40. A3-year-od gts brought tothe physician because of a 1-year history of short stature. She has no history of major medical ness. She is below the 3rd percentile for height and at the 10th percentle for weight. Physical examination shows coarse facial features and contractures of the large joints. X-ays ‘show dysostosis multiplex. Plasma lysosomal enzyme analysis shows increased P-hexosaminidase, Bglucuronidaso, f-galactosidase, and afucosidase ‘actives. Which of the folowing mechanisms isthe most Ikely cause of he lysosomal enzyme findings in this patient? © A) Abnormal targeting of these enzymes to lysosomes © 8) Deficiency ofthe other ysosomal enzymes in the cytoplasm © ©) Degradation of these enzymes within he cytoplasm © 0) Degradation of these enzymes wthin the isosomes © E) Storage of these enzymes within the cytoplasm21. 35-year-old woman with sickle cll tats brought tothe emergency department because of severe lft fank paln for 1 hour. She has a history of frequent headaches. Her blood pressure fs 150/90 mm Hg. Pressure onthe costophrenic angle causes pain. Urinalysis shows a few RBCs and numerous ‘neutrophils. A CT scan ofthe abdomen shows obstruction and dlaion ofthe lot ureter and blunting of several nal papillary pyramids, Which of the following isthe most likely diagnosis? © A) Acute glomeruionep hits O 8) Acute tubular necrosis © ©) Diabetic nephropathy O ) Pity ransitonal el carcinoma © E) Rena papiary necrosis22, 68-year-old man with dementia, Alzheimer type, has improvement in memory and cognition with donepezil therapy. Which ofthe following is the most likely mechanism of this beneficial effect? O A Blockade of cote uptake int presynaptic terminals © Bi) Blockade of tects on the nicotine receptors on muscle © 6) Enhanced ix of calcium nto the presynaptic terminal © _) Prevention a scaychaine release from subsequent action potentials OE) Prolongatin of cafchaline ofc in the synaptic cle23. ‘The graph shows the relationship between serum leptin concentration and BNI, expressed as (weight in ka) / (height in meters)? for eight patients labeled A through H. The dashed lies Indicate the upper and lower limits ‘of normal, Which ofthe following patents mos ikely has primary leptin deficiency? OA) Patient A © B) Patient B O ©) Patient c O D) Patient > OE) Pationt O F) Patent & © 6) Patients OH) Patient H24. 80-year-old man is brought tothe physician 2 days after the onset of double vision and drowsiness. Three weeks ago, he began using over-the-counter Cimetidine for dyspepsia. He has eplepsy vated with phenytoin forthe past 2 years. Physical examination shows nystagmus and an alaxie gall. Which of {he folowing effects of eimatcine on phenytoin is the most ikoly cause of the adverse effcts inthis pationt? © A) Attered binding to plasma proteins © 8) Altered binding to issue receptors © 6) Attered distribution to active receptors © ) Inhibition of metabolism O E) Inhibition of renal excretion25. AS0-year-old man comes tothe physician because of @ 3-month history of progressive dificult swallowing: he has had a 6 8g (161) weight loss during this period. He has smoked 1 pack of cigarettes dally for 40 years and consumes four to six beers daly. He is cachectc. Bilateral weezes are heard on ‘auscultation of the chest. chest x-ray shows enlargement ofthe partracheal and hilar lymph nodes. Subsequont ondoscopy shows a 6-cm mass inthe ‘mid esophagus. The mass is centrally ulcerated with an elevation of the surrounding mucosal rim. Examination ofa biopsy specimen ofthe mass is most likely to show neoplastic cals with which ofthe folowing? O A) Acinar formation O 8) Foci of keratinization © tnracytopaemic pigment © b) Neuroendocrine granules O E) Smooth muscle differentiation26. 25-year-old primigravid woman at 12 weoks' gestation comes tothe physician 1 hour after she passed a small amount of issue vaginally at home. Gross ‘examination of his issue shows an obvious felus. Microscopic examination of tissue obtained via dilatation and curettage shows chorionic vill with focal ‘edema and trophoblastic proliferation, Which of the following is the most likely dlagnosis? O A) Choriocarcinoma © 8) Complete hytaticvorm moe O ©) Partial hydaticitorm mole O D) Placenta accreta O E) Placental site trophoblastic tumor27. A2Y-year-old boy is admitted to the hospital because of genoralzed weakness, repeated episodes of vomiting, and coma after several days of reduced food intake because of a minor febrile ness. He is treated successfully with intravenous glucose. After 13 hours of fasting when the chit is well, his serum glucose, B-hydroxybutyrate, and free came concentrations decrease markedly, and serum concentrations of long-chain acyicamnitines increase. “Triglycerides containing only medium-chainfaty acids are fed, andthe serum B-hydroxybutyrate concentration increases tothe reference range. Which of the following disorders of faty acid motaboliem isthe most ikely diagnosis? © A) Caitine-scyamitne transloca decioncy O 8) Dietary carnitine dafcency O 6) Faty acy CoA synhatase decency OD) Medium-hain a6/ CoA dehydrogenase daency © E) short-chain acy! CoA dehytrogenase deficiency28. AS2-year-old man comes to the physician because of a §-day history of headaches and muscle weakness. His blood pressure is 175/95 mm Hg. Physical ‘examination show's no other abnormalities, Laboratory studies show: ‘Serum Nat 142 meg, ke 2mEQh HCO," 33mEgiL Creatinine 1.4 mld Cortisol 219! ‘Aerial blood gas analysis on room air pH 748 Poo, 43 mmHg Pasma renin activity is undetectable. Which ofthe following isthe most lkely cause ofthis patients hypertension? O A) Addison disease B) Chronic kidney disea: © ©) Cushing disease O D) Hyperaidosteronism © E) Pheochromocytoma29. 35-year-old homeless man is brought tothe emergency department by police after they found him slumped on a bench. His pulse is 40min, respirations ‘are 10/min, and blood pressure is 100/60 mm Hg, He is stuporous but can be aroused when shaken mildly, Physical examination shows constricted pupils. ‘This pation i most Ikely abusing which ofthe folowing substances? © A) Abcohot © 8) Barbiturates © ©) Benzodiazepines O ©) Mariuana O E) Opicids30. 22-year-old man is brought tothe emergency department 1 hour after being involved ina motor vehicle colsion. Physical examination shows deep lacerations tothe right lower extremity. Which ofthe fllowing functional capabilties ofthe involved muscies wil be decreased by fibrotic scar fermation at the sites of injury? © A) Formation of glycogen deposits © 8B) Maintonance of prolonged tension O 6) Passive stretching © D) Relaxation after contraction31. Astudy is conducted to assess the provalence and incidence of obesity in a group of middle-agad men. total of 900 men between the ages of 40 and 50 years are chosen to participate. The table shows the number of participants al baseline and a the follow-up study 5 years later for each BMI range. Number of Participants ant (gin) Baseline 5 Years Later Normal (< 25) 300 ‘Overweight (between 25 and 30) 500 (Obese (2 30) 100 ‘The prevalence of obesity inthis study population after S years is which ofthe following? O A) sonoo O 8) sars00 © ¢) sore00 O ) sar900 O €) 180075 O F) 150/825 O 6) 1507750 O ¥) 150190032, 55-year-old man comes to the physician because of @ -month history of hoarseness and diftcuty swallowing. He underwent an operation to resect a be of his lung because of lung cancer 1 year ago. Physical examination shows ploss of the lft eyelid and miosis ofthe left pupil. There is diminished flushing and sweating onthe lft haf ofthe face. This patent most lkely has disordered functon of neurons at which ofthe folowing labled locations in the photograph ofa cross section ofthe spinal cord?38, 28-year-old woman, gravida 3, para 2, comes tothe physician to request an elective abortion 2 days after she recalved a positive home pregnancy test result. Her last menstrual period was 6 weeks ago. Ultrasonography shows a uterus consistent in size with a 6-week gestation. After counseling, she {decides to undergo a medication-Induced abortion rather than a surgical abortion. An oral medication is adminstored, and she i instructed to return tothe Office in 2 days to receive @ second medication. The frst drug administered most ikely belongs to which of the folowing classes? © A) Human chorionic gonadotropin antibodies © 8) Onfocies O ©) Progesterone antagonists Ob) Prostaglandin synthesis ihibitors © E) Selective estrogen receptor modulators34, A t-year-old boy is brought tothe emergency department because of 6-day history of temperatures to 98.4°C (103°F) and a 2ay history of @ severe laper rash and sweling of his hands and feet. His temperature is now 39.4°C (103°F). A photograph ofthe genital area is shown. The face and ips appear red and the conjunctvae appear injected. There is bilateral cervical lymphadenopathy. The lungs are clear fo auscultation. Cardiac examination shows an ‘8, gallop with no murmur. There is edema and erythema of the hands and feet. Which of the folowing pathologie ndings Is most kal in this patont? O A) Acute arteritis with aneurysms in coronary arteries: O B) Epidermal hyperplasia with epidermal microabscesses and parakeratosis © ©) Granulomas with easeous necrosis in cereal lymph nodes © D) Granulomatous arterts in cervical and temporal arteries: O E) Paracortcal lymphoid hyperplasia with eosinophilic intranuclear inclusions in perihilar lymph nodes35. A2t-year-old man comes tothe physician because ofa lump in his serotum for 3 months. Physical examination shows a t-cm nontonder nodule In the Fight Scrotum. Transilumination shows a sokd, noncystic structure. An operation to remove the tests is dane. After incision ofthe skin and subcutaneous tissue, the nex fascial layer to be incised inthis patient isa direct extension of which of the following abdominal layers? O A) Dartos muscie © 8) External abdominal abique muscle © 6) Internal abdominal oblique muscle O D) Peritoneum O E) Transversalis fascia36. AS3-year-old man comes tothe physician fora follow-up examination. He began antibiotic therapy 1 month ago for acute bactrial pnoumonia, At the time ‘of diagnosis, a chest x-ray showed patchy pneumanic consoldation and a 2.5-cm perioheral nodular lesion inthe right upper lobe. His symptoms have since resolved, and an x-ray today shows absence ofthe pneurnonic consolidation. However, the lesion is sil prasent. APPD skin testis nonreactive. A ‘wedge resection is done by thoracoscopy. Histologic examination ofthe resected tissue shows a sold, wel-citcumscribed nodule composed predominantly ‘of mature carfiage admixed wth small amounts of fbrous issue and occasional cats ined by benign respiratory epithelium. Which ofthe fllowing best scribes this patent's pulmonary lesion? O A) Abscess: O B) Adenoma O ¢) Choristoma O D) Hamartoma O €) Teratoma37. Apreviously healthy 32-year-old man is brought to the emergency department because of a 1-day history of intermitent flashing spots and blued vision, vorniting, confusion, and difculy walking. He is a painter and says that yesterday he cleaned up a spilled botle of pant thinner. Ophthalmologic amination shows dilated puplis with hyperemia ofthe optic dsc and retinal edema, Physical examination shows tachypnoa. Serum studios show an ‘anion gap metabolic acidosis. The most appropriate pharmacotherapy for his patient is most ikely to inhibit the activity of which ofthe folowing? © Ay) Alcohol dehydrogenase O B) Aldehyde dehydrogenase O ©) Formaldehyde dehydrogenase © D) Lactate dehydrogenase © E) Pyruvate dehydrogenase:38, 68-year-old woman with a 20-year history of hypertension is brought o the emergency department 30 minutes ater the sudden onset of right-sided Weakness. Her speech is dysarthic. Physical examination shows drooping ofthe right side ofthe face. Visual field testing shows no deficits. Muscle Strongth is 45 in the right uppar extremity and 3/5 inthe right owor extramiy, Deep tendon reflexes aro 2+ in the uppar extremities and ef lower extromity ‘and 3+ in the right lower extremity Sensation is intact throughout. Babinsk sign is present on the ight. Mental satus examination shows no abnormalities Which ofthe folitng isthe moet ‘oly cause ofthis pation's conliton”™ O A) Border zone hypoperfusion © 8) Embotsm of the ight anterior cerebral artery © ¢) Lacunar infarct of the intemal capsule © D) Ruptured aneurysm of the circle of Willis © E) Thwombus of the left posterior cerebral artery39, AST-year-old man i brought tothe emergency department because of @2-hour history of severe abdominal pain and vomiting. Abdominal examination ‘shows difuse tendemess. ACCT scan of the abdomen and abdominal radiograph are shown; the arrows indicate an abnormal. The most likely cause of these findings is perforation of whic ofthe following structurs? O A) Duodenum O 8) Esophagus O ¢) tleum O D) Stomach © E) Transverse colon