eed ‘A 70-year-old man trom China has a poorly cffeentiated monoclonal carcinoma ofthe nasopharynx. DNA probes of neoplastic cells are most ely to Cetect the genome of which ofthe folowing vieuses? A) Cytomegalovirus e 6) Hepatitis B virus D) Herpesvirus 8 E) HTLV o °oeel ehemheeceeead _year-old woman, gravida 1, para 1, is brought to the emergency department because of a 2-day history of fever and severe vaginal bleeding. Four days ago, she delivered a healthy male newoorn spontaneously at term, Her temperature Is 38.1°C (100.6°F). Pelvic examination shows an open cervix and heavy vaginal bleeding, Uitrasonography of the uterus shows no retained placental tissue or large thrombi. I an operation is require to control the bleeding, gation of a branch ef which ofthe following arteries Is most appropriate? > Extemal tae Internal pudendal Median sacral Obturator 2 OW © )eed ‘A2'-yearold man is brought to the emergency department 45 minutes after sustaining muttple injuries in a motor vehicle eolsion. His blood pressure |s 90/50 mm Hg, Physical examination shows dfuse abdominal tendemass. Hes dlagnosadi ith laceration ofthe spiaen and undergoes spianactony. ‘The splenectomy most iksly precisposes this patient to develop future infection with which of the following causal organisms? A) Candida albicans ) Cytomegelovius ©) Escherichia col ) Herpes simplex virus o °o‘A 14year-od boy is brought to the physician by his mother because of daly headaches for 2 months. The headaches are described as a bateral aching Inthe temples. His mother states that he also "has not been himself for tne past few months. He seams mare confused, often forgetting names, dates, and places, and he is clumsy wth frequent falls. His school performance also has declined over the past quarter. Physical examination shows a broad based, ataxic galt. He is alert and oriented to person, place, and time, but he Is slow to answer questions. Chronic abuse of which ofthe folowing substances isthe most Ikely cause ofthis patients condition? A) Cocaine B) Etranol ) Methamphetamines ) PCP (phencyclidine) @An 18-year-old man has yellow nodules on the Achilles tendons of his feet and extensor tendons of his hands. Examination of tssus obtained on blopsy of one nodule shows a collection of foamy histiocytes within the dermis. His serum cholestercl concentration is 980 mg/dL. and serum llpoprotein lectrophoresis shows a selective increase in LDL. Which of the folloning ls the most ikely underying disorder? 8B) Detective receptor-binding 8-100 protein n LDL particles ) Diminution of receptorindependent LDL uptake by mononuclear phagocytes D) increased gastrointastinal absorption of datary fat E) Partial reduction in functional LDL recaptors of hepatocytes ° Di rs) @Exam Section eect eon ‘A 30-year-old man Is brought to the emergency department 1 minutes after he was found lunconscious in a park. On arrival, he is comatose. The pupils are 4 mm in diameter and not reactive to light. A CT scan of the head is shown. The most key cause of the coma Is. bleeding from which ofthe felloving structures? A) Bridaing vein B) Internal cerebral vein C) Lentieuiotrate artery outros, sinus F) Transverse sinus 6 © ro) rs‘A 38-year-old man is brought tothe emergency department because of @2-hour history of savere fatigue and dizziness. He has had profuse. watery diarrhea for 8 hours despte a lack of ora intake, He recently retumed trom a medical ele trip to a remote vilage In Honduras. His temperature is 36:7°C (28°F), pulse ls 122/min, ang blood pressure Is S0/50 mm Hg. Physical examination shows ary skin ane decrassed capllary rfl. Test of the S00 for occult blood is negative: the stool is gray and turbid. A Gram stain of the stool shows predominant gram-negative, comma-shaped bacteria there are no erythrocytes oF leukocytes, Wnich ofthe folowing nest describes the mechanism ofthe toxin that caused these findings? 8) Activation of guanylyl cyclase ) Activation of Nav-K- ATPase ) Activation of phosphodiesterase ) Deactivation of ADP-ibosylaton factors a‘A 60-year-old man comes tothe physician because of prosressive shortness of breath during the past 3 months. He states that for many years he has worked in a shipyard His respirations are 25imin. Blateal basilar crepltant crackles are heard. An x-ray ofthe chest shows reticulonadvlar pulmonary infitrates consistent with intersital fbrosis, Microscopic examination of sputum shows occasional elongate structures as shovn ‘The florosis was most ely intiated by interaction ofthese structures with which ofthe following cal types? F) Goblet cell G) Kulehtsky eat €) Chondrocyte H) Squamous epithelial cell ) Cilated columnar epithelial cell |) Type | pneumocyte 4) Type Il preumocyte AA) Alyaolarcapllary endothelial cell ) Clara cellA 84-year-old woman vith hypartansion an bilateral renal artery stenosis starts taking a nonsteroidal ant-inflammatory crug for back pain. Over the ext week, ofthe folowing? ‘A) Infiammation in he glomerular capiaries B) Infammation in the renal ntersttium ¢) Vasoconstrcting prostaglandins at the afferent arteriole 1) Vasoconsireting prostaglandins a the efferent arteriole EVV F) Vasoailating prostaglancins at the ent arteriole @ serum creatinine concentration increases ffom {.0 to 5.0 molGL. The most likely cause ofthis finding isthe crug's abit to inhibit wi‘A27-year-old primigravid woman at 34 weeks! gestation Is admitted tothe hospital because of nausea and vomiting, and abdominal pain for 12 hours. Her pregnancy has been otherwise unremarkable. Prior laboratory studies. including a complete blood count and serologic tests for HIV and hepatits, have shown no abnormalities. Her blood pressure now is 164/102 mm Hg, Abdominal examination shows right upper quadrant tenderness. Laboratory studies show Hemoglobin 7.4 g/d. Hematocrt 249% Platelet count 72,000/mm: Serum Creatinine 1-2 maid Total blirubin 2.3 mgiaL ast 4i2UiL ALT 126UIL Examination ofa peripheral blood smear is mest lkely to show a predominance of whieh of the fellowing n this patiant? A) Acantheeytes B) Heinz bodies C) Howell-Jolly bodies E) Spherocytes F) Target oe ®eek Adb-year-ld w ‘ago. She under arranged in smal man has a thyroidectomy because of asymmetric enlargement ofthe thyroid gland. frst noticed during a physical examination 6 weeks tan adrenalectomy for pheochromocytoma 3 years ago, Microscopically, the bilateral thyroid lesions are composed of spindle cells lustars. Deposit of amyjcld are present between neoplastic cells. Foci of C-cell hyperplasia are also present. The lesions are confirmed as malignant. Which ofthe folowing markers is most appropriate to moniter forthe development of recurrence of tne thyroid neoplasm? B) aFetoprotein C) Human chorionic gonadotropin ) Norepinephrine ) Thyrold-stimulating hormone ra‘A62-year-old man dies sudent examination shows a cardiac valve cefec inhi suden death? A) Aortic insufficiency CC) Mra insutfcleney 1) Mitral stenosis ) Puimonic insuficiency F) Pulmonic stenosis, oO file playing tennis. He had no known cardiac risk factors and no history of coronary artery disease, At autopsy, ‘and concentric left ventrcuar hypertrophy. Which of the folewing valve abnotmaities is most ikely Involves‘A 48-year-old woman comes tothe physician because of a 2-month history of fatigue and intermittent headaches. Her blood pressure is 180/110 mm Hg. Physical examination shows no other abnormalities. Serum studies show a decreased potassium concentration and increased aldosterone concentration. A CT scan ofthe abdomen shows a tumor onthe adrenal gland. Which ofthe folowing additonal fincings inthis patient most IKely supports the dlagnosis of an aldosterone-secreting adrenal adenoma? B) Decreased serum soclum concentration ) Decreased urine potassium concentration ) Increased plasma renin activity E) Increased serum sodium concentration F) Increased urine metanephrine concentration © CJ‘A 36-year-old man undergoes elective liposuction under general anesthesia. The operation Is terminated prematurely when the anesthesiologist notices that the patient has developed hyperthermia, tachycardia, and marked muscle rillty. The drug that should be administered has ich ofthe fllovang actions? Ay BB) Enhances renal tubular excretion of Ca C) Increases plasma Ca?" concentration 1D) Opens cellular membrane Ca and Na channels E) Shits Ca” ftom the extracellular to the intracellular space oOA its brought tothe physician for a well-child examination. Her normal development includes using a pincer grasp, finger feeding, standing while holding onto a table, and playing peskaboo, aja 15 oat 5)27 hich ofthe following best represents this patient's age (in months)? BG‘A pharmacauticel company is tying to davalop a long-acting walght-loss agent thet mimics tha activity of @ naturally occurring peptide thet eriginates In ‘acipose tissue, signals the brain about the amount of stored fat, and suppresses appetite by its action in the central nervous system. Theit best strategy for identitving usel peptides vould be to assess the binding of candidate peptides to the receptor for which ofthe following chemical mediators? A) Cholecystokinin Neuretansl Y Serotonin Somatostatin Substance P amoo © CG‘A 28:year-old woman comes tothe physician because of a 3-year history of regular menses. Menarche was at the age of 14 years. Puberty began at ‘the age of 12 years and progressed normally. Her blood pressure Is 116) 2 mm Hg. Phy ‘examination shows increased hair growth on the face and chest Palvic examination shows eltoromagaly and a normal-appeerng uterus, Sarum stuclas show increased concentrations of 1 T-nydroxyprogesterone and androstenedione. This patient most Ikely has a deficiency of which ofthe folowing enzyme actives? A) M1p-Hyaroxyiase B) T7o-Hydroxvlase D) 3E-Hydronysteroid denyerogenase E) So-Reductase ra ©A randomized controled study of 2000 patients with insomnia is conducted to evaluate the efficacy of a new medication to treat this condition. Ten subjects from bath the control and treatment groups do nat compete the study and are not included inthe analysis. Study subjecs in the tragiment group are able to fal asieep an average of § minutes faster than study subjects inthe control group, The derence is statistically significant (p=0.001), Subjects in neiter group report an improvement in qualty of ite. The investigators conclude that the new medication is efficacious in treating insomnia, These fincings are most likely an example of vhich ofthe following types of error? usion of subjects who did not have an exoscted res jure to ind a clinically significant result due tothe atrion of subjects ) Failure to reject a nul hypothesis when i isnot rue ) Rejecting a null hypothesis when itis true‘A 65-year-old man who recently emigrated from Brazil comes tothe physician because of an &-month history of shoriness of breath and fatigue Physical examination shows edema of the lower extremities, A chest x-ray shove cardiomegaly, An endomyocardial biopsy specimen shows inavidual ryote nacrosis with a mixed infammatoryInfitrate of neutrophils, T lymphocytes, macrophages, and eosinephis. Which ofthe folowing isthe most likely causal organism? A) Leishmania major B) Leishmania topic ©) Torocare canis ) Trichinela spiralis E) Trypanosoma bruce ; ) Wucherenia bancrofiA 8&:year-old woman comas tothe physielan for a follow-up examination & waeks after recovering from pneumoceecal pneumonia, X-rays ofthe chest show ne abnormaliies. Which ofthe following most likely allowed this resolution to occur? |A) Formation of granulation tissue B) Increased angiogenesis ) Metaplasia of mesenchymal cells to pneumocytes E) Proliferation of fibroblasts © od GBY-0ld man with Interstal pulmonary Nbrosis has a greater maximal expiratory flow rate than predicted, Which of the folowing best explains this finaing? 'A) Hypercapnie bronchodlatation 8) Hyperination ofthe lungs CC) Hypoxic bronchedllatation Fr E) Increased surfactant secretionxo emt Oxidized ~— 6-mercaptopurine —+ 6-methylmareaptepurine metabolites 6 thioguanine nucleotides 6-Mercaptopurine (5-MP) Is used to treat acute lymphoblastic leukemia, In humans, 6-MP Is acted on by a series of cellular enzymes to produce G-thioguanine ruceatides (6-TGN), These modified nucleotides can then be incorporated into DNA. Both the efficacy and toxicity of E-MP therapy are correlated vith the nal serum 6-TGN concentration. High serum concentrations of 6-TGN ae toxic and can lead to life-threatening complications. {-MP also can be acted ony xanthine oxidase (XO), thiopurine methytransterase (TPMT), ofboth (shown), Soth of these sequences for patents with acute Exogenously administ pathways lead tothe production of inactive and nontoxic metabolites. Which of the folowing are the clinical Iymphoblastic leukemia who are homezygous for low-activy alleles of TPMT? ‘A) They may be glven normal dos 8 ) They must be given increased doses of 6 MP ) They must be given nections of XO if treated with 6{An 83-year-old man is brought tothe emergency department after being found at home becriddien and confused. He takes no medications. Temperature is 36.6°C (96°F), pulse is 100/min, and blood pressure Is 85/60 mm Hg. Blood pressure Is unchanged after intravenous infusion of 1 fter ofisatonic saline. A pulmonary artery catheter is inserted and the following findings are obteinec: Cardiac output high Pulmonary capllay wedge pressure low Systemic vascular resistance los Which ofthe following Is the most likely cause of the hypotension? 8B) Gastrointestinal bleeding ) Hypothyroidism 1D) Massive pulmonary embolism E) Silent myocardial infarction 0 é i‘A 26-year-old man Is brought to the emergancy department 30 minutes after the sucan onset of shortness of breath. He has a 3-year hist Cocaine abuse, His temperature is 38.1°C (100.6°F), pulse is 100/min, and blood pressure is 150/45 mm Hg, Physical examination shows diminished pulses inthe eft upper extremity, Crackles are heard over all lung fields, A grade 26 diastolic murmur is heard best at the lft sternal border. A chest ‘ray shows a widened aoe arch, Which ofthe folowing Is the most likely clagnosis? vot A) Atharoscleratie aneurysm e ¢) Mycotie aneurysm D) Peeudoaneurysm ) Saccular aneurysm ra ©‘A 62-year-old man with alcohol-induced liver disease develops mass ‘2cktion to loop dlurtis, includes which ofthe folowing drugs? |A) Acetazolamide 8) Hydrechlorothiazide C) Indapamide ) Metolazone. é o °oA study Is designed to evaluate the ffleacy of coenzyme Q10 in improving cardiac output inpatients with congestive heart fallure (CHF). Sty patients vith CHE are recruited forthe study. Each subjects assigned by coin toss to one of two groups (standard care or standard care plus coenzyme 210) Which of the fllouing best deserbes this study design?” A) Case-control B) Case series ©) Crossover ) Cross-sectional E) Historical cohort q ra ©{A4-year-ld man comes tothe physician because of intermittent bloody diarhea and abdominal pain during the past month, Sigmoldoscopy and rectal blopsy spacimens show inflammatory bowel disease. A trial of a monacional atibody preparation Is begun. The antibody inthe preparation Is most ikly o be directed against which ofthe folowing components? A) Bradykinin B)C3a ) Class | MHC antigens D) Fibrin E) Prostaglandin E @ i 0Y-0ld woman with a 3-year history of hyperlipidemia comes tothe physician for a follow-up examination, A lou-cholesterol det and exercise program were found to be ineffective in eating her clsease 1 yaar afer dlaghasis, Treatment with lovastatin was inated then, and the dose has been slot increased to control er serum LDL-cholesterol concentration. She is unable to tolerate greater than 20 mg daily ofthis drug because offs averse effects, Physical examination shous no abnormalities. Serum studies show Cholesterol. total 240 magia HDL-cholesterol 38 mgidl. LDL-cholesterol 173 mgial Tiilyesrides 160 mga ‘An addtional cholasteral-decreasing drug Is added to her regimen that inhibits the transport of cholesterol through the intestinal wal. This drug is most Tksly which of he following? A) Cholestyramine 5 ©) Gemrbrozi D) Niacin E) Sknvastatin‘An 81-year-old woman Is admitted to the hospital because of a massive pulmonary embolism from a deep venous thrombosis. Her platelet count is 160,000/mm?. Appropriate pharmacotherapy is stated. One vieek later, her platelet count is 55,000/mm?, The thrombocytopenia was most lkely caused by a drug with which of the following machanisms of action? A) Activates tissue plasminogen B) Interferes withthe carboxylation of coagulation factors C) Ireversibly Inectivetes cyclooxygenase D E) Selectively inhibits factor Xa 7‘A 15-year-old gis brought to the physician by her mother because of a 1-day history of recness and painful skin folowing sunbathing. She reports hat she used sunblock evary fev hours. She takes no mecications. Physical examination shovs severe erythema of the back and extremities. There no bisters, Which of the folowing best describes her conaition? ‘A) Allergic reaction to the sun e (C) Rhus dermattis ) Second-tegree bum ) Thire-degree bum OGIna cinical tty polymorphic marker vith tee alles, 1.2 and. found io be ght ed tthe gone rope Katey dese Apecgestosvomn litisamateced yaa wspatetts 1 Mi 7-O thyacara fen th oloving mare's? mf TS 1 18 | 22 Affected female Affected male (© Unaffected female C Gy‘A 3-year-old boy with sickle cell disease has the insidious onset of fever and persistent pain in his left foot over the past 3 wooks. Hematocrit is stable, Leukocyte count is 15,000imm® with marked predominance of neutrhils. Which ofthe flloving is the most likely explanation for these findings? AA) Acute sickle c 8B) Aseptic necrosis ) Hemarthros E) Tuberculous arthritis a ° ©Mark ‘A 80-year-old woman part of her therapy, als A) Inhibition af 1,25-ethydroxychale rol hydroxylation ©) Intibiton of parathyroid hormone secretion ) Stimulation of ealltonin secretion ) Stimulation of estrogen secretion F) Stimulation of ostecblast¢meciated bone formationcenters ‘A 38-year-old woman comes tothe physician because of a 3-day history of sore throat During the examination, the patient is asked to probude the tongue and say "ah," which causes elevation ofthe area atthe tp ofthe arrow in the photograph shown. Function of ‘which ofthe flloving nerves most key is being tested by tis maneuver? A) Facial B) Glossopharyngeal ©) Hypociossal D) Spinal accessory @‘A previously heathy 72-year-old man is brought tothe physician because of weakness and fatigue. His hemoglobin concentration is 9.2 g/L. leukocyte count is 5400lmm?, and platelet count is 350,000/mm?,A peripheral blocd smear Is shown. Which of the following is the most likely cause ofthese findings? A) Aplastic anemia 8) Chronic myelogenous leukemia e ) E-Thalassemia major ) Veamin B..» (cobalamin) def rseee eet ‘A 18-year-old man Is admitted to the hospital following @ metor vehicle colsion, Physical examination shows a penetrating vound tothe right cerebral cortex with complete paralysis of the lft lower extremity, fracture of the right mid humerus with severing ofthe radial nerve, and a fracture ofthe right tibia. Treatment includes cast mmoblization of the right upper extremity and right knee and ankle. After 10 weeks, the casts are scheduled to be removed from the right upper and lover extremities, A this point, the deep tendon reflex is most likely fo be strongest in which ofthe following locations. in this patient? A les te 8B) Left biceps tendon ) Right brachioracials tendon ) Right patellar tendon © JComprehensive Bass Science Sel sessment A 66-year-old man with stage IV colon cancer comes tothe physician because of a 3-day history of severe dlarthea after recelving chemotherapy with ‘luorourecl, leucovorin, and irinotecan. The physician prescribes an opiois antidlarrheal agent with litt or no abilty te produce central nervous syst effects. even when given in relatively high doses. Which ofthe following agents was most lkely prescribed? A) Buprenorphine B) Codeine ) Hydrocodone ) Morphine GBPain score strasogs Cane Trae Wook {A study Is conducted to assess the afectivenass of injections of lkdecaine into "vigger points" of pain symptoms inpatients with fbromyalgia. ity patients are randomly assigned to biweekly trigger-point injections with 0.8% saline only or 0.8% saline plus ldocaine, The graph shows dally eef- reported pain scores in relation tothe injections. Which of the follovng isthe most likely explanation for these findings? 8) Regression to the mean 6) Selection bias D) Type Hl error E) Uncontrolled confouncing © (a‘of 100 households (average three residents par housahole), 4S naval with asthma are detactad, Which of the following Is the best estimate ofthe prevalence of astima? B) 20% 2) 30% 1) 40% E) 45% 0 ° Gy‘A a2-year-old woman comes tothe physician because of @ t-month history of abdominal pain, especially after eating fatty meals. She is 180.cm (5111 In) tall ang weighs 100 kg (220 Ib) BMI ls 31 kgim?. Physical examination shows jaundice and tenderness ofthe right upper quadrant ofthe abdomen. ‘An inerease in which ofthe following liver functions is most kal In this patient? 8B) Conjugation of rabin C) Deamination of amine acids ) Glycogen synthesis E) Secretion of angictensinogen @cee ‘A 16-year-old git comes tothe physician because of a 3-day history of fever. nonproductive cough, and fatigue. Her temperature Is 38.3°C (100.$°F) pulses 68imin, resplations are {@imin, and blood pressure Is 102/70 mm Hg. Physical examination shows pale conjunctvae. A chest x-ray shov's bilateral interstitial nitrates, A sample cf blood drawn for testing spontaneously agglutinates while awaiting transport tothe laboratory. Which of the following antibody isotypes is the most Ikely cause ofthe agglutination? Aylga B)lgD O)gE D) lac @‘Anew compounds taken up by bacterial cells. No energy is necessary for uptake, and the compound isnot concentrated in the cell. Which of the following best daseribas this mechanism of transport? A)ATP- yendent active transport 8 c ©) Group translocation ) Phosphorylation inked transport E) Protor-gradient-meclated transport‘A 60-year-old woman Is brought tothe physician 3 hours after the sudden onset of pain of her right ankle. She has a 4-year history of gracually sing serum creatinine concantrations, She began furosemide therapy 1 month ego for pedal edema, Currant maclications also inlude gliplzse for type 2 diabetes mellitus. Her pulse is 120/min, respirations are 25imin, and blood prassure Is 180/100 mm Hg. Physical examination shows exquisite tenderness to palpation ofthe right ankle joint. Analysis of joint Mu aspirate shows negatively birefringent crystals. Sensation to pinprck is decreased In the fst. The patient Isat increased risk for which ofthe folowing complications of the underlying process causing the jolnt findings? A) Cholelthiasis ©) Osteoartnts D) Osteoporosis Pathologic fracture a ° a‘A 65-year-old woman comes tothe physician because of a week history of low energy, itabilty, and crying spells. She has dificult faling asleep {and wakes up frequently at night. Her work as @ bookkeeper has been affected because she cannot focus. She has not been attending church or her bridge club, She has been taking lorazepam for 15 years for generalized anxisty disorder. She has had postmenopausal symptoms for 1 year successfull treated with estrogen replacement therapy. Her temperature Is 37°C (88.6°F), pulse is 82/min, and blood pressure Is 120/76 mm Hg. Physical examination and laboratory stuclas show no abnormalities. Mental status examination shows a constricted affect. She describes her mood as "sty." Her speech is slightly slowed, There is no evidence of psychosis, She says she wishes that she "wouldn't wake up some days" but does not have any Intent or plan to harm herself, Which ofthe folowing isthe most Ikely cause of this pallent's symptoms? A) Estrogen toxlety ) Generalized anxlety disorder ©) Lorazepam toxicty a) G‘A 38-year-old woman comes tothe physician because of a 2-year history of paln and heavy flow with manses. She stays home trom work approximately 1 day every 2 months because of her symptoms, Use of ibuprofen has nat been effective in treating the pain, She has one child, a 6- year-old caughtar, She and her husband have not bean abla to concelve another chi, but she says ths s no longer a peor. Thera isa family history of infertility. Physical examination shows @ mildly enlarged let ovary and retroflexed uterus. Ultrasonography ofthe ebdomen shows substantial evidence of ovarian cysts and one pertoneal cyst. A biopsy specimen of one ofthe cysts is most likely to show which ofthe folowing? A) Mueinous adenocercinoma 8) Ovarian germ-cell tumor ) Ovarian stromal tumor D) Polyeystc ovaries 5 GS ro c aS i‘Annewibom has male genital ducts but female external genitalia. Cytogenetic analysis shows a 46,XY karyotype, and genetic testing shows a mutation ofthe gene encoding Sa-reductase. inthe absence of this mutation, the apparent labia majora of this naborn would have developed into which of the following structures? A) Glans penis ) Penile shat ©) Penile urettra ) Prostatic utos ee eect ceeaeald ‘A 60-year-old man comes to the physician because of a 6-month history of fatigue. Four years ago, he had a subtotal gastrectomy after he sustained a {gunshot wound te the abdoman. Ha drinks sx to eight beers dally, Physical examination shows parasthesias of both hands. Laboratory stucias show Hemoglobin Hematoent ‘Mean corpuscular volume Leukocyte count Platelet count 165,000/mm: RBC folie acid 500 ngiml. (N=125-800) ‘Serum vitamin 8, (cobalamin) 10 pgimL (N= 160-195) The most ikely cause of his anemia is the absence of which ofthe following? A) Cardiac glands B) Chet cells ©) G (gastrin) cels, ee : ) Transcobalamin I ©Comprehensive Basle Sclnce Self Assessment ‘A 42-year-old woman comes to the physician because of a 3-year history of an Intermittent facial rash, Including the forehead, eyelids, nose, and cheeks. She says that the rash seems to be gating worse since she moved trom New York to Florida last year. She notes that she has always blushed sly, Spicy o0ds also precpltate a flushing reaction that seems to exacerbate the rash, Occasionally, het face bums and stings, and her skin f ary. Physical examination shows erythema ovar the nose anc cheeks, with scattered telanglectasias and a few panulls. Which of the following Is the most Ikely dlagnosis? A) Acne vulgaris B) Carcinoid syndrome C) Pityriasis rosea D) Rosacea E) Sebormheic dermatitis‘An 80-year-old man with type 2 diabetes metus is brought tothe physician because a 2-month history of severe constipation. Use of over-the-counter laxatives nas not relleved his symptoms. Abdominal examination shows distertion. Colonoscopy shows ne abnormal, This patent most ikely nas. cysfunetion of whieh of the folowing nerves? A) Hypegastre B) Inferior rectal ) Pelvie spl ) Perineal E) Sacral sympathetic © )‘A 38-year-old man is brought to the emergency department 30 minutes after being found near his home unable to stand upright. He appears lethargic. His pulse is 1 10/min, and blood pressure is 90/62 mm Hg vile supine. Physical examination shows cry mucous membranes and poor skin turgor. ‘Abdominal examination shows midepigastne tenderness. Laboratory studies show ‘Serum Nat 143 mEq/L Ke 32 meq ¢h 101 meq. Heo. ti megh ‘Acterial blood gas analysis on room a: pH 7.28 Peo, 23mm Hg Po, 98 mm Hg Which ofthe folowing isthe most likely current acid-base status inthis patient?” 8) Metabole akalosis ©} Mixed metabolic acidosis and metabolic alkalosis D) Mixed respiratory acidosis and metabolic alkalosis, ) Mixed respiratory acidosis and respiratory alkalosis F) Mixed respiratory akalosis and metabolic alkalos's G) Respiratory acidosis H) Respiratory alkalosis 0 GBA 30-year-old primigravid woman at 22 weeks’ gestation comes tothe physician because ofa t-day history of fever, chills, and muscle aches, Her ‘temperature is 39.4°C (10287), pulse Is 114/min, respirations are 15/min, and blood pressure Is 104/72 mm Hg. Physical examination shows a uterus consistent in size with @ 22-wesk gestation, Fetal heart sounds are heard, Her leukocyte count is 12,000%mm. Blood cultures grow gram-positive rods. Which of the following isthe most likely causal organism? A) Bacilus coreus B) Clostrisum perftingens ©) Stephylococeus aureus E) Streptococcus agalactiae (group 8) a ©‘A 75-year-old man comes to the physician because of a 2-year history of decreased force of his urinary stream and a need to urinate several time: throughout the night. His serum urea nitrogen (BUN) concentration is 65 mg/dL, and serum creatinine concentration is 5.0 mg/dL. Ultrasonography of the urinary tract shows bilateral hydronephrosis and llated ureter. Which ofthe folowing Is the most likely mechanism ofthis patient's renal fare? A) Decreased hydrostatic pressure n glomerular capilary 8) Decreased renal plasma flow ) Precipitation of proteins in the renal tubules Precipitation of ule acid in the renal tubules oO )Compreensiv Baie Science Saif Assesment ‘A 60-year-old man who emigrated from China tothe USA Is brought tothe physician because of a t-month history of progressive confusion and ‘swelling ofthe abdomen and legs. He has no history of major meaical lines. He vas a peanut farmer in China, He has smoked | pack of cigarettes dally fr 40 years; he does not drink alcohol, Physical examination shows mild ascites and ankle edema, The lver is palpable and rm at the right costal margin: the spleen isnot palpable, Serum studies show Albumin 4 g/dL Total lirubin 2.5 mgidl, Alkaline phosphatase 200 UL AST 45.Un ALT 60Un IgG entinepattisA vius positive Artishepatits B virus negative Antchepatis C virus negative Uitrasonography ofthe abdomen shows @ 10-cm hypodense lesion in the right lobe ofthe liver. A biopsy specimen of the lesion shows dysplastic hepatocytes in small clusters and rows three fo four cells in thickness. No normal architecture is seen within the lesion. Exposure to which ofthe tollowing best explains the liver blopsy findings in this patient? B) Hepatitis Avis C) Mercury D) Nicetine E) Ntrosamines Gy ra ° 3‘appears agitated. Her temperature Is 38.8°C (107.8°F). Laboratory studies show a leukocyte count of 14,000imnm?. She is admitted tothe hospital. Two hours later. the nurses note that she has torn up four breakfast menus because she found them to be too confusing. She Is highly educated, and her husband says that she does not behave this way at home, Which ofthe folowing isthe most Ikely cause ofthis patent's current mental status? A) Amnesia. ©) Dementia 1D) Mil cognitive impairment ) Occult cerebral infarction @‘A 48-year-old man comes tothe physician because of increasing bronzing of his skin, weakness, and fatigue during the past 3 months. Physical examination shows bronzing of he skin, hepetomegaly. and small tastes. Serum studies show Which ofthe folowing best expains the ndings int |A) Ferrochelatase deficiency 8) Increased erythropoietin production, ¢ ) Ineflectve enythropotesis, ) Transterin deficlency © ) AST ALT Iron Transterin saturation Ferrtin Testosterone Luteinizing hormone Follicle-stimulating hormone his pat Increased increased increased increased increased decreased‘A 16-year-old boy is brought tothe physician by his father because he has no signs of puberty. Sexual development is Tanner stage 2. Physical examination shows a circumelsed penls. The testas are soft and small wth a volume of § mL (N=20-30). The prostate is frm, nontender, and of ‘appropriate size. There are no lesions or discharge. His serum testosterone concentration is inthe prepubertal range. Measurement of which of the fallowing hormones in serum is most likely to determine whether the decreased serum testosterone concentration Is a result ofa lack of ptutary hormone stimulus in this paiant? A) Adrenocoricetropie hormone B) Estrogen ) Folicle-stimulating hormone D) Inhioin E) 0 C3Deane eet ete 21-year-old man comes to the emergency department because of excruciating anal pain for the past 4 hours. Examination shows a 18-mm, blue- tinged, rounded mass at the anal margin, This mass mast likely represents a thrombosis in a tributary of which of the following blood vessels? A) Inferior rectal arty 2 ) Midle rectal artery D) Middle rectal vain ) Superior rectal artery F) Superior rectal vein oO ® ZZA female newborn delivered at 36 weeks gestation isin respiratory distress. Apgar scores are 3 and 5 at 1 and 5 minutes, respectively. Physical examination shows cyanosis. Endotracheal and nasogastic tubes are placed. The x-ray shown depicts the nasogas tube in the left hemthorax. displacement ofthe mediastinum tothe right. and absence of Dowel gas in the abdomen. This condition most IKely results from which ofthe following embryologie events? A) Failure of epimere to migrate 8) Fallure of hypomere to migrate C)Hypoplasia ofthe lungs. D E) Mairotation of bowel o BY‘A 36-year-old man comes tothe physician for evaluation of recurrent episodes of sinusitis and bronchitis throughout his enti if. One of his sistars has, 8 similar Fistor of chronic upper respiratory problems. He Is marred But has no children, Cardiac examination shows point of maximum Impulse atthe ‘ourth intercostal space vithin the miclavicular ine onthe right. The hepatic margin is palpable on the lef. Endoscopy shows nasal polyps onthe left middle and inferior turbinates. Examination of issue obtained on biopsies ofthe polyp and adjacent mucosa shows thickened, cliated, pseucostratiied epithelium with small patches of squamous metaplasia and mild lymehovdinftration. Which of the electron microscople examination of the biopsy specimen of the epthellum? ovng structures is most likely to be absent on A) Actin laments B) Basal bodies ©) Basel lamina ) Desmosomes (maculae adherentes) F) Gap junctions G) Lysosomes H) Microtubules 1) Nuclear pores ®‘A 88-year-old woman comes tothe physician because of the gradual onset of ack of muscle month ago afer she was diagnosed with breast cancer that has metastasized to other ragions of her body. Physical examination shows 3, huscle strength, deep tencion reflexes, sensation, and proprioception are normal. The most ikely explanation for this left upper and lower extrem Patient's condition Is a metastatic tumor in which ofthe following lacations onthe left? B) Carabrum ©) Cervical spinal cord 1) Lumbar spinal cord ) Thoracte spinal cord 0 ron her lft arm and leg. Her symptoms began C3 ia ofthe‘Ten years after a total gastrectomy, a 60-year-old man hes ditfeuty walking, Mentation ane eranial nerve funetion are normal. He has ite spasticity In his arms and legs, markedly impaired proprioception In his fet, increased muscle stetch reflexes in his arms and knees, absence of muscle stretch reflexes inthe ankles, and bilateral extensor piantar responses. The most likely cause is deficiency of which ofthe following vitamins? AJA 8) B, (thiamine) ©), (pyridoxine 6 E) Biotin F)C SE 4) 1) Retinol‘A a2.year-ld farmer has a T-mm red scaly plaque onthe helical rim ofthe lft ear. A photomicrograph of tissue obtained o fallowing is the most Ikely diagnosis? 5) Basal cell carcinoma ) Keratoacantnoma D) Malignant melanoma ) Merkel cell carcinoma 7 jopsy ofthe plaque is shown. Which ofthe (345-year-old woman who isa farmer Is brought tt by her husband because of a 2-day history of confusion, lethargy, fever, headache, muscle pain, vomiting, and a rash on her wrists and ankles. Her husband tells the physician that she was bitten by a tick afew days ago. Her temperature is 38.6°C (101.5°F). Examination shows mutple red-purple papules on the distal extremities that progress to her trunk within several hours. The most appropriate treatment includes administration of which of he fllowing drugs? A) Ciprofioxacin B) Dapsone F) Streptomycin 6G) Sulfadiazine H) Sulfasalazine G ay-old wornan has left flank pain and gross hematuria. A mass Is palpable in the left upper quatirant ofthe abdomen. Abdominal Ulvasenogrephy shows 12-cm solic mass onthe lover pola of the left kichay. Anglograms show a hypervascular mass \Which ofthe following isthe ikely agnosis? ‘A) Nephrablastoma (Wms tumor) 8) Papllarytranstional.cellcarcinoma ) Renal cal acenoma ) Squamous cel earcinoma o J a‘A.47-year-old woman with psoriasis comes tothe physician for folow-up care, At her last appointment she was glven several topical 1sed In a specifies sequence twice daly, No improvemertis apparent at this appointment. Vit physllan to bagin the discussion ofthis patent's compliance with therapy? foams, which must ofthe folowing Is the most appropriate way for the ‘A)"Did you use the ereams twice dally?" 8) "How many tubes did you use inthe last month?" ) "How often did you skip treatments?” D) ) "Using something twies dally can be dfficut. | assume you are ike most patients who miss at least 10% of treatments: Oa) GA 22,yaarold man comas tothe physielan bacause of a G-menth history of law back paln and sttinas, luring the day; the pain radiates to his buttocks but not dav his legs. He also develops back stifinessifhe sits for protonged periods. Physical examination shows that the patient Is unable to bend forward completely. Which ofthe following is most likely to confirm the diagnosis? a) 8) ¢) 7 Measurement of erythrocyte sedimentation rate Serum antnelear antibody assay DEXA sean Electromyography of the lower extremities CG ich are worse in the meming and impcoveeects use of a 2-day history of ringing of his ears, nausea, and fatigue. His temperature is 37°C (88.6°F), pulse is 100/min, respirations are 24/min, and blood pressure is 140/85 mm Hg, Physical examination shows mid epigastric tenderness. ‘Ariaral blood gas analysis on room air shows: pH 742 Peo; 30mm Ha Po, 88 mm Hg HCO. 19 mEq Which ofthe folowing isthe most kal use ofthis patient's condition? 4) Intracerdiae shunt B) Obstructive sleep apnes ) Pulmonary embolism 9 E) Severe kyphosis ry 7[protein found in the brown adipose tissue of mice causes a leak of Hons Inward across the inner mitechoneral membrane. Which ofthe fo the most Ikely effect ofthis protein on oxidative phosphorylation and energy metabolism? |A) Decreased rato of oxygen consumption to ATP generation B) Decreased ratio of oxygen consumption to CO. production q raased ratio of oxygen consumption to CO, produetion E) No change in the ratos of oxygen consumption to ATP generation and oxygen consumption to CO. production ar) B jowing ts‘A 40-year-old woman comes to the physiclan because of a 1-year history of episodes of cramoy abdominal pan, intermittent dlarthea, and rectal bleeding with passage of mucus. Sha is 173 em (6 f& In tall and weighs 85 kg (120 lo) BMI 18 kgim?. Abdominal examination shows difuse tendemess with no rebouns tenderness, Sigmoldoscopy shows a few difuse ulcers, Which of tne folowing isthe most appropriate intial pharmacotherapy fortis patient? A) Amoxillin B) Bismuth subsalieyite ©) Loperamide D) Octreotide e oa) Acenters typical squamous cells of Y-0ld woman comes to the physician fora follow-up examination aftr two separate Pap smears showed Undetermined signifcance. Results of a molecular clagnostic test show the presence of the vital ES protein of human papillomavirus. This protein is 1 to promote call growth and malignancy by causing cellular p83 protein degradation. This degradation most lkaly begins wen the pS proteln Is ke targeted to which of he following types of cellular enzymes? A) Lysine acetytransterase B) Lysosomal protease C) Serine protease D) Tyrosine kinase @ i‘A27-year-ola woman comes tothe physician because of vaginal bleeding for 3 weeks. Her frst pregnancy ended witha spontaneous abortion months ago. She has not been able to afford medical treatment since undergoing diatation anc curettage at that time. Physical examination shows an Glarged uterus, Her serum B-human chorionic gonadotropin concentration is markedly increased. Ultrasonography of the pelvis shows material within the endometrial cavity and no intrauterine pregnancy. A CT scan shows a necrotic intrauterine mass and metastatic nodules In the lungs. Which of the following is the most Ikaly st of origin ofthis patient's concition? A) Allantois B) Blastocyst C) Decidua basalis ) Decicua capsuiaris oOeed Pere eee ‘A dsyearold boy s brought tothe physelan by his parents because he has had two bacterial urinary tract infections during the past year. Physical examination shows no abnormalities. Radiologie stucies of the urinary tract show marked dilation ofthe lef ureter fad renal pelvis, and minimal left-side ren function. & left napiractomy fs parformad. A photograph ofthe resected specimen is shown. Which ofthe following isthe most Ikely cause ofthe renal disease in this patient? ‘A) Adrenal cortical hyperplasia ) Nephrobiastoma (Wms tumor) ) Systemic upus erythematosus aA42-year-ld man comes tothe emergency department because of a 10-day history of progressive fever, shortness of breath, and nonproductive cough. He also has had a 20-kg (44-Ib) weightloss during the past 2 years. He immigrated to the USA from the Ivory Coast 4 years ago. His temperature is 38°C (100.4°F), and respirations are 32/min, The lungs are clear to auscuttation, A chest xray shows a cftuse Inerstal in trate, A silver stain ofa specimen obtained via bronchoscopy shows Preumocystsjrovec former P. carni) Treatment with high-dose prednisone and ‘timethoprim-sulfamethoxazole is itiated, and workup for HIV infection is done, Resuts shovr HIVELISA, positive HIV Westem blot Positive CD4+ Taymphoeyte count _22/mm? N>600) Plasma HIV-1 vialload —<50.copiesimL Which ofthe following best explain these laboratory results? A) Infection with HIVe2 ) Infection wth human T.iymphotrophic virus (HTLV) 1 c ) Infection with simian immunodeficiency virus E) Lack of infection with any HIV strain @‘A S8.year-old man undergoes a total thyroidectomy and central ymph node dissection fora 4-cmfolicular carcinoma of the thyroid. Twelve hours ater the procedure, he has paresthesias of his hands and feet. Vital signs are stable, but carpal spasms noted on inflation ofthe blood pressure cuff. Which ofthe following sets of laboratory findings in serum is most Ikely inthis patient? com> ra Parathyroid Hormone 1 1 Norma 1 Caletum © a‘A.62.year-old man comes tothe physician because ofa 3-month history of cffculy sleeping. He incicates that he sleeps better ithe sits upright in bed His pulse is 20/min, and blood pressure is 110/60 mm Hg, Physical examination shows increased jugular venous pressure and mi ankle edema Which ofthe following isthe most Ikely cause ofthe edema inthis patient? |A) Decreased capillary hydrostatic pressure 8B) Decreased capilary permeability CC) Decreased plasma colloid osmetie pressure 2 E) Increased capilary permeabilty F) Increased plasma coloid osmotic pressure e )‘A 13-year-old git has a grade 2/6, holosystalle murmur that Is heard best over the lef ith intercostal space adjacent to the sternum: it increases with Inspiration, This murmur Is most consistent with an abnormality of which ofthe folowing valves? A) Aottic 8) Mia Pulmonary D © ®‘A 24-year-old man comes to the physician because of a 2-day history of an icy rash on his arms anc! legs. He returned from a camping trip inthe woods § days ago. Examination of the upper and lower extremities shows a widespread edematous, erythematous rash with linear vesicles. The most lkaly cause of hase findings is activation of which of the following cell types? A)B lymphocytes B) Mast cells C) Natural ker cells D) Neutrophils @‘A naworn delivered at 38 weeks! gestation weighs 1800 g (4 Ib). Physical examination shows a petechial rash, mleroeaphaly, and hepatosplenomegaly. Results of serologic testing for cytomegalovirus antioodies are sho: Mother Newborn Cytomegalovins IgG + + Gytomegalovinus IgM = + \Which ofthe following is the most likely explanation fr the serologic findings inthis newtomn? A) Active transfer ot matetn EH ©) False-negative maternal serology ) False-positive neonatal serology E) Passive transfer of matemal cytomegalovus IgG and IgM antibodies mityto cytomegalovirus >‘A 10-year-old git Is brought tothe physlelan by her mather for a welkchié examination. She has not yat had a menstrual period. She Isat the Sh percentile for height and weight. Physical examination shows absence of breast bud development and no pubic or axillary hair. The mother asks how she will know when her daughter begins puberty, Itis most appropriate forthe physician to tell the mother that the fist objective sign of puberty will bbe whieh ofthe fllowing? a B) Development of axlary har (©) Development of pubic hair 1D) Onset of menses ) Rapialy increasing height a ° @Comprehensive Basle Sclnce Self Assessment /A28-year-old woman at 18 weeks’ gestation has palpitations. Laboratory studies show an increased serum total thyroxine (T,) concentration, Which of the following tests is best to confirm a diagnosis of hyperthyroidism inthis patient? a) 8 C) Radioactive iodine uptake ) Serum total tladathyronine (T:) E) Thyroid antibodies, 1e-needle aspiration biopsy ofthe tyroid gland oOCe eeclertieieiscn Reem aera ‘Three days after unprotected sex with a naw partner, asexually active 244yeer-old man noticed the development of small tender blisters on his penis, Some ofthe blisters broke {and lef open sores. He does not use condoms. A photograph ofthe lesions is shown. Which ofthe fellowing is the most Ikely causal agent? ‘A) Calymmatobacterium granulomatis 8) Chiamyata trachomat o 9 re 7 a) °eect Ten heathy human subjects are given @ new oral drug anc monitored for drug effect and toxicity. Blood samples are periodically taken and analyzed to define the human pharmacokinetics ofthe crug forthe fist ime. Which af the folowing best describes this tial? A) Precinical testing 5 C) Phase 2 D) Phase 3 E) Phase 4Caan eet ca ‘A 60-year-old man comes to the physician for an examination prior to employment. Physical examination shows no abnormalities. Laboratory studies sho Hemaglobin 14g Hematocrit 12% Leukocyte count 12,000%mm ‘Segmented neutrophils 48% Smallymphocytes 50% Monocytes 5% Platelet count 250,000imm Flow cytometry analyss of peripheral lymphocytes shows the following phenatype: cos 50% cot 40% cpa 10% p20 50% Surface kappa 47% Surface lambda 3% ‘Which ofthe following is most predictive ofa clonal lymphoid proliferation in this patient? |A) Absolute CD3+ T-lymphocyte count B) Absolute CD20+ B-lymphocyte count C) Absolute lymphocyte count 1) CD4:CD8 ratioegg. goataanagt cagggcagag coatctattg cttACATFIG CTICTGACAC 121 RAGTGIGTTE AGTAGCAACE TCARACAGAC ACCATGGTGC ACCTORCTCC. TONGGAGAAG Lei Teneccerta craccctors Goacaacats AACOTGGATG AAGTIGoTES TaRGGCCCTS TooTGGTCTA CCCTTEGACC 421 TEGGGATCTG TCCACTCCTS AIGCTOTIAT GOCAACCCT 401 GAAAGTOCTC GOTGCCTTTA GTGATGGCCT GGCTCACCTS S41 TOCCACACTG AGTGAGCTGC ACIGTGACAA GCIGCACGTG ‘Tha sequence surrounding the first to exons ofthe human f-globin gane is shown, withthe exons givan In bold capital lttars. The transition start codon is underlined, A mutation fram GA at position 355 (bold italics) is most likely to lead to B-!nalassemia by which ofthe following mechanisms? A) Greation ofa missense mutation that ead to he synthesis ota defective p-plobin 8 C) Disruption of polyadenylation of the mRNA ) Inhibition ofthe replication ofthis gene raMark ‘A 26-year-old woman comes tothe physician 5 weeks aftr the bith of her fst child, She worries constantly thatthe infantil and wakes him 40 to 14 times every night to make sure ha Is well. She has had ne erying spall or problems with appetite, She is worried that she wil infect the infant with her germs and washes her ovn hands 30 times per day. For 2 months prior tothe delivery, she worried about people breaking into her house and checked the lock on the front door three to four tines every right, She isnot breast-teeding. Which of the following Is the most appropriate pharmacotherapy? A) Alprazolam 8) Haloperidol ©) Lithium carbonate ) Methylphenidate PhensizineA female newoom Is delivered at 38 weeks! gestation. Apgar stores are 8 and 8 at 1 and 5 minutes, respectively. Physical examination shows a buiging,flc-filed mass approximately § cm in ameter ih the midline over the lumbosacral region. There are no spontaneous movements of the lower extremities. This abnormality most ikely occurred because of abnormal emoryonic development during whieh ofthe following periods postconception (indays)? aga e ©) 601075 D) 100 to 12 E) 1800 180 @eed ‘A 62-year-old man develops a pericardial ction rub 3 days after an acute myocarcial infarction. Which of the following is the most kely cause of the ‘ction rub? A) Cardiac tamponade 5 ) Ler ventrouler failure D) Mitral valve prolapse ) Purulent pericardial eftusion oO ra eeet eked ‘A 35-year-old woman has an abnormal Pap smear, Examination of tissue obtained on cervical biopsy shows mieroinvasive cervical carcinoma, Which ofthe folowing miroscople featuras lad to tis agnosis? 'A) Ful thickness ofthe epithelium cecupied by neoplastic ces Mere than haf of thevenithelium oecupled by neaplastie ca e . 1) Neoplastic cells invading blood vessels ) Neoplastic cali invading nerves‘A 30-year-old woman who Is at 20 weeks’ gestation comes tothe physician fora scheduled examination, Her pregnancy has been uncomplicated, and her cue cate was established by ultrasonography at 10 weeks! gestation. Fundal height is greater than expected for gestational age. Utrasonography shows markedly increased amniotic fuid volume, Which of he following abnormalities isthe most Ikely cause of these findings? A) Clef tip B) Encephalocele CC) Renal agenesis ) Urethral obstruction @A previously heathy 3-year-ld boy is clagnosed with bacterial colts caused by Salmonella enterica serovar erizonae. Which of the following factors best accounts forthe recruitment of neutrophils to the inflammatory ste by intestinal epithelial cells in this patent? A) Granulozyte colony: B) Histamine ¢ ) Leukocyte function-associated antigen E) Tolttke receptor-3 imulating factor oOComprehensive Gasic Science SelAssessment A TO-year-old man is admited tothe hospital or evaluation of the recent loss of mental function, He has a history of weight loss. He Is nt taking any rugs. Vital signs are normal, and he isnot dehydratad. Asie trom mid disonantation, findings on neurologle examination ara unremarkable. He has mild anemia, Laboratory studies show ‘Serum Na 110 mEq. cr 85 mEq - 44 megiaL Urea nitrogen (BUN) 18 mgiaL Creatinine 0.9 magia Plasma osmolality 250 mOsmevikg Unine osmolality 750 mOsmavig Which ofthe folowing Is the most katy dlagnosts? 'A) Adrenal carcinoma 8) Chronic interstial nephritis ©) Diabetes melitus 1D) Pneumococcal meningitis E oO ry © ©‘A 24-year-old man with a history of intravenous drug use Is brought to the emergency depart aroused. The frend reports that the patient injected himself vith a drug approximately 6 hours ago. Laboratory studies show a serum drug concentration of 0.30 mg/L. Assuming the crug exhibits first-order one-compartment kinetics, has a hatfife of 2 hours, and a volume of distribution of 200 L inthis patient, 4) 300 8 )600 ) 1000 =) 1250 oO hich of the following Is the most Ikely approximate quantity ofthe drug (in mg) injected? by his roommate 30 minutes after he could not be ©‘An examination is scaled so that the scores are approximately normally distributed vith a mean of 600 and a standard deviation of 100. Which of the following is the percentage of examinees with scores between 400 and 600? A) 16% 5) 50% c D) 20% GQ a‘A62-year-old woman with recurrent pulmonary emboll comes tothe physician fora follow-up examination, Physical examination shows no abnormalities. Laboratory stusias show a prothrombin time of 12 seconds, Warfarin therapy Is bagun.\hich of lecreased by 60% after the Intition of therapy? A) (proaccelern) 8) Vil (proconvertin c 1) X! (plasma thromboplastin antecedent) ) xil (Hageman factor) rs @ folowing eloting factors Is the frst to‘A 32-year-old woman, gravida 2, para 1, at 7 weeks! gestation comes to the emergency department because of vaginal bleeding for 3 days and Increasingly severe let abominal pin for 18 hours. Abdominal examination shows severe direct and rebound tendemess with guarding inthe ef lower quacrant. The cervical os Is closed. Her serum f-RCG concentration Is 6000 miU/mL. Ultrasonography shows an empty uterus. Which ofthe following is the most ikely clagnosis? ‘A) Abrupto placentas (C) Hydatiform mole ) Incomplete abortion E) Placenta previa F) Preterm labor G) Threatened abortion H) Vasa previa ryce eaters ‘A 14syear-old boy is brought to the emergency department 1 hour after collcing with a teammate while playing soccer. Physical examination shows edematous tissues ofthe left eye and mild depression of the left zygomatic bone. The skin between the left eye and the upper lip is um. He has louble vision whan asked to look upward. Damage to which ofthe following nervas is the most Ikely cause of tha sansory loss? ‘A) Buccal branch of he facial nerve 8) Lingual branch of the glossopharyngeal nerve C) Mandibular branch ot het 2) ) Ophthalmic division of the trigeminal nerve 0 ° Gi ©‘A 28-year-old woman comes to the physician because ofa 5-veek history of fatigue and a 4-day history of heart palptations and anxiety. She has primary hypothyroidism treated wth triedethyronine. She says that she has doubled the dose of the medication over the past weak because of fatigue. Her pulse is 11min, and blood pressure is 126/70 mm Hg. Physical examination shows a fre motor tremor of the hands, Deep tendon reflexes are brisk. Thyroid function testing Is most ikely to show which of the following sets of serum concentrations? Thyrold-stimulating _Free Froo Hormone Thyroxine Trlodothyronine 4 Increased increased increased 8) Increased increased decreased °) Increases decreased Increased D) Decreased Increased Increased 5 Increased decreased f (the bleesing A previously healthy 48-year-old nuligravid woman comes tothe physician because of excessive uterine bleeding for 3 months. She sa occurs both during her menses and at regular infavals. Menses had occurred at regular 26-10 38-day intervals. She Is 165 cm (8 5 in) ‘all and ‘weighs 72 kg (160 Ib); BMI is 27 kgm. During pelvic examination the adnexae are ronpalpable. Endometrial curettage shows abundant tissue. Which ofthe following isthe most Ikely cause ofthis patient's symptoms? AA) Adenomyosis. 8) CC) Endometrial metaplasia ) Endometriosis E) Endometrts @ ©‘A 36-year-old man wino uses crack cocaine dally comes to the emergency department because of a 2-hour history of substernal chest pain. He last used cocaine 6 hours ago, His temperature Is 37°C (38 6°F), pulse is 110/min, respirations are 14/min, and blood pressure Is 160/100 mm Hg, Which ofthe following Is the most appropriate next step in patient care? AA) Admit the patiant tothe hospital for cocaine detoxification B) z CC) Educate the pationt about the risks of cocaine use and send the patient home: ) Transfar the patient to a psychiatric taclty Y )‘A 32-year-old man comes tothe physician because of a 3-month history of sweling and tenderness of both breasts. He has been receiving thyrold hhormene and corlcosterold replacement tharapy since undergoing surgical removal ofa piutary adenoma 2 years ago. He bagan human chorionic {gonadotropin (nCG) injections 4 months ago. Which of the following is the most likely binding site and action of hCG that is causing the development of gynecomastia inthis patient? Tissue Effect A) Adrenal gland 17-hycroxyprogesterone synthesis 8) Breast rect stimulation ° Liver iestosterone metabolism D) Pituitary gland prolactin secretion oOee ‘A 64-year-old man is brought to the emergency department 3 hours after he developed shortness of breath with exertion and extreme fatigue. He has Ischemic haart dlsease. His pulse ls 125/min and iregular. and blood pressure Is 105/60 mm Hg. An ECG shows abalforlation. Intravenous ible Is acministerea, Ten minutes later, an ECG shows a normal sinus rythm, This patient at grestest risk for which ofthe folowing adverse drug eects luring the next 6 heurs? A) Atrioventricular block B) Avioventricular nodal CC) Sinus arrast ) Sinus tachycardia E 0 3} Za‘A 80-year-old man comes tothe physician because of a persistent cough forthe past 2 months. He has had a 6-kg(1t-b) weightloss during this peri. He is @ farmer and started itraconazole therapy 4 waeks ago for histoplasmosis acquired afer contact vith chicken coops, Current medications also Include hydrecnlorotniazige, enalapril, atenolal, omeprazole, and metoclopramide for hypertension and gastroesophageal refux. He appears thin Physical examination shows no ether abnormalities. An interaction between Itraconazole and which ofthe folowing drugs most Ikely accounts for the lack of effect of traconazole? A) Atenciol ) Enalapril ©) Hydrochiorethiazide ) Matoclopramide E‘A 34.year-old patient with AIDS develops pulmonary tuberculosis. No CD4+ T lymphocytes are detected in his peripheral blood. Which of the following celular components is mos ely to have deficient funcicn in he tuberculous lesions in this patient's kings? A) Eosinophils B) Fibroblasts ) Langhans giant cells ) Neutrophils ra ° ® a‘A AB-year-old man comes tothe physician because of yellow skin for 4 day 's. He lost his job 10 days ago. and he has been drinking eight to ten 12- ns of beer dally since then. Physical examination shows Jaundice, The liver is tender to palpation. Serum stucles show Total birubin 5.9 mola, Alkaline phosphatase 210 UL ast foun ALT B9un y-Slutamytransterase 38 (N Histologle examination of a Iver biopsy specimen wl me ikely shaw Wich ofthe following In ths patient? A) a,-Anttrypsin globules B) Glycogen C) Hemosiderin ) Lipofuscin, E)M‘A 28-year-old woman is brought tothe physician because of a -week history of double vision. One year ago, she had an episode of blury vision in her le eye that gradually Improved during the next 2 months wthout treatment, Neurologic examination shows thatthe right eye does not adduct ast the midline on horizontal gaze when lookhng to the let. When convergence Is tested, the right eye is able to adduct past the miline. Rightward horizontal gaze Is normal. Tis patient most likely has a lesion involving vhich of the folowing labaled structures In the photograph of the brain stam shown? G aeaters ‘An 18-month-old git is broughtto the physician fora follow-up examination, Separation ofthe umbilical cord was delayed after bith, She has had four severe skin infections caused by Staphylococcus aureus since birth; there has been ne pus formation atthe infection stes. Previous laboratory studies have showin persistent leukocytosis n ha absence of infection, Physical examination shows edematous, erythematous gums. Which ofthe faliowing mechanisms is most likely impaired inthis patient? A) Abilty to generate reactive oxygen species B) Activation of T lymphocytes to alloantigens and mitogens CC) Conversion of hydrogen peroxide to hypochiorous acid ) Generation of terminal membrane attack complex. GS ©‘A65-year-old woman comes tothe physician because of Infections has bean ineffactive. Examination shows atrophy of the labla minora and thin, perch ofthe following is the most Ikely diagnosis? ‘A) Candll infection E) Human papillomavirus infection ) Trichomoniasis, ) Urethral prolapse o ) ressive vulvar Itching over the past 2 months: treatment wth miconazole for yeast ke skin over the vulva and around the anus. Which‘A 34-year-old woman wth pyelonephritis has been treated with a bax Inhiots binalng te the 30S nbosoma, thereby blocking pratain synt ‘which of the following? A) Amoxielin B) Ciprotioxacin ©) Erythromycin E) Sufamethoxazole ial antibiote for 4 days ith no improvement in her condition. An antbioti that ularly, is added to her mecieation regimen. This antisctc Is most likely Caeaters ‘A 45-year-old woman comes to the physician fora follow-up examination 8 weeks after beginning tamoxifen therapy for estrogen- and progesterone- positive Invasive ductal carcinoma ofthe breast. Her 80-year-old sister also has hormone-sensitve breast cancer treated with tamoxifen. Physical examination shows no abnormalities. Serum studies show, decreased concentrations of endoxifen, the active metabolite ofthe prodrug tamoxifen, Genetic analysis shows the homozygous presence of cytochrome P450 206"4 alleles, Which of the following best represents the lkslinood that this patient's sister has the same alleles? A) 0% ©) 50% 2) 75% ) 100% GS ©‘A 2-manth-old by is given a vaccine that has been manufactured to convert T-ndependlent antigens to T-dependent forms to enhance protection in young chikiren, Which ofthe folowing vaccines has been given? ‘A) Diphtheria C) Measies ) Oral patio E) Tetanus 6 ©A 10-year-old boy has had anemia since bith, His spleen Is five times normal size, Splenectomy is incicated ifthe anemia is caused by which of the following disorders? ‘A) Fanconi anemia 8B) Glucose 6-phosphate dehydrogenase deficiency c D) Sickle cell aisease E) Thalassemia major‘An 80-year-old woman comes to the emergency department because of a 2-day history of “ealing funny." She says, "I have lost my pep." She has ever been admit tothe hospital, but she has a histor of poorly controlled hypertension, She just stared a medication 2 weeks ago but does not Fecal the name. Her blood pressure s 130/85 mm Hg. Physical examination shows no abnormalities. Her serum potassium concentration is 3 mEqiL Which ofthe folowing drugs isthe most Ikely cause ofthis patient's conciton? > Clonidine Lisinopril Metoprolol ‘Tramterene 3) e) oO ° 3} Za‘A ab.year-old African American weman comes to the physician bacause of a 2-waek history of fever, malaise, and dyspnes. Her temperature Is 36.7°C (98°F), and respirations are 20imin. Physical examination shows erythema nodosum, parctid enlargement, and hepaiosplenomegaly. Her serum calcium concentration s 18 mgial. A CT scan of the chest shows bilateral ilar adenopathy. Serum stusles are mast likely to show an increased concentration of, nich of the following? A) Calettonin B) Cholecaleltero °) Y ) 24.25-Dinydroxyeholecaleifaral ) Parathyroid hormone ® ©‘A 63-year-old man comes tothe physiclan because of a §-month history of exertional chest pain thats relieved by rest. He has smoked 1 pack of Cigarettes dally for 45 years, He nas mild hypertansion, but he takes no medications, Which of the flowing types cf lesions inthe lef antrior ‘descending coronary artery isthe most Ikely cause of his concition? ai . B) Embolsm from the left atrium C) Fresh thrombus on a £0%% stenosis ) Ruptured plaque overying @ 20% stenosis E) Vasospastic 100% occlusion a ©‘A 86-year-old man Is admitted tothe hospital fr treatment of sepsis. He appears anxious and confused, Treatment with vancomycin and ceftriaxone was inflated in the emergency department. His temperature ls 38.8°C (103.6°F), pulse is 132min, respirations are 2&/min, and blood pressure is 85/48 mm Hg, Physical examination shows warm, fushed skin that is moist with diaphoresis. There is no edema, Itis most appropriate to administer which ofthe folowing solutions a this time? |A) 8% Dextrose in water and 0.45% saline 8B) 5% Dextrose in water only ) 0.45% Saline only D) E)3% Saline oO ©‘A T9.year-old man Is brought to the emergency department by his wife 30 minutes after he lost consciousness for 30 seconds. On arrival, he is alert but he says that he is dizzy. There Is no urinary or fecal incontinence. His pulse Is 40/min and regular, and blood pressure Is 92/86 mm Hg. Physical ‘examination shows ne evidence of tongue bting. The lungs are clear to auscultation, Cardiac examination shove a variable intensity S, He is oriented to person, place, and te. An ECG shows a third-degree atrioventricular block. Which of the following Is the most appropriate nest step In management? 'A) Transesophageal echocardiography 8) Transthoracic echocardiography C) Insertion of pulmonary artery catheter >) ) Cardiac catheterzation with angioplasty F) Cardiac catheterization vith stent placement 0 Gi ieee ‘A.8-year-old man comes to the physician because of G-manth history of erectile dysfunction. Physical examination and laboratory evaluation sho ‘no abnormalities. If pharmacctherapy is Inccated, the most appropriate is a drug with which ofthe folowing mechanisms of action?’ A) Blockade of a-adrenergic receptors B) Increased actity of Sa-reductase C)Inhibtion of rite oxide retea 3) E) Stimulation off adrenergic receptorsfeeeetehe ree ores er es ‘A 20.year-old woman has ptosis, ephthalmeplagla, and lplopla. Examination of serum shows an autoantibody wit afity forthe acetylcholine receptor atthe postsynaptic neuromuscular junction. This patient is most lkely to have which of the following neoplasms? A) Glioma B) Muttiple myeloma C) Neuroblastoma 1) Rhabdomyosarcomayear-old boy comes to the physician because ofan &-kg (18-lb) weight gan during the past year. He has not had any major medical liness, He ays that he does not eat excessively and has a moderate level of activity, including playing got. His fath 178 cm (5 ft 10 in) tall and weighs 102 kg (226 Ib); BMI is 32 kgm When ‘hat my weight gain is inherited from my father?" Which of the folowing id paternal unc are all overveight. He Is © physician finishes examining the patient, the patient asks, "Do you think ‘most appropriate intial response by the physician? ‘A) "No, ifs because youre eating the wrong kinds of food, 88) "No, lets examine your environment more closely. as your paternal history s only incidental to your weight gain. "No. unfortunately its because you're eating too much" ) "Yes, your patemal family history Is the major contributing factor to your weight gain * aeect |A 57-year-old man with alcoholism has a cistended!abxiomen with shifting duliness ancl a Mud w spider angiomata. Which ofthe felowing is the most Ikely addtional finding? ve. He has caput medusae, palmar erythema, and A) Dial clubbing 8) Enlarged inguinal ymph nodes ) Flame-shaped retinal hemorrhages 3) ) Jugular venous astention Gi i‘A 80-year-old man comes tothe emergency depariment because of the susden onset of acute abdominal pain and tendemess, nausea, vomiting, and bloody dlarthea 2 hours ago. He has a history of cirrhosis and hepatocellular carcinoma, His blood pressure Is 89/60 mm Hg, His abdominal wall becomes tigi, with the loss of bowel sounds. During surgi! intevartion, half ofthe small infesting Is found to have a dark purple-red hemorrhage appearance. Which ofthe folowing is the most kely cause? A) Gacteral enters CC) Necratizing enterocolitis D) Peeudomembranous colts E) Ulcerative coltis F) Whipple cisease G 5