure volume ventricle
aortic valve aortic valve
(regurgitation)
aorta ventricle (diastolic) murmur ( turbulant flow) IMMediate
high-pitched blowing diastolic murmur
wild pulse pressure Aortic root dilatation ,bicuspid aortic valve
rheumatic valve
68. a.hyperkalemia
side effects : hypotension, hyperkalemia ,dry cough,angioedema
69. b.tricuspid regurgitation
Endocarditis related to intravenous drug use

19

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Endocarditis in intravenous drug abusers commonly involves the tricuspid valve. S aureus is the most common
causative organism.
70. D
Patent ductus arteriosusWide pulse pressure and low diastolic pressure/ Continuous rough "machinery"
murmur/
Renal artery stenosis refractory HTN/ ACE inhibitor(acute onset)/ Hx of atherosclerotic occlusive
disease or fibromuscular dysplasia
PheochromocytomaAttacks of headache, perspiration, palpitations, anxiety/HTN(sustain, paroxymal)/
elevated urinary catecholamines with normal serum thyroxine (T4 ) and thyroid-stimulating hormone (TSH)
Transposition of great vesselsHx of cyanosis that worsens shortly after birth/ Right atrial enlargement
Coarctation of aorta (hypertension)
71 . E
A. Sclerodermafibrosis of the skin and internal organs/ Raynaud phenomenon and antinuclear antibodies are
present
B. Giant cell arteritis Age over 50 years/ headache, jaw claudication, polymyalgia rheumatica, visual
abnormalities, and a markedly elevated erythrocyte sedimentation rate (ESR)
C. Takayasu arteritis young woman/ decrease or absence of peripheral pulses
D. Polyarteritis nodosa spares the lung but often affects the kidney, causing renin-mediated HTN/ Clinical
findings depend on the arteries involved/ Mononeuritis multiplex, Anemia, Livedo reticularis
E. Thromboangiitis obliterans extremities claudication, onset before age 45, tobacco use, distal extremities
ischemia
72. A.increased aldersterone
aldersterone adrenal cortex reabsorption sodium potassium loss distal renal
tubule
increased aldersterone Primary hyperaldosteronism (Conns disease)
Hypertension
Headache
Hypokalemia or can be normokalemia
Lack of edema compensate diuresis in a few days
Metabolic alkalosis
B. increased prostaglandin
HT PGI2 & PGE2 vasodilation BP
C. increased ANP
BP
D.activated renin-angiotensin system

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 aldosterone secondary hyperaldosteronism

A
E. increased vascular sympathetic activity
norE & Epinephrine VMA (a breakdown product of NorE)

sympathetic overactivity eg. Pheochromocytoma

Hypertension
Headache
Sweating
Tachycardia
Pallor
73 A acute pancreatitis

Serum amylase
pancreas, salivary glands, liver, small intestine, kidney, fallopian tube, tumors
Acute abdominal pain + radiation to back + relief on bending forward
Acute pancreatitis
adult Alcoholism (male) gallstones (female)
74 D Ileum

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The major component of bile acid absorption is active and occurs only in the terminal ileum
(Passive absorption - along the entire small intestine and colon)
75 D Mucin
NSAIDs Cyclooxygenase prostaglandin E2 (PGE2) mucus secretion

76 C splenic vein

22

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Cirrhosis portal hypertension portal vein hepatic vein inferior

vena cava Portal-systemic anastomosis vein
Splenic vein superior rectal vein rectal venous plexuses
rectal venous plexus internal hemorrhoid
pressure splenic vein spleen - splenomegaly
Left gastric vein esophageal vein
varices (hematemesis)-
Paraumbilical vein superficial epigastric veins
epigastric vein Caput Medusae
77 D spider telangiectasia

spider telangiectasia Cirrhosis portal hypertension

Spider telangiectasia - pathogenesis is incompletely understood; they are believed to result from alterations in sex
hormone metabolism. One study suggested that the presence of spider angiomata in men was associated with an
increase in the estradiol/free testosterone ratio
choices portal hypertension
78 D duodenal atresia
/ fail to pass meconium
atresia, stenosis
Hirschsprung disease
major duodenal papilla
ampulla of Vater
Double bubble sign

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 dilation of the stomach and proximal duodenum gas /

79 D adenylate cyclase
Rice watery stool Vibrio cholera ( invade epithelium bloody
mucous bloody diarrhea )
Toxin cholera toxin adenylate cyclase cAMP
ion channel ion lumen

80 A
aflatoxin
chronically Aflatoxin exposure Mutations p53 tumor suppressor gene
hepatocellular carcinoma
aflatoxin metabolite can intercalate into DNA and alkylate the bases
Choice
( nitrosamine) (obesity->GERD) gastric cancer

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 B atrophy of gastric parietal cell

Proton pump inhibitor H+/K+ ATPase parietal cell
81. D Occasional GI infection
82. B
Metoclopramide domperidone
-dopamine D2 receptor antagonists.
- the gastrointestinal tract : activation of dopamine receptors inhibits cholinergic
smooth muscle stimulation; increase esophageal peristaltic amplitude, increase
lower esophageal sphincter pressure, and enhance gastric emptying
-no effect on small intestine or colonic motility.
-block dopamine D2 receptors area postrema antinausea and antiemetic action.
83. C
- Colonic diverticulitis
Diverticulitis
- fiber Colonic diverticulitis dietary
by fiber a large bulky stool,
- : Physical activity , Obesity
84. D.
20
Cirrhosis, upper GI choice upper GI
Esophageal Varices Portal Hypertension
Branching Esophageal veins

85. C.
V.cholera Heat Labile toxin ETEC
ETEC ; Heat Labile Toxin
similar to Cholera toxin
- activated adenylated cyclase with production of cyclic AMP and increased secretion of wated and ions
86. A
transitional CA risk Phenacetin,Smoking,Aniline
87. D
1.030 water deprivation test normal Specific gravity: 1.025-1.032
dyes,Cyclophosphamide

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88. B. Calcitriol
* Hyperphosphatemia suppresses the renal hydroxylation of inactive 25-hydroxyvitamin D to calcitriol, so serum
calcitriol levels are low when the GFR is less than 30 mL/min.
* Hypocalcemia develops primarily from decreased intestinal calcium absorption because of low plasma calcitriol
levels and possibly from calcium binding to elevated serum levels of phosphate.
* Low erythropoietin (can cause anemia) hypocalcemia hyperphosphatemia
* Calcitriol is the hormonally active form of vitamin D
* It increases the level of calcium (Ca2+) in the blood by (1) increasing the uptake of calcium from the gut into
the blood, (2) decreasing the transfer of calcium from blood to the urine by the kidney, and (3) increasing the
release of calcium into the blood from bone
89. B. proximal tubule
Renal tubular acidosis (RTA)
Type 2 (proximal) RTA: Type 2 is impairment in HCO3 resorption in the proximal tubules,
producing a urine pH > 7 if plasma HCO3 concentration is normal, and a urine pH < 5.5 if plasma
HCO3 concentration is already depleted from ongoing losses. This syndrome may occur as
part of a generalized dysfunction of proximal tubules and can be associated with increased
urinary excretion of glucose, uric acid, phosphate, amino acids, citrate, Ca, K, and protein.
Osteomalacia or osteopenia (including rickets in children) may develop. Mechanisms may
include hypercalciuria, hyperphosphaturia, alterations in vitamin D metabolism, and secondary
hyperparathyroidism. Type 2 RTA is very rare and most often occurs in patients who have one of
the following:
Fanconi syndrome
Light chain nephropathy due to multiple myeloma
Various drug exposures (usually acetazolamide SOME TRADE NAMES DIAMOX,
sulfonamides, ifosfamide SOME TRADE NAMES IFEXMITOXANA, outdated tetracycline
SOME TRADE NAMES ACHROMYCIN V TETRACYN TETREX, or streptozocin SOME
TRADE NAMES ZANOSAR)
It sometimes has other etiologies, including vitamin D deficiency, chronic hypocalcemia with
secondary hyperparathyroidism, kidney transplantation, heavy metal exposure, and other
inherited diseases (eg, fructose intolerance, Wilson's disease, oculocerebrorenal syndrome [Lowe
syndrome], cystinosis).
90. furosemide
furosemide acts by inhibiting the Na-K-2Cl symporter in the thick ascending limb of the loop of Henle
91. B Acute tubular necrosis proximal tubule cell necrosis
92. A. Acute tubular necrosis

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CAUSES

True volume depletion - Volume depletion may be caused from gastrointestinal disease (vomiting,
diarrhea, bleeding), renal losses (diuretics, glucose osmotic diuresis), skin or respiratory losses
(insensible losses, sweat, burns), and third space sequestration (crush injury or skeletal fracture)
Hypotension
Edematous
Selective renal ischemia
Drugs affecting autoregulation

Urine volume the urine volume is typically, but not always, low (oliguria) in prerenal disease due to the
combination of sodium and water avidity. In comparison, patients with ATN may be either oliguric or nonoliguric.
Rate of rise of plasma creatinine concentration the plasma creatinine concentration tends to rise progressively in
ATN.
93. E
ADH permeability distal tubule collecting duct

94. A. Lupus nephritis
Systemic lupus erythematosus (SLE) The American College of Rheumatology
1982 revised criteria for the classification of SLE
Any 4 of the 11 criteria are required to classify a patient as having SLE. These criteria can be present serially
or simultaneously during any interval of observation.
1. Malar rash
o Fixed erythema, flat or raised, over the malar eminences, tending to spare the nasolabial folds.
2. Discoid rash
o Erythematous raised patches with adherent keratotic scaling and follicular plugging; atrophic
scarring may occur in older lesions.
3. Photosensitivity
o Skin rash as a result of unusual reaction to sunlight, by patient history or physician observation.
4. Oral ulcers
o Oral or nasopharyngeal ulceration, usually painless, observed by physician.
5. Arthritis

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Non-erosive arthritis involving 2 peripheral joints, characterised by tenderness, swelling, or

effusion.
6. Serositis (one of the following):
o Pleuritis: convincing history of pleuritic pain, pleural rubs on auscultation, or evidence of
pleural effusion.
o Pericarditis: documented by ECG, pericardial rub, or evidence of pericardial effusion.
7. Renal disorder (one of the following):
o Persistent proteinuria >0.5 g/day or >3+ if quantification not performed.
o Cellular casts: may be red cell, haemoglobin, granular, tubular, or mixed.
8. Neurological disorder (one of the following):
o Seizures: in the absence of offending drugs or known metabolic derangements; for example,
uraemia, ketoacidosis, or electrolyte imbalance.
o Psychosis: in the absence of offending drugs or known metabolic derangements; for example,
uraemia, ketoacidosis, or electrolyte imbalance.
9. Haematological disorder (one of the following):
o Haemolytic anaemia: with reticulocytes
o Leukopenia: <4000/mm^3 on 2 occasions
o Lymphopenia: <1500/mm^3 on 2 occasions
o Thrombocytopenia: <100,000/mm^3 in the absence of offending drugs.
10. Immunologic disorder (one of the following):
o Anti-DNA: presence of antibody to native DNA in abnormal titre
o Anti-Smith: presence of antibody to Smith nuclear antigen
o Positive findings of anti-phospholipid antibodies based on:
An abnormal serum level of IgG or IgM anticardiolipin antibodies
Positive test result for lupus anticoagulant using a standard method
A false-positive serological test for syphilis known to be positive for at least 6 months
and confirmed by Treponema pallidum immobilisation or fluorescent treponemal
antibody absorption (FTA) test.
11. Anti-nuclear antibody
o An abnormal titre of anti-nuclear antibody by immunofluorescence or an equivalent assay at
any point in time and in the absence of drugs known to be associated with drug-induced lupus
syndrome
o

Lupus nephritis is histologically evident in most patients with SLE, even those without clinical manifestations of
renal disease. The symptoms of lupus nephritis are generally related to hypertension, proteinuria, and renal
failure. >> case
Reference ; http://emedicine.medscape.com/article/330369-overview
http://bestpractice.bmj.com.cuml1.md.chula.ac.th/best-practice/monograph/103/diagnosis/criteria.html

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95 A. Ovary
45, XO or Turner syndrome There are characteristic physical abnormalities, such as short stature,
swelling, broad chest, low hairline, low-set ears, and webbed necks. Girls with Turner syndrome typically
experience gonadal dysfunction (non-working ovaries)
96 E. Human placental lactogen
Human placental lactogen (HPL), also called human chorionic somatomammotropin, is a polypeptide
placental hormone. Its structure and function is similar to that of human growth hormone. It modifies the
metabolic state of the mother during pregnancy to facilitate the energy supply of the fetus. HPL has anti-insulin
properties.
HPL affects the metabolic system of the maternal organism. HPL decreases maternal insulin sensitivity,
and, therefore, raises maternal blood glucose levels, whilst decreasing maternal glucose utilization, which helps
ensure adequate fetal nutrition
97. high proliferative glandular epithelium
Phase

Days Thickness Epithelium

menstrual phase 1-4

thin

absent

proliferative phase 4-14 intermediate columnar

secretory phase

29

15-28 thick

columnar. Also visible are helicine branches of uterine artery

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98. A. Increased androstenedione

Table 17-1 Definition of Polycystic Ovarian Syndrome
ESHRE/ASRM (Rotterdam) 2003
To include two out of three of the following:
1. Oligo or anovulation
2. Clinical and/or biochemical signs of hyperandrogenism
3. Polycystic ovaries (with the exclusion of related disorders)
NIH (1990)
To include both of the following:
1. Oligo-ovulation
2. Hyperandrogenism and/or hyperandrogenemia (with the exclusion of related disorders)

ASRM = American Society of Reproductive Medicine; ESHRE = European Society of Human Reproduction and
Embryology; NIH = National Institutes of Health.

99. estrogens
With increasing levels of estrogens, the external cervical os begins to dilate, and cervical mucus secretion
becomes clear and watery. With high levels of estrogens, cervical mucus, when placed between two glass slides
that are then pulled apart, can be stretched 15 to 20 cm before breaking. This property of cervical mucusthe
ability to be drawn into a fine threadis termed spinnbarkeit. When cervical mucus is allowed to dry on a glass
slide and is examined under low power by light microscopy, a fern pattern made up of salt crystals may be seen.
Spinnbarkeit and ferning reach a maximum at the midpoint of the menstrual cycle. Sperm can more easily
penetrate mucus with these characteristics.
100
D. Human papilloma virus
epithelium ectocervix squamous cell ( endocervix columnar)
Human papillomavirus cervical cancer
101
D. inhibit phosphodiesterase type 5 (PDE-5)
Sildenafil Viagra erection of penis erection of penis
nitric oxid(NO) corpus cavernosum
NO activate enzyme guanylate cyclase increase guanosine monophosphate (cGMP) muscle
relaxation increase blood flow to corpus cavernosum
sildenafil phosphodiesterase type 5 (PDE-5) cGMP the corpus
cavernosum sildenafil cGMP corpus cavernosum
erection

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102 D estrogen receptor antagonist

Tamoxifen competitively binds to estrogen receptors on tumors and other tissue targets, producing a nuclear
complex that decreases DNA synthesis and inhibits estrogen effects. Tamoxifen is indicated as the hormonal
treatment of choice for both early and advanced breast cancer in women of all ages
103 D Testosterone
Aggressive behavior, anxiety, Acne, hirsutism ,gynecomastia, testicular atrophy adverse reaction
testosterone
104 B

Prostatic zonation
Peripheral area CA prostate
Central ejaculatory duct
Transitional urethra area BPH hematuria
urethra
105 E
uterine contraction prostaglangin PGF2
N-SAIDs cyclooxygenase prostaglandin
thromboxane
106. E
PID Pelvic inflamatory disease
( ) ( )
107 A. T. pallidum
T. pallidum - painless, hard chancre, sexually transmitted disease,
= primary syphilis
108 D
50 1 2

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 amenorrhea menopause
Most women experience 'natural
menopause' between the ages of 45-55
years old.
Symptoms vary greatly, and not all
women experience menopausal symptoms.
Presentation frequently involves irregular
menstrual cycles, hot flashes and night
sweats, and vaginal atrophy.

Ovarian failure decreased estrogen and

progesterone loss of negative-feedback
on the hypothalamus and pituitary
increased FSH and LH levels (FSH is a
better marker of ovarian failure as its levels
are less variable than LH)
Normal cycle:

Anovulatory cycle:

109. C. Thyroglobulin
Thyroid Hormone
Thyroglobulin (Tg) tyrosine 2-3% thyroid follicular cell
thyroid hormone Tg follicular cell apical
EXOCYTOSIS colloid (lumen) iodine tyrosine thyroperoxidase enzyme
(TPO) IODINATION organification iodine 1 monoiodotyrosine
(MIT) 2 diiodotyrosine (DIT) COUPLING
MIT DIT T3 (triiodothyronine) DIT DIT T4 (tetraiodothyronine)
thyroid vesicle TSH PINOCYTOSIS follicular cell
lysosome (PROTEOLYSIS) free T3, T4 (T4:T3 = 4:1)

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http://www.bmb.leeds.ac.uk/teaching/icu3/lecture/25/index.htm

thyroid hormone 60% thyroid binding globulin (TBG) 30% thyroxine

binding prealbumin (transthyretin; TBPA) albumin unbound form 0.05%
T4 5-deiodinase T3
receptor nucleus biological activity T4
* goitrogen thiocyanates
thyroid hormone
thyroid
Thyroid tumors
Benign

Follicular adenoma
Papillary carcinoma

Thyroid tumors
Follicular cell origin

(regional metastasis)
Follicular carcinoma
(distant metastasis esp. bone)
Anaplastic carcinoma
Medullary carcinoma

Malignant
C-cell origin

(hereditary)
Follicular adenoma is the most common of all thyroid tumors (>90%).
Papillary tumors are the most common of all thyroid cancers (>70%).
Papillary thyroid carcinoma
Intranuclear pseudoinclusion
Psammoma bodies

Papillary pattern

33

Orphan Annie eye nuclear

inclusions
(nuclei with uniform staining, which

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Nuclear groove

appear empty)

DIAGNOSIS: Papillary thyroid carcinoma is usually discovered on routine examination as an asymptomatic

thyroid nodule that appears as a neck mass. In some instances, the mass may have produced local symptoms. This
mass is normally referred to a fine needle aspiration biopsy (FNA) for investigation.
FOLLOW-UP: In addition to the usual cancer follow up, patients should receive a yearly chest x-ray as well as
thyroglobulin levels. Thyroglobulin is not useful as a screen for initial diagnosis of thyroid cancer but is quite
useful in follow up of well differentiated carcinoma (if a total thyroidectomy has been performed). A high serum
thyroglobulin level that had previously been low following total thyroidectomy especially if gradually increased
with TSH stimulation is virtually indicative of recurrence. A value of greater than 10 ng/ml is often associated
with recurrence even if an iodine scan is negative.
PROGNOSIS: Most patients fall into the low risk category and are cured of the cancer at the time of surgery.
http://www.endocrineweb.com/conditions/thyroid-cancer/papillary-cancer
http://reference.findtarget.com/search/papillary%20thyroid%20cancer/
.. , Biochemistry of Hormone

110. D. Somatotroph

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X. Cell > Hormone secreted by the cell (diseases caused by hypersecretion)

A. Lactotroph > Prolactin (amenorrhea,galactorrhea)
B. Thyrotroph > TSH (Hyperthyroidism)
C. Corticotroph > ACTH (Cushing: moon face, red cheeks, buffalo humps, trunkal obesity, purple
striae)
D. Somatotroph > GH (Gigantism, Acromegaly: , carpal tunnel syndrome, OA)
E. Gonadotroph > FSH, LH (Amenorrhea)

Acromegaly

Cushings syndrome

113. C. Vasopressin (Antidiuretic hormone ;ADH)

ADH
( ) Hypothalamoneurohypophyseal System ADH cAMP (
tuble collecting duct)

( : http://www.medtechzone.com/data/sero/ADH.php)

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 B Oxytocin 1.
2. myoepithelial cell alveolus alveolar duct

A,D,E Renin-Angiotensin-Aldosterone System 1.Sympathetic stimulation
2.Hypotension 3.Decreased Sodium delivery

: http://www.merck.com/media/mmhe2/figures/MMHE_03_022_01_eps.gif
112.
Problem list
-
hyperthyroid
diffuse thyroid enlargement (60g) 25 g.
rubbery consistency - CA CA

TSH T4 - euthyroid goiter

A. Idiopathic cause
B. Decreased hormone production - T4
TSH feedback
C. Iodine deficiency Simple nontoxic goiter, which may be diffuse
or nodular, is noncancerous hypertrophy of the thyroid without hyperthyroidism, hypothyroidism, or
inflammation. Except in severe iodine deficiency, thyroid function is normal and patients are asymptomatic except
for an obviously enlarged, nontender thyroid. Diagnosis is clinical and with determination of normal thyroid
function. Treatment is directed at the underlying cause, but partial surgical removal may be required for very large
goiters. T4 compensate TSH TSH normal
early Simple nontoxic
goiter normal thyroid hormone Severe Iodine deficiency hypothyroidism
D. Autoimmunity - autoimmune Hashimoto's thyroiditis Graves' disease (
Hyperthyroid ) Hashimoto autoimmune thyroiditis

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 Hashimoto's thyroiditis chronic autoimmune inflammation of the thyroid with lymphocytic

infiltration painless thyroid enlargement and symptoms of hypothyroidism thyroid peroxidase
antibodies antithyroglobulin antibodies lymphocyte transient
hyperthyroid normal Hypothyroid thyroid
E. Decreased TRH release - TSH T4
early iodine deficiency normal Hashimoto's thyroiditis
early iodine deficiency common Hashimoto's thyroiditis
Hyper Hypo autoAb
113 E
pheochromocytoma adrenal medulla catecholamine
1. Heart rate
2. Blood pressure
3. Blood glucose
blood glucose hepatic gluconeogenesis
pheochromocytoma
1. Malignant hypertension
2. Resistant to treatment with standard antihypertensive drug
3. Tachycardia
4. Palpitation
114 E Hypertension for young age
Na+ (135-145)
K+ (3.5-5.0) Cl- (100-110)
hypokalemia 24-hour K+ urine
Normal 24-hour K+ urine
pathology Renal
hyperaldosteronism
E primary hyperaldostronism
115 A
dopamine agoinist
dopaminergic neuron inhibitory signal pituitary gland
116. A
Propylthiouracil
Mechanism of Action: thyroid peroxidase (TPO)
coupling DIT&MIT
deiodination peripheral tissue T4 T3 5-monoiodination
A
iodothyrosine deiodination MIT DIT

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117. C
Diabetes insipidus
Primary polydipsia Primary polydipsia (also called psychogenic polydipsia) is characterized by a primary
increase in water intake. This disorder is most often seen in anxious, middle-aged women and in patients with
psychiatric illnesses
Central DI Central DI (also called neurohypophyseal or neurogenic DI) is associated with deficient secretion of
antidiuretic hormone (ADH).
Nephrogenic DI

ADH (vasopressin)
DI
118. A
119. D

hormone thyroxine hormone thyroxine
metabolism thyroxine
myopathy muscle atrophy muscle weakness
hypokalemia thyroxine sympathetic Na+-K+ ATPase K+ shift
cell Na+ K+ metabolism

120. A
Cushings syndrome cortisol
cortisol zona fasiculata adrenal cortex , moon
face, buffalo hump, hyperpigmentation, muscle weakness, , abdominal striae,
emotion psychosis, depression cushings syndrome
exogenous ( steroid steroid ) endogenous
( cortisol pituitary adenoma, adrenal adenoma)

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121.
A. melatonin
B. luteinizing hormone
C. testosterone
D. parathyroid
E. thyroid hormone
A
melatonin : is produced by the pineal gland, a gland about the size of a pea, located in the center of the brain but
outside the blood-brain barrier. The melatonin signal forms part of the system that regulates the sleep-wake
cycle.
Light dependence Production of melatonin by the pineal gland is inhibited by light and permitted by
darkness. For this reason melatonin has been called "the hormone of darkness". Its onset each evening is called the
Dim-Light Melatonin Onset (DLMO) , peaks in the middle of the night. (circadian Rhythm)
luteinizing hormone : is a hormone produced by the anterior pituitary gland.
In females, an acute rise of LH called the LH surge triggers ovulation and development of the corpus
luteum.
In males, where LH had also been called interstitial cell-stimulating hormone (ICSH), it stimulates
Leydig cell production of testosterone.

testosterone :

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Parathyroid : parathyroid gland calcium phosphate metabolism

calcium phosphate
osteoclast activity
GI calcium vitamin D

Hyperparathyroid : Ca2+ increase , Phosphate desease

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osteopenia : osteitis fibrosa cystica , PTH osteclast

peptic ulcer
pancreatitis : calcium pancreatic enz.
Nephrocalcinosis : calcium phosphate renat stone renal failure
E. thyroid hormone
The thyroid hormones, thyroxine (T4) and triiodothyronine (T3), are tyrosine-based hormones
produced by the thyroid gland primarily responsible for regulation of metabolism. An important component in the
synthesis of thyroid hormones is iodine.
The major form of thyroid hormone in the blood is thyroxine (T4),
which has a longer half life than T3. The ratio of T4 to T3 released into the blood is roughly 20 to 1.
Function: They act to increase the basal metabolic rate, affect protein synthesis, help regulate long bone
growth (synergy with growth hormone), neuronal maturation and increase the body's sensitivity to catecholamines
(such as adrenaline)
122. E Dx: Graves disease
caused by autoantibodies to the TSH-receptor (TSHR-Ab) that activate that TSH-receptor (TSHR),
thereby stimulating thyroid hormone synthesis and secretion, and thyroid growth (causing a diffusely enlarged
goiter).
CVS : sympathetic activity - arrhythmia tachycardia, heat failure left ventricle hypertrophy

Edema : heart failure

Neuromuscular system : muscle weakness , hypoK
CNS : neuropsychitis sympathetic over activity agitation
GI : diarrhea GI motility thyroid hormone

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