1-A 65-year-old male comes to his doctor because for the last few years, his right

ankle has looked funny and is starting to cause him mild pain. On physical
examination, a grossly deformed and swollen joint can be seen that is noticeably
warm to the touch. As part of a thorough patient history, the doctor asks about
sexually transmitted infections and risky behavior, after which the patient admits to
having intercourse with prostitutes during the war. Which infection is likely to
have contributed to the patients condition?

A. Chlamydia trachomatis
B. Hepatitis C
C. Human papillomavirus
D. Neisseria gonorrhoeae
E. Treponema pallidum
2-A 33-year-old man presents to his family physician with a 2-day history of fever
with an abrupt onset, severe headache, myalgias, and a macular rash covering his
trunk. He is treated with doxycycline, and his fever subsides within 48 hours. What
would most likely be observed in a biopsy of the rash?

A. Immune complexes
B. Intracellular gram-negative bacteria
C. Intracellular trophozoites
D. Parasitic cysts
E. Spirochetes
3-A concerned mother brings her 16-year-old daughter into the local Emergency
Department. The daughter appears confused but responsive. Her body is covered in
a sunburn-like rash. The mother states she found her daughter vomiting in the
bathroom yesterday and brought her in as the rash worsened. Vital signs show a
temperature of 39.2C (102.5F) and blood pressure of 85/55 mm Hg. Blood cultures
are drawn, and the patient is treated empirically and symptomatically. Three days
later, the blood culture results return as positive for gram-positive bacteria. By this
time, the skin on the patient's hands has begun to peel off. What is the most likely
mechanism of the toxin producing this patient's symptoms?

A. Conversion of fibrinogen to fibrin

B. Destruction of cadherin proteins
C. Disruption of cell membranes
D. Enhancement of binding between T-cell receptors and MHC
E. Prevention of IgG-mediated opsonization
4-A 46-year-old man is treated with drug therapy after presenting with fever,
weakness, chills, and nonproductive cough. Several weeks later, he returns to his
physician with complaints of severe muscle weakness and very dark urine. In
reviewing this patients history, he has a family history of cardiovascular disease
and has been treated with an antihyperlipidemic drug for the past 2 years. His
laboratory values reveal a creatine kinase of 220 IU/L (60 and 174 IU/L). Which of
these drugs is most likely responsible for this patient presentation?

A. Chloramphenicol
B. Erythromycin
C. Levofloxacin
D. Tetracycline
E. SMX/TMP
5-A 52-year-old man presents with severe burning pain in his ankles. On
examination, heat and redness in the area were observed. Review of pertinent
history reveals that he worked as an importer of Oriental rugs and had recently
been treated successfully for a necrotic skin lesion on his right hand. What is the
mechanism of the first-line drug used for the treatment of this presentation?

A. Binding of the 30S subunit of the bacterial ribosome

B. Binding of the 50S subunit of the bacterial ribosome
C. Inhibition of dihydrofolate reductase
D. Inhibition of DNA gyrase
E. Inhibition of transpeptidase that cross-links the peptidoglycan chain of the cell
wall.
6-A 59-year-old male develops excessive sweating and salivation as well as diarrhea
while being treated with neostigmine for myasthenia gravis. To prevent these
unwanted effects, the drug that should be added to his current regimen is:

A. Atropine
B. Carbachol
C. Ipratropium
D. Prazosin
E. Propranolol
7-A 24-year-old female with severe acne complains of an increased number of
lesions. The dermatologist prescribes an oral antibiotic approved for the treatment
of these lesions. The drug most likely acts by which of the following mechanisms?

A. Blocks ribosomal initiation complex formation

B. Causes misreading of the genetic code
C. Disrupts cell membrane
D. Interferes with cell wall synthesis
E. Prevents binding of aminoacyl-tRNA to ribosomes
8-A 25-year-old male comes to the dentist and is found to have stained teeth. He
claims that his teeth have always been stained like this:
What is the mechanism of action of the antibiotic most likely responsible for this?
A.Binds the 50S ribosomal subunits and inhibits translocation
B.Disruption of the bacterial cell wall
C.Forms sulfide bonds with enzymes, rendering them inactive
D.Inhibition of aminoacyl-tRNA binding
E.Inhibition of ribosome translocation

9-A 6-year-old has developed crusted, weeping lesions of impetigo on the arms and
face. Culture yields Staphylococcus aureus. The isolate is positive for mecA gene.
Which of the following drugs would be most appropriate for this child?

A. Amoxicillin
B. Aztreonam
C. Gentamicin
D. Nafcillin
E. Vancomycin
10-A 65-year-old male, known to be a smoker, comes to his primary care physician's
office with a chief complaint of proximal muscle weakness, dysarthria, and diplopia
early in the mornings. He states that as he moves around the house, his weakness
disappears, but the next morning the weakness comes back. Electrophysiological
studies with repetitive nerve stimulation showimprovement, but administration of
an anticholinesterase agent did not. The patient's condition is most likely associated
with which of the following?

A. Blockage of the ligand channels in the postsynaptic membrane

B. Blockage of the release of neurotransmitters into the synaptic cleft
C. Blockage of voltage-gated channels of calcium
D. Blockage of voltage-gated channels of sodium
E. Clumping of neurotransmitter vesicles into one large vesicle
F. Destruction of the neurotransmitter post-synaptic receptors
G. Destruction of the Schwann cells
11-A healthy 45-year-old man undergoes treatment of a kidney stone. He is in the
lithotomy position for two hours for his procedure and awakens from surgery
without difficulty. However, when he gets out of bed, he notices an inability to
dorsiflex his foot. The damage to this nerve was likely due to pressure at which site
during surgery?

A. Acetabulum
B. Anterior superior iliac spine
C. Fibular head
D. Greater trochanter
E. Medial malleolus
12-Following a prolonged surgery, a patient is unable to extend his wrist or fingers
on his right hand, has moderate weakness of forearm flexion at the right elbow, and
complains of numbness and tingling on the lateral dorsal aspect of the right hand.
Which of the following structures is most likely to have been injured?

A. C6 nerve root
B. Median nerve
C. Medial cord of the brachial plexus
D. Radial nerve
E. Ulnar nerve
13-A 44-year-old man presents to the outpatient clinic complaining of a lesion on his
penis. His medical history indicates multiple instances of recent unprotected sex. On
physical examination, a penile shaft lesion resembling a chancre is noted. Blood
tests reveal a positive rapid plasma reagin. An intramuscular injection of penicillin G
is administered. The patient comes back for a followup visit a week later, and when
he walks into the room, his right hip drops when his right foot is raised off the
ground. The injured nerve provides innervation to muscles that perform what
action?

A. Abduction of the thigh

B. Adduction the thigh
C. Extension of the thigh
D. Lateral rotation of the thigh
E. Medial rotation of the thigh
14-A 54-year-old man complains to his physician that he is having progressive
discomfort in his leg during movement of the foot. On physical examination, the
physician noted a decreased pulse in the dorsalis pedis artery. Compression of a
blood vessel in which of the following locations would most likely result in this
decreased blood flow of the dorsalis pedis artery?

A. Anterior compartment of the leg

B. Deep to the gastrocnemius and soleus muscles
C. Lateral compartment of the leg
D. Neck of the fibula
E. Posterior to the medial malleolus
15-A 60-year-old man presents to his physician complaining of pain in the wrist,
hand, and knee joints associated with swelling, tenderness, and heat. Laboratory
studies reveal a normocytic, normochromic anemia with an elevated erythrocyte
sedimentation rate. Serum is positive for IgM antibodies against autologous IgG. A
sample of synovial fluid from the affected joints is most likely to reveal which of the
following?

Protein IgM Th17

lymphocytes IL-1 TNF
A.
B.
C. --
D. --
E.
16-While playing outside, an 8-year-old boy falls from a tree and lands on his left
upper limb, with much pain. The emergency room physician examines the boy and
determines that he has damaged the axilla on one side. The exam reveals that
extension of the wrist and pronation of the forearm are normal, but flexion of the
elbow and supination are significantly weakened. Which of the following was most
likely damaged in the fall?

A. Lateral and medial cords of the brachial plexus

B. Musculocutaneous nerve
C. Posterior cord of brachial plexus
D. Posterior division fibers of brachial plexus
E. Radial nerve at lateral elbow
17-A newborn is born with a cleft lip, but normal development of the hard palate.
Which of the following facial primordial that failed to fuse resulted in the cleft?

A. Mandibular and the frontonasal prominences

B. Mandibular and the medial nasal prominences
C. Maxillary and mandibular prominences
D. Maxillary and medial nasal prominences
E. Medial and lateral nasal prominences
18-A 13-year-old African American boy presents to the emergency room with his
father, complaining of pain and swelling of his right knee. The child noticed the
swelling 2 days ago, but attributed it to the minor injury he suffered when he was
kicked in the knee while playing soccer a week ago. The father said that his son has
been irritable and feverish for the past 2 days, but when he started limping, he
decided to come to the emergency room. Family history includes a younger brother
with sickle-cell disease.

Vital signs include: Temperature 38.5C (101.3F) BP 123/78 mmHg, heart rate
100/min, respiratory rate 20/min.
On examination, the prepubescent boy appears apprehensive, but in no acute
distress. Physical examination of the leg reveals an acutely tender, swollen, and
erythematous right knee that is resistant to passive motion. The remainder of the
leg is unremarkable.

Total leukocyte count: 12,300 Hb: 13

Hematocrit: 40%
Neutrophils: 78%
MCV: 82
Lymphocytes: 10%
Platelet count: 200,000/mm3
Monocytes: 8%
Eosinophils: 5%
Basophils: 1%

Arthrocentesis of the knee is performed. Synovial fluid and blood culture results are
still pending. What is the most likely diagnosis?
A. Osteomyelitis
B. Reactive arthritis
C. Rheumatoid arthritis
D. Septic arthritis
E. Sickle-cell pain crisis
19-A 55-year-old woman is brought to the doctor after complaining about
generalized bone pain, particularly in her legs. She has also noted some bumps on
her fingers. An x-ray of her legs shows thin bones and signs of previous small
fractures. Lab tests show elevated alkaline phosphatase and diminished
phosphorus. An x-ray of her hands shows the following:
Laboratory testing shows a normal serum creatinine level. Which of the following is
most likely to be present in this patient?
A.High calcium
B.High sodium
C.Low chloride
D.Low parathyroid hormone
E.Low vitamin D
20-A 65-year-old man comes to the physicians office due to a 1-month history of
tense blisters inside his elbows and behind his knees. The blisters are very itchy and
have affected his sleep. He denies any recent travel or recent infections. The
blisters do not rupture easily. His past medical history includes hypertension and
diabetes, currently controlled with furosemide and metformin, respectively. He
denies smoking or drinking and walks about one mile three times a week. On
examination, several tense bullae with erythematous bases are noted on the
flexural regions of this elbow and knees. The normal skin does not separate when
firm pressure is applied. The bullae are pictured below:
Autoantibodies against which epithelial cell junction cause this disease?
A.Desmosome
B.Gap junction
C.Hemidesmosome
D.Intermediate junction
E.Tight junction
21-A 29-year-old woman presents to her primary care physician with the new
appearance of several small, red, scaly, painful skin lesions over the extensor
surface of her elbows, scalp, and behind her ears. Physical exam reveals
erythematous macules in these areas as well as a few silvery plaques. She also
notices that her nails appear yellow and thick. The patient has recently recovered
from a viral illness. Her mother has similar skin problems, though the patient cannot
remember the diagnosis. Biopsy of one of the lesions is likely to show:

A. Atypical and dysplastic keratinocytes and parakeratosis

B. Multinucleated giant cells
C. Neutrophils in the epidermis and neutrophil aggregates in the stratum corneum
layer
D. Perivascular lymphocytes with intraepidermal vesicles
E. Vacuolization of basal epidermis and follicular plugging
22-A 57-year-old female is brought to the emergency department after a motor
vehicle accident. She was driving an SUV at 50 mph and texting when she failed to
notice the car in front of her slowing down and hit the car from behind. The airbags
deployed and the front engine compartment of her car crumpled inward. In the
emergency department , the patient is alert, oriented, and in moderate pain. Her
vitals are normal. On physical examination, she has numerous lacerations on her
face and arms from broken windshield glass. On chest auscultation there is bilateral
air movement. The patients right leg is noted to be shortened and internally
rotated. Motor strength is 1/5 on flexion of the knee, on extension of the thigh, and
on dorsiflexion of the foot. Sensation to fine touch is decreased in the posterior
thigh, leg, and foot. Motor and sensory functions are normal in the left lower
extremity. Which of the following nerves is most likely injured?

A. Femoral
B. Obturator
C. Pudendal
D. Sciatic
E. Superior gluteal
23-A 65-year-old male who is lifting boxes out of a storage unit feels a sudden pain
in his lower back and goes to his doctor. The doctor notes weakened left foot and
toe dorsiflexion and reduced sensation in the left great toe. An MRI is most likely to
discover herniation of which of the following discs?

A. L1
B. L2
C. L4
D. L5
E. S1
24-A 17-year-old male working in his high schools theater department is drinking at
a theater tech party when he decides to climb a ladder and work on the paint on
some of the spring productions sets. Losing his balance, he falls and hits his neck
on the ground. EMS is called, and he is taken to the emergency room, where an MRI
shows herniation of his C6 disc. This patient is most likely to show which of the
following clinical signs?

A. Diminished ability to initiate arm abduction

B. Diminished biceps reflex
C. Diminished sensation in fifth finger
D. Diminished sensation in middle finger
E. Inability to horizontally abduct the arm
25-The axons of the neurons whose cell bodies are located in the outer Rexed
laminae of the left dorsal horn of the spinal cord terminate into which of the
following structures?

A. Dorsal root ganglion

B. Left fasciculus gracilis
C. Left spinothalamic tract
D. Right lower medulla
E. Right VPL nucleus of the thalamus
26-A 60-year-old woman presenting for an annual physical notes that she has been
feeling pain "in her bones" for the past few months. She describes increasing
hearing difficulties as well, but she felt this was just because she was getting older.
Her husband adds that he feels her face has a slightly different shape than it used
to. Concerned, her physician orders a radiograph of her skull. The skull shows areas
of radiolucency from osteolysis and areas of cortical thickening with increased bone
density and some sclerosis. The expected laboratory results on a routine blood
chemistry panel would be:

A. Decreased calcium, decreased phosphate, decreased alkaline phosphatase

B. Decreased calcium, decreased phosphate, increased alkaline phosphatase
C. Increased calcium, decreased phosphate, increased alkaline phosphatase
D. Normal calcium, normal phosphate, decreased alkaline phosphatase
E. Normal calcium, normal phosphate, increased alkaline phosphatase
27-A 2-month-old baby boy is brought in for "floppiness." His feeding habits and
weight are appropriate for age, and he does not seem to be in any distress. Physical
examination confirms general hypotonia. The infant has no difficulty with eye
movements or blinking. After an extensive workup and eventual muscle biopsy, he
is diagnosed with a relatively rare condition called congenital fiber-type
disproportion, in which one type of muscle fibers is disproportionately smaller than
the other type of muscle fibers. The type of muscle fiber affected by this disease
normally has which of the following characteristics?

A. Poor in myoglobin, mitochondria, and oxidative enzyme content

B. Rich in ATPase enzymes
C. Slow to contract
D. Fatigued rapidly
E. Abundant in extraocular muscles and muscles of the hand
28-A 32-year-old pipe-fitter lacerates his hand on the sharp edge of a pipe and has it
sutured in an emergency room. On day 5, which of the following adhesion molecules
make up most of the noncellular substance in the granulation tissue of the wound?

A. Cadherin B. Fibrinogen
C. Fibronectin D. Integrin
E. Laminin F. Selectin
29-A 19-year-old man visits a dermatologist after learning about the ABCDEs of
melanoma in his college health class. He is concerned about a few dark, slightly
irregular skin lesions (shown above, left). He has had them as long as he can
remember, and he doesn't think they have changed much recently, but he is
uncertain and wants them evaluated. The dermatologist biopsies one of the lesions
(shown above, right). Which of the following is true?
A.These lesions are generally benign.
B.These lesions are malignant and are at risk for metastasizing.
C.These lesions are malignant but rarely metastasize.
D.These lesions are premalignant, and the patient should be managed carefully.
E.These multiple lesions are paraneoplastic and indicate a malignancy elsewhere.

30-A 66-year-old female presents to her physician with lower back pain. She
describes the pain as dull, and any type of movement exacerbates the pain. The
patient denies any recent trauma to her back. Two years ago she suffered a Colles
fracture of the wrist after she tripped and fell. Her last menstrual period was at the
age of 42, and she denies using hormonal replacement. Dual-energy x-ray
absorptiometry was performed, and her T-score was -2.6. Which of the following are
the most likely findings on further laboratory testing?

Serum calcium Phosphate Alkaline phosphatase Parathyroid hormone (PTH)

A. Decreased Decreased Increased Increased
B. Decreased Normal Increased Normal
C. Increased Decreased Increased Increased
D. Normal Normal Increased Normal
E. Normal Normal Normal Normal