Professional Documents
Culture Documents
NBME 22 Offline (MedicalBooksVN)
NBME 22 Offline (MedicalBooksVN)
A 49-year-old man comes to the physician because of increasingly severe pain in his left hip during the past
2 months. He was recently discharged from a rehabilitation facility for treatment of alcoholism. He says , "The pain
gets so bad at times that it even hurts my golf game. " He has pain with weight bearing. Physical examination shows
limited active and passive range of motion of the left hip . Hip x-rays show no abnormalities A coronal Trweighted
MRI is shown. Which of the following is the most likely cause of this patient's pain?
A) Avascular necrosis
B) Hyperparathyroidism
C) Osteitis deformans
D) Septic arthritis
E) Tuberculous osteomyelitis
A 16-year -old girl has pain and tingling in her left hand when she goes backpacking. The symptoms resolve 5 minutes after she takes off her backpack. Which of the following
abnormalities is the most likely cause?
This patient has most likely been abusing which of the following substances?
A) Alcohol
B) Amphetamines
C) Diuretics
D) Laxatives
E) Thyroid hormone
A 67-year - old woman comes to the physician because of a 1-year history of a nonproductive cough and progressive shortness of breath with exertion. She has not had fever or any
other symptoms. She has no history of serious illness and takes no medications. She does not smoke. Vital signs are within normal limits. Pulse oximetry on room air shows an
oxygen saturation of 92%. Fine, dry crackles are heard at both lung bases. Physical examination shows clubbing of the hands. There is no peripheral edema. A chest x-ray shows
fine linear opacities in the lower third of the lungs bilaterally. A CT scan of the chest shows bibasilar interstitial reticulonodular markings with interlobular septal thickening
Pulmonary function tests show a normal FEVt an FVC of 48% of predicted, and diffusion capacity of the lung for carbon monoxide of 55% of predicted . Which of the following is the
most likely diagnosis?
A) Hypercalcemia
B) Hyperuricemia
C) Hypokalemia
D) Hyponatremia
E) Hypophosphatemia
A 12-year - old girl is referred to the emergency department by her physician because she has been unable to walk for 5 days. Her parents appear very anxious , but she seems
unconcerned about her symptoms . Her temperature is 37 0°C (98.6°F), pulse is 70/min, and blood pressure is 115/70 mm Hg . Deep tendon reflexes in the lower extremities are
equal bilaterally. Sensation to pain and to light touch is variable. Which of the following is the most likely diagnosis?
A) "Don't worry. I will be there for you and make sure everything turns out the way you want."
B) "Eating right and exercising will not help prevent cancer."
C) "In fact , as you probably know, the major risk for lung cancer is smoking . "
D) "It must be difficult for you to accept this diagnosis when you feel healthy."
E) "Regardless of your good habits, it's time to realize that you have lung cancer."
B, C, D , and
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A 49-year-old man has had the gradual onset of numbness and pain of the left index finger over the past 3 weeks Pulses are full and equal bilaterally The left index finger is
mottled blue and pale. Laboratory studies show :
Hemoglobin 14.5 g/dL
Hematocrit 41.7%
Erythrocyte count 4.6 million/mm 3
Leukocyte count 8500/ mm 3
Neutrophils 74%
Eosinophils 4%
Lymphocytes 20%
Monocytes 2%
Mean corpuscular volume 89 pm 3
Platelet count 1, 530,000/mm 3
Examination of bone marrow shows normal cellularity, normal iron stores, and megakaryocytic hyperplasia Which of the following is the most likely diagnosis?
6
that their child will be affected with oculocutaneous albinism?
i A) 1 in 4
B) 1 in 100
C) 1 in 200 * *
D) 1 in 600
E) 1 in 40, 000
A 65-year - old man starts using topical fluorouracil for treatment of actinic keratoses on his scalp. Fluorouracil is most likely effective for this patient because it inhibits which of the
following enzymes?
A) Thymidine kinase
B) Thymidine reductase
C) Thymidylate synthase
D) Uracil phosphoribosyltransferase
E) Uracil reductase
A 73- year - old man has difficulty urinating and frequent urination. Improvement of these symptoms is most likely to result from treatment with a drug that blocks which of the following
labeled sites?
Tyrosine
*4
DOPA
Choline
4i
» Storage
** granule m Acetylcholine
Bti I c Q Acetylcholinesterase
Reuptake carrier
-® rn —
f Acelylchollne receptor
H
A) Anabolic state
B) Glycogen depletion
C) Lipolysis
D) Negative nitrogen balance
E) Starvation ketosis
A 22-year - old woman who is at 16 weeks' gestation has decreased serum concentrations of a-fetoprotein and unconjugated estriol and an increased serum concentration of human
chorionic gonadotropin . Which of the following disorders affecting the fetus is most likely?
A) Angelman syndrome
B) Beckwith-Wiedemann syndrome
C) Down syndrome
D) Fragile X syndrome
E) Myotonic dystrophy
F) Prader-Willi syndrome
A 50-year - old man comes to the physician 3 days after his first generalized tonic-clonic seizure. He has a 1-month history of frequent episodes of a pins-and-needles sensation
around the mouth and in the hands and feet. He also has had occasional episodes of involuntary contraction of the muscles of the hands or feet leading to wrist flexion or foot
plantar flexion. His pulse is 80/min, and blood pressure is 150/ 90 mm Hg Neurologic examination shows mild, diffuse hyperreflexia. An abnormality of which of the following serum
electrolyte concentrations is the most likely explanation for his symptoms?
A) Bicarbonate
B) Calcium
C) Chloride
D) Potassium
E) Sodium
A 50-year - old man who has smoked 2 packs of cigarettes a day for 34 years has experienced gradually increasing shortness of breath on exertion , chronic cough productive of
thick sputum, and frequent episodes of wheezing The anteroposterior diameter of his chest is increased Diminished breath sounds and scattered rhonchi are audible throughout
the lung fields. Which of the following laboratory abnormalities is expected?
C) Granuloma
) D) Lymphocytic infiltrate
E) Neutrophilic infiltrate
A 5-year-old boy with mental retardation is grossly obese and has facial features of Prader-Willi syndrome (PWS). Karyotyping and fluorescent in situ hybridization studies do not
show deletion in the usual site on chromosome 15 . Which of the following findings is most likely to confirm PWS in this child?
The most appropriate treatment for this patient is a drug with which of the following mechanisms of action?
A) Antagonism of murein hydrolase
B) Blockade of microtubule polymerization
C) Disruption of the pathogen cell membrane
D) Induction of cytochrome P450 enzymes
E) Inhibition of pathogen cell wall synthesis
In patients with adenosine deaminase deficiency, there is a 50- to 100- fold increase in dATP concentration in T lymphocytes. This increase in dATP inhibits which of the following
enzymes , thus compromising DNA synthesis?
A) DNA ligase
B) DNA polymerase I
C) Nucleoside monophosphate kinase
D) Ribonucleotide reductase
E) Thymidylate synthase
Patients with mucolipidosis II (l-cell disease) lack the phosphotransferase required for the formation of mannose 6-phosphate residues that are normally attached to enzymes
destined for the lysosome. The mannose 6-phosphate sorting signal is normally added to proteins in the c/s-Golgi. Which of the following most likely occurs to the lysosomal
enzymes in these patients?
A) Berry aneurysm
B) Fusiform aneurysm
C) Hyperplastic arteriolosclerosis
D) Medial arterial calcification (Monckeberg arteriosclerosis )
E) Temporal arteritis
A case-control study is conducted to assess the relationship between exposure to environmental tobacco smoke and sinusitis. The table shows the results of the study
Cases Controls
Exposed to smoke 20 25
Not exposed to smoke 5 100
A) Diffusion of insulin across the plasma membrane by an increase in intracellular bicarbonate concentration
B) Diffusion of insulin across the plasma membrane through a glucose transporter
C) Diffusion of insulin across the plasma membrane through a protein transporter
D) Enzymatic hydrolysis of the plasma membrane
E) Fusion of an intracellular vesicle with the plasma membrane
i. A 60-year -old man comes to the physician because of progressive shortness of breath during the past 3 months. He
states that for many years he has worked in a shipyard. His respirations are 25/min . Bilateral basilar crepitant
crackles are heard. An x-ray of the chest shows reticulonodular pulmonary infiltrates consistent with interstitial
fibrosis. Microscopic examination of sputum shows occasional elongate structures as shown. The fibrosis was most
likely initiated by interaction of these structures with which of the following cell types?
A) Alveolar capillary endothelial cell O F) Goblet cell
B) Alveolar macrophage G G) Kulchitsky cell
C) Chondrocyte O H) Squamous epithelial cell
D) Ciliated columnar epithelial cell O I) Type I pneumocyte
E) Clara cell G J) Type II pneumocyte
A 65-year - old woman with a 20- year history of osteoarthritis of the hands now has pain radiating down the distal anterior thigh, knee, medial leg , and foot. Bony outgrowth of
vertebrae compressing one of the spinal nerves is suspected. Compression of a nerve root in which of the following intervertebral foramina is the most likely cause of her
symptoms?
A) T-10 to 11
B) L-1 to 2
C) L-3 to 4
D) S-1 to 2
E) S-4 to 5
-
A 15 year- old girl is brought to the physician by her mother because of a 1-day history of redness and painful skin following sunbathing. She reports that she used sunblock every
few hours. She takes no medications Physical examination shows severe erythema of the back and extremities. There are no blisters Which of the following best describes her
condition?
A) Allergic reaction to the sun
B) First-degree burn
C) Rhus dermatitis
D) Second-degree burn
E) Third-degree burn
A 48-year-old man begins furosemide therapy for pedal edema associated with biventricular failure and hypertension Five days later, the edema is not fully resolved, and his serum
potassium concentration has decreased from 4.2 mEq/L to 3 mEq/L. A drug with which of the following actions should be added to this patient's medication regimen?
A) Actinomyces israelii
B) Bacillus anthracis
C) Klebsiella pneumoniae
D) Pseudomonas aeruginosa
E) Streptococcus pneumoniae
fhrou l
A) 10^ h e r a t e (i n Umin) mrough the aneurysm .
The estimated cross-sectional area of the aneurysm is 2 cm 2 and the mean velocity of blood flow
B) 2.4
C) 3.2
D) 3.6
E) 4.0
A 66-year -old man develops worsening shortness of breath and swelling of the legs. He had a myocardial infarction 6 months ago. Pulse is 120/min, and blood pressure is 135/ 82
mm Hg Examination shows distended jugular veins, bilateral crackles, and pitting edema in the lower extremities. Serum sodium concentration is 129 mEq/L . Which of the following
is most likely responsible for the hyponatremia in this patient?
A) Angioedema
B) Hyperthyroidism
C) Hyponatremia
D) Hypoparathyroidism
E) Lung cancer
A 57-year - old woman comes to the physician because of episodes of burning, shock-like pain on the left side of her face during the past 4 months . She has several episodes each
day. usually caused by chewing. The pain lasts from 5 to 10 seconds. Neurologic examination shows no abnormalities . Which of the following is the most likely diagnosis?
A) Cluster headache
B) Migraine
C) Multiple sclerosis
D) Temporal arteritis
E) Trigeminal neuralgia
A 42-year -old man comes to the physician because of a 1-month history of fatigue, excessive thirst , and frequent urination with large volume. He is 178 cm (5 ft 10 in) tall and
weighs 61 kg (135 lb); BMI is 19 kg/ m 2. His pulse is 96/min, and blood pressure is 104/60 mm Hg. Physical examination shows dehydration . Fasting laboratory studies show:
Serum
Glucose normal
ADH (vasopressin) increased
Osmolality increased
Urine osmolality decreased
In addition to a low- sodium diet, which of the following drugs is the most appropriate treatment for this patient?
A) Acetazolamide
B) Desmopressin
C) Furosemide
D) Hydrochlorothiazide
E) Spironolactone
A 1-year- old boy is found to have an impairment of the respiratory burst of phagocytes. He has a family history of immunodeficiency. This patient is at greatest risk for infection
caused by which of the following organisms?
A) Enterococcus faecium
B) Escherichia coli
C) Haemophilus influenzae
D) Staphylococcus aureus
E) Streptococcus pneumoniae
F) Streptococcus pyogenes (group A)
A 13-year - old girl is brought to the physician by her mother for a routine well-child examination. Neither the child nor the mother has any particular health concerns. The patient is
doing well in school and participates in soccer and lacrosse in a local recreation league The physician wants to ask the patient about sexuality and sexual activity. Which of the
following actions by the physician is most appropriate?
A) Ask the mother to leave the room before asking the patient any questions
B) Ask the patient to leave the room and then ask the mother about her daughter
C) Ask the questions with both the mother and the patient present
D) Give the patient a questionnaire that she can fill out at home
E) Tell the patient that some sensitive questions are next and that only she can ask her mother to leave the room
i. A 28-year-old man comes to the emergency department because of a 6-hour history of cramping and severe left midabdominal pain
He had a single episode of vomiting . His temperature is 37°C (98.6°F). Abdominal examination shows a mass in the midabdomen. A
CT scan of the abdomen with contrast is shown ; the abnormality is indicated by the arrows Intussusception of which of the following
portions of the intestinal tract is the most likely cause of this patient’s pain?
A) Appendix
B) Cecum
C) Duodenum
D) Jejunum
E) Stomach
An Rh- negative woman, gravida 3, para 2, has had an increasing bilirubin concentration in amniotic fluid obtained between 22 and 29 weeks' gestation . Umbilical cord blood
obtained at 29 weeks' gestation had a hematocrit of 6.2%. Transfusion of which of the following types of packed red cells to the fetus in utero should be used to correct the anemia'?
A) A, Rh-negative
B) A, Rh-positive
C) AB , Rh-negative
D) AB, Rh-positive
E) B, Rh-negative
F) B, Rh-positive
G) O, Rh-negative
H) O, Rh-positive
A 35-year - old woman has weakness and fever When she was 25 years old, she was treated for Hodgkin disease with mechlorethamine, oncovin, procarbazine, and prednisone.
She has had a splenectomy There is no evidence of lymphadenopathy. A peripheral blood smear shows numerous blast forms. Which of the following is the most likely explanation
for these findings?
A) Chondrosarcoma
B) Eosinophilic granuloma
C) Ewing sarcoma
D) Multiple myeloma
E) Nephroblastoma (Wilms tumor)
F) Osteosarcoma
G) Small lymphocytic lymphoma
A 35-year - old man with bronchial asthma starts taking albuterol Which of the following changes in second messenger levels is most likely in the cells affected by this treatment?
A) Decrease in cAMP
B) Decrease in cGMP
C) Decrease in inositol 1, 4, 5-trisphosphate
D) Increase in cAMP
E) Increase in cGMP
F) Increase in inositol 1,4,5-trisphosphate
A 57- year - old woman comes to the physician 2 weeks after finding a lump in her left breast on self -examination Physical examination shows a 2-cm mass in the upper inner
quadrant of the left breast. Carcinoma is suspected. X-rays show multiple lesions in the vertebral column, and metastatic disease is suspected. Which of the following veins draining
the breast provides the most direct pathway for malignant cells to travel to the vertebral column?
A) Axillary
B) Cephalic
C) Intercostal
D) Internal thoracic (mammary)
E) Lateral thoracic
A 10-year - old boy receives a renal transplant from a living , related donor for cystic renal dysplasia. Three months later , there is tenderness at the site of the graft , and serum
creatinine concentration increases from 1.0 to 2.0 mg/dL. Which of the following findings on renal biopsy is most likely to confirm a diagnosis of rejection?
A) Arteriolar C 3 deposition
B) Dilation of Bowman space
C) Fibrous scars with plasma cells
D) Glomerular neutrophils and necrosis
E) Lymphocytes infiltrating tubular epithelium
F) Red blood cell casts
G) Subcortical necrosis
An 18-year-old man comes to the physician 10 days after injuring his right hand during a game of tag football. He says that he was attempting to tag an opposing player when he
inadvertently caught the tip of his ring finger on the other player's jersey. He felt a popping sensation at the tip of his finger and then immediately felt sharp pain localized to the
finger. He noticed swelling of the finger several minutes later. Examination of the right hand shows mild tenderness over the palmar tip of the ring finger. He is unable to flex the
distal interphalangeal joint of the right ring finger, but he is able to flex the metacarpophalangeal and proximal interphalangeal joints. This patient most likely injured a tendon whose
muscle is supplied by fibers from which of the following nerve roots?
A) C3
B) C4
C) C5
D) C6
E) C7
F) C8
A 35 - year - old man comes to the physician because of a 6-week history of pain in his right arm and tingling sensation in the fingers of his right hand Physical examination shows
weakness of extension and pronation of the right forearm. The triceps muscle stretch reflex is decreased Which of the following nervous structures is most likely involved?
A) C6 nerve root
B) C7 nerve root
C) C8 nerve root
D) Median nerve
E) Radial nerve
A 27-year -old woman comes to the physician because of swelling in her left arm that began 10 days after a spontaneous abortion in the middle of her second trimester. A
radiocontrast study shows axillary vein thrombosis. Laboratory studies show:
Bleeding time normal
Prothrombin time increased
Partial thromboplastin time increased
Thrombin time normal
Which of the following is the most likely cause of this woman's condition?
A) Antiphospholipid antibodies
B) Antithrombin deficiency
C) Dysfibrinogenemia
D) Protein C deficiency
E) Protein S deficiency
The risk for hemorrhagic stroke from drug X is investigated by utilizing a questionnaire about drug use in 702 patients with hemorrhagic stroke and in 1376 control subjects
contacted by random-digit dialing. Which of the following best describes this study design?
A) Case-control study
B) Cohort study
C) Cross-sectional survey
D) Randomized, double-blind experiment
E) Randomized, single-blind experiment
. A 4-year-old boy is brought to the physician by his parents because he has had two bacterial urinary tract infections
during the past year. Physical examination shows no abnormalities Radiologic studies of the urinary tract show marked
dilation of the left ureter and renal pelvis, and minimal left-sided renal function. A left nephrectomy is performed. A
photograph of the resected specimen is shown. Microscopic examination of the renal parenchyma is most likely to show
which of the following?
A) Amyloidosis
B) Interstitial inflammation
C) Membranous glomerulonephritis
D) Nephroblastomatosis
E) Renal cell carcinoma
Which of the following is required for the synthesis of glucosamine from fructose 6-phosphate?
A) Arginine
B) ATP
C) Carbamoyl phosphate
D) Glutamine
E) A/-acetylglutamate
A 25- year-old woman comes to the physician because of a 6-month history of irregular menstrual periods and progressive acne. Menses have occurred at irregular 25- to 42-day
intervals. She is 170 cm (5 ft 7 in) tall and weighs 100 kg (220 lb); BMI is 35 kg/m 2. Her voice is deep Physical examination shows dark hair over the upper lip and chin, and open
and closed comedones over the face, chest, and back . Serum studies are most likely to show which of the following in this patient?
Fasting Luteinizing
Insulin Testosterone Hormone
A) Increased increased increased
B) Increased increased decreased
C) Increased decreased increased
D) Decreased increased increased
E) Decreased increased decreased
F) Decreased decreased decreased
A 56- year -old woman is brought to the emergency department by her husband because she has had headache , confusion, and difficulty speaking and walking for the past 2 days
Mental status shows confusion and memory loss Her temperature is 38.9°C (102°F). Brudzinski and Kernig signs are absent. Analysis of cerebrospinal fluid shows:
Opening pressure 260 mm Hp
Leukocyte count
(mostly lymphocytes) 208/mm 3
Protein 52 mg/dL
Glucose 40 mg/dL
An EEG shows abnormalities in the right temporal lobe and periodic lateralized epileptiform discharges. Which of the following is the most likely diagnosis?
A) Aseptic meningitis
B) Bacterial encephalitis
C) Herpes encephalitis
D) Neurosarcoidosis
E) Tuberculous meningitis
A 66-vear - old man comes to the physician because of a 2-month history of the inability to maintain an erection He also has had fatigue and difficulty sleeping and concentrating
during this period. Three months ago , he had a cerebral infarction with right hemiparesis that has gradually resolved. Physical examination shows no abnormalities. Which of the
following additional pairs of findings in this patient is most likely on history taking?
Libido Nocturnal
Erections
A) Normal normal
B) Normal decreased
C) Decreased normal
D) Decreased decreased
A 52-year -old man is brought to the emergency department 1 hour after he was found next to a faulty space heater He is confused . Physical examination shows reddish-tinged skin
Arterial blood gas analysis on room air shows a Po 2 within the reference range and carboxyhemoglobin concentration of 40% (N=2%). He is intubated and mechanically ventilated
with supplemental oxygen. Assuming no further carbon monoxide (CO) exposure, which of the following is the best estimate for the time it will take for the removal of all the
CO-carrying erythrocytes from this patient's circulation?
A) 1 Day
B) 2 Weeks
C) 1 Month
D) 4 Months
E) 1 Year
A randomized controlled trial is conducted to assess the effect of diuretic therapy on the risk for cerebral infarction in patients with systolic hypertension . A total of 4736 patients with
systolic blood pressure measurements greater than 140 mm Hg and diastolic blood pressure measurements ranging from 50 mm Hg to 85 mm Hg are randomly assigned to receive
diuretic therapy or placebo. After 5 years, results show:
Cerebral Infarction
Yes No Total
Diuretic Therapy 123 2242 2365
Placebo 194 2177 2371
Total 317 4419 4736
Which of the following best represents the absolute risk reduction for cerebral infarction in patients receiving diuretic therapy?
A) (194/2177) - (123/2242)
B) (194/2371) - (123/2365)
C) (123/2242) / (194/2177)
D) (123/2365) / (194/2371)
E) (194/2177) / (123/2242)
F) (194/2371) / (123/2365)
A newborn has cyanosis, tachypnea , and retractions of the muscles of the chest wall during inspiration. She weighs 2500 g (5 lb 8 oz). Arterial blood gas values while she breathes
room air are:
pH 7.04
Pco 2 65 mm Hg
Po 2 35 mm Hg
HCO 3- 15 mEq/L
.
Hemoglobin 9 g/dL
Hematocrit 27% 0
Leukocyte count 10,500/ mm 3
v V
Neutrophils 65% ©
Lymphocytes
Monocytes
25%
8% '6 >/ <
Eosinophils 2% Q
Reticulocyte count
Mean corpuscular volume
8%
95 pm 3
n
o©<P3
'i i
Platelet count 18,000/ mm 3
0
Prothrombin time
Partial thromboplastin time (activated)
Fibrinogen
Fibrin split products
12.8 sec (INR=1.0)
32 sec
245 mg /dL (N=200-400 mg/dL)
<10 (N=<10)
A
&
r
too
.
^ +
?
A peripheral blood smear is shown . Which of the following is the most likely cause of these findings? «
•
A) Aplastic anemia me
B) Disseminated intravascular coagulation
C) Fulminant liver failure
D) Thrombotic thrombocytopenic purpura
E) Vitamin B 12 (cobalamin) deficiency
A 39-year -old woman with rheumatoid arthritis comes to the physician for a follow-up examination. Treatment with multiple medications, including prednisone and methotrexate has
not been effective at slowing the progress of her condition. The most appropriate next step in pharmacotherapy is a drug that blocks the effects of which of the following cytokines?
A) Interferon gamma
B) lnterleukin-2 (IL-2)
C) IL- 4
D) IL-10
E) Tumor necrosis factor-a
A 57-year -old woman comes to the office because of a 5-week history of progressive weakness in her arms and legs. She says the weakness is most apparent when she tries to lift
dishes out of overhead cupboards and when she walks up and down flights of stairs. Muscle strength initially improves upon repetitive manual motor testing Sensation is intact in
all extremities. Which of the following mechanisms best explains this patient’s weakness?
A) Alprazolam
B) Haloperidol
C) Lithium carbonate
D) Methylphenidate
E) Phenelzine
F) Sertraline
A 5-year-old boy is brought to the physician because of a 4-day history of red cheeks and rash over his arms and legs. He also has a 1-week history of fever. He has received all of
the scheduled childhood immunizations His vital signs are within normal limits. Physical examination shows malar erythema and a red, lacy rash over the upper and lower
extremities His hemoglobin concentration is 10 g/dL (N=11— 15). Which of the following is the most likely cause of this patient's anemia?
Which of the following tests should be used to determine whether the means are statistically different?
A) Chi-square
B) Rank correlation
C) Sign test
D) f-Test
A 60- year- old woman comes to the physician because of a 1-year history of episodes of involuntary rhythmic jerking of her right leg and foot. These episodes last approximately
3 minutes . Neurologic examination shows an increased right ankle jerk reflex A Babinski sign is present on the right . An MRI of the brain shows a 2-cm, round, enhancing lesion
within the interhemispheric fissure in the region of the central sulcus. Which of the following is the most likely diagnosis?
A) Astrocytoma
B) Lymphoma
C) Meningioma
D) Metastatic carcinoma
E) Oligodendroglioma
A 6-year- old boy who recently emigrated from Russia is brought to the physician by his parents because of unstable gait and incoordination for 2 weeks. He has had frequent pale,
bulky stools for 4 years and two episodes of bacterial pneumonia and chronic cough since the age of 1 year He is below the 3rd percentile for height and weight. Increased rhonchi
are heard over both lung fields Neurologic examination shows ataxia, absence of deep tendon reflexes , and loss of proprioception . Stool analysis shows an increased fat
concentration . Which of the following vitamins is most likely deficient in this patient?
A) Biotin
B) Niacin
C) Vitamin C
D) Vitamin D
E) Vitamin E
A 27-year - old man who is a construction worker is brought to the emergency department 30 minutes after he fell from a ladder approximately 14 feet onto a pile of boards from a
demolished house A long , sharp piece of wood penetrated his left side , immediately inferior to the middle of the body of his left 12th rib A CT scan shows that the wood sliver has
grazed the inferior pole of the left kidney and its tip is resting in the structure immediately anterior. This structure is most likely which of the following?
A) Azathioprine
B) Cyclosporine
C) Methylprednisolone
D) Rapamycin
E) Tacrolimus
A 42-year -old woman is brought to the emergency department by her husband after having a generalized tonic-clonic seizure. She tells the physician that she smelled a foul odor for
several seconds immediately before the seizure . Her husband did not perceive the odor. From which of the following regions of the brain did the seizure most likely arise?
A) Brain stem
B) Frontal lobe
C) Occipital lobe
D) Parietal lobe
E) Temporal lobe
A 35-year- old man is brought to the hospital after a diving accident. Evaluation shows complete transection of the spinal cord superior to the level of sympathetic nervous outflow.
Which of the following responses will most likely occur if he develops a systemic infection?
A) Alteration of the thermostatic set point
B) Cutaneous vasoconstriction
C) Diaphoresis following aspirin ingestion
D) Generalized involuntary shivering
E) Heat production by brown fat
A 54-year- old woman with hypertension and bilateral renal artery stenosis starts taking a nonsteroidal anti-inflammatory drug for back pain. Over the next week , her serum
creatinine concentration increases from 10 to 5.0 mg/dL. The most likely cause of this finding is the drug's ability to inhibit which of the following?
A) Inflammation in the glomerular capillaries
B) Inflammation in the renal interstitium
C) Vasoconstricting prostaglandins at the afferent arteriole
D) Vasoconstricting prostaglandins at the efferent arteriole
E) Vasodilating prostaglandins at the afferent arteriole
F) Vasodilating prostaglandins at the efferent arteriole
). A 12-year- old girl who recently immigrated to the USA from Central Africa is brought to the physician because of a 5-week history of
increasingly severe abdominal pain and vomiting blood. Her temperature is 37.8°C (100°F) , pulse is 110/min, respirations are 27/min, and
blood pressure is 112/65 mm Hg. Physical examination shows hepatosplenomegaly and abdominal ascites. Laboratory studies show :
Leukocyte count 13, 400/mm 3 (N=4500-13,500)
Segmented neutrophils 42%
Eosinophils 15%
Lymphocytes 37%
Monocytes 6%
A photomicrograph of a stool specimen is shown . Which of the following is the most appropriate pharmacotherapy for this patient?
A) Fluconazole
B) Levofloxacin
C) Metronidazole
D) Praziquantel
E) Trimethoprim-sulfamethoxazole
«
A 38 year old man who lives at sea level flies to a mountain resort in Colorado lor a skiing vacation He takes a carbonic anhydrase inhibitortabletd er arriving at the resort to help
adjusUo the altitude Two hours after drug ingestion, which of the following changes in urinary pH, bicarbonate, and volume are most likely this pa
HCOj'
pH ( mEq / L ) Volume
A) T T T
B) T i
C) T i T
D) T i 1
E) 1 T T
F) i T i
G) i i T
H) 1 i 1
A 45-year -old man with poorly controlled type 2 diabetes mellitus comes to the physician because of a 1-month history of low-grade fever He is receiving hemodialysis for end-
stage renal disease. His temperature is 37°C (98.6°F), pulse is 72/min, and blood pressure is 144/92 mm Hg. Physical examination shows a subclavian catheter inserted below the
right clavicle The lungs are clear to percussion and auscultation . Cardiac examination shows no murmurs. Two of two blood cultures grow nonhemolytic, catalase-negative, gram-
positive cocci in pairs and chains. Which of the following is the most likely causal organism?
A) Enterococcus faecalis
B) Listeria monocytogenes
C) Staphylococcus aureus
D) Staphylococcus epidermidis
E) Streptococcus pneumoniae
A 2-year- old boy is brought to the physician because of fever and cough for 2 days . He has had two episodes of Streptococcus pneumoniae bacteremia and multiple ear and sinus
infections since birth . His temperature is 38.4°C (101 1°F). Physical examination shows no tonsillar tissue. Crackles are heard in the right lower lobe of the lung Which of the
following is the most likely immunodeficiency syndrome in this patient?
A) Bruton agammaglobulinemia
B) Chediak-Higashi syndrome
C) Chronic granulomatous disease
D) DiGeorge syndrome
E) lgG2 deficiency
F) Isolated IgA deficiency
of these data, a-actinin is
myofibril from the plasma membrane in cardiac myocytes . On the basis
of the
Microelectrode injection of antibodies to a-actinin results in the detachment
micrograph of a normal cardiac myocyte shown?
most likely located at which of the following labeled sites in the electron
An 82-year -old woman has been bedridden since surgical repair of a hip fracture 6 months ago. Healing has proceeded slowly, and her physician is concerned that deep venous
thrombosis may develop . A drug that suppresses the action of which of the following factors is most likely to decrease this patients risk for thrombosis
A) Carboxylation of precursor proteins
B) Nitrous oxide
C) Prostacyclin (PGI 2)
D) Protein C
E) Proteins
F) Thrombomodulin
A 42 -year - old man comes to the physician because of numbness and tingling in both legs for 2 weeks. Sensation to vibration is decreased in the lower extremities and feet . Deep
tendon reflexes are decreased in the knees and ankles. A Romberg sign is positive . Which of the following is the most likely cause of these findings?
A) Anaphylaxis
B) Diarrhea
C) Increased blood pressure
D) Tachycardia
E) Tricuspid valvular insufficiency
An 84-year -old woman comes to the physician because of a 2-month history of a sore on her left hand. Physical examination shows a red , scaly, raised plaque on the dorsum of the
left middle finger. The diagnosis of squamous cell carcinoma is made The ability of this tumor to invade the basement membrane is most likely facilitated by which of the following?
A) Ewing sarcoma
B) Fibrosarcoma
C) Multiple myeloma
D) Neurofibrosarcoma
E) Osteoid osteoma
F) Osteosarcoma
G) Prostate adenocarcinoma
H) Renal adenocarcinoma
I) Tuberculosis of the spine
Following a stroke , a patient is hoarse and cannot detect pinprick or cold on the left side of the face or the right side of the body Damage is most likely to have occurred in which of
the following areas of the brain on the left?
A) Bacteroides fragilis
B) Campylobacter jejuni
C) Escherichia coli
D) Helicobacter pylon
E) Salmonella typhi
F) Vibrio cholerae
G) Yersinia enterocolitica
A 45-year -old man with Li-Fraumeni syndrome agrees to participate in an investigational study of tumor suppressor gene disorders. A mutation is found in his p53 tumor suppressor
gene that converts an arginine to a proline at amino acid position 248 (R 248P). This change alters hydrogen bonding between the mutant p53 tumor suppressor gene protein and
the thymidine oxygen and adenine ring nitrogen of DNA Which of the following is the most likely result of this mutation on the transcription of genes that inhibit cell division and
contain the consensus sequence TATA (A/T) (A/T) at -30 bp 5' to the transcription start site?
A) Decreased binding of DNA polymerase
B) Decreased binding of RNA polymerase
C) Increased binding of DNA polymerase
D) Increased binding of RNA polymerase
E) Increased binding of trans factors
A 79-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 92/56 mm Hg. Physical examination shows no evidence of tongue biting . The lungs
are clear to auscultation. Cardiac examination shows a variable intensity Sr He is oriented to person, place, and time. An ECG shows a third-degree atrioventricular block Which of
the following is the most appropriate next step in management?
A) Transesophageal echocardiography
B) Transthoracic echocardiography
C) Insertion of pulmonary artery catheter
D) Insertion of transvenous pacemaker
E) Cardiac catheterization with angioplasty
F) Cardiac catheterization with stent placement
A 12-year- old boy is swimming in a mountain stream He is immersed up to his neck in 60°F water for 20 minutes. Which of the following sets of physiologic changes is most likely
,
A) Androstenedione
B) Dihydrotestosterone
C) Estradiol
D) Estriol
E) Testosterone
A 44 - year - old man comes to the physician because of fever and mild abdominal discomfort for the past 3 days. He has a 10- year history of intravenous drug abuse. Temperature is
39.0°C (102.2°F). pulse is 108/min, and blood pressure is 150/ 94 mm Hg. The liver edge is percussed to 12 cm (4.8 in), and there is a prominent systolic pulsation of the liver.
Which of the following is the most likely diagnosis?
A) Ask the patient to identify the pros and cons of smoking cessation
B) Detail the long-term health effects of smoking
C) Initiate pulmonary function tests
D) Prescribe bupropion
E) Recommend nicotine replacement therapy
A 39-year -old woman comes to the physician because of increasing hair growth on her face for the past year. She has not had a menstrual period during this time. A CT scan of the
pelvis shows an ovarian tumor on the left . Serum testosterone concentration is 450 ng/ dL (N=20-60 ng /dL). Which of the following laboratory values is most likely increased due to
the increased serum testosterone concentration?
A) Alkaline phosphatase
B) Follicle-stimulating hormone
C) Hemoglobin
D) High-density lipoprotein
E) Prostate-specific antigen
During a study of symptomatic proximal deep venous thrombosis , patients with this condition are randomly assigned to receive either dalteparin subcutaneously for 5 to 7 days and
then oral warfarin for 6 months , or dalteparin alone subcutaneously for 6 months No placebo controls are used. The probability of recurrent thromboembolism at 6 months is 10% in
the dalteparin group and 19% in the warfarin group Which of the following best describes this study design?
A) Case-control study
B) Case series
C) Observational cohort study
D) Open-label clinical trial
E) Open-label crossover study
A 5-year- old boy is brought to the physician because of pain in the right eye at night for the past week. There is no family history of neoplasia Examination shows strabismus and
tenderness in the eye . The left eye is normal. Examination of the retina shows the presence of a mass. The physician explains to the parents that the boy is unlikely to develop any
other neoplasms. The first mutation leading to this neoplasm most likely occurred in which of the following?
A) Germ cells
B) Retinal cells
C) Somatic cells of the child
D) Somatic cells of the parents
E) Zygote
A 78-year - old man comes to the physician because of a 3-month history of increasingly severe back pain that is worse at night and persists regardless of his activity level Physical
examination shows no abnormalities . His serum alkaline phosphatase activity is increased. An x-ray of the spine shows numerous lytic lesions along the vertebral column Which of
the following is the most likely diagnosis?
A) Chondrosarcoma
B) Ewing sarcoma
C) Metastatic carcinoma
D) Osteitis deformans (Paget disease)
E) Osteosarcoma
A 48-year - old man comes to the emergency department because he is vomiting blood. Six months ago, he had a 3-month hospital stay for severe alcohol-induced pancreatitis. His
recovery was complicated by a pseudocyst of the pancreatic tail that required surgical drainage. Examination shows splenomegaly. Hemoglobin concentration is 8.5 g/dL ; platelet
count is 56, 000/mm 3. Which of the following vessels is most likely thrombosed?
A) Gastroduodenal artery
B) Gastroduodenal vein
C) Inferior pancreaticoduodenal artery
D) Inferior pancreaticoduodenal vein
E) Left gastric artery
F) Left gastric vein
G) Splenic artery
H) Splenic vein
A 28-year - old man has recurrent pancreatitis associated with familial hypertriglyceridemia Administration of a drug with which of the following effects is most appropriate?
A) Angiotensin II
B) Dipalmitoyl lecithin
C) Phosphatidylinositol 4,5-bisphosphate
D) Phosphatidylserine
E) Sphingomyelin
A 27-year-old man is brought to the emergency department 2 hours after injuring his left ankle while rock climbing. His pulse is 80/min,
respirations are 25/min, and blood pressure is 135/90 mm Hg. Physical examination shows swelling on the medial and lateral aspects of
the left ankle and severe pain on palpation. An x -ray of the left ankle is shown. This patient 's injury most likely occurred when his left foot
was forcibly moved into the extreme of which of the following positions?
A) Dorsiflexion
B) Eversion
C) Inversion
D) Plantar flexion
Two patients, a 54-year - old man (Patient X ) and a 76- year-old woman (Patient Y ), are about to receive intravenous vancomycin for severe gram -positive bacterial infections. Both
patients weigh 70 kg (154 lb) Patient X has an estimated glomerular filtration rate (GFR) of 60 mL/min , and Patient Y has a GFR of 20 mL/min. Which of the following parameters
of their drug therapy is most likely to be the same in both Patient X and Patient Y?
A) Elimination half-life
B) Loading dose
C) Serum drug concentration at 12 hours
D) Time to steady - state concentration
). A previously healthy 6-year-old boy is brought to the physician by his mother because of a 1-week history of an itchy
rash in his armpits, both hands and feet , and groin. The itching is most intense at night and keeps him awake. His
vital signs are within normal limits. Examination of the skin shows multiple erythematous papules , some with burrows
and many of which are excoriated , similar to the ones shown in the photograph. Which of the following questions to
the mother will be most helpful in establishing the diagnosis?
A) "Do you have any pets at home ?”
B) "Does anyone else in the family have an itchy rash like this?"
C) "Does your child take any medications?"
D) "Has there been any recent travel?"
E) "Have you changed soaps or detergents lately?"
A patient in the early stages of hemorrhagic shock is most likely to have which of the following?
A) Decreased ventilatory rate due to inhibition of the respiratory center
B) Flushing due to cutaneous vasodilation that occurs secondary to sweating
C) Increased renal blood flow due to sympathetic activation
D) Sweating due to parasympathetic stimulation of sweat glands
E) A weak pulse due to decreased stroke volume
A 45 -year -old man with chronic pancreatitis caused by alcohol use disorder comes to the office because of a 3-month history of diarrhea . Physical examination shows no
abnormalities. Examination of a stool specimen shows a markedly decreased amount of fecal elastase Which of the following medications is most appropriate for this patient’s
diarrhea ?
A) Ciprofloxacin
B) Lactobacillus
C) Loperamide
D) Pancrelipase
E) Somatostatin
A 48- year - old man with renal artery stenosis undergoes stent placement. Femoral access is used to place the stent. After entrance into the aorta , the guide wire should be
advanced superiorly just beyond which of the following structures to approach the right renal artery in this patient?
A) Celiac trunk
B) Internal iliac artery
C) Superior mesenteric artery
D) Testicular artery
A 13-year -old boy is brought to the physician for a well-child examination. He says that he is teased by his peers for "having breasts like a girl." He has no history of medical illness
He takes no medications. He is at the 50th percentile for height 60th percentile for weight , and 60th percentile for BMI. Physical examination shows a small, soft mound of tissue
bilaterally beneath the areola. His genital development is Tanner stage 3 . Which of the following is the most appropriate next step in management?
A) Reassurance
B) Measurement of serum growth hormone concentration
C) Measurement of serum luteinizing hormone concentration
D) Measurement of serum testosterone concentration
E) Mammography
A 62-year - old man comes to the physician's office for excision of an invasive squamous cell carcinoma on the lower lip . The physician has explained the reasons for the procedure,
the technique to be used, the possible complications of the procedure, and the identity of the physician who will be performing the procedure. Which of the following additional
information is required for informed consent?
A) Alternative treatments
B) Availability of a second opinion
C) Cost of the procedure
D) Expected recovery time
E) Medications used during the procedure
A 35-year - old man comes to the physician because of an itchy rash on his hands , waist , and feet for 2 days. He says that his wife and three teenaged children are beginning to
develop the same symptoms. He says, "We live near a wooded area and love to hike in the woods." Physical examination shows 2-mm erythematous papules in the finger webs
wrists, umbilicus, genital area , and toes. Scrapings of the lesions show mites and eggs. Which of the following is the most appropriate next step by the physician?
A) Instruct the patient to hire an exterminator to treat his home
B) Instruct the patient to use diethyltoluamide (DEET ) bug spray while hiking
C) Instruct the patient to wear a long- sleeved shirt and pants while hiking
D) Prescribe penicillin for the patient and his family
E) Prescribe permethrin for the patient and his family
A 45-year -old man with end-stage renal failure is brought to the emergency department by his mother because of his feelings of depression and apathy for 2 weeks. He has been
receiving dialysis three times weekly for 5 years , but he has missed the last three sessions because , "I've been too depressed to do anything since my wife left me 3 weeks ago. "
Bilateral crackles are heard on auscultation of the chest. Mental status examination shows confusion Serum studies are most likely to show a decrease in which of the following
concentrations?
A) Bicarbonate
B) Creatinine
C) Magnesium
D) Phosphate
E) Potassium
F) Urea nitrogen (BUN)
A 50-year - old man comes to the physician for follow -up treatment of progressive, disabling osteoarthritis during the past 6 years. The physician has just learned of a promising
experimental treatment for this condition The company that produces the new drug is offering physicians $100 for each case referred for treatment The physician believes that the
patient is a good candidate for this drug Which of the following best describes whether the physician should tell this patient that she will receive $100 for the referral?
A) No; the arrangement is contractual between the physician and the company, not the patient
B) No, because the patient may ask for the money
C) No, especially if the protocol clearly spells out that the patient is not to know
D) Yes, and offer to share the money with the patient
E) Yes ; the patient may wish to consider the money's influence on the physician's recommendation
A study is conducted to assess the prevalence of hypertension in Caucasian people compared with African American people. A total of 500 Caucasian participants (Group X ) and
500 African American participants (Group Y ) between the ages of 25 and 40 years are enrolled Blood pressure readings are taken from each participant three times over a period of
3 months. The prevalence of hypertension in Group X is 10% , and the prevalence in Group Y is 16%. Which of the following statistical tests is most appropriate to determine if this
difference is statistically significant?
A) Analysis of variance
B) Chi-square test
C) Independent f-test
D) Multiple logistic regression
E) Paired f-test
F) Pearson correlation
A 30-year - old man is brought to the emergency department 30 minutes after being stabbed in the abdomen during a robbery. His pulse is 130/min, and respirations are 28/ min. His
mean arterial pressure is 50 mm Hg , and pulse pressure is 5 mm Hg to 10 mm Hg. A diagnosis of rupture of the aorta is made Which of the following is expected to occur as a
compensatory response to this rupture?
A) C1 inhibitor
B) CD 40 ligand
C) Factor VIII (antihemophilic factor)
D) IgA
E) NADPH oxidase
F) Plasminogen activator
A 50-year - old man with chronic gastritis is diagnosed with a marginal zone lymphoma of the stomach. Which of the following organisms is most likely associated with the
development of this lymphoma?
A) Cryptosporidium parvum
B) Cyclospora cayetanensis
C) Epstein-Barr virus
D) Helicobacter pylori
E) HIV-1
F) HTLV-1
A 52-year - old man with stable angina pectoris begins treatment with a medication that decreases cardiac preload and increases coronary artery blood flow. This patient is at greatest
risk for which of the following adverse effects of this medication?
A) Bradycardia
B) Constipation
C) Headache
D) Hearing loss
E) Nausea
F) Visual disturbance
A 62-year - old man comes to the physician for a follow -up examination . He has hypertensive nephropathy and chronic renal insufficiency. Current medications include clonidine and
calcium acetate . His blood pressure is 145/92 mm Hg. Laboratory studies show a serum creatinine concentration of 3.5 mg/dL and serum calcium concentration of 7.8 mg /dL.
Which of the following additional sets of serum concentrations is most likely in this patient?
Inorganic Parathyroid
Phosphorus Hormone Calcitriol
A) Increased increased decreased
B) Increased decreased increased
C) Increased decreased decreased
D) Decreased increased increased
E) Decreased increased decreased
A 56-year- old man develops brief episodes of ventricular tachycardia 14 hours after having an acute myocardial infarction . The arrhythmia will be treated with a loading dose of
lidocaine followed by a continuous infusion of the same drug over the next 24 hours at a rate to maintain a therapeutic steady-state drug concentration (Css) in plasma. To maintain
a Css of lidocaine, the appropriate rate of infusion of the drug is best determined by which of the following calculations? (CL=drug clearance, Vd=volume of distribution, t1/2=half-life)
A) CL x Css
B) CL / Css
C) CL x V/2
D) CL / V/2
E) Vd x Css
F) Vd / Css
G) Vdxt1/2
H) Vd / V/2
A 3-month-old girl is brought to the physician by her mother for a well-child examination. Her mother says that the infant can lift her head when lying prone. The patient is eating well
and recently started sleeping about 6 uninterrupted hours through the night . The mother adds that the baby does not yet smile in response to human faces and has not started to
coo or gurgle with attention The patient is at the 25th percentile for length and weight and 10th percentile for head circumference. Physical examination shows no other
abnormalities Which of the following best describes this infant’s development?
Motor Social Verbal and
Cognitive
A) Normal normal normal
B) Normal normal delayed
C) Normal delayed normal
D) Normal delayed delayed
E) Delayed normal normal
F) Delayed normal delayed
G) Delayed delayed normal
H) Delayed delayed delayed
A 29-year- old woman has an inflammatory disease involving her joints, kidneys, serosal surfaces, anterior chamber of the eye, and choroid plexus. Which of the following is the
most likely mechanism of this disorder?
A) Antibasement membrane antibody-dependent cell-mediated cytotoxicity
B) Antibasement membrane antibody-dependent complement-mediated cytotoxicity
C) Cell-mediated cytotoxicity
D) Immune complex-mediated cytotoxicity
E) Release of vasoactive compounds from IgE- stimulated basophils
F) Systemic release of interleukin-1 (IL-1) and tumor necrosis factor
A 72-year -old man with multiple myeloma agrees to participate in an investigational chemotherapy clinical trial Prior to enrollment in the study, peripheral blood B and T
lymphocytes are isolated and undergo Southern blot analysis of lymphoid cell-specific genes. Using a single B-lymphocyte J-region probe , analysis of the B-lymphocyte DNA shows
a 1 5-kb band. Analysis of the T-lymphocyte DNA using the same J-region probe shows a 6-kb band The 6-kb band most likely signifies which of the following?
,
A) Ask the patient with the nephew present if he feels safe at home
B) Ask the patient's nephew if he often loses his temper around the patient
C) Contact adult protective services
D) Determine if the patient's nutritional needs are being met
E) Meet with the patient's family and advise them on how to care for someone with Down syndrome
A 53-year - old woman shows evidence of adrenal failure. On CT scan , both adrenal glands appear normal in configuration but decreased in size. Which of the following is the most
likely diagnosis?
A) Autoimmune adrenalitis
B) Disseminated coccidioidomycosis
C) Metastatic carcinoma from the lung
D) Retroperitoneal idiopathic fibrosis
E) Tuberculosis
A 45-year - old woman comes to the physician for a follow- up examination 8 weeks after beginning tamoxifen therapy for estrogen- and progesterone-positive invasive ductal
carcinoma of the breast Her 50-year- old sister also has hormone- sensitive breast cancer treated with tamoxifen Physical examination shows no abnormalities Serum studies
show decreased concentrations of endoxifen, the active metabolite of the prodrug tamoxifen . Genetic analysis shows the homozygous presence of cytochrome P450 2D6 * 4 alleles.
Which of the following best represents the likelihood that this patient's sister has the same alleles?
A) 0%
B) 25%
C) 50%
D) 75%
E) 100%
S. A 22-year - old man comes to the physician because of infertility. The photomicrograph shows tissue obtained on biopsy of the scrotal
testes . Which of the following is the most likely genetic abnormality?
A) 45,X/ 46, XY
B) 46,XX
C) 46,XY
D) 47 ,XXX
E) 47,XXY
A 42-year - old man is brought to the emergency department because he says he feels as if he is "frozen in ice . " Examination shows muscle rigidity. Toxicology screen shows
evidence of exposure to MPTP (N-methyl- 4-phenyl-1,2,3,6-tetrahydropyridine). Which of the following neuronal cell bodies are primarily affected?
A) Adrenal gland
B) Hypothalamus
C) Ovarian FSH receptors
D) Ovarian LH receptors
E) Vaginal estrogen receptors
An 86-year -old man who lives in a skilled nursing care facility is brought to the physician because of a 3-week history of chronic nonproductive cough . He says that he is tired in the
mornings because the cough interrupts his sleep Physical examination shows no abnormalities except for the cough . A chest x-ray shows no abnormalities In addition to further
evaluation to determine the cause of his cough, which of the following drugs is most appropriate to treat this patient while avoiding the adverse effect of constipation?
A) Codeine
B) Dextromethorphan
C) Diphenhydramine
D) Morphine
E) Tiotropium
Which of the following drug effects is the most common reason for noncompliance with cyclic antidepressant therapy?
A) Antiadrenergic
B) Anticholinergic
C) Antihistaminic
D) Cholinomimetic
E) Sympathomimetic
A 65-year-old man comes to the physician for a follow-up examination. He has a 15-year history of poorly controlled type 2 diabetes mellitus, resulting in multiple peripheral
neuropathies . Neurologic examination shows wasting of the interosseous muscles of the left hand and inability to abduct the fingers of this hand; plantar flexion of the right foot is
absent. The function of which of the following pairs of nerves is most likely impaired in this patient?
A) Adenylyl cyclase
B) Guanylyl cyclase
C) Janus kinase
D) Phospholipase C
E) Tyrosine kinase
A 52-year - old man comes to the physician because a lump in his inguinal region, which had been present for 4 months, has recently enlarged and become painful. It is determined
that a direct inguinal hernia is present , and a segment of gut has pushed through the superficial inguinal ring. Which of the following will be impaired if the herniated gut compresses
the nerve that lies on the external surface of the spermatic cord at the superficial inguinal ring?
A) Autosomal dominant
B) Autosomal recessive
C) X-linked dominant
D) X -linked recessive
E) Multifactorial
An 18-month-old boy is admitted to the hospital because of generalized tonic-clonic seizures. He has a history of mild developmental delay. There is no family history of seizure
disorder or major medical illnesses. He is at the 25th percentile for length, the 25th percentile for weight , and the 25th percentile for head circumference. Physical examination
shows six hypopigmented macules scattered on the torso and a raised , flesh-colored lesion on the back . An MRI of the brain shows multiple lesions in the cerebral cortex . Which of
the following is the most likely diagnosis?
A) Ataxia -telangiectasia
B) Incontinentia pigmenti
C) Neurofibromatosis 1
D) Sturge-Weber syndrome
E) Tuberous sclerosis complex
A 62-year - old woman comes to the physician 3 days after discovering a painless mass in her left breast during self-examination. She has not had any weight loss or other recent
symptoms. Mammography 18 months ago showed no abnormalities. Menopause occurred at the age of 50 years. She takes no medications. She has no family history of breast
cancer. Physical examination shows a 2-cm, firm, nontender mass in the upper outer quadrant of the left breast . There is no axillary lymphadenopathy or nipple discharge.
Mammography shows an extremely radiodense mass with irregular margins; it contains clustered irregular microcalcifications. Which of the following is the most likely diagnosis?
A) Breast abscess
B) Carcinoma of the breast
C) Fibroadenoma
D) Fibrocystic changes of the breast
E) Intraductal papilloma
A 65-year-old man comes to the emergency department because of a 1-day history of shortness of breath . He has hypertension and type 2 diabetes mellitus. There is no history of
heart disease. Current medications include hydrochlorothiazide, ramipril, and metformin . He does not smoke. His temperature is 37°C (98.6°F), pulse is 110/ min , respirations are
28/min, and blood pressure is 152/92 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 90%. Cardiac examination shows an S 3. A grade 2/6 systolic murmur is
heard over the lower left sternal border radiating to the axilla . The point of maximal impulse is diffuse and most prominent in the axillary line. Which of the following findings is most
likely on pulmonary auscultation?
A) Crackles
B) Egophony
C) Unilateral decreased breath sounds
D) Wheezing
E) Whispered pectoriloquy
Thirty minutes after taking 2 aspirin tablets for a tension headache, a 17- year -old girl has difficulty breathing . An adverse reaction to the aspirin is suspected. In the future , she should
take which of the following drugs to treat her headaches?
A) Acetaminophen
B) Ibuprofen
C) Ketorolac
D) Naproxen
E) Sumatriptan
A 38-year -old man is admitted to the hospital after sustaining multiple injuries in a farm implement accident . The day after admission, his plasma fibrinogen concentration is
increased Which of the following is the most likely cause of this finding?
A) Acute-phase response
B) Anaphylaxis
C) Disseminated intravascular coagulation
D) Hemoconcentration
E) Histamine triple response
Nicotinic acid acts at which of the following labeled sites in the diagram of lipid metabolism?
Hepatocyles
"
Blood \
Gut Ac - CoA
i
LDL
^T LDL m
a
o
HMG CoA-
IB LDL zr
Cholesterol <D
L
A
I
ile acids c
\ ? at
o
O A) OB) O C) O D) O E)
A 31-year - old woman in the second trimester of pregnancy is brought to the emergency department because of vaginal bleeding. Blood pressure is 140/ 95 mm Hg Ultrasound
examination shows a conceptus with patches of tissue containing vesicular structures but no apparent embryo. The tissue is surgically removed and genetic analysis shows a
.
69 XXY karyotype The presence of which of the following would indicate that an embryo had been formed within this conceptus?
A) Cytotrophoblast
B) Hematopoietic stem cells
C) Primary stem villus
D) Syncytiotrophoblast
E) Trophoblastic lacunae
A new virus has been isolated that causes encephalitis. The viral particle contains an RNA-dependent DNA polymerase . Which of the following types of RNA is most likely to be the
genome of this virus?
A) Double-stranded circular
B) Double-stranded linear
C) Single- stranded negative-sense
D) Single-stranded positive-sense
A 53-year- old woman with a long history of fibromuscular dysplasia involving the left renal artery develops hypertension . Her left kidney is 7.4 cm (N = 10 cm). She is being
evaluated for a revascularization procedure; a left kidney biopsy is performed Which of the following histologic findings is most likely?
A) Endodermal cells
B) Epithelial cells in the yolk sac wall
C) Neural crest cells
D) Paraxial mesodermal cells
E) Splanchnic mesodermal cells
A 36-year - old woman comes to the physician because of a 4-month history of chronic fatigue. Physical examination shows a macular rash over the face. Serum studies show the
presence of antibodies against nucleosomes but not against histones. Urinalysis shows blood and 3+ protein. A biopsy specimen of renal tissue is consistent with lupus nephritis.
Treatment with prednisone is begun. This drug acts by binding to its receptor in which of the following sites?
A) Displacement
B) Projection
C) Rationalization
D) Reaction formation
E) Suppression
Parenterally administered cholera vaccines consisting of killed whole bacterial cells have very limited efficacy. Which of the following is the primary reason for this failure?
A) Inferior mesenteric
B) Inferior rectal
C) Superior mesenteric
D) Superior rectal