nbme 16

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1.

20 yo woman with 8 yr
hx of intermittent HA's,
flashing lights in right
visual field, f/by
unilateral THROBBING
headache with
NAUSEA, vomiting,
with menses

MIGRAINE HA-rmbr "POUND"-Pulsatile, One-day duration,

Unilateral, Nausea, Disabling.
pulsating pain with
N/photophobia/phonophobia/aura.
Avoid TYRAMINE-containing
products

2.

intense periorbital
pain, tears, rhinorrhea,
smoker, for 15 mins-3
hours

Repetitive brief HA',s Excruciating

periorbital pain with lacrimation
and rhinorrhia. may induce Horner
syndrome, mc in males/smoker,
band around head. Tx" inhaled
Oxygen, sumatriptan

3.

80 yo old woman
fracture of femur given
morphine, soon her
resp's are 6/min, has
PINPOINT pupils,
serum Cr is 1.8mg/dL,
best explan of
intoxication in pt?

morphine is metabolized to active

metabolites that accumulate, she is
having renal failure possibly,
PINPOINt suggests intoxication.

4.

child, with infection

that has sickle cell
anemia, given
prophylaxis with PCN,
what is the mcc?

streptococcus pneumoniae is the

mcc of sepsis in sickle cell patients
and splenectomy!

5.

bulimia nervosa
patient treatment?

cognitive behavioral therapy +

FLUOXETINE (ssri)

6.

stabbing pain noticed

after shaving, pain is
reproduced upon
touching lateral nasal
ala, nerve supplying
this region exits where
in the skull?

FORAMEN ROTUNDUM--V2-trigeminal neuralgia

chemotherapy regimen
for 55 yr old w non
hodgkin lymphoma is
vinblastine. normal
function of which cells
and tissues resistant to
this agent?

VENTRICULAR CARDIAC MUSCLE

CELLS---vinblastine attacks rapidly
dividing cells so since heart cells
don't divide, and is a PERMANENT
CELL 9neurons, skeletal, cardiac m,
Rbc's). all other cells divide.

child with 6 month

history of difficulty
walking and leg pain,
has mild atrophy of
LE''s, hammer toes,
high stepping gait,
cause?

absence of MYELIN SHEATHS, this is

charcot-marie tooth dx. hereditary
MOTOR & SENSORY neuropathy,
also see foot drop/scoliosis/high or
flat arches. defective prodcution of
proteins involved in stx/fxn of
periph nerves or myelin sheath

7.

8.

9.

HCM, spinocerebellar degeneration

specifically DC's (spinal ataxia),
kyphoscoliosis, DM, hammer toes

Friedreich ataxia-initial loss of

sensory (DRG),
with
accompanying
gait ataxia,
hammer toes, AR,
HCM(mc of death
and bulbar
dyxfunction,
unable to protect
airway),
impairment of
mit functioning

10.

loss of DTR's, vibratory sense,

proprioception, staggering gait, freq
falling, nystagmus, dysarthria, pes
cavus, HCM,

Friedreich ataxia

11.

dec frataxin, GAA repeats, similar to VIT

E deficiency,child 5-15 yo

friederich ataxia

12.

16 yo boy dives into shallow pool that is

3 feet deep, unable to move RIGHT
upper and lower extremities, where is
the lesion?

lesion is at the
lateral
corticospinal tract
(CST), if lesion in
the SC--always
motor deficit-IPSIlateral. so
here, RT sided
paresis due to
right side lesion.

13.

19 yr old girl withdrawn and isolated,

uninterest, very anxious and depressed
by listening to radio that only she can
hear. thinks about a government
scheme to control the psychic pain
people feel. she's disheveled and
malodorous. normal vital signs no
abnormalities. mentally she's
distracted. she has sad mood and
anxious, sad, blunted affect. best
therapy?

patient has
Schizophrenia-treat with
antipsychotic-risperidone

14.

previously healthy 52 yo F, 2 mo hx of
progressive difficulty swallowing,
double vision, and slurred speech.,
ptosis of the eyelids and waddling gait.
muscle strength shows fatigable
weakness of the neck, arms, hands, and
fingers. Repetitive nerve stimulation
shows a 25% decrease in muscle action
potentials in several muscles. Which of
the following mechanisms is the most
likely cause of this patients disease?

BINDING OF
AUTOAb to ACH
receptor BY AN
ANTIBODY-myasthenia
gravis

15.

PREV HEALTHY, young adult

male, hears voices in head for 2
men for the past 2 weeks, is
afraid of physician when seen

BRIEF, PSCYHOTOIC
DISORDER, usually lasts
<1 month, SUDDEN
onset,

16.

woman with progressive m.

wkness and difficulty walking for
3 months, loss of Patella and
achilles tendon reflexes, wkness
and DECREASED muscle bulk,
sensations of
joint/position/pain/temp are
normal. cause?

DEGENERATION OF
MOTORNEURONS OF
LUMBAR CORD---either
ALS or poliomyelitis,
patient is presenting
with LMN lesion,
desruction of Anterior
horn

sudden onset severe headache,

right pupil is 6mm, nonreactive
to light, impaired adduction,
nuchal rigidity, aneurysm to
what artery?

Pcom---posterior
communicating artery
rupture--The aneurysm
pressed on the
oculomotor nerve and
Trochlear Nerve. The
eye is blow bc the right
thing to be lost on
oculomotor compression
is parasympathetics
then the motor. The eye
can't adduct bc Superior
oblique helps with
adduction thats why its
difficult for people with
this paralysis to go down
stairs they can't look
medial and down.

17.

18.

21 yr old, 2 week hx of refractory

back pain from MVA, asks for
more opiods to manage pain,
phys exam shows no
abnormilites, correct response?

Determine which drugs

have been prescribed
for the patient in the
past, want to give a
nonjudgmental
response.

19.

65-yo F, 3mo hx of HA, wknss of

her arms, and left flank pain; wt
loss, Physical examination shows
weakness of the proximal upper
and lower extremity muscles.
There is augmentation of
strength with repetitive testing
of the deltoid muscles. An MRI of
the brain shows a single welldemarcated mass surrounded by
edema in the right frontal lobe. A
stereotactic biopsy specimen of
the lesion shows a malignant,
small blue cell neoplasm that
expresses citokeratin,
chromogranin, and
synaptophysin.

Pulmonary small cell

carcinoma metastatic to
the brain--50% of adult
brain cancers are mets,
and the augmentation
of muscle strength with
repeated testing
suggests lambert eaton,
so small cell lung cancer
metastasis

20.

female, motor vehicle accident,

symptoms of meningitis , spleen
removed?

Older asplenic
person with
meningitis --> knee
jerk streptococcus
pneumoniae

21.

breast cancer patient, develops

increased numbness and tingling of
hands and feet during chemotherapy
intervals, which drug caused it?

Vincristine-mechanism-microtubules for
axonal transport

22.

79 year old sustained hip fracture,

gardener, wine with dinner every
night, what would help to decrease
risk for additional fractures?

WALK DAILY

23.

76 year old lives in california, takes

beta blocker for HTN, painful
swelling of right big toe, drinks
homemade distilled liquor, textile
factory, what is the most likely
cause?

drinking from
home-distilled
liquor.--CHRONIC
ALCOHOL ABUSE--is
a risk factor for 2nd
gout

24.

8 year old with breast bud

development and few pubic hairs,
mothers asks about this, appropriate
response?

this is NORMAL
development-tanner stage II
(pubarche--pubic
hair appears),

25.

70 yo man, wife recently died,

difficulty sleeping/cries, enjoys
grandchildren visits/bowling. No
other depressive sx/suicidal
ideation.

schedule appts to
monitor patient;

26.

CF patient with weakness, numbness

and tingling for 3 wks, and difficulty
walking, not adherent to medication
for past 6 mo's, bilat wkness and dec
tendon reflexes in UE and LE, ataxic
gait, which vitamin is the cause?

VITAMIN E!!!!

27.

poliovirus lacks 5"mCAP, yet is still

translated? why?

no cap-->still
translated because
of PRESENCE OF
INTERNAL
RIBOSOME ENTRY
SITE--located in the
5'UTR (untranslated
region).

28.

G as subunit lacks GTPase activity in

the tumor, what is increased?

Adenylate cyclase!!! -G alpha s- uses

adenyl Cyclase as it's
messenger, gtp is
hydrolysed and rxn
stops,but as it's
mutated inc AC

29.

table shows
intermediates of
glycolytic pathways,
asks what would be
inhibited indirectly if
increased glucose
concentrations present

Glyceraldehyde-3-phosphate
dehydrogenase is the right one,
because 1,3-bisphosphoglycerate
and pyruvate are the only ones
<100% and are both downstream
the enzyme Glyceraldehyde-3phosphate dehydrogenase (in
glycolysis pathway). clearly drop
in glucose conc seen from fructose
1 6 bisphosphate to
glyceraldehyde 3 phosphate and
so on

37.

12 Year-old girl is brought to the

physician for a follow up
examination. Three months ago, she
sustained a complex fracture of the
left tibia, which required cast
immobilization. the Cast is
removed. Examination of the left
Calf Shows that it is smaller than the
right Calf. Which of the following
processes in this patient's myocytes
is the most likely cause of these
findings

protein degradation--Polyubiquitination

30.

hypoglycemia, lethargy,
diarrhea of 18 month
old, Increased
DICARBOXYLIC ACIDS,
given medium chain
TG's for 6 months after
he became responsive
to IV tx, what is
deficient?

LONG CHAIN ACYL-CoA DH

deficiency---LCAD!!!

38.

strep pneumoniae capsular type are

investigated, after adding Dnase, no
colonies of S.pneumonia expressing
the capsule are isolated, cause?

natural
TRANSFORMATIONrmbr ADDITION OF
Dnase

39.

31.

low blood glucose,

hypoketotic, m. biopsy
shows intracellular
fatty-acyl carnities, mc
sx's present are
N/V/seizures

MCAD deficiency

62-year-old man with unstable

angina pectoris undergoes coronary
catheterization. In order to visualize
the anterior interventricular (left
anterior descending) artery, the tip
of the angiographic catheter would
need to be placed into the orifice of
which of the following arteries

32.

hypoketotic,
hypoglycemic +
accumulation of 16C's
FA (eg. palmitate)

LONG chain acyl-coa DH

deficienccy

LCA. The LAD is a

branch of the LCA, so
to view the LAD you
would need to
advance the catheter
to its orifice on the
LCA. If you advance
further, you would
be in the L circumflex
since the LCA
bifurcates into the
LAD and L
circumflex.

40.

hypotonia,
hypoketotic,
hypoglycemia,
myoglobinuria, muscle
weakness,

Carnitine deficiency--CAT-1
deficiency

woman takes Fish oil AND a

SUPPLEMENT to treat her
dyslipidemia, mechanism of action?

antagonizes VLDL
cholesterol secretion-NIACIN

41.

34.

symptoms/presentation
similar to mcardles,
except they occur after
PROLONGED excercise

MCAD deficiency

54y F admitted with acute MI, at

which point there were no
murmurs or signs of heart failure;
but 2 days later, she has acute SOB
and sweating; HR 100, RR 24, BP
160/98. Crackles bilaterally,
+murmur.

35.

location of Acyl
transferase? CAS-II?

acyl-transferase in CYTOSOL, CASII in MITochondria

36.

Type 1 DM, becomes

hypoglycemic, loses
consciousness without
warning, how do you
treat?

GLUCAGON, stimulates hepatic

glucose release

So SOB and Crackles

must be fluid backing
up into the lung...
therefore left sided
heart failure -> the
concept is that
ischemia of the
papillary muscles
lead to Mitral insuff. > murmur is
holosystolic high
pitched loudest at
apex

33.

42.

what increases pulmonary

lymph

IV infusion of 0.9% normal

saline--It will increase the
hydrostatic pressure and
decrease the plasma oncotic
pressure, both of which will
lead to fluid extravasation
and thus lymph flow (to get it
back into circulation.

43.

78 y/o man. fever, chills,

sob. Urinary catheterization
for prostatic obstruction.
Soft S1, normal S2. Diastolic
mumur in 2nd left
intercostal accentuated
when leans forward.

Bacterial endocarditis with

Enterococcus. Recall that
Enterococcus faecalis is
associated with endocarditis
post-GU procedures

9 month old, severe

respiratory distress dies,
autopsy shows VS and
Persistent truncus
arteriosus, what cells were
absent during development?

Neural crest cells form the

aorticopulmonary septum
and endocardial cushions.

45.

elderly with HBV negative

PAN, has proximal muscle
weakness and myalgia,
biopsy shows what?

PAN shows transmural

inflamm w/ fibrinoid necrosis,
or SEGMENTAL ISCHEMIC
NECROSIS

46.

Thrombosis of the SMA.

Ischemia caused by
thrombosis is most likely to
affect directly which of the
following structures?

JEJUNUM

2 hr episode of loss of vision

in his right eye 2 days ago.
He underwent a left femoral
popliteal bypass 3 months
ago for peripheral vascular
diseases. Funduscopic exam
shows cholesterol emboli.
Most likely cause?

Right ophthalmic. The central

retinal artery is a branch of
the ophthalmic artery.

60 yr old w no history of
bleeding has coagulation
testing prior to coronary
artery bypass grafting. His
prothrombin time is 11.5 sec
(INR=1.0) <-whats inr?
and activated partial
thromboplastin time is 160
secs. what inflamm resp is
abnormal?

Kallikrein is an activator of the

intrinsic coagulations cascade.
Deficiency of kallikrein leads
to defective intrinsic pathway
which is measured with PTT (
is increased in dysfunction of
the intrinsic pathway as in
the clinical vignette)

44.

47.

48.

49.

28. 27 y/o with hodgkins gets bone

marrow transplant. two weeks after
transplant, develops an
erythematous, maculopapular rash,
diarrhea, and elevated serum liver
enzymes and bilirubin. no evidence
of infection or drug reaction found.
what's the mechanism of these
symptoms? It's graft vs host so
answer should be c right?

It's graft vs host. The

grafted cells are
having an immune
response against the
transplant recipient.
This is why she's
presenting with
systemic symptoms
and not those
confined to the
transplanted
material.

50.

6 month boy history of recurrent

upper and lower resp infections, has
hypocalcemia and trted w calcium
supplementation. He went
operative repair of coarctation of
aorta in newborn period. He has
broad nasal bridge and dysplastic
pinnae. cause of infections?

t-lymphocyte
deficiency.
Parathyroids are
gone and thymus is
gone.

51.

woman delivers baby with

dysmorphic features and numerous
organ anomalies, mother had
multiple spontaneous abortions,
first liveborn child, what is the
cause

unbalanced
chromosomal
arrangement

52.

cut right food after cleaning barn ,

wbc is 57,000, erythema at the right
lower calf extremity, edema and
tenderness, wat describes the
response to patient's injury

Leukomoid reaction

53.

24 year old woman 8 year history of

seizure disorder that is refractory to
medication. Physical examination
shows flesh colored papules in the
nasolabial folds accompanied by
hypopigmented macules. An MRI of
the brain shows subependymal
nodules. Which of the following is
the most likely cause of these
findings?

TUBEROUS
SCLEROSIS

54.

drug injection with angiotensin II,

table shows drug x, and drug x + ang
II, what is drug x?

they inject both ATII

and Drug X. even if
drug X was an ACE-I,
you are bypassing
the block by putting
ATII directly into the
bloodstream. Hence,
partial agonist
because the site of
action is the ATII
receptor.

55.

56.

in a cough, what happens to

the vocal cords while
swallowing, after irritation,
while coughing?
is close, close and open?

close (while swallowing), close

(immed after laryngeal irrit)
and open (while coughing)

the difference in isoflurane

and nitrous oxide of 2 groups
- anyone know the answer to
that? Grp X - 1.5XMAC
isoflurane, Grp Y - .75xMAC
each of isoflurance and
nitrous oxide.

Blood-gas partition
coefficient--measure of the
solubility of the inhalation
anesthetic in the blood
relative to its solubility in the
inspired air. Circulating
blood provides the means of
anesthetic delivery to the
brain and the partial
pressure determines the
rate of transfer into the CNS.
The solubility of an agent in
blood determines how
rapidly the partial pressure
rises in the blood

57.

non selective alpha and beta

antagonist?

Labetolol is an alpha 1 and

beta antagonist, other is
Carvedilol

58.

A yr old boy is brought to the

physician for developmental
delay. There is a h/o hearing
loss in her mother and
delayed speech in his older
sister. His maternal uncle
had stroke like episodes at
25 yrs of age. PE shows
opthalmoplegia and
hypotonia. His serum LA
conc is increased. Which of
the following best explains
the findings in this family

MELAS ( mitochondrial
encephalomyopathy, Lactic
acidosis and stroke like
episodes) as in this clinical
vignette are mitochondrial
inherited. Variable
expression in mitochondrial
inherited disease is called
heteroplasmy.

To determine whether
children of workers in a lead
foundry sustain neurological
damage from exposure to
dust on their parent's
clothing, a test for motor
skills was given to 30 first
graders whose parents has
worked at the foundry for 5
years or longer and to 30
controls. Which of the
following groups of children
would be the proper control
group for this study

first graders who's parents

never worked at the foundry

59.

60.

61.

During experimental study of

oxygen consumption in the
kideny, experimental animals are
ventilated with a 100% nitrogen.
Cells from which of the following
areas of the kindey are most
likely to show the first sign of
anoxic injury?
MOst susceptible site of hypoxia

When i hear ischemia

immediately comming
thing about TUBULAR

48 yo. man is referred for

evaluation of possible
hypertension. ON the basis of ten
measurements , the patient;s
average diastolic blood pressure
is 113 mm Hg, and the standard
deviation is 8mm Hg. IF four
rather than ten measurements of
the mean blood pressure are
made, Which of the following is
the expected impact on the size
of the 95% condifence interval
about the mean blood pressure?

Increase in width. The

range is already pretty
high but the more
measurements you
make the narrower it
gets. The fewer
measurements you take
the wider the range
becomes. If you
measure 1000 times...
the mean will become
something between 110120, cause there will be
less very high/very low
values

Acute tubular necrosis

can be caused by
ischemic or nephrotic
injury
Ischemic secondary to
decreased renal blood
flow hypotension, shock,
sepsis, hemorrhage,
CHF, Results in death of
tubular cells that may
slough into tubular
lumen proximal tubule
and thick ascending
limb are highly
susceptible to injury.

If you measure 4 times:

the range increases
cause the values that
are out of range have a
higher impact on the
mean and the deviation
62.

male with palpable hard nodule

on prostate has an increased pSA.
Fine needle biopsy :
adenocarcinoma
during radical prostatectomy
which of the structures is at
greatest risk for injury?

pelvic parasympathetic
PLEXUS, this is why
these pts are at great
risk of impotence

63.

need to strengthen infraspinatus

and teres minor muslces, what
action needs to be peformed
against resistence that will
benefit pt?

lateral (external)
rotation

66-year-old man has a surgical excision of a

brain mass; a photomicrograph of excised
tissue is shown. He has smoked 1 pack of
cigarettes daily for the past 50 years. His
blood pressure is 130/90 mm Hg. Laboratory
studies show polycythemia, hypercalcemia,
and microscopic hematuria.
Immunostaining of the tissue is positive for
epithelial membrane antigen and negative
for carcinoembryonic antigen. Which of the
following is the most likely site of the
primary neoplasm?

KIDNEY

65.

48-year-old woman comes to the physician

because of a 6-month history of irregular
menstrual periods and hot flashes. Her last
menstrual period was 35 days ago, and she
had scant blood flow. Menses had
previously occurred at regular 28-day
intervals. Physical examination shows mild
thinning of the vaginal tissue.

labs? premenopausal-increased
FSH and LH,
decreased
estrogen.

66.

44-year-old man comes to the physician

because of a 2-month history of abdominal
pain and diarrhea. The pain is temporarily
relieved after eating and by the use of
antacids. Physical examination shows
epigastric tenderness. Laboratory studies
show a serum gastrin concentration of 500
pg/mL (N=50-100) and gastric acid secretion
of 80 mEq/h (N=6-40). Which of the
following is the most definitive treatment
at this time to decrease this patient's risk
for complications?

Surgical
removal of
the
suspected
tumor

64.

67.

A 5-year-old boy with mental retardation

is grossly obese and has facial features of
Prader-Willi syndrome (PWS). Karyotyping
and fluorescent in situ hybridization
studies do not show deletion in the usual
site on chromosome 15. Which of the
following findings is most likely to
confirm PWS in this child?

A ) Deletion in
the short arm
of
chromosome
15
B ) Duplication
within
chromosome
15
C ) Large
trinucleotide
repeat
expansion in
the PWS area
of
chromosome
15
D ) Maternal
origin of both
chromosomes
15
E)
Translocation
in the short
arm of
chromosome
15

68.

A 1-year-old boy is brought to the

physician for a well-child examination.
The mother is concerned because her son's
fine, pale hair has not changed color since
birth. His eyes are blue. During
ophthalmologic examination, the patient
turns away from the flashlight and starts
crying. Which of the following is the most
likely cause of the pale skin color in this
patient?

INABILITY TO
PRODUCE
MELANIN

69.

newborn develops resp distress. p/e shows

cyanosis, decreased breath sounds. chest
xray while pt is supine shows multiple
cystic appearing areas on the left and
decreased aeration on the right. what is
the diagnosis

Congenital
Diaphragmatic
Hernia

70.

38 y/o woman seems to have a

gastrinoma (serum gastrin
concentration is 2000 (normal <100).
She also has multiple lipomas and
two large non bleeding ulcers. she is
started on a proton pump inhibitor.
what measurement should you
follow

CALCIUM--work up
every pt with a
gastrinoma for
MEN1, which will
include serum
calcium
(parathyroid
tumors?), PTH, and
pituitary hormones.

71.

Liver showing centrilobular pallor

and swelling of hepatocytes and
kidneys showing proximal
convoluted epithelial cells. Which is
the mechanism?

Decreased function
of Na/K ATPase,
because there is
insufficient ATP due
to decreased
oxidative
phosphorylation

72.

26 yr old dude has tenesmus and

bloody diarrhea. Apppearance of
intestine from rectum to mid
ascending colon shown in pic.
Terminal ileum is normal(so we know
its not chrons!) biopsy shows micro
abscesses within the crypts and
depletion of mucus from goblet cells?

ULCERATIVE
COLITIS

54 yr old man w/ aneurysm in distal

portion of his abdominal aorta.
Estimated cross-sectional area of the
aneurysm is 2 cm^2 and the mean
velocity of blood flow thru the
aneurysm is 20cm/sec. which of the
following best represents the flow
rate in L/min thru the aneurysm?

2.4, Flow = Area x

Velocity = (2 cm^2) x
(20 cm/sec) = 40
cm^3/sec = 40
mL/sec
Then convert to
L/min

55 yr old dude w contipation taking

meds for chronic persistent cough n
sinus congestion. which ingredient in
this med most likely cause of this
patients new symptom?
dextromethorphan right

dextromethorphan,
codein analog that
is an opiate taht can
cause constipation

73.

74.

75.

a previously healthy 27-year-old

woman comes to physician because
of a 3 week history of episodes of left
sided chest pain and tenderness. the
pain radiates to the back and is
exacerbated when she reaches over
her head or behind her back. she has
not had shortness of breath,
sweating, or light-headedness. her
temperature is 37.1 pulse is 92/min,
respirations are 14/min, and blood
pressure is 130/86 mm Hg.
Cardiopulmonary examination
shows no abnormalities.
examination shows tenderness to
palpation 2 cm lateral to the midline
and 10 cm below the clavicle on the
left

COSTOCHONDRITIS

76.

23 yr old diagnosed w sjoren

syndrome has burning pain in her
toes for past month. rates pain 3 on
10 point scale. she uses capsaicin
cream for pain which produces
partial relief. Neuro exam shows
decreased perception of
temperature over feet bilaterally.
Sensation to vibration,
proprioception, reflexes, muscle
strength, muscle tone, and bulk are
normal. Which neurotransmitter
mediating pain

substance P

77.

15 yr old boy, 6'3 and weights 165 lb,

BMI 21 kg, pulse is 85/min and
bounding/ bp is 110/40. dislocation
of right lens. Pectus excavatum.
grade 3/6 decrescendo diastolic
murmur heard at aortic area. Wide
mediastinum. Genetic defect in what

FIBRILLIN--marfans

78.

28 yr old lady w/ 1 month history of

pelvic pain that has become
increasingly severe during the past
week. Her mensrual flow has been
unusually heavy during her last three
menstrual periods. Menses have
occurred at 24-28 day intervals since
menarche at the age of 12 years. Phys
exam shows a palpable mass in the
left adnexa. Serum studies show an
increased CA 125 concentration.
Vaginal ultrasonography shows an 8
cm mass in the left ovary. During
surgical removal of the ovary, which
of the following structures passing
inferior to the ovary must be
protected

URETERS--water
under the bridge!!!!!!

79.

he question with diabetic pt

taking hydrochlorothiazide
whose BP doesn't go down, and
what additional drug to use. I
would also use an ACE or an ARB,
but in this case the pt has renal
dz (diabetes and
microalbuminuria)

According to FA, ist line

for HTN and diabetes is
ACEi/ARB, then Ca
channel blockers, then
diuretics, beta blockers
and alpha blockers

80.

lady stung by bee 30 minutes ago

She develops urticarial lesion. 6
hours later the area becomes
underrated and firm. What
explains the induration at the
site of the sting?

s"influx of macrophages
producing IL1, IL6, TNF
alpha"--. decrease in
expression of adhesion
molecules on vascular
endothelial cells,
decrease in serum C
reactive protein
concentration, influx of
macrophages producing
IL1, IL6, and TNF alpha,
Lysis of endothelial cells
by the alternative
compliment pathway,
vasoconstriction. first
part of the reaction is
mediated by histamine.
Six hours later, your
body essentially has a
foreign body reaction to
the venom, which is why
macrophages

81.

18 yr old dude w acute

lymphblastic leukemia has 3 day
history of intermittent fever and
left sided chest pain. He's in 5th
week of induction
chemotherapy consisting of
asparaginase, daunorubicin,
prednisone, and vincristine. His
absolute neutrophil count has
been less than 500/mm for the
past month. Temp is 102 F and
he has dullness to percussion
and decreased breath sounds on
the left side. Chest X-ray shows a
left lower lobe infiltrate and a
moderate pleural effusion on
the left. Photo of pas-stain of
pleural fluid shown in the pic of
the question. Whats the
appropriate therapy?

amphoterecin B

82.

23 y/o difficulty maintaining

erection b/c of MVA that damaged
thoracic spinal cord. He can get
erection if stimulated physically -->
the reflex arc involved between
what nerve and the sacral
parasympathetic nerves

best explanation for

the intact spinal
reflex arc btwn sacral
parasympathetic
nerves and
PUDENDAL nerves

83.

Patient undergoes radical

prostatectomy. Which of following
is at risk of injury?

...

84.

25 y/o woman w/ history of irregular

menstrual periods, deep voice,
hirsutism, acne. Serum studies of
insulin, testosterone, and lutenizing
hormone show what?

LH:FSH ration >2.0,

insulin increased,
glucose increased

85.

Retired boxer that gets mask like

face, rigid movements, shuffling
gait, resting tremor. What is the
cause of this?

It was neuronal
degeneration from
chronic traumatic
encephalitis (since he
was a pro boxer, he
got hit in the head a
bunch of times)

86.

AA man with CHF and ejection

fraction of 30%. What drug is
contraindicated?

sildenafil

87.

what changes occur after you return

to sea level and have greater oxygen
delivery?

increased HCT

88.

what's wrong with occult blood for

colon cancer screening?

NOT SENSITIVE

89.

Surgical repair of AAA in man with

horseshoe kidney--what
complicates this surgery

anamolous origins of
multiple renal
arteries to each
kidney

90.

Problem trafficking vesicles to Golgi

increased RER
because products
back up

91.

central cath with 4-micrometer

elliptical, purple, budding
organisms and the blood agar plate
next to it, budding cells

candida

92.

Young man with left flank pain

radiating to groin; tenderness in left
flank and LLQ abdomen; mildly
hypoactive bowel sounds and
negative occult blood in stool

ureteral calculous is
causing the problem

93.

Middle aged man with 2 months of

diarrhea and abd pain that's relieved
temporarily with eating and
antacids. Serum gastrin is 500
(normal 100) and gastric acid
secretion is 80 (6-40). Most definitive
treatment to decrease risk of
complications?

remove the
gastrinoma

94.

chronic pyelonephritis

blunted calyces with

scarring

95.

killing of gram positive diploccoi,

which of the following enzymes is
going to initiate intracellular
killing?

NADPH OXIDASE

42 year old woman undergoes

biopsy of suspicious calcifications
seen on routine mammograms.
Light microscopy shows a poorly
demarcated region consisting of
poorly cohesive cells growing in
sheets. The nucleus to cytoplasmic
ratio approaches 1.1, and prominent
nucleoli are observed there is
microscopic evidence of invasion
into stromal tissues. She has no
adenopathy ct scans show no
evidence of hepatic pulmonary or
bone metastases. These findings are
most consistent with which of the
following

high grade, low

stage, since she has
no metastasis and no
lymphadenopathy.
remember the TNM;
tumor size, lymph
nodes and
metastasis

97.

Spinal needle goes posteriorly

between l3 and l4 for anasthesia.
what ligament will be traversed to
reach the canal?

ligamentum flavum

98.

effects of smoking on pulmonary

defense and maintenance
mechanisms. For 1 week, normal
male rats are exposed to levels of
cigarette smoke comparable to
those encountered by humans who
smoke cigarettes. Results of
pulmonary testing are compared
with baseline levels obtained the
week before the smoke exposure.

Mucus Production
and Secretion up

96.

in response to
cigarette smoke,
combustible fumes
and etc mucus
production always
increases. Just think
of the reid index in
chronic bronchitis,
the submucosal
mucous glands
increase in size in
response to cigarette
smoke because they
are secreting more
mucous in order to
clear all those nasty
inhaled carcinogens

99.

Alveolar Macrophage Function up

the inhaled
carcinogens
from cigarette
smoke
damage the
lining of the
alveoli. in
response to
this alveolar
macrophages
aggregate to
clear up the
mess

100.

Activity of Airway Cilia down

this one
should be
easy.
carcinogens
in cigarette
smoke
destroy cilia
cells lining the
airway.

101.

3 yo alcoholic, homeless man comes to ed

by police. appears cachectic, fever.
clubbing of fingers, breath smells, missing
teeth, numerous cavities. has increased
fremitus, dullness to percussion, and
tubular breath sounds in right lower lung.
leukocyte count 11.4k. sputum grows
purulence, gram + cocci in chains, and
gram - bacilli. x ray shows cavitation in
right lower lung lobe with surrounding
infiltrate. sputum will likely grow which
of the following?

Normal oral
flora.
Homeless
person + poor
dentition +
lung infection
= aspiration
pneumonia.
Aspiration
involves
infection with
normal oral
flora.

102.

Sigmoid colon mass revealing

adenocarcinoma. Which LNs would it
mets to?

IMA

103.

a 36 yr old man comes to doc cuz of a 2 hr

history of pain and swelling of right calf.
He has no shortness of breath or chest
pain. he completed an 18 hr flight trip.
Theres an occlusion of right femoral vein.
Drug with which mech of action should
be used?

antithromin
III activation

104.

38 yr old lady undergoes choleystectomy

w anesthesia. She awakens
postoperatively, is nauseated, and
vomites three times in 20 minutes. Whats
the treatment for nausea and vomiting in
this patient

Ondansetron.
Good for
post-chemo
AND postsurgical.

105.

106.

5 yr old boy comes to doc cuz of 8 mo

history of recurrent middle ear and upper
resp infections. history of impaired motor
and cognitive function. he has
hepatosplenomegaly. cultured skin
fibroblasts shows inclusion bodies and
deficiency in activity of nacetylglocosamine 1 phosphtransferase.
cell secret large amount of acid hyrolases
in culture medium. these enzymes are
unable to target which organelle? is it
lysosomes?

lysosomes--i
cell disease

a 31 yr old woman has invasive squam cell

carcinoma of cervix. Biopsy of cervix shows
tumor cells express hpv, type 16 antigens.
which of the following cells recognizes and
kills these virus infected tumor cells?

T
lymphocytes.
Tumor cells
are killed by
CD8+ T cells
and NK cells;
better
answer
between the
two (if you're
unlucky) is
CD8+ T cells

107.

sharp intermittent CP starts suddenly,

decreased by leaning forward,
Auscultation of the chest shows a harsh
scratchy sound that is pressent in both
systole and diastole

pericarditis

108.

cute myelocytic leukemia receives high

dose cyclophosphamide in preparation for
hematopoietic stem cell transplantation.
the administration of which of the
following is most likely to decrease the
toxicity from this chemotherapy regimen?

MESNA

52 old man w 3 week history of increased

thirst and urinary freq. had 10 lb weight
loss. has hypertension and hyperlipedemia
trted w pravastatin and matoprolol. he's
5'11, mildly ill, weights 240lb. vmi is 34
kg/m. Pulse is 94/ min , respiratoins are
16/min and bp is 130/80. exam shows no
other abnormalities. Whats increased in
this patient?

fasting
serum
glucose
(patient has
metabolic
syndrome)

ady needs advice on losing weight. she's

been taking thyroxine to lose weight. her
thyroid function is normal. Findings on
histopathologic exam of thyroid gland?

ATROPHY,
By taking
thyroxine,
she'll cause
TSH levels to
go down,
which will
reduce
thyroid
stimulation.

109.

110.

111.

28 yr old lady has 1 week history of

fever/chills. she had 10 lb weight loss
during that time. 5 year history of
chronic sinusitis and gone thru
operations for sinus obstruction.
appears mildly distressed. she's 5'5
and weights 110. vmi 18 and
temperature is 102F. diminished
nasal septa. chest X-ray w multiple
pulmonary nodules. antibodies
against proteinase 3

wegener's
granulamoutsosis

112.

lady burned herself while cooking for

past few months. loss of pain and
temp sensation in both upper
extremities and portion of trunk
from clavicles to below the nipples.
touch, vibratory, proprioception are
normal. wasting of small muscles of
hand. mdi of head and spine will
show what?

Syrinx: She has a

cape-like
distribution of
pure sensory
impairment.

113.

newborn male tachypneic and

hypoxemic. what altered structure
changes in type 2 pbeumocytes is
most likely cause of patients
condition?

Decreased lamellar
bodies. Lamellar
bodies are
secretory
organelles. The
type II
pneumocytes
make surfactant,
and this infant has
respiratory
distress syndrome,
so they're not
secreting as much

114.

30 yr old w hemoptysis, dyspnea,

weakness, hematuria. bronchoscopy
shows diffuse plum hemorrhages
bilaterally. he has focal glomerular
necrosis w crescent formation and
linear deposition of IgG and c3 in
glomerular capillary loops. which of
the following is responsible for his
disease?

Crescentic =>
RPGN. Often
caused by
goodpasture's,
which is Abs
against basement
membrane. It
often has lung
involvement as
well.

115.

3 lb female born w rough grade 2/6

continuous machine like murmur
along left sternal border, increased
precordial activity and bounding
peripheral pulses. treatment will
inhibit activity of which of the
following enzymes?

Indomethacin
closes the PDA by
inhibiting
production of
PGE2, which is an
arachidonic
derivative and
therefore made by
Cyclooxygenase
(COX). Therefore,
COX is the answer

116.

35 y/o man with burning

abdominal pain after meals.
epigastric tenderness and
abdominal CT shows
pancreatic mass.
Immunohistochemical
labeling of neoplastic cell has
antibodies against?

Gastrin. They wanted

your thought process to
be: Gastritis + pancreatic
mass = Zollinger-Ellison -->
Neoplastic cells have an
abundance of gastrin.

122.

20 yo severe dysuria, painful vulvar rash for

2 days, shows vesicular lesions with
erythematous base on right vulva

(HSV) genital
herpes-painful,
multiple,
penile, vulvar
or cervical
vesicles and
ulcers, other
sx's:
F/HA/myalgia

117.

75 yo woman with osteopenia

on a follow-up examination.
Occasional acetaminophen,
supplemental Calcium and vit.
D. No smoking, drinking and
walks 3 miles daily,
BMI 24 kg/m2. Stable wight for
10 years, Pulse-68/min, BP124/72 mm Hg. Physical shows
no problem.
Labs given to compare Today
and 10 years ago:
Serum creatinine 1.o 1.0
Urine creatinine excretion
1000mg/24h 1200 mg/24h
creatinine clearance 64
mL/min 83 mL/min
Which is the most like cause of
decreased creatinine clearance
rate?

NORMAL AGING.
decreased creatinine
clearance over 10 years is
just a loss of nephrons
with age, which has been
compensated for by
angiotensin and
aldosterone to prevent
serum creatinine from
rising overall.

123.

70-year-old woman is brought to the

emergency department by her husband 45
minutes after he found her unresponsive
on the living room floor. She has
generalized anxiety disorder treated with
diazepam. Her husband said she recently
began taking an over-the-counter
medication for heartburn. She is
obtunded and responds only to painful
stimuli. An interaction with which of the
following drugs is the most likely cause of
her condition

CIMETIDINE

124.

3-year-old boy is brought to the physician

by his parents because of a 1-week history
of nonproductive cough, wheezing, and
nausea. Coarse bilateral crackles are heard
on auscultation of the chest. Physical
examination shows no other
abnormalities. Stool culture shows a 1.6cm roundworm larva. A chest x-ray shows
bilateral infiltrates

feces--ascaris
lumbroicodes

118.

Bronchial epethelial defect in

cystic fibrosis

Protein structure (it's a

CHANNEL not a receptor)

119.

38 y/o woman seems to have a

gastrinoma (serum gastrin
concentration is 2000 (normal
<100). She also has multiple
lipomas and two large non
bleeding ulcers. she is started
on a proton pump inhibitor.
what measurement should you
follow?

calcium
125.

6-week-old boy is brought to the physician

for a follow-up examination after newborn
hemoglobin electrophoresis showed
homozygosity for hemoglobin S. Daily
treatment with penicillin is
recommended. This treatment will most
likely decrease this patient's risk for
infection with which organism

streptococcus
pneumoniae

120.

64 y/o man with abnormal

densities in hilar region.
Biopsy shows round cells with
little cytoplasm that are 2x's
size of lymphocytes. Which
abnormality would you find?

hyponatremia, I think,
because of SIADH from a
small cell carcinoma

126.

67 yr old lady hip replacement operation

has shortness of breath and pain of back
with deep breathing. She's anxious..calf
shows erythma...has large embolism
occluding blood flow. Answer is dead
space right since its a perfusion defect?

DEAD SPACE

121.

64 yo old alcoholic,
disoriented, jaundice, spider
angiomatas, flapping of hands
up and down when
outstretched, neomycin
admin, mechanism?

killing of bacteria in the

gut that generate
ammonia----Neomycin is a
nuclear bomb to bacteria

127.

previously healthy 67 yr old lady w 3 day

history of fever, shortness of breath,
nonproductive cough, headache, and
muscle pain. Temp is 102 F. lungs clear to
auscultation. Exanm shows no
abnormalities. which vaccine coulda
prevented

INFLUENza

128.

long history of atrophic gastritis has

increased lethargy and fizziness during
past 2 weeks. pale skin and mucous
membranes. no palpabl adenopathy. liver
edge palpable. decreased vibratory
sensation. hct of 27%, mcv 112, and
platelet count 200,000. Abscence of what?

parietal cells

129.

loudy urine after knee replacement. Temp

is 100.4 F. Bandaged left knee and
indwelling foley cath. Micro shows
numerous gram negative rods. urine
culture brain heart infusion medium
grows more than 100,000 bacterial
colonies predominantly one thats oxidase
positive and produces diffusible green
pigment.

pseudomonas

ncrease in the amount of iron inside

cultured hepatocytes leads to an increase
in the amount of ferritin gene products
detected by Westem blotting.

translation of
ferritin mRNA

130.

It does not change the amount of ferritin

gene products detected by Northem
blotting or by the polymerase chain
reaction.

134.

Lady in study..steroid hormone in

saliva...regular 28 day cycle with
ovulation at day 14..during test, lab
study shows increased estradiol and
decreased progesterone..what day
was this hormones measure?

day 12, After

estrogen surge, Lh
causes ovulation.
Progesterone is no
where before
ovulation because
there is no egg
(Remember, progestation, no egg,
no gestation, no
progesterone!)

135.

39 yr old lady w rheum.arthritis.

Trtment with multiple meds,
including prednisone and
methotrexate hasn't been effective.
Next step in treatment is drug that
blocks effects of which of the
following cytokines?

TNF-alpha
inhibitor

136.

Pic of anus, surrounding is red. 28 yr

lady comes to doc cuz of 3 wk history
of intermittent anal itching, pain w
dedication, bright red blood w
wiping. She admits to intermitting
constipation.

VENOUS HTN-external
hemorrhoids, very
painful

137.

2 yr old man w moderate

splenomegaly but no
lymphadenopathy. lymphocytes
have cytoplasmic projections and
positivity for acid phosphatase even
in the presence of tartrate. diagnosis?

TRAP+ = Hairy cell

leukemia

These results suggest that iron increases

the frequency of which of the following
events?
131.

132.

133.

59 old man history of fevers he ache. pdf

of csf shows herpes simplex virus. give
drug that inhibits which enzyme?
acyclovir so DNA polymerase correc

dna
polymerase

138.

4 month boy w recurrent sinopulmonary

infections since birth. Phys exam shows
hypo pigmentation of skin, eyes, hair,
ecchymoses over trunk and extremities.
Blood smear shows giant granules in
neurtophils and eosinophils.

chediak
hegashi recurrent
infections +
partial
albinism +
peripheral
neuropathy

12 yr old girl immigrated to us from

central africa has 5 wk history of
severe abdominal pain and vomits
blood. temperature is 100F pulse is
110/min, respirations are 27/min,
and BP is 112/65 mmHg. Phys exam
shows hepatosplenomegaly and
abdominal ascites. Leukocyte count
slightly above normal..photo of the
stool specimen

PRAZIQUANTEL--parasites (bendy
worms) are killed
by -bendazoles
(bendy drugs) or
praziquantel

139.

man with fever, dysuria, enlarged

prostate, organism?

causes of BPH
include UTI--mcc is
E.coli

140.

Man who develops a temperature

after running a 10-km race. The man
temperature is going to return back
to normal due to which of the
following mechanisms?

Evaporation of
sweat

141.

an investigator is conducting a study

of antiretroviral agents. The plan is to
identify which agents inhibit entry of
the HIV virus into the CD4+ T
lymphocytes

en - fu - virtide
inhibits fusion.

62 yr old man has pain in the left hip for 3

wks. X-ray of ship shows 4.5 cm
destructive osteoblastic lesion w an
associated fracture in proximal femur and
2 separate similar smaller lesions in the
bony pelvis. Needle core biopsy of femur
shows metastatic carcinoma. Whats the
most likely primary site of the cancer

prostate--osteoblastic
lesion mets to
prostate

55 yr old lady 3 month history of

shortness of breath. Takes daily
multivitamin. Leukocyte count
8000 , ca2+ 12 mg, urea nitrogen
10 mg, creatinine 1 mg,
phosphorus 4.2 mg, X-ray shows
enlarged hilar lymph nodes and
reticulonodular infiltrates in
upper lung fields. Analysis of
biopsy specimen shows
noncaseating granulomas. What
are serum values

increased PTH 1,25

dihydroxycholecalcifero--sarcoidosis

143.

cystitis caused by vancomycin

resistant enterococcus faecalis.
which of the following
mechanisms best explains the
antibiotic resistance of this
organism?

Vanco resistance is d-ala

d-ala substituted for dala d-lac

144.

10 yo sudden onset progresive

SOB, numerous eosinophils,
charcot leydin crystals, what is
involved in pathogenesis of this
dx?

Leukotrines in general
cause asthma

145.

newborn baby diagnosed with

hypothyroidism,
ultrasonography shows the
absence of any thryoid tissue at
the neck.which exlplains
normal development in the nb?

T4. The baby is normal,

but doesn't have a
thyroid, the only way it
could be would be if
mom gave the baby the
final effector -- T4. All
other require a
functional thyroid gland

55-year-old man comes to the

physician because of a 3-day
history of fever, chills, nausea,
vomiting, and diarrhea. He says
he has been unable to eat or
drink anything without
vomiting and has had little
urine production during the
past 12 hours. His temperature
is 37.8C (100F). His pulse is
92/min, and blood pressure is
110/70 mm Hg while supine;
pulse is 110/min, and blood
pressure is 80/60 mm Hg while
standing. Physical examination
shows dry mucous membranes
and a soft abdomen with mild,
diffuse tenderness.

volume depletion

142.

146.

147.

itamin D supplements are inactivated, so

you're still relying on your liver, and then
your kidney (with activation via PTH -- key
step) to turn it into 1,25-dihydroxy. If her
parathyroids are working properly, you
shouldn't see more than a slight elevation
in Ca++ even with excess vitamin D. Beyond
all that though, it was basically asking you
what the mechanism is through which
vitamin D increases Ca++ levels.

...

148.

A) Bullous pemphigoid antigen

- Sub-Epidermal Blisters
- Hemidesmosomes
- Epidermal basement membrane
- Spares Oral Mucosa
B) Collagen Type VII
- Epidermolysis bullosa acquisita
C) Cytokeratin
- Participate in maintaining the structural
integrity of cells
D) Desmoplakin
- Paraneoplastic pemphigus antigen
E) Plakoglobin
- Pemphigus vulgaris antigen
- Supra-Basal Blisters
- Desmosomes
- Affects Oral Mucosa
- Plakoglobin binding by human
Desmoglein 3 & 1

...

149.

)38 yo woman comes to physician for preemployment exam; she has no history of
serious illness; she takes no meds; her vitals
are normal; PE shows no abnormalities

irondeficiency

Lab studies show: Hb 8.2, Hct 25%, MCV 69,

leukocytes 5900, retic 0.8%, platelets 350K
150.

old man w sudden right sided

weakness...right perioral droop. muscle
strength 4/5 on right. babinski present on
the right. ct scan of head shows normal.
week later, ct shows small area of hypo
density involving left internal capsule
consistent w loss of tissue. which cell types
most likely to clear necrotic tissue in this
area?

microglial =
macrophage
in brain

151.

2wks post-transplant pt w/ erythematous,

maculopapular rash, diarrhea, increased
LFTs and bilirubin. What caused his sx

Donor T
lymphocytes

152.

10y/o F anemic with hx of splenectomy,

recent cholecystectomy. CBC: low Hb,
normal MCV, PC, increased Reticulocyte
Count. Peripheral smear shows pale RBCs.
Underlying abnormality

erythrocyte
spectrin

153.

Cholesterol emboli on funduscopic exam. Likely origin of embolus

right opthalmic

154.

Heterogenous pedunculated mass in L atrium in 19y/o M

myxoma

155.

Cystic Fibrosis = defect in what in bronchial epithelium?

protein structure

156.

15 yr old female ingested Vit D in a suicide attempt. Follow up 1 month later show Ca [C] 10.4 (slightly
elevated) What is the mechanism of increased Ca.

Increased
absorption of ca in
GIT--Vitamin
promotes
absorption of Ca+
in the GIT

157.

case control study is conducted to explore a possible association between exposure to an herbicide and
the diagnosis of non hodgkin lymphoma. controls are matched to cases by age, gender, and race.
exposure status is determined by interviewing the subjects. on matched pair analysis, the odds ratio is 3.2
( 95% confidence interval : 1.4-5.4) which of the following is most likely to affect the validty of this study?

Biased
measurement of
the Exposure

158.

24 year old african american man comes to the physician because of a 3 month history of red bumps on
his face and chin. he says that the bumps are itchy and painful. physical examination shows hyper
pigmented papules over the cheeks, jawline, and neck. which of the following is the most likely
diagnosis?

pseudofolliculitis
barbea--razor
burn and African
americans get it
frequently