1.

A healthy 25-year-old woman who is at 24 weeks' gestation develops heartburn within

an hour after eating. Which of the following is the most likely cause?
A) Decreased competency of the lower esophageal sphincter
B) Decreased esophageal motility
C) Increased gastric acid production
D) Increased gastric emptying
E) Increased gastric motility
A
2. After sampling red wine and cheese, a 55-year-old man has a severe pounding
headache. Pulse is 110/min, and blood pressure is 230/145 mm Hg. He is most likely
taking which of the following drugs?
A) Diphenhydramine
B) Enalapril
C) Imipramine
D) Nitroglycerin
E) Tranylcypromine
E
3. A 12-year-old girl is admitted to the hospital because of marked shortness of breath,
an erythematous rash, and painful, swollen hip and knee joints. Antistreptolysin O titer
is abnormally high. X-ray film of the chest shows an enlarged heart. She develops
intractable congestive heart failure and dies on the second hospital day. Which of the
following cardiac abnormalities is most likely to be seen at autopsy?
A) Granulomatous pericarditis with caseous necrosis
B) Multiple microabscesses in the myocardium
C) Myocardial edema with Aschoff bodies
D) Stenosis of the aortic valve
E) Stenosis of the mitral valve
C
4. A female neonate has an enlarged clitoris. Pregnancy and delivery were uneventful.
Laboratory studies on blood taken at 7 days of age show hyponatremia and
hyperkalemia. Microscopic examination of the adrenal cortex is most likely to show
which of the following features?
A) Dysplasia
B) Hyperplasia
C) Hypoplasia
D) Metaplasia
E) Neoplasia
B
5. A 19-month-old girl dies after ingesting a bottle of her mother's iron sulfate
supplements. At autopsy, microscopic examination of hepatic tissue shows lysosomal
 degradation. Which of the following is the most likely mechanism of this finding?
A) Activation of glutathione peroxidase activity
B) Inhibition of glutathione-S-transferase activity
C) Peroxidation of DNA
D) Peroxidation of membrane lipids
D
6. An increase in the activity of which of the following enzymes is most likely to
increase the rate of metabolism of
glucose 6-phosphate through glycolysis in the liver?
A) Fructose 1,6-bisphosphatase
B) Fructose 1,6-bisphosphate aldolase (aldolase A)
C) Fructose 2,6-bisphosphatase
D) Glucokinase
E) 6-Phosphofructo-1-kinase
E
7. Which of the following drugs produces vasoconstriction that is not blocked by
prazosin and bradycardia that is blocked by scopolamine?
A) Amphetamine
B) Angiotensin
C) Norepinephrine
D) Phenylephrine
B
8. Three weeks after being bitten by a friend's puppy in Mexico, a 32-year-old man has
tingling at the site of the bite followed by severe agitation and disorientation. The
initial wound healed without complications. The puppy died 2 weeks ago. The route
by which the infecting virus entered the brain is
A) blood-borne virions infecting cerebral capillary endothelial cells
B) blood-borne virions infecting choroid plexus cells
C) blood cells that cross the blood-brain barrier
D) transport within the axons into the central nervous system
E) virions carried by lymphatic drainage to the brain
D
9. A 3-week-old female infant with dehydration develops bilateral renal vein thrombosis,
but only the right kidney infarcts. Collateral drainage via which of the following veins
most likely prevented infarction of the left kidney?
A) Left ovarian
B) Left third lumbar
C) Splenic
D) Superior mesenteric
A
10. A protein contains a 30-amino acid structural motif with four cysteine residues
coordinated to a zinc atom. In which of the following is this structured motif most
likely to be found?
A) Nucleosome
B) Ribonuclease
C) Ribosome
D) Spliceosome
E) Transcription factor
E
11. A 46-year-old man is killed in an automobile accident. The photograph shows a
kidney at autopsy. Which of the following would have been expected in this patient?
A) Cerebral arterial aneurysms
B) Hypertensive heart disease
C) Multiple hepatic cysts
D) Normal renal function
E) Vesicoureteral reflux
D (Pic shows horseshoe kidney)
12. A 48-year-old man comes to his physician because his wife noticed that his right
pupil is "small." Physical examination shows that the right pupil is constricted and
does not react to light. His left pupil is normal. These findings are most likely due to
a lesion involving which of the following structures on the right?
A) Cervical spinal cord
B) Frontal eye fields
C) Lateral geniculate nucleus
D) Optic tract
E) Visual cortex
A
13. A patient who is taking probenecid is expected to have an increased excretion of
which of the following?
A) Cephalosporin
B) Creatinine
C) Penicillin
D) Tetracycline
E) Urate
E
14. Which group of regulators involving inflammatory or immediate (type I)
hypersensitivity reactions is capable of causing increased vascular permeability and
attraction of leukocytes?
A) Essential fatty acids
B) Leukotrienes
 C) Prostaglandins
D) Thromboxanes
B
15. A previously asymptomatic 42-year-old man who has been seropositive for HIV for 4
years comes to the physician because of the recent onset of fever, cough, and weight
loss. An x-ray film of the chest shows bilateral pulmonary infiltrates. A methenamine
silver-stained preparation of bronchoalveolar lavage fluid is shown. Which of the
following immunologic abnormalities most likely led to the development of this
pulmonary process?
A) Circulating immune complex-induced injury
B) Decrease in the number of CD4+ T lymphocytes
C) Inactivation of pulmonary macrophages
D) Increase in selective cytotoxic CD8+ T-lymphocyte activity
E) Loss of natural killer cell function
B
16. A 64-year-old woman comes to the physician's office because of gradually worsening
abdominal cramps, nausea, diarrhea, flushing of the skin, and heart palpitations.
Twenty-four hour urinary 5-hydroxyindoleacetic acid excretion is increased. The
most likely cause of these findings is a neoplasm originating in which of the
following structures?
A) Adrenal gland
B) Esophagus
C) Kidney
D) Small intestine
E) Spleen
F) Thyroid
D
17. A 62-year-old man develops numerous superficial blisters over the scalp, face, groin,
and trunk. New lesions develop over areas subjected to minimal trauma. Biopsy of
one of the lesions shows an intraepidermal blister with suprabasal acantholysis.
Serologic studies are likely to show an autoantibody directed against which of the
following?
A) Anchoring filaments
B) Basement membrane proteins
C) Desmosomal proteins
D) Hemidesmosomal proteins
E) Integrins
C
18. Benign prostatic enlargement causes a characteristic impression on the urinary
bladder in which area of the cystogram?
B
19. A hyperactive 6-year-old girl develops microcytic anemia, cerebral edema, and
ataxia. Determination of which of the following serum enzyme activities is most
likely to confirm the diagnosis?
A) 5-Aminolevulinic acid (-ALA) dehydrogenase
B) Glucose 6-phosphate dehydrogenase
C) Glutathione transferase
D) Lactate dehydrogenase
E) Pyruvate kinase
A
20. During DNA replication, which activity contributes to the fidelity (accuracy) of the
DNA polymerase?
A) DNA ligase
B) Endonuclease
C) 35 Exonuclease
D) 53 Exonuclease
E) Helicase
C
21. During which phase of the ventricular action potential shown does norepinephrine
influence the influx of Ca2+?
A)
B)
C)
D)
E)
C
22. A 32-year-old man comes to the physician for a routine examination. He tells the
physician that he has gained weight, but that he doesn't enjoy eating or many other
activities. He says he needs at least 11 hours of sleep, but still feels fatigued most
days and has difficulty concentrating. He is 178 cm (5 ft 10 in) tall and weighs 90 kg
(198 lb). Which of the following psychiatric disorders is most likely to be present in
this man?
A) Antisocial personality disorder
B) Major depressive disorder
C) Obsessive-compulsive disorder
D) Post-traumatic stress disorder
E) Somatization disorder
B
23. An afebrile 8-year-old girl is evaluated for mild edema and a "puffy" face. She
recovered from an untreated sore throat and fever 3 weeks ago. Urinalysis shows
moderate proteinuria and hematuria with occasional red cell casts. A
 photomicrograph of renal tissue obtained on biopsy is shown. Which of the
following is most likely responsible for the cellular infiltrate shown?
A) Bradykinin
B) C5a
C) Histamine
D) N-formylated peptides
E) Serotonin
B
24. The majority of cellular proteins and RNA are synthesized throughout the cell cycle
and are only interrupted briefly during M phase. Synthesis of which of the following
proteins occurs predominantly in S phase of the cell cycle?
A) Cyclins
B) DNases
C) Histones
D) RNA polymerases
E) snRNPs (small nuclear ribonucleoproteins)
F) Tubulins
D
25. Tolerance of B lymphocytes to self-antigens develops in which compartment?
A) Bone marrow
B) Lymph nodes
C) Peyer's patches
D) Spleen
E) Thymus
A
26. Five months after initiation of chemotherapy, a 54-year-old woman has
nonproductive cough, fever, and gradually progressive dyspnea. An x-ray film of the
chest shows alveolar-interstitial infiltrates. Cultures of material obtained on bronchial
lavage are consistently negative. The drug most likely to cause this adverse effect is
A) atenolol
B) bleomycin
C) cytosine arabinoside
D) metronidazole
E) nalidixic acid
F) nitrofurantoin
G) penicillin
H) sulfasalazine
I) tetracycline
B
27. A 78-year-old man has had urinary retention for the past week. He has been treated
for the past 2 weeks with a drug for chronic neuropathic pain. The drug is most likely
to be
A) amitriptyline
B) bupropion
C) carbamazepine
D) fluoxetine
E) trazodone
F) venlafaxine
A
28. A 20-year-old man ingests 1 L of water over 1 hour. Which of the following sets of
changes is most likely at the end of the hour?

Plasma

ADH Urine Urine

(vasopressin) osmolality flow

A)

B)

C)

D)

E)

F)

G)

H)

E
29. A 14-year-old girl is brought to the physician's office by her mother who is
concerned that the girl has not begun to menstruate. Physical examination shows
 normal breast development, no pubic hair, normal female external genitalia, bilateral
inguinal hernias, a vagina that ends in a blind pouch, and no palpable uterus or
ovaries. Ultrasound examination confirms the absence of internal female genitalia.
The underlying problem in this patient is related to which of the following?
A) Defective androgen receptors
B) Excess production of fetal estrogen
C) Excess production of fetal progesterone
D) Insufficient fetal testosterone production
E) Insufficient production of paramesonephric (mllerian) inhibitory factor during
fetal development
A
30. Eight hours after ingesting 30 g of acetaminophen in a suicide attempt, a 17-year-old
boy is admitted to the hospital with nausea and vomiting. If left untreated, the
complication most likely to develop in this patient is
A) cardiac arrhythmia
B) gastrointestinal bleeding
C) hepatic necrosis
D) respiratory depression
E) tonic-clonic seizures
C
31. Fetal and maternal erythrocytes have the same concentration of 2,3-
bisphosphoglycerate. However, compared with maternal hemoglobin (HbA), fetal
hemoglobin (HbF) has a higher oxygen affinity, which facilitates transplacental
diffusion of oxygen. The presence of which of the following polypeptide chains in
HbF accounts for this finding?
A) Chains alone
B) Chains alone
C) Chains
D) Both and chains
C
32. A 55-year-old man being treated for congestive heart failure becomes confused about
his medications and takes an overdose of digoxin. Five hours later, he reports
anorexia, nausea, vomiting, and visual disturbances. Serum digoxin concentration is
10 ng/mL (toxic > 2.5 ng/mL); serum potassium concentration is 7.2 mEq/L. Which
of the following is the most likely cause of the hyperkalemia?
A) Hyporeninemic hypoaldosteronism
B) Increased renal tubular absorption of potassium
C) Inhibition of Na+-K+ ATPase
D) Intravascular hemolysis
E) Rhabdomyolysis
c
33. A 67-year-old man is admitted to the hospital because of worsening dyspnea over the
past 6 hours. He was diagnosed with hypertension 10 years ago. Temperature is 36 C
(96.8 F), pulse is 100/min, respirations are 22/min, and blood pressure is 136/87 mm
Hg. Physical examination shows an S3 gallop by cardiac auscultation and bilateral
coarse rales halfway up the lungs bilaterally. Which of the following is the most
appropriate dietary order for this patient?
A) Clear liquid diet
B) Enteral feeding via a nasoenteric tube
C) Full liquid diet
D) High-fiber diet
E) Low-residue diet
F) Parenteral nutrition via a central venous access
G) Protein-restricted diet
H) Regular hospital diet
I) Sodium-restricted diet
I
34. What is the major consequence of a hereditary defect in the production of active
pyruvate kinase in the liver and in erythrocytes?
A) Decreased capacity to fix CO2
B) Decreased gluconeogenesis from alanine
C) Decreased oxidation of pyruvate
D) Decreased production of ATP from glucose
E) Increased affinity of hemoglobin for oxygen
D
35. A 4-cm bronchogenic cyst is an incidental finding at autopsy of a 55-year-old man.
The cyst most likely arose from which of the following embryologic structures?
A) Allantois
B) Foregut
C) Mesonephric (wolffian) duct
D) Metanephric duct
E) Omphalomesenteric duct
B
36. A 50-year-old woman comes to the physician because of swelling of her left cheek
for 2 weeks. An elevation with a small opening in the area shown by the arrow is
noted on examination of the oral mucosa. This area is most likely the opening of
which of the following structures?
A) Draining abscess
B) Fistula
C) Parotid gland duct
 D) Sublingual gland duct
E) Submandibular gland duct
C
37. An unimmunized 10-month-old girl is brought to the emergency department because
of temperatures to 40 C (104 F) and listlessness for 24 hours. Examination shows a
stiff neck. Leukocyte count is 24,000/mm3. Gram's stain of cerebrospinal fluid shows
small pleomorphic gram-negative bacteria that require NAD and hemin for growth.
A vaccine for which of the following organisms would have prevented this infection?
A) Bordetella
pertussis
B) Clostridium
tetani
C) Corynebacterium
diphtheriae
D) Haemophilus
influenzae
E) Neisseria
meningitidis
F) Salmonella
typhi
G) Streptococcus
pneumoniae
D
38. A fluorescent molecule of 2000 daltons is microinjected into a single cell of an
epithelial layer. When the layer is examined in a fluorescence microscope, the
molecule remains confined to that cell. However, when a fluorescent molecule of 800
daltons is injected into a single cell of an epithelial layer, it quickly appears in the
adjacent cells. Which of the following is responsible for the spread of the smaller
molecule?
A) Desmosomes (maculae adherentes)
B) Focal contacts
C) Gap junctions
D) Intermediate junctions
E) Tight junctions (zonulae occludentes)
C
39. A 55-year-old man with multiple primary liver abscesses caused by Escherichia coli
and anaerobic bacteria has fever and shaking chills. Which of the following is the
most likely cause of these symptoms?
A) Associated abscess in the hypothalamus
B) Hypothalamic response to leukocytosis
C) Leukocyte inflammation of the hypothalamus
D) Release of fragments of damaged hepatocytes into the circulation
E) Release of leukocyte cytokines into the circulation
E
40. An obese 44-year-old man with type 2 diabetes mellitus is unable to achieve
appropriate glycemic control with diet and exercise. The physician consequently
prescribes a sulfonylurea. This class of drugs promotes the release of insulin from
pancreatic cells through which of the following factors?
A) Inhibition of ATP-sensitive K+ channels
B) Inhibition of Na+K+ ATPase
C) Inhibition of voltage-sensitive Ca2+ channels
D) Stimulation of guanylylate cyclase
E) Stimulation of phosphodiesterase
A
41. A 10-year-old boy with asthma has been receiving oral hydrocortisone daily in
increasing doses for the past 2 years. He is obese and has growth retardation and
edema of his lower limbs. Which of the following is the most likely explanation for
the edema?
A) The drug binds to both glucocorticoid and mineralocorticoid receptors
B) The drug is converted to a mineralocorticoid in the liver
C) Pulmonary production of angiotensin is increased
D) Renin activity is increased because of stress
E) Secretion of ADH (vasopressin) is increased because of stress
A
42. A 34-year-old woman has had fatigue, irritability, intermittent lightheadedness, and
heavy menstrual periods for the past 6 months. Laboratory evaluation is most likely
to show which of the following?
A) Decreased serum vitamin B12 (cyanocobalamin) concentration
B) Hypercalcemia
C) Hypocalcemia
D) Increased serum vitamin B12 (cyanocobalamin) concentration
E) Megaloblastic anemia
F) Microcytic anemia
F
43. Which of the following features of the inactivated poliovirus vaccine best explains
why it prevents paralytic polio but does not prevent replication of the virulent
poliovirus in the enteric tract?
A) It does not elicit cell-mediated immunity to viral capsid proteins
B) It does not elicit neutralizing antibody to virulent poliovirus
C) It elicits IgG but not secretory IgA
D) It only protects against one serotype of virulent poliovirus
C
44. Which of the following immunosuppressive agents acts in the lymphocyte by
 complexing to and inactivating the lymphocyte-specific phosphatase calcineurin?
A) Antilymphocyte globulin
B) Azathioprine
C) Corticosteroids
D) Cyclosporine
E) OKT3 monoclonal antibody
D
45. A 21-year-old woman comes to the physician because of a vaginal discharge for the
past 2 weeks. She has had 3 sexual partners in the past 6 months. Examination shows
tenderness with cervical motion. The discharge is mucopurulent and the cervical os is
erythematous and edematous. This patient is at greatest risk for the development of
which of the following?
A) Aortic aneurysm
B) Endocarditis
C) Endometrial carcinoma
D) Infertility
E) Multiple births
F) Ovarian carcinoma
G) Rheumatoid arthritis
D
46. An elderly woman has had generalized bone pain and a loss of height over the last 5
years. Complete blood count is normal. Serum calcium, phosphate, and creatinine
concentrations and serum alkaline phosphatase activity are within the reference
range. Serum protein electrophoresis shows no abnormalities. X-ray films of the
spine show generalized loss of bone density and a compression fracture of T-8.
Which of the following is most likely to be seen in tissue obtained on biopsy of the
iliac crest?
A) Cysts filled with fibroblasts and giant cells
B) Disorderly osteoblastic and osteoclastic activity
C) Sheets of plasma cells
D) Thin trabeculae with low osteoclastic activity
D
47. Phenylketonuria is an autosomal recessive disease. What is the probability that the
asymptomatic brother or sister of a child with the disease is a heterozygous carrier?
A) 0
B) 1/4
C) 1/2
D) 2/3
E) 3/4
D
48. When a cytogenetic abnormality is suspected in an infant with multiple congenital
anomalies, chromosomes from circulating leukocytes are analyzed. These
chromosomes are most condensed and easiest to evaluate in which of the following
states?
A) Anaphase
B) Interphase
C) Metaphase
D) Prophase
E) Telophase
C
49. Which of the following tests best distinguishes central diabetes insipidus from
nephrogenic diabetes insipidus?
A) Injection of ADH (vasopressin)
B) Injection of hypertonic saline
C) Injection of insulin
D) Water deprivation
E) Water loading
A
50. A 27-year-old man with type 1 diabetes mellitus is brought to the emergency
department because of stupor and diabetic ketoacidosis. His diabetes is usually well
controlled. His wife says he has had a fever and productive cough for several days
and has been taking an over-the-counter cough syrup. Which of the following is the
most likely cause of the ketoacidosis?
A) Cough syrup
B) Dehydration
C) Failure to take insulin
D) Infection
E) Lack of exercise
D