NBME 27

BLOCK 1
1. 46XY karyotype + 4 months later, baby born with female phenotype. USG shows male
genital ducts. - 5-alpha reductase deficiency. Testosterone forms SEED - SV, ED,
Epididymis & Vas Deferens. Testo converted to DHT with 5 alpha reductase. DHT
responsible for male external genitalia. Deficiency of steroid sulfatase enzyme leades to
X-Linked Icthyosis due to accumulation of cholesterol sulphate in skin.
2. C/o cystic fibrosis presenting with bilateral weakness, decreased DTRs and ataxic
gait. - Vitamin E deficiency. Such patients can have acanthocytosis on peripheral
smear.
3. Hypertensive women with ECG showing sum of magnitudes of S wave in lead V2 and
R wave in lead V5 as 45mm. Cellular changes in left ventricle - Increased sarcomeres in
an array in parallel with each other. >35mm s/o left ventricular hypertrophy. Decreased
sarcomeres with increased fibroblasts seen in Myocardial scar formation & fabry’s
disease. Increased sarcomeres in an array in series with each other is seen in dialated
cardiomyopathy. Increased sarcomeres with decreased abumdance of f-actin seenin
Hypertrophic cardiomyopathy. Sarcomeres in parallel increase contractile force and
cause thickening. Sarcomeres in series increase length.
4. Pic of cellulitis with micro pic showing gram positive cocci in chains -
Streptococcus pyogenes (Group A). Clostridium perfringens - Gram pos bacillus -
necrotising fascitis - alpha toxin - gas gangrene. Enterococcus - gamma hemolytic group
D Strept - nosocomial UTI. Staph aureus - gram positive cocci in clusters - purulent
cellulitis. Strept Pyogenes Grp A - gram pos cocci in chains - non purulent cellulitis - beta
hemolytic - bacitracin sensitive.
5. Patient with decreased respiration secondary to narcotic induced resp depressions,
Increase in cerebral blood flow seen with - Increased CO2 concentration in blood.
Hypocapnoea will cause vasoconstriction. Hypercapnoea will cause cerebral
vasodialation. Opioid induced resp depression causes hypercapnoea with increased H+
ion concentration in blood.
6. H. Influenza vaccine is - Conjugated capsular polysaccharide. Similar ex are
N.Meningitidis and strept pneumoniae. Ex of toxoid based vaccine - C. Diptheria,
cl.tetani and bordetella pertussis.
7. AIDS patient with abdominal cramps and watery diarrhoea - Cryptosporidium
Parvum - Intra luminal cysts on acid fast stain. Other infections in AIDS patients -
Candida causes esophagitis and oral thrush - Pseudohyphae & budding yeasts.
Cryptococcal meningitis - India ink stain / mucicarmine stain with narrow budding. CMV
is HHV-5, Causing esophagitis, pneumonia and retinitis, intracellular inclusion bodies
called cowdry bodies. MAC causes atypical pneumonia and GIT infection.
8. Vaginal bleeding in post menopausal woman, Strongest risk factor for endometrial
adenocarcinoma - Estrogen therapy. Endogenous sourse of estrogen production are
adipose tissue and increased number of lifetime ovulatory menstrual cycles. (Early
menarche and late menopause). Nulliparity (since pregnancy helps in post pon of
menstrual cycles). Endometrial Ca is estrogen sensitive.
9. Overdose of metformin - Increased lactic acid concentration. Other drug
cyclophosphamide causes SIADH.
10. Patient on only juice, fruit diet & grains + regular marijuana smoker. - s/o IDA - RBCs
shall have pale color, small size and normal shape.
11. Iv drug user - Tricupid valve abnormality. TV Endocarditis - staph, pseudomonas
and candida. - Holosystolic murmur at left lower sternal border. Risk factor for RHF.
Complications include TR and septic pul emboli.
12. M protein spike - B lymphocyte neoplasia.
13. Radioactivity of a radiolabelled hormone X is detected only around region of plasma
membrane. Hormone X is similar to - Prolactin. Radioactivity detected within nuclear -
Aldosterone, cortisol, thyroid and estradiol.
14. Max sensitivity - (A) Least false negative.
15. C/o HIV with violaceous raised cutaneous plaques - s/o kaposi sarcoma presenting
with - Proliferating spindle cells forming slit like spaces filled with blood.
16. Cause of respiratory alkalosis - Breathing a gas mixture with low pO2.
17. C/o weakness and pain only during external rotation of shoulder. - Infraspinatus
injury. Supraspinatus - Abduction; Infraspinatus - External rotation; Teres minor - (TEA)
External rotation and adduction; Subscapularis - Internal rotation; Teres major - Internal
rotation and adduction; Latissmus dorsi (LAId) - Adduction and Internal rotation.
18. Case history suggestive of myco TB - Cord factor protects bacteria from phagocytic
killing and is directly cytotoxic to macrophages.
19. PE shows 1cm ulcer on right LE and many erythrmatous macular lesions over both
LE. Fluctuant 3x5cm mass in femoral lymph node. CXR shows bilateral infiltrates. Gram
stain shows numerous neutrophils with gram negative bacilli. - Yersinia pestis. Caused
by infected fleas. Can also be acquired with direct handling of infected animals (cats).
Causes ulcerglandular disease (buboes). Coxiella burnetti causes Q fever, exposure
occurs through contact with contaminated livestock. Chronic Q fever can cause
endocarditis. Ehrlicia vector is tick not flea. Francisella is through contact with infected
rabbits.
20. Thyroidectomy 3 weeks ago. C/o 2 week h/o fatigue, difficulty swallowing and
paraesthesias of her lips and fingers + painful wrist spasms. On low dose ppnl, ECG
shows prolonged QT interval. S/o - Hypoparathyroidism. Caused by hypocalcemia
which presents with peri-oral paraesthesias, carpopedal spasm, laryngospasm and
prolonged QT interval.
21. To access the renal arteries from the femoral artery approach, the catheter should be
advanced to area just superior to Testicular artery.
22. Remodelling of scar during first year after injury is mediated by - matrix
metalloproteinases.
23. C/o AV Fistula - Increased cardiac output with increased right atrial pressure.
Increased preload, decreased SVR, high capacitance low pressure venous system. Size
of fistula is most predictive of developing high output HF.
24. Unilateral decreased breath sounds, dull percussion note, decreased TF and no
adventitious sounds - Pleural effusion and atelectasis. Hyper resonant breath sounds in
Pneumothorax. TF is increased only in Consolidation.
25. Reason for women being osteoporotic earlier than men. - “Men start out with
higher peak bone mass compared with women.”
26. For GERD cases, drug that binds irreversibly to its site of action (H+K+ ATPase on
luminal side) to inhibit gastric acid formation, - Esomeprazole (PPIs). Other class of H2
receptor blockers eg.famotidine are reversible competitive antagonists. Misoprostol, a
PGE1 analog, regulates thru G-protein coupled receptor inhibition of cAMP leading to
decreased H+K+ ATPase activity. Sucralfate + HCL forms thick viscous coating that binds
to proteins on mucosal surface.
27. Anti-diabetic drugs pioglitazone (thiozolidenedione) and gemfibrozil (fibrate) initiate
their effects by binding to PPARs.
28. Priapism - Lack of input from Sympathetic fibers from the prostatic plexus.
29. Skin biopsy showing non acantholytic blister with separation from epidermis from
the basement membrane. Autoantibody directed against - Hemidesmosomal proteins.
30. -
31. Fibronectin mRNA would most likely be increased in renal mesangial cells incubated
in a medium containing glu-6-phosphate to produce AGEs with type 1 collagen, as
fibronectin is critical component of matrix.
32. Lesion of cerebellar vermis - Gait ataxia, titubation and nystagmus. Lesion of
cerebellar hemisphere - Dysdiadochokinesia, dysmetria of finger nose testing, intention
tremor and gait ataxia. Positive romberg sign is with lesion of dorsal column - medial
lemniscus pathway.
33. MEPP depends on ligand gated sodium channels. EPP depends on presynaptic
release of ach to activate the calcium channels. Botulinum shall inhibit the presynaptic
release of ach thereby decreasing the magnitude of EPP.
34. Maneuver for ruling out cerebellar tumor - Rapid alternating movements. Babinski
sign - plantar flex with abduction of toes - UMN lesion; Doll’s eye (oculocephalic reflex) -
brainstem reflex. Glabellar tap - s/o frontal lobe immaturity in infancy, advanced
dementia as a frontal release sign; Tinel sign - s/o carpal tunnel syndrome.
35. To encourage for stopping smoking - “What thoughts have you had about quitting
smoking?”.
36. 46 yrs old patient’s visual acquity is 20/20 bilaterally. On hand held charts, he can
read 20/20 line only if he holds the card more than 14 inches away. - Normal age related
changes. Helmholtz theory of accomodation - Contraction of ciliary muscles relaxes
tension of zonular fibers upon lens - Lens become round - Increased diopteric power -
allows focus on objects at closer distances. Age related hardening of lens and decreased
accomodative ability results in presbyopia.
37. Gastrin - released by parietal cells. Intense acidophilic cytoplasm. C/o post prandial
abdominal pain + epigastric tenderness + orthostatic hypotension + diaphoresis in
setting of duodenal or pancreatic lesion - Peptic ulcer secondary to zollinger ellison
syndrome.
38. CT brain showing dark zone with most of left hemisphere involving territory of MCA.
Occlusion of MCA in dominant hemisphere will occlude broca’s area, wernicke’s area
and arcuate fasciculus. - Global aphasia. Spatial neglect is caused by damage to
parietal lobe in non dominant hemisphere, which leads to hemineglect on contralateral
side of body.
39. C/o sarcoidosis. LN will show - Granuloma formation.
40. Participants in a study are recruited via advertisements and all persons who answer
the advertisement are selected for study. - Self selection. Potential source of selection
bias.
41. New drug that prevents the polymerization of actin filaments is tested. Inhibition of
phagocytosis seen in leukocytes. Polymerization of actin is a crucial step in
phagocytosis as it permits the extension of T cell membrane around the pathogen
allowing for its encapsulation and internalization.
42. 1yr old Girl with c/o coarse facial appearance, clouded cornea,
hepatosplenomegaly, stiff joints or joint contractures, developmental delay, intellectual
disability. Urine shows increased conc of dermatan sulphate and heparan sulphate. -
Alpha iduronidase deficiency. AR Hurlers syndrome. Another MP is hunters syndrome
which is deficiency of iduronate sulphatase. XLR, pearly papular skin lesions.
43. Neonate with micrognathia, glossoptosis causing difficulty feeding and respiratory
distress, cleft palate. S/o Pierre Robin syndrome. Due to defect in development of first
pharyngeal arch.
ARCH BONES MUSCLES CARTILAGE NERVES
FIRST Maxilla, Pterygoid, - CN V1 & V2
mandible mylohyoid
SECOND Hyoid bone, Stapedius, - CN VII
temporal bone platysma,
stylohyoid
THIRD Stylopharyngeous - CN IX
FOURTH Cricothyroid, thyroid CN X - sup
muscles of soft laryngeal
palate branch
SIXTH Intrinsic m of Cricoid, CN X -
larynx except arytenoid, Recurrent
cricothyroid corniculate & laryngeal
cuneiform branch

44. Ovarian cancer first drains into lymph nodes - Along the ovarian vessels.
Abdominal, both lower extremities, left upper extremity - Para-aortic LN > Cisterna
chyli > thoracic duct > left subclavian vein. Right side above diaphragm - Right lymphatic
duct > right subclavian vein.
45. Case history with serum studies showing increased concentration of 5-dALA and
porphobilinogen. - Deficiency of Porphobilinogen deaminase. C/w Acute intermittent
porphyria which presents with psychosis, abdominal pain, burgundy colored urine
following medication exposure. AIP is AD. Other disorders - Deficiency of d-ALA
Synthatase - X Linked sideroblastic anemia. Deficiency of ferrochelatase -
Erythropoietic protoporphyria seen with lead poisoning presenting with photosensitivity.
Deficiency of uroporphyrinogen decarboxylase - Porphyria cutanea tarda presenting
with cutaenous photosensitivity and blistering.
46. 7yrs old girl with severe left knee pain, tachycardia, high fever, swollen knee unable
to flex, leukocyte count > 35k/cumm, high ESR - Septic arthritis. Monoarticular. Other
condition JRA - present with extrarticular manifestations - Uveitis, LDP and rash. Lyms
disease - ixodes tick, borrelia burgdorferi, Erythema migrans, arthritis, heart block and
cranial nerve palsies.
47. Difference in urine concentrating ability with age. - Decreased renal tubule
responsiveness to ADH (Vasopressin).
48. 4yrs old boy had sore throat and fever 15 days ago. Now has red urine. UA showing
3+ blood, 2+ proteins, RBC 30-50/hpf and few RBC casts. - Proliferative
glomerulonephritis. Deposition of IgG and C3 throughout mesangium and capillary
walls. Presence of low serum C3 con and positive ASLO titres and Anti DNAase titres.
49. Scalp showing irregular shaped areas of alopecia with short broken hairs of different
lengths - Trichotillomania. Alopecia areata - broken hairs of same length.
Hypothyroidism - Diffuse alopecia. Menke disease - Kinked hairs. Tinea capitis - Scaly
patches of alopecia with black dots on scalp.
50. Role of IkB in Nf-kB from IL-1 binding to Il-6 induction. - Release NF-kB after
undergoing phosphrylation.

BLOCK 2
1. After removal of a tumor on distal portion of rectum which was extensively attached to
the posterior aspect of prostate. Pelvic splanchnic nerves are vulnerable to damage in
periprostatic surgeries and can result in erectile dysfunction.
2. Oxygen therapy in preterm neonate can result in - Retinopathy of prematurity. Focus
is to protect - Retina. Fetal retinal vascularization is dependent on - VEGF.
3. Antibiotic that inhibits DNA gyrase - Ciprofloxacin. Resistance to fluroquinolones is
mediated by production of membrane efflux pumps. FQs are effective for treatment of
atypical pneumonia such as caused by legionella. Other drug rifampin binds to DNA
dependent RNA polymerase. Tetracyclins bind to 30s inhibiting elongation of protein
synthesis. Vancomycin binds to D-Ala-D-Ala and inhibiting cell wall peptidoglycan
formation. Vanco is not degraded by beta-lactamases, hence used for MRSA, ARE and
Clostridium difficile. ARE - Ampicillin resistant enterococcus.
4. Girl with suicidal tendancies, black and white thinking and broken relationships -
Borderline personality disorder.
5. Side effect of inhaled beta 2 adrenergic agonist - Tremors. Other side effects are -
hypokalemia, hyperglucemia, tachycardia, HTN and headache. Remember to control
tremors, we use beta blocker ppnl.
6. Patient with central lung lesion and hypercalcemia - Squamous cell carcinoma. Sq
cell carcinoma - central, cavitatory and hypercalcemia due to PTHrP. Small cell
carcinoma - Central, Cushing syndrome, SIADH, Lambert eaton syndrome,
paraneoplastic lumbic encephalitis, SACD.
7. Laceration stopped bleeding and is covered with the clot. Finding results from hepatic
synthesis of - Proteins that result in the production of fibrin strands.
8. An antibiotic ointment applied to eyes of neonate to prevent ocular infections inhibits -
Bacterial protein synthesis. Erythromycin which binds to 50s ribosome. Neonatal
conjunctivitis - 3-5 days, gonococcal. 5-14 days, chlamydial. > 14days, Herpes. Penicillin
and cephalosporins act by inhibition of bacterial cell wall synthesis.
9. Liver biopsy shows margination of nuclear membrane, intact cell membranes and
cells smaller in size than normal. Cell size anomaly is triggered by release of cytochrome
C. Apoptosis.
10. Kidney picture showing staghorn calculi - Proteus Mirabilis.
11. Hydroxyurea administered in sickle cell disease has beneficial effect of - Increased
hemoglobin F concentration. This decreases freq of sickle cell pain crisis and
transfusion requirements.
12. Examination of 3 yr old boy shows ptosis and smooth philtrum. - Maternal use of
alcohol is implicated.
13. 2SD over @ 38.8 and 99% CI over @ 41.3. They wanted individuals between 38.8
and 41.3. so 99.7% - 95% is 4.7%. so roughly 4.7/2 ~ 2% is the answer. Or 2.5% - 0.3%
~ 2.2% as answer.
14. Dose of glipizide was increased which caused hypoglycemia - Due to increased
release of insulin from the pancreas. Glipizide is 2nd gen SFU. Acts by closing
potassium channel in pancreatic beta islet cell membrane > depolarization > opening of
voltage gated calcium channels > calcium influx > endogenous insulin release > insulin
increases peripheral uptake of glucose and promote glycogen, TG and protein synthesis.
Adminstration of acarbose - Decreased alpha glucosidase activity in GIT. Metformin -
Decreases hepatic production of glucose.
15. 2 weeks after kidney transplant, biopsy of transplanted kidney shows inflammatory
infiltrate affecting small arterioles. Acute T cell mediated transplant rejection (TCMR) -
Host CD8+ T cells recognize class I MHC molecules on renal allograft cells.
DONOR HOST CELLS REACTION
CD8 T cells Renal allograft TCMR
CD4 T cells Renal allograft Chronic allograft
dysfunction
CD4 T cells Dendritic cells Acute GVHD
CD8 T cells Dendritic cells Augment immune
response against
host tissues
CD4 T cells Lymphocytes Graft Vs Leukemia
effect

16. C/o sleep disorder should adopt sleep hygiene - “Try getting up the same time
everyday, even if you dont get much sleep.”.
17. Lack of CD18 expression. Leukocytes deficient in - Migration. Absence of pus, lack
of leukocytes at site of infection. Blood has high leukocyte count.
18. Increase in intra cranial pressure is done by - Decreasing the respiratory rate.
PaCO2 changes can be altered by tidal volume and respiratory rate.
19. Patient has been prescribed topical caspaicin cream for pain which depletes
Substance P from sensory nery endings. Agonist of TRPV1 which gradually depletes
substance P from nerves.
20. Child with IUGR continues to grow slowly. C/o uniparental maternal heterodisomy. -
Genomic imprinting of growth genes. Heterodisomy is in meiosis 1. Isodisomy is in
meiosis 2.
21. Tip of olecranon obscured by golf ball sized tender fluctuant mass with well defined
borders. - Bursa.
22. Infant with 3 day h/o fever which subsided followed by rash for 1 day. - Pic shows
Roseola infantum or exanthem subitum - HHV6. Rash on trunk then spreading to
extremities.
23. Pic showing side of hand having multiple papules with burrows and some of which
are excoriated. S/o scabies. - “Does anyone else in the family have an itchy rash like
this?”.
24. Vessel indicated in picture is - Posterior cerebral artery. Occlusion of PCA causes -
Contralateral visual field defect.
25. During first 5 mins after delivery, there is increase in - Pulmonary blood flow In
neonate. Due to oxygen induced pulmonary vasodilation. Fetal circulation : Oxygenated
blood > umbilical vein > DV > IVC, gets mixed with deoxygenated blood from lower
portion of fetus > RA > FO > LA. RA > RV > Pulmonary trunk > DA > Aorta.
26. During prolonged strenuous exercises, glucose is released from liver and kidney.
27. Substance responsible for edema and erythema - Bradykinin. Due to localized
vasodialation of post capillary venules. Mediators are - histamine, PGE2 and bradykinin.
28. Systolic ejection murmur heard over left sternal border. ECG shows Right axis
deviation and right ventricular atrophy. - s/o Atrial septal defect. Holosystolic murmur at
left lower sternal border. - VSD.
29. Pretest probablity ~ prevalence of disease. 650/1000 * 100 = 65%. Prevalence
impacts PPV directly and NPV indirectly.
30. Phase 1 NM blockade induced by Sch is enhanced by concurrent administration of
Drug X. However, when drug X is administered in phase 2 of blockade, it is found that
drug X reverses the effect of Sch. Drug X - Neostigmine. Sch is structurally similar to
Ach but not metabolized by Ach-esterase. Rather metabolized by
pseudocholineresterase in plasma and liver, thus causing prolonged depolarization.
Atropine acts on muscarinic receptor. Neostigmine acts on nicotinic receptor.
31. 10yrs old girl has increased testosterone levels. Unregulated increase in hormone
production by Ovarian sertoli - leydig cells is responsible for patient’s hirsuitism.
Increased DHEA and DHEA-S are seen when adrenal gland is involved. Pituitary
acidophilic hormones are prolactin and GH. Pituitary basophilic hormones are - FLAT -
FSH, LH, ACTH,TSH. Zona fasciculata increases cortisol which is responsible for
hypertension, insulin resistance, lipodystrophy and myopathy. Zona glomerulosa is for
aldosterone component.
32. Ph chromosome - Tyrosine kinase.
33. Patient with hypertension and hypokalemia, increased cortisol:cortisone ratio,
decreasing aldosterone concentration and plasma renin activity. Inhibition of
11beta-hydroxysteroid dehydrogenase type II. Seen with consumption of licorice.
21-hydroxylase deficiency would cause hypotension and hyperkalemia.
34. Decreased calcium intake in children - Decreased peak bone accretion during
adolescence. Calcium, vitamin D, Estrogen, Testosterone are required for bone mineral
density. Mutation of ALPL gene which codes for alkaline phosphatase -
hypophosphatasia which presents with impaired bone mineralization.
35. Patient has history of recurrent infections, umbilical cord stump redness, high grade
fever with peripheral blood leukocytosis. S/o LAD - Beta 2 integrin defect.
36. 3 yrs old boy with abdominal pain and vomitting. Noticed 20cm, white worms in
stools. H/o immigration. High pitched bowel sounds. - Ascaris lumbricoides.
37. Strongest predisposing risk factor for pancreatic adenoca - Cigarette smoking.
38. Congenital fusion of atlas to occipital bone ass. with C2-C3 vertebral fusion. Flexion
and extension of neck would place strain on - Atlantoaxial joint.
39. Drug that interferes with protein synthesis by binding to anti-codon on human tRNA
binds to - AUG. tRNA has acceptor stem which binds specific amino acid, T-Arm which
binds to ribosome, D-Arm which attaches to aminoacyl t-RNA synthetase, Anticodon
arm which binds to anticodon.
40. Individual wishes to support effective public health intervention to decrease the
incidence of SCD, Placement of external automatic defibrillators in public spaces
throughout the city is viable option.
41. Proteus mirabilis infection prone to - Struvite stones. Urease catalyses conversion of
urea into ammonia and CO2. ammonia makes urine alkaline. Solubility of struvite
decreases in alkaline solution and precipitates as crystal.
42. Duodenal contents have high trypsinogen, chymotrypsinogen and preelastase. -
Enteropeptidase deficiency.
43. Esophageal dysmotility - Decreased esophageal peristalsis and decreased LES
tone.
44. Pain sensation decreased in left lower extremity - Right lateral spinothalamic tract
lesion.
45. Alcoholic patient with epigastric pain and blood in vomittings, large and distended
abdomen. Bleeding vessels are enlarged due to increased blood flow from - Left gastric
veins. Portal vein starts at confluence of left gastric vein, splenic vein and sup
mesenteric vein.
46. Pic showing hypersegmented neutrophil - Folic acid deficiency.
47. Course of catheter after enetering into femoral artery for embolizing agent into
vessels that lead the leimuomata - External iliac artery > internal iliac artery > uterine
artery.
48. C/o hypotension + tachycardia + cool pale extremities, faint peripheral pulses and
crackles + jugular venous distension - Cardiogenic shock.
49. Patient of chronic pancreatitis with foul smelling stools need - Fat soluble vitamin
supplementation.
50. C/o dislocation of lenses bilaterally + increased serum concentration of methionine
and homocysteine and decreased concentration of cysteine. - Deficiency of -
Cysthionine beta synthase.

BLOCK 3
1. History suggestive of ITP with positive test for circulating anti platelet antibodies. -
Platelet destruction.
2. NNT = 1/ARR. ARR = Difference in risk exposed - risk in non exposed. ~1%. NNT =
100.
3. Valproic acid inhibits histone deacetylase which will affect - Transcription.
4. Increased BT, Moderately suppressed Factor VIII and moderately suppressed
ristocetin cofactor activity. - Von willebrand disease.
5. Shallow, vesicular lesions on shaft of penis - Genital herpes. LGV - Small painless
genital ulcers with tender inguinal LDP. Syphilis demonstrates primary with painless
chancre, secondary with fever, LDP and condyloma lata, tertiary with aortitis, gummas
and tabes dorsalis.
6. Aldehyde reacts with Lysine residue of another collagen molecule to cause cross
linking.
7. Painless lesion with sun exposure and rough to touch (gritty texture) - Actinic
keratosis.
8. C/o systolic ejection murmur at apex + ST segment elevation in anterolateral leads +
enlarged cardiac silhoutte - Acute coronary syndrome. Acute pericarditis - PR
depressions. Pulmonary embolism - S1Q3T3 pattern.
9. Hydrochlorothiazide act on - Distal tubule.
10. Woman with long standing h/o anovulation, endometrial hyperplasia and enlarged
ovaries with multiple cysts. Adipose tissue is likely producing - Estrone.
11. Immediately post op, patient develops hypotension requiring infusion of dopamine.
After 24hours, develops HTN with raised creatinine and oliguria. - Acute tubular
necrosis from ischemia.
12. Most likely cause of trypsinogen activation. - Enterokinase.
13. Result og mutation on the transcriptional genes that inhibit cell division and contain
consensus sequence TATA ! -30bp5’ to transcription start site - Decreased binding of
RNA polymerase. Transcription is related to RNA polymerase and transcription factors.
14. Drug causing achillis tendon rupture - Levofloxacin.
15. In c/o mechanical ventillation, To decrease arterial PCO2 - Increase the frequency at
constant tidal volume. 2 parts of ventillator process - oxygenation and ventillation.
Oxygenation is diffusion of oxygen from alveoli into blood. Ventillation is diffusion of CO2
from blood into alveoli. Oxygenation is dependent on - PEEP, FiO2 & increased no. Of
alveoli. Ventillation is dependent on - minute ventillation which is dictated by Tidal
volume & Respiratory rate. Increase in ventillation, decreases aPCO2. Increase in PEEP
& FiO2 increases aPO2. Size of ET Tube decreases Peak airway pressure and increases
maximum inspiratory flow rate.
16. Central lung lesion with increased urine 5-HIAA - Carcinoid tumor. Production of
high concentration of serotonin from carcinoid tumor results in carcinoid syndrome.
Syndrome is seen in metastatic GIT or primary carcinoid of non-GI origin.
17. Aromatization of testosterone to estrogen leads to closure of epiphysis in later
stages of puberty.
18. Girl of type 1 DM with 10kg weight loss, BMI 17, HbA1c of 8.4%. Cause of weight
loss - Decreasing the amount of self administered insulin doses.
19. Increased concentration of very long chain fatty acids, phytanic acid and pipecolic
acid - S/o Zellwager syndrome. - EM would show absence of peroxisomes.
20. During chemotherapy, addition of ondansetron may decrease emesis by blocking
Serotonergic (5-HT3) receptors. Other drugs - Mirtazapine (for depression) and
phentolamine (for hypternsive emergencies) are selective and non selective
alpha-2-adrenergic antagonists respectively.
21. History s/o FAP - Biallelic loss of function of the APC gene. FAP is also ass with
duodenal adenoca, hepatoblastoma, thyroid and pancreatic cancer.
22. Cigarette smoking - Increases mucus production, decreases activity of airway
cilia, decreases alveolar macrophage function.
23. Patient with an uncomplicated grief reaction - Schedule regular appointments to
monitor the patient.
24. Lung biopsy showing necrotizing vasculitis, granulomas and eosinophilic necrosis. =
Churg strauss syndrome.
25. Pic showing urothelial carcinoma. Risk factor - Cigarette Smoking.
26. Pregnant woman @ 20 weeks gestation experiencing increased respirator rate. -
Respiratory compensation for fetal metabolic production of CO2. Progesterone
induces increased minute ventillation and respirations.
27. Steady state concentration is when rate of elimination = rate of drug administration.
Depends on no. Of half lives. For 97% concentration, 5 half lives. ~15hrs.
28. HPV16 E6 protein is most likely to produce highest titres in cervical ca. Self
antigens have poor immunogenicity.
29. B1 deficiency causes downregulation of glial high affinity glutamate receptors before
neurons are lost. Initially affected cells are - Astrocytes. They protect the brain from
glutamate induced excito-toxicity.
30. Aripiprazole - causes Partial agonism of D2 receptors. Else most antipsychotics are
reversible dopamine antagonists.
31. Girl c/o blemishes which are scattered comedones and papules on face and back.
Drug that decreases cohesion between epidermal cells and increases epidermal cell
turnover - Tretinoin. Comedone (acne) is hair follicle blocked by keratin + compounded
by androgenic stimulation of sbaceous glands, hence refd as pilosebaceous unit with
increased sebum pdtn. This predisposes to staph epidermidis and propionibacterium
acne.
32. Coffee drinking histories of persons with cancer are compared with those of healthy
persons - Case control study.
33. ATP molecules to be hydrolyzed during secretion of one H+ ion. - 1. Secretion is
performed by H+K+ ATPase.
34. Compression of C5-C6 segment - Abduction of the upper extremity.
35. Lab values show Decreased total cholesterol, LDL, VLDL and chylomicrons. Stool
has increased fat concentration. Family members similarly affected. Mutation seen in -
APO-B. Normal HDL. Defect in APOA - Tangiers disease presenting with decreased
HDL.
36. Diarrhoea - Metabolic acidosis - Decreased pH, decreased HCO3-, decreased K+,
decreased CO2.
37. C/o HIV. Biopsy of solitary enhancing lesion from right frontal lobe shows
lymphoplasmacytic infiltrate plus many 3x7mm crescent shaped organisms with central
nuclei. S/o Toxoplasma gondii. Mode of transmission - Ingestion.
38. Invasion of the malaria parasite into the cell cytoplasm leads to processing of
parasite proteins and presentation by class I MHC molecules.
39. Normal BP + Serum studies showing increased 17-hydroxyprogesterone and
androstenedione - 21-Hydroxylase deficiency.
40. Constricted pupils and stupor - Heroin (Opioid) intoxication.
41. Young patient with Systolic murmur best heard at upper right sternal border.
Pressure tracing shows large peak pressure gradient between LV and aorta. C/w Aortic
stenosis. - Congenital bicuspid valve.
42. Cell type facilitating the re-innervation of skin of foot - Schwann cells.
43. Isolated deficiency of carbonic anhydrase in erythrocytes will present with greater
concentration of Chloride ions in venous blood.
44. C/o Type 2 DM with increased skin pigmentation, moderate ascites and
esophagogastric varices. S/o hereditary hemochromatosis. Pic showing - Iron pigment
deposition in hepatocytes.
45. Translation by host ribosome is necessary for reproduction of new coronavirus in
the respiratory epithelium.
46. Propanolol causing weak pulse due to - Decreased slope of diastolic
depolarization. Class II anti-arrhythmic drug. Other agents - Class I - Sodium channel
blockers, Class IA - Increase AP, ERP and prolonged QT interval, Class IB - Decreases
AP and ERP, Class IC - Increases ERP in AV node. Repolarization is presented by closing
of calcium channels and opening of potassium channels. Class III - Potassium channel
blockers, do not allow them to open. Class IV - Calcium channel blockers, do not allow
them to close. Class I, Class III and Class IV all decrease the rate of repolarization phase.
47. 58 yrs old woman with mild urinary leakage when she washes her hands or when she
hears water running. - Uninhibited bladder contractions. Overactive bladder presenting
with urge incontinence.
48. Norepinephrine is the primary NT for - Post ganglionic sympathetic nerves in the
prostate. Preganglionic nerves release Ach. Post ganglionic nerves release NE. In
adrenal gland, sympathetic nerves release Ach directly onto chromaffin cells in medulla,
and Medulla releases EPI/NE into circulation.
49. Order of measures of central tendency, smallest to largest - Mode < median <
mean.
50. Natural killer cells target tumor cells in response to absence of expression by class
I MHC molecules at low concentration. At higher inoculations, number of tumor cells may
overwhelm the capacity of NK cells to combat tumor proliferation, resulting in marked
growth of tumor.

BLOCK 4
1. Features of gout + high S.Uric acid. - No specific enzyme or renal defect. First MTP
joint - negatively birefringent needle shaped crystals.
2. Intention to treat analysis - Include all patients.
3. Age related PK change which explains the patient’s response to current dose of oral
morphine - Decreased first pass effect. This would increase serum concentration of
morphine causing s/o opioid toxicity.
4. TMP-SMX causing red serum. - Enzyme deficiency permits hemoglobin oxidation.
5. Preterm neonate with feeding intolerance, abdominal distension and passage of soft
bloody stools. - Necrotising enterocolitis.
6. C/o Gluten sensitive enteropathy ass with dermatitis herpetiformis - Granular pattern
of IgA deposition. Other conditions - Bullous pemphigoid - Bull’s eye pattern of IgE
deposition, linear pattern of C4b deposition & longitudinal pattern of IgG deposition. SLE
- Speckled pattern of IgM deposition.
7. Appropriate therapy fpr decreasing risk of MI in a patient with high LDL cholesterol
and TG levels - Decreases S.LDL cholesterol concentration.
8. A patient is unsure about receiving a transplant and wishes to get kidney from one of
his relatives than from cadaver. - “I want to be sure that i understand your concerns
about getting a transplant.”.
9. Patient treated with allopurinol. Develops rash, AKI, pyuria, hematuria. Renal biopsy
shows normal glomeruli with prominent lymphocytic/histiocytic infiltrate in periglomerular
and peritubular tissues with occ eosinophil and rare neutrophils. S/o Acute interstitial
nephritis - Immune reaction.
10. Hemoptysis + hematuria + HTN + Proteinuria - Goodpasture syndrome.
11. 10 yrs old boy with dark brown urine, hemolytic anemia, thrombocytopenia, raised
urea and creatinine, presence of schistocytes on PS. - Hemolytic uremic syndrome.
Mutation of C3 and CD46 - Atypical HUS.
12. C/o MVA, sustains large bowel perforation in area of cecum. To prevent excessive
intraoperative hemorrhage, it is important to ligate - Ileocolic artery, branch of Superior
mesenteric artery.
13. Mitochondrial disease inheritance - Heteroplasmy.
14. Nesiritide, drug identical to BNP - Causes increased urine flow.
15. C/o decreased bone mineral density, hypercalcemia, hypercalciuria - Primary
hyperparathyroidism.
16. Child has homozygous deletion of SMN1 gene presenting with progressive
hypotonia and areflexia. S/o Spinal muscular atrophy - AR disorder. Severe infantile
variant, wednig hoffman disease, presents with hypotonia and respiratory failure in first 6
months of life.
17. Cleft lip, failure of fusion of - Maxillary and nasal prominences.
18. Complicatio of angiodysplasia of ascending colon - Hemorrhage.
19. Tea and toast diet. PE shows red and purple macules around hair follicles. C/o
vitamin C deficiency - Inadequate hydroxylation of procollagen.
20. Semen analysis showing azoospermia. FSH & LH are markedly low. S.Testosterone
is normal to borderline high. - Use of exogenous testosterone.
21. Metanephric blastema and sprouting of ureteric bud for nephron differentiation and
formation of glomerulus. - Reciprocal inductive interaction.
22. C/o leg pain following exertion and improving with rest. Decreased dorsalis pedis
pulses and decreased ankle brachial index. A drug which acts by altering platelet
function and providing direct arterial vasodialation. - Cilostozol. PDE3 inhibitor.
23. -
24. Recurrent headache + retinal hemangioblastoma + pancreatic cystic lesion +
cerebellar midline lesion - Von Hippel Lindau disease.
25. Modality to establish cause of recurrent pneumonia. S/o obstructive lesion at same
site - Bronchoscopy.
26. Spanish patient doesnt understand english and family says he should not be told if
any bad news and they should be allowed to make decisions about his treatment. - “Use
a Spanish speaking interpreter to determine how much th epatient wishes to know
about diagnosis and treatment”.
27. Increased plasma concentration of 5-ALA. Deficiency indicated - Ferrochelatase.
28. C/o painless slow enlarging cystic mass on left side neck due to incomplete fusion
during embryonic development. Opening of duct located - Anterior to the
sternocleidomastoid muscle.
29. Purulent discharge from right sphenoethmoidal recess is noted - Superior to
superior concha.
30. Tender right clavicle plus pain on movement of right shoulder. Structure of clavicle
which will assist in producing new bone to heal the fracture clavicle - Periosteum.
Primary bone healing is by haversian canal system when bones are rigidly fixed together.
Secondary bone healing is by stem cells from periosteum and endosteum forming a
callus when there is range of motion at fracture site.
31. Clomiphene - Antiestrogenic activity in pituitary gland, Increased effect on FSH
and LH release.
32. LMP 9 weeks ago. Now complaining of left quadrant abdominal pain and vomitting.
Site - Uterine tube.
33. Incidence - 200 / 2000 ~ 10%.
34. Pic shows Giardia lamblia. Chronic infection causes - Intestinal malabsorption.
35. Drug resistance in HIV - Reverse transcription. Protease inhibitor inhibits assembly.
Fusion inhibitors inhibit binding. Steps in HIV replication - BFRt-IRAB - Binding >
Fusion > RT > Integration > replication > Assembly > Budding.
36. After release of histamine, Mast cells begin denovo synthesis of - Prostaglandins.
37. Decreased strength and elbow flexion - C5-C7.
38. CXR showing consolidation of right lower lobe of lung. Injury to normal pulmonary
tissue by inflammatory cells releasing - Reactive oxygen species.
39. Pic shows pituitary tumor which can compress upon optic chiasma causing - Visual
field deficit. (Bitemporal hemianopsia).
40. At high altitude, patient has taken 3 days CA inhibitor. Cause of orthostatic
hypotension - Hypovolemia.
41. C/o chronic liver disease. Decreased conc of total T4, normal concentrations of TSH
and Free T4. - Decreased thyroxine binding globulin synthesis.
42. C/o right sided hemiparesis - Lesion of left lateral corticospinal tract.
43. Laxative abuse with Diarrhoea - Decreased S.Potassium, Decreased S.HCO3,
Increased chloride.
44. CXR showing arrow at Visceral pleura.
45. MPO deficiency - Inability to produce hydroxy - halide radicals.
46. Increased activity of B7 surface marker is most indicative of langerhans cell
activation.
47. 4 yrs old boy with intellectual disability, large long head with prominent jaw, forehead
and large ears + high arched palate + hyperextensible fingers and joints. - Fragile X
syndrome. Macro-orchidism also seen after puberty. CGG trinucleotide repeat
expansion within FMR1 gene.
48. Pic showing endometrial biopsy with tortuous glands and spiral arterioles. -
Secretory phase.
49. Articular / Hyaline cartilage in joints in Osteoarthritis - Type II collagen affected.
50. Diagnosis of hypochondriasis - Frequent health care visits.