TOPNOTCH FINAL EXAM ANSWER KEY SEPTEMBER 2018

Item #
KEY
ANSWER EXPLANATION
Patient's BMI is ~34. BMI Classification for Asians: Underweight
(<18.5), Normal (18.5-22.9), Overweight (23-24.9), Pre-obese (25-
29.9), Obese (>30), Type 1 Obese (30-40), Type 2 Obese/Morbidly
Obese (40.1-50), Type 3 Obese (>50).
1 A

Neurofibrillary tangles are paired helical filaments formed from a

hyperphosphorylated form of the microtubule associated protein,
tau. Choice B pertain to neuritic plaques. Choice C pertain to
2 A caspases. (Harper's Illustrated Biochemistry, 28th ed., pp. 1209-
1210)

Alpha ketoglutarate undergoes oxidative decarboxylation in a

reaction catalyzed by a multi-enzyme complex similar to that
involved in the oxidative decarboxylation of pyruvate. Arsenite
3 A inhibits the reaction, causing the substrate alpha ketoglutarate to
accumulate. (Harper's Illustrated Biochemistry, 28th ed. p. 307

All are true. (Harper's Illustrated Biochemistry, 28th ed. p. 101)

4 D
Muscle generates over half of the total body pool of free amino
acids, and Liver is the site of the urea cycle enzymes necessary for
5 B disposal of excess nitrogen. (Harper's Illustrated Biochemistry, 28th
ed., p. 487)
Transamination reactions, which interconvert pairs of alpha-amino
acids and alpha-keto acids, are readily reversible, and also function
6 A in amino acid biosynthesis. (Harper's Illustrated Biochemistry, 28th
ed., p. 491)
All do not participate in transamination (Harper's Illustrated
7 D Biochemistry, 28th ed. P. 491)
A derivative of vitamin B6, PLP forms an enzyme-bound Schiff base
intermediate that can rearrange in various ways. During
transamination in the urea cycle, enzyme-bound PLP serves as a
8 D carrier of amino groups. (Harper's Illustrated Biochemistry, 28th ed.,
p. 491)

The condition is known as Zellweger syndrome and choices A, B

9 D and C are true in this condition. (Harper's Illustrated Biochemistry,
28th ed., p. 976)
Hers' Disease (Harper's Illustrated Biochemistry, 28th ed., p. 335)
10 E
 Glycophorin is a major integral membrane glycoprotein of human
11 C erythrocytes (Harper's Illustrated Biochemistry, 28th ed., p. 267)
Only A and C are true. Prion diseases involve an altered
12 E SECONDARY-TERTIARY structure of a naturally occuring protein,
PrPc. (Harper's Illustrated Biochemistry, 28th ed., p. 91)
Only A and B are true. (Harper's Illustrated Biochemistry, 28th ed.,
13 E p. 923)
Vitamin C, alcohol and fructose enhance iron absorption. (Harper's
14 A Illustrated Biochemistry, 28th ed., p. 925)
A high intake of protein does not lead to positive nitrogen balance;
although it increases the rate of protein synthesis, it also increases
the rate of protein catabolism, so that nitrogen equilibrium
15 B is maintained, albeit with a higher rate of protein turnover. (Harper's
Illustrated Biochemistry, 28th ed., p. 927)

The key to initiation of the visual cycle is the

16 A availability of 11-cis -retinaldehyde. (Harper's Illustrated
Biochemistry, 28th ed., p. 933)
Pellagra is characterized by a photosensitive dermatitis. As the
condition progresses, there is dementia and
possibly diarrhea. Untreated pellagra is fatal. Although the
nutritional etiology of pellagra is well established, and
tryptophan or niacin prevents or cures the disease, additional
factors, including deficiency of riboflavin or vitamin
B6 , both of which are required for synthesis of nicotinamide from
17 D tryptophan, may be important. In most
outbreaks of pellagra, twice as many women as men are affected,
probably the result of inhibition of tryptophan
metabolism by estrogen metabolites. (Harper's Illustrated
Biochemistry, 28th ed., p. 944)

In most outbreaks of pellagra, twice as many women as men are

affected, probably the result of inhibition of tryptophan metabolism
18 A by estrogen metabolites. (Harper's Illustrated Biochemistry, 28th
ed., p. 944)
Two proteins that contain -carboxyglutamate are present in bone,
osteocalcin, and bone matrix Gla protein. Osteocalcin also contains
hydroxyproline, so its synthesis is dependent on both vitamins K and
19 C C; in addition, its synthesis is induced by vitamin D. The release into
the circulation of osteocalcin provides an index of vitamin D
status. (Harper's Illustrated Biochemistry, 28th ed., p. 942)

Aminotransferase (transaminase) reactions form pyruvate from

alanine, oxaloacetate from aspartate, and alpha-ketoglutarate from
glutamate. Alanine, cysteine, glycine, hydroxyproline, serine,
threonine, and tryptophan yield pyruvate; arginine, histidine,
20 D glutamine, and proline yield -ketoglutarate; isoleucine, methionine,
and valine yield succinyl-CoA; tyrosine and phenylalanine yield
fumarate. (Harper's Illustrated Biochemistry, 28th ed., p. 310)
 All statements are true except A. The upper medial quadrant is
21 A supplied by the POSTERIOR and not the anterior rami. (Snell's
Clinical Anatomy by Regions, 9th ed., pp. 436-437)
All structures pass through the middle cranial fossa except medulla
oblongata, which passes through the foramen magnum, a part of
22 B the POSTERIOR cranial fossa. (Snell's Clinical Anatomy by
Regions, 9th ed., p. 536 table 11.1)

A. The psoas major lies POSTERIOR to the psoas minor.

B. The psoas major arises from the 12th thoracic to 5th lumbar
vertebrae.
C. The fibers run downward and LATERALLY and leave the
abdomen to enter the thigh by passing behind the inguinal
23 D ligament.
D. It flexes the thigh at the hip joint on the trunk, or if the thigh is
fixed, it flexes the trunk on the thigh, as in sitting up from a lying
position. TRUE
E. It is unimportant and is absent in 40% of patients. (This is true
for PSOAS MINOR, not major.) (Snell's Clinical Anatomy by
Regions, 9th ed., p. 136)

A. The ureteric bud arises as an outgrowth of the

MESONEPHRIC (not metanephrogenic) duct.
B. In the human, the METANEPHROS (not mesonephros) is
responsible for the permanent kidney.
C. The metanephros develops from the ureteric bud and the
24 C metanephrogenic cap. (TRUE)
D. The developing kidney is initially a pelvic organ and receives
its blood supply from the pelvic continuation of the aorta, the
MIDDLE (not upper) sacral artery.
E. The surface of the kidney is LOBULATED (not smooth) at
first, but after birth, LOBULATION DISAPPEARS (it doesn't
become slightly lobulated.) (Snell's Clinical Anatomy by Regions,
9th ed., p. 212)
In thoracotomy, the following tissues will be incised: (a) skin, (b)
subcutaneous tissue, (c) serratus anterior and pectoral muscles, (d)
external intercosal muscle and anterior intercostal muscle, (e)
25 D internal intercostal muscle, (f) innermost intercostal muscle, (g)
endothoracic fascia, and (h) parietal pleura. (Snell's Clinical
Anatomy by Regions, 9th ed. p. 46)

B. Each levator costa is TRIANGULAR in shape.

26 B The rest of the statements are TRUE. (Snell's Clinical Anatomy by
Regions, 9th ed., pp. 46-47)
Visceral pain from the gallbladder, as occurs in patients with
cholecystitis or gallstone colic, travels in nerve fibers that
accompany sympathetic nerves. Involvement of the central
diaphragmatic parietal peritoneum, which is innervated by the
27 A phrenic nerve (C3, 4 and 5), can give rise to referred pain over the
shoulder because the skin in this area is innervated by the
supraclavicular nerves (C3 and C4). (Snell's Clinical Anatomy by
Regions, 9th ed., p. 225)
 Intermediate fibers: The puborectalis forms a
sling around the junction of the rectum and anal
canal. The pubococcygeus passes posteriorly to be
inserted into a small fibrous mass, called the anococcygeal
28 C body, between the tip of the coccyx and the anal
canal. ILIOCOCCYGEUS is part of the POSTERIOR fibers of the
levator ani. (Snell's Clinical Anatomy by Regions, 9th ed., pp. 247-
248)

Direct branches of the inferior mesenteric artery include: left colic,

sigmoid, and superior rectal arteries. Right and middle colic arteries
29 A are direct branches of the superior mesentery artery. (Snell's
Clinical Anatomy by Regions, 9th ed., p. 217)
When looking up and to the right, the predominant muscles are: right
eye, superior rectus muscle; left eye, inferior oblique muscle. Choice
B is looking up and to the left; Choice C is looking down and to the
30 A right; Choice D is looking down and to the left; Choice C is both eyes
looking down and midline. (Snell's Clinical Anatomy by Regions, 9th
ed., p. 559 figure 11.24)

All of the statements are true. (Junquiera's Basic Histology, 11th ed.
31 E Chapter 8: Bone)
All of the statements are true. (Junquiera's Basic Histology, 11th ed.
32 E Chapter 21: Male Reproductive System)
All are correct except B. Monocyte-colony-forming cell makes
promonocyte to monocyte. Megakaryocyte-forming cell makes
33 B megakaryoblast to megakaryocyte. (Junquiera's Basic Histology,
11th ed. Chapter 13: Hematopoiesis, figure 13-1)
Proportion of ciliated cells to goblet cells is altered.
34 A
The myelin of its nerve fibers is produced by
OLIGODENDROCYTES, not by Schwann cells. (Junquiera's Basic
35 C Histology, 11th ed., Chapter 23: Photoreceptor and Audioreceptor
Systems
The neurohypophysis consists of the pars nervosa and the neural
36 A stalk. (Junquiera's Basic Histology, 11th ed., Chapter 20: Endocrine
Glands)
Adipose functions as energy reservoir and for heat production.
37 D (Junquiera's Basic Histology, 11th ed., Chapter 5: Connective
Tissue Table 5-1)
Keratin bundles, visible under the light microscope, are called
TONOFILAMENTS. They end at and insert into the cytoplasmic
densities of the desmosomes. The filaments play an important role
38 A in maintaining cohesion among cells and resisting the effects of
abrasion. (Junquiera's Basic Histology, 11th ed., Chapter 18: Skin)
 A. Paneth's cells: found in basal portion of intestinal glands;
exocrine cells with secretory granules in their apical cytoplasm
B. Goblet cells: cells of the small intestine, interspersed between
39 D absorptive cells, produce acid glycoproteins of the mucin type
C. Enterocytes: are tall columnar cells, each with an oval nucleus
in the basal half of the cell.
D. Peyer's patch
E. Brunner's glands: found in the duodenum
All are true of Littre's glands. (Junquiera's Basic Histology, 11th ed.
40 D Chapter 19: The Urinary System)

This is an infection secondary to Streptococcus agalactiae, the most

common agent of meningitis in 5 to 30-day-olds. Important
laboratory criteria for confirmation of infection is when CSF is
41 D CAMP-positive. (Jawetz Medical Microbiology, 25th ed., Chapter
14: The Streptococci)

Local infection of superficial layers of skin, especially in children, is

called impetigo. It consists of superficial vesicles that break down
and eroded areas whose denuded surface is covered with pus and
later is encrusted. It spreads by continuity and is highly
communicable, especially in hot, humid climates. More widespread
42 A infection occurs in eczematous or wounded skin or in burns and may
progress to cellulitis. Group A streptococcal skin infections are often
attributable to M types 49, 57, and 59–61 and may precede
glomerulonephritis but do not often lead to rheumatic fever.
(Jawetz Medical Microbiology, 25th ed., Chapter 14: Streptococci)

All statements are true. (Jawetz Medical Microbiology, 25th ed.,

43 D Chapte 45)
C glabrata is unique among these pathogens because it produces
44 D only yeast cells and no pseudohyphal forms. (Jawetz Medical
Microbiology, 25th ed., Chapte 45)
Two simple morphologic tests distinguish C albicans, the most
common pathogen, from other species of Candida: After incubation
in serum for about 90 minutes at 37°C, yeast cells of C albicans will
45 D begin to form true hyphae or germ tubes (Figure 45–21), and on
nutritionally deficient media C albicans produces large, spherical
chlamydospores (Jawetz Medical Microbiology, 25th ed., Chapte
45)
This is a case of trypanosomiasis and mechanism of infection is
46 B through a bite of a tsetse fly. (Jawetz Medical Microbiology, 25th ed.,
Chapter 46: Medical Parasitology)
Diagnostic test used to confirm is visualization of trypomastigotes
47 B (extracellular) in blood smear, CSF or lymph node aspirate. (Jawetz
Medical Microbiology, 25th ed., Chapter 46: Medical Parasitology)
Treatment for trypanosoma brucei with late CNS involvement is
48 C Melarsoprol. (Jawetz Medical Microbiology, 25th ed., Chapter 46:
Medical Parasitology)
 The toxin spreads along nerves to the central nervous system,
where it binds to gangliosides, suppresses the release of inhibitory
neurotransmitters, and yields prolonged muscle spasms. (Jawetz
49 E Medical Microbiology, 25th ed., Chapter 21: Infections Caused by
Anaerobic Bacteria)

While respiratory compromise occurs as a result of upper airway

obstruction or involvement of the diaphragm, autonomic dysfunction
has emerged as the major cause of death. (Jawetz Medical
50 A Microbiology, 25th ed., Chapter 21: Infections Caused by Anaerobic
Bacteria)

Botulism should be treated with antitoxin. Infant botulism follows the

ingestion of spores, germination of the spores, and toxin production
in vivo; honey is a common vehicle for spread of the spores in
51 A infants.
(Jawetz Medical Microbiology, 25th ed., Chapter 21: Infections
Caused by Anaerobic Bacteria)

This is a case of Diphtheria. All choices describe Corynebacterium

diphtheriae. Choice E refers to that of Listeria. (Jawetz Medical
52 E Microbiology, 25th ed., Chapter 12: Aerobic Non-spore Forming
Gram-positive Bacilli)
This describes Listeria monocytogenes (flagellar driven or tumbling
53 B motility). (Jawetz Medical Microbiology, 25th ed., Chapter 12:
Aerobic Non-spore Forming Gram-positive Bacilli)
All are correct about diphtheria toxin. (Jawetz Medical Microbiology,
54 E 25th ed., Chapter 12: Aerobic Non-spore Forming Gram-positive
Bacilli)
A. hyaluronic acid instead of lipotechoic acid; B. correct; C.
55 B lipotechoic acid instead of lipopolysaccharide (Jawetz Medical
Microbiology, 26th ed., Chapter 14, p. 211)
All are correct (Jawetz Medical Microbiology, 26th ed., Chapter 14,
56 D p. 212)
ASO appears in humans after infection with any streptococci.
57 D (Jawetz Medical Microbiology, 26th ed., Chapter 14, p. 212-213)
This is a case of relapsing fever, characteristically caused by
58 B Borrelia recurrentis. (Jawetz Medical Microbiology, 26th ed.,
Chapter 24, p. 331-333)
Only statement A is correct. They are highly flexible and move both
by rotation and twisting. They are large, loosely coiled spirochetes
59 A among the red cells in blood smears. (Jawetz Medical Microbiology,
26th ed., Chapter 24, p. 331-333)
Statement B explains relapsing fever caused by borrelia recurrentis.
60 B (Jawetz Medical Microbiology, 26th ed., Chapter 24, p. 331-333)

Option A is for insulin. Option C is Acetylcholine and norepinephrine.

61 B Option D is for steroid hormones. Source: Pretest Phyisology High
Yieal Concepts
 Only option B is true. Source: Ganong's Review of Medical
62 B Physiology, 24th ed., pg.559
Rapid arrhythmia would decrease cardiac output. Source:
63 C Ganong's Review of Medical Physiology, 24th ed., pg.514
The description is consistent with dicrotic notch. Source: Ganong's
64 C Review of Medical Physiology, 24th ed., pg.512
In metabloc alkalosis due for example to protracted vomiting with
loss of HCl from the body, ventilation is depressed and the arterial
65 B PCO2 rises, raiding the H concentration toward normal. Source:
Ganong's Review of Medical Physiology, 24th ed., pg.629
The stimulatory effects of hypoxia on ventilation are not clearly
manifest until they become strong enough to override the
conterbaancing inhibitory effects of a decline in arterial H
66 B concentration and PCO2. Source: Ganong's Review of Medical
Physiology, 24th ed., pg.630-631

Glomus cells comprises the islands of cells in each carotid and

67 E aortic body. Source: Ganong's Review of Medical Physiology, 24th
ed., pg.628
The respiratory minute volume is proportional to the metabolic rate,
68 C bu the link between metabolism and ventilation is CO2, not O2.
Source: Ganong's Review of Medical Physiology, 24th ed., pg.627
Growth hormone is protein anabolic hormone and produces positive
nitrogen and phosphorus balance. The other options are reverse of
69 A the true effect of GH. Source: Ganong's Review of Medical
Physiology, 24th ed., pg.382
Loud sounds initiate a reflex contraction of the middle ear muscles.
70 B Source: Ganong's Review of Medical Physiology, 24th ed., pg.210
All options are expected when ECF volume declines. Source:
71 E Ganong's Review of Medical Physiology, 24th ed., pg.670
An expansion of the ECF volume increases secretion of ANP and
72 C BNP by the heart and this causes natriuresis and diuresis. Source:
Ganong's Review of Medical Physiology, 24th ed., pg.669
Alcohol decrease vasopressin secretion. Source: Ganong's Review
73 C of Medical Physiology, 24th ed., pg.667
Migrating motor complexes are initiated by motilin. Source:
74 C Ganong's Review of Medical Physiology, 24th ed., pg.470
All are true except B. Source: Board Review Series Physiology by
75 B Costanzo.
The receptor being described is a Meissner's corpuscle
76 B
Pacinian corpuscles (group II afferents) are distributed throughout
77 C muscle. They detect vibration. Source: Board Review Series
Physiology by Costanzo.
All options are true. Source: Board Review Series Physiology by
78 E Costanzo.
 Vasodilator metabolites accumulate because of increased
metabolism of the exercising muscle. This vasodilation accounts for
the overall decrease in TPR that occurs with exercise. Note that
79 B activation of the sympathetic nervous system alone would cause an
increase in TPR. Source: Board Review Series Physiology by
Costanzo.

All other options is reversed. Source: Board Review Series

80 B Physiology by Costanzo.

Elements of Reckless Imprudence: (a) that the offender does or fails

to do an act, (b) that the doing or the failure to do an act is voluntary,
(c) that it be without malice, (d) that material damage results, (e) that
there is inexcusable lack of precaution on the part of the offender,
81 C taking into consideration his employment or occupation, degree of
intelligence, physical condition, other circumstances regarding
persons, time and place (Solis)

Only death is part of the general damages. The rest of the choices
82 B are special damages (Solis)
A and C are justifiable grounds. B should be chronically ill instead of
83 B acutely ill. It is nonjustifiable to refuse an acutely ill patient. (Solis)
The doctor may refuse to attend a civil case if the place of trial is
84 A more than 100 kms.
Only B constitutes illegal practice of medicine. Other choices does
85 B not constitute practice of medicine and hence will not be charged
with illegal practice of medicine. A nurse cannot prescribe.
Homeotransplantation: unrelated human donor to human recipient;
Allograft: transplantation between genetically non-identical
86 A members of the same species; Heterotransplantation: animal donor
to human recipient; Xenograft: transplantation between different
species
Incestuous qualified seduction: this includes seduction where there
is blood relationship. The woman seduced may need not be a virgin
or may be more than 18 years of age. Elements include sexual act
87 C between the offender and the offended party, and ascendant who
seduces his descendant

All are included except C which is a scientific method of identification

88 C
A and B are correct. C should be reversed.
89 C
Only A is a microscopic exam for blood and blood stains for
90 A identification
Phosphorus: Dark brown
91 D
There is intention to kill. If no intention to kill, then it is frustrated
92 C homicide
 Accidental suicide is third degree suicide
93 C
This refers to an ante-mortem wound

94 C

There is always an after fire in an entrance wound. The rest of the

95 C statements are false
All are true
96 D
Only statement B refers to heat exhaustion. The rest of the choices
97 B refer to heat stroke.
Exaggerated emotions mean that blood alcohol is at 150-300mg%
98 C
All are true
99 E
All symptoms are descriptive of a sulfuric acid poisoning.
100 B

Most of the systemic lesions of SLE are caused by immune

101 B complexes (Type III Hypersensitvity). Source: Robbins and Cotran
Pathologic Basis of Disease, 9th ed., pg. 221.
Minimal mesangial lupus nephritis (Class I) is very uncommon and
characterized by immune complex deposition in the mesangium
identified by immunoflourescence and by electron microscopy but
102 A without structural changes by light microscopy. Source: Robbins
and Cotran Pathologic Basis of Disease, 9th ed., pg. 222

Diffuse lupus nephritis (class IV) is the most common and severe
form of lupus nephritis. The lesions are similar tothose in class III,
but differ in extent; typically, in class IV nephritis half or more of the
glomeruli are affected. Subendothelial immune complex deposits
may create a circumferential thickening of the capillary wall, forming
103 B “wire loop” structures on light microscopy. Source: Robbins and
Cotran Pathologic Basis of Disease, 9th ed., pg. 224

Double stranded DNA id specific for SLE along with Smith (Sm)
antigen. Source: Robbins and Cotran Pathologic Basis of Disease,
104 B 9th ed., pg. 219, Table 6-10
 The most common cause of autosomal recessive SCID is a
105 B deficiency of enzyme adenosine deaminase (ADA) Source: Robbins
and Cotran Pathologic Basis of Disease, 9th ed., pg. 239
Some patients develop a morbiliform rash shortly after birth because
maternal T cells are transferred across the placenta and attack the
106 B fetus, causing GVHD. Source: Robbins and Cotran Pathologic Basis
of Disease, 9th ed., pg. 239
Without HSC transplantation, death occures within first year of life.
107 B Source: Robbins and Cotran Pathologic Basis of Disease, 9th ed.,
pg. 239
Source: Robbins and Cotran Pathologic Basis of Disease, 9th ed.,
108 B pg. 239
DiGeorge syndrome is a T-cell deficiency that results from failure of
development of the thrid and fourth pharyngeal pouches. Individuals
with this syndrome have a variable loss of T cell-mediated immunity
(resulting from hypoplasia or lack of thymus), tetany (resulting from
109 C lack of the parathyroids) and congenital defects of the heart and
great vessels. Source: Robbins and Cotran Pathologic Basis of
Disease, 9th ed., pg. 241

Follicular hyperplasia is caused by stimuli that activate humoral

immune responses. It is defined by the presence of large oblong
germinal centers (secondary ollicles), which are surrounded by a
collar of small resting naive B cells (the mantle zone). Features
favoring a reactive (nonneoplastic) hyperplasia include (1)
preservation of the lymph node architecture, including the
interfollicular T-cell zones and the sinusoids; (2) marked variation in
110 B the shape and size of the ollicles; and (3) the presence of frequent
mitotic figures, phagocytic macrophages, and recognizable light and
dark zones, all of which tend to be absent from neoplastic follicles.
Source: Robbins and Cotran Pathologic Basis of Disease, 9th ed.,
pg. 585

Paracortical hyperplasia is caused by stimuli that trigger T-cell–

mediated immune responses, such as acute viral infections (e.g.,
infectious mononucleosis). The -cell regions typically contain
immunoblasts, activated T cells three to four times the size of resting
lymphocytes that have round nuclei, open chromatin, several
prominent nucleoli, and moderate amounts of pale cytoplasm. The
expanded T-cell zones encroach on and, in particularly exuberant
111 B reactions, efface he B-cell follicles. In such cases immunoblasts
may be so numerous that special studies are needed to exclude a
lymphoid neoplasm. In addition, there is often hypertrophy of
sinusoidal and vascular endothelial cells, sometimes accompanied
by infiltrating macrophages and eosinophils. Source: Robbins and
Cotran Pathologic Basis of Disease, 9th ed., pg. 585
 Sinus histiocytosis (also called reticular hyperplasia) refers
to an increase in the number and size of the cells that line
lymphatic sinusoids. Although nonspecific, this form of hyperplasia
may be particularly prominent in lymph nodes draining
cancers such as carcinoma of the breast. The lining lymphatic
112 B endothelial cells are markedly hypertrophied and macrophages
are greatly increased in numbers, resulting in the expansion and
distension of the sinuses.
Source: Robbins and Cotran Pathologic Basis of Disease, 9th ed.,
pg. 585

Poststreptococcal Glomerulonephritis
This is a prototypical glomerular disease of immune
complex etiology, which is decreasing in frequency in the
United States but continues to be a fairly common disorder
worldwide. It usually appears 1 to 4 weeks after a streptococcal
infection of the pharynx or skin (impetigo). Skin
infections are commonly associated with overcrowding
and poor hygiene. Poststreptococcal glomerulonephritis
113 B occurs most frequently in children 6 to 10 years of age, but
children and adults of any age can also be affected. In the typical
case, a young child abruptly
develops malaise, fever, nausea, oliguria, and hematuria
(smoky or cola-colored urine) 1 to 2 weeks after recovery
from a sore throat. Source: Robbins and Cotran Pathologic Basis of
Disease, 9th ed., pg. 909-911

More than 95% of affected children eventually recover

renal function with conservative therapy aimed at maintaining
sodium and water balance. A small minority of
children (perhaps fewer than 1%) do not improve, become
severely oliguric, and develop a rapidly progressive
form of glomerulonephritis (described later). Some of the
remaining patients may undergo slow progression to
114 B chronic glomerulonephritis with or without recurrence of
an active nephritic picture. Prolonged and persistent heavy
proteinuria and abnormal GFR mark patients with an unfavorable
prognosis. Source: Robbins and Cotran Pathologic Basis of
Disease, 9th ed., pg. 911

Minimal Change Disease – relatively benign, responsive to

115 B corticosteroids and or other immunosuppressive therapy. Source:
Robbins and Cotran Pathologic Basis of Disease, 9th ed., pg. 917
The escape of fluid, proteins, and blood cells from the vascular
system into the interstitial tissue or body cavities is known as
116 B exudation. Source: Robbins and Cotran Pathologic Basis of
Disease, 9th ed., pg. 73
There are several mechanisms responsible for the increased
permeability of postcapillary venules, a hallmark of acute
117 B inflammation. Source: Robbins and Cotran Pathologic Basis of
Disease, 9th ed., pg. 74
 Liquefactive necrosis in contrast to coagulative necrosis, is
characterized by digestion of the dead cells, resulting in
transformation of the tissue into a liquid viscous mass. It is seen in
focal bacterial or, occasionally, fungal infections, because microbes
stimulate the accumulation of leukocytes and the liberation of
enzymes from these cells. The necrotic material is frequently
118 B creamy yellow because of the presence of dead leukocytes and is
called pus. For unknown reasons, hypoxic death of cells within the
central nervous system often manifests as liquefactive necrosis.
Source: Robbins and Cotran Pathologic Basis of Disease, 9th ed.,
pg. 43

A characteristic finding in sputum or bronchoalveolar lavage

specimens is Curschmann spirals, which may result from extrusion
of mucus plugs from subepithelial mucous gland ducts or
bronchioles. Also present are numerous eosinophils and Charcot-
119 C Leyden crystals; the latter are composedof an eosinophil protein
called galectin-10. Source: Robbins and Cotran Pathologic Basis of
Disease, 9th ed., pg. 682

Subendocardial lesions, perhaps exacerbated by

regurgitant jets, can induce irregular thickenings called
120 D MacCallum plaques, usually in the left atrium. Source: Robbins and
Cotran Pathologic Basis of Disease, 9th ed., pg. 558

Aminoglycosides have concentration-dependent killing ; that is,

increasing concentrations kill an increasing proportion of bacteria
and at a more rapid rate. They also have a significant postantibiotic
effect, such that the antibacterial activity persists beyond the time
during which measurable drug is present. The postantibiotic effect
of aminoglycosides can last several hours. Because of these
121 D properties,
a given total amount of aminoglycoside may have better efficacy
when administered as a single large dose than when administered
as multiple smaller doses. Source: Katzung Basic and Clinical
Pharmacology, 12th ed pg. 823

See Topnotch hand outs on Autacoids

122 B
See Topnotch hand outs on Pharmacology
123 B
See Topnotch hand outs on Pharmacology
124 A
Oxytocin is used during second-trimester abortions. Source:
125 B Katzung Basic and Clinical Pharmacology, 12th ed, pg. 674
See Topnotch hand outs on Antidiabetic agents
126 D
 Loss of bone mineral density and increased atypical extremity bone
fractures in women are described to both compounds (Pioglitazone
& Rosiglitazone), which is postulated to be due to decreased
127 C osteoblast formation. Source: Katzung Basic and Clinical
Pharmacology, 12th ed., pg.758

Denosumab is a human IgG monoclonal antibody specific for human

RANKL (receptor activator of nuclear factor kappa-B ligand).By
binding RANKL it inhibits the maturation of osteoclasts, the cells
128 B responsible for bone resorption. Katzung Basic and Clinical
Pharmacology, 12th ed., pg. 994

Clarithromycin and erythromycin are similar with respect to

antibacterial activity except that clarithromycin is more active
against Mycobacterium avium complex.
129 B Katzung Basic and Clinical Pharmacology, 12th ed., pg. 841

The most prominent untoward effect is skin discoloration ranging

from red-brown to nearly black.
130 D Katzung Basic and Clinical Pharmacology, 12th ed., page 846

The major clinical toxicity associated with didanosine therapy is

dose-dependent pancreatitis. Other risk factors for pancreatitis (eg,
alcohol abuse, hypertriglyceridemia) are relative contraindications,
and concurrent drugs with the potential to cause pancreatits,
131 D including zalcitabine, stavudine, ribavirin, and hydroxyurea, should
be avoided. Katzung Basic and Clinical Pharmacology, 12th ed., pg.
872

Diuretics are effective in lowering blood pressure by 10-15 mmHg in

most patients, and diuretics alone often provide adequate treatment
for mild or moderate essentail hypertension. In more severe
hypertension, diuretics are used in combination with
132 B sympathoplegics and vasodilator drugs to control the tendency
toward sodium retention caused by these agents. Katzung Basic
and Clinical Pharmacology, 12th ed., pg. 173

Pheochromocytoma is sometimes treated with metyrosine. This

agent is a competitive inhibitor of tyrosine hydroxylase, the rate
limiting step in the synthesis of dopamine, norepinephrine, and
133 B epinephrine. Metyrosine is especially useful in symptomatic patients
with inoperable or metastatic pheochromocytoma. Katzung Basic
and Clinical Pharmacology, 12th ed., pg. 156

The primary indication of dexmedetomidine is for sedation of initially

intubated and mechanically ventilated patients during treatment in
intensive care setting. It also produces the requirements for opiods
134 C in pain control. Katzung Basic and Clinical Pharmacology, 12th ed.,
pg.141

Adenosine is currently the drug of choice for prompt conversion of

paroxysmal supraventricular tachycardia to sinus rhythm because
135 B of its high efficacy (90-95%) and very short duration of action.
Katzung Basic and Clinical Pharmacology, 12th ed.,pg.245
 It is reasonable to counsel women to take extra 25 mcg thyroxine
tablet as soon as they are pregnant and to separate thyroxine from
prenatal vitamins by at least 4 hours. Because of the elevated
maternal TBG levels and, therefore elevated total T4 levels,
136 D adequate maternal dosages warrant maintenance of TSH between
0.5 and 3.0 mU/L and the total T4 at or above the upper range of
normal. Katzung Basic and Clinical Pharmacology, 12th ed., pg. 691

Exenatide has homology with native GLP-1, and a glysine

substitution to reduce degradation by DPP-4. It undergoes
glomerular filtration, and dosage adjustment is required only when
137 C the creatinine clearnace is less than 30 mL/min. Katzung Basic and
Clinical Pharmacology, 12th ed., pg. 760

The most common adverse effects in patients treated with this drug
are hot flushes, which resemble those experienced by menopausal
patients. They tend to be mild, and disappear when the drug is
138 B discontinued. Katzung Basic and Clinical Pharmacology, 12th ed.,
pg. 743

Artemisinin-based combination therapy is now the standard for

treatment of uncomplicated falciparum malaria in nearly all areas
endemic for falciparum malaria. These regimens were developed
because the short plasma half-lives of the artemisinins led to
139 B unacceptably high recrudescence rates after short-course therapy,
which were reversed byh inclusion of longer-acting drugs. Katzung
Basic and Clinical Pharmacology, 12th ed., pg. 921

Posaconazole is the newewst triazole. It is the broadest spectrum

member of the azole family, with activity against most species of
Candida and Aspergillus. It is the only azole with significant activity
140 D against agents of mucormycosis. Katzung Basic and Clinical
Pharmacology, 12th ed., pg.855

Meckel's diverticulum is the most prevalent congenital anomaly of

the GI tract, affecting approximately 2% of the general population.
Meckel's diverticula are designated true diverticula because their
walls contain all of the layers found in normal intestine. Their
141 C location varies among individual patients, but they are ususally
found in the ileum within 100 cc of ilececal valve. Source: Schwartz's
Principle of Surgery, 10th edition, pg. 1163

Epithelialization is characterized primarily by proliferation and

migration of epithelial cells adjacent to the wound. The process
begins within 1 day of injury and is seen as thickening of the
142 B epidermis at the wound edge. Source: Schwartz's Principle of
Surgery, 10th edition, pg. 245

Options A-D are correct while option E is included but completed

specifically within 6 hours and given to hypotension that does not
143 E respond to initial fluid resuscitation. Source: Schwartz's Principle of
Surgery, 10th edition, pg. 125
 In the later phases of postoperative antibiotic treatment of serious
intra-abdominal infection, the absence of an elevated white blood
cell count, lack of band forms of PMNs on peripheral smear, and
lack of fever provide close to complete assurance that infection has
been eradicated. Under these circumstances, antibiotics can be
discontinued with impunity. However, the presence of one or more
of these indicators does not mandate continuing antibiotics or
144 E altering the antibiotics administered. Rather, a search for an extra-
abdominal source of infection or a residual or ongoing source for an
intra-abdominal infection )e.g., abscess or leaking anastomosis)
should be sought, the latter mandating maneuvers to effect source
control. Source: Schwartz's Principle of Surgery, 10th edition, pg.
146

An isolated fracture of the ulna shaft or a "nightstick fracture",

occurs from a direct blow to the side of the forearm. A Monteggia
fracture is an ulna shaft fracture with a radial head dislocation. A
145 C Galeazzi fracture is a radial shaft fracture with disruption of the distal
radioulnar joint at the wrist. Source: Schwartz's Principle of Surgery,
10th edition, pg. 1760

The EXIT procedure is an abbreviation for ex utero intrapartum

treatment. It is used in circumstances where airway obstruction is
predicted at the time of delivery, due to the presence of a large neck
mass, such as a cystic hygroma or teratoma or congenital tracheal
stenosis. In general terms, cystic neck masses such as
146 C lymphangiomas have a more favorable response to an EXIT
procedure as compared to solid tumors, such as teratomas,
particularly in premature infants. Source: Schwartz's Principle of
Surgery, 10th edition, pg. 1645

A major complication of repaired TOF is the development of

pulmonary insufficiency, which subjects the RV to the adverse
147 D effects of acute and chronic volume overload. Source: Schwartz's
Principle of Surgery, 10th edition, pg. 725
Category II F which is multiple hairline or slightly thickened septa
without measureable enhancement and may contain nodular
calcification. Also includes hyperdense cysts >3 cm. It has ~3% risk
148 C of malignancy and should be followed for progression. Source:
Schwartz's Principle of Surgery, 10th edition, pg. 1655

In North America, surgery is recommended when RAI is

contraindicated as in patients who have confirmed cancer or
suspicious thyroid nodules, are young, desire to conceive soon (<6
months) after treatment, have has severe reactions to antithyroid
149 E medications, have large goiters (>80g) causing compressive
symptoms and are reluctant to undergo RAI therapy.Source:
Schwartz's Principle of Surgery, 10th edition, pg. 1533
 In the setting of elective splenectomy, patients should be vaccinated
2 weeks prior to surgery to optimize antigen recognition and
processing/ If splenectomy is performed emergently, vaccinations
can be administered postoperatively and consideration should be
150 C given to delaying administration for 2 weeks to avoid the transient
immunosuppression associated with surgery. Source: Schwartz's
Principle of Surgery, 10th edition, pg. 1439

Penetrating trauma: CPR > 15 min and no signs of life is already a

151 C contraindication for emergency department thoracotomy. Source:
Schwartz's Principle of Surgery, 10th edition, pg. 167
Specific mammographic features that suggest a diagnosis of breast
cancer include a solid mass with or without stellate features,
asymmetric thickening of breast tissues and clustered
152 E microcalcifications. Source: Schwartz's Principle of Surgery, 10th
edition, pg. 525

Stage IIB is either T2N1M0 or T3N0M0. Source: Schwartz's

153 D Principle of Surgery, 10th edition, pg. 534
All options listed are clinical situations where SLN dissection is not
154 E recommended. Source: Schwartz's Principle of Surgery, 10th
edition, pg. 545
Oversew is one of the surgical options in the treatment of duodenal
ulcer, unless the patient is in shock or moribund, a definitive
155 A procedure should be considered. See Source: Schwartz's Principle
of Surgery, 10th edition, pg. 1068.
All options are prognosis of Carcinoma of the Gallbladder. Source:
156 E Schwartz's Principle of Surgery, 10th edition, pg. 1335
Tumors close to the main pancreatic duct and large (>2cm) tumors
157 B may require a distal pancreatectomy or pancreaticoduodenectomy.
Source: Schwartz's Principle of Surgery, 10th edition, pg. 1391
TURP is the mainstay of endoscopic surgical BPH treatment. It is
extremely effective at improving flow and decreasing residual urine.
Complications are rare but include incontinence and excessive fluis
absorption of the hypotonic irrigatring solution used during
158 D resection, resulting in the tranurethral resection syndrome. It is due
to hyponatremia and fluid overload and althoguh rare, can result to
death. Source: Schwartz's Principle of Surgery, 10th edition, pg.
1665

A concussion is defined as temporary neuronal dysfunction

following nonpenetrating head trauma. The head CT is normal, and
159 A deficits resolve over minutes to hours. Source: Schwartz's Principle
of Surgery, 10th edition, pg. 1718
All options are included. Smoking is also a concern. Source:
160 E Schwartz's Principle of Surgery, 10th edition, pg. 1514
 Any combination of four or more criteria, with at least one in the
clinical and immunologic category, well documented at any time
during an individual's history, makes it likely that the patient has
161 D SLE. Source: Harrison's Principle of Internal Medicine, 19th ed.,
pg.2126

Discoid lupus erythematosus (DLE) is the most common chronic

dermatitis in lupus; lesions are roughly circular with slightly raised,
scaly hyperpigmented erythematous rims and depigmented,
atrophic centers in which all dermal appendages are permannetly
162 C destroyed. LEsions can be disfiguring, particularly on the face and
scalp. Source: Harrison's Principle of Internal Medicine, 19th ed.,
pg. 2127-2128

Subacute cutaneous lupus erythematosus (SCLE) consists of scaly

163 B red pathces similar to psoriasis or circular flat red-rimmed lesions.
Source: Harrison's Principle of Internal Medicine, 19th ed., pg.2128
NSAIDs has higher incidence of aseptic meningitis. Source:
164 B Harrison's Principle of Internal Medicine, 19th ed., pg.2130
Application of the newly revised criteria yields a score of 0-10, with
score of ≥6 fulfilling the requirements for definite RA. Source:
165 C Harrison's Principle of Internal Medicine, 19th ed., pg.2143
Synovial fluid WBC can vary widely, but generally range between
5000 and 50,000 WBC/uL compared to <2000WBC/uL for non-
166 A inflammatroy condition such as oesteoarthritis. Source: Harrison's
Principle of Internal Medicine, 19th ed., pg.2144
The most common form of joint involvement in ARF is arthritis with
objective evidence of inflammation, with hot, swollen, red, and/or
tender joints and involvement of more than one joint and almost
always affecting large joints. The joint manifestations of ARF are
167 C highly responsive to salicylates of other NSAIDs. Indeed, joint
involvement that persists for more than 1 or 2 days after starting
salicylates is unlikely tobe due to ARF. Source: Harrison's Principle
of Internal Medicine, 19th ed., pg.2151

Milder cases can ususally be managed by providing a calm

environment. In patients with severe chorea, carbamazepine or
sodium valproate is preferred to haloperidol. A response may not be
168 B seen for 1-2 weeks after sypmtoms subside. Source: Harrison's
Principle of Internal Medicine, 19th ed., pg.2153

Primary Sjogren's syndrome is diagnosed if options B-D are

present. Labial biopsy is needed if diagnosis is uncertain and to rule
169 E out other conditions. Source: Harrison's Principle of Internal
Medicine, 19th ed., pg.2167
Pleural reaction overlying a subpleural focus is common. The ghon
focus (lesion forming an initial infection), with or without overlying
pleural reaction, thickening and regional lymphadenopathy, is
170 B referred to as the Ghon complex. Source: Harrison's Principle of
Internal Medicine, 19th ed., pg.1108
 Lymph node TB presents as painless swelling of the lymph nodes,
most commonly at posterios cervial and supraclavicular sites. Lyph
nodes are usually discrete at early disease but develop into a matted
171 B nontender mass over time and may result into a fistulous tract
draining caseous material. Source: Harrison's Principle of Internal
Medicine, 19th ed., pg.1109

In one study, adjunctive dexamethasone significantly enhaced the

chances of survival among persons >14 years of age but did not
172 D reduce the frequency of neurologic sequelae. Source: Harrison's
Principle of Internal Medicine, 19th ed., pg.1111
When a type 1 lepra reactions precede the initiation of appropriate
antimicrobial therapy, they are termed doengrading reactions and
the case becomes histologically more lepromatous; when they occur
173 A after the initiation of therapy, they are termed as reversal reactions
ans tha case becomes more tuberculoid. Source: Harrison's
Principle of Internal Medicine, 19th ed., pg.1125

Type 1 lepra reactions are best treated with glucocorticoids. Source:

174 C Harrison's Principle of Internal Medicine, 19th ed., pg.1127
All options can be a possible explanation. Source: Harrison's
175 E Principle of Internal Medicine, 19th ed., pg.1755
When Anti-HBc IgM is reactive when others are not, it is referred to
176 B as window period. Source: Harrison's Principle of Internal Medicine,
19th ed., pg.2017
All are true regarding the prognosis of viral hepatitis. Source:
177 E Harrison's Principle of Internal Medicine, 19th ed., pg.2018
Hypotension is the most common acute complication of
hemodialysis, particularly among patients with diabetes mellitus. It
178 C is brought about by numerous factors. Source: Harrison's Principle
of Internal Medicine, 19th ed., pg.1824
Atopy is the major risk factor for asthma and nonatopic individuals
179 A have very low risk of developing asthma. Source: Harrison's
Principle of Internal Medicine, 19th ed., pg. 1669
Omalizumab is a blocking antibody that neutralizes circulating IgE.
180 D It is given as a subcutaneous injection every 2-4 weeks. Source:
Harrison's Principle of Internal Medicine, 19th ed., pg.1678

All options are part of the initial assessment. Source: Williams

181 E Obstetrics, 24th ed., pg.1279
Cesarean delivery is not recommended for women with history of
182 C HSV infection but no active genital disease at the time of delivery.
Source: Williams Obstetrics, 24th ed., pg.1274
Women who develop mumps in the first trimester may have an
increased risk of spontaneous abortion. Infection in pregnancy is
183 C not associated with congenital malformations, and fetal infection is
rare. Source: Williams Obstetrics, 24th ed., pg.1242
 Transient leukopenia can be documented in up to 10% of women
taking antithyroid drugs, but this does not requires therapy
cessation. In 0.3-0.4%, however, agranulosytosis develops
suddenly and mandates drug discontinuance. It is not dose related
184 B and with acute onset, thus serial leukocyte counts are not helpful. If
fever or sore throat develops, women are instructed to discontinue
medication immediately and report for a complete blood count.
Source: Williams Obstetrics, 24th ed., pg.1149

All of the options given are risk factors may occur alone or in
185 E combination. Source: Williams Obstetrics, 24th ed., pg.787
All options are observed once any degree of uterine inversion is
186 E recognized. Source: Williams Obstetrics, 24th ed., pg.787
The recipient neonate may have circulatory overload from heart
187 C failure and severe hypervolemia and hyperviscosity. Source:
Williams Obstetrics, 24th ed., pg.905
Corticosteroid therapy for lung maturation is given and delivery is
188 B instituted after maternal stabilization in a setting of DIC. Source:
Williams Obstetrics, 24th ed., pg.756
The American Dietitic Association (2008) recommends that caffeine
intake during pregnancy be limited to less than 300 mg daily, or
189 C approximately three 5-oz cups of percolated coffee. Source:
Williams Obstetrics, 24th ed., pg.187
CDC guideline minimum criteria for diagnosis of Acute PID are lower
190 D abdominal tenderness, adnexal tenderness and cervical motion
tenderness. Source: Comprehensive Gynecology, 6th ed., pg. 550
Uncomplicated VVC are likely to be C. albicans. Other options are
191 C parameter of complicated VVC. Source: Comprehensive
Gynecology, 6th ed., pg. 538
All options listed are absolute contraindications . Source:
192 E Comprehensive Gynecology, 6th ed., pg. 376
Germ cell tumors are the most common gynecologic neoplasm in
this age group, and fortunately most are benign ovarian teratomas.
The most common malignant germ cell tumos is the dysgerminoma
193 A followed by endodermal sinus tumors. Source: Comprehensive
Gynecology, 6th ed., pg. 212

Didelphic involve a complete duplication of the vagina, uterus and

194 D cervix. Source: Comprehensive Gynecology, 6th ed., pg. 194
Vulvovaginitis is the most common gynecologic problem in the
prepubertal female. It is estimated that 80-90 % of outpatient visits
of children to gynecologists involve the classis symptoms of
195 B vulvovaginitis: introital irritation (discofort/pruritus) or discharge.
Source: Comprehensive Gynecology, 6th ed., pg. 202

All options are true. Source: Comprehensive Gynecology, 6th ed.,

196 E pg. 661
The clinical stage described is consistent with Stage IIA. Source:
197 B Comprehensive Gynecology, 6th ed., pg. 670
 If it is necesarry to perform a conization or preferably a wedge
resection of the cervix during pregnancy, it is probably best to
perform this during the second trimester, when the risks of fetal loss
198 B anf hemorrhage are minimal. Source: Comprehensive Gynecology,
6th ed., pg. 681

Piver and colleagues have defined five classes to describe the

extent of the operation. Class I guarantees the removal of the entire
cervix and uterus. The uereter is not disturbed from its bed. I many
199 A cases, this is described as an extrafascila hysterectomy, the type
used after preoperative radiation for treatment of a barrel-shaped
cervix. Source: Comprehensive Gynecology, 6th ed., pg. 675

The description is consistent with Stage II Endometrial cancer.

200 B Source: Comprehensive Gynecology, 6th ed., pg. 720

Subtle seizures consist of chewing motions, excessive salivation,

and alterations in the respiratory rate including apnea, blinking,
201 E nystagmus, bicycling or pedaling movements, and changes in color.
(Nelson's Textbook of Pediatrics, 19th ed. Chapter 586)
Myoclonic seizures are brief focal or generalized jerks of the
202 D extremities or body that tend to involve distal muscle groups.
(Nelson's Textbook of Pediatrics, 19th ed. Chapter 586)
The Aicardi syndrome, which occurs exclusively in infant girls, is
associated with coloboma of the iris and retinal lacunae, refractory
seizures, and absence of the corpus callosum. Inspection of the skin
may show hypopigmented lesions characteristic of tuberous
203 A sclerosis or the typical crusted vesicular lesions of incontinentia
pigmenti; both neurocutaneous syndromes are associated with
generalized myoclonic seizures beginning early in life. (Nelson's
Textbook of Pediatrics, 19th ed. Chapter 586)

Statements A, B and C are correct about neonatal seizures.

204 D (Nelson's Textbook of Pediatrics, 19th ed. Chapter 586)
Only A and B are true. Option C is incorrect. preterm infants,
including those of very low birthweight, should be vaccinated at the
same chronologic age as full-term infants and according to the
routine childhood immunization schedule. One exception to this
205 E recommendation is hepatitis B vaccination of those born of HBsAg-
negative mothers with low birthweights (i.e., <2 kg). Initiation of
vaccination in this case should be delayed until the infant is 1 mo of
age. (Nelson's Textbook of Pediatrics, 19th ed. Chapter 282)

All statements are true. (Nelson's Textbook of Pediatrics, 19th ed.

206 D Chapter 282)
The IgM titer diminishes and the IgG titer rises during the 2nd wk or
later. IgG responses peak within 2-6 wk. The change from IgM
synthesis to predominately IgG synthesis in B lymphocytes requires
207 B T-lymphocyte cooperation. IgG antibodies are produced in high
concentrations and are critical to resistance to infections. (Nelson's
Textbook of Pediatrics, 19th ed. Chapter 282)
 Mild dehydration (3-5%): normal or increased pulse, decreased
urine output, thirsty, normal physical examination

Moderate dehydration (7-10%): tachycardia, little or no urine output,

irritable/lethargic, sunken eyes and fontanel, decreased tears, dry
mucous membranes, mild tenting of the skin, delayed capillary refill,
cool and pale
208 C Severe dehydration (10-15%): rapid and weak pulse, decreased
blood pressure, no urine output, very sunken eyes and fontanel, no
tears, parched mucous membranes, tenting of the skin, very
delayed capillary refill, cold and mottled (Nelson's Textbook of
Pediatrics, 19th ed. Chapter 47)

As a guideline for oral rehydration, 50 mL/kg of the oral rehydration

solution (ORS) should be given within 4 hr to patients with mild
dehydration and 100 mL/kg over 4 hr to those with moderate
dehydration. Supplementary ORS is given to replace ongoing losses
from diarrhea or emesis. An additional 10 mL/kg of ORS is given for
each stool. Fluid intake should be decreased if the patient appears
fully hydrated earlier than expected or if the patient develops
periorbital edema. Breast-feeding should be allowed after
209 D rehydration in infants who are breast-fed; in other patients, their
usual formula, milk, or feeding should be offered after rehydration.
Along with its nutritional benefits, early refeeding decreases the
duration of diarrhea. (Nelson's Textbook of Pediatrics, 19th ed.
Chapter 48)

Body Weight Fluid per Day

0-10 kg 100 mL/kg
11-20 kg 1,000 mL + 50 mL/kg for each kg > 10 kg
> 20 kg 1,500 mL + 20 mL/kg for each kg > 10 kg*
210 A *The maximum total fluid per day is normally 2,400 mL. (Nelson's
Textbook of Pediatrics, 19th ed. Chapter 46)

Congenital rubella affects virtually all organ systems. The most

common manifestation is intrauterine growth retardation. Other
common findings include cataracts, bilateral or unilateral, which are
frequently associated with microphthalmia; myocarditis and
structural cardiac defects (e.g., patent ductus arteriosus or
211 A pulmonary artery stenosis); "blueberry muffin" skin lesions, similar
to those seen in congenital cytomegalovirus infection; hearing loss
from sensorineural deafness; and meningoencephalitis
(Nelson's Textbook of Pediatrics, 19th ed. Chapter 226)

The diagnosis is confirmed by finding rubella-specific IgM antibody

in the neonatal serum, or by culturing rubella virus from the infant
(nasopharynx, urine, or tissues). Virus can be shed in the urine for
212 E 1 yr or longer.
(Nelson's Textbook of Pediatrics, 19th ed. Chapter 226)
 It is especially important for girls to have immunity to rubella before
they reach childbearing age.
Pregnant women should NOT be given live rubella virus vaccine and
should avoid becoming pregnant for 3 mo after they have been
213 E vaccinated. Routine serologic testing of postpubertal women before
rubella immunization is not necessary. (Nelson's Textbook of
Pediatrics, 19th ed. Chapter 226)

The incubation period is 1-7 days. The clinical manifestations are

variable and are influenced by the age of the patient. In infants and
young children, the disease may be undifferentiated or
characterized by fever for 1-5 days, pharyngeal inflammation,
rhinitis, and mild cough. A transient, macular, generalized rash that
blanches under pressure may be seen during the first 24-48 hr of
fever. Myalgia and arthralgia occur soon after the onset and
increase in severity. Joint symptoms may be particularly severe in
patients with chikungunya infection. From the 2nd-6th days of fever,
214 A nausea and vomiting are apt to occur, and generalized
lymphadenopathy, cutaneous hyperesthesia or hyperalgesia, taste
aberrations, and pronounced anorexia may develop.
About 1-2 days after defervescence, a generalized, morbilliform,
maculopapular rash appears that spares the palms and soles. It
disappears in 1-5 days. (Nelson's Textbook of Pediatrics, 19th ed.
Chapter 246)

All are true of the pathogenesis of Dengue Fever (Nelson's Textbook

215 D of Pediatrics, 19th ed. Chapter 246)
Normal saline is more effective in treating shock than the more
expensive Ringer lactated saline. Transfusions of fresh blood or
platelets suspended in plasma may be required to control bleeding;
they should not be given during hemoconcentration but only after
216 E evaluation of hemoglobin or hematocrit values. Salicylates are
contraindicated because of their effect on blood clotting. (Nelson's
Textbook of Pediatrics, 19th ed. Chapter 246)

The majority of children with SLE are adolescent females. Clinical

evidence of renal disease occurs in 30-70% of children. The clinical
findings in patients having the milder forms (all class II, some class
III) of lupus nephritis include hematuria, normal renal function, and
proteinuria of less than 1 g/24 hr. Some patients with class III and
all patients with class IV nephritis have hematuria and proteinuria,
reduced renal function, nephrotic syndrome, or acute renal failure.
217 E In rare patients with proliferative glomerulonephritis, the urinalysis
may be completely normal. Patients with class V nephritis commonly
present with nephrotic syndrome.
(Nelson's Textbook of Pediatrics, 19th ed. Chapter 506)
 WHO class IV nephritis (diffuse proliferative lupus nephritis) is the
most common and most severe form of lupus nephritis. All glomeruli
contain massive mesangial and subendothelial deposits of
immunoglobulin and complement. On light microscopy, all glomeruli
show mesangial proliferation. The capillary walls are frequently
218 D thickened owing to subendothelial deposits creating the wire-loop
lesion and often demonstrate necrosis, crescent formation, and
scarring. (Nelson's Textbook of Pediatrics, 19th ed. Chapter 506)

This is a case of ITP. One to 4 wk after exposure to a common viral

infection, a small number of children develop an autoantibody
directed against the platelet surface. The exact antigenic target for
most such antibodies in acute ITP remains undetermined. After
binding of the antibody to the platelet surface, circulating antibody-
219 A coated platelets are recognized by the Fc receptor on the splenic
macrophages, ingested, and destroyed. A preceding history of a
viral illness is described in 50-65% of cases of childhood ITP.
(Nelson's Textbook of Pediatrics, 19th ed. Chapter 476)

The majority of cases of TTP are caused by an acquired deficiency

of a metalloproteinase responsible for cleaving the high molecular
weight multimers of VWF, which appear to play a pivotal role in the
220 C evolution of the thrombotic microangiopathy. In contrast, levels of
the metalloproteinase in HUS are usually normal. (Nelson's
Textbook of Pediatrics, 19th ed. Chapter 476)

All are true. In fact, epidemiology is often described as the basic

science of public health, and for good reason. First, epidemiology is
a quantitative discipline that relies on a working knowledge of
probability, statistics, and sound research methods. Second,
221 D epidemiology is a method of causal reasoning based on developing
and testing hypotheses. (Principles of Epidemiology in Public Health
Practice 3rd edition, CDC, p. 1-2)

William Farr built upon Graunt’s work by systematically collecting

and analyzing Britain’s mortality statistics. Farr, considered the
father of modern vital statistics and surveillance, developed many of
222 D the basic practices used today in vital statistics and disease
classification. (Principles of Epidemiology in Public Health Practice
3rd edition, CDC, p. 1-7)

five major tasks of epidemiology in public health practice were

identified: public health surveillance, field investigation, analytic
studies, evaluation, and linkages.17 A sixth task, policy
223 E development, was recently added. (Principles of Epidemiology in
Public Health Practice 3rd edition, CDC, p. 1-15)

The hallmark of an analytic epidemiologic study is the use of a valid

224 A comparison group. (Principles of Epidemiology in Public Health
Practice 3rd edition, CDC, p. 1-18)
 Effectiveness refers to the ability of a program to produce the
intended or expected results in the field; effectiveness differs from
efficacy, which is the ability to produce results under ideal
conditions.
225 A Efficiency refers to the ability of the program to produce the intended
results with a minimum expenditure of time and resources.
(Principles of Epidemiology in Public Health Practice 3rd edition,
CDC, pp. 1-18,19)

Analytic studies. The descriptive approach involves the study of

disease incidence and distribution by time, place, and person. It
includes the calculation of rates and identification of parts of the
226 C population at higher risk than others. (Principles of Epidemiology in
Public Health Practice 3rd edition, CDC, p. 1-17)

This is a case-control study. (Principles of Epidemiology in Public

227 C Health Practice 3rd edition, CDC, pp. 1-48,49)
It is a necessary cause. An agent that is usually harmless in healthy
persons may cause devastating disease under different conditions.
Pneumocystis carinii is an organism that harmlessly colonizes the
respiratory tract of some healthy persons, but can cause potentially
lethal pneumonia in persons whose immune systems have been
228 B weakened by human immunodeficiency virus (HIV). Presence of
Pneumocystis carinii organisms is therefore a necessary but not
sufficient cause of pneumocystis pneumonia. (Principles of
Epidemiology in Public Health Practice 3rd edition, CDC, p. 1-54)

After the disease process has been triggered, pathological changes

then occur without the individual being aware of them. This stage of
subclinical disease, extending from the time of exposure to onset of
disease symptoms, is usually called the incubation period for
229 A infectious diseases, and the latency period for chronic diseases.
During this stage, disease is said to be asymptomatic (no
symptoms) or inapparent. (Principles of Epidemiology in Public
Health Practice 3rd edition, CDC, p. 1-59)

Sporadic refers to a disease that occurs infrequently and irregularly.

Endemic refers to the constant presence and/or usual prevalence
of a disease or infectious agent in a population within a geographic
area. Hyperendemic refers to persistent, high levels of disease
occurrence.
Occasionally, the amount of disease in a community rises above the
expected level. Epidemic refers to an increase, often sudden, in the
230 B number of cases of a disease above what is normally expected in
that population in that area. Pandemic refers to an epidemic that
has spread over several countries or continents, usually affecting a
large number of people. (Principles of Epidemiology in Public Health
Practice 3rd edition, CDC, p. 1-72)
 A common-source outbreak is one in which a group of persons are
all exposed to an infectious agent or a toxin from the same source.
If the group is exposed over a relatively brief period, so that
everyone who becomes ill does so within one incubation period,
231 A then the common-source outbreak is further classified as a point-
source outbreak. (Principles of Epidemiology in Public Health
Practice 3rd edition, CDC, p.1-75)

The mode is the value that occurs most often in a set of data. And
232 A in this case, it is 3. 000112223333334444 (Principles of
Epidemiology in Public Health Practice 3rd edition, CDC, p.2-16)
0,0,0,1,1,2,2,2,3,3,3,3,3,3,4,4,4,4 (When added, this is 42 divided
233 B by 18 = 2.33) (Principles of Epidemiology in Public Health Practice
3rd edition, CDC, p.2-25)
When the distribution is skewed to the right, mean > median > mode.
234 A (Principles of Epidemiology in Public Health Practice 3rd edition,
CDC, p.2-14)
In a proportion, the numerator must be included in the denominator.
235 C (Principles of Epidemiology in Public Health Practice 3rd edition,
CDC, p.3-6)
Proportionate mortality is the proportion of deaths in a specified
population during a period of time that are attributable to different
236 A causes. (Principles of Epidemiology in Public Health Practice 3rd
edition, CDC, p.3-6)
Odds ratio: (AD)/(BC); A: 1200, B: 300, C: 800, D: 200 hence,
237 A (1200x200) / (800x300)=1% (Principles of Epidemiology in Public
Health Practice 3rd edition, CDC, p.3-45)
A histogram is a graph of the frequency distribution of a continuous
variable, based on class intervals. It uses adjoining columns to
represent the number of observations for each class interval in the
distribution. An epidemic curve is a histogram that displays the
238 A number of cases of disease during an outbreak or epidemic by times
of onset. (Principles of Epidemiology in Public Health Practice 3rd
edition, CDC, p.4-31,32)

Refer to recommended immunization schedule for adults aged 19

239 D years or older by medical condition released by the CDC.
The SCREEM represents the family resources. It helps family
members identify and assess their resources to meet a crisis. It is
240 D composed of the following measures: Social, Cultural, Religious,
Economic, Educational and Medical.