44, 75-year-old man with alcoholism is brought tothe emergency department 30 minutes after he began vomiting blood. He has a history of portal hypertension. Abdominal examination shows spider anglomata. Which of the followings the most likely cause ofthis patient's hemalemesis? © A) Anastomosis between the superior and inferior mesenteric veins © B) Aortoesophageal fistula © C) Inflammation of the distal esophagus © ) Retrograde biood flow between tributaries ofthe left gastric to the azygos veins © €) shunting of blood fom the portal parsumbiical veins tothe superior epigastric veins45. A 10-year-old boy with spinal muscular atrophy is brought tothe emergency department because of a 2-week history of nausea and vomiting. He also has hhad decreased appetite during this period. One week pir to hs ness, his entire family had simlar symptoms which improved after a few days. Physical ‘examination shows decreased skin turgor, dry mucous membranes, and difuse muscle weakness and alrophy. Laboratory studies show: Serum Nat Ps cr Hoo, Urea nitrogen Glucose Urine pH ‘Specific gravity Glucose Protein Ketones REC wee 140 mEgiL (N=138-145) A mEQlt (N=34-47) 105 mEaiL (N=95~105) 48 mEqjL (N=22-28) 18 maid (N=5-18) 30 mgldL (N=60-100) 50 (N-4.6-80) 1.020 (N=1.003-1.080) ‘race a Opt met \Which ofthe folowing biochemical cycles inthe ler is most likely providing this patient's bran with an energy source at this time? O A) Alanine gucose cyto © B) Camitine-acylcamitine cycle O ©) Lactic acid cycle © D) Ticarboxytic acid cycle O E) Urea cycle48. 45-year-old man comes to the physician because of @ month history of progressive shortness of breath with exertion. He has a history of frequent nosebleeds since adolescence. He is 178 cm (5 t 10 in) tall and weighs 79 kg (175 Ib): BAM is 25 kgim?. Physical examination shows the findings inthe photographs. Inhaled albuterol does not improve his symptoms. Which of the folowing isthe most Ikely cause of his patients condition? O A) Atrial septal defect © 8) Hypertension O ¢) Pulmonary arteriovenous shunting © D) Reactive airway disease O E) Thromboembolism447. 66-year-old woman comes tothe physician fo follow-up examination 3 months afer she underwent a total colectomy for ulcerative clits. She ‘subsequently required an ileostomy. She feels generally well and has resumed a nearly normal diet. Her temperature Is 37°C (98.6°F), pulse is 92min, and blood pressure is 100160 mm Hg. Physical examination shows mialy decreased skin turgor and a wel-healedleostomy site. Laboratory studies show: Serum Nat ba cr Hos Urea nitrogen Greatnine ‘Ateial blood gas analysis pH Peo Po: Which of the folowing best cescrbes this patient's acis-base disturbance? © A) Anion gap metabolic acidosis, partially compensated © 8) Anion gap metabotc acidosis, uncompensated O €) Chronic respiratory alkalosis, partially compensated O D) Chronic respiratory alkalosis, uncompensated © E) Non-anion gap metabolic acidosis, partially compensated ‘© F) Nomanion gap metabolic acidosis, uncompensated 136 meg 3mEqlL 114 mEq 14 mEq S2mgidl A mgd. 732 20mm Hg 80mm Hg48, 65-year-old man who isa veteran comes to the office because of a 3-month history of increasingly sovere pain of his low back. He has no history of ‘major medical ilness. Physical examination shows point tenderness over the spine atthe levl of LS. Laboratory studies show: Hemoglobin 989%. Hematocrit 28% Serum ca® 14.2 mala. Creatinine 2.2 mala. as {8000 mala (N=850-1500) X-rays ofthe spine show a compression fracture at LS and four tic lesions in the lac crest. Examination of a bone marrow biopsy specimen confims the Glagnosis and the presence ofa chromosomal translocation. Treatment wih a chemotherapeutic regimen, including a proteasome inhibitor, i started, \Which ofthe folowing is most key to occur in the affected cals as a result ofthis therapy? O A) Decreased calcium release © B) Decreased genomic instability © ©) Decreased ubiquitination D) Increased protein degradation © E) Induction of apoptosis.49. 58-year-old woman comes tothe office for a follow-up examination 2 days afer she noticed a lump inher left breast on self-examination. Menopause ‘occurred 6 years ago. Physical examination shows a 1-cm, poorly circumscribed, nodular mass in the let periareolar tissue. Mammograpty shows an il- defined density suspicious for malignancy. A needle biopsy specimen is nondlagnostc. Microscopic examination ofthe excised mass shows a large diated ‘space lined by glandular epithelium and surrounded by a dense lymphoplasmacyticintammatory inflate; the associated lumen is filed with ipidladen ‘macrophages and amorphous debris. Which of the following isthe most likly diagnosis? O A) Acute mastitis © 8) Fibroadenoma O 6) Fibrocystic changes D) Intraductal carcinoma © E) Mammary duct ectasia50. An 1814-g (4b) female newborn is delivered inthe hospital at 24 weeks’ gestation toa 25-year-old primigravid women via spontaneous vaginal delivery. Examination of the newborn shows no peripheral cyanosis. There isa grade 3/6, continuous murmur over te lft midclavicular, second intercostal space. [A the age of 2 days, the newborn develops respiratory distress. Echocarciography shows a falure of a vascular structure to close. The embryoiogc origin ofthis anomaly is most key which ofthe following aortic arches? OA) First © B) Second O ©) Fourth O ©) Finn O €) sian41. A75:year-old woman with non-small cll carcinoma ofthe lung is brought o the physician because of a 2-day history of lethargy and cognitive impairment ‘One month ago, she completed a 1-year regimen of chemotherapy and cranial iradiaton. One week ago, she received the diagnosis of major depressive lisorder and began therapy wih a solective serotonin reuptake inhitr. She speaks with a blunted affect. Physical examination shows no abnormalities. Her Mini-Mental State Examination score is 20/30. Serum studies show a sodium concentration of 122 mEqIL. The patient appears confused and falls asleep during the examination. Which ofthe following isthe most ikely diagnosis? O A) Delirium © 8) Dementia, atzheimer type © C) Dementia caused by Pick disease © D) Serotonin syndrome O E) Vascular dementia42, An 18-year-old man is brought tothe emergency department 30 minutes after sustaining injuries in a motor vehicle colision. He has abdominal pain. His pulse is 120/min, and blood pressure is 80/60 mm Hg. Physical examination shows multiple contusions over the trunk and abdominal tendemass. A chest ‘cray shows multiple rib fractures. ACT soan of the abdomen is shown. Which ofthe following organs is mest Ikely injured in this patient? O A) Bladder O B) Liver O ¢) Pancreas O 0) spleen © €) Stomach43, A15-yoar-old git is brought to the physician because of a 3-day history of fever, sore throat, and malaise. Her tomperature is 392°C (102.6°F). Physical ‘examination shows difuse pharyngeal erythema, moderately enlarged tonsil, and tender anterior and posterior cervical lymphadenopathy. A complete blood count shows: Leukocyte count 19,500Imm® (N=3600-10,500) ‘Segmented neutrophils 20% Bands m% Eosinophils 2% Lymphocytes 25% Lymphocytes, atypical 30% Monocytes e% Incubation ofthis patient's serum with sheep erythrocytes results in agglutination. The atypical lymphocytes in this patient are most likly which ofthe fallowing cll types? © A) Biymphocytes © 8) cots Tiymphocytes © ¢) cose Tymphocytes O D) FOXPS-expressing regulatory T lymphocytes. O E) Natura killer cells