1.

A 59-year-old woman comes to the physician because of a 1-year history of pain and
stiffness in her fingers and knees. The stiffness lasts for about 10 minutes after she
wakes
up in the morning. She also reports that her knee pain is worse in the evening. She drinks one
glass of wine daily. Her only medication is acetaminophen. She is 175 cm (5 At 9 in) tall and
weighs 102 kg (225 lb); BMI is 33 kg/m2. Physical examination shows firm nodules on the
distal interphalangeal joints of the index, ring, and little fingers of both hands. Which of the
following is the most likely diagnosis
A. Pseudogout
B. Rheumatoid arthritis
C. Gout
D. Septic arthritis
E. Osteoarthritis

2. A 51-year-old woman comes to the emergency department because of a 1-day history

of severe pain in her left knee. To lose weight, she recently started jogging for 30
minutes a few times per week. She has type 2 diabetes mellitus and hypertension
treated with metformin and chlorothiazide. Her sister has rheumatoid arthritis. She is
sexually active with two partners and uses condoms inconsistently. On examination,
her temperature is 38.5°C (101.39F), pulse is 88/min, and blood pressure is 138/87
mm Hg. The left knee is swollen and tender to palpation with a significantly impaired
range of motion. A 1.5-cm, painless ulcer is seen on the plantar surface of the left foot.
Which of the following is most likely to help establish the diagnosis?
A. Perform MRI of the knee
B. Perform arthrocentesis
C. Measure HLA-B27
D. Measure rheumatoid factor
E. Perform ultrasonography of the knee
F. Measure serum uric acid levels
97. A 59-year-old woman comes to

3. A 47-year-old woman comes to the physician because of progressive pain and

stiffness in her hands and wrists for the past several months. Her hands are stiff in the
morning; the stiffness improves as she starts her chores. Physical examination shows
bilateral swelling and tenderness of the wrists, metacarpophalangeal joints, and
proximal interphalangeal joints. Her range of motion is limited by pain. Laboratory
studies show an increased erythrocyte sedimentation rate. This patient's condition is
most likely associated with which of the following findings?
A. IgG antibodies with a TNF-a binding domain on the Fc region
B. HLA-DQ2 proteins on white blood cells
c. Membrane proteins that bind to the Fc region of IgG
D. HLA-B27 protein on white blood cells
E. HLA-A3 proteins on white blood cells
F. IgM antibodies against the Fc region of IgG
 4. A 35-year-old man with a known history of peptic ulcer disease comes to the physician
with sudden onset of pain, swelling, and redness at the base of his great toe. Physical
examination shows swelling, erythema, and exquisite tenderness involving the right first
metatarsophalangeal joint. Fine-needle aspiration of the joint shows needle- shaped,
negatively birefringent crystals. After making the diagnosis, the physician prescribes an
appropriate medication. Shortly after starting the medication, the patient develops
nausea, vomiting, and diarrhea. Which of the following is the most likely mechanism of
action of the drug prescribed to this patient?
A. Decreased renal tubular uric acid reabsorption
B. Inhibition of cyclooxygenase activity
C. Inhibition of microtubule formation
D. Inhibition of phospholipase A2 activity
E. Inhibition of xanthine oxidase activity

5. . A 70-year-old man comes to the physician because of a painless skin lesion on his
neck for the past 5 months. The lesion has gradually become darker in color and is
often pruritic. He has a similar lesion on the back. He is a retired landscaper. He has
smoked half a pack of cigarettes daily for 45 years. Physical examination shows a 0.9
cm hyperpigmented papule on the neck with a greasy, wax-like, and stuck-on
appearance. Histopathologic examination is most likely to show which of the
following?
A. S100-positive epithelioid cells with fine granules in the cytoplasm
B. Koilocytes in the granular cell layer of the epidermis
c. Nests of melanocytes at the base of rete ridges and the dermis
D. Immature keratinocytes with small keratin-filled cysts
E. Fibroblast proliferation with small, benign dermal growth

6. Macular, hyperpigmented lesions on the forehead and cheeks in women are

characterized for
A. melasma
B. melanoma
C. basal cell carcinoma
D. lentigo

7. Which of the following describes the major difference between a first- and second
generation antihistamine?
A. selectivity at H1 receptors
B. ability to cross the blood-brain barrier
C. effectiveness in treating allergies
D. potency at blocking H1 receptors
E. indications for use
 8. A 26 year old female reports to have a subcutaneous bump that is soft and movable on
palpation. She underwent an operation to remove the mass because of the cosmetic
issues. Microscopic examination revealed a benign tumor shown on the image. What is
the most likely diagnosis?
A. Liposarcoma
B. Lipoma
C. Fibroma
D. Fibrosarcoma
E. Rhabdomyoma

9. A 45-year-old obese man with a history of alcohol abuse and hypertension develops
joint swelling and pain. His rate excretion rate is 950 mg/day (normal value 250-750
mg/24 hr). Which of the following agents is the best long term treatment for his
condition?
A. probenecid
B. allopurinol
C. piroxicam
D. lesinurad
E. colchicine

A 55-year-old man presents with pain in the left arm. Laboratory studies show elevated serum
levels of calcium and Parathyroid hormone. An X-ray of the left arm reveals multiple small bone
cysts and pathologic fractures. Biopsy of the affected bone discloses numerous giant cells in a
cellular and fibrous stroma. The patient undergoes removal of a parathyroid adenoma. Which
of the following best describes the pathogenesis of bone pain and
pathologic fractures in this patient?
A. Enhanced osteoblast activity
B. Impaired mineralization of osteoid
C. Increased bone resorption
D. Increased mineralization of bone
E. Osteoporosis

An investigator is studying an experimental treatment for HIV infection that inhibits the
maturation of new HIV virions. Patients who are taking the drug are observed for several years
and side effects are recorded. A correlation is established between the drug and the
development of impaired glucose tolerance. In addition, a significant portion of the patients who
take the drug for several years develop kidney stones and show increased fat accumulation in
the neck with loss of subcutaneous fat in the face and extremities. Which of the following
processes is most likely targeted by this drug?
A. Viral entry into host cell
B. Viral polypeptide cleavage
C. Viral DNA integration into host DNA
D. Viral budding from host cells
E. Reverse transcription of viral RNA
A 64-year-old woman complained to her physician of persistent back pain for the past 3 days.
Dual-energy ×-ray absorptiometry showed diffuse osteoporosis of the spine and hips. The
physician prescribed calcium and vitamin D supplementation and alendronate, one tablet daily.
Which of the following actions most likely mediated the therapeutic effect of alendronate in the
patient's disease?
A. Stimulation of osteoblast activity
B. Stimulation of intestinal calcium absorption
c. Inhibition of renal calcium excretion
D. Inhibition of osteoclast activity
E. Inhibition of renal synthesis of calcitriol

. A 61-year-old man comes to the office to follow up on acute arthritis. He was seen at a
nearby urgent care center 6 weeks ago for sudden-onset pain and swelling in the ankle. The
patient was treated with an unknown analgesic with rapid relief of his pain. Since that time, his
pain has resolved completely and he is now feeling well. Past medical history is notable for
recurrent renal colic. On examination, his ankle appears normal with no redness, warmth, or
swelling. The serum uric acid level is 9.8 mg/dL. Which of the following is the best agent for
the long-term management of this patient?

A. Antibiotics
B. Cyclooxygenase inhibitor
c. Glucocorticoid
D. Lipoxygenase antagonist
E. Uricosuric agents
F. Xanthine oxidase inhibitor

A 51-year-old man has endured episodes of intense local pain involving his left foot for the
past 4 months. The pain may last hours to days. Physical examination identifies the right
metatarsophalangeal (MP) joint as the focus of tenderness and swelling, but minimal loss of
joint mobility. A painless 2-cm nodule with overlying ulcerated skin is present on the lateral
aspect of the MP joint. Beneath the eroded skin is a chalky white deposit of soft material. A
firm 1-cm subcutaneous nodule on the extensor surface of the left elbow is excised and has
the microscopic appearance shown in the figure. Which of the following mechanisms is most
important in causing joint injury in this man?

A. Activation of neutrophils by phagocytosis of rate crystals

B. Release of TNF causing acute joint inflammation
C. Giant cell reaction against Mycobacterium tuberculosis
D. Reduced metabolism of homogentisic acid
E. Deposition of serum cholesterol into the synovium

A 60-year-old man presents with a slowly enlarging lesion just beneath his right eye.
Physical examination finds a 7-mm pearly papule with irregular raised margins and a central
depression. A biopsy from this lesion would most likely reveal which of the following
histologic changes?
A. Hyperplasia of the epidermis forming numerous keratin-filled pseudocysts B.
Hyperplasia of the stratum corneum forming a central keratin-filled "crater" C.
Infiltrating groups of basaloid cells having peritumoral clefting
D. Infiltrating groups of eosinophilic cells with keratin formation
E. Infiltrating spindle-shaped cells with melanin production

A 14-year-old boy comes to the physician because of an itchy rash on his right arm for 1 day.
The rash started as small papules, then progressed into blisters with oozing. He has had atopic
dermatitis since the age of 6 years. His vital signs are within normal limits. A photograph of the
patient's arm is shown. There is no lymphadenopathy. Avoidance of contact with which of the
following would most likely have prevented this patient’s symptoms?

A. Antibiotics
B. Cats
C. Bees
D. Plants
E. Sun
F. Gluten

. An 81-year-old farmer presents with a 2-cm, red, slightly raised plaque on his face. A
biopsy revealed a malignant tumor of the skin shown on the image below. What is the most
likely diagnosis?

A. Squamous cell carcinoma

B. Basal cell carcinoma
C. Melanoma
D. Merkel cell carcinoma
E. Seborrheic keratosis
. A 53-year-old man comes to the physician for a follow-up examination after an open fracture
of the right tibia. Three months ago, he went on an expedition to Egypt, where he fell down
while running away from a snake. He was treated with open reduction and internal fixation.
He reports that, since his fall, his leather hat no longer fits. He has also had progressive
hearing loss over the past year. He works as a professor of archeology. He takes ibuprofen
for bone pain. Physical examination shows bowing of the right leg. Which of the following
changes in bone ar chitecture is the most likely underlying cause of this patient's symptoms?
A. Deposition of lamellar bone interspersed with woven bone
B. Subperiosteal bone resorption and cystic degeneration
c. Accumulation of inadequately mineralized osteoid
D. Formation of multiple punched-out lytic lesions in bony cortex
E. Loss of cortical bone mass and thinning of trabeculae

A 30-year-old hospitalized patient with AIDS has a CD4 cell count of 50/uL. He is being treated
with a highly active antiretroviral therapy (HART) regimen consisting of zidovudine (ZDV),
lamivudine (3TC), and indinavir. Other drugs being administered to this patient include
ganciclovir, clarithromycin, rifabutin, and trimethoprim-sulfamethoxazole. The drug in this
patient's regimen that inhibits posttranslational modification of viral proteins is A. Acyclovir
B. Indinavir
c. Lamivudine
D. Rifabutin
E. Zidovudine

. A woman with a BMD T-score of -3 is given daily subcutaneous injections of

Teriparatide to increase bone formation. Which effect is most likely produced by this
treatment?
A. increased absorption of dietary calcium
B. increased serum levels of vitamin D
C. decreased activation of osteoclasts
D. increased activation of osteoblasts
E. adsorption of the drug to bone

A 60-year-old woman complains of intermittent joint pain and morning stiffness for the past
couple of years. Her hands have been affected the most, and she has recently had difficulty
gardening because of the pain. There is no history of coronary or cerebrovascular disease. On
physical examination, the joints are tender to palpation, warm, and swollen. An X-ray of her
hands is shown. An anti-inflammatory medication is prescribed.What is the mechanism of
action of the drug most likely prescribed?
A. Decreased leukotriene production
B. Decreased prostaglandin production
C. Decreased thromboxane production
D. Increased arachidonic acid level
E. Increased prostacyclin level

A 60-year-old otherwise healthy man has a remote history of gastritis associated with a
medication prescribed for his osteoarthritis. Recently, he started experiencing more joint pains
while performing daily activities. He asks his family physician for pain medication to manage
his osteoarthritis. Which of the following analgesics should be prescribed?

A. Aspirin
B. Celecoxib
c. Diciofenac
D. Ibuprofen
E. Indomethacin

AT, a 23-year-old woman with severe asthma, has been taking oral prednisone to reduce her
asthma attacks. She is encouraged when you tell her about budesonide, an inhaled steroid.
The topical administration and short half-life of budesonide greatly reduce the risk of systemic
side effects compared with oral prednisone. The long-term daily oral administration of
therapeutic doses of prednisone results in which of the following adverse effects?
A. Anemia
B. Decreased bone density
c. Elevated serum calcium concentration
D. Hyperplasia of cells in the zona fasciculata and zona reticularis of the adrenal cortex E.
Increased male-pattern hair growth in women

A 26-year-old man presents with a pigmented papule on his neck. He reports to have this
papule for several years. The lesion has not grown in size and didn't change its appearance,
but he is worried and asks for the excision of his papule. The microscopic slide is given to
you. What is the most likely diagnosis?

A. Melanoma
B. Junctional nevus
C. Solar elastosis
D. Sebortheic keratosis
E. Keratoacanthoma

A 37-year-old woman with an HIV infection comes to the physician for a follow-up
examination. Six months ago, combined antiretroviral therapy consisting of dolutegravir,
tenofovir, and emtricitabine was initiated. Laboratory studies show a decrease in the CD4
count and an increase in the viral load despite ongoing treatment. The patient is switched to a
new treatment regimen, including a drug that acts by preventing viral DNA synthesis without
undergoing intracellular phosphorylation. Which of the following is the most likely drug?
A. Enfuvirtide
B. Efavirenz
C. Raltegravir
D. Lamivudine

Which drug exerts a fungicidal effect by inhibiting synthesis of the fungal cell wall? A.
micafungin
B. posaconazole
C. fucytosine
D. nystatin
E. terbinafine

A 42-year-old man comes to the physician with a 3-month history of an itchy rash on his face.
Six months ago, he was diagnosed with early-onset Parkinson disease. His only medication is
pramipexole. Physical examination shows the findings seen in the photograph. There is
copious dandruff on his scalp without underlying erythema. Which of the following is the most
likely diagnosis?
A. Seborrheic dermatitis
B. Atopic dermatitis
C. Dermatomyositis
D. Systemic lupus erythematosus
E. Allergic contact dermatitis
F. Rosacea
G. Psoriasis

A 58-year-old woman comes to the emergency department due to sudden-onset, severe back
pain. The patient has had no major trauma and says that the pain started after she sat down
too quickly on a hardwood chair. She has a long history of rheumatoid arthritis and
hypothyroidism and has been treated with several medications over the course of many
years. The patient has midline tenderness over the lower thoracic spine. The straight leg
raising test is negative. Thoracolumbar spine X-ray reveals a fracture of the tenth thoracic
vertebra. Which of the following mechanisms is the most likely cause of this patient's current
condition?
A Adverse effect of indomethacin
B. Adverse effect of prednisone
C. Bisphosphonate-induced osteonecrosis
D. Chronic undertreatment of hypothyroidism

A 56-year-old woman comes to the emergency department because of a 3 day history of

malaise, dysuria, blurred vision, and a painful, itchy rash. The rash began on her chest and
face and spread to her limbs, palms, and soles One week ago, she was diagnosed with
trigeminal neuralgia and started on a new medicine She appears ill Her temperature is 38°C
(100.4°F) and pulse is 110/min. Physical examination shows conjunctival injection and
ulceration on the tongue and palate. There is no lymphadenopathy Examination of the skin
shows confiuent annular, erythematous macules, bullae, and desquamation of the
palms and soles. The epidermis separates when the skin is lightly stroked. Which of the
following is the most likely diagnosis?
A. Bullous pemphigoid
B. Steven-Johnson syndrome
c. Pemphigus vulgaris
D. Erythema multiforme
E. Drug-induced lupus erythematosus
F. DRESS syndrome
G. Staphylococcal scalded skin syndrome

A male patient with AIDS has a CD4 T lymphocyte count of 50 cells/ul (nomal, 600-1500
cells/uL). He is being maintained on a multidrug regimen consisting of acyclovir,
clarithromycin, dronabinol, fluconazole, lamivudine, indinavir, trimethoprim, sulfamethoxazole,
and zidovudine. The drug that provides prophylaxis against cryptococcal infections of the
meninges is
A. Acyclovir
B. Clarithromycin
C. Fluconazole
D. Lamivudine
E. Trimethoprim-sulfamethoxazole

A 34-year-old man with ulcerative colitis is hospitalized after developing Intense abdominal
pain, loose stool, and hematochezia. He has been taking 5-aminosalicylate with good control of
his symptoms until now He is prescribed prednisone to reduce the inflammation and achieve
remission of his acute flare. The physician recommends initiating a 60-mg dose with a slow
taper in dosing daily until he is completely weaned off the medication. Which of the following
side effects is most likely to arise from long-term maintenance use of the newly prescribed
medication?
A. Adrenal hyperplasia
B. Agranulocytosis
c. Hip fracture
D. Immune reconstitution syndrome
E. Spider angiomata

. A 17-year-old girl complains of a painful, swollen left elbow and fever. In the previous few
days her right knee was also swollen and slightly painful The physician notices several oral
ulcers and an edematous and tender left elbow Laboratory tests are notable for weakly positive
antinuclear antibodies and anemia, she has no sexual history. Which of the following is the
most specific antibody for the patient's condition?
A. Anti IgG
B. Anti-Jo-1
c. Anti-Smith
D. Anticentromere
E. Antimicrosomal
. A 56-year-old woman with rheumatoid arthritis comes to the physician for a follow-up
examination. She has no other history of serious illness Menopause occurred 1 year ago.
Current medications include anti-rheumatic drugs and hormone replacement therapy. She
exercises regularly. A DEXA scan shows a T-score of -1.80, indicating decreased bone
density. Which of the following drugs is most likely involved in the pathogenesis of this
finding?
A. Sulfasalazine
B. Medroxyprogesterone acetate
C. Naproxen
D. Prednisone
E. Adalimumab

An investigator is studying the efficiency of a new anti-gout drug in comparison to colchicine

in an experimental animal model. The test group of animals is injected with the new drug,
while the control group receives injections of colchicine. Which of the following cellular
functions will most likely be impaired in the control subjects after the injection?

A. Stereocilia function
B. Muscle contraction
c. Axonal transport
D. Transmembrane signal transduction
E. Intercellular adhesion

. A 32-year-old woman comes to the physician because of fatigue and difficulty swallowing
for 6 weeks. She also complains of painful discoloration in her fingers when exposed to cold
weather. She has smoked one pack of cigarettes daily for 4 years. She appears younger
than her stated age. Physical examination shows smooth, swollen fingers with small white
calcifications on her fingertips bilaterally. This patient is at increased risk for which of the
following complications?
A. Liver citthosis
B. Chronic obstructive pulmonary disease
c. Pulmonary hypertension
D. Glomerular basement membrane disease
E. Aortic aneurysm
F. Chondrocalcinosis

A mother brings her 12-year-old son to the pediatrician's office because he is complaining of
leg pain. The pain is located at the proximal right tibia and has persisted over the past 2
weeks. The mother also notes that the child has had intermittent fevers during this time, On
examination, the site is erythematous and swollen. A biopsy of the site shows sheets of many
uniform cells with scant clear cytoplasm and no evidence of normal bony matrix. Which of the
following is the most likely diagnosis?
A. Ewing sarcoma
B. Giant cell tumor
c. Osteochondroma
D. Osteomyelitis
E. Osteosarcoma
A 20-year-old man complains of pain and swelling around his right knee. A radiograph shows
a destructive mixed lytic and blastic mass arising from the metaphysis of the distal tumor. The
microscopic figure is provided. What is the most likely diagnosis?

A. Osteoblastoma
B. Osteoid osteoma
C. Osteosarcoma
D. Chondrosarcoma
E. Rhabdomyoma

. A 58-year-old white man with hypertension and type 2 diabetes mellitus comes to the
physician because of a 3-month history of a painless lesion on his lower lip. He has smoked
one pack of cigarettes daily for 20 years. He has worked as a fruit picker for the past 25 years.
His current medications include captopril and metformin. Examination of the oral cavity shows
a single ulcer near the vermillion border. Which of the following is the most likely diagnosis?
A. Squamous cell carcinoma
B. Herpes labialis
c. Pemphigus vulgaris
D. Aphthous stomatitis
E. Actinic keratosis
F. Traumatic ulcer
G. Basal cell carcinoma

A 49-year-old woman has been bothered for at least 20 years by recurring skin lesions that
are most prominent over the elbows and knees and also sometimes on the scalp and
lumbosacral area. These skin lesions are silvery to salmon-colored 1- to 4 cm plaques with
scaling. The lesions seem to form more readily at sites of minor trauma, such as a superficial
abrasion. She has had increasing pain in her left hand and in her hips, more prominent on the
left, over the past 2 years. On physical examination, she has yellow brown discoloration with
pitting of the fingernails. The distal interphalangeal joints of digits two and three of the left hand
are slightly swollen and tender. There is minimal reduction in left hip mobility and no swelling or
warmth to the touch. A radiograph of the left hip shows minimal joint space narrowing and
surface erosion. Bone density is not markedly reduced. During the next 10 years, the joint pain
persists, but there is no joint destruction or deformity. She continues to have the same skin
lesions. Which of the following is most likely to be seen on biopsy of these skin lesions?
A. Bandlike upper dermal infiltrate of lymphocytes
B. Epidermal spongiosis with dermal edema and eosinophils
C. Focal keratinocyte apoptosis
D. Hyperkeratosis with parakeratosis and elongated ridges
E. IgG deposited at the dermal-epidermal junction

. A previously healthy 13-year-old girl is brought to the physician for evaluation of a 2- month
history of fatigue. She reports recurrent episodes of pain in her right wrist and left knee. During
this period, she has had a 4-kg (8.8-Ib) weight loss. Her mother has rheumatoid arthritis. Her
temperature is 38°C (100.4°F). Examination shows diffuse lymphadenopathy. Oral examination
shows several painless oral ulcers. The right wrist and the left knee are swollen and tender.
Laboratory studies show a hemoglobin concentration of 9.8 g/dL, a leukocyte count of
2,000/mm3, and a platelet count of 75,000/mm3. Urinalysis shows excessive protein. This
patient's condition is associated with which of the following laboratory findings?
A. Positive monospot test
B. Leukocytoclastic vasculitis with IgA and C3 immune complex deposition c.
Anti-Ds-DNA antibodirs
D. Positive pathergy test
E. Anti-citrullinated peptide antibodies
F. Excessive lymphoblasts
G. Reed-Stemberg cells
H. Positive HLA-B27 test

. A 45-year-old obese man with a history of alcohol abuse and hypertension develops joint
swelling and pain. His rate excretion rate is 950 mg/day (normal value 250-750 mg/24 hr).
Which of the following agents is the best long term treatment for his condition?

A. probenecid
B. allopurinol
C. piroxicam
D. lesinurad
E. colchicine

A 20 years old male presents with: X-ray of the right hip reveals sclerosis, fragmentation of
the femoral head, bone scan shows decreased perfusion to the femoral head. These
radiographic features are specific to which of the following disease?

A. Rheumatoid arthritis
B. Spondyloarthritis
C. Legg-Calve-Perthes disease (avascular necrosis
D. Osteoarthrosis

. A 23-year-old athletically built woman comes to the physician complaining of multiple red,
ring-like lesions on her body, as seen in the image. A careful history reveals that she
acquired these skin lesions after using poorly cleaned yoga mats at a local gym. The
physician prescribes a medicine to clear her rash. After 15 days of taking the medication, the
woman returns to the office. The skin lesions are clearing, but she has noticed that patches
of her skin have become darker than normal.
Which of the following medications is this patient most likely taking? A.
Amphotericin B
B. Fluconazole
C. Flucytosine
D. Itraconazole
E. Ketoconazole

. A 42-year-old woman has had increasing pain and swelling of the joints of her hands and
feet for several months. It is becoming very difficult for her to perform common household
tasks. A microscopic image of the synovium of a proximal interphalangeal joint in her hand is
shown.

Which of the following laboratory serologic findings would most likely be positive in this
patient?
A. Anticentromere antibody
B. Antinuclear antibody
c. Borrelia burgdorferi antibody
D. HLA-827
E. gM anti-gG

A 42-year-old woman comes to the physician because of a 10-month history of joint pain and
stiffness in her wrists and fingers. The symptoms are worse in the morning and improve with
activity. Physical examination shows swelling and warmth over the MCP and wrist joints in both
hands. An x-ray of the hands is shown. Synovial biopsy from an affected joint would most likely
show which of the following?
A. Noninflammatory superficial fibrin deposits
B. Monosodium urate crystals
c. Calcium pyrophosphate crystals
D. Noncaseating granulomas
E. Proliferation of granulation tissue

. A 32-year-old homeless man presents to the emergency department with multiple fractures
after falling down a flight of stairs. Radiographs indicate that some of these fractures actually
occurred before the fall and that some of the fractures may be pathologic. Laboratory studies
show low levels of vitamin D and phosphate, a low-normal
level of calcium, and an elevated level of alkaline phosphatase. What type of histologic
finding would corroborate this patient's most likely diagnosis?
A. Areas of increased unmineralized osteoid adjacent to normal trabeculae B.
Hypoproliferation of osteocytes in cortical bone
c. Lack of a medullary canal and decreased numbers of osteoclasts
D. Neutrophilic infiltration and necrotic changes in trabeculae
E Sheets of bone matrix displacing normal bone structure, with bizarre large cells

. A 69-year-old woman taking hydralazine for hypertension presents with joint pain and chest
pain. On cardiac examination, the patient has a pericardial rub. What is the diagnosis?
A. Dermatomyositis
B. Drug induced SLE
C. Polymyalgia rheumatica
D. Felty syndrome

. A 26-year-old female with acquired immunodeficiency syndrome (AIDS) develops

cryptococcal meningitis. She refuses all intravenous medication. Which antifungal agent can
be given orally to treat the meningeal infection?
A. Ketoconazole
B. Ampothericin B
C. Fluconazole
D. Nystatin

A patient with Addison disease continues to have hyperkalemia despite receiving adequate
replacement doses of hydrocortisone (cortisol). Which drug should be added to the treatment
regimen to reduce serum potassium levels?
A. dexamethasone
B. fludrocortisone
C. triamcinolone
D. prednisone
E. aldosterone

. A 43-year-old woman comes to the physician because of a 1-day history of rash on the trunk
and lower extremities. Three days ago, she visited a spa resort with multiple swimming pools
and whirlpools. A friend of hers who also visited the spa has developed a similar rash. She
does not smoke or drink alcohol and takes no medications. She appears well. Her vital signs
are within normal limits. Examination shows multiple erythematous, excoriated papules, and
pustules over the trunk and upper thighs. Inflammation of which of the following structures is
most likely responsible for this patient’s condition? A. Superfical epidermis
B. Hair follicles
C. Sebaceous glands
D. Papillary dermis
E. Eccrine sweat glands

. A 38-year-old woman presents to the emergency department complaining of increasing

muscle weakness and pain. She first noticed the muscle weakness approximately one month
ago, and it has gradually worsened since then. During the same time she has had increasing
difficulty swallowing her meals. Two weeks prior to this visit, she recalls swelling and a rash
over her eyelids. On physical examination, deltoid and quadriceps strength are
2/5 bilaterally. Creatine kinase, lactate dehydrogenase, and aldolase levels are elevated.
Which auto-antibody would diagnostic testing find to be elevated?
A. Anti-dsDNA
B. Anti-Jo-1
C. Anti-igG
D. Anti-microsomal
E. Anti-mitochondrial

A previously healthy 3-year-old girl is brought to the physician by her parents for the
evaluation of recurrent episodes of pain in her left wrist and right knee for 4 months. She has
not had any trauma to the knee or any previous problems with her joints. She attends
daycare. Her mother has rheumatoid arthritis. Her vital signs are within normal limits.
Examination of the right knee and left wrist shows mild swelling, tenderness, and warmth;
range of motion is slightly decreased. No other joints are affected. The remainder of the
examination shows no abnormalities. Laboratory studies show:
Hemoglobin 12.4 g/dL

Leukocyte count 9,000/mm

Platelet count 200,000/mm

Erythrocyte sedimentation rate 50 mm/h

Serum

Antinuclear antibodies Positive

Rheumatoid factor Negative

This patient is at increased risk for which of the following complications? A.

Sepsis
B. Ailanto-axial subluxation
C. Airway obstruction
D. Inflammation of sacroiliac joints
E. Valvular lesion
F. Nephritis
G. Coronary artery aneurysm
H. Blindness