1-A 7-year-old male is brought to the emergency department.

His mother noticed

that he began to have problems walking and standing upright over the past 72
hours. He attends an after-school play group and, along with several other children
at the facility, had diarrhea that lasted for 4 days in the previous week. His mother
denies her child having any associated fever, chills, or vomiting. Nerve conduction
studies show a slow conduction velocity. A lumbar puncture is performed and
reveals the following:
White blood cell counts: 3/mm3
Chloride: 110 mEq/L
Glucose: 50 mg/dL
Lactate dehydrogenase: 1.5 U/mL
Proteins: 60 mg/dL
Opening pressure: 90 mm H2O
What is the most likely mechanism that led to the weakness in his legs?
A. Antibodies attacking the myelin sheaths of the peripheral nerves Guillain-Barre
Syndrome increase in CSF protein Campylobacter Jejuni
B. Autoantibodies attacking myelinated axons in the central nervous system
C. Destruction of the anterior horn cells in the spinal cord
D. Neurotoxin released by a tick attached to the skin
E. Toxins binding to presynaptic cholinergic receptors
2-A 25-year-old African male with no significant past medical history presented to
the emergency department with complaints of weakness and headache of 1-week
duration. Upon review of systems, he also complains of myalgia and intermittent
fever and chills. Further questioning reveals that he returned from Sierra Leone
approximately 2 weeks prior to his presentation. His peripheral blood smear is
shown below. Which of the following patterns of laboratory tests are most likely in
this patient?
Hemoglobin
Total Bilirubin
Indirect Bilirubin - Increased
Lactate Dehydrogenase - Increased
Haptoglobin
A. Decreased
Decreased
Increased
 Increased
Increased

B.
Decreased
Increased
Decreased
Decreased
Decreased

C.
Decreased
Increased
Decreased
Increased
Decreased

D.
Decreased
Increased
Increased
Increased
Decreased

E.
Increased
Decreased
Increased
Decreased
Increased
3-A 1-week-old infant is brought to the emergency department by his mother. He
has been febrile for the past 12 hours and has not been feeding. The mother had a
healthy pregnancy but received no prenatal care. The infant was born vaginally
without complications and had been healthy until yesterday evening when he
became febrile. The infant is hypotensive, and has tachypnea and tachycardia. A
chest x-ray reveals patchy pulmonary infiltrates. Blood cultures are positive for a
catalase-negative, -hemolytic, gram-positive coccus. What is the key factor that
contributes to the ability of the causative organism to cause disease?
A. Antigenic variation
B. Cell wall components that drive cytokine secretion
C. Production of a slime layer
D. Specialized attachment proteins
E. Secretion of exotoxins Group B Strep Agalactiae
4-In bone marrow transplantation, the donor marrow is reinfused into the recipient
through a vein. These transfused hematopoietic cells, despite systemic dispersion,
grow only in the recipient's bone marrow. One mechanism by which this may
happen is (the):
A. Filtering of infused marrow microparticles in marrow capillaries
B. Interaction of bone marrow endothelial selectins and stem cell integrins
C. Preparation of the marrow growth environment by pre-irradiation
D. Slowing of blood flow in marrow sinusoids
E. Uniqueness of von Willebrand factor produced by marrow endothelial cells
5-A 35-year-old African American woman presents to the emergency room with
fever, chills, and abdominal pain. She has a known diagnosis of systemic lupus
erythematosus (SLE) and is on corticosteroid treatment. CT scan reveals a large (14
cm) abscess on her liver, and fine needle aspiration is performed. The aspirated
fluid is thick and yellow-brown in color. A trichrome stain is performed on the fluid.
Cytology findings are notable for a lack of WBCs and the presence of pathogenic
organisms (seen in the image).
Which of the following is the most likely initial site of infection?
A. Appendix
B. Biliary tract
C. Colon
D. Kidney
E. Oral cavity

6-A 22-year-old woman delivers a seemingly healthy baby boy. Within 24 hours,
however, the newborn's skin develops a yellowish tinge. Laboratory tests performed
on the newborn yield the following results:
Total bilirubin: 19.5 mg/dL
Red blood cell count: 2.2 million/mm3
Direct Coombs test: Positive
Testing on the mother shows a positive indirect Coombs test. Additionally, both the
mother and the son have type O blood. Which of the following is most likely true?
A. The boy has increased conjugated bilirubin.
B. The boy is the mother's firstborn child.
C. The boy's father must be Rh negative.
D. The disease is caused by anti-IgM antibodies.
E. The mother did not receive routine prenatal care.
7-A 22-year-old woman from southern Colorado presents to her physician with a 2-
day history of fever, chills, and night sweats. She is a college student who
volunteers regularly at a local pet shelter. She has no history of travel. Physical
examination reveals a pale, ill-looking woman with tachycardia, hypotension, and
painful, right inguinal lymphadenopathy. Blood cultures are positive for an oxidase-
negative, lactose nonfermenting, non-H2S-producing rod.
How did the patient acquire this infection?
A. A cat bite
B. A flea bite Yersinia Pestis
C. Consumption of food contaminated by an infected person
D. Consumption unpasteurized milk
E. Inhalation of the organism
8-A 33-year-old woman visits a gynecologist because her three previous
pregnancies have all ended in fetal loss. She says she first went to a different
gynecologist for evaluation, but felt that "he was a bad doctor and a liar" and
decided to seek answers elsewhere. Upon chart review, the new gynecologist learns
that the first doctor initiated a workup for pelvic inflammatory disease, which
yielded a positive test for syphilis. When the first gynecologist had asked about the
possibility of venereal disease, the patient had become angry and offended,
insisting that she and her husband have always been faithful to each other. Routine
physical examination is unremarkable. Laboratory testing with a complete blood
count reveals mild thrombocytopenia. Additional testing in this patient might
uncover what related finding?
A. Chlamydial infection - PID
B. Deep vein thromboses Antiphospholipid Syndrome
C. Infectious mononucleosis
D. Septate uterus
E. Shortened partial thromboplastin time
9-A 46-year-old man complains of constant tiredness and shortness of breath while
climbing stairs. Past history is noteworthy for partial gastrectomy for a bleeding
gastric ulcer 6 years ago. Physical examination shows generalized pallor and a
beefy red tongue. Neurologic examination reveals paresthesias and decreased
vibration sensation. CBC shows hemoglobin 7.2 gm/dL (normal 13 to 16 gm/dL) with
an MCV 119 fL (normal 80 to 99 fL). What disease mechanism best describes the
pathogenesis of this man's anemia?
A. Clonal stem cell abnormality
B. Immune destruction of erythroblasts
C. Impaired DNA synthesis Vit B12
D. Impaired heme synthesis
E. Impaired globin chain synthesis
10-A 21-year-old college student presents to her physician, complaining of a sore
throat. Physical examination reveals lymphadenopathy of cervical lymph nodes and
an enlarged, tender spleen. After review of the complete blood count (CBC), a
peripheral blood smear (PBS) is ordered. The leukocyte seen in the image
represents a/an:
Complete Blood Count (CBC)
Patient
Reference range
Hemoglobin
13.2
1216 mg/dL
MCV
91
8099 fL
Platelets
212
150400 X 103 /mL
Neutrophils
6.6
18 X 103 /mL
Lymphocytes
9.1
14 X 103 /mL
A. Activated T cell lymphocyte
B. Lymphoblast of acute lymphoblastic leukemia
C. Reactive monocyte
D. Virally infected B cell lymphocyte
E. Virally infected T cell lymphocyte
11-A 33-year-old African American man with no past medical history presents to his
primary care physician to discuss the vaccines he needs for his upcoming
backpacking trip in Malaysia. He is informed that in addition to vaccines, he will
need to take an oral medication for malaria prophylaxis. Two days after the patient
takes his first dose of chloroquine, he notices shortness of breath, a racing heart,
and dark urine. He returns to the clinic for help. On physical exam, significant
findings include scleral icterus and pallor. Which of the following is present in this
patient's erythrocytes?
A. Clustered DNA
B. Excess glycoprotein
C. Increased iron concentration - Chloroquine
D. Membrane blebs
E. Precipitated protein
12-A patient presents to clinic complaining of headache, fever, and sweating while
asleep. The physician staffing the clinic notes cervical lymphadenopathy and
arranges for a lymph node to be biopsied. The tissue sample has the following
microscopic appearance:
What is the most likely clinical description of this patient?
A. An 8-year-old African boy with a known history of Epstein-Barr virus Burkit
B. A 20-year-old Caucasian woman with no medical history Nodular Sclerosing
Type Hodgkin Lymphoma associated more common in females
C. A 40-year-old Caucasian man with Helicobacter pylori gastritis - MALTOMA
D. A 55-year-old Caucasian man infected with human Herpesvirus-8 Kaposi
Sarcoma
E. A 65-year-old African American man with widespread disease CLL
transforming to Small cell lymphoma
13-A medical student performing research on the coagulation cascade finds that
blood from a particular strain of laboratory mouse demonstrates a prolonged
clotting time in test tubes. Additional testing reveals that the mouse strain also
exhibits stunted activation of the kinin cascade. What protein is likely decreased or
absent in the blood of this particular mouse strain?
A. Factor II
B. Factor VII
C. Factor X
D. Factor XI
E. Factor XII
14-A 5-year-old boy with a painful, swollen knee is found to have a bleed within the
joint. Coagulation testing reveals the following: the aPTT is prolonged and the PT is
within normal limits. To investigate the prolonged aPTT, mixing studies are
performed by mixing the patient's plasma at a 1:1 ratio with plasma from other
known donors. Results of these studies are shown below.
aPTT [30-40s]
Patient's plasma + Normal Plasma 32s
Patient's plasma + Factor VIII deficient plasma 38s
Patient's plasma + Factor IX deficient plasma 59s
Given these results, which of the following is most likely?
A. Approximately half of the patient's brothers are expected to have the same
condition.
B. The patient has a congenital deficiency of factor II.
C. The patient has a factor inhibitor.
D. The patient's father shares this disease.
E. The patient's sisters have a 50% chance of sharing this disease.
15-After feeling slightly ill for several days, a 20-year-old white man notices
darkening of his urine and a yellowish tinge to his skin. Routine laboratory testing is
performed at the local clinic and reveals:
Hb 12.5 g/dL
Hct 32.1%
RBC count 4.0 million/mm3
MCV 80.1 um3
MCH 30.5 pg/cell
MCHC 39.0 pg/cell
Retic count 6%
No abnormal globin chains are detected. Coombs (anti-human globulin test) is
negative. Which of the following defects is most likely to be present in the patient's
red blood cells?
A. Abnormal membrane skeleton proteins
B. Decrease in -globin chains
C. Decrease in -globin chains
D. Defective glucose 6-phosphate dehydrogenase
E. Defective pyruvate kinase
16-A 53-year-old man comes to his doctor complaining of weakness and fatigue. He
also notes that he has been having frequent nosebleeds and has had a fever for the
past few days. On physical exam, a massively enlarged spleen is noted. The
peripheral blood smear reveals the following type of cell:
Which of the following histological stains is most likely to be useful for confirming
the diagnosis?
A. CD 19
B. Kappa light chain
C. Leukocyte alkaline phosphatase
D. Myeloperoxidase
E. Tartrate resistant acid phosphatase Hairy Cell Leukemia

17-A patient, recently diagnosed with a hematologic malignancy, undergoes a

karyotype, which reveals the following:
This karyotype signifies a worse prognosis for which of the following malignancies?
A. Acute lymphoblastic leukemia
B. Adult T-cell leukemia
C. Chronic lymphocytic leukemia
D. Chronic myelogenous leukemia
E. Hairy cell leukemia
18-A 25-year-old African American man presents to his doctor with fatigue, yellow
skin, and dark urine. He recently was treated with antibiotics after being diagnosed
with community-acquired pneumonia. He reports never having these symptoms
before, though he states that his parents told him he had yellow skin shortly after
being born. Physical exam reveals splenomegaly. A peripheral blood smear is most
likely to find which of the following:

E picture is the answer G6PD Bite Cells

19-A 45-year-old male with a history of IV drug abuse presents with bilateral pleural
effusions. Large malignant lymphocytes are present in the effusion. There is no
significant lymphocytosis in the blood, and no masses or prominent
lymphadenopathy are detected. Flow cytometry demonstrates the expression of B
cell markers on the malignant lymphocytes consistent with a primary effusion
lymphoma. The etiologic agent associated with this malignancy is:
A. Epstein-Barr virus (EBV)
B. Hepatitis B virus (HBV)
 C. Human herpes virus type 8 (HHV-8) Kaposis Sarcoma associated with Primary
Effusion Lymphoma
D. Human papilloma virus (HPV)
E. Human T lymphotrophic virus type 1 (HTLV-1)
20-A 57-year-old male presents to his physicians office with pneumonia. A complete
blood count (CBC) reveals pancytopenia. A peripheral blood smear (PBS) is
performed, and the red blood cells appear normal. A smear of the buffy coat of the
blood reveals the cells seen in the image. A bone marrow aspirate results in a dry
tap (no hematopoietic particles are identified). The biopsy is marginally adequate
and reveals increased reticulin (fibrosis). Further evaluation of the cells in question
would be expected to show:
A. CD3 positive immunophenotype
B. Cyclin D1 positive immunophenotype
C. Mechanical fragility on the peripheral blood smear
D. Positive acid phosphatase staining after incubation with tartrate Hairy Cell
Leukemia
E. Positive staining for myeloperoxidase

21-An 83-year-old male presents to the hospital with an upper respiratory tract
infection. Complete blood count reveals a decreased hematocrit. Laboratory testing
shows an elevated serum indirect bilirubin and an elevated serum lactate
dehydrogenase. Blood smear reveals anisocytosis and poikilocytosis with helmet-
shaped red blood cells, very small red blood cells, and red blood cell fragments.
Chest x-ray is negative for pneumonia but reveals a mechanical heart valve. This
patients red blood cells suffer from which of the following?
A. Cytoplasmic maturation defect Thalassemia or Heme Synthesis defect
B. Extrinsic survival defect
C. Intrinsic survival defect
D. Nuclear maturation defect
E. Proliferation defect
22-A 35-year-old male smoker presents with an acute bronchitis that has not gotten
better with antibiotic therapy. The patient describes progressive shortness of breath
over the past several months. A chest x-ray reveals features of emphysema. An
abdominal ultrasound suggests diffuse hepatic fibrosis. A liver biopsy would most
likely show:
A. Abundant liver iron with fibrosis
B. Granulomatous inflammation of biliary ducts
C. Numerous portal lymphocytes and plasma cells - Hepatitis
D. PAS-positive globules in hepatocytes
E. Periductal onion-skin fibrosis around bile ducts- Primary Sclerosing Cholangitis
23-A 17-year-old girl presents to her family physician with fatigue and a sore throat.
Physical examination reveals cervical lymphadenopathy and mild splenomegaly. A
representative photograph from the peripheral blood smear is shown below.
Which of the following markers would you expect these cells to express on their
surface?
A. CD20
B. CD3 Infectious Mononucleosis EBV All T cells have CD3
C. CD34
D. CD38
E. TdT

24-A New York City businessman who recently returned from Africa presents to an
urgent care clinic complaining of headache and fever. He is given empiric
medication for viral fever and sent home. The following week he is brought to the
emergency department by his wife with chills, diaphoresis, and fever of 41.7oC,
splenomegaly, and anemia. She says that these febrile episodes have occurred
every other day, punctuated by alternate days of drenching sweats and weakness.
He is hospitalized and treated with chloroquine and another medication to prevent
relapse and spread of the disease. At what point in the diagram does the additional
medication disrupt the life cycle?
A. A
B. B - P. Vivax/Ovale
C. C
 D. D
E. E
F. F

25-A 31-year-old female in her fifteenth week of pregnancy presents to the ED with
a swollen, painful, red right calf. She complains of difficulty walking. An ultrasound
reveals deep vein thrombosis. Which of these mechanisms would provide the safest
and most effective treatment for this patient?
A. Conversion of plasminogen to plasmin
B. Inactivation of thrombin Warfarin/Heparin HIT syndrome
C. Increased supply of reduced vitamin K
D. Inhibition of phosphodiesterase
E. Reduction of thromboxane production
26-After being hospitalized for deep vein thrombosis, a 67-year-old woman is placed
on anticoagulation therapy. The medical team begins treating her with warfarin,
along with heparin for the first few days of treatment. However, seven days after
initiation of anticoagulation, the patient's thrombosis worsens, and she develops
clinical signs of a pulmonary embolism. What laboratory finding might be expected
in this patient?
A. Decreased prothrombin time
B. Hypernatremia
C. Increased factor V
D. Increased protein S
E. Thrombocytopenia - HIT
27-An otherwise well 42-year-old woman is found to have an abnormal complete
blood count drawn during a routine physical. She is anemic with hemoglobin of 10.2
mg/dL. Mean corpuscular volume (MCV) is 59 fL, RBC count is 5.5x106/L, and red
cell distribution width (RDW) is 16.5%. Which of the following represents the most
like pathologic mechanism of the patient's anemia?
A. Autoimmune destruction of peripheral erythrocytes
B. Chronic gastrointestinal bleeding Iron Deficiency
C. Excessive cytokine production due to chronic inflammatory disorder
D. Loss of gastric parietal cells
E. Reduced expression of beta-globin - thalassemia
28-A 46-year-old man seeks the advice of his physician because he has noticed the
recent development of several macular patches of pale-colored skin on his hands
and fingers. He states that these areas seem to be numb and insensitive to pain.
Past medical history is notable for work as a missionary in India 5 years ago. A skin
biopsy of one of the lesions is positive for histiocytes filled with acid-fast bacilli.
What is the mechanism of microbial resistance for the drug used to treat this
condition?
A. Alteration of topoisomerase
B. Decreased binding of dihydropteroate synthase - Dapsone for Leprosy
C. Inactivation by acetyltransferase - Aminoglycosides
D. Inactivation by beta lactamase
E. Mutation of catalase-peroxidase TB INH
29-A child with sickle cell anemia is seen in a hematology clinic. Her mother states
that she has been feeling very tired lately. The girl is very pale, and a complete
blood count shows severe anemia. A bone marrow aspirate is devoid of erythroid
precursors. How does the most likely causal agent produce its mRNA?
A. A complementary strand of RNA is created using a viral polymerase
B. By transcription from its genome in the cytoplasm
C. By transcription from its genome in the nucleus Parvovirus B19 DNA Virus SS
and Linear - smallest
D. By transcription from the provirus
E. The viral genome is used as mRNA
30-A 2-month-old infant whose birth was notable for an umbilical hernia and joint
contractures is brought to the pediatrician for repeated follow up for failure to
thrive. The pediatrician notes that the infant has a low nasal bridge, bulging
forehead, poor motor control, and macroglossia. Blood testing shows elevated levels
of various lysosomal enzymes in the patients serum. This patients problem is due
to a lack of which of the following posttranslational modifications?
A. Carboxylation of glutamic acid
B. Hydroxylation of prolyl residues
C. N-linked glycosylation of asparagine
D. O-linked glycosylation of serine
E. Phosphorylation of mannose
31-A 67-year-old man is brought to the emergency room by his wife because of a
severe headache, changes in his vision, and confusion. She notes that he has a
fever, seems more tired than usual recently, and has been losing weight. He also
has had frequent nosebleeds. Urinalysis reveals significant proteinuria. Serum
protein electrophoresis with immunofixation reveals the following:
Which of the following is the most likely cause of the patient's neurological
symptoms?
A. Autoantibodies
B. Decreased cerebral blood flow
C. Hypocalcemia
D. Infection
E. Toxic metabolites
Immunofixation electrophoresis is done for Multiple Myeloma or Walenstrom
Macroglobulinemia
32-A 33-year-old G4P4 Caucasian woman presents with fatigue. She has had four
children, ranging in age from 13 months to 8 years, and the only pregnancy-related
complication was postpartum hemorrhaging after delivering her last child. Her
menses have returned to her baseline, which she considers "heavy." One of her
children had a cough and fever 2 weeks ago. Laboratory evaluation reveals a WBC
of 6,100/mm3, hemoglobin of 10.5 g/dL, hematocrit of 31.2%, and platelet count of
239,000. Erythrocyte sedimentation rate is within normal limits. Serum ferritin is 40
pM/L. Serum Iron is 50 g/dL. Total iron binding capacity is 370 g/dL. Thyroid
stimulating hormone is 1.9 mIU/L. Blood smear reveals microcytic, hypochromic red
blood cells with occasional rod-shaped forms. Which of the following is the most
likely cause?
A. Anemia of chronic disease
B. Decreased iron intake
C. Increased iron loss Iron Deficiency
D. "Normal" fatigue from raising four children
E. Parvovirus B19 infection
33-Therapeutic monoclonal antibodies can be developed to specific cell proteins.
Rituximab, for example, attaches to the CD20 protein on the cell membrane, greatly
enhancing the effectiveness of antibody-dependent cell-mediated cytotoxicity
(ADCC) in destroying neoplastic lymphoma cells. In which organ is treatment of its
most common extra nodal lymphoma with rituximab unlikely to be of benefit?
A. Breast
B. Colon
C. Salivary gland
D. Skin
E. Stomach Extra-nodal marginal zone diffuse B cell Lymphoma
34-After an extended hospital stay, a 63-year-old American-born woman dies of
sepsis. The family requests an autopsy. Most of the patient's organs are normal
aside from evidence of damage secondary to sepsis. Her liver, however,
demonstrates the following appearance:
Patients with this condition:
A. Have an increased risk for a metastatic malignancy to the liver
B. Have an increased risk of thrombosis
C. Have likely developed the disease due to hepatitis B infection
D. Have undetectable levels of serum aspartate and alanine aminotransferase
E. May develop hemorrhoids due to the disease

35-A 32-year-old male complains that he has been feeling unusually tired for the
past week. He also notes that his urine is cola-colored early in the morning. Physical
examination reveals a normal-sized liver and spleen. Subsequent studies reveal that
the patients red blood cells lyse in an iso-osmotic solution of sucrose. Complete
blood count reveals the following:
Hemoglobin: 11.7g/dL
Hematocrit: 35.1%
Reticulocytes: 1.2%
Platelet count: 250000/mm3
Mean corpuscular volume: 77 um3
White blood cell count: 7.5 x 103/ul
Neutrophil %: 65
Lymphocyte %: 28
Monocyte %: 5
Eosinophil %: 2
This patient is at increased risk developing which of the following complications:
A. Aplastic crisis
B. Aseptic necrosis of the femoral head
C. Budd-Chiari syndrome - PNH
D. Dactylitis
E. Painful priapism
36-A 22-year-old college student at Northern Michigan University presents to the
campus health clinic on a Monday morning in April. She complains that she was
outside in a t-shirt and shorts over the spring-like weekend and now has blisters
over her arms and legs. Physical examination shows multiple vesicles over her
hands, arms, legs, and face. Physical examination shows that the hair on her arms
and the tops of her cheeks is prominent. A skin punch biopsy shows a non-
inflammatory subepithelial blister, which is negative by immunofluorescence for
immunoglobulin. Urinalysis is reported as reddish-brown in color, but negative for
hemoglobin.
The defect most likely causing her symptoms can be localized to what cellular
component?
A. Cytoplasm Porphyria Cutanea Tarda
B. Golgi apparatus
C. Mitochondrion
D. Nucleus
E. Plasma membrane
37-The treatment regimen administered to recipients prior to bone marrow
transplantation is designed to eradicate the patient's underlying disease and
prevent rejection of the transplanted marrow. In which of the following diseases is
no eradication treatment needed prior to transplantation?
A. Aplastic anemia
B. Leukemia
C. Myeloperoxidase deficiency
D. RAG gene deficiency
E. Sickle cell disease
38-A 12-year-old boy is brought to the pediatric emergency room by his parents.
The child seems confused and irritable. His parents state he has been like this for a
few days, and his fever has recently worsened. During physical examination, the
physician records a temperature of 39C (102.3F). While in the emergency room,
the patient experiences a violent seizure. Despite the medical team's attempts at
resuscitation, the patient dies. The parents request an autopsy, during which the
following finding is discovered:
What was the most likely cause of this patient's fatal disease?
A. Haemophilus influenzae
B. Herpesvirus
C. Rabies virus
D. Naegleria fowleri
E. Sports injury

39-A 29-year-old spelunker has just returned from Western Africa with vague
symptoms of fever, headache, joint pain, weakness, diarrhea, and vomiting. After
waiting in the emergency room lobby for 3 hours, he develops shortness of breath,
chest pain, bleeding gums, and profuse rectal bleeding. The patient is quickly
rushed to quarantine for resuscitation, and the Centers for Disease Control is
contacted. What are the characteristics of the most likely etiologic agent?
A. dsDNA, enveloped, icosahedral
B. ss(-)RNA, enveloped, 8 segmented
C. ss(-)RNA, enveloped, filamentous
D. ss(+)RNA, naked, icosahedral
E. ss(+)RNA, enveloped, icosahedral
40-A 45-year-old African American male presents to his primary care physician for
regular checkup. He was diagnosed with HIV 20 years ago, but recently he has been
noncompliant with his antiretroviral medications. Further evaluation reveals that his
CD4 count is 60cells/l, and he is started on trimethoprim-sulfamethoxazole (TMP-
SMZ) as a prophylactic agent against Toxoplasma gondii. A complete blood count is
performed 3 days after initiating TMP-SMZ. It reveals the following:
Hgb: 11.5 g/dL
BUN: 15 mg/dL
WBC: 900 cell/mm3
Platelet: 190 K/uL
What is the next step in management of this patient?
A. Continue him on TMP-SMZ
B. Switch him to clindamycin
C. Switch him to dapsone-pyrimethamine
D. Switch him to dapsone-pyrimethamine plus leucovorin
E. Switch him to pyrimethamine-sulfadiazine
41-A 19-year-old man is scuba diving for his first time. After spending some time
exploring the sea bottom, he sees a large sea creature swimming toward him.
Startled, he quickly swims over 100 feet back up to the boat. Within an hour, he
begins to feel malaise, anorexia, and a headache, along with painful elbows and
shoulders. Which of the following is most responsible for this man's symptoms?
A. Increased tissue CO
B. Increased tissue CO2
C. Increased tissue N2
D. Increased tissue N2O
E. Increased tissue oxygen radicals
42-An elderly man is brought to the emergency room after his family came to check
on him and found him lethargic and weak. He notes that he ate some old food three
days ago and has been having severe diarrhea since then. He says that he knows
he needs to stay hydrated, so he has been drinking as much water as possible. His
serum Na is found to be 122 mEq/L. In the emergency room, the physicians give the
patient 3 percent saline, which has a sodium concentration approximately 3 times
that of normal plasma, to help correct his hyponatremia. This will have which of the
following effects on his fluid balance?
A. Decrease in ECF volume, decrease in ICF volume, increase in osmolarity
B. Decrease in ECF volume, increase in ICF volume, no change in osmolarity
C. Increase in ECF volume, decrease in ICF volume, increase in osmolarity Gain of
Hypertonic Solution
D. Increase in ECF volume, increase in ICF volume, increase in osmolarity
E. Increase in ECF volume, increase in ICF volume, no change in osmolarity
43-A 39-year-old woman with a recent history of treated DVT had an intrauterine
device inserted for effective, safe contraception. Within weeks, she presented with a
fever and severe lower abdominal pains. An antibiotic was administered, and within
hours of treatment, she began to experience blood in her urine and stool,
accompanied by bruises on her arms and legs.
Which drug was she most likely administered?
A. Amoxicillin
B. Cefotetan causes vit. K deficiency
C. Ciprofloxacin
D. Tetracycline
E. Sulfamethoxazole/Trimethoprim
44-A multiparous 33-year-old Rh-negative woman seeks the advice of her physician
regarding the risks of having another child. She has received standard anti-Rh
therapy with each of her pregnancies. Which of the following tests is best to
establish her current antibody status?

A. Direct Coombs test

B. Enzyme-linked immunoassay
C. Flow cytometry
D. Indirect Coombs test
E. Radioimmunoassay
45-A 24-year-old man presents to his physician for an annual physical. He appears
extremely muscular and listed his occupation as "bodybuilder" on the clinic's intake
form. He claims not to take any medication other than "supplements." His only
complaint is occasional moderate pain in the right upper quadrant of his abdomen.
His physician orders abdominal imaging, which reveals a 5 cm, single, solid, well-
demarcated mass far from the capsule of his liver. The lesion does not appear
vascular, and his liver is not cirrhotic. What is the most likely risk posed to this
patient by his liver mass?
A. Abdominal hemorrhage
B. Development of carcinoma
C. Migratory thrombophlebitis
D. Secondary biliary cirrhosis
E. Widespread metastases
46-A 2-year-old boy is brought to his pediatrician for a yearly check-up. He appears
well nourished, and his mother has no concerns. Although he has started eating
solid foods, he is still predominantly bottle-fed and drinks at least six cups of cow's
milk daily. His hematocrit is slightly low, and a blood smear shows red blood cells
that are pale and small. Which of the following defects is most likely present in this
patient's erythroid lineage cells?
A. Cytoplasmic maturation defect
B. Extrinsic survival defect
C. Intrinsic survival defect
D. Nuclear maturation defect
E. Proliferation defect
47-Routine blood testing on a 10-year-old boy of Thai ethnicity reveals decreased
Hgb, Hct, and MCV values. Notably, the child's red blood cell count is elevated, his
RDW is high, and his iron studies are normal. Hemoglobin electrophoresis reveals
that 30 percent of the patient's hemoglobin is Hb Bart. The mechanism of the
genetic abnormality is most similar to the genetic alteration most commonly seen in
which type of tumor?

A. Breast cancer
B. Chronic myelogenous leukemia
C. Colon adenocarcinoma
D. Nonsmall-cell lung cancer
E. Wilms tumor
48-A 14-year-old boy wakes up one night drenched in sweat and feeling hot. He tells
his parents, who notice their son's neck appears swollen. In the morning, they bring
him to a pediatrician, who records a temperature of 39C (102.3F) and confirms
swollen cervical lymph nodes. He also palpates a mass in the patient's abdomen. He
then orders a CT scan, which confirms the presence of a growth near the boy's
ileocecal valve. A biopsy of the mass shows numerous malignant lymphoid cells
with a very high mitotic rate and interspersed tingible-body macrophages. What
molecular aberration drives the growth of this tumor?

A. A translocation involving an RNA-binding protein on chromosome 22q

B. Altered expression of an apoptotic regulation protein
C. Amplification of the n-myc oncogene
D. C-myc overexpression secondary to translocation
E. Tyrosine kinase activity linked to the breakpoint cluster region
F. Upregulation of a retinoid receptor
49-A 6-year-old boy of Mediterranean ethnicity complains of malaise 6 hours after
eating a meal that included fava beans. The mother noticed that his urine was red
in color and collected some to show the doctor. On examination, the urine specimen
is now "muddy-brown" in color. Peripheral blood smear shows numerous
schistocytes, and a supravital stain shows Heinz bodies. The current abnormal
(brown) color of the urine is due to:

A. Bilirubin
B. Hemoglobin
C. Iron
D. Methemoglobin
E. Urobilinogen
50-
A 77-year-old man presents with fatigue, low-grade fevers, and a "lumpy neck." He
has no recent travel history or sick contacts. He noticed the lumps in his neck a
couple of years ago, but the fatigue and fevers began several weeks ago. Physical
examination reveals lymphadenopathy involving cervical and submandibular lymph
nodes, as well as hepatosplenomegaly. Complete blood count reveals a white blood
count of 31,000/l with 90% lymphocytes, hematocrit of 31%, and 67,000
platelets/l. A blood smear is shown below. What is this man's most likely diagnosis?
A.
Acute lymphocytic leukemia

B.
Chronic lymphocytic leukemia

C.
Diffuse large B-cell lymphoma

D.
Hodgkin lymphoma

E.
Squamous cell carcinoma
51-A 35-year-old man is admitted to the hospital for repair of an inguinal hernia. He
has no previous medical history. As part of his routine blood testing, a CBC is drawn
and reveals a hemoglobin of 13.5, an RBC count is 7.5 million, and an MCV of 65.
His hemoglobin electrophoresis is shown below.
What is the most likely interpretation of his blood-work studies?

A.
-thalassemia trait

B.
-thalassemia minor

C.
-thalassemia major

D.
Iron deficiency anemia

E.
Normal hematopoietic function
52-A 24-year-old male medical student had surgery to remove his impacted wisdom
teeth. It took 1 hour for the bleeding to stop. Further evaluation reveals diminished
von Willebrand levels and increased thromboplastin time (PTT). What directly
caused PTT to be elevated in this patient?

A. Deficiency in factor II
B. Deficiency in factor VII
C. Deficiency in factor VIII
D. Deficiency in factor IX
E. Vitamin K deficiency
53-A 31-year-old nurse presents to the health department for a pre-employment
screening. She has no significant medical history. She denies illicit drug use. She
admits to having unprotected sexual intercourse within the last year. A hepatitis
panel is ordered and the results of the serologic testing are as follows:

HBeAg: Negative
HBsAg: Negative
HBsAb: Positive
HBcAb IgG: Positive

What is the most appropriate statement that can be concluded from these test
results?

A. The patient has been exposed to hepatitis B and is in the acute period.
B. The patient has been exposed to hepatitis B and is in the chronic period.
C. The patient has been exposed to hepatitis B and is in the window period.
D. The patient has been exposed to hepatitis B and has recovered.
E. The patient has never been exposed to hepatitis B but has been vaccinated.
54-A 35-year-old man presents to a free health clinic worried that he has contracted
HIV. His HIV EIA is positive, so his serum is submitted for Western blot analysis for
confirmatory testing. The technologist interpreting the results of the Western blot
determines that it is inconclusive. Which of the following blots is most
representative of an inconclusive result?
A.
A

B.
B

C.
C

D.
D
E.
E
55-A 66-year-old male presents to his physician with complaints of weakness and
fatigue. The patient reported to having unintentional weight loss over the past few
weeks. Physical examination reveals a low-grade fever, lymphadenopathy, and
splenomegaly. A blood peripheral smear reveals the following:
What is the next step in management of this patient?

A.
ABL tyrosine kinase inhibitor

B.
All-trans retinoic acid

C.
Bone marrow transplant

D.
Interferon alpha

E.
Purine nucleoside analogs
56-A 24-year-old woman is found down in the street and is brought to the ER. Her
pulse oximeter reads 87 percent, but her A-a gradient is calculated to be 7 mmHg
(normal for a young adult is 5 to 10). Which of the following could be the cause of
her findings?

A. Barbiturate intoxication
B. Carbon monoxide poisoning
C. Persistent truncus arteriosus
D. Pulmonary edema
E. Pulmonary embolism