Form 26

Block 1
1. A 22-year-old man is brought to the emergency department 20.minutes after sustaining a knife wound to the right side
of his chest in a fight at a local bar On arrival, he is short of breath. His pulse is 1138Mnin, respirations am 301mm.
and blood pressure is 106O80 mm Hg. Physical examination shows that the trachea is deviated lo the left. Further
physical examination of the traumatized side is most likely to show which of the following pulmonary findings?

A. Crackles
B. Egophony
C. Hyperresonant percussion
D. Increased Fremitus
E. Stridor
F. Wheezing
G. Whispered pectoriloquy

2. A 9-year-old boy is brought to the physician because he told his teacher that his fingers felt "funny" after he swung on
the monkey bars 2 hours ago. Neurologic examination shows numbness and tingling in the ring and small fingers of
the left hand. The physician concludes that the ulnar nerve may have been stretched while he was hanging from the
bars. Which of the following other functions should be checked to assess the integrity of the ulnar nerve in the left
limb?

A. Abduction of the index, middle, ring, and small finger

B. Abduction of the thumb
C. Extension of the index, middle, ring, and small fingers
D. Extension of the thumb
E. Opposition of the thumb

3. An investigator is studying patients with West Nile virus infection. During a 5-year period, data are collected on 25
patients diagnosed with this condition as confirmed by testing at the Centers for Disease Control and Prevention.
Demographic information on the patients is reported {age, gender, and ethnicity), as well as information about likely
sources of infection. Which of the following best describes this study design?

A. Case series
B. Case control study
C. Cohort study
D. Correlation study
E. Cross sectional study

4. A 55-year-old woman who is a physician is admitted to the hospital because of a fractured femur sustained in a motor
vehicle collision. Two days after admission. she develops tachycardia, restlessness, diaphoresis. and anxiety. She
says that "vague shapes" are coming out of the walls_ Which of the following is the most likely cause of this patient's
current condition?

A. Acute stress disorder.

B. Alcohol withdrawal.
C. Bipolar disorder
D. Histrionic personality disorder
E. Panic disorder

5. A newborn is delivered at 40 weeks' gestation to a 20-year-old woman after an uncomplicated pregnancy. Physical
examination shows male-like external genitalia, with clitoral hypertrophy and labial fusion. The karyotype is 46,XX.
The serum concentration of cortisol is decreased and serum concentrations of 17-hydroxyprogesterone,
androstenedione and testosterone are increased. Which of the following is the most likely cause of the findings in this
newborn?

A. Androgen receptor mutation

B. Defect in adrenal steroid biosynthesis.
C. Deficiency of enzyme activity in gonadal steroid hormone biosynthesis
D. Increase anti-mullerian hormone secretion.
E. Translocation of the SRY gene to one of the X chromosomes.
 Form 26

6. A 35-year-old woman. gravida 3, pare 2, develops a massive hemorrhage after the vaginal delivery of a
healthy female newborn at 38 weeks' gestation. She underwent a cesarean delivery 2 years ago because of
cephalopelvic disproportion. A hysterectomy is required at this time to control the bleeding. The gross and
microscopic appearances of the uterus are shown. Which of the following is the most likely cause of the
postpartum hemorrhage in this patient?

A. Abruptio Placentae
B. Ectopic Pregnancy
C. Endometriosis
D. Leiomyomata uteri
E. Placenta Accreta
F. Placental site trophoblastic tumor

7. A 70-year-old man with poorly controlled hypertension is brought to the emergency department 30 minutes
after the sudden onset of weakness of the left side of his face and body. He is alert and able to follow
commands. His pulse is 80/min, and blood pressure is 190/90 mm Hg. Physical examination shows mild
flattening of the nasolabial fold on the left side and weakness and hyperreflexia of the left upper and lower
extremities. There are no sensory deficits, but he has mild dysarthria. Six months later, histologic examination
of the area of the injury is most likely to show proliferation of which of the following cell types?

A. Astrocytes
B. Ependymal cells
C. Microglial cells
D. Neurons
E. Oligodendrocytes

8. An 18-month-old boy in West Africa with perinatally acquired HIV infection is exposed to a child in his village
with a fever and an erythematous, maculopapular rash. Three weeks later, the 18-month-old boy develops
giant cell pneumonia, but there is no evidence of a rash. Which of the following viruses is the most likely
cause of the pneumonia?

A. Coxsackievirus
B. Influenza virus
C. Measle virus
D. Rubella virus
E. West Nile virus

9. A previously healthy 19-year-old woman comes to student health services because of a 3-day history of
vulvar itching and vaginal discharge. She has a new sexual partner and uses no contraception. Speculum
examination shows a profuse yellow-gray discharge in the vagina. The pH of the discharge is 6. Microscopic
examination of the discharge shows clue cells. Addition of KOH to the discharge produces a strong amine
odor. Which of the following is the most likely cause?

A. Bacterial vaginosis
B. Bacteroides fragilis
C. Candida albicans
D. Haemophilus ducreyi
E. HSV
F. HIV
G. HPV
 Form 26

H. Pneumocystitis jirovecii
I. Treponema pallidum
J. Trichomonas vaginallis

10. A female newborn is delivered vaginally at 37 weeks' gestation after an uncomplicated pregnancy, labor, and
delivery. Physical examination shows a narrow cranium that is elongated in the anteropostenor dimension.
Premature closure of which of the following during embryogenesis is the most likely cause of his anomaly?

A. Bregma
B. Coronal suture
C. Lambda
D. Lambdoid suture
E. Sagittal suture

11. A healthy 35-year-old woman who wishes to become a regular platelet donor comes to a blood donation
center. Blood is obtained by venous phlebotomy into sodium citrate and processed to yield platelet-rich
plasma (PRP) for platelet function studies. She has no personal or family history of bleeding disorders.
Aliquots of the PRP are subsequently analyzed using a light-transmittance platelet aggregorneter. Adding a
51.iNI solution of which of the following reagents to the PRP is most likely to cause a rapid and irreversible
aggregation pattern in these studies?

A. Adenosine diphosphate
B. Collagen monomer
C. Immunoglobulin
D. Norepinephrine
E. Prostacyclin

12. A 64-year-old woman develops pain and stiffness of the proximal interphalangeal joints and the right knee.
The pain is made worse by activity and is relieved by rest. X-rays of the knee show a narrowed joint space
with radiodense subchondral bone and cyst formation. Knee fluid aspirate shows:
Appearance clear, yellowish
Leukocyte count 250/mm 3 (N<200)
Neutrophils 5% (N<25%)
Glucose 101 mg/dL (N=80-100)

Which of the following is the most likely cause 01 her condition?

A. Acute gouty arthritis

B. Osteoarthritis.
C. Rheumatoid arthritis
D. Septic arthritis
E. Normal age related changes in joints

13. An 8-year-old boy is brought to the physician by his parents because of disruptive behavior. They say, 'He is
easily distracted, constantly interrupts us while we are talking. and seems to be always moving. His teacher says he
is always talking with his neighbors, has trouble completing tasks. and refuses to wait his turn when playing games."
Physical examination shows no abnormalities. If drug therapy is indicated, administration of a drug with which of the
fallowing mechanisms of action is most appropriate?
Antagonism of B-adrenergic receptors
Blockade of voltage gated Na Channels
Enhanced action of y-aminobutyric acid GABA at GABAa receptors
Increase release of dopamine and nor epinephrine
Selective. Inhibition of uptake of serotonin at nerve terminals.
 Form 26

14. A 62-year-old man undergoes a physical examination on his arrival at the penitentiary to
serve his prison sentence. A routine PPD skin test shows a 14-mm area of induration at 48
hours. A chest x-ray is shown. Reciprocal activation of the two immune cell types involved
in the pathogenesis of this patient's pulmonary lesions is mediated by interferon-
gamma and which of the following cykokines?
Interleukin 4
Interleukin 5
Interleukin 7
Interleukin 10
Interleukin 12
15_ A 12-year-old boy is
admitted to the hospital
because of lethargy_ hip
pain, and a temperature of
39.4*C (103°F)_ He has
been hospitalized several
other times because of
pneumonia. His neonatal
period was normal.
Complete blood counts are
within normal limits, and a
test for HIV antibody is
negative. Blood cultures
grow Staphylocaccas
aoreus. Serum
electrophoresis is most
likely to show which of the
following patterns?
16_ A 32-year-old woman
comes to the physician 1
day after she noticed a
large red lesion on her
back. One week ago, she
returned from vacation in Cape Cod, After evaluation, a diagnosis of erythema chronicum
migrans is made. Prior to prescribing an antibiotic, the physician asks the patient if she
D

could possibly be pregnant because an adverse effect of the antibiotic active against lhe
causal organism is incorporation into fetal bones and teelh, causing yellow diSCOlOratiOn.
The most likely mechanism of this drug is inhibition of which of the following?
Attachment of tRNA to ribosomes
Dihydrofolate reductase
DNA repair by BNA gyrase
Electron transport
 Form 26

E) Transpeptidation of peptidoglycan
17. A female newborn delivered at term develops jaundice, hepatomegaly and rash shortly after delivery..
Pregnancy was complicated by a 2-week febrile illness during the first trimester. The newborn is at the 25th percentile
For length, 30th percentile for weight, and 26th percentile for head circumference. One week later, a CT scan of the
head shows intracranial calcifications. Two days later, she becomes increasingly lethargic and develops respiratory
distress and seizures. She his 8 2-year-old Sister who attends day care. Which of the following is the meat likely
causal
Cytomegalovirus
Herpes simplex virus
Measles Virus
Mumps virus
Varicella-zoster virus
18. A previously healthy 35•year•old woman develops hypoxernia 35 minutes after ingesting a near•lethal dose of
barbiturates. She has not aspirated. Which of the following sets of arterial blood gas values (in mm Hg) is most likely
in this patient?
P02 PCO2 A-a 02
40 50 35
40 60 40
50 25 10
50 80 10
60 35 25

19. A 1-year-old boy is brought to the physician by his parents because of a 4-week history of progressive generalized
tonic-clonic seizures and a strange odor to his urine. He has a history or delayed development He was adopted from an
orphanage In Russia at the age of 6 months. Physical examination shows fair skin and blond hair. His phenyialanine
hydroxylase gene k homozygous for a point mutation (GT—AT) in intron 12 of the affected gene that causes skipping of
exon 12. Which of the following is the most Likely explanation for axon skipping in this patient's affected gene?
Alternative polyadenylation site
Deletion of 5' untranslated region
Expansion of trinucleotide repeat
Gene duplication
Nonhomologous recombination
0) Nonsense mutation
A) RNA splice error
B) X inactivation

20. A 65-year-old woman has ascites. Which of the following additional findings
indicates a diagnosis of constrictive pericarditis rather than cirrhosis?
A) Edema of the lower extremities
B) Esophageal varices
C) Hypoalbuminemia
D) Hyponatremia
E) Increased jugular venous pressure
F) Splenomegaly

21. A 37-year-old man camas to the physician because or a 1-week history of nausea,
vomiting. and abdominal pain_ He ate raw oysters while vacationing in Mexico 2
weeks ago_ He has smoked 1 pack of cigarettes daily for the past 15 years but has
now lost the desire Co smoke_ Physical examination shows scleral icterus and
slight enlargement and tenderness of the liver. Which of the following pathogens is
most likely responsible for the development of these symptoms in this patient?
A) Epstein-Barr Virus
B) Hepatitis A virus
C) Hepatitis B virus
D) Hepatitis C virus
E) Vibrio vulnificus
 Form 26

22_ Which of the following labeled depolarizations is associated with

the smallest stroke volume?

A B C D E

23 An investigator conducts a clinical study of 300 patients with stages III

and IV colon carcinoma_ It is found that over lime, metastases show
en increasing potenbal for growth and resistance to chemotherapy.
Which of the following mechanisms of the cell cycle best explains this
observation?
A) Decreased expression of cyclin B during G2/M transition
B) Decreased phosphorylation of RBI protein during G1-S transtition
C) Genomic Instability during s,G2 and M phase
D) Overexpression of p15, p16, and p18 during G1 phase
E) Overepxression of p21, p27, p57 proteins during all phases

24. A 45-year-old homeless man is brought to the emergency

department by police 30 minutes after he was found unconscious.
His breath and clothes smell of alcohol. His temperature is 36.8'C
(96.2'9, pulse is 66(min, respirations are 1,1(min, and wood pressure
is 110/55 mm Hg, Physical examination shams bronzed skin and
wider angiomata on the chest. Laboratory studies show
Hemoglobin 10 skit.
Hematoont 30%
Mean corpuscular volume In jrn
Leukocyte count 9000fmmj
Segmented neutroph4s 70%
Lymphocytes 20%
Monocyles 10%
Platelet count 160,000/mm1
Serum
Ferritin 200 ngirriL
Vitamin 13,(cobalamin) 500 pgimL .IN=160-950)
RBC folate 20 ngiML N=168440)
A peripheral blood smear shows occasional hypersegrnented
nautrophils and 3+ oval macrocytes. Serum studies are mall likely
to show which of the following sets of additional findings?
Methylmalonic Acid Homocysteine
A ) I n c r e a s e d I n c r e a s e d
B ) I n c r e a s e d N o r m a l
C ) I n c r e a s e d D e c re a s e d
D ) N o r m a l I n c r e a s e d
E ) N o r m a l N o r m a l
F ) N o r m a l D e c r e a s e d
G) Decreased Increased
H ) D e c r e a s e d N o r m a l
I) Decreased Decreased
25. A 5-4-year-old woman with a 25-year history or
rheumatoid arthritis that is refractory to therapy is
admitted to Ina flosp-ital for a joint replacemeht
operation. Preoperative- laboratory studies show;
Hemoglobin Platelet count
Mean oorpnaoular volume Serum
Leukocyte count Iron
 Form 26

Transfenin 10_5 gicIL

79 iirriz
8900.1rnm3
230,0001mm•
40 ligkit,
220 mgidL (N=200-400)
A photomicrograph of a Prussian blue iron-stained smear of bone marrow
aspi.ralle is shown. Which of the following is the most likely cause or the
anemia?
 Form 26

A) Autoimmune hemolysis
B) Chronic disease
C) Iron deficiency
D) Marrow replacement by
neoplastic tissue
E) Myelodysplasia
F) B-Thalassemia minor

ri

26. A40-year-old woman with chronic

paraplegia caused by multiple
sclerosis is brought to the
physician because of severe,
debilitating muscle cramps for the
past 3 weeks_ Treatment with
baclofen resolves her muscle
cramps_ Which of the following
receptors most likely decreased
the muscle spaslicity in this
patient?
A) A2-Adrenoreceptor
B) B2-Adrenoreceptor
C) y-Aminobutyric acid B
receptor
D) Calcium-sensing receptor
E) Ryanodine Receptor
27, A 35-year-oid man is brought to
the emergency departmenl
because of multiple injuries
suslained in a motor vehicle
collision 45 minutes ago, He is
lethargic and confused. The right
pupil is sluggishly reactive la light
and is 1 aim larger than the left
pupil. There is mild left
herniparesis. Further examination
shaves fracture of the tight femur,
ruptured spleen, and hemorrhagic
pleural effusion. A CT scan of the
head shows a subdural hernatoma
on the right with mass effect and
midline shift. He is intubated and
mechanically hyperventilated_
 Form 26

Which of the following is the most

likely rationale for hyperventilation
in this patient?
A) Cause cerebral
vasoconstriction
B) Decrease pulmonary
atelectasis
C) Increase cerebral blood flow
D) Increase Intracranial pressure
E) Increase oxygenation
28. A 45-year-old man carries la the
physician because of a 2-month
history, of a dull pain on the left
side of his scrotum. Examination
of the left side of the scrotum
shows a bluish appearance of the
skin and a palpable mass that
feels like a bag of worms. Which
of the following veins is mast
likely obstnxted in this patient?
A) Inferior mesenteric vein
B) Inferior vena cava
C) Inferior vesical vein
D) Internal iliac vein
E) Left renal vein
 Form 26

29. After being given an infusion or mannitol ODD mM), a healthy parson is most likely
to have which of the following changes in plasma osmolaliry arid plasma AUH
(vasopressin) concentration?

51

C
Plasma osmolality trnOsmol/Lt
CoirtF61
0.
bili>1111AILACP
e
I 12

30. A 35-year-old man comes to the physician because of a 8-month history of burning
abdominal pain that occurs 1 a Eto 2 hours after he eats. He also has had black stools
for 2 days. Use of over-the-counter antacids and histamine-2 (HO-receptor blocking
a
1 1
agents has not been effective a -
in relieving his symptoms. He is sweating profusely
and has light-headedness when he stands. His blood pressure is 105170 aim Hg
while sitting_ Physical examination shows epigastric tenderness. ACT scan of the
abdomen shows a 1-crn mass in the pancreas. Immunohislochemical labeling of
neoplastic cells in a biopsy specimen is most likely to involve the use of antibodies
directed to which of the following substances?
A) Amylase
B) Gastrin
C) Glucagon
D) Human pancreatic polypeptide
E) Insulin
F) Lipase
G) Serotonin
H) Somatostatin
I) Vasoactive intestinal polypeptide

31, A 52-year-old woman with a long-slariding history of generalized anxiety disorder

comes to the physician for a follow-up examination. She has been taking an anxiol
ytic drug for 12 years. but she is not currently under a psychiatrists care because
she says she is feeling better and that she prefers this physician to psychiatrists.
She has hyperlipidemia, hypertension, and mild type 2 diabetes mellitus treated with
pharmacotherapy. Following physical examination and laboratory studies, the
physician makes adjustments to the patient's medication regimen. Two days later,
the physician receives 12 calls from the patient for clarification of treatment
recommendations; this pattern has occurred frequently in the past. In particular, the
patient fixates on the potential toxicities of her medications. She often asks
questions that have specifically been answered during the recent office visit. Which
of the following is the best approach to manage this patient's needs?
A) Advise the patient that constant question of recommendation suggest a
lack of trust, and that she should seek care from a provider in whom she
has confidence
B) Advice staff to ignore the patietns calls if they are too frequent
C) Contact one of the patient's family members to engage his or her help in
enforcing more responsible use of the physician's times
D) Insist that the patient obtain routine psychiatric care
E) Set conditions and establish limits for phone calls, and set up a regular
schedule of office visits

32. A55•year-aid man comes to the physician because of a 2-month history of

decreased appetite; he also has had a 9-kg (20-lb) weight loss and an intermittent
 Form 26

rash during this period. Physical examination shows necrolytic migratory erythema
over the axillae and groin. Laboratory studies show a serum glucose concentration
of 280 mg/dL and plasma glucagon concentration of 1500 pgrmt. (N1=20-100). A
CT scan of the abdomen shows a mass at the head of the pancreas. Which of the
following processes is most likely occurring in this patient's liver?
A) Decreased activity of carnitine acetyltransferase
B) Glycogen synthesis
C) Increased activity of actyl-CoA carboxylase
D) Inhibition of ketogenesis
E) Partial oxidation of fatty acids
 Form 26

33. A health care screening for diabetes mellitus is conducted at a weekend market
with subjects including both men and women ranging in age from 25 to 95 years.
Blood samples are obtained, and the blood glucose concentrations are determined
The results are shown in the table'
Patient Glucose (rigidLl
1 70
2 120
3 120
4 140
5 110
6 95
75
145
105
10 85
11 85
12 90
13 120
14 100
15 190
Which of the following best represents the median blood glucose concentration for
this group (in mgfdL)7
A) 95
B) 105
C) 110
D) 120
E) 125

34. An investigator is studying a laboratory strain of HIV-1. Curing the experiment, point
ablations are introduced in the long terminal repeat region of the vines. InfeetiOn of
a human T-lymphocyte line wilh the mutant virus results in markedly decreased viral
replication compared with infection with the wild-type virus. A mutation most likely
directly affected which of the following phases or the viral life cycle?
A) Attachment of the virus to the cell surface
B) Budding of the virus from the cell membrane
C) Fusion of the viral envelope and cell membrane
D) Integration of the provirus into the host cell genome
E) RNA splicing to produce an mRNA encoding the envelope glycoproteins

35. A 56-year-old man is brought to the emergency department. 1 hour after having a
generalized tonic-clonic seizure during his morning run. Vital signs are within normal
limits. MR10 of the brain show a mass in the lateral aspect of the precentral gyrus of
the frontal lobe. eased on the MRI findings, which of the following additional deficits
is most likely in this patient?
A) Atrophy of the left upper extremity
B) Decreased proprioception in the right upper extremity
C) Decreased sensation in the left lower extremity
D) Deviation of the tongue to the right
E) Weakness of the left lower area of the face
F) Weakness of the right lower extremity

36. A male newborn is found to have a defect in anchoring fibrils_ Which of the
following skin findings is most likely in this patient?
G) Blisters
H) Easy bruising
I) Eczematous rash
J) Inability to sweat
K) Thickened skin
L) Ulcers
 Form 26

37. A55-year-old woman with systemic lupus erythematosus has an increased serum
C-reactive protein (CRP} concentration. Which of the following 15 the most likely
source of the increased serum CRP concentration in this patient?
A) Bone marrow
 Form 26

B) Brain
C) Kidney
D) Liver
E) Lymph node
F) Skin

31 A 52-year-old woman undergoes surgical excision of a large mullinodular goiter.

During rhe operation, the superior thyroid artery is used as a landmark to avoid
damage to a nerve proximal to that vessel. Which of the following best describes
this nerve?
A) External branch of the superior laryngeal nerve
B) Inferior root of the ansa cervicalis
C) Nerve to the mylohyoid
D) Phrenic nerve
E) Transverse cervical nerve

39. A 23-year-old woman is broughl to the emergency department because of

shortness of breath for 2 weeks. Her respirations are 28irnin. Physical examination
shows no other abnormalilies. Laboratory studies show:
Serum
Na• 135 mEcift
4.0 mEq/L
CI 110 mEgt
HOC. 15 mEofl_
Arterial oil on room air 7.25
Urine
Sodium 20 rriEtI/L
Chlorine 30 rnEd/1_
Potassium 15 mEq/1_
Which of the following is the most likely diagnosis?
A) Alcoholic ketoacidosis
B) Crohn disease
C) Diabetic ketoacidosis
D) Lactic acidosis
E) Renal tubular acidosis
F) Salicylate poisoning

40. A 40-year-old woman comes to the physician for a follow-up examination 1 week
altar having a second increased blood pressure measurement. Her pulse is
72/min, and blood pressure is 168/104 mini Hg in both arms while sitting.
Physical examination shows no other abnormalities. Treatment with lisloopril and
hydrochlorothlazide is initiated. One month later, her blood pressure is 120/80 mm
Hg. Which of the following sets of hormonal changes is most likely in this patient?
Angiotensi Angiotensi Bradykinin
A) n
IncI n II
Inc no change
B) Inc Dec Inc
C) Inc Dec Dec
D) Dec Inc Inc
E) Dec Inc Dec

41. A 47-year-old man with a history of rheumatic valvular disease comes

to the physician because of chest pain and difficulty breathing for the
 Form 26

past 2 days. An ECG shows an acute myocardial infarction.

Examination shows a systolic murmur_ Pressure tracings from the
aorta, left ventricle (LV), and left atrium (LA) are shown. Which of the
following is the most likely diagnosis?
 Form 26

A) Aortic obstruction
B) Aortic regurgitation
C) Left Ventricular aneurysm 0)
D) Mitral obstruction
E) Rupture of the chordae
tendineae

Ti m e
42_ A 65-year-old man who has chronic lymphocytic leuitemia has the sudden
onset of fatigue and shortness of brealh. Laboratory studies show:
Hemoglobin 6.5 gidL
Fiemalocrit 19%
Leukocyle 50.000imm,
count 170:000imma
Platelet
count
Reticulowte 4 mgidL
count Serum 0.5 mg./dL

A peripheral blood smear

is shown. Which of the
following is the most likely
cause d the anemia?
A) Aplastic anemia
B) Autoimmune
hemolysis
C) Hereditary
spherocytosis
D) Microangiopathic
hemolysis
E) Monoclonal
gammopathy

43. A 20-monlh-old girl is brought to the physician by her mother because the
mother is concerned about her daughters development and behavior. The
girt is able to walk and run and has a vocabulary, of at least 100 words_
However, when she attends playdates with other children, she prefers to play
by herself and *HI strike another child on the head if that child attempts to
 Form 26

join her in playing wish a particular toy. which of the following best explains
this patient's actions during play?
A) Attention-deficit/hyperactivity disorder
B) Conduce disorder
C) Early sign of autistic disorder
D) Oppositional defiant disorder
E) Normal behavior for age
 Form 26

44. A 42-year-old man is struck by a motor vehicle. His only injury is a closed
fracture of the proximal tibia. Initial naurovascular examination shows no deficits.
Twenty-four hours later, he has increased leg pain and parasthesias in the dorsal
space between his first and second toes. The patient begins to pass dark red
urine arid becomes oliguric. Urinalysis Is positive for blood but no erythrocytes
are seen on microscopic examination. Which of the following acute disorders is
the most likely cause of the renal failure?
A) Glomerulonephritis
B) Hemolytic-uremic syndrome
C) Interstitial nephritis
D) Nephrotic syndrome
E) Tubular necrosis

45. A 62-year-old man is being evaluated for

rectal bleeding, An x-ray of the
gaztrointesbnal tract with contrast
material is shown. Which of the following
Is the most likely explanation for the
feathery appearance in lha portion of the
gastrointestinal tract indicated by X
when compared with the portion
Indicated by Y7
A) Absence of circular muscle
B) Fewer villi
A) Greater bowel motility
B) Greater mucosal surface area
C) Less circular and longitudinal
smooth muscle

46. An investigator conducts a phase 1 clinical trial to lest the efficacy of a

systemic antagonist to lymphocyte function-associated antigen 1 (LFA•1). The
drug is approved for topical administration to treat keraloconjunctivitis sicca in
patients with multiple sclerosis. During the trial. it is found that these patients
are at an increased risk for bacterial infection as a result of this drug. The most
likely explanation for this risk is drug•indueed blockade of which of the following
segmented neutrophil activities?
A) Activation of phagocytosis
B) Adhesion to the endothelium
C) Diapedesis through the capillary wall
D) Migration to the site of injury
E) Rolling at the vessel pheriphery

47. A 30-year•old man develops urinary incontinence 2 weeks after successful

 Form 26

treatment of a fracture of the left pelvis that was sustained at work. He was
pinned against a loading dock by a took moving in reverse. Physical
examination shows a distended bladder. Qystomefrography shows absence of
rnIclurition reflexes. After the bladder fills lo capacity, overflcrw of urine occurs
through the urethra a few drops at a time. This patient most likely sustained
additional injury to which of the following during his initial accident?
A) External urinary sphincter
B) Hypogastric nerve
C) Pelvic nerve
D) Pudendal nerves
E) Skeletal motor fibers
 Form 26

ZO
AB Tr. 2 Mal.,!,
Fastmg Serum Glucose

443. During an investigatiOnal study. fasting serum glucose

concentrations are collected from a population of healthy individuate. and a
population of patients with type 2 diabetes mellitus. The results are shown in the
graph. Swttching from cut point A to cut point B would most likely result in which of
the following changes in test characteristics regarding identification of patients with
type 2 diabetes mellitus?
A) Decreased specificity
B) Improved sensitivity
C) Increase in false-negatives
D) Increase in false-positives
E) No change

49. A previously healthy 20-year-old woman comes to the emergency

department because of a 3-day history or fever, shaking chills, headaches,
fatigue, and joint and muscle pain, She recently spent the Summer working as a
lifeguard an Long Island, New York. She has never traveled outside the USA.
She underwent splenectomy for injuries sustained in a motor vehicle collision at the
age of 6 years. Her temperature is 39.1°C (102.4°4 Physical examination shows no
other abnormalities. A peripheral blood smear shows small inrraarythrocytic rings:
the result of a polymerase chain reaction test for Plasmodium species is
negative_ Which of the following is the most likely causal organism?
A) Babesi Microti
B) Barontella bacilliformis
C) Bordetlla bronchiseptica
D) Borrella burgdorferi
E) Brucella melitensis

50_ Free purine and pynmidine bases are reutilized in normal metabolism. In children
with Lesch-Nyhan syndrome who have intellectual disability, poor muscle
coordination, and self-mutilation tendencies, there is a defect in the salvage of which
of the following pairs of bases?
A) Adenine and thymine
B) Guanine and hypoxanthine
C) Guanine and uric acid
D) Uracil and cytosine
 Form 26

E) Xanthine and hypoxanthine

DONE
 Form 26

Block 2

1. A 22-year-old woman comes to the physician because of a 6-month history of

frequent headaches and fatigue. She tells the physician that she oflen overeats when
she is anxious and has been making herself vomit and using laxatives for the past 2
years. She is 16.8 ern {5 ft 6 In) tall and weighs 59 kg (130 lb); BMI is 21 kgfrn ,.
Physical examination will most likely show which of the following conditional
A) Arthritis
B) Decreased body hair
C) Dental caries
D) Galactorrhea
E) Pituitary adenoma
F) Tachycardia
G) Thyroid gland enlargmetn

2. A 32-year-old woman comes to the physician because she is concerned about

fertility. Menses occur at regular 28-day intervals. Physical examination shows no
abnormalities. An endometrial biopsy specimen is obtained from the uterine wall.
Histologic sections show a well-developed stratum basale. intact spiral arteries.
abundant endometrial stroma, and long, straight uterine glands with no secretions in
their lumens. Based on this description. which of the following labeled options best
corresponds to the point in the patient's menstrual cycle at which the biopsy was
done?

A) B) C) D)

3 In a healthy 25-year-old man with a normal diet and fluid intake, which of the
following substances filtered by the kidney has the greatest fraction excreted in
urine?
A) Glucose
B) Magneisum
C) Sodium
D) Urea
E) Water

4. A 68-year-old woman comes to the physician for a follow-up examination 3 months

after she underwent a total colectorny for ulcerative colitis. She subsequently
required an ilecistorny. She 1-feels generally walk and has resumed a nearly normal
diet_ Her temperature is 37 C {98 6'9, pulse is 921min, and blood pressure Is
104160 rrirri Hg. Physical examination shows mildly decreased skin turgor and a
well-healed ileosterny site. Laboratory studies show.
Serum
Na.• 136 mEq./IL
K• 3 rrii-_tiL
Cl' 114 mEq/L
HC05- 14 mEcio'L
Urea nitrogen 32 mgiciL
Crealinine 1 mgirdL
Arterial blood gas analysis
on room air:
pH 7.32
Pco7 30 mrn Hg
P02 BO mm Hg
Which of the following best describes this patient's acid-base disturbance?
A) Anion gap metabolic acidosis, partially compensated
 Form 26

B) Anion gap metabolic acidosis, uncompensated

C) Chronic respiratory alkalosis, partially compensated
D) Chronic respiratory alkalosis, uncompensated
E) Non-anion gap metabolic acidosis, patially compensated
 Form 26

F) Non-anion gap metabolic acidosis, uncompensated

5_ A 22-year-old woman who has D-thalassemis has a 0-hemoglobin allele that carries
a single base substitution (A • 5) at the splice acceptor site of the second intron.
Which of the following events in expression of the (1-hemoglobin gene is most likely
to be impaired by this mutation?
A) Binding of nucleosomal histones to the transcript
B) Cleavage of the transcript by RNA ligase
C) Modification of the transcript by small nuclear ribonucleoproteins
D) Recognition of the transcript by signal recognition particle
E) Transport of the transcript out of the nucleus

6. A 26-year-old white woman tomes to the physician for a follow-up exammation. Two
days ago, she was discharged from the hospital after being treated for a hypertensive
crisis with seizure. She has no Other history of major medical illness. Current
medications include a 0-adrenergic blacker.
dihydropyridine calcium channel blocker, end a centrally acting agent Waring
presynaplicaz receptors. Her temperature is 37'C (98.6°F). pulse is 54/rnia, and blood
pressure is 1820100 mm Hg. Physical examination shows trace ankle edema.
Cardiac examination shows an S,gahlop. Ascii abdominal bruit is heard left of the
umbilicus. Abdominal ulbrasonography shows normal-sized kidneys and a normal
liver, spleen, pancreas, and gallbladder: a Smell left ovarian cyst is noted. Laboratory
studies show that complete blood count, serum electrolyte concentrations, and renal
and liver function lest results are within the reference, ranges. Which of the following is
the mast likely cause of this patient's secondary hypertension?
A) Chronic kidney disease
B) Coarctation of the aorta
C) Fibromuscular dysplasia of the left renal artery
D) Hyperthyroidism
E) Primary hyperaldosteronism

7. Receptors for all of the members of the steroid hormone 'family share which of the
following features?
A) Calcium-mediated intracellular effects
B) GTP-binding proteins
C) Mitochondrial membrane association
D) Plasma membrane association
E) Zinc-containing DNA-binding domains

e. A 52-year-old man who Is in the hospital with malignant hypertension, heart failure,
and a mild renal Impairment is being treated with captoptil, nitroprusside, and
furosemide. After 48 hours of therapy, his blood pressure is controlled, but he
develops metabolic acidosis, lethargy, and difficulty breathing. Which of the following
SUbStariCeS most likely caused these adverse effects in this patient?
A) Cyanide
B) Iron
C) Lead
D) Nitric oxide
E) Selenium

S. A 10.-year-old boy with spinal muscular atrophy is brought to the emergency

department because of a 2-week history of nausea and vomiting. He also has had
decreased appetite during this period, One week prior to his illness, his entire family
had similar symptoms which improved after a few days_ Physical examination shows
decreased skin tuTgor, dry mucous membranes, and diffuse muscle weakness and
atrophy. Laboratory studies show:
Serum
140 mEq/L (N.138-145)
1{*- 4 mEcirl.. (N=3.4-4/)
Cl 105 rnEdiL (N95-105)
FPCDs 18 rnEri1L(h1.22-28)
Urea nitrogen 18 mgrrIL (N=.5-18)
 Form 26

Glucose 30 ingtc11.. (N=60-100)

Urine
pN 5.0 (N.4.8-6.0)
Specific gravity 1.020 (N=1.003-1.030)
Glucose none
Protein Irate
Ketones 4+
RISC Whpf
W8C 0,rhpf
Which of the following biochemical cycles in the liver is most likely providing this
patient's brain with an energy source at this time?
 Form 26

A) Alanine-glucose cycle
B) Carnitine-Acylcarnitine cycle
C) Lactic Acid cycle
D) Tricarboxylic acid cycle
E) Urea cycle

10. An 18-month-old bay is brought to the emergency department because of lethargy

tor 3 hours. He has not eaten well for the past 24 hours. He had cardiorespiralory
arrest associated with hypoglycemia after an episode of diarrhea 10 months4 ago.
On arrival, he is unresponsive. His temperature iS 37"C (98.6'F), pulse is 1 10/min,
respirations are 25/min, and blood pressure is 100060 mm HT Physical examination
shows hepatomegaly. Laboratory Studies show:
Serum
Glucose decreased
Ketones decreased
Camitine decreased
Urine
Ketones decreased
Dicarboxylic acids present
Following intravenous administration of glucose. he becomes responsive. Medium-
chain triglycerides are administered daily for 6 months. At a follow-up examination,
his semen glucose concentration is within the reference range. A deficiency of
which of the following enzymes is the most likely cause of these findings?
A) Glucose 6-phosphatase
B) HMG-CoA lyase
C) Hormone-sensitive lipase
D) Lipoprotein lipase
E) Long-chain acyl-CoA dehydrogenase
F) Phosphoenolpyruvate carboxykinase

11, A45-year-old man comes to the physician because of a 6-month history of

progressive shortness of breath with exertion. He has a history of frequent
nosebleeds since adolescence. He is in cm (5 ft 10 in tall and weighs 79 kg (175
Ih); BMI is 25 kg/m2. Physical examination shows the findings in the photographs.
Inhaled albuterol does not improve his symptoms. Which of the following is the most
likely cause of !his patienrs condition?
A) Atrial septal defect
B) Hypertension
C) Pulmonary arteriovenous shunting
D) Reactive airway disease
E) Thromboembolism

12. To investigate the association between cellular telephone use and the
development of brain tumors, 782 patients with brain tumors are compared with 799
age- and sex-matched patients who do not have a malignancy. The results of the
study find that there was no increase Fn the odds ratio for cellular telephone use in
patients who had brain cancer compared with those who did not have cancer.
 Form 26

Which or the following best describes this study design'o

A) Case-control study
B) Case Series
 Form 26

C) Cross-sectional study
D) Prospective cohort study
E) Randomized clinical trial
F) Retrospective cohort study

13. A bronchial smooth muscle preparation is maintained in a tissue bath.

Bioactive substances can be applied to the smooth muscle, and
contraction and relaxation of the smooth muscle can be measured. The
results of administration of
Ihrornhoxana A, (TXA) and
prostaglandin E, (PGE,) are
shown. Which of the following is
the most likely mechanism of the
effect of application of the PGE
2?
A) Activation of phospolipase A2
B) Closing K channels
C) Increase in cAMP
D) Increase in inositol 1,4,5-
trisphosphate
E) Inhibition of 5-lipoxygenase

14. IlIstone a cetyltransferases catalyze the acetylabon of lysine residues in the amino-
terminal tails of histories. Which of the following is the most likely effect of this
covalent modification on chromatin structure?
A) Decreases the affinity of histones of DNA
B) Decreases the nucleosome content of the nucleus
C) Increase the affinity of histones for DNA
D) Increase the nucleosome content of the nucleus
E) Removes histone H1 from DNA
F) Removes histone H4 from DNA

15. A 65-year-old man who is a veteran comes to the office because of a 3-month
history of increasingly severe pain of Hs low back. He has no history of major
medical illness. Physical examination shows point tenderness over the spine at the
level of L5_ Laboratory studies show:
lierneglobin 9.8 girl'.
liematocrit 28%
Serum
Ca2.- 11.2 rrigidL
Crealinine 2.2 rrigirdL
IgG 8400 mgidL (N=850-1500)
X-rays of the spine show a compression fracture at 1_5 and four lytic lesions in the iliac
crest. Examination of a bone marrow biopsy specimen
 Form 26

confirms the diagnosis and the presence of a chromosomal trenslocation.

Treatment with a chemotherapeutic regimen, including a proteasome inhibitor, is
started Which of the fallowing is most likely to occur in the affected ce31s as a
result of this therapy?
A) Decreased calcium release
B) Decreased genomic instability
C) Decreased ubiquitination
D) Increased protein degradation
E) Induction of apoptosis
 Form 26

IS. A 3,s,r.nr-oirl
mmonal man rasa
MMemama]
remota:I he-minted
fragment Umber Inlmernebral
arenamdlfrom
scredulmt WraM ax Lemnectomy
of Me arc!
blorpng label-NI
mina
M1ar onsI
MN
r9kaJ lumbar
onlranna ro,heMai CT
npur.plcon17 Is Me mall mnnrnimete ftanInn

A) B) C) D) E)

17. A 15-year-old girl is brought to the physician by her mother because of a 1-year
history of Increasingly severe abdominal pain that occurs periodically, but not
regutarty. Physical examination shows abdominal tenderness that is most acute
around the umbilicus. The physician suspects ectork endometrial tissue, and an
operation is scheduled. During the operation, an 8-cm piece of tissue is removed
from the ileal region on the antimesenrenc side of the bowel approximately 90 cm
proximal to the ileocecal junction. The patient's pain resolves postoperatively_
The ectopic tissue was most likely located in which of the following structures?
A) Ascending colon
B) Falciform ligament
C) Ileal polyp
D) Meckel diverticulum
E) Vermiform appendix

18. A 35-year-old woman and her 35-year-old husband come to the physician for
genetic counseling aver their son is diagnosed with a rare metabolic disease_
Assuming Hardy-Weinberg equilibrium, the physician tells the parents about the
Incidence and carrier frequency of this disorder. Which of the following is most
likely lo disturb the Hardy-Weinberg equilibrium of this disorder?
A) Appreciable rate of gene mutation
B) Random matings in the population
C) Relatively large population
D) No selection against a certain genotype
E) No significant immigrant population

18. An 18141 0-141 female newborn is delivered in the hospital at 24 weeks' gestation
to a 25-year-old primigravid woman via a spontaneous vaginal delivery.
Examination of the newborn shows no peripheral cyanosis. There is a grade 3.43,
continuous murmur over the left midclavic,ular, second intercostal space. At the
age of 2 days, the newborn develops respiratory distress. Echocardiography
shows a failure of a vascular structure to close. The embryologic origin of this
anomaly is most likely which of the following aortic arches?
A) First
B) Second
C) Fourth
D) Fifth
E) Sixth
 Form 26

20_ A 45-year-old man comes Co the physician because of progressively

worsening, constant pain in his !eft thigh over the past 3 months. He
is a long-distance runner. An x-ray of the femur shows thickening of
the diaphysis and disruption of the cortex with focal areas of
Increased calcification, A glistening mass containing several cysts is
surgically exciSed. A photomicrograph of tissue from the mass is
shown. Which of the following is the most likely diagnosis?
 Form 26

A) Atypical stress fracture

B) Chondrosarcoma
C) Enchondroma
D) Ewing Sarcoma
E) Giant Cell carcinoma
F) Multilobulated bone
cyst
G) Osteosarcoma

a • lOr F 7
:10

4, 41
ir

21An $1-year-old woman

is admitted to the
hospital because of a
massive pulmonary
embolism from a deep
venous thrombosis.
Her platelet count is
180.000/mm,..
Appropriate
pharmacotherapy is
started. One week
later. her platelet count
*55.001:Vmm3. The
thrombovitopenia was
most likely caused by a
drug with which of the
following, mechanisms
of action
A) Activates tissue
plasminogen
B) Interferes with the
carboxylation of
coagulation factors
C) Irreversibly
inactivates
cyclooxygenase
D) Potentiates the
action of antithrombin
III
E) Selectively inhibits
factor Xa

22_ A 613-year-old man

 Form 26

dies 1 month after the

onset of difficulty with
short-term memory
and anxiety_ lie
underwent surgical
excision of small cell
carcinoma 1 year ago_
Degenerative changes
are most likeky to be
concentrated at which
of the following labeled
sites an the normal
MRI of the head?

A) B) C) D)
E) F)
 Form 26

23 A Kt-year-old woman comes to the physician because of a 1-year history of

severe abdominal pain after meals; she also has had an unintentional 9-kg (20-
113) weight loss during this period_ The pain is relieved when she decreases the
amount of food that she eats_ She has a history of atherosclerosis and
underwent triple coronary artery bypass grafting 2 years ago. Physical
examination shows a soft, nontender abdomen and an abdominal bruit_ Pedal
pulses are diminished. The most likely cause of this patient's symptoms is
stennsis of which of the following arteries?
A) Greater pancreatic
B) Hepatic
C) Right gastric
D) Superior mesenteric
E) Supraduodenal

24. An investigator obtains a serum sample from an individual previously immunized

with a vaccine that elicits immunity to Clostridium tetani. Administration of this
serum to a guinea pig prior to challenge with a potentially lethal dose of C. tetani
Is mast likely to mediate protection to the challenge rinse Illmugh binding of
antibody to which of the following products of the bacterial cells?
A) Capsular polysaccharide
B) Cell wall polysaccharide
C) Exotoxin
D) Fimbria
E) Flagellum
F) Peptidoglycan

- 1 1\

41 1:11

2An lerryear-ple men is brought tp the emergency [10par-el-tent 31) minutes after
sesieining irqunee in a meter vehicle eelliston, He has ebiornindi pain, His puive
is 1201min, one blood pressure is 80160 mm Hg. Physical examination shows
multiple confusions over the trunk end abdominal lendames-s. A chest x-ray
shows multiple rib Fractures. ACT Stan or he abdomen is shown. Whith of the
foliowing organs is most likely injured in this patient?
A) Bladder
B) Liver
C) Pancreas
D) Spleen
E) Stomach
20A 15 year-old girl i5 brought to the phyvcian because or a 3-day hi5bory of
fever, sore throat. and malaise. Her temperature iS 34.TG {102.6°F). Physical
examination shows dirtuSe pharyngeal erythema. moderately enlarged
tonsilt.. and tender anterior and posterior cervical lymphatlenopathy. A
complete blend daunt shows:
Leukocyte COCCI l9.50INMin 3 (hi 3500--10.504:1)
SnmentedneuirophiFs 30%
Bands 7%
tosinophils 2%
Lymphocytes 25%
Lymphocytes_ atypical 30%
litoriontrie5
 Form 26

incunntion of this patient's serum with sheen erVihrOL-Ylni lasults In agolutination.

The atypical lymphocytes in this patient are mast likely which of The sollehmag cell
toes",
A) B Lymphocytes
B) CD4 T lymphocytes
C) CD8 T lymphocytes
D) FOXP3-expressing regulatory T lymphocytes
 Form 26

E) Natural killer cells

27, A 65-year-old man comes to the physician's office because of the sudden onset of loss
of vision In the left eye. There is no pain, He has a 15-year history of well controlled type
2 diabetes mellitus and hypertension. He had a myocardial infarcbon 2 years ago.
Temperature is 36.7°C (913.1*F). pulse is 72ernin, respirations are 161nin, and blood
pressure is 200/100 mm Hg. Funduscopic examination shows a pale, white retina with
retinal artery narrowing and decreased filling of the retinal veins. Which of the following
is the most likely cause of the toss of vision?
A) Malignant hypertension
B) Retinal artery embolism
C) Retinal detachment
D) Retinal vein thrombosis
E) Vitreous hemorrhage secondary to neovascularization

28 A 55-year-old woman comes to the physician because of a 3-year hislory of weakness,

fatigue, decreased appetite, and constipation. She says that she did not receive medical
treatment For these symptoms 'because she did not have health insurance until recently,
She was admitted 10 the hospital 1 year ago because of renal calculi, but she could not
afford to pay for follow-up care. X-rays al that time were indicative of osteitis fibrosa
cystica. Vital signs are within normal limits. Physical examination shows bony tenderness
and muscle strength of 415 with decreased tone. Serum studios show an ,ncr2ased
calcium cancan/Fallon and a decreased phosphorus concentration. Which of the
fallowing is the most likely diagnosis?
A) Adult T-Lymphocyte leukemia
B) Chief cell adenoma of the parathyroid gland
C) Familial hypocalciuric hypercalcemia
D) Medullary carcinoma of the thyroid gland
E) Multiple myeloma

29. A 52-year-old man with chronic renal

failure receives a cadaveric kidney Z. -

transplant. Postoperatively. he is given § 4 § . 7 1 :d r

cyclosporine for immunosuppressive e ler •

therapy. Six weeks after the "Tr

operation, he develops hypoxernia

with an arterial Poe of 40 man Hg. A SP

pholomiorograph of a Iransbronchial
7 C

biopsy • 10
specimen is shown. Which of the
following pathophysiologic
mechanisms best explains this
patient's hypoxernia?

A) Alveolar exudation due to

Cryptococcus neoformans 4, I -V
•
infection 4 !!. At'Srif
B) Cytomegalovirus pneumonitis . ,• , J. 1.4 1P.
•
4*
., o . .. .......
. lk. • N.,
with diffuse alveolar damage r •
.t
01 4r : ,
C) Neutrophilic alveolar 0 t '

consolidation due to k 1111 ' I '

pneumococcal pneumonia f
'~ 4 .„seil ir ?
D) Pneumocystits jirovecii infection 4 -, -, :

, `.
with alveolar exudation
E) Vascular invasion by aspergillus
 Form 26

30. A 58-year-old woman comes to the office for a follow-up examination 2 days after
she noticed a lump in her left breast on self-examination. Menopause occurred 6
years ago. Physical examination shows a 1-cm. poorly circumscribed. nodular mass
in the left periareolar tissue. Mammography shows an ill-defined density suspicious
for malignancy_ A needle biopsy specimen is nondiagnostic. Microscopic
examination of the excised mass shows a large dilated space lined by glandular
epithelium and surrounded by a dense lymphoplasmacytic inflammatory infiltrate;
the associated lumen is filled with lipid-laden macrophages and amorphous debris.
Which of the following is the most likely diagnosis?
A) Acute mastitis
B) Fibroadenoma
C) Fibrocystic changes
D) Intraductal carcinoma
E) Mammary duct ectasia

31, A 3-year-old girl is brought to the physician because of a 2-week history of easy
bruisability, She has had frequent, large, foul-smelling stools for 3 months. She was
found to have cystic fibrosis at the age of 18 months_ She is below the 3rd
percentile for height and weight_ Physical examination shows several ecchymotic
areas over the extremities. This patient most likely has a deficiency of which of the
following?
A) Antithrombin III
B) Platelets
C) Protein C
D) Vitamin B12
E) Vitamin C
F) Vitamin K
G) Von Willebrand factor

32. A 75-year-oki man with alcoholism is brought to the emergency department 30

minutes after he began vomiting blood_ He has a history of portal hypertension_
Abdominal examination shows spider angiomata. Which of the following is the most
likely cause of this patient's hematemesisl
A) Anastomosis between the superior and inferior mesenteric veins
B) Paraoesophageal fistula
C) Inflammation of the distal esophagus
D) Retrograde blood flow between tributaries of the left gastric to the azygos
veins
E) Shunting of blood from the portal paraumbilical veins to the superior
epigastric veins

33. A study is conducted to assess 32 patients in a community of 1900 who have

developed drug-resistant tuberculosis during a 1-year period. These patents are
removed from the community for treatment_ Assuming that the risk for infection and
susceptibility to the disease is constant, which of the following best represents the
number of individuals most likely to develop subsequent drug-resistant tuberculosis
during the next year?
A) 27
B) 29
C) 31
D) 32
E) 33

3.4. A 63-year-old woman comes to the physician because of a 5-day history of

shortness of breath and swollen legs. Her respirations are 251min and labored, and
blood pressure is 1301/50 mm Hg_ She has a large subclavian arteriovenous fistula
caused by a stab wound to the left supraclavicular
area 15 years ago. Physical examination shows 2+ edema of the lower extremities.
Which of the following findings is most likely in this patient?
A) Decreased arterial oxygen saturation
 Form 26

B) Decreased mixed venous oxygen saturation

C) Decreased stroke volume
D) Increased resting cardiac output
E) Increased systemic vascular resistance

35. A 78•year•old man comes to the physician with his daughter because of low back
pain for 3 months. He underwent a bilateral orchiectorny 2 years ago for prostate
cancer_ Ha speaks French fluenfly, but he knows only a few English words. His
daughter offers to serve as an interpreter. After thanking the daughter for her offer, it
is most appropriate for the physician to slate which of the following?
A) "Have you interpreted for your father before in a medical capacity?"
B) "I believe it would be awkward for a daughter to interpret for her father."
 Form 26

C) "It is best that I use a professional French interpreter."

D) "Please ask your father if he's ready to begin the examination."
E) "That would be fine. I'll just ask you to step out of the room for the physical
examination."
36. A22-year-old man is admitted to the hospital for treatment of a ruptured appendix.
His temperature is 38.9'C (102'F). Abdominal examination shows guarding,
rebound tenderness, and extreme tenderness of the right lower quadrant. He
undergoes exploratory laparotomy, and en abscess containing Foul-smelling pus is
found. A Gram stain of exudate shows numerous segmented neutrophils, gram-
positive cocci, gram-positive rods, and gram-negative rods. Aerobic culture of the
exudate at 37°C on blood and MacCon key agar plates yields only entenacocci.
Which of the following bacteria is most likely to be among the gram-negative rods?
A) Bacteroides fragilis
B) Escherichia coli
C) Legionella pneumophila
D) Moraxella catarrhalis
E) Proteus mirabilis

37. A newborn delivered at 28 weeks' gestation is in severe respiratory distress. The

immature alveoli of this newborn's lungs have a diminished ability to serve as sites
of effective gas exchange. An increase in which of the following parameters best
explains this finding?
A) Alveolar radii
B) Lung compliance
C) Lung elastic recoil
D) Pleural pressure
E) Surfactant secretion

38_ A 7-year-old boy is about to undergo an appendectomy. An intravenous catheter

needs to be inserted, but the patient is extremely tearful of being stuck with a
needle while awake_ The most appropriate anesthesia administered by mask lo
anesthetize this patient quickly would have which of the following characteristics?
A) High blood solubility
B) High cerebrospinal fluid solubility
C) High lipid solubility
D) Low blood solubility
E) Low lipid solubility

39. A 7e-year-old woman comes to the physician because e a 2-day history of

abdominal pain, nausea, and vomiting. Her temperature is 38.9"C (102"F). pulse is
80/min, respirations are 261min, and blood pressure is 117/79 mm Hg. Abdominal
examination shows tenderness of3 the left lower quadrant_ Laboratory studies show
a leukocyte count of 2.2,500/rnm with 8% bands. ACT scan of the abdomen shows
an abscess in the left lower quadrant The patient undergoes drainage of the
abscess and a partial 5igmoidectorny br a ruptured diveniculum. Neutrophil
activation in this patient is directed, in part, by bacterial lipopolysacchandes. As a
result, these lipopolysaccharides most likely bind to which of the following
neuirophit receptor types?
A) Cytokine
B) G protein-linked
C) Ion channel linked
D) Nuclear
E) Toll-like

40. A 2-year-old boy is brought to the physician because of a 6-month history of failure
to thrive. Cardiac examination shows a grade 4/6
murmur caused by increased pulmonic flow, followed by a fixed, widely spilt S2
Echocardiography shows hypertrophy of the right atrium, right ventricle, and
 Form 26

pulmonary arteries_ This patient most Wkely has which of the following congenital
cardiac anomalies?
A) Atrial septal defect
B) Patent ductus arteriosus
C) Persistent truncus arteriosus
D) Tetralogy of Fallot
E) Transposition of the great arteries
F) Ventricular septal defect
 Form 26

41_ A homeless 45-year-old man comes to the clinic because of localized back pain
far the past 3 months_ He has not seen a health cam provider in more than 20
years. Physical examination shows tenderness over the lower thoracic spine.
There are no obvious neurologic deficits. X-rays of the spine show narrowing of
the disc space between T10 and T11 and destruction of the adjacent T10
vertebral body. Which of the following is the most likely cause of these findings?
A) Hyperparathyroidism
B) Multiple myeloma
C) Osteitis deformans (Paget disease)
D) Sarcoidosis
E) Tuberculosis

42. A25-year•old man comes to the physician because of sores on his penis for 2
days. Physical examination shows vesicular and ulcerative lesions on the penis.
Drug therapy is initialed. One week later, his symptoms resolve. Which of the
following enzymes is required to activate the most commonly prescribed drug?
A) ATPase
B) Cytochrome P450
C) Protease
D) Reverse transcriptase
E) Thymidine kinase

43. A40-year-old man has moderate edema. A 24-hour urine collection contains 15 g of protein
(N150 mg/24 h). Which of the following is the most
likely mechanism of The edema/
A) Decreased capillary hydrostatic pressure
B) Decreased plasma oncotic pressure
C) Increased plasma oncotic pressure

D) Decreased permeability of postcapillary venules

E) Increased permeability of postcapillary venules

44. A 14-year-old girl is brought to the physician by her mother because of episodes
of increasingly severe facial blemishes during the past 6 months.
She says that she does not eat high-fat foods or use makeup. Use clan astringent
soap has not resolved her symptoms. Menarche occurred at
e age of 12 years. A photograph of her lace is shown. Which of the following best
describes the pathologic mechanism of this patient's condition?
A) Acceleration of the proliferation of cells in the dermis by increased estrogen
production
B) Colonization of apocrine sweat glands by fungi
C) Decreased blood flow to skin capillaries by overproduction of elastic fibers
D) Follicular epidermal hyperproliferation with excess production of sebum
 Form 26

E) Thickening of the basement membrane in response to increased pubertal serum

estrogen concentrations

45. The :Ilustration shows the aracltdonic cascade that is activated when skin is
exposed to poison ivy. Within this cascade, which of the fallowing is the
major mechanism of analogs of aorticosteroids?
 Form 26

A) Acceleration of the metabolism of arachidonic

acid Cell Merribraie
Phospholipids
B) Inhibition of receptors medizting selected IPhospkiolip
responses to prostaglandins and leukotrienes a sa JiMithiliOn
C) Nonselective inhibition of cyclooxygenase and eflic itl
lipoxygenase
D) Regulaation of phospholipase A2 Prom,.:

Tissue receptors %Sulk

ritietigeld
46. A 32-year-old woman comes to the physician because of a 3-month history of
headaches. Two weeks ago, she moved to an area women's sheer because her
husband had been hitting her. She lakes no medications. Physical examination
shows multiple bruises in different stages of healing over the face, neck, and trunk.
There is circumferential bruising on bath sides of the neck. Which of !he following
statements is most appropnate to gather pertinent information from this patient?
A) "Did you bring your records from the emergency room with you?"
B) "I see some bruising on your neck. How did that happen?"
C) "Please demonstrate to me how this neck bruising occurred."
D) "This looks like you were choked. Is that true?"
E) "What sort of device did your husband use on your neck?"

47. A 4a-ye at-old man comas io the physician because of a 1-month history of lower
abdominal pain and increased urge to defecate. Capability to prevent spontaneous
detention is intact. He sustained nondisplaced multiple fractures of the pelvis 2
months ago in a motor vehicle collision. He initially was on bed rest with pelvic
support, progressed to non-weight-hearing crutch walking, and now is partial
weight tearing with crutches. Medications now include naprosyn three times daily.
Physical examination shows an anal wink. Neurologic examination shows intact
rectal sphincter tone_ This patient is able to sustain cortical control over defecation
via which of the following nerves?
A) Conus medullaris
B) Hypogastric nerves
C) Myenteric plexus
D) Pelvic nerves
E) Pudendal nerves

46. A 57-year-old woman comes is the physician because of chronic shortness of

breath and swollen legs for 2 months, Her respirations are 12/min. Physical
examination shows edema of the lower extremities_ Auscultation cilia chest shows
each cardiac systole associated with a thrusting impulse palpable along the left
sternal border, most prominently In the third, fourth, and fifth intercostal spaces,
Which of the following disorders is the most likely cause of !his cardiac finding?
A) Aneurysm of ascending aorta
B) Left arterial hypertrophy
C) Left ventricular hypertrophy
D) Pericardial effusion
E) Right atrial hypertrophy
F) Right ventricular hypertrophy

49. A 75-year-old woman with non-small cell carcinoma of the lung is brought to the
physician because of a 2-day history of lethargy and cognitive impairment. One
munlh ago, she completed a 1-year regimen of chemotherapy and cranial
irradiation. One week ago, she received the diagnosis of major depressive disorder
and began therapy with a selective serotonln reuptake inhibitor. She speaks with a
blunted affect. Physical examination shows no abnormalities. Her Mini-Mental State
Examination scare is 20/30. Serum studies show a sodium concentration of 122
 Form 26

mEg/L. The patient appears confused and falls asleep during the examination.
Which of the following is the most likely diagnosis?
A) Delirium
B) Dementia, Alzheimer type
C) Dementia caused by Pick Disease
D) Serotonin syndrome
E) Vascular dementia
 Form 26

50. A 52-year-old woman with type 2 diabetes mellitus and hyperchoresteralernra crxnes
to ti-ie physician fora follow-up examination. Since her diagnosis 14 months ago, she
has been exercising regularly, eating healthier foods, and taking omega-3 fatty acid
supplements, She has had a 9-kg (20-lb) weight loss dunng this period. She is 166
cm (5 ft 6 in) tall end now weighs 62 kg (137 Ib); MI is 22 kgirn7. Physical examination
shows
no abnormalities. Serum studies show decreased glucose and cholesterol
concentrations since her last vlsi1 2 months ago, She says,
glad everything is nne, but I am worried that I warn be able to stay an this regimen
and that my health will get worse.' Which of the following best describes this
patient's stage of change?
A) Precontemplation
B) Contemplation
C) Preparation
D) Action
E) Maintenance
 Form 26

DONE
 Form 26

BLOCK 3

A43-year-old woman comas to the physician because of a fi-month history of

altered consciousness. During the interview. she stops talking in mid-senlerice, lums
her head 10 the right, and extends and stiffens her right upper extremity. She has a
blank look and does not respond to any questions. She then has some repetitive lip
smacking and piclUng movements of the hands. The episode lasts approximately
30 seconds_ She slowly returns to her normal state during the next 4 to 5 minutes.
The most likely diagnosis is which of the following types of seizures?
A) Absence
B) Complex partial
C) Generalized tonic-clonic
D) Simple partial motor
E) Simple Partial sensory

2. A22-year-old woman of Irish descent is brought lo the emergency department

because of a 1-hour history of severe pain and coldness of her left
leg_ She has an ID of O. and she dropped out of high school in the tenth grade. Her
parents and two older siblings have normal intelligence mid have no history of these
symptoms. Ophthalmologic examination shows a partially dislocated lens in the
right eye_ Physical examination shows mottling and loss of pulses in the left lower
extremity and fool_ Arteriography of the left lower extremity shows thrombosis of the
femoral artery. This patient most likely has a metabolic disorder involving which of
the following amino acids?
A) Glycine
B) Homocyst(e)ine
C) Leucine
D) Phenylalanine
E) Tyrosine

3. An investigator anempting to develop a vaccine for gonorrhea produces an

attenuated organism that he administers to female rats as an inhaled aerosol_
Swabs of vaginal secretions show a significant increase in antibodies specific for
gonorrheal antigens. Which of the following mechanisms best accounts for this
immune response in the genital tract?
A) Fecal-oral transfer of attenuated organisms
B) Synthesis of IgG by circulating lymphocytes exposed to antigens in the
lung
C) Trafficking of IgA-producing lymphocytes to see all mucosal sites
D) Transport of attenuated Neisseria gonorrhoeae from the lung to the vaginal
mucosa
E) Transport of circulating IgM across the vaginal epithelium

4. A 50-year-old woman from Egypt comes to the physician because of painless blood
in her unne for 2 weeks. Urinalysis is within the reference range. Urine cytologic
findings show malignant squamous epithelia/ eels. Which of the following is the
strongest predisposing risk factor for this type of tumor?
A) Chronic pyelonephritis
B) Cigarette smoking
C) Diabetic nephropathy
D) Excessive consumption of caffeine
E) Long-term use of phenacetin
F) Schistosoma haematobium infection
 Form 26

5. The higher incidence of birth defects in children born to women more than 55 years
old may be the result of environmental influences on
chromosomes in developmentally arrested Docytes at which of the following
stages of call division?
A) Prophase, meisosis I
B) Prophase, meiosis II
C) Metaphase, meiosis I
D) Metaphase, meiosis II
E) Telophase, meiosis I
 Form 26

6. A 65-year-old man with diabetes mellitus develops a neuropathy of the

cranial nerve indicated by the arrow in the normal brain stern, Which of
the following is the most likely associated functional deficit?

A) Complete ptosis of the ipsilateral eye

B) Inability to abduct the ipsilateal eye
C) Ipsilateral sensorineural deafness
D) Lack of tear fomration in the ipsilateral eye
E) Paralysis of ipsilateral jaw muscles

7. A42-year-old man comes to the physician because of a 1-week history of a

diffuse, painless rash on his back. He first noticed the rash after he spent a week
sunbathing at the beach. He says the rash does not itch. A photograph of the rash
is shown. Which of the following is the most Jikely causal' organism?
A) Malassezia furfur
B) Staphylococcus aureus
C) Streptococcus pyogenes
D) Treponema pallidum
E) Trichophyton rubrum
B. A8-year-old boy is brought to the emergency department because of coughing.
wheezing, and rapid breathing for 6 hours. He was diagnosed with an upper
respiratory tract infection 2 days ago_ His temperature is 37.2' {grFl, pulse is
126imin, respirations are 44, min, and blood pressure is 00/60 mm Ha. Inspiratory
 Form 26

and expiratory wheezes are heard throughout the lung fields. There is decreased
tactile frernitus. Which of the following Is the most likely diagnosis?
 Form 26

A) Asthma
B) Atelectasis
C) Bronchitis
D) Left-sided heart failure
E) Pneumococcal pneumonia

9. Asa-year-old man comes to the physician because of a 2-week history of

progressive shortness of breath while climbing stairs to his office every morning.
He reports no other problems, but he is concerned. because his father had a
major myocardial Infarction at the age of 52 years. His pulse is 110/min and
regular, respirations are 10rrnin, and blood pressure is 135!95 mm Hg. The lungs
are clear to auscultation_ Cardiac examination shows normal heart sounds with a
physiologic split of 52 Stress echocardiography shows hypokinesis of the posterior
left ventricle with increasing activity levels. Which of the following is the most likely
cause of the posterior left ventricular findings in this patient?
A) Disruption of the sympathetic nerves to the left ventricle
B) Extravascular compression of the coronary arteries
C) Increased left ventricular end-diastolic pressure
D) Increased myocardial oxygen consumption
E) Stenosis of the right coronary artery

10. A 58-year-old man comes to the physician because of a 1-month history of not
being able to sustain an erection for sexual intercourse, although he has no
difficulty during masturbation_ His wife of 40 years died 2 years ago after a
prolonged illness. He began dating recently_ He has a imultinodUlar goiter but
takes no medications. His serum Ihyroid-stimulating hormone concentration is
4.0 1.11XmL, and serum testosterone concentration is within the reference range.
He does not have any symptoms of major depressive disorder. Which of the
following pairs of additional findings is most likely to be found on history taking?
Libido Nocturnal Erection
A) Decreased Decreased
B) Decreased Normal
C) Normal Decreased
D ) N o r m a l N o r m a l

11. A 46-year-old woman comes to the office because of a 3-month history of fever,
malaise, and easy bruising. Her mother and maternal grandmother died of breast
cancer at the ages of 49 and 52 years, respectively. Her temperature is 38°C
(100.4°F), pulse is 115finin, respirations are 16/min, and blood pressure is
125190 mm Fig. Physical examination shows numerous large ecchymosas over the
bunk and lower extremities. Laboratory studies show an increased leukocyte count
with immature segmented neutrophils. Genetic testing shows the presence of the
Philadelphia (Phi) chromosome. Which of the following best explains this
patient's current condition?
A) ABL activation of the p23 tumor suppressor gene
B) Fusion protein influence on the cell cycle
C) Point mutation in the ABL oncogene
D) Point mutation in the BCR gene
E) Under expression of the p53 tumor suppressor gene

12. An 11-year-old boy receives succinylerpoline arid sevoflurane for anesthesia

during surgical repair of a hernia. During the procedure, the patient develops
muscle rigidity, tachycardia, hyperkalemia, hypocalcernia, and hyperthermia.
This patient most likely carries a vanant forrn of the gene coding for which or
the following?
A) N-Acetyltransferase
B) Cytochrome P450 2D6
C) Cytochrome P450 3A4
D) Glutathione synthetase
 Form 26

E) Ryanodine receptor

13. While digging in the forest, an archaeologist finds the skeleton of a child in a
shallow grave, Examination of the skull shows frontal bossing: there is delayed
eruption of the teeth and abnormal enamel formation of those teeth That are
erupted. The spine and arm bones show no a bnorrnalities. The tibias show marked
bowing. Which CIF the following was the most likely cause of this child's skeletal
defects?
a) Osteitis deformans (Paget disease)
b) Osteogenesis imperfecta
c) Rheumatic fever
 Form 26

d) Tuberculosis
e) Vitamin B1 (thiamine) deficiency
f) Vitamin D deficiency

s, s, s,

Ti m e
14. The diagram depicts a cardiac murmur heard in a healthy 92-year-old man. Which
of the following age-related processes is responsible for the murmur?
A) Calcification of the mitral valve
B) Enlargement of the mitral valve annulus
C) Fibrosis and calcification of the aortic valve
D) Myxomatous degeneration of the aortic valve cusp
E) Myxomatous degeneration of the mitral valve

15. A 2-month-old boy is brought to the physician because of a 7-day history of

hoarseness. His mother has AIDS and used cocaine throughout her pregnancy.
Physical examination shows no abnormalities. A t beroptic laryngoscopic
examination shows a nodule on the left vocal cord, Which of the following viruses is
the most likely cause of this nodule?
A) CMV
B) HSV
C) HIV
D) HPV
E) VZV

15.. In biosynthesis of thyroid hormones, iodide is concentrated by the thyroid gland

and oxidized by thyroidal peroxidase to iodine. Iodine iodinates amino acid residues
within the thyroglobulin molecule. Which of the following amino acids undergoes
iodination?
A) Histidine
B) Phenylalanine
C) Proline
D) Tryptophan
E) Tyrosine

17_ A healthy 70-year-old woman has participated in a longitudinal study of the effects
of aging on performance during pulmonary function tests for the past 50 years. She
has undergone a complete set of tests, including arterial blood gas analyses, every
5 years. Which of the following sets of changes best represents this woman now
compared with her results at the age of 20 years?
Residual Arterial A-a P02 difference
A) volume
Inc P02
Inc Dec
B) Inc Dec Inc
C) No change Inc Inc
D) No change Inc Dec
E) Dec Inc Dec
F) Dec Dec Dec

18 A 54-year-old man with a 25-year history of alcoholism is brought to the emergency

department by his wife because of a 1-day history of confusion. He is disoriented
and disheveled. His pulse is 110,min. respirations are 20/min, and blood pressure is
 Form 26

100/54 mm Hg. Physical examination shows signs of dehydration and jaundice, and
spider angiorriata over the face and chest. There is a flapping, up-arid-down motion
of the hands when the upper extremities are outstretched horizontally_ Abdominal
examination shows distention with bulging flanks and shifting dullness_ in addition to
other appropriate pharmacotherapy, administration of oral neomycin is begun. Which
of the following primary mechanisms of action is most likely to occnr in this patient as
a result of this drug treatment?
A) Binding of ammonia and other hepatically cleared toxins in the gut
 Form 26

B) Blockade of new protein synthesis by the liver

C) Blockade of two successive steps in the metabolism of folic acid
D) Increased endotoxin production where bacterial overgrowth occurs in the gut
E) Killing of bacteria in the gut that generate ammonia

19, An investigaWrial drug (Drug X) under development for the treatment of

hypertension is being tested in phase 1 clinical trials. A significant number or
outlasts develop dose-dependent increases in serum AST and ALT activities.
The investigators hypothesize that this effect is due to oxidative stress. Assuming
that biopsy samples of the liver can be obtained from the subjects, which of the
following would be the best measure of hepatic oxidative stress caused by Drug
X?
A) Concentration of mRNA for C-reactive protein
B) Detection of nitrated proteins in hepatic cell membranes
C) Microsomal cytochrome P450 concentration
D) Rate of state 3 mitochondrial respiration
E) Ratio of GSH:GSSG

20. A 28-year-old woman comes to Ihe physician because of a 4-day history of

palpitations, severe neck pain, fatigue, and malaise. Her pulse Is 1201min and
regular_ Physical examination shows a diffusely tender, mildly enlarged thyroid
gland. There is no exophthalmos. Serum studies show a thyroid-stimulating
hormone concentration of 0.01 pU/mL. Which of the following is the most likely
diagnosis?
A) Factitious thyrotoxicosis
B) Graves disease
C) Subacute granulomatous thyroiditis
D) Thyroid abscess
E) Toxic multinodular goiter

21 A 56-year-old man with esophageal +(arises who is awaiting liver transplantation

undergoes placement of a transjugular porlosysiemic shunt. During the procedure, a
catheter with a slant is threaded through the right internal jugular vein and clown
through the vena Gaya to the liver. To relieve lhe portal hypertension via this route, the
stent should be placed betivisen a branch of the portal vein and which of the following
additional veins?
A) Esophageal
B) Hepatic
C) Left gastric
D) Splenic
E) Superior mesenteric

22. AO-year-Did gil is brought to the physician for a follow-up examination. She has
been receiving treatment with potassium citrate monohydrate since the diagnosis of
renal tubular acidosis was made at the age of 2 years. Physical examination shows
no abnormalities. Serum studies show:
Na 142 rnEo/L
CI • 115 iinErilL
18 mEq/L
Urea nitrogen 9 mg/dL
Creatinine O. mg101..
A defect in renal emmoniegenesis is Suspected_ Which of the following substrates
is the most likely source of ammonia production in this patent?
A) Creatinine
B) Glutamine
C) Glycine
D) Leucine
E) Urea
 Form 26

23, An 8-year-oid girt is brought to the physician by her parents because of abdominal
pain for 3 days. She is at the 90th peroentite for height and the 80th percentile for
weight Breast, pubic hair, and axillary hair development is Tanner stage 3_ Pelvic
examination shows a firm. smooth, right ovarian mass. Ultrasonography of the
abdomen confirms the presence of an 8-cm-diameter ovarian mass. Which of the
following types of ovarian lesions is most likely In Ibis patient?
A) Cystadenocarcinoma
B) Dermoid cyst
 Form 26

C) Embryonal rhabdomyosarcoma
D) Fibroma
E) Granulosa cell tumor
F) Krukenberg tumor
G) Papillary carcinoma

24. An 18-month-old 01 is brought to the physician because of failure to thrive and

frequent wet diapers. She is at the 3rd percentile for length and weight. Physical
examination shows dehydration, decreased muscle tone, and bowing of the legs_ Slit
lamp examination shows crystals in the corneas. Serum studies show
hypophosphalemia, hypo kalemia, and a nonanion gap metabolic acidosis. Urine
studies show a pH of 5, gluCeSUria, phosphaturia, and generalized a minciac3duria.
Which of the following is the most likely cause of the metabolic acidosis in this patient?
A) Decreased carbonic anhydrase activity in the distal tubule
B) Decreased carbonic anhydrase activity in the proximal tubule
C) Decreased hydrogen ion secretion in the distal tubule
D) Decreased hydrogen ion secretion in the proximal tubule
E) Decreased sodium bicarbonate reabsorption in the distal tubule
F) Decreased sodium bicarbonate reabsorption in the proximal tubule

25 A45-year-old woman with chronic myaloganous leukemia comas to the physician for
a follow-up examination. Physical examination shows pallor3 and bleeding gums.
Laboratory studies show a leukocyte count of 90.004)+Mm (60% blasts) and a
platelet count of 27,000itrin3. A drug regimen of mitoxantrone, vinblastine, and
thioguanine is initiated, with no improvement. During the last cycle of scheduled
treatment, a sample of the blast cells is harvested, and the intracellular
concentrations of i-Moxantrone and vinblastine in these blast cells are found to be
undetectable. An increase in which of the following mechanisms best explains this
observation?
A) Drug efflux pump P-glycoprotein activity in leukemic cells
B) Drug metabolism by the hepatic CYP450 system
C) Drug metabolism by novel heme enzyme in leukemic blast cells
D) Production of sphingomyelin by the leukemic cells
E) Renal excretion of the drugs
F) Thiopurine methyltransferase activity in the leukemic cells

26. A 47-year-old woman comes to the physician because she wants to "do something
about my wrinkles.' Physical examination shows fine wnnides in phoiodemagect
skin on the face Treatment with tretinoin is started. Collagen synthesis will most
likely be increased in this patient by which of the following mechanisms?
A) Activation of nuclear gene transcription
B) Decreased cAMP production
C) Displaced vitamin A from cellular stores
D) Increased sebum production
E) Protection of keratinocytes from UVB irradiation

27. A 60-year-old woman is receiving Osplatin therapy for advanced transdional cell
bladder cancer. She develops paresthesias, and the medication is stopped. The
medication likely damaged the largest cells in the region labeled 'Er in the drawing
of the spinal cord shown. The damage to these cells would most likely lead to
which of the fallowing motor signs?
 Form 26

A) Babinski sign
B) Clonus
C) Fibrillations
D) Hyporeflexia
E) Muslce atrophy
 Form 26

28A42-year-old man has an aulloimmune disorder resulting in proximal muscle

weakness of the lower extremities_ Arrows in the photomicrograph shown
Indicate membranes that contain high concentrations of channels that are
targeted by this condition. Which of the following is the most likely
diagnosis?
A) Multiple sclerosis
B) Myasthenia gravis
C) Myasthenic (Lambert-Eaton) syndrome
D) Periodic paralysis

29. An investigator is studying Heqicobacter pylori strains isolated from the

same patient over several years. The immune response to proteins produced
by these strains is observed_ It is found that the original pylori isolate from
the patient expresses one protein recognized by the patient's antibodies, but
subsequent isolates do not express Mis protein. Sequencing of the gene
encoding the protein from the original and subsequent isolates is done. It is
found that subsequent isolates have nine consecutive cytidine residues.
whereas the original isolate has eight. The results are shown.
original isolate:
A C C C C C C C C A C T C A A AT T C A A C C T A G C
Thr Pro Pro THr Qin Me Glu Pro Ser
.
Subsequent isolates:
. . . A C C C C C C C C C A C T C A M T T G A A C C TA G
Thr Pro Pro His Sisir Asn $TcP
Which of the followino mechanisms best explains this genetic change?
A) Crossing over
B) DNA excision repair
C) Slipped-strand mispairing
D) Thymidine dimer formation
E) Transposon insertion

30. A 36-year-old man comes to the physician's office without an appointment

and demands to he seen immediately. He has had a sore throat for
24 hours and explains his problem is more important than the other patients'
because he is a vocafist. He is extremely upset when the receptionist
explains he will need to wait for 1 hour to see the physician. He talks with her
constantly while he waits. He says. wife and I split like 3 months
ago. We have a 6.monlh-pId boy, but she was just so into her pregnancy, she
had no time for me. And she doesn't really appreciate my music. I need full
support from my lady. Especially when my band's just about to make ii big."
Which of the following is the most likely personality disorder?
A) Antisocial
 Form 26

B) Borderline
C) Compulsive
D) Dependent
E) Histrionic
F) Narcissistic
 Form 26

G) Paranoid
H) Schizoid

31A 56-year-old man comes to the physician because of a 3-month history of

intermittent regurgitation of material with an acidic taste. He is unable to sleep and
has missed 3 days of work during the past month because of the symptom. Various
non-pharmacologic measures. including elevating the head of his bed and decreasing
his dietary tat intake and portion size, have resulted in only mild improvement_
Physical examination shows no abnormalities. Esophageal endosoopy shaves severe
erosions; there are no other structural abnormalities. The most appropriate
pharmacotherapy Far !his patient is a drug with which of the following mechanisms of
action on ths parietal cells?
A) Agonism of cholecystokinin B (CCK) receptor
B) Agonism of prostaglandin E receptor 3 (EP3) receptor
C) Antagonism of histamine-2 (H2) receptor
D) Antagonism of muscarinic (M3) acetylcholine receptor
E) Irreversible inhibition of H-K ATPase

32. A 38-year-old man with a 3-year history of type 2 diabetes mellitus comes tr the
physician fora follow-up examination. In addition to taking an oral
antlhyperglycernic agent, he has tried controlling his condition with diet modifications
and exercise. lie Is 108 cm (3 ft 2 in) tall and weighs 113 kg
(2si) BMJ is 32 kgim 2. Physical examination shows no other abnormaiitres. His
hemoglobin Al Is 14%. The physician recommends initiation of insulin injections to
obtain better control over the patient's brood glucose tonoentration. The patient
responds, "I know that insulin would help control my blood sugar. But a- lot of people
in my farnifii have diabetes, and insulin made them really sick at limes. This patient
is most likely at which of the following stages of change regarding insulin
administration?
A) Precontemplation
B) Contemplation
C) Preparation
D) Action
E) Maintenance

33. A 2-year-old boy has had recurrent bacterial infections with markedly increased
absolute neutnophll counts in the blood (30,000-150.0130/mmay Studies of
neutrophils show:
Test Substance Patient {% Control)
 Form 26

Bacterial killing
Normal opsonized 80±20
patient serum 70±15
Patient qpsanized normal
serum Phapocytosis 85:20
Normal opsonized 60:20
patient serum
Patient opsonized normal 90:15
serum Chemotaxis 10±5
Normal patient
C5a
Patient patient
C5a
Which of the following is the most likely diagnosis?
A) Chronic granulomatous disease
B) Leukocyte adhesion deficiency
C) Myeloperoxidase deficiency
 Form 26

34. A 62-year-old man has had petechine and easy bruising for the past month. He
has a 2-year history of alcoholic cirrhosis with portal hypertension, Laboratory
studies show.
Hemoglobin 10 WEIL
Hemalout! 30%
Leukocyte count 4000/mm,
Neuaophils 65%
Lymphocytes 30%
Monocytes 4%
Eosinophils 1%
Basophils 0%
Retioulocyte count 8% of red cells 3
Mean corpuscular volume 1023 urn
Platelet count 68,000/mm
Prothrombin time 16 sec
Partial lhromboplastin lime 28 sec
(activated)
Sarum
Fibrinogen 200 mgidL{N•=200-400 ingfriL)
Fibrin split products <10 (1'4 5 10)
Which of ihe following is the most likely cause of the pancylopenfa,
A) Disseminated intravascular coagulation
B) Hypersplenism
C) Iron deficiency
D) Vitamin B deficiency
E) Vitamin C deficiency

35. A 35-year-old woman carries to the emergency department 3 hours after the
sudden onset of severe right-sided back pain, She has a history of recurrent urinary
tract infections_ Her most recent infection was 1 month ago; she was successfully
treated for Klebsioilet pneumaniae with antibiotics, The patient is not taking any
medications, She says that she has been eating more fast rood and drinking less
water during the past month because of a busy schedule, She is sexually active and
uses a spermicidal cream for contraception. Her temperature is 37'0 (913.6"F).
pulse is 1001min, respirations are 14/min, arid blood pressure is 138/66 mm Hg.
Physical examination shows marked tenderness lo palpation over the right flank_
Urinalysis shows:
pH 8
Protein 1-i
RBC 30-35/hpf
WBC 20-251190
An excess of which of the following is the most likely underlying cause of this patient's
flank pain?
A) Calcium oxalate
B) Cystine
C) Magnesium ammonium phosphate
D) Potassium citrate
E) Uric acid

36_ Following blockage of a cerebral artery, the neurons that die from hypoxia release
a neurotransmitter that promoles excessive calcium influx. lysis, and call death in
nearby undamaged neurons, Which of the following substances is the primary
cause of this cascade of excitotoxicity?
A) Acetylcholine
B) V-Aminobutyric acid
C) Glutamine
D) Glycine
E) Norepinephrine

37. A study is conducted to assess the relationship between angiotensin gene

polymorphisms {I versus D alleles) and the development of progressive renal
disease due to lgAnephropathy. A tine' or 250 patients are enrolled: 125 patients
with progressive renal disease due to IgAnephropathy (Group X) and 125 patents
with IgA nephropathy with stable renal disease {Group V. Resutts show that 67
 Form 26

patients in Group X have the D allele, whereas 12 patients in Group Y have the D
allele. Which of the following tests is most appropriate to determine whether there is
a significant difference in the prevalence of the D allele between these two groups?
A) Analysis of variance
B) Chi-square test
C) Linear regression
 Form 26

D) Nonparametric regression
E) Student's t-test

38A AA-year-DM woman oixnee to the physician because of a 3-week history of

severe headache. She is. 157 cm j5 ft 2 in) tall and weighs 86 kg (19(11b); BMI
is 35 kg.rm,. Funduscopic examination shows papillederna. An MRI of the brain
shows no abnormalities. A lumbar puncture is don-e. Cerebrospinallluki (CSF)
analysis shows an opening pressure of 32 cm H2O. In addition l0
recommendations regarding dietary changes and weight loss. treatment with
acetazolamide is begun. This drug will most likely improve the patient's
symptoms by which of the following mechanisms?
A) Decreased CSF production by the choroid plexus
B) Decreased venous pressure around the arachnoid granulations
C) Increased permeability of tight junctions (zonulae occludentes) between
endothelial cells
D) Increased sodium permeabiity of the ependyma
Duni per 10,940 (Year11

E) Increased water transport by astrocyte end-foot processes

NONSMOKERS SMOKERS
nurstriie ry•incei./.9-.1kire C1,114
NOM! rikikIWO chnimacroi quintals. IterOlquoltiin, DursAnit
whew. [roam} 11,111111e. 1, TW71 qv4Il4
39. The graphs show the combined effect of total serum cholesterol concentration and
diastolic blood pressure an age-adjusted coronary artery disease death rates for
bath smokers and nonsmokers. Two persons, X and Y, have the following data:
Smokes Okastolic Blood Pressure Total Serum
Cholesterol
X no 72 mrrh H9 180
mgicIL
yes 95 mmHg 250 rngldL
Compared with X. which of the following is the relative risk of dying from coronary
artery disease for Y?
A) 2
B) 6
C) 12
D) 30
 Form 26

E) 55

40.. A 32-year-old wornan comes lo the physician because of a 3-month

history of fevers_ weakness, grid night sweats. Physical examination
811-0411S enlarged axillary lymph nodes. A photomicrograph of tissue
obtained on biopsy of an affected node is shown. A slain for acid-fast
bacilli is negative. Which of the following is most li-kely involved in the
pathogenesis of these findings?
 Form 26

A) Activation of alternate complement pathway

B) Streptococcal infection of the region drained by the
lymph node
C) Type I (immediate) hypersensitivity reaction
D) Type III (immune complex-mediated
E) Type IV (delayed) hypersensitivity reaction

41. A previously healthy 42-year•old Asian woman is brought to the emergency

department because of a 24-hour history of nausea, vomiting, and progressive
lethargy. She has smoked 1 pack of cigarettes daily for 25 years and drinks four
glasses of wine daily. She uses high-dose acetaminophen daily for headaches. She
does not use iftit drugs. She is 155 cm (5 ft 1 in) tall and weighs SO kg MD lb}; BMI
is 21 kg/m2. She ks responsive to painful stimuli. Initial laboraiory studies show
increased hepatic aminotransferase. Which of the fallowing effects of alcohol most
likely contributed to this patient's condition?
A) Decreased generation of N-acetyl-p-benzoquinoneimine
B) Increased glucuronidation
C) Increased hepatic glutathione stores
D) Increased sulfation
E) Induction of cytochrome P450

42. A27.year-old man has hepatornegaly and mild jaundice. Serum alkaline
phosphatase and y-glutarnyllransfecase activities are increased. Which of the
following properties or these enzymes allows them to be used to detect deeds in
bile flow?
A) Present in bile ductules
B) Present on the basal surface of hepatocytes
C) Released from the gallbladder
D) Required for bile salt synthesis
E) Required for bilirubin conjugation
F) Required for heme catabolism

43. A 68-year-old woman is brought to the emergency department 3 'lours after

failing onto her right wrist while working in her yard_ Examination of the right
 Form 26

wrist shows swerling and ecohyrnoses. Passive flexion of the right wrist
exacerbates the pain. An x•ray of the right wrist is shown. Whitt of the following
is the most likely catiwof these findings?
 Form 26

A) Avascular necrosis of the scaphoid

B) Avulsion of the ulnar styloid process
C) Dislocation of the first proximal phalanx
D) Disruption of the radioulnar joint
E) Fracture of the distal radius

44. During
a genome projecl, an experimental animal is round to have a DNA sequence with
similarities to a growth hormone receptor. Which of the following peptide segments
shown is the transmembmne segment?
A
Alt LM! NISASPAin Ter LYS Pre
4111
PlullitrASIlii.VAIro TrP Val
94 PI* ON Lem Tr alu ON Sex
Asp Mu Tff Olu Lev Asp FIFE 4h
Lys Ser Leu GM LvE,Asp
B
hp
Sur LeuCvsAla Arp
Asp Ser Otr Thr Sar Cvsalv CysOlu Aka [vs Thv
ON LIEU
C
149 hisAla Sa Lvs
ahr Ber
T I TA r g 1 - 11 s T h r 4 1 v e t i A l a A s n
A r p i r p A r g Ly s F i c L e u
p
Asp Tyr Aan8Er AspA 1 4 lu MeAsis iltAV Asp Thr Asp elu '1-
n1311031u OlEfiThr
E
Leuval Lcu MY Pt Gk Met lie CityVal VW Ile vel Val
LeuLeuVal Lou Leo Ile PFIV
GteAvo Olu 141 Lau ale Lau Lau Lauasp O V. Pro Ot Sr
Lou ThrAla a<la Aid City
F
LA Gar OM UUNII OW Qin Argl.wi her Po Olu Tr Sr bra) 40,54 Tpr Thr Sr
tee Me Lau Tur

45. A20-year-old woman comes to the physician because her menstrual period is 1
week late. Menses had occurred at regular 28-day intervals. She had unprotected
 Form 26

sexual intercourse with her boyfriend 20 days ago. A urine pregnancy test result is
positive. Which of the following best describes the stage & development of the
embryo at !his time?
A) The cytrotrophoblast is present, but the syncytiotrophoblast has not yet
formed
B) Gastrulation is complete, but there are only two germ layers
C) The neural plate is present, but the neural tube is not yet complete
D) Placental development is complete, but the embryo is resistant to
teratogens
E) The sclertome cells having begun migrating, but the somites have not yet
formed

46. A 50-year-old man collapses and dies while running to catch an

airplane. A photograph of his aortic valve is shown. Which of the
following best describes the lesion?
 Form 26

A) Calcified congential bicuspid valve

B) Infective endocarditis
C) Myxomatous degeneration
D) Postinflammatory valve stenosis

47. A 16-year-old boy has a 6-month history of type 1 diabetes mellitus and requires
deity insulin injections. His blood glucose control has been poor recently. which the
physician suspects may be related to the patient's reluctance to self-administer
insulin. Which of the following questions is most appropriate to broach this issue
with the patienl7
A) "Giving yourself insulin injections can be difficult. What's it like for you?"
B) "I get the feeling you have not been taking your insulin regularly. Would yo like me
to arrange some training for you by our nurses?"
C) "It's been my experience that most poorly controlled diabetics have trouble giving
themselves insulin. Do have this problem?"
D) "You are clearly having difficulty with insulin injections. Would you like to arrange
for a family member to give you your shots?"
E) "You seem to have missed your shots. How often has this happened?"

48 A 36•year-old man who is heterorygous for an LDL-receptor deficiency has a total

serum cholesterol concentration of 330 rng/dt. After taking a drug that inhibits
cholesterol synthesis, his total serum cholesterol concentration decreases to 200
ragodt..) Which of the following proteins would be upregulated as a result of drug
therapy '
A) Cholesterol acyltransferase
B) Hepatic lipase
C) LDL receptor
D) Lipoprotein lipase
E) Lysosomal cholesterol esterase

49. A study is conducted to evaluate the effectiveness of cough medication in crOldren.

A total of 120 patients under the age of 12 years who have been diagnosed with a
viral upper respiratory tract infection are randomly selected to receive
dextromelhorphan or no treatment. The participants were recruited from several
emergency deparh-nents in an urban area. Parents complete a rating scale for their
children's cough al baseline and 1 day after receiving dextromethorphan or nothing.
The results shoo, a statistically significant improvement In cough scores for
patients receiving dextromethorphan {o=0_04}oorripared with children receiving no
treatment. Which of the following is the most significant limitation to the internal
validity of this study?
A) Lack of blinding between groups
B) Limited number of participants
C) Marginal statistical significance
D) Study location limited to only emergency departments
E) Subjective nature of the survey instrument
 Form 26

50. A 56-year-old man comes to the physician fora routine examination. His stool is
positive for occult blood. Colonoscopy shows a pedunculated growth that is
coarsely lobulated and 1.4 cm in diameter. The excised lesion is covered by colonic
epithelium and composed of branching glands lined by tall hyperchromalic cells.
Some areas appear mildly dysplastic, but there k no evidence of invasion of the
stalk. Which of the following oncogenes is most likely to be activated in this lesion?
 Form 26

A) Erb
B) Fos
C) K-ras
D) P53
(TP53)
E) Rb
F) src

DONE
 Form 26

Block 4

1_ A 59-year-old man comes lo the physician because of a 3-month history of

progressive difriculty swallowing; he has had a 6_13.kg (15-ib) weight loss during this
penod. He has smoked 1 pack of cigarettes daily for 40 years and consumes four to
six beers daily. He is cachectic. Bilateral wheezes are heard on auscultation of the
chest. A chest x-ray shows enlargement of Ihe paralracheal and hilar lymph nodes_
Subsequent encloscopy shows a 6-cm mass in the mid esophagus. The mass is
centrally ulcerated with an elevation of the surrounding mucosa! rim. Examination of
a biopsy specimen of the mass is most likely to show neoplastic cells with which of
the following?
A) Acinar formation
B) Foci of keratinization
C) Intracytoplasmic pigment
D) Neuroendocrine granules
E) Smooth muscle differentiation

2. A 52-year-old man comes to the physician because of a 5-day history of

hfaitchiiches and muscle weakness. His blood pressure is 175155 urn Hg. Physical
examination shows no other abnormalities_ Laboratory studies. show'
Serum
Na• 142 mEgri..
K• - 2 rrIEWL
HOD, 33 mEdri_
Grealinine 1.4 mg/I:IL
Corlisol ligidL
Arterial blood gas analysis on mom air:
pH 7.45
Pco2 48 mm Hg
Plasma renin activity is undetectable. Which of the following is the most likely cause of
this patient's hypertension?
A) Addison disease
B) Chronic kidney disease
C) Cushing disease
D) Hyperaldosteronism
E) Pheochromocytoma

3. A 21-year-old man comes to the physician because of a lump in his scrotum for 3
months. Physical examination shows a 1-cm nontender nodule in the right scrotum.
Transillurnination shows a solid, noncystlo structure. An operation to remove the
leslis is done. After incision of Itie skin and subcutaneous tissue, the next fascia!
layer to be incised in this patient is a direct extension of which of the following
abdominal layers?
A) Dartos Muscle
B) External abdominal oblique muscle
C) Internal abdominal oblique muscle
D) Peritoneum
E) Transversalis fascia

4. A 24-year-old man who is serving overseas in the US Armed Forces is brought to a

medical unit 30 minutes after sustaining multiple injuries caused by an explosion that
forcibly ejected him from the vehicle he was driving_ On arrival, he is conscious and
hemodynamically stable. His respirations are 30/min. Physical examination shows
visible shrapnel protruding from the lower sternum. Which of the following structures
within the pericardial sac is most likely damaged in this patient?
 Form 26

A) Ascending Aorta
B) Left atrium
C) Left ventricle
D) Right atrium
E) Right ventricle
 Form 26

5. A 60-year-old man develops palpitations over a 6-week period during which he has
been drinking approximately a cups of coffee per day. A rhylhrn strip from his ECG
is shown. Which of the following is mast likely responsible for the palpitations in this
man?
A) Second-degree atrioventricular block
B) Sinoatrial exit block
C) Supraventricular premature beats
D) Third-degree atrioventricular block
E) Ventricular tachycardia
6. A 42-year-old woman comas to the physician because of a 3-week history of
numbness of the fingers on the left hand. Neurologic examination shows loss of
touch graphesthesia and Toss of hyo-poinldiscemination in the left hand_ This
patient most likely has a lesion in which of the following locations a the hemispheres
shown?

A) B) C) D) E) F) G) H) I) J)

7. The graph shows the relationship between serum leptin concentralion and WA,
expressed as (weight in kg) I (height in meters) 2 for eight patients labeled A
through H. The dashed lines indicate the upper and lower lir&ts of normal.
lArnicti of the following patients most likely has primary leotin deficiency'?
A) Patient A
B) Patient B
C) Patient C
D) Patient D s A B C
E) Patient E
F) Patient F
G) Patient G ID Norma)
H) Patietent H
E
F H
Bhlt rri
(k 2
5, A 66-year-old women with a 2D-year history of hypertension is brought to the emergency
department 30 minutes after the sudden onset of right-sided weakness. Her speech is
dysarthric. Physical examination shows drooping of the right side of the face. Visual field
testing shows no deficits. Muscle strength is 415 in the right upper extremity and 315 in
the right lower extremity_ peep tendon reflexes are 2+ in die upper extremities and refit
lower extremity and 3+ in the right lower extremity. Sensation is intact throughout.
Babinski sign is present on the right. Mental status examination shows no abnormalities.
Which of the following is the most likely cause of this patient's condition?
A) Border zone hypoperfusion
 Form 26

B) Embolism of the right anterior cerebral artery

C) Lacunar infarct of the internal capsule
D) Ruptured aneurysm of the circle of Willis
E) Thrombus of the left posterior cerebral artery
 Form 26

9. A 50-year-old man is brought to the physician 2 days after the onset of double vision
and drowsiness. Three weeks ago, he began using over-the-counter cimelidine for
dyspepsia. He has epilepsy treated with phenytoin Mr the past 2 years_ Physical
examination shows nystagmus and an ataxic gall. Which of the following effects of
cimetidine on phenytoin is the most likely cause of the adverse effects in this
patient?
A) Altered binding to plasma proteins
B) Altered binding to tissue receptors
C) Altered distribution to active receptors
D) Inhibition of metabolism
E) Inhibition of renal excretion

10 A 60-year-old woman dies of a myocardial infarction. incidental 'findings on

examinational autopsy include multiple 0.6-to 1-cm stool-filled outpouchings of the
sigmoid colon alongside the taeniae coli, The outpouchings protrude through the
muscularis propria. hAioroscopic examination of a lesion shows a thin wall
consisting of attenuated colonic mucosa and submtroosa. Which of the following
mechanisms best explains the formation of these lesions in the colon?
A) Abnormal development of the muscularis propria
B) Atrophy of the muscularis propria
C) Hyperplasia of the columnar epithelium
D) Increased intraluminal pressure
E) Neoplastic proliferation of the columnar epithelium

11. A previously healthy 32-year-old man is brought to the emergency department

because of a 1-day history of intermittent flashing spots and blurred vision,
vomiting, c:CinfaSiOn, and difriailty walking, 1-10 is a painter and says that
yesterday he cleaned up a spilled bottle of paint thinner. Ophthalmologic
examination shows dilated pupils with hyperemia of the optic disc and retinal
edema. Physical examination shows lachypnea. Serum studies show an anion gap
metabolic acidosis, The most appropriate phannanotherapy for this patient Is most
likely to inhibit the activity of which of the following?
A) Alcohol dehydrogenase
B) Aldehyde dehydrogenase
C) Formaldehyde dehydrogenase
D) Lactate dehydrogenase
E) Pyruvate dehydrogenase

12. A 35-year-old homeless man is brought to the emergency department by police

after they found him slumped on a bench_ His pulse is 40knin, respirations are
10/min_ and blood pressure is 100/60 mm I-10. He is stuporous but can be amused
when shaken mildly_ Physical examination shows constricted pupils. This patient is
most likely abusing which of the following substances?
A) Alcohol
B) Barbiturates
C) Benzodiazepines
D) Marijuana
E) Opioids

13. Ina 3-week-old knockout mouse, a leg bone reaches only half the length of Dial of
a similar-aged wild-typo rims& The epiphyseal plates in the bone of the transgenic
animal are significantly narrower than in the bone of the wild-type animal. The
knockout mouse most likely has a deficiency of which of the Following?
A) Calcitonin
B) Cortisol
C) Insulin-like growth factor I
D) Platelet-derived growth factor
 Form 26

E) Thyroxine (T4)

14. A 14-year-old boy is brought lo the physician's office because of decreased

appetite and abdominal pain over the past 3 weeks. His mother says that during
the same time he has withdrawn from everyone and sleeps constantly, He
describes his symptoms vaguety. Physical examination is normal. Dunng further
history-taking, it is most critical for the physician to obtain information about which
of the following?
A) Developmental history
 Form 26

B) Family history of affective disorder

C) Orientation to time, place, and person
D) School history
E) Suicidal ideation or attempts

15_ A 57-year-old man is brougnt to the emergency department because of a 2-hour

history of severe abdominal pain and vomiting. Abdominal examination shows
diffuse tenderness. A CT scan of the abdomen and abdominal radiograph are shown
the arrows indicate an abnormality. The most likely cause of these findings is
perforation of which of the following structures?
A) Duodenum
B) Esophagus
C) Ileum
D) Stomach
E) Transverse colon

16_ A 57-year old man has a

hemoglobin concentration of 18.5
g"dL. A peripheral blood smear is
shown. These findings are most
consistent with which of the
following disorders?
A) Agnogenic myeloid metaplasia
B) Chronic obstructive pulmonary
disease
C) Hereditary hemochromatosis
D) Hypersplenism
E) Myelodysplastic syndrome

17_ A3-year-old girl is brought to the physician because of a 1-year history of short
stature. She has no history of major medical illness. She is below the 3rd percentile
for height and al the 14th percentile for weight. Physical examination shows coarse
facial features and contractures of the large joints. X-rays show dysostosis
 Form 26

multiplex. Plasma lysosomal enzyme analysis shows increased fl-haxosaminida se.

p-glucuronidase, p.-galactosidase, and a-fucosidase activities. Which of the
following mechanisms is the most likely cause of the iysosornal enzyme findings in
this patient?
A) Abnormal targeting of these enzymes to lysosomes
B) Deficiency of the other lysosomal enzymes in the cytoplasm
C) Degradation of these enzymes within the cytoplasm
 Form 26

D) Degradation of these enzymes with the lysosomes

E) Storage of these enzymes within the cytoplasm

18. A 55-year-old men comes to the office because of a 7-year history aired. dry, didny skin
aver his hack and buttocks. Use of emollients end topical CCrliouMuroids NM not
improved his symptoms. He has no other history of major modeal illness. His vital signs
are within normal limits. Physical examination shows the findings in the photograph.
Laboratory studliss show 'Blasi nophilia and increased serum concentrations of igA and Ig
E. Malignant transformation of which of the following cell hypes is the most likely cause
F) of the findings in this fal,enr?
A) Blastocytes
B) Eosinophils
C) Macrophages
D) Mastoid cells
E) Monocytes
F) T lymphocytes

10. A 4 0-year-Nd woman comes to the physician because of a 2-month history of

increasing redness around her nose and cheeks, and pimples around her mouth-
She appears very upset and tells the physician, "l look like a teenaged Santa Claus'
Which of the following initial responses by the physician l5 mast appropriate?
A) "Can you tell me how often you go out in the sun and what kind of protection you
use?"
B) "Don't worry. Let me assure you this is not a serious condition."
C)"It's upsetting when you have a skin problem on your face."
D) "Maybe a little. At least you are keeping your sense of humor about the situation."
E) "You really do look rather odd. I can understand why you are so upset."

20_ A 15-year-aid girl with acute myelogenous leukemia undergoes a bone marrow
transplant procedure. Her 19-year- Id brother is the donor. Blood group and human
leukocyte antigen (h-li__A) typing of patient and donor leukocytes. are:
Patient DO11101-
Blood Group AB, Rh-positive A, Rh-positive
HLA-A 2, 3 2. 3
1-ILA-43 5, 7 5, 19
FILA-DR 2, 5 2, 5
Three weeks later. she develops a temperature of 37.4°C (99.3"F); a diffuse,
erytnamatous rash over most of the body, including the palroar and plantar wriaces:
and watery diarrhea- Serum stud es show an AST activity of 120 LI/L (N=5-55) and
ALT activity of 1130 I.J.+1. (N=5-45). Which of the following is the most likely
diagnosis?
A) Acute rejection
B) Cytomegalovirus infection
C) Graft-versus-host disease
 Form 26

D) Hepatitis C
E) Hyperacute rejection
F) Leukemia recurrence
G) Serum sickness
 Form 26

21. AM-year-old man comes to the physician because of a 1-week history of

temperatures to 38.3°C (101T), chills, and chest and back pain. Two weeks ago,
he returned from a trip to Costa Rica, where he had been performing ecologic
studies of bats in their cave habitats. He reports exposure to bat urine and feces
during his studies. Today, his temperature is 38.1 6C (100.6'F). Physical
examination shows no other abnormalities. A complete blood count and serum
chemistry studios are within the reference ranges. A chest x-ray shows bilateral
reticulonodular infiltrates. The virulence of the most likely infectious agent in this
patient depends on which of the following?
A) Elaboration of polyribitol phosphate
B) Growth inside nonactivated macrophages
C) Invasion of host tissues and vasculature
D) Phenotypic switching from yeast to hyphae in the host
E) Production of lipopolysaccharide capsule

22. A 35-year-old man comes to the physicists after he noticed a dark. lesion on his
back. Physical examination shows a dark, irregularly shaped, raised region on the
back. He has a history of frequent sun exposure at the beach. A biopsy specimen 0
the region confirms the diagnosis of a melanoma. Which of the following embryonic
tissues most likely formed this tumor?
A) Dermatome
B) Lateral plate mesoderm
C) Neural crest
D) Nonneural ectoderm
E) Prechordal plate mesoderm

23. One hundred patients discharged from the hospital with a diagnosis of proximal
deep venous thrombosis were followed for the developmenl of venous ulceration
for up to B years VT group)_ They were compared to a group of 200 patients who
were discharged from Use hospital with a diagnosis of pneumonia (the control
group). At the end of 5 years, 25 patients in the CVT group and 10 patients in the
control group developed venous ulceration. Which of the following is the
attributable (excess) risk per one hundred patients for development of venous
ulceration following deep venous thrombosis over 5 years?
A) 1
B) 2
C) 2.4
D) 2.5
E) 10
F) 20
G) 24
H) 25

24- A 25-year-old primigravid woman at 12 weeks' geslation comes to the physician 1

hour after she passed a small amount of tissue vaginally at home. Gross
examination of this tissue shows an obvious fetus. Microscopic examination of
tissue obtained via dilatation and curettage shows chononic villi with focal edema
arid trophoblastic proliferation. Which of the following is the most likely diagnosis?
A) Choriocarcinoma
B) Complete hydatidiform mole
C) Partial hydatidiform mole
D) Placenta accrete
E) Placental site trophoblastic tumor
25. A 35-year-old woman with sickle cell trait is brought to the emergency department
because of severe left flank pain for 1 hour. She has a history of frequent
headaches. Her blood pressure Is 150/90 mm Hg. Pressure on the costophrenic
angle causes pain. Urinalysis shows a few RBCs and numerous neutrophils. ACT
 Form 26

scan of the abdomen shows obstruction and dilation of the left ureter and blunting
of several renal papillary pyramids. Which of the fallowing Is the meal likely
diagnosis?
A) Acute glomerulonephritis
B) Acute tubular necrosis
C) Diabetic nephropathy
D) Papillary transitional cell carcinoma
E) Renal papillary necrosis
 Form 26

26. A 22-year-old man is brought to the emergency department 1 hour after being
involved Ina motor vehicle collision. Physical examination shows deep lacerations
lo the right Icwer extremity, Which of the following functional capabilities of the
involved muscles will be decreased by fibrotic scar formation at the sites of
injury?
A) Formation of glycogen deposits
B) Maintenance of prolonged tension
C) Passive stretching
D) Relaxation after contraction

27, An-yew-old man with dementia, Alzheimer type, has improvement in memory
and cognition with donepexil therapy. Which of the following is the most likely
mechanism of this beneficial effect?
A) Blockade of choline reuptake into presynaptic terminals
B) Blockade of effects on the nicotinic receptors of muscle
C) Enhanced influx of calcium into the presynaptic terminal
D) Prevention of acetylcholine release from subsequent action potentials
E) Prolongation of acetylcholine effects in the synaptic cleft

213. A 21-4-year-old boy is admitted to the hospital because of generakted

weakness, repeated episodes of vomiting, and coma after several days of
reduced food intake because of a minor febrile illness. Fle is treated successfully
with intravenous glucose_ After 13 hours of fasting when the child is well, his
serum glucose, 8.-hydroxybutyrate, arid free camitine concentrations decrease
markedly, and serum concentrations of long-twin acylcamitines Increase,
Triglycandas containing only medium-chain fatty acids are fed, and the serurri13-
hydroxybulyrate concentration increases to the reference range. Which of the
following disorders of fatty acid metabolism is the most likely diagnosis?
A) Carnitine-acylcarnitine translocase deficiency
B) Dietary carnitine deficiency
C) Fatty acyl CoA synthetase deficiency
D) Medium-chain acyl CoA dehydrogenase deficiency
E) Short-chain acyl CoA dehydrogenase deficiency

n An investigator is conducting a study of the efficacy of certain vitamins in helping to

prevent hear! disease in woman_ Eight thousand women, 45 years of age or older.
are enrolled in the study. Two thousand women receive vitamin C only, 2000
receive vitamin E only, 2000 receive both vitamins C and E, and 20D0 receive
a placebo. The investigator finds that the vitamins are ineffective in helping to
prevent heart disease. Which of the following best describes the study 'design
used in this clinical trial?
A) Crossover
B) Cross-sectional
C) Factorial
D) Nested
E) Simple

30 An 8-year-old girl is brought to the physician by her mother 1 hour after her cat
scratched her on her right arm_ The mother says that the patient developed
bright red streaks along her arm within minutes of being scratched. The
scratches were painful, and the paiient was crying when she showed the injury to
her mother. Examination of the right forearm shows the surface linear streaks
with intact skin, but there is no taloixi. The appearance of the red streaks most
likely indicated which of the following host responses to this injury?
A) Bacteria-generated capillary congestion
B) Complement-activated coagulation
C) Histamine-stimulated vasodilation
D) IgE-mediated eosinophil degranulation
E) Trauma-induced arteriolar hemorrhage
 Form 26

31 A 28-year-old woman, gravicla Para 2, comes to the physician to request an -elective

abortion 2 days after she received a positive home pregnancy test result_ I ler last
menstrual period was B weeks ago. Ultrasonagraphy shows a uterus consistent in
size with a s-week gestation. After counseling, she decides to undergo a
medication-induced abortion rather than a surgical abortion. An oral
medication is administered, arid she is Instructed to return to the office in 2
days to receive a second medication. The first drug administered most likely
belongs to which or the fallowing classes?
A) Human chorionic gonadotropin antibodies
B) Oxytocic
 Form 26

C) Progesterone antagonists
D) Prostaglandin synthesis inhibitors
E) Selective estrogen receptor modulators

32, A 3.5-year-old woman is brought to the emergency department

comatose after she sustained mu ILip le injuries in a motor vehicle
collision. During the next few days, she develops sepsis and respiratory
insufficiency, and then the
dies.. A photomicrograph
of her lungs obtained at
autopsy is shown. If this
patient had recovered,
regeneration of Ihe
alveofar epithelium would g, 1

have been accomplished .• ' •Y•

vta hyperplasia of which of · •• •••
·
1
the following call types? o
1 )

A) Alveolar capillary
edothelial cell
B) Alveolar macrophage
„
C) Chondrocyte .
· •
D) Ciliated columnar „. .
·
tir
,
epithelial cell . 7.
i •

E) Club cell " V

F) Globlet cell · 14 •-r •

A
.

G) Kutchitsky cell •
•
. •
H) Squamous epithelitla 7
_ • _..
Li •

cell _

I) Type I pneumocyte
J) Type II pneumocyte

33. A researcher in a pharmaceutical company designs a new protease inhibitor that

inhibits replication of HIV in T lymphocytes in culture in subseguent assays, which of
the following findings is most likely to indicate that the compound Is working
soecrficath, as a protease inhibitor?
A) The drug prevents integration of proviral DNA into the host genome
B) The RNA is partially reverse transcribed into proviral DNA
C) There is a lack of a mature core
D) Transcription from the HIV promoter is blocked
E) The virus does not bind to CD4 in the presence of the drug
 Form 26

34. A 1-year-old troy is brought to the emergency department because of a t3-day

history of temperatures to 39.4°C (103°Fj and a 2-day history of a severe diaper
rash and swelling of his hands and feet. His temperature is now 39.46C (1(13'F). A
photograph of the gendal area is shown. The face and lips appear red and the
conjunctivae appear injected. There is bilateral cervical tymphadenopathy. The
lungs are clear to auscultation. Cardiac examination shows an S, gallop with no
murmur. There is edema and erythema of the hands and Feel. Which of the
following pathologic findings is most likely in &Is patient?
 Form 26

A) Acute arteritis with aneurysms in coronary arteries

B) Epidermal hyperplasia with epidermal microabscesses and parakeratosis
C) Granulomas with caseous necrosis in cervical lymph nodes
D) Grandulomatous arteritis in cervical and temporal arteries
E) Paracortical lymphoid hyperplasia with eosinophilic intranuclear inclusion
in perihilar lymph nodes

35. A healthy 21-year-old woman is concerned that her son will develop a familial neurologic
disorder. Her older brother died at the age of 45 years after
developing restlessness, forgetfulness, incoordination, altered handwriting
and speech, and subsequently, chorea. Autopsy showed atrophy of Ihe basal
ganglia. Their mothe4 died al the age of 55 years of a similar disorder. Which of
the following best approximates the risk of this woman's son for developing the
disorder?
A) Essentially zero
B) 25%
C) 33%
D) 50%
E) 100%

M. A 55-year- Id men comes to this physician because of a 2-morph history of

hoarseness and difficulty swallowing. Ha underwent an operation to reseal a lobe
of his lung because of lung cancer 1 year ago. Physical examination snows penis
of the keit eyeed end mosis or the lei pupil. There is diminished flushing end
sweating on the left half of the 'Lace. This Patient moll likely has disordered
funclion ei neurons al which of kr, ralioAvig labeled lo-veons in the Rhetopraph or
a cress section of the spinal cord?

A) B) C) D) E) F)

37. A healthy 28-year-old woman participates in an exercise study. Several

physiologic variables are measured as she runs on a treadmill. The ambient
room temperature is 75°F. She reaches a steady state that increases her
oxygen consumption threakkl. She continues to exercise at that level for 29
minutes. During the first 5 minutes of exercise, the vascular resistance of
which of the following is likely to show the greatest increase from resting values
in this volunteer?
A) Coronary
B) Cutaneous
C) Exercising muscle
D) Pulmonary
E) Splanchnic
F) Systemic

38 A 31-year-old woman is brought to the emergency department by her husband

 Form 26

because of difficulty breathing and severe muscle weakness for 10 minutes_ She
has a 3-year history of myasbhenia gravis treated with neostigrnine. The husband
reports that she doubled her dosage 2 days ago because she was feeling
extraordinarily weak, but her weakness has increased since then_ Which of the
following events is the most likely cause of the increased muscle weakness in this
patient?
A) Autoimmune hyperactivation of nicotinic receptors
B) Autoimmune inactivation of muscarinic receptors
 Form 26

C) Desensitization of nicotinic receptors

D) Excessive degradation of acetylcholine
E) Hypersensitization of muscarinic receptors
F) Insufficient release of acetylcholine

39 A 62-year-old man with hypertension comes to the physician because of a 10-day

history of fatigue and shortness of breath. His temperature is 37.4°C (99_4°F),
pulse is 10.21min, respirations ate 18/min, and blood pressure is 110170 mm Hg.
Pulmonary examination shows diffusely decreased breath sounds and a prolonged
expiratory phase. Cardiac examination shows distant heart sounds. There is 1+
pretibial edema of the lower extremities. Pulmonary function testing shows:
FEV, 65% of predicted
FVC 90% of predicted
FEVJFVC 60% of predicted
Which of the following is the most likely diagnosis?
A) Cardiac tamponade
B) Chronic obstructive pulmonary disease
C) Congestive heart failure
D) Mitral stenosis
E) Pleural effusion
F) sarcoidosis

40. A55-year-old man has a cough. hemoptysis, and dyspnea. He has smoked 2 packs
of cigarettes daily for the past 30 years. Examination shows bilateral conjunctival
edema, distention of sublingual veins, and edema of the upper extremities. Which
of the following additional findings is most likely to be present on examination?
A) Bisferiens carotid pulsation
B) Increased jugular venous pressure
C) Pansystolic apical murmur
D) S3
E) S4

41. A study is conducted to assess the prevalence and incidence of obesity in a group
of middle-aged men. A total of 904 men between Ehe ages of 40 and 50 years are
chosen to participate, The table shoves the number of participants at baseline and
at Me follow-up study 5 years later for each POI range.
Number of Participants
M I (kgitri
<25
Baseline 5 Years Later
Normal ( } 300 225
Overweight {between 25 and 30) 500 525
Obese 00) 100 150
The prevalence of obesity in (his study population afler 5 years is which of the
following?
A) 50/100
B) 50/500
C) 50/800
D) 50/900
E) 150/375
F) 150/525
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G) 150/750
H) 150/900
 Form 26

42. A 53-year-old man comes to the physician for a follow-up examination. He

began antibiotic therapy 1 month ago for acute bacterial pneumonia. At the time
of diagnosis, a chest x-ray showed patchy pneumonic consolidation and a 2.5-
cm peripheral nodular iesion in the right upper lobe. His symptoms have since
resolved, and an x-ray today shows absence of the pneumonic consolidation.
However, the lesion is still present. A PPD skin test is nonreactive. A wedge
resection is done by thoracascopy. Histologic examination of the resected
tissue shows a solid, well-circumscnbed nodule composed
predominantly of mature cartilage admixed with small amounts of fibrous
tissue and occasional clefts lined by benign respiratory epithelium. Which of
the following best describes this patient's pulmonary lesion?
A) Abscess
B) Adenoma
C) Choristoma
D) Hamartoma
E) Teratoma

43. A 40-year-old woman has had hyperoalcemia for 1 year and recently passed a
renal calculus. Serum parathyroid hormone and calcium concentrations are
increased, and serum phosphate concentration is decreased. Parathyroid
hormone most likely causes art increase in the serum calcium concentration by
which of the following mechanisms?
A) Decreased degradation of 25-hydroxycholecalciferol
B) Direct action on intestine to increase calcium absorption
C) Direct action on intestine to increase magnesium absorption
D) Increased synthesis of 25-hydroxycholecalciferol
E) Inhibition of calcitonin production
F) Stimulation of 1,24-dihydroxy cholecalciferol production

44. Which of the following best explains why deoxygenated blood can carry more
carbon *oxide for a given Pco2 than oxygenated blood?
A) Deoxyhemoglobin does not bind to 2,3-bisphosphoglycerate as efficiently as
oxyhemoglobin
B) Deoxyhemoglobin has a lower capacity to form carbamino compounds than
oxyhemoglobin
C) Deoxyhemoglobin has a lower pKa than oxyhemoglobin
D) Deoxyhemoglobin is a better buffer of hydrogen than oxyhemoglobin
E) Oxygen and carbon dioxide compete for the same binding site in
hemoglobin
F) Oxyhemoglobin binds nitric oxide with a higher affinity than
deoxyhemoglobin

45. A t7-year-old boy with chronic renal

i n i s u i t i o i e n c y L i n d e r g o e s a u n i l a t e r a l n e p h r e o t o m y. A
photograph of the resected kidney is shown, Which of the
following pathologic processes is most likely present in
the kidney?
 Form 26

A) Acute glomerulonephritis
B) Acute tubular necrosis
C) Angiomyolipoma
D) Autosomal recessive polycystic kidney disease
E) Fibromuscular dysplasia
F) Hydronephrosis
G) Nephroblastoma
H) Papillar necrosis
I) Renal vein thrombosis
J) Stag horn calculus
 Form 26

46. A25-year-old woman at 36 weeks' gestation undergoes an oxytabn stress test to

evaluate the integrity of the placental circulation. Based an the results, a full-scale
induction of labor with oxylocin is started. Treatment with oxylocin is most likely to
activate which of the following substances in this patient's uterine smooth muscle?
A) Adrenergic nerve terminals
B) Cholinergic nerve terminals
C) Ligand-gated calcium channels
D) Na-K ATPase
E) Voltage-gated chloride channels

47. A 73-year-old man with porymicrobial sepsis begins treatment with a variety of
antibiotics. including gentamicin (current dose indicated to table). Three days later,
serum gentamicin concentrations are 8.8 ugtmL (peak) and 2.5 pg/mL (trough).
Which of the following dose regimens is most appropriate for achieving a peak
serum gentamicin concentration between 4 and 10 pg/mL and a trough
concentration of less than 2 pg/mL?
Intravenous Time between Each Dose
Administration (mg) (Current = 8 hours)
A) (Current
60 = 80 mg) 6
B) 80 6
C) 80 12
D) 120 8
E) 120 12

48. In an experimental design evaluating assays for the bactericidal effect of

inflammatory cells, which of the following compounds is considered the most
elficie.ni in the killing of bacteria by neutrophils?
A) Bactericidal permeability increasing protein
B) Hypochlorite
C) Lactoferrin
D) Lysozyme
E) Major basic protein

49. An 80-year-old marl comes to the physician because of bleeding gums and bruises
under his skin. He lives by himself and follows a diet low in vegetables and fruits.
His prothrombin time is normal. Which of the following enzymes is most likely
compromised in this clinical scenario?
A) 2,3-Epoxide reductase
B) Glucose 6-phospahte dehydrogenase
C) Hexokinase
D) Methionine synthase
E) Prolyl hydroxylase
F) Pyruvate carboxylase
G)Pyruvate dehydrogenase

50 A 40-year-old woman has easy bruising and rnenorrhagia. Platelet count is

100,000/mm3. and bleeding time is prolonged. Factor VIII (antihernophilic factor)
concentration is decreased, and platelet adhesion to collagen is abnormal. VIThich
of the 'Viewing is the most likely diagnose
A) Hemophilia A
B) Hemophilia B
C) Immune Thrombocytopenic purpura
D) Ingestion of aspirin
 Form 26

E) Systemic lupus erythematosus

F) Thrombotic thrombocytopenic purpura
G)Von Willebrand disease