1.

A 29-year-old woman develops headache and shortness of breath 10

minutes after a transfusion of packed red blood cells is begun. Her
temperature is 37.8 C, pulse is 100/min, respirations are 20/min, and
blood pressure is 90/60 mm Hg. The transfusion is stopped immediately.
Laboratory studies show free hemoglobin in urine and plasma. Which
of the following erythrocyte blood group antigens is the most likely
cause of this patient's transfusion reaction?

A) ABO
B) Duffy
C) Kell
D) MN
E) Rh
2. 62-year-old man with ischemic heart disease is admitted to the hospital
because of a 4-day history of increasingly severe chest pain. Physical
examination shows no abnormalities. Angiography shows a blockage in
the anterior interventricular (left anterior descending) artery. A stent is
placed to relieve the obstruction. The stent contains paclitaxel. This drug
works to decrease the incidence of restenosis through which of the
following mechanisms of action?

A) Enhanced endothelial growth over the stent

B) Increased adhesion of the stent to the atheromatous lesion
C) Prevention of platelet adhesion to the stent
D) Prevention of smooth muscle growth over the stent
E) Stabilization of the cholesterol core of the atheromatous lesion
3. A newborn is delivered at 40 weeks’ gestation. Physical examination
shows ambiguous genitalia and testes in the inguinal canals.
Chromosomal analysis shows a 46,XY karyotype. Serum studies show
increased testosterone and decreased dihydrotestosterone
concentrations, suggesting a decreased activity of steroid 5-alpha
reductase 2. Hypoplasia of which of the following structures is most
likely in this patient?

A) Ductus deferens
B) Ejaculatory ducts
C) Epididymis
D) Prostate
E) Seminal vesicles
4. A 28-year-old woman comes to the physician because of intermittent
severe headaches during the past 2 weeks. Her mother and maternal aunt
were diagnosed with hypertension at the ages of 23 and 27 years,
respectively. The patient’s blood pressure is 220/110 mm Hg in both
upper extremities. Abdominal examination shows a periumbilical bruit.
Angiography is most likely to show which of the following in this patient?

A) Aneurysmal dilation of the abdominal aorta

B) Beaded stenosis of the left renal artery
C) Diffuse peripheral vascular disease
D) Left subclavian artery occlusion with arm raising
E) Narrowed diameter of the aortic arch
5. A 25-year-old man comes to the physician because of a 6-month history
of diarrhea, fatigue, and weight loss. Physical examination shows pallor.
Laboratory studies show macrocytic anemia, hypercellular bone marrow,
and erythrocyte precursors that are abnormally large. Which of the
following is the most likely explanation for the hematologic findings in this
patient?

A) Defect in cytoskeleton of the erythrocyte membrane

B) Defect in a glycolytic enzyme of the erythrocyte
C) Hemoglobinopathy
D) Impaired DNA synthesis
E) Impaired heme synthesis
6. A 16-year-old boy is brought to the physician for drainage of his third
liver abscess in 3 years. Cultures of fluid obtained from the two prior
abscesses grew Staphylococcus aureus and Burkholderia cepacia,
respectively. Culture of fluid obtained via needle aspiration of the current
lesion grows Aspergillus species. Which of the following is the most likely
diagnosis?

A) Chédiak-Higashi syndrome
B) Chronic granulomatous disease
C) Job syndrome
D) Leukocyte adhesion deficiency
E) X-linked agammaglobulinemia
7. A 24-year-old woman has increased range of motion in most of her
joints. She is 183 cm tall and weighs 59 kg, BMI is 18 kg/m2. Examination
shows pectus excavatum. Auscultation of the chest discloses a new
diastolic murmur. Which of the following is the most likely cause of the
murmur?

A) Aortic insufficiency
B) Atrial septal defect
C) Mitral insufficiency
D) Mitral stenosis
E) Ventricular septal defect
8. A 42-year-old woman with recurrent episodes of hypoglycemia comes to
the physician for a follow-up examination. She recently underwent an
exploratory laparotomy to confirm the diagnosis of insulinoma, but no
abnormalities were found. She is 173cm tall and weighs 55kg, BMI is
18kg/m2. She appears mildly anxious. Her 2-hour postprandial serum
glucose concentration is 70 mg/dL. Which of the following is the most
likely diagnosis?

A) Conversion disorder
B) Factitious disorder
C) Hypoglycemia
D) Insulinoma
E) Metabolic syndrome
9. A35-year-old man has a sinus tachycardia of 120/min. Which of the
following best describes the relationship of ventricular contraction and
relaxation in this patient?

A) Diastole and systole are equally prolonged

B) Diastole and systole are equally shortened
C) Diastole is prolonged more than systole
D) Diastole is shortened more than systole
E) Systole is prolonged more than diastole
F) Systole is shortened more than diastole
10. A 58-year-old man with type 2 diabetes mellitus, a history of renal
stones, dyslipidemia, and hypokalemia requires diuretic therapy for
hypertension. Thiazide and loop diuretics differ most markedly in which of
the following parameters of concern in this man?

A) Glucose tolerance
B) Plasma lipid concentration
C) Plasma potassium concentration
D) Plasma uric acid concentration
E) Urinary calcium excretion
11. A 60-year-old woman is found to have osteoporosis. Her last
menstrual period was 10 years ago. She has a history of deep venous
thrombosis. The physician wishes to initiate treatment with a medication
that will improve the patient’s bone density without increasing her risk for
thrombosis and hot flashes. A drug from which of the following classes is
most appropriate for this patient?

A) Bisphosphonates
B) Gonadotropins
C) Ovarian sex hormones
D) Selective estrogen receptor modulators
E) Vitamin D analogs
12. A 48-year-old man comes to the physician because of an episode of
fever, cough, chills, and shortness of breath 5 days ago that began several
hours after he helped a friend bale and store hay on a farm. The
symptoms resolved within 2 days, but he is concerned about what could
have caused the incident. He takes no medications and does not smoke
cigarettes. His temperature is 37 C, and respirations are 12/min. The lungs
are clear to auscultation of the chest. Which of the following conditions is
the most likely cause of this patient’s acute episode of respiratory
symptoms?

A) Allergic bronchopulmonary aspergillosis

B) Byssinosis
C) Desquamative interstitial pneumonia
D) Hypersensitivity pneumonitis
E) Pulmonary alveolar proteinosis
13. A 9-month-old boy is brought to the emergency department because
of an upper respiratory tract infection and decreased appetite for 2 days
and rapid breathing for 6 hours. He is at the 3rd percentile for length and
weight. He appears acutely ill. Physical examination shows lethargy and
dehydration. Laboratory studies show ketosis, metabolic acidosis,
hypoglycemia, anemia, and methylmalonic aciduria. He improves
following treatment with intravenous fluids and glucose. Direct
sequencing of the patient’s leukocyte DNA fails to show mutations in the
methylmalonyl-CoA mutase gene. In addition to dietary protein limitation,
administration of which of the following is most appropriate for this
patient?

A) Biotin
B) Folic acid
C) Niacin
D) Vitamin B6 (pyridoxine)
E) Vitamin B12 (cyanocobalamine)
14. A 56-year-old man comes to the physician because of a 2-month
history of cough productive of blood-tinged sputum. He has smoked 1
pack of cigarettes daily for 30 years. CT of the chest shows a 4-cm mass in
the right upper lobe that is obstructing the superior vena cava. Blood
from this patient’s neck and right upper extremity is most likely returning
to his heart through which of the following routes?

A) Anterior jugular and transverse scapular veins

B) Facial and inferior temporal veins
C) Internal mammaries and intercostal veins
D) Jugular and subclavian veins
E) Suprascapular and thyrocervical veins
15. A 30-year-old primigravid woman at 18 weeks’ gestation comes to the
physician for a prenatal visit. Physical examination shows a uterus
consistent in size with an 18-week gestation. Ultrasonography shows
several intracranial anomalies, including a single ventricle, small
cerebrum, fused thalami, and agenesis of the corpus callosum. These
findings were most likely caused by the failure of which of the following
structures to differentiate?

A) Diencephalone
B) Mesencephalone
C) Prosencephalone
D) Rhombencephalone
E) Telencephalone
16. A 63-year-old man with a long history of
sun exposure develops the skin lesion shown.
Which of the following is the most likely
diagnosis?

A) Actinic keratosis
B) Basal cell carcinoma
C) Malignant melanoma
D) Seborrheic keratosis
E) Squamous cell carcinoma
17. A 32-year-old man comes to the physician for a follow-up examination
after he was diagnosed with HIV infection. His CD4+ T-lymphocyte count is
55/mm3 (N>500) and plasma HIV viral load is greater than 100,000
copies/mL. Results of genotype show that the patient’s viral strain is
broadly resistant to protease inhibitors, non-nuclease analogs, and
nucleotide inhibitors. Which of the following drugs is most likely to be
active against the HIV strain in this patient?

A) Cidofovir
B) Efavirenz
C) Enfuvirtide
D) Ritonavir
E) Stavudine (d4T)
18. A 76-year-old man comes to the emergency department because of a
3-day history of inability to urinate. History includes progressive difficulty
urinating, especially initiating the stream, for the past year. Physical
examination shows a markedly enlarged prostate and a large, tender
suprapubic mass. Catheterization produces 2 L of urine. Ultrasonography
shows large kidneys with dilated calyces. Serum studies show a urea
nitrogen concentration of 40mg/dL and a creatinine concentration of 3.6
mg/dL. Arterial PO2 is 90 mm Hg. Which of the following sets of additional
arterial blood gas findings is most likely in this patient?
pH PCO2 HCO3-
A) 7.25 44 18
B) 7.32 30 15
C) 7.36 44 24
D) 7.40 50 30
E) 7.48 50 36
F) 7.50 30 22
19. A 22-year-old man is brought to the emergency department 30
minutes after having a generalized tonic-clonic seizure that began in his
left leg. He has a 3-year history of intermittent arm stiffening in his left
arm followed by spasms of his left thigh. He states that he thinks the
episodes may be associated with intense workouts at the gym. He has
no personal or family history of seizures. Physical examination shows
no abnormalities. An MRI of the brain is most likely to show a lesion at
which of the following locations?

A) Left frontal cortex

B) Left parietal lobe
C) Left temporal lobe
D) Right frontal cortex
E) Right parietal lobe
F) Right temporal lobe
20. A 16-year-old boy who plays high school football comes to the
physilian because of a painful, pruritic rash on his groin and upper
thigh. Physical examination shows a rash with red, scaling margins.
Direct microscopic examination of a KOH preparation of a skin scraping
shows fungal hyphae and arthrospores. Which of the following is the
most likely causal agent?

o A) Actinomyces israelii
o B) Blastomyces dermatitidis
o C) Candida albicans
o D) Coccidioides immitis
o E) Histoplasma capsulatum
o F) Paracoccidioides brasiliensis
o G) Penicillium marneffei
o H) Pneumocystis jiroveci (formerly P. carinin)
o I ) Trichophyton rubrum
21. A 27-year-old woman is admitted to the hospital
because of a 1-week history of lower abdominal pain
that became more severe 2 days ago. She also has
had fever, nausea, and vomiting. Her temperature is
38.4°C (101.2°F), pulse is 110/min, and blood
pressure is 135/90 mm Hg. Abdominal examination
shows tenderness in the right lower quadrant to light
palpation and percussion. A CT scan of the abdomen
with oral and intravenous contrast is obtained. Shortly
after having the test, she develops audible wheezing in all lung fields and the
rash shown in the photograph. Her pulse now is 120/min, and blood pressure
is 90/65 mm Hg. Which of the following best describes the mechanism of this
patient's skin reaction?
A) Cytokine release from segmented neutrophils
B) Direct activaticy of mast cells
C) IgE antibody release from eosinophils
D) Increased production of bradykinin
E) Systemic entry of bacterial endotoxins
22. A 25-year-old nulligravid woman comes to the physician because of a
3-day history of vaginal discharge and suprapubic discomfort. She has not
had fever, chills. nausea, or vomiting. She had two episodes of gonococcal
cervicitis during the past year. She is sexually active with multiple partners.
Her temperature is 37°C (98.6°F). Bimanual examination shows no
cervical motion or adnexal tenderness. There is a yellow discharge from
the cervical os. Cultures of the discharge are sent to the laboratory to test
for Chlamydia trachomatis and Neisseria gonorrhoeae. Urinalysis shows
trace WBCs. A urine pregnancy test result is negative. In addition to
appropriate antibiotics, which of the following is the most appropriate
action by the physician to preserve this patient's fertility?

A) Discussion with the patient about proper condom use

B)Hysterosalpingography
C)Pelvic ultrasonography
D) Administer vaccination for human papillomavirus
E) Prescribe an oral contraceptive
23. A 48-year-old man with a 30-year history of type 1 diabetes mellitus
comes to the physician because of the sudden onset of double vision.
Ophthalmologic examination shows no abnormalities except for
weakness of abduction of the left eye. Which of the following is the
most likely cause of the development of double vision in this patient?

o A) Cavernous sinus thrombosis

o B) Diabetic mononeuropathy
o c) Middle cerebral artery thrombosis
o D) Ophthalmic artery embolism
o E) Ophthalmoplegic migraine
24. A 35-year-old man with chronic hepatitis C comes to the physician
because of a 2-week history of weakness and a rash on his legs.
Physical examination shows 2+ edema and a purpuric rash over the
lower extremities. His serum creatinine concentration is 2.9 mg/dL.
Serum C3 and C4 concentrations are markedly decreased.
Urinalysis shows numerous dysmorphic RBCs but no RBC casts.
Which of the following is the most likely cause of these findings?

o A) Acute postinfectious glomerulonephritis

o B) Antiglomerular basement membrane disease
o C) Essential mixed cryoglobulinemia
o D) Lyme disease
o E) Subacute bacterial endocarditis
25. A 53-year-old woman having an acute inferior myocardial infarction
develops sinus bradycardia and hypotension. Administration of which of
the following is the most appropriate next step to increase this patient's
heart rate?

o A) Amiodarone
o B) Atenolol
o c) Atropine
o D) Phenylephrine
o E) Verapamil
26. A 24-year-old woman comes to the
physician because of a 3-day history of
vaginal discharge with itching. She is
currently being treated with ciprofloxacin for
cystitis.
Her vital signs are within normal limits. A
photograph of the vaginal area is shown.
Which of the following is the most likely
causal organism?

A) Candida albicans
B) Chlamydia trachomatis
C) Herpes simplex virus
D) Neisseria gonorrhoeae
E) Trichomonas vaginalis
27. A 23-year-old woman comes to the physician because of a 1-month
history of chronic sinusitis. She began treatment with broad-spectrum
antibiotics 3 weeks ago, but her symptoms have persisted. Nasal
endoscopy shows obstruction of the drainage of the left maxillary sinus.
Cannulation of the sinus through its normal drainage route to the nasal
cavity is scheduled. Which of the following is the most appropriate
location for cannula placement in this patient?

o A) At the anterior portion of the piriform aperture

o B) At the hiatus semilunaris in the middle meatus
o c) At the sphenoethmoidal recess
o D) Immediately anterior to the torus tubarius
o E) Immediately inferior to the anterior margin of the superior
conchae
28. A 14-year-old boy is brought to the physician because of a 2-week
history of progressively severe pain in his right leg just below the knee.
An x-ray of the involved area shows a large, partly calcified mass that
erodes the medullary canal of the tibia, infiltrates the cortex, and
extends into the adjacent soft tissue. A biopsy of the lesion identifies
primitive cells]in a lace-like meshwork of bone with numerous mitoses.
Which of the following is another common site of origin for this
pathologic process?

1. Clavicle
2. Femur
3. Metacarpal bones
4. Ribs
5. Vertebrae
29. A 67-year-old man comes to the physician because of numbness in
his hands and feet for 3 months. Vitamin B 12 (cobalamin) deficiency is
suspected. An increased serum concentration of which of the following
is most likely to confirm the diagnosis?

o A) Acetoacetate
o B) Alanine
o C) Lactate
o D) Leucine
o E) Methionine
o F) Methylmalonate
30. A 20-year-old woman (III-1) comes to the physician for cancer risk assessment. She has a
family history of breast cancer in her maternal grandfather and maternal aunt. Previous genetic
analysis of the aunt showed a mutation in the BRCA2 gene. The patient's 45-year-old mother does
not wish to undergo genetic testing. A pedigree is shown. Which of the following best represents
the-probability that this patient inherited the gene mutation in this family?
o A) 0%
o B) 25%
C) 50%
o D) 75%
o E) 100%
31. A 28-year-old woman comes to the physician for advice on a weight
loss plan. She is 163 cm (5 ft 4 in) tall and weighs 86 kg (190 /b); BMI
is 33 kg/m2. Physical examination shows no other abnormalities. She
has read an article on the Internet that outlines a balanced diet of 1500
kcal/day. She says, "It's not as strict of a diet as some of my friends
have tried. I think I can follow it for a long time." At her current level of
physical activity, she expends approximately 2500 kcal/day. Based on
this information, this patient will most likely lose weight at which of the
following rates?

o A) One-half pound weekly

o B) One pound daily
o c) Two pounds weekly
o D) Three pounds weekly
o E) Five pounds weekly
32. A 56-year-old woman comes to the physician because of shortness of breath
over the past several months. She smokes 2 packs of cigarettes daily and is not
interested in quitting. Respirations are 24/min. She is barrel-chested. Breath
sounds are decreased over all lung fields, and pulmonary function testing shows
an obstructive pattern. Oxygen saturation on room air is 91% at rest and 82% with
exercise. After telling the patient that her lungs show signs of damage from
tobacco. which of the following approaches by the physician is most appropriate in
beginning to address advance directives with this patient?
o A) "As long as you continue to smoke, it would be futile for me to be

aggressive with your medical care."

o B) "Have you ever considered what medical treatment you would want if your

breathing worsens?"
o C) "If you continue to smoke, you'll need to find a new physician."

o D) "In my experience, people with your type of lung damage do not do well

when put on mechanical ventilation. I'm sure you wouldn't want a tube in your
throat, would you*
o E) "It is very important that I make plans for your future health care."

o F) "You are shortening your life span. We need to discuss what medical

treatment you want."

33. A 48-year-old woman comes to the physician for a routine health
maintenance examination. Her husband of 20 years died 2 years ago.
Her vital signs are within normal limits. Physical examination shows no
abnormalities. During the examination, the patient mentions that she
has begun dating again. It is most appropriate for the physician to
counsel this patient about which of the following?

A) Cohabitation
B) Condom use
C) Couples counseling
D) Frequency of sexual intercourse
E) Oral contraceptive use
34. A 44-year-old man comes to the physician because of a 2-month
history of dry mouth, muscle weakness, constipation, inability to achieve
an erection, and progressive fatigue. He has smoked 1 pack of cigarettes
daily for 30 years. His temperature is 36.7°C (98°F), pulse is 70/min,
respirations are 10/min, and blood pressure is 110/70 mm Hg. Neurologic
examination shows weakness of the deltoids, biceps, iliopsoas, and
quadriceps, and absence of all muscle stretch reflexes. Sensation to all
modalities is normal. A chest x-ray shows a right lung mass. Laboratory
studies show antibodies directed against the P/Q-type voltage-gated
calcium channel. Which of the following mechanisms is the most likely
cause of the neurologic findings in this patient?

o A) Blockade of motor nerve conduction

o B) Central inhibition of a-motoneuron firing
o C) Decreased excitation-contraction coupling
o D) Hyperpolarization of the muscle membrane
o E) Impaired acetylcholine release at the neuromuscular junction
35. A 2-month-old male newborn is brought to the emergency
department because of noisy and difficult breathing for 6 hours.
Laryngoscopy shows multiple, slender, finger-like excrescences on
both vocal cords. The newborn's condition is most likely caused by
maternal infection with which of the following during pregnancy?

o A) Chlamydia trachomatis
o B) Herpes simplex virus
o C) HIV
o D) Human papillomavirus
o E) Treponema pallidum
36. A 44-year-old man is brought to the emergency department 30
minutes after he fell off a ladder from a height of 10 feet. His pulse is
70/min, and blood pressure is
125/80 mm Hg. Physical examination shows multiple ecchymoses over
the upper extremities and trunk. In response to the injury, activation of
the endothelium of this patient's blood vessels has most likely resulted
in which of the following?

o A) Decreased ADP concentration

o B) Decreased GTP concentration
o C) Decreased thromboxane A2 concentration
o D) Decreased tissue plasminogen activator concentration
o E) Increased cGMP concentration
o F) Increased von Willebrand factor concentration
37. During a study of primary human hepatocytes, it is found that these
cells dedifferentiate when grown in culture and lose many of the
synthetic and metabolic functions unique to in vivo hepatocytes.
Coculturing the primary hepatocytes with biliary epithelial cells
preserves many aspects of the differentiated state of the hepatocytes.
Compared with hepatocytes grown alone, the cocultured hepatocytes
most likely produce an increased amount of which of the following?

o A) Alanine
o B) Fructose
o C) Maltose
o D) Pyruvate
o E) Urea
38. A male newborn has multiple dysmorphic features suggestive of
Down syndrome. Chromosomal analysis is ordered. Which of the
following choices is most appropriate regarding what the parents
should be told?

A) The newborn has some features of Down syndrome, and

chromosomal analysis has been requested
B) The newborn has some unusual features on examination, and a test
has been ordered that may help determine a diagnosis
C) The physician's concerns should not be mentioned because the
parents would worry unnecessarily if the physician is wrong
D) Some tests have been ordered, the results of which will be
communicated at the routine 2-week examination of the newborn
39. A healthy 58-year-old man comes to the physician because of
progressive hair loss during the past few years. He says that his father
and grandfathers had a similar pattern of baldness. Examination of the
scalp shows hair loss in an "M-" shaped pattern over the frontal
hairline. Which of the following mechanisms best expiains the hair loss
in this patient?

A) Decreased 5a-reductase activity

B) Dihydrotestosterone binding to androgen receptors
C) Increased activity of cytochrome P450 aromatase
D) Increased testicular testosterone production
40. A 55-year-old man volunteers as a subject for a cardiac function
study. Vital signs and a physical examination are obtained.
Echocardiography shows thickening of muscle tissue of the left
ventricle. Subsequent testing is most likely to show which of the
following underlying conditions in this man?

A) Aortic regurgitation
B) Coronary artery disease
C) Hypertension
D) Mitral stenosis
E) Mitral valve prolapse
41. A 36-year-old man with sarcoidosis comes to the emergency
department because of a 3-hour history of severe left flank pain
radiating to his groin. He says the pain varies in intensity but never
ceases completely. His temperature is 37.5°C (99.5°F), pulse is
100/min, respirations are 16/min, and blood pressure is 144/92 mm Hg
Physical examination shows left flank tenderness. Serum studies show
a calcium concentration of 11.2 mg/dL. Urinalysis shows microscopic
blood. Which of the following mechanisms is the most likely underlying
cause of this patient's condition?

o A) Activation of osteoclast-activating factor

o B) Increased a1-hydroxylase activity
o c) Increased intestinal absorption of oxalate
o D) Inhibition of urinary calcium excretion
o E) Stimulation of parathyroid hormone secretion
o F) Upregulation of vitamin D receptors
42. An investigator is studying a substance abuse problem among
school-age children that involves taking large doses of over-the-counter
cough medication containing dextromethorphan. The effects range from
mild excitement with hallucinations to a sense of complete dissociation
from the body. The investigator notes that this substance is an N-
methyl-D-aspartate receptor antagonist. The psychological effects of
this substance most closely resemble those of which of the following?

A) Codeine
B) Ketamine
C) Methamphetamine
D) Propofol
E) Tetrahydrocannabinol
43. A 40-year-old man has a history of cerebellar
hemangioblastoma and retinal angiomas.
Urinalysis shows microscopic blood. A CT scan
of the abdomen shows a renal mass, and a
nephrectomy is performed. The cut surface of the
resected kidney is shown. Which of the following
is the most likely diagnosis?

A) Hemangioma
B) Metastatic bronchogenic carcinoma
C) Myelolipoma
D) Renal adenocarcinoma
E) Transitional carcinoma
44. A 65-year-old man is brought to the emergency department 30 minutes after the sudden onset
of tearing chest pain that radiates to his back. He has smoked 1 pack of cigarettes daily for 40
years. His pulse is 115/min, and blood pressure is 170/110 mm Hg. Physical examination and a
chest radiograph show no abnormalities. Contrast axial (left) and sagittal (right) CT scans of the
chest and abdomen shown confirm thoracoabdominal dissection of the aorta; the arrows indicate
the vessel perfused by the false lumen. Occlusion of this vessel will most likely result in
compromised blood flow to which of the following organs?

o A) Colon
o B) Kidney
o c) Pancreas
o D) Small bowel
o E) Spleen
45. A 32-year-old woman comes to the physician because of
intermittent chest pain that is "not severe but rather annoying." Her
mother died of sudden cardiac arrest at age 51 years. A midsystolic
click is heard in the fifth intercostal space in the left midlavicular line.
Which of the following cardiac abnormalities is most likely in this
patient?

A) Atrial septal defect

B) Bicuspid aortic valve with stenosis
C) Mitral valve prolapse
D) Patent foramen ovale
E) Tricuspid regurgitation
46. A 38-year-old woman comes to the physician because she has not
had a menstrual period for 3 months. She also has had increased facial
and chest hair growth over the past 2 months. She is 170 cm (5 ft 7 in)
tall and weighs 64 kg (141 |b); BMI is 22 kg/m2. Her pulse is 80/min,
and blood pressure is 140/78 mm Hg. Physical examination shows
hirsutism and vaginal atrophy. Her serum testosterone concentration is
400 ng/dL (N=15-60), and measurement of urine collection of 17-
ketosteroids is 10 mg/24 h. Ultrasonography of the pelvis shows a
normal-sized left ovary and a right ovarian mass. Which of the following
is the most likely diagnosis?

o A) Germ cell tumor

o B) Granulosa tumor
o C) Polycystic ovarian disease
o D) Sertoli-Leydig tumor
o E) Thecoma
47. A 60-year-old man comes to the physician because of a 6-month
history of increasing hoarseness. He has smoked 2 packs of cigarettes
daily for 40 years. Laryngoscopic examination shows a mass consistent
with a malignant neoplasm in the larynx, involving the right vestibular
fold. This neoplasm is most likely to metastasize initially to which of the
following groups of lymph nodes?

A) Cervical
B) Mediastinal
C) Submandibular
D) Submental
E) Supraclavicular
48. A 49-year-old woman with poorly controlled hypertension
comes to the emergency department because of a 2-day history of
progressive shortness of breath. Current medications are
amlodipine, clonidine, enalapril, hydrochlorothiazide, and
metoprolol. She has not taken any of her medications for 5 days
because she ran out and could not afford to refill her prescriptions.
Her pulse is 98/min, respirations are 32/min, and blood pressure is
240/120 mm Hg. Pulse oximetry on room air shows an oxygen
saturation of 86%. Physical examination shows no significant
ankle edema. Bilateral crackles are heard over all lung fields.
Cardiac examination shows a loud S4. A chest x-ray shows
pulmonary edema. An ECG is shown. Which of the following is the
most likely mechanism of this patient's congestive heart failure?

o A) Atrial fibrillation
o B) Cardiac tamponade
o c) Diastolic dysfunction
o D) Dilated cardiomyopathy
o E) Myocardial ischemia
o F) Papillary muscle rupture
49. A 6-year-old boy is admitted to the hospital because
of an 8-hour history of fever, headache, and nausea.
Administration of intravenous (IV) fluids and empiric
antibiotics is started pending culture results. A lumbar
puncture is done, and a photomicrograph of a Gram
stain of cerebrospinal fluid is shown. During the next 24
hours, he develops bleeding from his gums and from all
IV puncture sites. He is intubated for respiratory failure,
and norepinephrine is administered for blood pressure
support. The most likely cause of this patient's new
symptoms is which of the following infection-related
complications?

A) Adrenal hemorrhage
B) Cerebral edema
C) Congestive heart failure
D) Pulmonary embolism
E) Toxic epidermal necrolysis
50. A 43-year-old woman comes to the physician because of a 2-month
history of intermittent abdominal pain. The pain occurs after fatty meals
and is localized to the right upper quadrant. Ultrasonography of the
abdomen shows cholelithiasis. The patient elects to begin a trial of
ursodiol therapy before considering operative treatment.
Which of the following is the primary mechanism of action of this
medication?

o A) Decreased cholesterol secretion into bile

o B) Enhanced cholesterol absorption
o C) Enhanced hepatic cholesterol synthesis
o D) Inhibition of bile acid synthesis
o E) Inhibition of 3-HMG-CoA
1. A 58-year-old woman comes to the physician because of a 2-month history of
intense pain on the right side of her body. She describes the pain as a constant,
burning sensation of variable intensity. Over-the-counter medications have not resolved
her pain. Six months ago, she sustained a cerebral infarction accompanied by loss of
sensation over the right side. Neurologic examination shows loss of sensation to light
touch and proprioception on the right side. Light touch of the skin elicits pain. No motor
deficits were detected. The most likely cause of this patient's condition is a lesion in
which of the following labeled areas in the MRI
of a normal brain?

A) A
B) B
C) C
D) D
E) E
2. A homeless 30-year-old man who is living in a shelter is brought to
the emergency department because of a 2-day history of cough
productive of bloody sputum. A chest x-ray shows a cavitary lesion in
the right upper lobe and calcifications in the right hilum. An acid-fast
smear of sputum is positive. Sputum is inoculated into mycobacterial
culture media. Which of the following best represents the expected time
before positive culture results will be available?

o A) Less than 24 hours

o B) 2-3 days
o c) 4-7 days
o D) 2-5 weeks
o E) 4-6 months
3. A 41-year-old man has the acute onset of abdominal pain caused by
a calculus at the right ureterovesical junction. The pain is most likely to
radiate to which of the following locations on the right?

A) Costovertebral angle
B) Upper quadrant of the abdomen
C) Groin
D) Lower leg
E) Foot
4. A 35-year-old man is admitted to the
hospital because of confusion, indifference,
and lethargy for 3 months. Ophthalmologic
examination shows sluggish pupillary
responses and horizontal nystagmus;
neither eye moves past the midline on
lateral gaze. A Romberg test is positive,
and his gait is severely ataxic. He develops
hemorrhaging from esophageal varices and
dies 5 days later. The brain at autopsy is
shown in the photograph. Which of the following is the most likely diagnosis?

o A) Central pontine myelinolysis

o B) Hepatic encephalopathy
o C) Hepatolenticular degeneration (Wilson disease)
o D) Ruptured cerebral aneurysm
o E) Traumatic injury
o F) Wernicke encephalopathy
5. A 30-year-old woman is brought to the physician because of a 2-day
history of double vision and deviation of the eyes. Her symptoms began
24 hours after a motor vehicle collision. Physical examination shows
left ptosis, and the left eye has developed a "down and out" location.
Which of the following is most likely to occur in this patient when light is
shined into the right eye?

Right Pupil Left pupil

A) Constriction constriction
B) Constriction no change
C) Constriction Marcus Gunn sign
D) No change no change
E) Dilation constriction
F) Dilation no change
G) Dilation Marcus Gunn sign
6. A 57-year-old woman with hypertension and hyperlipidemia
comes to the physician for a follow-up examination. She has
smoked 1 pack of cigarettes daily for the past 40 years. When the
physician asks the patient if she is interested in quitting smoking,
she replies that she might like to quit sometime in the next 6
months, but she feels ambivalent about giving up her "crutch." This
patient is most likely at which of the following stages of change?

o A) Precontemplation
o B) Contemplation
o C) Preparation
o D) Action
o E) Maintenance
7. A 9-year-old girl is brought to the physician because of a 6-day history of
abnormal movements of the left side of her face and left arm. The movements
are involuntary and present only when she is awake. In addition, she has
developed spontaneous outbursts of crying. She has received all of the
scheduled childhood immunizations. Her temperature is 37.7°C (99.9°F), pulse
is 80/min, respirations are 17/min, and blood pressure is 100/70 mm Hg.
Physical examination shows intermittent grimacing and tongue fasciculations.
When asked to squeeze the physician's fingers using her left hand, the
pressure of the grip fluctuates continuously. A grade 2/6, systolic murmur is
heard over the mitral focus. Neurologic examination shows abrupt,
nonrhythmic, involuntary movements of the left upper extremity and hand.
There is no sensory loss or involvement of the pyramidal tract. Which of the
following is the most likely diagnosis?

o A) Brain abscess
o B) Conversion disorder
o c) Hepatolenticular degeneration (Wilson disease)
o D) Huntington disease
o E) Sydenham chorea
8.A 5-year-old boy with a 4-day history of perianal itching is diagnosed
with pinworms. Albendazole treatment is initiated. Which of the
following best describes the mechanism of action of this drug?

A) Alteration of the cytoskeleton by binding to tubulin

B) Depolarization of the myoneural junction
C) Inhibition of the cytochrome P450-dependent demethylation
system
D) Inhibition of DNA and RNA synthesis
E) Inhibition of monoamine oxidase
9.A 27-year-old man comes to the physician because of a 2-month
history of difficulty swallowing, and episodes of vomiting and substernal
chest pain. He has had a 6,8-kg (15-Ib) weight loss during this period.
Use of over-the-counter antacids has not relieved his symptoms. He is
183 cm (6 ft) tall and weighs 73 kg (161 |b); BMI is 22 kg/m2. An upper
GI barium swallow shows a dilated esophagus with constriction at the
gastrosophageal junction. There is no peristalsis in the esophagus;
however, there are peristaltic waves in the stomach and small
intestine. The most likely cause of his condition is a lesion of which of
the following structures that affect the lower
esophagus?

o A) Enteric ganglia
o B) Greater splanchnic nerve
o C) Nucleus ambiguus
o D) Phrenic nerve
o E) Superior mesenteric ganglion
 10. A 27-year-old man comes to the physician with his 25-year-old wife
because of a 5-year history of inability to conceive. He has no history
of major medical illness.
Previous examination of his wife showed no abnormalities.
Examination of the external male genitalia and testes shows soft
lobulated masses bilaterally. Semen analysis shows a sperm count of
0.8 million/mL (N>20 million). Ultrasonography of the scrotum shows
bilateral abnormalities that cause increased temperature within the
scrotunT Which of the following additional findings is most likely in this
patient?

A) Absence of the scrotal ligaments

B) Cryptorchidism
C) Obstruction of the ductus deferens
D) Testicular torsion
E) Varicocele
11. A 27-year-old woman comes to the office because of a 6-month
history of progressive numbness and weakness that are more
prominent in her legs than in her arms.
Vital signs are within normal limits. Neurologic examination shows
weakness of hand grasp and dorsiflexion and plantar flexion of the
lower extremities. Sensation in all four extremities is diffusely
diminished. To avoid motor dysfunction, the most appropriate next
step in diagnosis is obtaining a biopsy specimen from which of the
following peripheral nerves?

o A) Deep fibular (peroneal)

o 8) Femoral
o c) Obturator
o D) Sural
o E) Tibial
12. A 32-year-old man comes to a medical clinic in Santiago, Chile,
because of a 6-week history of persistent pain and swelling of his
right arm that began after he fell while hiking. Two months ago, he
began an extended solo backpacking trip through a remote part of
the Andes Mountains. He splinted the arm with a stick. His food
supply has been limited to saltine crackers, peanut butter, and
processed cheese spread. Today, an x-ray of the right upper
extremity shows a poorly formed callus and nonunion of the fracture
ends. This patient most likely has decreased function of which of
the following proteins?

A) Alkaline phosphatase
B) Histidine deaminase
C) Matrix metalloproteinase
D) Neutrophil elastase
E) Prolyl 4-hydroxylase
13. A 31-year-old nulligravid woman comes to the physician
because she and her husband have not been able to conceive for
the past 3 years. Her husband has been evaluated, and no
problems were found. She has an intact hypothalamic-pituitary-
ovarian axis, and her serum estrogen concentration is within the
reference range. Clomiphene therapy is started. Which of the
following effects is most likely to occur in this patient?

o A) Decreased contractile activity of the uterine myometrium

o B) Decrease inhibitory estrogen feedback on the pituitary gland
o c) Facilitation of blastocyst implantation
o D) Increased pulsatile release of prolactin
o E) Increased survival of the corpus luteum
 14. During a clinical study of the sickle cell allele, an investigator
finds a frequency of 1/20 among African Americans and a
frequency of 1/200 among Americans of Hispanic descent. Which of
the following genetic mechanisms originally produced this
stratification of allele frequency?

A) Assortative mating
B) Balanced polymorphism
C) Founder effect
D) Gene flow
E) Heterozygote advantage
15. A 14-year-old boy is brought to the office for a health
maintenance examination. He tells the physician that he is
concerned about a small lump that he noticed under his left breast 2
months ago. His vital signs are within normal limits. He is at the
50th percentile for height and 75th percentile for weight. Physical
examination shows a 2.5-cm, mildly tender, rubbery mass under the
left areola. His sexual maturity rating (SMR) is 2 for genital and
pubic hair development. The remainder of the examination shows
no other abnormalities. Which of the following is the most likely
diagnosis?

A) Breast cancer
B) Costochondritis
C) Physiologic gynecomastia
D) Sebaceous cyst
E) Seminiferous tubule dysgenesis (Klinefelter syndrome)
 16. An investigator is studying the effects of carnitine depletion in
an experimental mouse model. The mice are fed a carnitine-
deficient diet, and it is hypothesized that this will result in
hepatocytes undergoing either autophagy or apoptosis. Which of
the following is the most appropriate marker to identify autophagic
cells in this study?

A) Activation of caspase 3
B) Activation of caspase 8
C) Formation of isolation membranes
D) Recruitment of Fas-associated death domains
E) Release of cytochrome c
17. A 45-year-old man with HIV infection comes to the office because of a
6-week history of swelling near the left side of his neck. His most recent
CD4+ T-lymphocyte count was 42/mm (N≥500), and plasma HIV viral load
was 55,000 copies/mL. He currently takes no medications. His
temperature is 38.0°C (100.4°F), pulse Is 72/min, respirations are 12/min,
and blood pressure is 120/81 mm Hg. Physical examination shows a left
supraclavicular mass. Immunohistochemical staining of a biopsy specimen
of the mass confirms the presence of the causal virus's DNA and
replication within lymphoma cells but not in nearby normal cells. Which of
the following is the most likely explanation for the tumor formation?

A) Chronic immune activation of B lymphocytes

B) Chronic immune activation of T lymphocytes
C) Inhibition of B-lymphocyte tumor surveillance
D) Inhibition of T-lymphocyte tumor surveillance
E) Malignant transformation of B lymphocytes
F) Malignant transformation of T lymphocytes
18. A 10-month-old girl develops a cough and grunting following a 3-day
hospital stay for surgical repair of a cleft palate. Her temperature is 39.2°C
(102.6°F), and respirations are 40/min. Crackles are heard over most lung
fields, and breath sounds are decreased. There is a mild pleural rub in the
right upper thorax. Her leukocyte count is 68.000/mm3 (85% segmented
neutrophils. 10% bands, and less than 5% myeloblasts, promyelocytes, and
myelocytes). Which of the following mechanisms most likely caused the
increased leukocyte count in this patient?

o A) Accelerated release of cells from the bone marrow postmitotic reserve pool
o B) Decreased margination and rolling of circulating cells
o C) Increased production of myeloblasts in the spleen
o D) Shift in bone marrow from eosinophil production to segmented neutrophil
production
o E) Transformation of myeloid stem cells
19. A 6-year-old boy is admitted to the hospital because of fever
and cellulitis of his right hand. Examination of the hand shows a 2-
cm, erythematous, macular lesion on the dorsum of the right hand.
Intravenous treatment with nafcillin is begun. During the next 24
hours, he develops a temperature of 39°C (102.2°F). Blood cultures
eventually grow methicillin-resistant Staphylococcus aureus.
Production of hich of the following most likely caused this
organism's resistance to methicillin?

A) Altered porins in the cell envelope

B) Antibiotic efflux pump
C) Increased production of folate
D) New penicillin-binding protein
E) Penicillinase
20. A 33-year-old man comes to the physician with his wife for a routine
health maintenance examination. His medical records show that he has a 10-
year history of alcoholism. The patient minimizes the amount and impact of his
drinking and says. "I do not have a drinking problem." However, further
questioning suggests a continuing dependence on alcohol. Physical
examination shows mild tremulousness, palmar erythema, and a palpable liver
edge. Which of the following actions by the physician is most appropriate?

A) Ask the patient to attend a few 12-step program meetings before his
next appointment
B) Ask the patient's wife to encourage him to stop drinking
C) Express concern about the drinking and ask the patient to return after
thinking about it
D) Say nothing further about the drinking but schedule a follow-up
appointment
E) Tell the patient he will need to find another physician if he continues to
drink
21. An 85-year-old man develops fever, chills, and a cough
productive of thick brownish sputum while in the hospital for
treatment of a hip fracture. His temperature is 37.7 C. A chest x-ray
show a creatinine concentration of 0.8 mg/dL. A sputum culture
grows Pseudomonas aeruginosa. Combination drug treatment is
initiated. Five days later, his serum creatinine concentration
isergents 2 mg/dL. Which if the following drugs is the most likely
cause of these laboratory findings?

o A) Ampicillin
o B) Aztreonam
o C) Ciprofloxacin
o D) Erythromycin
o E) Gentamicin
22. A 6-month-old boy is brought to the emergency department
after being found unresponsive in his crib. He is successfully
resuscitated. His serum glucose concentration is 20 mg/dL. Urine
contains dicarboxylic acids; there are no ketones. The most likely
cause of these symptoms is a defect in which of the following

o A) Amino acid catabolism

o B) Fatty acid B-oxidation
o C) Gluconeogenesis
o D) Glycogen storage
o E) Glycolysis
 23. A 48-year-old woman comes to the physician for a routine health
maintenance examination. She says that she is beginning menopause
because she has had irregular menstrual periods over the past year. She
asks the physician if "the change of life" will make her irritable, depressed,
and lose interest in sexual intercourse Which of the following responses by
the physician is most appropriate?

A) "As you age, it is normal to have less interest in sex."

B) "Hot flashes and personality changes are part of the menopause
experience, but some of the newer antidepressants will make you feel better."
C ) "Most women go through menopause without experiencing disabling
changes in their emotions or sexual interest."
D) "Starting hormone replacement therapy soon will decrease both
menopausal symptoms and decrease the risk for heart disease."
E) "These days, we can use hormone replacement therapy to prevent all the
symptoms of menopause."
24. An obese 45-year-old man comes to the physician
because of a 3-week history of nausea, vomiting,
abdominal cramps, and diarrhea. He has a 3-week history
of muse zing is geard on ausculati is grape a syst cardia
murie a Piysical examination 5 mis he dome are and
alpale midad mineral nontender mass. A CT scan of the
abdomen shows a 3-cm midileal mass and hepatomegaly
with a single 5-cm mass. The mass in the ileum is
resected. Gross and microscopic appearances of the
resected mass are shown. Which of the following is most
likely secreted in measurable quantities from this patients
lesion?

o A) CA 19.9
o B) CA 125
o c) Carcinoembryonic antigen
o D) 5-Hydroxyindoleacetic acid
o E) Vanillylmandelic acid
25. A 25-year-old man is brought to the emergency department by his wife
because of confusion for 8 hours. His wife says that he consumed an
excessive amount of alcohol at a party the night before, but he does not use
illicit drugs. She adds that he had not eaten anything for the preceding 24
hours. Physical examination shows no abnormalities, and neurologic
examination shows no focal findings. He is not oriented to person, place, or
time. His symptoms are relieved by intravenous administration of 50%
glucose. This patient most likely had a limited glucose production because of
which of the following changes in hepatic metabolism?

A) Decreased inorganic phosphate

B) Decreased lactate
C) Decreased NADH
D) Increased inorganic phosphate
E) Increased lactate
F) Increased NADH
26. A 55-year-old man comes to the physician because of a rash on
his face and body 2 weeks after undergoing allogenic hematopoietic
cell transplantation for muitiple myeloma. Physical examination
shows a maculopapular rash over the cheeks, upper trunk, and
palms. Histologic examination of a section of this patient's affected
skin is most likely to show basal keratinocytes undergoing which of
the following processes?

A) Apoptosis
B) Hyperplasia
C) Hypertrophy
D) Metaplasia
E) Necrosis
27. A 30-year-old woman, gravida 2, para 2, with epithelial ovarian
cancer comes to the office to begin her first cycle of a planned six
cycles of paclitaxel therapy. This treatment is designed to produce
drug-induced arrest at which of the following cell cycle checkpoints?

o A) DNA damage
o B) DNA replication
o c) G1 to S transition
o D) Restriction point
o E) Spindle formation
28. A 70-year-old man comes to the physician because of a 1-
month history of heavy, pressing substernal chest pain that occurs
when he walks up a flight of stairs. The symptoms are relleved by
rest. The physician prescribes a drug to alleviate the symptoms.
Within the cell, the drug acts by breaking down into a compound
that binds to a protein to increase intracellular concebtrations of
GMP, resulting in vasodilation. This binding most likely occurs in
which of the following cell locations?

o A) Cytosol
o B) Golgi complex
o c) Mitochondria
o D) Nucleus
o E) Peroxisome
o F) Plasma membrane
29. A 30-year-old man comes to the physician for a routine health
maintenance examination. Physical examination shows no
abnormalities. Laboratory studies show an increased serum
creatinine concentration. Renal ultrasonography shows multiple
cysts involving both kidneys. Renal ultrasonography of the patient's
father shows cystic kidneys; his serum creatinine concentration is
within the reference range. Similar examination of the patient's
mother showed no abnormalities. Which of the following genetic
mechanisms best explains the findings in this family?

o A) Anticipation
o B) Decreased penetrance
o c) Heteroplasmy
o D) Pleiotropy
o E) Variable expression
30. A 70-year-old man is brought to the emergency department because of a
3-day history of fever and progressive shortness of breath. He also has a
history of cough productive of yellow sputum that has recently become thick
and green. He has smoked 1 to 2 packs of cigarettes daily for 40 years. His
temperature is 40°C (104°F). and respirations are 22/min. Physical
examination shows decreased breath sounds. A chest x-ray shows right lower
lobe infiltrates surrounding a 3-cm, rounded lesion containing an air-fluid level.
Which of the following immune cell activities most likely predominates in the
center of this lesion?

o A) B-lymphocyte antibody production

o B) Macrophage free-radical generation
o C) Natural killer cell-mediated killing
o D) Segmented neutrophil acid hydrolase activation
o E) T-lymphocyte perforin synthesis
31. A pharmaceutical company develops a new oral medication
(Drug X) for the treatment of type 2 diabetes mellitus. Study results
have shown that the mechanism of action is mediated by blocking
the ATP-dependent potassium channel on pancreatic ß cells.
Based on these findings, Drug X is most similar to which of the
following?

o A) Exenatide
o B) Glyburide
o C) Metformin
o D) Pioglitazone
o E) Sitagliptin
32. An investigator is conducting a study of the effects of alcohol
consumption in young adults. A total of 250 participants between the
ages of 21 and 25 years are recruited for the study. Blod alcohol
concentrations are measured using a breathalyzer after repeated oral
doses of pure (95%) ethanol. Results show that female participants
become more intoxicated and have higher blood alcohol
concentrations compared with male participants receiving an
equivalent dose of ethanol. Which of the following characteristics of the
female participants best explains these findings?

o A) Decreased alcohol dehydrogenase activity

o B) Induction of enzymes in the microsomal ethanol-oxidizing system
o c) Presence of genetic polymorphisms of alcohol dehydrogenase
o D) Presence of genetic polymorphisms of aldehyde dehydrogenase
o E) Relatively higher proportion of total body water
33. A 35-year-old woman hay had nervousness and insomnia for 2
weeks. She has asthma that has been successfully treated with a slow-
release theophylline preparation for 4 months. Recent use of which of
the following is the most likely cause of these symptoms?

A) Barbiturates
B) Cigarettes
C) Cimetidine
D) Diazepam
E) Phenytoin
 34. A 15-year-old girl with a 7-year history of asthma is brought to
the physician for a follow-up examination. She has been
taking oral prednisolone for 2 months for exacerbations of her
condition. Her respirations are 28/min. Physical examination
shows expiratory wheezing. Pulmonary function studies show
decreased FEV, and decreased FEV, /FVC ratio. A
leukotriene receptor antagonist is prescribed and the patient's
clinical condition improves. This drug blocks receptors that
belong to which of the following types?

o A) G protein-coupled
o B) Ligand-gated
o C) Nuclear
o D) Protein kinast
o E) Voltage-gated
 35. A 52-year-old man who lives in Indiana comes to
the physician because of a 1-month history of
fever and nonproductive cough. He is a
construction worker. His temperature is 38.4°C
(101.1°F), pulse is 84/min, respirations are
14/min, and blood pressure is 110/70 mm Hg.
Scattered crackles are heard over all lung fields.
A chest x-ray shows bilateral interstitial infiltrates.
A photomicrograph of a specimen obtained via
transbronchial biopsy is shown. The most likely
causal organism in this patient has a cell wall
composed of which of the following?

o A) N-Acetylglucosamine-N-acetylmuramic acid
o B) Cellulose
o c) Glucans
o D) Polyglutamic acid
o E) Teichoic acid
36. An investigator is studying a T-lymphocyte clone that
recognizes a peptide from the hemagglutinin glycoprotein of
influenza virus. In the context of human leukocyte antigen
(HLA)-DR2, this clone most likely recognizes a peptide that
was combined with HLA-DR2 in which of the following cellular
compartments?

A) Cytosol
B) Endoplasmic reticulum
C) Endosomes
D) Mitochondria
E) Nucleus
 37. An investigator is studying the effects of complement proteins
on acute inflammation in an experimental mouse model.
During the study, sections of skin are harvested before and
after simultaneous dermal injection of Staphylococcus aureus
and a single complement protein. The concentration of several
biochemical mediators is measured before and after injection.
Compared with baseline measurements, increased
concentrations of histamine, leukotriene B4, and serotonin are
found after injection. Which of the following complement
proteins was most likely injected during the experiment?

o A) C1q
o B) C2a
o C) C2b
o D) C5a
o E) C5b
38. A 62-year-old woman with a 25-year history of type 2 diabetes
mellitus comes to the office for a follow-up examination. She is 165 cm
(5 ft 5 in) tall and weighs 79 kg (175 |b); BMI is 29 kg/m2. Physical
examination shows no other abnormalities. The physician recommends
that she receive an influenza virus vaccine at this visit. Administration
of this vaccine is most likely to produce protective antibodies against
which of the following viral structural proteins?

o A) Hemagglutinin
o B) M1 matrix protein
o C) M2 ion channel
o D) Neuraminidase
o E) Nucleoprotein
 39. A 42-year-old man with end-stage renal disease undergoes
transplantation with a kidney from a cadaveric donor. During
the operation, following anastomosis of the renal vessels, the
transplanted kidney becomes cyanotic and mottled. The
kidney fails to excrete urine and is removed. Which of the
following is the primary cause a nonfunction of the
transplanted kidney?

o A) Fibrin thrombi in capillaries

o B) Interstitial eosinophilic infiltration
o C) Neutrophilic infiltration of venules
o D) Organizing thrombus in the renal artery
o E) T-lymphocyte infiltration of tubules
40. A 30-year-old man comes to the
physician because of a 2-month history
of episodes of headache, fever, and
shaking chills since he returned from a
6-month trip to the Mayan ruins in
southern Mexico. His temperature is
39°C (102.2°F). Physical examination
shows no other abnormalities. A
photomicrograph of a Wright-stained peripheral blood smear
is shown. Which of the following vectors is the most likely
source of infection in this patient?

A) Body louse
B) Kissing bug
C) Mosquito
D) Sandfly
E) Tsetse fly
 41. A 37-year-old woman has had fatigue and
headaches for 1 month. Laboratory studies
show a hemoglobin concentration of 9 g/dL,
mean corpuscular volume of 82 nm3, platelet
count of 75.000/mm3, and leukocyte count of
32,000/mm3, the majority of which are
immature granulocytes. Prothrombin and
partial thromboplastin times are prolonged. A
peripheral blood smear is shown. Which of the
following is the most likely diagnosis?

o A) Acute lymphocytic leukemia

o B) Chronic lymphocytic leukemia
o C) Chronic myelogenous leukemia
o D) Hairy cell leukemia
o E) Promyelocytic leukemia
 42. A 65-year-old woman comes to the physician because
of a 10-week history of low-grade fever, fatigue, and
pain in her right arm. She recalls no trauma to the arm.
She has a history of cancer treated with radiation
therapy. Her temperature is 37.7°C (99.8°F). Physical
examination shows tenderness of the right distal
humerus. Laboratory studies show anemia. An x-ray of
the right upper extremity is shown. This patient most
likely has an abnormality of which of the following cell
types?

A) Hematopoietic stem cells

o B) Monomyelocytic stem cells
o C) Natural killer cells
o D) Osteoclasts
o E) Plasma cells
 43. A 21-year-old college student comes to the physician because
of a 3-month history of depressed mood and insomnia. During
this period, her school performance has deteriorated, and she
has not kept up with stamp collecting, a hobby she used to
enjoy. Two years ago, she had a 1-month episode of euphoric
mood during which she barely slept and had promiscuous
encounters with strangers. Physical examination today shows
no abnormalities. Mental status examination shows
psychomotor retardation and suicidal ideation. Which of the
following is the frost likely diagnosis?

o A) Bipolar disorder
o B) Chronic fatigue syndrome
o C) Cyclothymic disorder
o D) HIV infection
o E) Major depressive disorder
44. An 8-year-old boy is brought to the physician by his mother
because of a 6-month history of difficulty reading and impulsive
behavior. His full-scale IQ is 103, and his reading and math
achievement scores are 101 and 97, respectively. The Conners Rating
Scales and Child Behavior Checklist show clinically significant levels of
inattention, impulsivity, and hyperactivity. Mood disorder scales and
results of a hearing loss test and a vision test are within the reference
ranges. The most appropriate therapy for this patient is a drug that
affects which of the following neurotransmitters?

o A) Acetylcholine
o B) y-Aminobutyric acid
o C) Glutamate
o D) Norepinephrine
o E) Serotonin
45. A 37-year-old man who is addicted to heroin begins methadone
therapy. Which of the following pharmacologic approaches best
describes this type of therapy?

A) Substitution with a longer-acting agonist

B) Substitution with a mixed agonist/antagonist
C) Substitution with a preparation with quicker elimination
D) Symptomatic treatment of piloerection
E) Symptomatic treatment of withdrawal
46. A 52-year-old man comes to the physician because of a 2-week history
of clumsiness of his left foot when playing soccer. He also has a 2-month
history of intermittent tingling in his left leg. Sensation to fine touch,
vibration, and position is decreased in the left lower extremity. Muscle
strength and deep tendon reflexes are normal throughout. An MRI of the
spine is most likely to show a lesion compressing which of the following
regions of the spinal cord?

A) Anterolateral funiculus on the left at C2

B) Anterolateral funiculus on the right at C2
C) Anterolateral funiculus on the left at T8
D) Anterolateral funiculus on the right at T8
E) Dorsal funiculus on the left at C2
F) Dorsal funiculus on the right at C2
G) Dorsal funiculus on the left at T8
H) Dorsal funiculus on the right at T8
47. The figure shows the effects of
drug X, administered intravenously,
on heart rate, atrioventricular (AV)
conduction velocity, and force of
ventricular contraction. Drug X most
likely has which of the following
actions?

o A) alpha-Adrenergic agonist
o B) alpha-Adrenergic antagonist
o c) betta-Adrenergic agonist
o D) betta-Adrenergic antagonist
o E) Muscarinic agonist
o F) Muscarinic antagonist
48. Drug X is injected intravenously into three
subjects (including one control subject). The
control subject is not pretreated, whereas the
other two subjects are pretreated with either
prazosin or cocaine. Blood pressure is recorded
directly from the brachial artery (see graph). Drug
X is most likely which of the following?

A) Epinephrine
o B) Isoproterenol
o C) Phenylephrine
o D) Physostigmine
o E) Tyramine
49. A 54-year-old man with severe hypertension suddenly collapses
and loses consciousness while having an argument on the telephone.
Physical examination shows pinpoint pupils and decorticate posturing.
A CT scan of the head is most likely to show which of the following
types of hemorrhage?

o A) Epidural
o B) Intraparenchymal
o c) Intraventricular
o D) Subarachnoid
o E) Subdural
50. A 62-year-old woman is brought to the
emergency department 1 hour after she
collapsed suddenly at home. A normal AP CT
angiogram of a portion of the cerebral arterial
circulation is shown; the arrow indicates the
area of occlusion. Which of the following
neurologic findings would be most likely in this
patient?

o A) Ataxic movements of the left extremities

o B) Ataxic movements of the right extremities
o c) Left homonymous hemianopia
o D) Right homonymous hemianopia
o E) Weakness of the left lower extremity
o F) Weakness of the right lower extremity
1.A 31-year-old man comes to the physician 1 day after he noticed that
the right side of his face was lower than the left while shaving. On
physical examination, he is unable to grimace his right cheek or elevate
his right evebrow. Neurologic examination shows impaired facial
expression and loss of taste in the anterior two thirds of the tongue.
Which of the following additional neurologic findings is most likely in
this patient?

o A) Double vision
o B) Hoarseness
o C) Hyperacusis
o D) Impaired facial sensation
o E) Impaired sweating
2. A 3-year-old boy is brought to the physician because of a 6-month
history of a sway back when standing. His brother had a history of
muscle weakness and died of pneumonia at the age of 12 years.
Physical examination shows hip girdle weakness. His serum creatine
kinase concentration is markedly increased. This patient's symptoms
are most likely caused by the accumulation of a defective protein in
which of the following locations in muscle cells?

o A) Cytoplasm
o B) Lysosome
o c) Mitochondria
o D) Nuclear membrane
o E) Peroxisome
o F) Smooth endoplasmic reticulum
3. A previously healthy 50-year-old man is brought to
the physician because of a 2-week history of blurred
vision. Neurologic examination shows inability of the
left eye to look to the left. The right eye movement
shows no abnormalities. This patient most likely has
a lesion in which of the following labeled cranial
nerves in the photograph of the brain stem shown?

A) A
B) B
C) C
D) D
E) E
4. A 55-year-old man comes to the office because of a 2-week history
of an increasingly large and painful lump on his right shoulder. The
lump began as a pea-sized red bump. He has no history of serious
illness and takes no medications. Temperature is 38.0°C (100.4°F); all
other vital signs are within normal limits. Physical examination shows a
5-cm, inflamed carbuncle on the right shoulder. Treatment with a 7-day
course of cephalexin is initiated. The carbuncle in this patient is most
likely located in the layer of skin that has which of the following
embryologic precursors?

o A) Dermatome
o B) Myotome
o c) Neurotome
o D) Sclerotome
o E) Syndetome
5. A 55-year-old man with a 10-day history of a
blistering rash on his back comes to the physician for
a follow-up examination. He completed a course of
antiviral medication 3 days ago, and he continues to
have moderate pain. His vital signs are within normal
limits. Physical examination shows the findings in the
photograph. This rash is most likely located in which
of the following dermatomes?

A) T4
B) T7
C) T11
D) L1
E) S1
6. An 8-year-old boy is brought to the physician
because of an itchy rash for 3 days. Physical
examination shows an excoriated rash over the right
wrist and around the waist. A 1.5-cm linear tunnel is
seen over the right wrist. A photomicrograph of
scrapings from the affected area is shown. Which of
the following is the most likely causal organism?

o A) Leishmania donovani
o B) Loa loa
o C) Malassezia furfur
o D) Sarcoptes scabiei
o E) Trichophyton mentagrophytes
7. A 32-year-old woman comes to the physician because of a 6-week
history of pain at the base of her right thumb. She does not recall any
trauma but says that she typically carries her heavy 6-month-old son
with her right arm. Her vital signs are within normal limits. A test
involving flexion of the fingers over the thumb to make a fist, followed
by unar deviation, is positive on the right. Which of the following is the
most likely cause of this patient's pain?

o A) Bursitis
o B) Enthesitis
o c) Osteoarthritis
o D) Osteomyelitis
o E) Tenosynovitis
8. A 35-year-old man comes to the office because
of a 3-month history of an enlarging, painless lump
on the back of his left thigh. He also has had
weakness in his left thigh and leg. Physical
examination shows a 7-cm, hard, nonmobile
swelling on the left posterior thigh. Sensation to
pinprick is decreased along the posterior thigh and
below the knee. Sagittal and axial views from a CT
scan of the left thigh are shown. A biopsy specimen
of the lump confirms a rhabdomyosarcoma. The
most likely cause of the findings in this patient is
compression of which of the following nerves?

A) Femoral
B) Llioinguinal
C) Lateral femoral cutaneous
D) Obturator
E) Posterior cluneal
F) Sciatic
9. An 8-year-old boy is brought to the physician after his teacher
reported that he has difficulty sprinting. He is able to exercise normally
at a less vigorous pace. After exercise of the right upper extremity, a
blood sample obtained from the vein just proximal to the exercised
muscle does not show the expected increase in serum lactic acid
concentration. An inborn error of metabolism in which of the following
pathways in skeletal muscle is most likely in this patient?

o A) Beta oxidation
o B) Gluconeogenesis
o C) Glycogen synthesis
o D) Glycogenolysis
o E) Pentose phosphate pathway
10. A 9-year-old boy is brought to the physician by his mother 1 day
after he had severe leg cramps while playing soccer. The mother says
that he also has a 2-month history of fatigue and clumsiness, and that
his face lacks expression. He tires easily with exercise. He has a 3-year
history of migraine. He is at the 60th percentile for height and weight.
Vital signs are within normal limits. Physical examination shows
bilateral ptosis and limited vertical and horizontal gaze. His speech is
slightly slurred. Examination of a muscle biopsy specimen shows
ragged red fibers. Which of the following is the most likely diagnosis?

o A) Becker muscular dystrophy

o B) Duchenne muscular dystrophy
o C) Mitochondrial myopathy
o D) Myotonic dystrophy
o E) Spinal muscular atrophy type 1
11. During a study of exercise physiology, a healthy 30-year-old woman
runs on a treadmill for 20 minutes at a rate of 7 miles per hour. At the
end of the study, her cardiac output has increased from 5 L/min to 15
L/min; the cerebral perfusion pressure has remained relatively
constant. Which of the following mechanisms best explains this
findings?

A) Decreased intracranial pressure

B) Increased cerebrospinal fluid reabsorption
C) Increased venous drainage
D) Myogenic arteriolar constriction
E) Reflex bradycardia
12. An 84-year-old man is brought to the emergency department 30
minutes after an episode of syncope. Transthoracic echocardiography
shows a 4-cm myxoma occupying the majority of the left atrium. The
tumor will be excised using a robotically assisted operation via an
oblique right atriotomy and transection of the interatrial septum. When
making the incision into the left atrum to remove the myxoma, which of
the following regions of the interatrial septum should be avoided in
order to prevent injury to the cardiac conduction system?

o A) Crista terminalis
o B) Fossa ovalis region
o C) Posteroinferior region above the opening of the coronary sinus
o D) Superoanterior region above the limbus of the fossa ovalis
o E) Superoposterior region posterior to the fossa ovalis
13. A 76-year-old man who has had no medical care for more than 10 years
comes to the physician because of a 3-week history of intermittent episodes of
dizziness and feeling faint. He says the symptoms are worse when he rises after
lying down. He is unable to be even moderately physically active because of the
dizziness. He has had no chest pain or shortness of breath during this period. His
pulse is 30/min, respirations are 15/min, and supine blood pressure is 100/40 mm
Hg. Physical examination shows no other abnormalities. An ECG is shown. This
patient most likely has which of the following dysrhythmias?

A) Atrial fibrillation
o B) Atrial flutter
o C) Second-degree atrioventricular block
o D) Sinus arrest
o E) Sinus bradycardia
o F) Third-degree atrioventricular block
14. A 22-year-old man comes to the office because of a 3-month
history of episodes of severe abdominal pain with nausea and vomiting.
Abdominal examination shows epigastric tenderness to palpation
without rebound tenderness or guarding. Serum studies show a
triglyceride concentration of 2000 mg/dL, amylase activity of
2000 U/L, and lipase activity of 1800 U/L. Abdominal ultrasonography
shows no evidence of biliary tract obstruction. A drug from which of the
following classes is most appropriate to treat this patient's lipid
abnormality?

o A) Bile acid sequestrant

o B) Cholesterol absorption inhibitor
o C) Fibric acid derivative
o D) HMG-CoA inhibitor
o E) Omega-3 fatty acids
15. A 42-year-old woman comes to the
physician because of a 6-month history
of progressive loss of peripheral vision.
Ophthalmologic examination shows
bitemporal hemianopia with normal
fundi and visual acuity. A sagittal T1-
weighted MRI of the brain with contrast
is shown; the arrow indicates an abnormality. To surgically access and
resect the mass via a nasal approach, which of the following sinuses
must be traversed?

o A) Ethmoid
o B) Frontal
o C) Maxillary
o D) Sphenoid
16. An investigator studying bronchial circulation interrupts this
circulation in experimental animals. As a result, which of the following
processes is most likely to be affected?

A) Alveolar macrophage production

B) Clearance of pulmonary edema
C) Delivery of nutrients to the tracheal wall
D) Hypoxic pulmonary vasoconstriction
E) Surfactant production
17. A 65-year-old man with chronic obstructive pulmonary disease
comes to the office because of a 2-week history of progressive
shortness of breath. He had smoked 1 pack of cigarettes daily for 40
years before quitting 1 year ago. Current medications include albuterol
as needed. His respirations are 18/min. Physical examination shows
wheezing. Pulmonary function testing shows an FEV, that is 55% of
predicted value compared with 65% 1 year ago. It is most appropriate
to add a drug to this patient's medication regimen that binds to or
interferes with which of the following?

o A) B-Adrenoreceptors
o B) Interleukin-1 (IL-1) synthesis
o C) Leukotriene receptors
o D) Mast cell degranulation
o E) Muscarinic receptors
o F) Phosphodiesterase
18. A 67-year-old man who is a retired coal
miner comes to the physician because of a
2-year history of progressive shortness of
breath. He also has had a 23-kg (50-Ib)
weight loss during this period. He appears
cachectic. He is 175 cm (5 ft 9 in) tall and
now weighs 54 kg (120 Ib); BMI is 18 kg/m2.
His temperature is 36.8°C (98.2°F), pulse is 100/min, respirations are 22/min, and
blood pressure is 137/83 mm Hg. Physical examination shows symmetric air entry
with no crackles or wheezes. A chest x-ray and photomicrograph of lung tissue
obtained on biopsy are shown. The structure indicated by the arrow in the
photomicrograph most likely represents which of the following?

o A) Aspergillus species hyphae

o B) Collagen
o C) Fibrinogen
o D) Hyaline membranes
o E) Microabscess
19. A 40-year-old woman with primary pulmonary hypertension comes
to the physician for a follow-up examination. Her blood pressure is
190/100 mm Hg. Echocardiography shows a peak pulmonary systolic
pressure of 65 mm Hg. Treatment with bosentan is started. This
therapy is most likely to result in blockade of the action of which of the
following peptides in this patient?

o A) Calcitonin gene-related peptide

o B) Endothelin
o C) Neuropeptide Y
o D) Substance P
o E) Urotensin II
20. A previously healthy 59-year-old man comes to the emergency
department because of a 1-day history of fever, shortness of breath,
and productive cough. He appears to be in moderate distress. His
temperature is 38.4°C (101.1°F), and respirations are 26/min. Pulse
oximetry on room air shows an oxygen saturation of 88%. Bronchial
breath sounds are heard over the right lung base posteriorly with
egophony and increased tactile fremitus. A chest x-ray shows right
lower lobe pneumonia. Which of the following mechanisms is the most
likely cause of the hypoxia in this patient?

o A) Alveolar fibrosis
o B) Hypoventilation
o C) Right-to-left cardiac shunt
o D) Right ventricular failure
o E) Ventilation-perfusion mismatch
21. A 27-year-old man is brought to the emergency department
because of increasingly severe left-sided chest pain during the past 12
hours. The pain worsens on deep inspiration. He was moving furniture
when the pain began. His father died of a myocardial infarction at the
age of 58 years. His respirations are 18/min. Palpation over the
costochondral junction to the left of the sternum reproduces the pain.
Cardiac examination shows no abnormalities. Which of the following is
the most likely diagnosis?

A) Coronary artery disease

B) Costochondritis
C) Pericarditis
D) Pleurisy
E) Pulmonary embolism
F) Rib fracture
22. A 35-year-old womanIcomes to the physician because of a 2-week
history of fatigue. Six months ago, she visited family in Brazil, where
she was exposed to domestic and farm animals. Physical examination
shows no abnormalities except for pallor. Laboratory studies show a
hemoglobin concentration of 7.2 g/dL and a hematocrit of 23%. Which
of the following is the most likely causal organism?

o A) Enterobius vermicularis
o B) Necator americanus
o C) Schistosoma mansoni
o D) Taenia solium
o E) Trichuris trichiura
23. A 61-year-old man comes to the physician because of a 3-week history
of progressive loss of appetite and difficulty swallowing. His last medical
examination was 10 years ago. He has taken calcium carbonate for
chronic heartburn and nonsteroidal anti-inflammatory drugs (NSAIDs) for
joint aches for the past 10 years. He drinks approximately four to five 12-
ounce beers daily. His diet consists primarily of meat and simple
carbohydrates. He appears cachectic. Physical examination shows no
other abnormalities. Esophagogastroduodenoscopy shows a stricture at
the esophagogastric junction. Examination of a biopsy specimen of the
esophagus shows adenocarcinoma. Which of the following is the strongest
predisposing risk factor for this patient's condition?

o A) Alcohol use
o B) Chronic heartburn
o c) Gender
o D) Low-fiber diet
o E) NSAID use
24. A 57-year-old woman with a history of gastrosophageal reflux
disease undergoes upper endoscopy. Results show a 4-cm, bulging
nodule in the stomach covered with an intact mucosal surface. The
mass is subsequently resected, and examination shows that it is
contained within the submucosa; it is fleshy and well circumscribed with
minimal mucosal alterations. A diagnosis of gastrointestinal stromal
tumor is made. Further examination of this tumor is most likely to show
which of the following molecular alterations?

o A) Activation of the APC/ß-catenin pathway

o B) Activation of KIT receptor tyrosine kinase
o C) Mutation of CDH1 (E-cadherin) protein
o D) Translocation of chromosomes 9 and 22
o E) Translocation of chromosomes 11 and 18
25. A 42-year-old man with a history of duodenal peptic ulcer disease
has the sudden onset of severe epigastric and right upper quadrant
abdominal pain. The abdomen is rigid, tightly distended, and
hyperresonant. An x-ray of the abdomen shows air under both sides of
the diaphragm. Which of the following structures is most likely involved
with the patient's ulcer?

o A) Ampulla of Vater
o B) Anterior duodenal wall
o C) Celiac plexus
o D) Head of the pancreas
o E) Retroperitoneal portion of the duodenum
26. A 52-year-old man comes to the physician because of vomiting for
24 hours. He has a 1-week history of chronic constipation with bloating
and abdominal pain. He is 183 cm (6 ft) tall and weighs 111 kg (245 lb);
BMI is 33 kg/m2. Abdominal examination of the left lower quadrant
shows muscle guarding; palpation of this area produces pain. A CT
scan of the abdomen shows diverticula. The diverticula are most likely
present in which of the following regions of the gastrointestinal system
in this patient?

o A) Cecum
o B) Descending colon
o c) Ileum
o D) Rectum
o E) Sigmoid colon
27. A previously healthy 48-year-old woman comes to the emergency
department because of a 4-hour history of constant abdominal pain and
fever. The pain radiates to the right shoulder and is accompanied by
nausea and vomiting with no blood. She takes no medications. She
does not smoke cigarettes or drink alcohol. She is in acute distress.
Her temperature is 38.2°C (100.8°F), pulse is 104/min, respirations are
22/min, and blood pressure is 142/86 mm Hg. Abdominal examination
shows marked tenderness of the right upper quadrant with voluntary
guarding. Bowel sounds are decreased. Which of the following
responses is expected in this patient on palpation of the right upper
quadrant of the abdomen during the respiratory cycle?

o A) Decreased pain and expiratory arrest

o B) Decreased pain andunspiratory arrest
o C) Increased pain and expiratory arrest
o D) Increased pain and inspiratory arrest
o E) No change in pain or respirations
28. A 25-year-old man is brought to the emergency department by
ambulance 2 hours after the sudden onset of severe midepigastric
abdominal pain. He vomited a small amount of bloody fluid shortly after the
pain began. En route, his pulse is 150/min, and blood pressure is 80/40
mm Hg. Perforation of the duodenum is suspected. Which of the following
sets of abdominal physical findings is most consistent with this diagnosis?

A) Absent bowel sounds, rigid abdominal wall, tenderness and

guarding throughout
B) Active bowel sounds, distention, right lower quadrant tenderness
and rebound
C) Hyperactive bowel sounds, soft abdomen, no tenderness
D) Hypoactive bowel sounds, distention, tenderness and guarding in
the left lower quadrant
E) Normal bowel sounds, enlarged tender liver, positive fluid wave
29. A 31-year-old man is admitted to the hospital because of flank and
abdominal pain. A CT scan of the abdomen shows an aneurysm of the
proximal portion of the superior mesenteric artery. This aneurysm is
most likely to compress and impede venous blood flow from which of
the following organs?

o A) Left kidney
o B) Liver
o C) Right kidney
o D) Right suprarenal (adrenal) gland
o E) Spleen
30. During an experiment, a drug that specifically dilates the efferent
arterioles of the kidney is infused into an experimental animal. Which of
the following sets of renal changes is most likely to occur in response to
the drug?

A)
B)
C)
D)
E)
F)
G)
H)
31. An experimental animal receives a carbonic anhydrase inhibitor.
One hour later, which of the following sets of changes in plasma is
most likely in this animal?

A)
B)
C)
D)
E)
F)
G)
H)
 32. A 30-year-old Asian American man comes to the physician because of a
4-day history of blood in his urine. He had an upper respiratory tract
infection that resolved 3 weeks ago. His temperature is 37.4°C (99.4°F),
pulse is 82/min, and blood pressure is 160/90 mm Hg. Physical
examination shows no abnormalities. Urinalysis shows RBCs that are too
numerous to count and 2+ protein. A 24-hour urine protein collection
shows 1200 mg. A renal biopsy specimen shows mesangial proliferation
with rare crescents, mesangial IgA, C3, few IgG deposits, and electron-
dense deposits in vessel walls and mesangium. Which of the following
best describes the pathogenesis of this patient's disease?

o A) Anti-glomerular basement membrane antibodies to type IV collagen

o B) Antineutrophil cytoplasmic antibodies with epithelial proliferation
o C) Dysfunctional type IV collagen resulting in defective glomerular basement
membrane synthesis
o D) Immune dysfunction resulting in visceral epithelial cell injury and loss of
glomerular polyanions
o E) Increased IgA synthesis, mesangial lgA entrapment, and alternate
complement pathway activation
33. A 62-year-old man is admitted to the intensive care unit after having
a myocardial infarction. During the next 36 hours, his serum creatinine
concentration increases to 3.9 mg/dL and his urine output decreases.
Three days later, he develops polyuria. At the time of discharge from
the hospital, his serum creatinine concentration is 2.6 mg/dL. Which of
the following is the most likely cause of this patient's episode of acute
kidney injury?

o A) Acute papillary necrosis

o B) Acute tubular necrosis
o C) Atheroembolic renal disease with acute renal infarction
o D) Hypertensive nephrosclerosis
o E) Volume overload
34. A 33-year-old woman comes to the emergency department
because of a 4-day history of progressive shortness of breath that is
worse at night. Five days ago, she had an uncomplicated vaginal
delivery of a female newborn at term. Her respirations are 22/min.
Bilateral crackles are heard on auscultation of the chest. Cardiac
examination shows the point of maximal impulse to be displaced
laterally and an S, gallop. An ECG shows sinus tachycardia and
nonspecific ST-T segment and T-wave changes. Echocardiography
shows a left ventricular ejection fraction of 30%, global hypokinesis,
and mild mitral regurgitation. Which of the following is the most likely
diagnosis?

o A) Cardiomyopathy
o B) Coronary artery disease
o c) Hypertensive heart disease
o D) Pulmonary embolism
o E) Valvular heart disease
35. A 27-year-old woman who has had type 1 diabetes mellitus for 10
years delivers a plethoric, large newborn weighing 5 kg (11 lb).
Eighteen hours after delivery, the newborn develops hypoglycemia.
Which of the following is the best explanation for the hypoglycemia?

o A) Glucagon secretion by pancreatic a cells is decreased in the

newborn
o B) Hepatic enzymes for gluconeogenesis are increased in the
newborn
o C) Hepatic glycogen content is depleted in the newborn
o D) Insulin secretion by pancreatic betta cells is increased in the
newborn
o E) Maternal insulin crossed the placenta
36. A 29-year-old woman with type 1 diabetes mellitus gives birth at
home to a male newborn at 30 weeks' gestation. During transport to the
hospital, the newborn develops respiratory distress. The lower ribs and
sternum retract in inspiration, and an expiratory grunt is audible. An x-
ray of the chest shows uniform reticulogranular densities in both lung
fields. Arterial PaO2 is 60 mm Hg. Blood and sputum cultures are
negative. Whicn of the following is the most likely cause of the
hypoxemia in this newborn?

A) Atelectasis
B) Bullous emphysema
C) Diffuse pulmonary fibrosis
D) Hyperplasia of type I pneumocytes
E) Intra-alveolar exudate consisting of neutrophils
 37. A 24-year-old woman has the onset of fever, chills, and
lower abdominal pain on the second day of her menstrual
period. Examination shows tenderness localized to the
fallopian tubes and ovaries. A complete blood count shows
leukocytosis. Which of the following is the most likely causal
organism?

o A) Gardnerella vaginalis
o B) Neisseria gonorrhoeae
o C) Staphylococcus aureus
o D) Streptococcus agalactiae (group B)
o E ) Trichomonas vaginalis
38. A 31-year-old man comes to the physician because of
a 4-day history of vague lower abdominal discomfort. He
has been treated with chemotherapy for the last
4 months for testicular embryonal carcinoma. His serum a-
fetoprotein concentration, which was initially markedly
increased, is now zero. Imaging studies show a persistent
6-cm, well-circumscribed, retroperitoneal mass. The mass
is resected and a representative section is shown. Which
of the following is the most likely diagnosis?

o A) Idiopathic retroperitoneal fibrosis

o B) Metastatic choriocarcinoma
o C) Metastatic embryonal carcinoma
o D) Metastatic teratoma
o E) Scar following chemotherapy
39. A 68-year-old man is diagnosed with metastatic prostate cancer.
The most appropriate treatment should include a drug with which of the
following mechanisms of action?

o A) Androstenedione aromatase inhibitor

o B) Estrogen receptor partial agonist-antagonist
o c) Gonadotropin-releasing hormone agonist
o D) Microtubule function inhibitor
o E) Somatostatin receptor agonist
40. A 29-year-old man comes to the physician with his 27-year-old wife
because they have been unable to conceive for 1 year. Previous
examination of the wife showed no abnormalities. Physical examination
shows normal genitalia. His serum testosterone and luteinizing
hormone concentrations are within the reference ranges and serum
follicle-stimulating hormone concentration is increased. Semen analysis
shows decreased sperm count. A decreabed serum concentration of
which of following is the most likely in this patient?

o A) Androstenedione
o B) Dihydrotestosterone
o C) Estradiol
o D) Inhibin B
o E) Sex hormone-binding globulin
41. A 30-year-old woman comes to the physician
because of the 3-week history of palpitations; she
also had a 4.5 kg weight loss during this period. Her
pulse is 110/min. Physical examination shows a
goiter and a fine resting tremor. Serum studies show
a thyroid-stimulating hormone concentranion of <0.1
nU/mL and thyroxine (T4) concentration of 50 ng/dL.
A thyroidal iodine (123I) uptake scan is shown. Which
of the following structures is identified by the arrow in
this image?

A) Ectopic thyroid tissue

B) Parathyroid gland
C) Pyramidal lobe
D)Salivary gland tumor
E) Thyroid adenoma
42. An 18-year-old woman with a 3-year history of type 1 diabetes
mellitus is brought to the emergency department because of a 2-day
history of light-headedness and respirations are 22/min, and blood
pressure is 98/68 mm Hg. Physical examination shows dry mucus
membranes and decre skin turgor. Her breath has a fruity aroma.
Which of the following mechanisms is most likely occurring in this
patient?

o A) Decreased formation of 3-hydroxybutyric acid

o B) Decreased gluconeogenesis from lactic acid
o C) Decreased glycogenolysis
o D) Increased activity of hormone-sensitive lipase
o E) Increased cholesterol synthesis
o F) Increased glycogen synthesis in the liver
43. A 40-year-old woman comes to the physician because of episodes
of fainting during the past 2 weeks. She also has a 3-month history of
easy fatigability, irritability. headaches on awakening, and extreme
hunger. Physical examination shows no abnormalities. Her serum
glucose concentration is 35 mg/dL. A CT scan of the abdomen shows a
mass in the pancreas. Immunohistochemical labeling of neoplastic cells
obtained on biopsy of the mass is most likely to involve the use of
antibodies directed to which of the following pancreatic secretory
products?

A) Gastrin
B) Glucagon
C) Insulin
D) Somatostatin
E) Vasoactive intestinal polypeptide
44. A 68-year-old woman has been hospitalized for 2 weeks because of
severe pneumonia complicated by septicemia and respiratory failure.
She has a long-standing history of type 2 diabetes mellitus and a family
history of chronic autoimmune (Hashimoto) thyroiditis. Her serum
triiodothyronine (T,) and thyroxine (T, ) concentrations are below the
reference ranges, and serum thyroid-stimulating hormone and free T,
concentrations are within the reference ranges. Which of the following
best explains these findings?

A) Antithyroid antibodies
B) Euthyroid sick syndrome
C) Hypothyroidism
D) Increased serum T4 -binding globulin concentration
E) lodine deficiency
45. A 65-year-old woman comes to the office because of a 6-week
history of a rash on her face and hands; the rash is exacerbated by sun
exposure. She also has had difficulty climbing stairs and holding her
arms above her head, such as when
combing her hair. Examination of the hands
shows the findings in the photograph. This
patient most likely has which of the
following underlying conditions?

o A) Amyloidosis
o B) Bronchiectasis
o C) Cancer
o D) Optic artery occlusion
o E) Renal failure
46. A 35-year-old man is brought to the emergency department 30 minutes after
fainting while at work. He is conscious and is able to state his name and what he was
doing before the episode. He says that he has had fatigue during the past 3 weeks. He
has no history of major medical illness and takes no medications. His mother died of
ovarian cancer at the age of 40 years. His maternal grandfather died of colon cancer at
the age of 49 years. The patient does not smoke or drink alcoholic beverages. He
appears pale. His temperature is 37.5 C, pulse is 110/min, respirations are 20/min, and
blood pressure is 95/55 mm Hg. Physical examination shows no other abnormalities.
Laboratory studies show hemoglobin concentration of 6,2 g/dL and hematocrit of 19%.
Test of the stool occult blood is positive. Colonoscopy shows an isolated right-sided
mass. Examination of a biopsy specimen of the mass shows a poorly-differentiated
adenocarcinoma with mucinous features. Immunohistochemistry of the biopsy
specimen is most likely to show loss of expression of which of the following proteins?

o A) APC
o B) BRCA1
o c) Betta-Catenin
o D) MSH2
o E) p53
47. A 45-year-old man is brought to the emergency department
because of a 45-minute history of abdominal pain, diaphoresis, and
weakness. Two hours ago, he spilled a chemical on his left arm while
mixing the solution for crop dusting. His respirations are 8/min, and
blood pressure is 100/55 mm Hg. Physical examination shows
salivation, wheezing, diaphoresis, and muscle weakness. After
confirming the identity of the solution, the physician begins treatment
with atropine and pralidoxime. The chemical solution most likely
contained which of the following?

o A) Carbaryl
o B) 2,4-Dichlorophenoxyacetic acid
o C) Paraquat
o D) Parathion
o E) Pyrethrin
48. Public health officials in a large metropolitan city in the US would
like to decrease the prevalence of obesity in the city's population. A tax
on carbonated and other sugar-based beverages is subsequently
implemented. Which of the following best describes this type of
intervention?

o A) Clinical
o B) Community
o C) Secondary
o D) Tertiary
49. A 68-year-old man is diagnosed with metastatic prostate cancer.
The most appropriate treatment should include a drug with which of the
following mechanisms of action?

A) Androstenedione aromatase inhibitor

B) Estrogen receptor partial agonist-antagonist
C) Gonadotropin-releasing hormone agonist
D) Microtubule function inhibitor
E) Somatostatin receptor agonist
50. A study is done to determine the relationship between use of oral
contraceptives and cervical cancer. Study subjects include 50,000
women who are using oral contraceptives and 50,000 women who
have had a tubal ligation. After 2 years of follow-up, the rate of in situ
cervical cancer is 18 per 10,000 women among users of oral
contraceptives and 3 per 10,000 among sterilized women (p<0.05).
Which of the following is the design of this study?

o A) Case control
o B) Case series
o c) Cohort
o D) Cross-sectional
o E) Randomized clinical trial
1. A study is conducted to assess the normal frequency distribution of
plasma sodium concentrations in a given population. Results show that
the mean is 141 mEq/L and the standard deviation is 3.2 mEg/L. Which
of the following best represents the percentage of values that will fall in
the interval between 134.6 mEg/L and 147.4 mEq/L?

o A) 25%
o B) 33%
o C) 50%
o D) 67%
o E) 90%
o F) 95%
o G) 97.5%
o H) 99%
2. Numerous cross-sectional studies in different populations have
shown a significant relationship between the use of tanning beds and
the development of melanoma. The odds ratios of these studies range
from 3.2 to 7.1. In these studies, the number of hours of tanning bed
use was highly correlated with an increase in the size and number of
dysplastic nevi. Which of the following is the greatest limitation in
establishing causality from these studies?

o A) Biologic plausibility
o B) Consistency of the findings
o C) Dose response
o D) Strength of association
o E) Temporal sequence of events
3. An 18-year-old female college freshman comes to the health center because of a 3-month
history of fatigue and intermittent headaches. She also has had an unintentional weight loss of 4
kg (9 lb) during the past 6 weeks and difficulty concentrating on her schoolwork. She moved from
her home to a campus dormitory 5 months ago. She was an avid tennis player but says she has
not played since school began because she has no energy and has lost interest in sports. She
notes that she recently broke off her long-distance relationship with her boyfriend back home. She
tearfully says she feels lonely and is frustrated with her performance on final examinations. She
occasionally drinks alcoholic beverages "to help with sleep." She does not use illicit drugs. She
appears thin and has a sad affect. Physical examination shows no abnormalities. Which of the
following is the most appropriate initial response by the physician?

o A) "Although this is a difficult time for many, I'm concerned that you're not coping well. Have
you had any feelings of hurting yourself?"
o B) "Have you made any friends on campus yet? Sometimes a student support group is the
best remedy for transitional stress."
o C) "It seems that this difficult transition has made you depressed. What are your thoughts
about receiving additional care in the hospital, where you can be in a safe environment”
o D) "It's normal to feel homesick and lonely during your fight year away from home. Planning a
visit home to be with your family might help you feel better."
o E) "Transitioning to college life is difficult for many students. It will get better once you
become accustomed to your surroundings."
4. A healthy 40-year-old woman comes to the physician because she is
concerned that she has breast cancer. She takes no medications. She has two
children, aged 8 and 10 years. Menarche occurred at the age of 13 years, and
she began menopause 1 year ago. During the family history portion of the
interview, the patient begins to cry and says, "My mother died of breast cancer
when she was 52 years old, and I know that I have breast cancer. That's why I
came to see you today." Which of the following is the most appropriate initial
response by the physician?

A) "Are there any other major illnesses you are afraid you might have?"
B) "I'm sorry to hear about your mother, but I wouldn't worry about getting
breast cancer at your age."
C) "Let's discuss your overreaction and what this really means."
D) "Let's just take it one step at a time; there is no need to cry before we know
for sure."
E) "Tell me why you trink you may have breast cancer."
5. A 55-year-old man comes to the physician because of a 4-month
history of cough and chest pain. He has smoked 1 pack of cigarettes
daily for 30 years. Physical examination shows no abnormalities. A
chest x-ray shows a 3-cm mass in the right lower lobe of the lung. It is
most appropriate for the physician to begin to communicate the x-ray
findings in which of the following manners?

o A) "I'd like to refer you to a specialist who will be better able to tell
you about your chest x-ray results than I am."
o B) "I'm afraid I have bad news; the chest x-ray showed an
abnormality in your lung that concerns me."
o C) "I'm sorry, but you are almost certainly going to need an
operation and chemotherapy."
o D) "Let's make an appointment for you and your wife next week so I
can tell you both the results at that time."
o E) "We need to do more tests before I can give you the final results
of your x-ray."
6. A 65-year-old Iranian woman is brought to the physician by her
daughter because of a 2-month history of abdominal pain. She does
not speak English, but her daughter does speak English. They brought
a report from an endoscopy clinic that shows gastritis. It is most
appropriate for the physician to communicate the findings and
treatment plan to the patient in which of the following manners?

A) Explain the information to the daughter so she can relay it to

her mother
B) Refer the patient to a physician who speaks her language
C) Reschedule the appointment when the receptionist who
speaks Farsi will be in the office
D) Use a professional translator in explaining the information to
the patient
E) Write the information on a piece of paper in English so the
patient can use a translator of her choice later
7. A recent clinical trial compares the use of Drug A to the standard
treatment of symptomatic genital herpes. The study involves 10,000
people with genital herpes who are randomly assigned to receive Drug A
or standard treatment. Results of the trial show that the duration of
symptoms in patients who received Drug A is 4 days, versus 4.5 days in
patients who received standard symptomatic measures (p<0.05). The
manufacturer of Drug A recommends the use of Drug A in the clinical
treatment of genital herpes. Based on the study's results, which of the
following is the most appropriate reason to question the manufacturer's
recommendation?

o A) The investigators used an inappropriate study design

o B) It is likely that there was a Type I error
o C) It is likely that there was a Type Il error
o D) The observed difference is not clinically significant
o E) The observed difference is not statistically significant
o F) There was insufficient power
8. A 58-year-old man dies from heart failure that
was refractory to therapy. At autopsy his heart
weighs 490 g. Sections of his heart are shown.
Which of the following is the most likely diagnosis?

o A) Congestive heart failure resulting from

repeated infarcts
o B) Mitral valve prolapse
o C) Pulmonary stenosis
o D) Rupture of the papillary muscle
o E) Septal rupture
9. The graph shows the growth of Escherichia coli in culture media
containing glucose and lactose. Which of the following is the most likely
explanation for the observed growth pattern?

o A) Altered (nonfunctional) catabolite activator protein

o B) Glucose depletion followed by induction of the lac operon
o C) Increased B-galactosidase synthesis in the first 4 hours of
growth
o D) Lactose depletion followed by glucose utilization
10. An unimmunized 10-year-old boy is brought to the emergency
department by his mother because of a 2-day history of progressively
severe abdominal pain and vomiting. One week ago, he had fever,
headache, earache, and swollen painful glands anterior to his ears. His
temperature is 38.8°C (101.9°F). Physical examination shows bilateral
swollen, tender parotid glands and moderate epigastric tenderness.
Serum studies show mildly increased amylase and highly increased
lipase activities. This patient's primary infection most likely caused
which of the following complications?

o A) Appendicitis
o B) Bowel obstruction
o C) Common bile duct obstruction
o D) Pancreatitis
o E) Viscus perforation
11. A 12-year-old boy is brought to the emergency department 30
minutes after falling from his skateboard. He reports pain in his right
elbow. Physical examination shows that his right forearm and hand are
cold and pale and have no pulse. There is swelling of the elbow region.
This patient most likely has a fracture of which of the following
structures?

A) Head of the radius

B) Lateral epicondyle of the humurus
C) Olecranon process of the ulna
D) Radial tuberosity
E) Supracondylar region of the humerus
12. A 60-year-old man comes to the physician because of the gradual
onset of muscle weakness during the past 5 years. He takes no
medications. Physical examination shows no skin lesions or rashes.
There is marked weakness of the distal muscles. Corticosteroids are
administered. At a follow-up examination 6 weeks later, his condition
has not improved. His serum creatine kinase concentration is
increased. The results of assays for antinuclear antibody and U1
ribonucleoprotein are negative. Microscopic examination of a skeletal
muscle biopsy specimen shows inflammatory cells and basophilic-
rimmed vacuoles. Which of the following is the most likely diagnosis?

A) Chronic inflammatory polyradiculoneuropathy

B) Inclusion body myositis
C) Mixed connective tissue disease
D) Myasthenia gravis
E) Systemic lupus erythematosus
13. A 64-year-old woman with chronic obstructive pulmonary disease comes to the
emergency department because of a fainting spell 1 hour ago. She says she felt
light-headed and weak for approximaely 20 seconds after an episode of severe
coughing. She thinks she may have lost consciousness. She has had nasal
congestion and throat irritation for the past 3 days. She is not taking any
medications. Which of the following mechanisms is most likely responsible for the
syncope?

A) Cerebral embolus originating from intracardiac thrombus

B) Decreased cardiac output caused by increased intrathoracic pressure
C) Decreased cerebral perfusion caused by atrial arrhythmia
D) Generalized tonic-clonic seizure triggered by increased cerebral
irritability
E) Vasodilation caused by respiratory alkalosis
14. A 58-year-old woman comes to the office because of a 1-month history of fatigue, fever,
shortness of breath, and joint pain; she also has had a 3.2-kg (7-Ib) weight loss during this
period. Her temperature is 37.6°C (99.7°F), and respirations are 34/min. Physical
examination shows tenderness to palpation over the maxillary sinus, nasal ulcerations, and a
bulging, red left tympanic membrane. Laboratory studies show:

Erythrocyte sedimentation rate 65 mm/h

Serum C-reactive protein 8.2 mg/L (N=0.08-3.1)
Urine
Blood 2+
Protein 2+

Histologic examination of a biopsy specimen of affected lung tissue shows granulomata and
vasculitis. An autoantibody is most likely directly binding which of the following cell types in
this patient?

o A) Basophils
o B) Endothelial cells
o C) Fibroblasts
o D) Neutrophils
o E) Plasma cells
15. A 33-year-old man with HIV infection comes to the physician
because of a 3-day history of headaches, intolerance to light, and
severe neck stiffness. His temperature is 39.5°C (103.1°F). Physical
examination shows photophobia and nuchal rigidity. Analysis of
cerebrospinal fluid obtained on lumbar puncture shows cryptococci.
Initial therapy with combination antifungal medication, including
fluconazole, successfully resolves the symptoms. Fluconazole most
likely impaired or inhibited which of the following fungal targets in this
patient?

o A) Cell-wall 1,3-ß-glucan synthase

o B) De novo pyrimidine synthesis
o C) Ergosterol synthesis
o D) Microtubule depolymerization
o E) RNA polymerase
16. A 50-year-old man with a follicular B-lymphocyte lymphoma has a
translocation involving chromosomes 14 and 18 with fusion of the
immunoglobulin heavy chain locus (IgH) to the BCL2 gene. Which of
the following is the most likely oncogenic effect of this translocation?

o A) Deletion of BCL2
o B) Deletion of IgH
o C) Overexpression of BCL2
o D) Overexpression of IgH
o E) Underexpression of BCL2
o F) Underexpression of IgH
17. A drug rapidly distributes in total body water and has an elimination
half-life of 8 hours. In a patient who weighs 80 kg (176 lb; total body
water of 50 L), an intravenous drip is started which will maintain a drug
concentration in plasma of 20 mg/L at steady state. The time it will take
(in hours) from the start of the intravenous drip for plasma drug
concentration to reach 18 mg/L (90% of the steady state value) is
closest to which of the following?

A) 8
B) 18
C) 28
D) 38
E) 48
18. A 27-year-old woman is brought to the emergency department 1 hour after
cutting her left wrist with a razor blade during a fight with her boyfriend. She cut
herself after she assaulted him with a knife, accusing him of cheating on her. This
is the third time she has physically assaulted her boyfriend. She was prescribed
clonazepam by her primary care physician. She states that she does not use
alcohol or illicit drugs. She smells of beer. She tells the physician that she does not
trust anyone because her stepfather repeatedly raped her from the ages of 8 to 13
years. Physical examination shows a 3-cm laceration on the left wrist. Serum
alcohol concentration is undetectable. She demands hydrocodone for the pain.
This patient most likely has which of the following types of personality disorders?

o A) Antisocial
o B) Avoidant
o C) Borderline
o D) Narcissistic
o E) Obsessive-compulsive
19. A 38-year-old woman has had a slowly
enlarging pink papule on her left cheek for 1
year. A photomicrograph of a biopsy specimen of
the papule is shown. Which of the following is
the most likely diagnosis?

A) Actinic keratosis
B) Basal cell carcinoma
C) Fibrous histocytoma
D) Malignant melanoma
E) Seborrheic keratosis
F) Squamous cell carcinoma
20. In a study of the use of ultrasonography for the early detection of
prostate cancer, 35 of 50 men with prostate cancer have abnormal test
results, and 20 of 100 men without prostate cancer have abnormal test
results. Which of the following is the specificity of this test?

o A) 20%
o B) 30%
o C) 50%
o D) 70%
o E) 80%
21. A 47-year-old woman comes to the physician because of a 1-week
history of yellow-tinged eyes and itchy skin. Physical examination
shows scleral icterus and multiple excoriations over the trunk. Serum
studies show:

Total bilirubin 8 mg/dL

Alkaline phosphatase 450 U/L
ALT 45 U/L
Antimitochondrial antibodies present

This patient most likely has a deficiency of which of the following?

o A) Folic acid
o B) Vitamin B6 (pyridoxine)
o c) Vitamin B12 (cobalamin)
o D) Vitamin C
o E) Vitamin D
22. A 47-year-old woman comes to the physician because of a 1-week
history of yellow eyes and itching skin. Physical examination shows scleral
icterus and excoriations over the trunk. Serum studies show:

Total bilirubin 8 mg/dL

Alkaline phosphatase 450 U/L
ALT 45 U/L
Antimitochondrial antibody titer 1:80 (N=absent)

This patient most likely has a deficiency of which of the following vitamins?

o A) Folic acid
o B) Vitamin A
o C) Vitamin B1 (thiamine)
o D) Vitamin B6 (pyridoxine)
o E) Vitamin B12 (cobalamin)
o F) Vitamin C
23. A 25-year-old woman comes to the physician because of progressive fatigue during the
past 5 months. She says that she falls asleep several times daily. She takes no medications.
She is 152 cm (5 ft) tall and weighs 154 kg (340 Ib); BMI is 66 kg/m2. Her blood pressure is
150/90 mm Hg. Physical examination shows no other abnormalities. Laboratory studies
show:

Hemoglobin 18.1 g/dL

Hematocrit 54%
Serum glucose 140 mg/dL
Arterial blood gas analysis on room air:
pH 7.25
PCO2 61 mm Hg
PO2 60 mm Hg
The results of a urine drug screen are negative. Which of the following is the most likely
cause of the somnolence in this patient?

o A) Hyperglycemia
o B) Hypertension
o C) Hypoventilation
o D) Polycythemia
o E) Psychogenic disorder
24. A 26-year-old woman with mild intellectual developmental disorder is
brought to the physician by her father because he is concerned about her
recent disruptive behavior. The father often conducts business with clients at
home, and the patient frequently interrupts his business meetings wearing
revealing clothing. She has three sisters who are married, and she often states
that she wants her own husband. The father asks the physician to prescribe
enough medication for his daughter so that she no longer embarrasses him.
Which of the following is the most appropriate initial action by the physician?

o A) Speak to the patient privately about what motivates her behavior

o B) Advise the patient's father to conduct his business outside of the home
o C) Recommend that the father restrict the patient to her room during his
meetings
o D) Discuss with the patient's father the possibility of placing his daughter in
a group home
o E) Prescribe a medication that will suppress the patient's libido
25. A 68-year-old man comes to the physician because of a 6-month history of
progressive shortness of breath. He also has a 1-month history of nonproductive
cough. He has a long history of joint pain treated with prednisone. He does not
smoke cigarettes, but he was raised in a coal mining community. Vital signs are
within normal limits. Physical examination shows no jugular venous distention or
edema. There are small painless nodules along the extensor surface of both
forearms, ulnar deviation, and swan neck deformities of the fingers. Bilateral
diffuse crackles are heard on auscultation of the chest. A chest x-ray shows a
diffuse fibronodular infiltrate with a right pleural effusion. A thoracentesis is done,
and pleural fluid analysis shows straw-colored fluid containing 200 leukocytes/mm'
and a glucose concentration of 12 mg/dL (N=70). Which of the following is the
most likely underlying cause of his current condition?

o A) Goodpasture syndrome
o B) Polymyalgia rheumatica
o C) Rheumatic fever
o D) Rheumatic heart disease
o E) Rheumatoid arthritis
o F) Granulomatosis with polyangitis
26. An 82-year-old woman is brought to the physician by her son because of a 1-
year history of increasing word-finding difficulty and a 3-year history of increasing
forgetfulness. She has hypertension and hypercholesterolemia. Her medications
are lisinopril and atorvastatin. Her blood pressure is 120/80 mm Hg. Physical
examination shows no abnormalities. On mental status examination, she is alert
and attentive. She recalls one of five parts of a name and address after 5 minutes,
and does not recognize the remaining parts when given clues for each. She recalls
zero of three figures 5 minutes after copying them. She cannot name the point of a
pen or the band of a watch. Degeneration of which of the following is the most
likely cause of this patient's memory changes?

A) Basal forebrain
B) Caudate and putamen
C) Frontal cortex
D) Hippocampal formation
E) Mammillary bodies
F) Medial thalamus
G) Substantia nigra
27. A 53-year-old woman comes to the
physician because of a 1-month history
of persistent headaches. Physical
examination shows no abnormalities.
CT scans of the head are shown.
Further studies confirm a tumor of the
hypophysis. This patient is at greatest
risk for compression of which of the
following nerves?

A) Olfactory
B) Optic
C) Oculomotor
D) Trochlear
E) Trigeminal
28. A new rare genetic disease is caused by a mutation in the gene
coding for cysteine-tRNA. This results in the substitution of tyrosine for
cysteine. Which of the following is the most likely major effect of this
amino acid substitution?

o A) Disulfide bonds are not formed

o B) Formation of alpha-helices is inhibited
o C) Formation of ß-sheets ceases
o D) Glycosylation is incomplete
o E) Translation stops prematurely
29. A 36-year-old man comes to the physician because of fever and
frequent slimy stools for 2 weeks. He recently emigrated from Ecuador.
His temperature is 38.2°C (100.8°F). Abdominal examination shows
mild tenderness of the right upper quadrant. Examination of the stool
shows mucus. Colonoscopy shows multiple flask-shaped ulcers that
have undermined and destroyed large areas of the intestinal
epithelium. Which of the following is the most likely causal organism?

A) Ascaris lumbricoides
B) Cryptosporidium parvum
C) Entamoeba histolytica
D) Schistosoma mansoni
E) Taenia solium
30. During a study, an investigator sequences a mature mRNA isolated
from a human cell line. Adenine is found to repeat 200 times at the 3'
end of mRNA. This polyadenylation will most likely have which of the
following effects on the translation of mRNA?

o A) Addition of lysine residues

o B) Destabilization of mRNA
o C) Initiation of translation
o D) Stabilization of mRNA
o E) Termination of translation
31. A male newborn is delivered at 26 weeks' gestation to a healthy mother.
Pulmonary function testing shows:

Echocardiography shows no congenital cardiac deformities. Which of the following

is the most likely cause of this newborn's condition?

A) Excessive pulmonary capillary hydrostatic pressure

B) Excessive surfactant production
C) Incompletely formed bronchioles
D) Increased alveolar surface tension
E) Interalveolar fibrosis
32. An experiment is conducted to assess the adaptation of certain
bacteria to hospital environments. The investigator identifies antibiotic
resistance markers located on transposons that permit bacteria to
adapt to these environments and perpetuate resistance. These
transposons are observed to be mobile genetic elements that can
incorporate into a chromosome without having DNA homology. Which
of the following factors permits this genetic promiscuity?

o A) Alu repeat sequences

o B) Homology sequences
o C) Insertion sequences
o D) Proteases
o E) Topoisomerases
33. A 27-year-old man comes to the physician because of a 3-week
history of pain in his back and flanks. His blood pressure is 153/87 mm
Hg. Palpation of the abdomen and flanks shows enlarged kidneys
bilaterally. Renal ultrasound shows multiple cysts in the cortex and
medulla of each kidney. Cysts are also likely to be found in which of the
following organs?

o A) Adrenal glands
o B) Colon
o C) Liver
o D) Lungs
o E) Testicles
34. A 23-year-old woman has a grade 3/6 systolic murmur. Cardiac catheterization shows:

Pressure (mm Hg) O2 Saturation(%)

Right atrium 6 75
Right Ventricle 30/5 80
Pulmonary artery 30/20 80
Left atrium 10 96
Left ventricle 110/10 96
Aorta 110/70 96

Which of the following is the most likely diagnosis?

o A) Aortic stenosis
o B) Atrial septal defect
o C) Mitral regurgitation
o D) Pulmonic stenosis
o E) Tricuspid regurgitation
o F) Ventricular septal defect
35. While being treated for urosepsis in the intensive care unit, a 69-year-old man develops bleeding from sites
of intravenous catheterization. He is receiving cefepime, dopamine, and 0.9% saline. He is obtunded. His
temperature is 38.2°C (100.8°F), pulse is 90/min, respirations are 30/min, and blood pressure is 90/60 mm Hg.
Physical examination shows oral bleeding and oozing at intravenous catheter sites and previous puncture sites.
Laboratory studies show:

Hemoglobin 12 g/dL
Hematocrit 36 %
Leukocyte count 25,800/mm3
Platelet count 35,000/mm3
Prothrombin time 15 sec (INR=1.2)
Partial thromboplastin time 56 sec
Serum
Urea nitrogen (BUN) 27 mg/dL
Creatinine 1.3 mg/dL
AST 57 U/L
ALT 67 U/L
D-dimer positive

Which of the following is the most likely diagnosis?

o A) Congestive splenomegaly
o B) Disseminated intravascular coagulation
o C) Hepatic failure
o D) Immune thrombocytopenic purpura
o E) Thrombotic thrombocytopenic purpura
36. A 46-year-old man comes to the emergency department because of an 18-hour history
of fever, nausea, vomiting, and severe pain of his middle and left upper abdomen that
radiates to his back. He recently returned from a 3-day fishing trip with some friends; he
drank six to eight beers daily during this period. He says that he has had similar symptoms
after binge drinking in the past. He has hyperlipidemia treated with simvastatin. He appears
diaphoretic. His temperature is 39.3°C (102.8°F). Abdominal examination shows mild
distention and tenderness over the epigastric region and left upper quadrant. Laboratory
studies show:

Leukocyte count 17,000/mm3

Serum
Ca2+ 7.5 mg/dL
Amylase 185 U/L
Lipase 300 U/L

This patient most likely has which of the following underlying processes?

o A) Abscess
o B) Caseous necrosis
o C) Fibrinoid necrosis
o D) Liquefaction necrosis
o E) Saponification of fat
37. A study is conducted to assess the distribution of preoperative serum creatinine concentrations
among a small group of patients who are scheduled to undergo operative procedures at a local
hospital. Seven consecutive patients are enrolled. The results are shown:

Patient Number Serum Creatinine (mg/dL)

1 0.5
2 0.6
3 0.8
4 0.9
5 1
6 5
7 10

During documentation of these measurements, the fourth datum point (0.9) is inadvertently
recorded as 9. Which of the following measures will be most impacted by this error?

o A) Accuracy
o B) Mean
o C) Median
o D) Mode
o E) Precision
o F) Range
38.A study is cunducted to assess the efficacy of bisphosphonate treatment in
preventing vertebral fractures in women with low bone density. A total of 257
women with low bone density and no history of fractures are randomly assigned to
receive a bisphosphonate or placebo for 3 years. Results show:

Based on these data, which of the following mathematical expressions should be used to
calculate the number of women that must be treated with bisphosphonate to prevent one
fracture?

o A) (32/98)/(42/88)
o B) (42/88)/(32/98)
o C) 1/(32/64-98/186)
o D) 130/(42-32)
o E) 260/(186-64)
39. An 18-year-old woman comes to the physician because of a 3-week history of intermittent double vision and transient
vision loss. She also has had a 9-kg (20-Ib) weight loss during the past 5 months due to decreased appetite. She is 152
cm (5 ft) tall and now weighs 51 kg (112 lb); BMI is 22 kg/m2. Her temperature is 38°C (100.5°F), and blood pressure is
146/88 mm Hg. Funduscopic examination shows a recent retinal hemorrhage of the left eye. Cardiac examination shows
bilateral carotid bruits. Radial pulses are diminished on the right side and absent on the left side. Laboratory studies
show:

Hemoglobin 10.5 g/dL

Hematocrit 32%
Mean corpuscular volume 95 nm3
Leukocyte count 13,250/mm3 with normal differential
Erythrocyte sedimentation rate 84 mm/h
Serum
IgA 650 mg/dL
IgG 3100 mg/dL
IgM 852 mg/dL
Antinuclear antibodies weakly positive
Rheumatoid factor weakly positive

Histologic examination of a carotid artery in this patient will most likely show which of the following types of vasculitis?

o A) Acute neutrophilic
o B) Fibrinoid necrotizing
o C) Granulomatous
o D) Leukocvtoclastic
o E) Lymphocytic
40. A 56-year-old woman comes to the physician because of progressive shortness of
breath and cough during the past 2 weeks. Her respirations are 20/min. Crackles are
heard on auscultation. A chest x-ray shows bilateral pleural effusions. A thoracentesis
is done. Pleural fluid analysis shows:

Appearance translucent, mildly yellow

Specific gravity 1.005
Protein 0.4 g/dL
Mesothelial cells 5/mm3
Lymphocytes 1/mm3

Which of the following is the most likely underlying cause of the findings in this patient?

o A) Bacterial pneumonia
o B) Congestive heart failure
o C) Metastatic carcinoma to the lung
o D) Pulmonary tuberculosis
o E) Systemic lupus erythematosus
o F) Thoracic duct obstruction
41. Two randomized, double-blind studies (Study X and Study Y) are conducted to assess
the efficacy of a new chemotherapeutic agent. For each study, patients are randomized to
receive either placebo or the new experimental chemotherapy; all subjects are then followed
for a mean of 5 years. Follow-up rates are 92% in Study X and 91% in Study Y. Results
show:

The relative risk of dying of cancer is 0.7 in Study X (95% confidence interval of 0.2 to 2.4)
and 0.6 in Study Y (95% confidence interval of 0.5 to 0.7). Which of the following best
accounts for this difference in confidence intervals?
o A) Bias
o B) Difference in follow-up rates
o C) Difference in number of patients
o D) Different population
o E) Randomization error
42. A previously healthy 4-year-old boy is brought to the physician because of a 1-week history of easy
fatigability and swelling of his face and feet. His temperature is 37.1°C (98.8°F), pulse is 100/min,
respirations are 20/min, and blood pressure is 85/67 mm Hg. Physical examination shows facial edema,
abdominal distention, and a 3-cm umbilical hernia. There is 3+ pitting edema of the ankles and feet.
Laboratory studies show:

Serum
Na+ 131 mEq/L (N=138-145)
Albumin 2.5 g/dL (N=3.5-5.5)
Cholesterol 210 mg/dL (N=109-189)
Triglycerides 111 mg/dL (N=30-86)
Urine protein 4+

One week later, the patient develops a temperature of 39°C (102.2°F), severe abdominal pain, and chills.
Abdominal paracentesis yields turbid peritoneal fluid that grows Streptococcus pneumoniae. Further
studies will most likely show a decrease in which of the following in this patient?

o A) B-lymphocyte differentiation
o B) Natural killer cells
o C) Neutrophil oxidative burst
o D) Serum IgG concentration
o E) T-lymphocyte population
43. A 24-year-old primigravid woman at 36 weeks' gestation comes to the physician because of a
3-day history of ankle swelling. She has gained 2.7 kg (6 lb) during the past week. She has no
history of major medical illness, and her pregnancy has been uncomplicated. Her temperature is
37°C (98.6°F), pulse is 85/min, and blood pressure is 160/100 mm Hg. Physical examination
shows a uterus consistent in size with a 36-week gestation. There is mild facial edema and pitting
edema of the lower extremities and ankles bilaterally. Laboratory studies show:

Hemoglobin 12 g/dL
Hematocrit 36 %
Platelet count 95,000/mm3
Serum creatinine 1.3 mg/dL
Urine protein 3+

Labor is induced, and the patient delivers a healthy male newborn. The placenta is removed and
sent for analysis. Histologic examination of the placenta is most likely to show which of the
following characteristics of this patient's gestational disorder?

o A) Acute chorioamnionitis
o B) Atherosis of decidual vessels
o C) Chronic villitis.
o D) Placenta accreta
o E) Villous edema
44. A 48-year-old woman comes to the emergency department 2 hours after the sudden onset of severe
flank pain. She also has a 2-month history of mild exacerbation of her baseline constipation. She has had
no fever, chills, pain with urination, or increased urinary frequency. She has a history of infrequent urinary
tract infections, with the most recent occuring more than 5 years ago. She has no personal or family
history of renal calculi. Her pulse is 92/min, and blood pressure is 138/88 mm Hg. Physical examination
shows no other abnormalities. Laboratory studies show:

Serum
Na+ 144 mEq/L
K+ 3.8 mEq/L
CI- 100 mEq/L
HCO3- 27 mEq/L
Ca2+ 10.6 mg/dL
Urea nitrogen 19 mg/dL
Creatinine 0.8 mg/dL
Phosphorus 2.9 mg/dL
Urine blood 2+

Which of the following is the most likely cause of these findings?

o A) Hyperoxaluria
o B) Hyperparathyroidism
o C) Hyperuricemia
o D) Hypervitaminosis D
o E) Milk-alkali syndrome
45. A 5-year-old girl with a history of recurrent infections since the age of 4 months is brought to the physician for
a follow-up examination. She has had multiple episodes of pneumonia, sinusitis, otitis media, and diarrhea. She
is at the 20th percentile for height and weight. Her temperature is 37.4°C (99.3°F). Mild crackles are heard
bilaterally over the lower lung lobes. Laboratory studies show:

Leukocyte count 10,500/mm3 (N=5500-15,500)

Segmented neutrophils 57%
Eosinophils 2%
Lymphocytes 34%
CD3+ T lymphocytes 67%
CD19+ B lymphocytes 28%
CD56+ natural killer cells 5%
Monocytes 7%
Serum
IgA undetectable (N=14-159 mg/dL)
IgG 25 mg/dL (N=3451236)
IgM 410 mg/dL (N=43-207)

This patient most likely has an abnormality of which of the following immune system components?

o A) Activation-induced deaminase
o B) CD40 ligand
o C) Class II MHC protein
o D) Common y chain of the interleukin-2 (IL-2) receptor
o E) Recombination-activating gene 1
o F) Terminal complement
46. A 68-year-old woman comes to the physician for a follow-up examination after a routine endoscopy for dyspepsia showed large
esophageal varices. She has a
25-year history of type 2 diabetes mellitus. She also has hypertension and hyperlipidemia. She does fiot have any history of liver
disease, blood transfusions, or intravenous drug use, and she does not drink alcohol. Her current medications are 81-mg aspirin,
insulin, lisinopril, and simvastatin. She appears alert. She is 168 cm (5 ft 6 in) tall and weighs 110 kg (242 lb); BMI is 39 kg/m.
Physical examination shows scattered spider angiomata over the chest and upper extremities. Abdominal examination shows no
ascites. The spleen tip is palpated 4 cm below the left costal margin. Laboratory studies show:

Hemoglobin 12.2 g/dL

Hematocrit 36%
Mean corpuscular volume 102 nm3
Platelet count 92,000/mm3
Serum
Total bilirubin 1.8 mg/dL
AST 65 U/L
ALT 85 U/L
Ferritin 62 ng/mL
Hepatitis B surface antigen negative
Hepatitis B surface antibody positive
Hepatitis C virus negative

Ultrasonography shows coarsened liver echotexture with increased echogenicity. Which of the following is the most likely cause of
the liver findings in this patient?

o A) Adverse drug effect

o B) Chronic hepatitis B
o C) Fatty liver
o D) Hepatolenticular degeneration (Wilson disease)
o E) Prior excessive alcohol use
47. A 3-year-old girl is brought to the physician because of a 4-day history of irritability, vomiting, decreased urinary frequency and
volume, and diarrhea. She visited a local petting zoo with her family 1 week ago. Her temperature is 38°C (100.4°F), pulse is
100/min, respirations are 30/min, and blood pressure is 130/100 mm Hg.
Physical examination shows pallor, petechiae over the chest, and mild abdominal tenderness. Laboratory studies show:

Hemoglobin 5.9 g/dL (N=11-15)

Hematocrit 31% (N=28%-45%)
Erythrocyte count 3.1 million/mm3 (N=3.9-5.31)
Leukocyte count 18,000/mm3 (N=6000-17,500)
Reticulocyte count 4.5% (N=0.5%-1.5%)
Platelet count 52,000/mm 3 (N=150,000-400,000)
Serum
Urea nitrogen 210 mg/dL (N=5-18)
Creatinine 1.1 mg/dL (N=0.3-0.7)
Bilirubin, total 2.5 mg/dL (N=0.1-1)
Direct 0.2 mg/dL (N=0.0-0.4)
Indirect 2.3 ma/dL (N=0.1-0.6)
Lactate dehydrogenase 550 U/L (N=120-500)

Direct antiglobulin (Coombs) test result is negative. A photomicrograph of peripheral blood smear is shown.Acetaminophen,
amlodipine, and fluid and nutritional support are administered. In addition to thrombi-containing platelet aggregates, which of the
following would cause occlusion of small renal vessels in this patient?

o A) Elastin
o B) Fibrin
o C) Hemosiderin
o D) IgA
o E) IgE
o F) IgG
48. A 72-year-old woman with mild dementia is brought to the office because of a nosebleed for 2 hours.
She has no history of previous bleeding problems. There is no family history of bleeding disorder. She
lives in a dilapidated farmhouse infested by rodents and has extensive exposure to rat poisons. Her
temperature is 37.1°C (98.7°F), pulse is 85/min, respirations are 14/min, and blood pressure is 142/92
mm Hg. Physical examination shows bleeding from the left nostril with no petechiae.
Laboratory studies show:

Hemoglobin 14 g/dL
Hematocrit 42%
Leukocyte count 5500/mm3
Platelet count 210,000/mm3
Prothrombin time 25 sec (INR=4)
Partial thromboplastin time 48 sec
Plasma fibrinogen 250 mg/dL (N=200-400)

Treatment with an infusion of fresh frozen plasma controls the hemorrhage. Which of the following
structural modifications in plasma coagulation proteins is most likely absent in this patient?

o A) Aggregation into high-molecular-weight polymers

o B) Association with soluble cofactor molecules
o C) Gamma carboxylation of glutamate residues
o D) Rearrangement of disulfide bonds
o E) Removal of N-terminal amino acids
o F) Surface expression of select platelet proteins
49. A 65-year-old woman comes to the office for a follow-up examination. She has chronic
kidney disease, hypertension, and type 2 diabetes mellitus. Current medications are
lisinopril, atorvastatin, and sitagliptin. She does not smoke or drink alcoholic beverages. Vital
sighs are within normal limits. Physical examination shows decreased sensation to
monofilaments over the distal lower extremities. Laboratory studies are shown:

Hemoglobin 8.7 mg/dL

Hematocrit 26%
Mean corpuscular volume 84 nm3
Reticulocyte count 3.2%
Serum
Creatinine 2.5 mg/dL
Ferritin 198 ng/mL

Which of the following is the most likely cause of the laboratory findings in this patient?

o A) Decreased erythropoietin production

o B) Decreased liver iron stores
o C) Decreased serum 2,3-bisphosphoglycerate concentration
o D) Increased concentration of autoantibodies
o E) Increased erythrophagocytosis
o F) Increased Pco2
50. A study is conducted to assess the effectiveness of an intervention at
decreasing the incidence of hypertension. Patients at risk for this disease are
enrolled in the study and are assigned to either a group receiving the
intervention or a group that does not receive intervention. The hypothesis
states that the intervention decreases the annual incidence of hypertension.
The table is a conceptual representation of the randomized clinical trial.

Which of the following labeled cells in the table represents a Type II error?

A) A.
B) B.
C) C.
D) D.
YOINK!!!!