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Section 2 1.A 45-year-old man is brought to the emergency department after being found unconscious on the street.

In the ED the man reports a one-day history of nausea !omiting abdominal pain and increased thirst after a t"o-day alcohol binge. #lood tests re!eal greatly ele!ated le!els of serum lactate. $hich of the follo"ing could ha!e pre!ented this patient%s lactic acidosis& 'AD( )hiamine *lucose +olate ,obalamin 2. A 45-year-old man "ith a --year history of hypertension presents to his family physician for an annual chec.-up. (e is obese and has a family history of coronary heart disease. (e also has a history of alcohol abuse and suffers from .no"n cirrhosis of the li!er and 'IDD/. A lipid panel sho"s a total cholesterol of 245 mg0d1 an 1D1 of 123 mg0d1 an (D1 of 22 mg0d1 and a triglyceride of 1-3 mg0d1. )he patient has been unable to lo"er his cholesterol using lifestyle changes alone. )he doctor therefore recommends drug therapy. $hich of the follo"ing is the most appropriate treatment for this patient%s high cholesterol& 1o!astatin *emfibro4il ,holestyramine 'icotinic acid +iber -. A 53-year-old "oman is diagnosed "ith colorectal carcinoma of the sigmoid colon "ith li!er metastases. She undergoes left hemicolectomy and is subse5uently started on ad6u!ant chemotherapy "ith methotre7ate. After 8 "ee.s of chemotherapy she follo"s up "ith her doctor to assess the efficacy of the treatment.

$hich of the follo"ing "ould be found in this patient& Increased dihydrofolate and increased d9/: Decreased dihydrofolate and increased d9/: Increased dihydrofolate and decreased d9/: Decreased dihydrofolate and decreased d9/: 'ormal dihydrofolate and normal d9/: 4. A 24-year-old "oman has suffered from diabetes mellitus since the age of 13. (er physician recommends the addition of lisinopril to her medical regimen. $hich of the follo"ing organs has lisinopril and other angiotensin-con!erting en4yme inhibitors been demonstrated to protect in diabetics& Eyes (eart ;idneys 'er!es :ancreas 5. A 52-year-old man has a history of a massi!e myocardial infarction and subse5uent congesti!e heart failure. (e complains to his physician of "orsening breathlessness and fatigue. (is blood pressure is 122085mm(g and his heart rate is 133 beats per minute. $hich of the follo"ing beta-bloc.ers has additional alpha1 bloc.ing properties belie!ed to be intrinsic to its efficacy in the treatment of congesti!e heart failure& Atenolol ,ar!edilol /etoprolol

:ropranolol )imolol 8. A 82-year-old man complains of s"ollen an.les. :hysical e7amination confirms lo"er e7tremity edema. (is physician prescribes furosemide. $hich of the follo"ing best describes the site of action of furosemide& Ascending loop of (enle ,ortical collecting tubule Distal con!oluted tubule *lomerulus :ro7imal tubule 2. A -5-year-old "hite male presents to his primary care doctor "ith complaints of headache and malaise. (is blood pressure is ele!ated. (e has periorbital and pretibial edema. 9rinalysis re!eals hea!y proteinuria. $hich of the follo"ing is the most li.ely principle component of his proteinuria& A. #. ,. D. E. Albumin ;appa light chains 1ambda light chains )amm-(orsfall protein )ransthyretin

<. A 45-year-old male presents to his primary care physician "ith complaints of abdominal pain relie!ed "ith meals. (e has been ta.ing ranitidine "ith some relief. Esophagogastroduodenoscopy re!eals a duodenal ulcer. )ests for (elicobacter pylori are negati!e. )he patient is placed on omepra4ole. $hich of the follo"ing is the action of omepra4ole& Antagonism of parietal cell histamine receptor Enhancement of duodenal bicarbonate secretion Inhibition of gastrin release

Inhibition of parietal cell hydrogen0potassium A):ase Stimulation of lo"er esophageal sphincter tone =. A drug company is testing the efficacy of an anti-(I> drug pictured belo". )he agent is currently being tested in in !itro systems using cultured human cells infected "ith (I>. )reatment of these cells "ith this drug "ould cause a decrease of

!iral ?'A !iral en!elope protein !iral protease !iral re!erse transcriptase !iral D'A 13. A 6udge ordered D'A tests on t"o men /1 and /2 in!ol!ed in a paternity suit. #oth claim that they are the father of baby @. *enetic tests based on a D'A restriction fragment that e7hibits polymorphism "ere performed. #lood "as dra"n from the baby the mother A+B and the t"o men. D'A "as e7tracted and polymerase chain reaction "as performed. )he D'A "as then restriction digested separated out by gel electrophoresis and southern blotted Asho"n at rightB. A radioacti!e probe "as used that bound to a se5uence "ithin the fragment that e7hibited polymorphism. #ased on the data "hich of the follo"ing is the most li.ely conclusion&

/1 is the father of baby @. /2 is the father of baby @. 'either /1 nor /2 is the father of baby @. + is not the mother of baby @.

'othing can be concluded from the data 11. An 1<-year-old #/@ bi.e acrobat sustains a saddle area impact during a faulty landing from a tric.. :hysical e7amination is significant for scrotal s"elling and ecchymosisC bruising and superficial scratching of the perineum are also noted. )he ne7t step should be insertion of a urinary catheter retrograde cystogram retrograde urethrogram suprapubic catheter insertion trans urethral prostatic resection A)9:?B 12. A 45-year-old man begins treatment for fluid retention related to alcoholic li!er disease "ith spironolactone. $hich of the follo"ing is a side effect of potassium sparing diuretics li.e spironolactone& *ingi!al hyperplasia *ynecomastia (yperlipidemia (ypo.alemia (yponatremia 1-. A 58-year-old man begins treatment "ith a diuretic for lo"er e7tremity edema. Se!eral "ee.s later he complains to his physician about a !ery painful right foot. #y e7amination his right first metatarsal 6oint is grossly erythematous and e75uisitely tender. 1aboratory tests are obtained creatinine 1.mg0d1 sodium 143 mg0d1 potassium -.5 mg0d1 uric acid D 13.2 mg0d1. $hich of the follo"ing is most li.ely the diuretic prescribed by the patient%s physician& Aceto4olamide

Amiloride #umetanide Spironolactone )riamterene 14. A patient "ith depression has failed courses of SS?Is and tricyclics and the decision is made to put her on an /AE inhibitor. She is cautioned about the ris.s of eating tyraminerich foods such as certain cheeses and red "ine. $hich of the follo"ing /AE inhibitors is safest "hen strict tyramine a!oidance is impossible& :henel4ine /oclobemide (armaline Deprenyl )ranycypromine 15. A 18-year-old "oman presents to her pediatrician "ith a t"oday history of coughing "hee4ing chest tightness and shortness of breath. She has had repeated episodes of the same symptoms for "hich she has !isited the same pediatrician. )he patient also has a history of allergy to cat dander. $hich of the follo"ing is the most appropriate drug for long-term control of this patient%s disease& Indomethacin :ropanolol /ontelu.ast Sulfasala4ine 1eu.otriene

18. A 13-day-old infant in the neonatal I,9 began sho"ing signs of tachypnea and cyanosis of the mucous membranes. )he infant "as also noted to ha!e nasal flaring and significant intercostal retraction "hile breathing. An arterial blood gas sho"ed a :aE2 of 55 and a p( of 2.-1. (istological analysis of a microscopic lung biopsy from this patient is sho"n. $hich of the follo"ing is deficient in this patient&

:hosphatidylethanolamine :hosphatidylinositol Diacetylphosphatidylserine Dipalmitoylphosphatidylcholine :hosphatidylglycerol 12. A 25-year-old "oman "ith sic.le cell anemia complains of right .nee pain and s"elling o!er the past "ee.. :hysical e7am re!eals )131+ #: 12-023 (? <<. )he right .nee is diffusely s"ollen "ith 6oint line tenderness and limited range of motion. 1absF 'a 141 ,l =2 ; 4.2 (,E- 24 neutrophils 1-.2 differential <5G hemoglobin 15g0d1 platelets -33 3330mm. Hoint aspiration is performed. )he results are most li.ely to indicate "hich of the follo"ing diagnoses& #one infarct Staphylococcus aureus septic arthritis Staphylococcus epidermidis arthritis Salmonella septic arthritis /eningococcal septic arthritis 1<. A 22-year-old intra!enous cocaine abuser is hospitali4ed after fre5uent bouts of hemoptysis. Echocardiography re!eals a !egetati!e mass of the tricuspid !al!e. #lood cultures are

positi!e in three out of three bottles. )he organism most li.ely to be cultured from the blood is Staphylococcus epidermidis Streptococcus !iridans Staphylococcus aureus Streptococcus pyogenes Escherichia coli 1=. A 23-year-old college student presents to the Student (ealth ,enter "ith complaints of itchy "atery eyes snee4ing and nasal congestion at the onset of rag"eed season. (e is concerned about the sedating effects of medication "ith mid-terms coming up. $hich of the follo"ing agents through action at the histamine1 receptor is most li.ely to ameliorate his symptoms "ithout causing sedation& ,imetidine Diphenhydramine (ydro7y4ine 1oratadine ?anitidine 23. A 52-year-old "oman has a lifelong history of debilitating migraines. She begins treatment "ith sumatriptan "ith great impro!ement in her headache pattern. $hich of the follo"ing best describes the site of action of sumatriptan& 5-()1A 5-()1D 5-()5-()4

5-()2 21. A 58-year-old man is brought to the emergency department "here he presents "ith !omiting lethargy and disorientation. (e also displays mar.ed hypotonia and tremors. )he patient has a respiratory rate of -5. #lood tests re!eal e7tremely ele!ated ammonia le!els. )he disease in this patient could ha!e been caused by a deficiency of ornithine transcarbamoylase carbamoyl phosphate synthetase II alanine aminotransferase glutamate dehydrogenase D-amino o7idase 22. A 24-year-old man presents for a routine chec.-up for his 6ob. En physical e7amination you note that his radial pulse is strong and his femoral pulse is "ea.. Iou get a routine chest @ ?ay and the radiologist informs you that there is JnotchingJ of the ribs. $hat is the most li.ely diagnosis& :atent ductus arteriosus Dissecting aortic aneurysm :ericarditis ,oarctation of the aorta ?ib fracture compressing the descending thoracic aorta 2-. A 25-year-old female presents because she is "orried that her neighbor has been spying on her. She notes that "hen she goes to bed at night she hears his car start and dri!e a"ayC she says that is because "ith her lights off there is nothing on "hich for him to spy. En se!eral occasions she has found his mail in her mailbo7 "hich she suspects "as put there as an e7cuse for him to come o!er to her house and retrie!e it though she admits he has ne!er actually come o!er. $hen they see each other in the yard he smiles at her and says J*ood day miss J "hich she is

sure is a secret message to her though she cannot crac. it. She has no hallucinations and is not "orried about anyone else spying on her. She "as recently promoted at "or.. (er most li.ely diagnosis is schi4ophreniform disorder delusional disorder borderline personality disorder schi4otypal disorder brief psychotic reaction 24. A -4-year-old man "ith cluster headaches has failed multiple therapies. (e recei!es good relief from the use of methysergide but his physician insists on fre5uent drug holidays during "hich his headaches return. $hich of the follo"ing side effects of methysergide is minimi4ed through the use of drug holidays& Anosmia *ingi!al hyperplasia *ynecomastia (irsutism ?etroperitoneal fibrosis 25. A -8-year-old man presents to his family physician complaining of sudden se!ere pain and s"elling of his left an.le and .nee that came on one day ago. #oth 6oints are erythematous edematous "arm and tender to palpation. )he patient also complains of fe!er chills and malaise. (e reports drin.ing appro7imately 43 beers o!er the past t"o days. $hich of the follo"ing is the most appropriate inter!ention for this patient& Eral neomycin @anthine (ypo7anthine

1actate ,olchicine 28. A 22-year-old "oman is hospitali4ed in a coma after sustaining blunt head trauma in an automobile accident. Se!eral hours after she "as admitted the patient began to !oid large !olumes of urine A433 ml0hourC specific gra!ityF 1.33-B. Administration of "hich of the follo"ing is most li.ely to confirm the diagnosis in this patient& Aldosterone +urosemide /annitol #romocriptine >asopressin 22. A 45-year-old "oman has undergone a hysterectomy "ith bilateral oophrectomy for bleeding uterine leiomyomas. )"o "ee.s post-surgery an abdominal ultrasound re!eals a left hydronephrosis. $hat is the most li.ely complication of her surgery that could cause this pathology& 1eft pyelonephritis ,ystitis 1eft nephrolithiasis 1eft ureteral ligation #ladder prolapse 2<. 14-year-old girl suffers from asthma. She has been re5uiring fre5uent dosing of her inhaler especially at night. (er physician prescribes a ne" inhaled medication "ith a longer duration of action to control her nighttime symptoms. $hich of the follo"ing is a long-acting beta2 agonist&

Albuterol /etaproterenol :irbuterol Salmeterol )erbutaline 2=. A 15-year-old boy has poorly controlled asthma despite the use of inhaled corticosteroids. (is physician adds 4ileuton to his medical therapy. $hich of the follo"ing best describes the action of 4ileuton& ,yclo-o7ygenase1 inhibitor ,yclo-o7ygenase2 inhibitor 5-lipo7ygenase inhibitor Inhibitor of mast cell degranulation 1)D4-receptor antagonist -3. A 2-month-old girl presents to the emergency department "ith sei4ures and se!ere muscular "ea.ness. :hysical e7am re!eals a cherry-red spot on the infant%s macula but is negati!e for any organomegaly. )he most li.ely cause of the symptoms seen in this infant is a deficiency of iduronate sulfatase arylsulfatase A beta-glucocerebrosidase he7osaminidase A sphingomyelinase -1. A 12-year-old boy presents to the emergency room because of loss of feeling and mo!ement in his left foot. A peripheral smear demonstrates red blood cells that are uniformly circular and

homogeneous in color. diagnosis&

$hich of the follo"ing "ould confirm the

(emoglobin electrophoresis 'itroblue tetra4olium test Serum iron ferritin and )I#, le!els

Esmotic fragility test (emagglutination at 4o, -2. A 14-year-old boy during a routine office !isit as.s about his ris. of mental illness. (is mother and father both ha!e schi4ophrenia. Apart from his increased ris. of schi4ophrenia his ris. is highest for bipolar disorder panic disorder schi4oid personality disorder substance abuse schi4oaffecti!e disorder --. A 2<-year-old "oman is brought to the emergency department after being rescued from an apartment fire "here she "as trapped in her bathroom. She presents "ith dyspnea tachypnea stridor and hoarseness. (er nose hairs appear to be singed and bronchoscopy re!eals edematous and erythematous respiratory mucosa. :ulse o7imetry demonstrated =2G o7ygen saturation "hile an arterial blood gas sho"ed an o7ygen saturation of 53G. $hat is the most appropriate treatment for this patient& (yperbaric o7ygen $hole blood +resh fro4en plasma +errous sulfate

$atchful "aiting -4. A 12-year-old boy is brought to his pediatrician by his mother "ith a t"o-day history of tea-colored urine. (e recently completed a fi!e-day course of penicillin for Streptococcal pharyngitis. (is blood pressure is ele!ated. (e has periorbital edema. $hich of the follo"ing is the most li.ely microscopic renal lesion& #asement membrane immune comple7 deposition #asement membrane thic.ening +oot process effacement /esangial proliferation Subepithelial immune comple7 deposition -5. A -1-year-old "oman is found to ha!e antibodies to the centromeres of some of her D'A. $hich of the follo"ing "ould you e7pect to be associated "ith her disease& )elangiectasias #iliary cirrhosis Esophageal adenocarcinoma (ypercalcemia (ot flushes -8. A 2--year-old patient "as brought by police to the E? after neighbors obser!ed him acting bi4arrely in the street. (e had been agitated and combati!e ta.en to one E? Atreatment un.no"nB and then brought to this E? "here though a"a.e he appears e7tremely "ithdra"n. (e is drooling and s"eatingC physical e7am re!eals up"ard nystagmus hyperrefle7ia and pinpric. tests elicit no response at all. (is temperature is mildly ele!ated. )his is most li.ely a case of catatonia

:,: into7ication 1SD into7ication haloperidol administration neuroleptic malignant syndrome -2. A -3-year-old female presents to her primary care physician "ith complaints of fre5uency urgency and dysuria o!er the last t"el!e hours. 9rinalysis re!eals many leu.ocytes. She is treated "ith a three-day course of oral ciproflo7acin. $hat is the primary target of the antimicrobial action of ciproflo7acin& #inding of the -3S subunit #inding of the 53S subunit ,ompetiti!e inhibition of dihydrofolate reductase Inhibition of D'A-dependent ?'A polymerase Inhibition of D'A gyrase -<. A --year-old boy is referred to a pediatric infectious disease specialist for a history of recurrent pneumonia perianal abscesses and fungal infections. :hysical e7amination re!eals lymphadenopathy and hepatosplenomegaly. #iopsies of the patient%s s.in and colon re!eal e7tensi!e granulomatous inflammation. )he defect responsible for the disease in this patient is found in # lymphocytes ) lymphocytes eosinophils neutrophils mast cells -=. A 52-year-old man is referred to a cardiologist for progressi!e dyspnea s"elling of his feet and an.les and fatigue. (e also complains of coughing and "hee4ing. )he patient reports a 23-year history of smo.ing. :hysical e7amination re!eals 6ugular

!enous distention hepatomegaly and a bluish discoloration of his s.in. )he most li.ely etiology of this patient%s condition is pulmonary hypertension systemic hypertension portal hypertension mitral regurgitation aortic stenosis 43. A 12-year-old male is hit in the left temporal area "ith a baseball. Although initially complaining loudly "ithin 23 minutes he slips into unconsciousness and recusitati!e efforts are futile. 1aceration of "hich of the follo"ing !essels is most li.ely in this boy& 1eft temporal artery 1eft anterior descending artery 1eft middle cerebral artery 1eft middle meningeal artery ,erebral bridging !eins 41. A -5-year-old man presents to the emergency department "ith a fi!e-hour history of nausea !omiting and diarrhea. (e also complains of headache an7iety and shortness of breath. (is respiratory rate "as noted to be -5 and a bluish discoloration of his oral mucous membranes "as obser!ed. )he patient tells the doctor that he "or.s at a dental office and accidentally ingested a large amount of ben4ocaine earlier in the day. A potassium cyanide test is performed and is positi!e Aturns bright redB. $hich of the follo"ing is the most appropriate treatment for this patient& (emato7ylin $right%s stain

:eriodic acid schiff /ethylene blue /asson trichrome 42. A 82-year-old man presents to the emergency department "ith the abrupt onset of fe!er chills and cough producti!e of rustycolored sputum. A sputum sample is obtained.

$hich of the follo"ing antibiotics is the best empiric treatment for this patient& ,eftria7one ,iproflo7icin *entamicin /etronida4ole :enicillin 4-. A 2-year-old girl de!elops a pharyngitisC her parents treat her "ith a homeopathic remedy. +our "ee.s later the girl has edema and hematuria. )he initiating microorganism for this e!ent "as E. coli Streptococcus agalactiae Streptococcus pyogenes Epstein-#arr !irus Influen4a !irus

44. A 44-year-old "oman is referred to a deto7ification clinic for chronic alcohol abuse. She is put into a 12-step program and is also started on a!ersion pharmacological therapy. Such a drug "ould inhibit alcohol dehydrogenase acetaldehyde dehydrogenase pyru!ate dehydrogenase alpha-.etoglutarate dehydrogenase glutamate dehydrogenase 45. A 24-year-old female presents to her primary care doctor "ith complaints of a pruritic rash present for the last se!eral days. )he rash began after a rela7ing resort "ee.end that she spent s"imming snor.eling and sitting in the hot tub. )he rash is concentrated in areas co!ered by her s"imming suit. $hich of the follo"ing is the most li.ely etiologic agent& :seudomonas aeruginosa :seudomonas pseudomallei Streptococcus pyogenes Staphylococcus aureus Staphylococcus epidermidis 48. A 52-year-old man presents "ith cough and chronic sinusitis of the ma7illary sinus. (e also relates blood in the urine. 9rinalysis re!eals a nephritic pattern. #ronchoscopy and biopsy re!eal a focal necroti4ing !asculitis and numerous granulomas. (e has had fe!er and loss of -3 pounds in the last month. $hich of the follo"ing "ould you e7pect to see in the blood& Antibodies to double-stranded D'A Antibodies to the centromeres of chromosomal D'A c-A',A

p-A',A Antibodies to the acetylcholine receptor 42. A 14-year-old girl presents "ith multiple s.eletal deformities including bo"ing of the legs frontal bossing and o!ergro"th of the costochondral 6unction. $hich of the follo"ing is the most li.ely cause of her disorder& >itamin D deficiency >itamin A deficiency >itamin , deficiency >itamin #12 deficiency (ypoparathyroidism 4<. $hich of the follo"ing antibiotics% mechanism of action re5uires binding to the -3S subunit of the ribosome& A4ithromycin ,hloramphenicol ,lindamycin )etracycline )obramycin 4=. A 1--month-old girl presents to her pediatrician "ith irritability and lethargy. :hysical e7am re!eals a protuberant belly hepatomegaly alopecia and areas of une!enly pigmented s.in. #lood tests sho" an albumin of 2.5 mg0d1. In order to treat this patient%s underlying condition one "ould need to supplement her diet "ith 2333 .cal of carbohydrates daily 5 g of protein daily

2333 .cal of fats daily cobalamin and folate daily 533 g of ferrous sulfate daily 53. A 15-year-old boy "ith cystic fibrosis presents to his pediatrician "ith lethargy fatigue and failure to thri!e. (e reports recent episodes of light-colored and foul-smelling stool that seem to float. #lood tests sho" hemoglobin of 11.2 g0d1 hematocrit of -8G and a serum calcium of 5.5 mg0d1. Supplementation "ith "hich of the follo"ing is most appropriate to treat the underlying cause of his condition& >itamin D +errous sulfate ,alcium 1ipase +iber