NBME

18
Annotated with (hopefully) correct answers
- Correct answers are in written in on questions with a large, red ”No” symbol
- Cmd+F or Cntrl+F age of pt or keywords to find the question you’re looking for
- Two questions are missing from the screenshots I was given
- All First Aid references/pictures are from FA2016

Keep pushing yourself.

You got this. Step 1 will be yours.
- Dipalmitoylphosphatidylcholine

Male newborn delivered at 28 weeks, neonatal respiratory distress syndrome, ABG shows decreased pH, decreased Po2 increased PCO2. A deficiency in which of the following most likely caused the disorder?
- Dipalmitoylphosphatidylcholine
12-year-old boy with mother concerned about enlarged left breast and family history of breast cancer. Left breast is slightly larger than right, nipple mildly tender. Penis slightly enlarged and pubic hair curling and beginning to darken at
base. Best next step?
- Reassure the mother that physical findings are not uncommon for his age
 - Plasmid loss
Vancomycin-resistant Entercoccus. VRE is a
bacterial strain of Enterococcus that has acquired
resistance to the antibiotic vancomycin through
the uptake of a plasmid that has the resistance.
VRE can be resistant to not just vancomycin, it
can be resistant to other antibiotics commonly
used for Enterococcus infections such as
aminoglycosides, and ampicillin

Investigator studying vancomycin-resistant strain of Enterococcus faecalis. Ten generations created. Culture inoculated and resulting bacterial colonies are screened for vancomycin
resistance. Vancomycin-sensitive colonies observed at frequency of one per 100 cells. Mechanism of decreased vancomycin resistance?
- Plasmid loss
 • Whenever you see a case with positive High-dose Dexamethasone
suppression test then pick the option of doing brain CT [because it's
most likely Cushing disease i.e. ACTH-secreting pituitary adenoma]
• But don't forget that a positive Low-dose DST could also be a sign of Depression
or obesity.
• Major depression with psychotic elements can be assessed with a
positive DST because they have high cortisol levels that can be
suppressed with DST
• Whenever you see a case with negative High-dose dexamethasone
suppression test then pick the option of doing lungs or abdomen CT or
U/S because it's most likely ectopic ACTH source (such as lung CA or
Adrenal adenoma)

35-year-old man with severe back pain, gained 8 kg in the past 6 months, decreased peripheral vision, compression fracture spine at T10 and L1, healing left rib fracture at T6, imaging shows pituitary macroadenoma. This tumor
produces which?
- ACTH
A 25-year-old man is admitted to the hospital because of severe crush injuries to the chest and extensive burns over 30% of his body surface area. Three hours later, he develops tachypnea and dyspnea. Arterial blood gas analysis on
room air shows a decreased Po2 and Pco2. A chest x-ray shows bilateral interstitial and alveolar infiltrates. The patient is intubated and mechanically ventilated. Damage to which of the following is most likely to preclude restoration of
normal tissue architecture and pulmonary function in this patient?
- Basement membranes
66-year-old woman is brought to the emergency department by her daughter because of a 2-day history of fever, flank pain, pain with urination, and nausea. Ten days ago, she was admitted to the hospital for similar symptoms and
was diagnosed with acute pyelonephritis. She was discharged with instructions to take oral ciprofloxacin after a 3-day course of intravenous ciprofloxacin resulted in improvement. She also has hypertension, hyperlipidemia, and
osteoporosis. Current medications also include alendronate, calcium carbonate, ezetimibe, hydrochlorothiazide, and simvastatin. Her temperature is 39.1°C (102.4°F), and blood pressure is130/80 mm Hg. The most likely cause of this
patient’s current condition is an interaction between her current oral antibiotic and which of the following medications?
- Calcium carbonate

- Calcium carbonate

Ciprofloxacin and calcium carbonate should not be taken

orally at the same time. Products that contain magnesium,
aluminum, calcium, iron, and/or other minerals may
interfere with the absorption of ciprofloxacin and reduce
its effectiveness. If possible, it may be best to avoid
taking calcium carbonate while your are being treated
with ciprofloxacin. Otherwise, you should take
ciprofloxacin either 2 to 4 hours before or 4 to 6 hours
after the calcium carbonate dose.
32-year-old woman has new neuro finding while being tx for acute infection of sphenoid sinus. Imaging shows cavernous sinus thrombosis on left. Additional finding most likely?
- Inability to abduct the eye

- Inability to abduct the eye

71-year old woman with coronary disease and well-controlled hypertension is brought to the physician 2 hours after sudden onset of weakness of her left leg. Her BP 145/85 mmHg. Neurologic exam: weakness and decreased sensation
over the left lower extremity. There are no other sensory or motor deficits. Which labeled structure is site of injury?
- A (Pre/postcentral gyrus; motor/sensory cortex)

(Pre/postcentral gyrus; motor/sensory cortex)

Girl has chronic cough with thick sputum, abdominal cramps in RLQ, and frequent resp infections. Clubbing of fingers, hyperresonance on chest percussion. Diffuse crackles and scattered wheezes. On xray - diffuse hyperinflation of the
right upper lobe. She has a healthy brother. What's the likelihood he is a carrier for the condition?
- 2/3
48-year-old recently diagnosed with lupus and difficulty working as schoolteacher because of severe pain and swelling of joints. Current meds include
prednisone, hydroxychloroquine, and oxycodone for pain. Best action to adapt to illness?
- Encourage the patient to participate in a support group for persons with her condition
19-year-old man with gastrointestinal bleeding. Laparotomy done and 5-cm blind outpouching on antimesenteric side of terminal ileum 15 cm from ileocecal
valve resected. Pathology shows?
- Heterotopic gastric mucosa

- Heterotopic gastric mucosa

14-year-old girl with type 1 diabetes mellitus and 4-hour history of lethargy, confusion, disorientation. Symptoms gradually developed and she did not take
her usual insulin dose during a sleepover. HR 110, RR 24 deep and rapid, bp 95/75. Labs: glucose 450, arterial pH 7.15. ABG?
pCO2/HCO3-/Anion gap
- decreased/decreased/increased

- decreased/decreased/increased
Full-term newborn in respiratory distress. Imaging shows abdominal contents in left pleural cavity. Maldevelopment of which structure led to diaphragm
defect?
- Left pleuroperitoneal membrane

- Left pleuroperitoneal membrane

19-year-old woman is admitted to the hospital for antibiotic treatment of meningococcal meningitis. She is stabilized. Three days later, her pulse is 120/min,
and blood pressure is 60/30 mm Hg. Physical examination shows bilateral flank tenderness. Serum studies show a sodium concentration of128 mEq/L,
potassium of 5.4 mEq/L, and bicarbonate of 20 mEq/L. Which of the following is the most appropriate next step to determine the cause of this patient's
hypotension?
- Adrenocorticotropic hormone stimulation test

- Adrenocorticotropic hormone stimulation test

Retrospective study of incidence and outcome of subarachnoid hemorrhage. Incidence is 15 per 100,000 people, mortality is 6 per 100,000 people.
Incidence remains constant, case fatality rate?
- 40%
15-year-old girl comes with lack of improvement of facial acne. Tried topical clindamycin and benzoyl peroxide PE severe acne vulgaris. Says, "Please help
me." She has never been sexually active. Tx?
- Isotretinoin
20-year-old woman with 2-week fever, shaking chills, headaches, fatigue, and joint and muscle pain. Spent summer workin as lifeguard in Long Island, New
York. Has splenectomy for motor vehicle collision 6 years ago. T 102.4 F. Peripheral blood smear shows small intraerythrocytic rings. Polymerase chain
reaction for Plasmodium is negative. Causal organism from bite of?
- Tick
16-year-old girl calls the physician on a Friday night 2 hours after a condom broke during sexual intercourse with her boyfriend. She asks the physician to
prescribe an emergency oral contraceptive. The physician on call is not the patient's regular physician and does not dispense emergency contraception for
moral reasons. After the physician respectfully informs the patient that he does not prescribe this contraceptive, it is most appropriate for the physician to
state which of the following?
- "I can have one of my colleagues call you back to further discuss your concerns."
35-year-old woman with fever and sharp chest pain for 3 days. T 101.3F. Friction rub heard. All cuases of secondary pericarditis ruled out. Cause of primary
pericarditis?
- Virus

Virus
“Primary” acute pericardial disease (acute pericarditis or tamponade presenting without an apparent cause)
In a 25-year-old patient who underwent splenectomy, target cells are seen on peripheral smear. These cells are seen due to loss of function of which portion
of spleen?
- Red pulp

- Red pulp
64-year-old with non-Hodgkin lymphoma and 3-day history of abdominal pain and nausea. T 99.7F, HR 100, bp 130/80. Abdominal exam tenderness of
flanks and lower quadrants. BUN 34 and creatinine 3.8. CT shows bilateral hydronephrosis and lymphadenopathy compressing ureters. Tx to improve renal
function?
- Bilateral stents in the ureters

http://www.score95.com/blog/blog/usmle-obstruction-of-the-urinary-tract/
40-year-old man with orthostatic hypotension, loose stools for 1 year, and history of type 1 DM. Stool studies are normal. What is the pathophysiological
mechanism of the diarrhea?
- Motility disorder

- Motility disorder
2-month-old female with T 102F, vomiting, diarrhea, dehydration. Exam of stool shows viral particles with wheel-like shape. Properties of virus?
Type of nucleic acid/envelop/capsid symmetry
- Double-stranded RNA, segmented/no/icosahedral

- Double-stranded RNA,
segmented/no/icosahedral
17-year-old boy whose mother concerned about physical development. 10th percentile for height and 25th for weight. FSH is 5, testosterone 8 (N=10-35).
Physical finding on patient?
- Gynecomastia
50-year-old man undergoes operative repair of inguinal hernia. Surgeon has received written informed consent from patient. After epidural received,
patient decides he does not want to have surgery. Best response?
- "Tell me about your concerns and why you want to cancel the operation."
62-year-old with angina pectoris is referred for cardiac catheterization. Patient worried about hospital-associated infection. Studies show 30% of patients
require admission after procedure, and 2 percent of admitted patients acquire hospital infection. Patient's risk for infection overall?
- 6/1000

.3 * .02 = 6/1000
Studying epithelial repair of small intestine in experimental animal. Wants to identify most active cell division location. Where is this cell activity found?
- Base of the crypt

- Base of the crypt

71-year-old man admitted for prostatic resection. Normal mental status. 2 days after surgery, confused and restless. Cannot sleep and restless, seeing little
men coming through window. Dx?
- Delirium

- Delirium
35-year-old woman passed out while washing dishes. Began to feel weak and dizzy, husband shares with nursing staff history of bulimia nervosa, and has
been binging more frequently. Suspected she has been vomiting. Labs of patient?
K+/HCO3-/Anion Gap/pH
- decreased/increased/normal/increased
65-year-old woman comes to the physician because of a 1-week history of a swollen, painful left knee. Her temperature is 38°C (100.4°F), and blood
pressure is 110/65 mm Hg. Examination of the left knee shows erythema and swelling of the joint and decreased range of motion. A photomicrograph of
synovial fluid obtained by arthrocentesis is shown. This patient's synovial fluid most likely contains which of the following?
- Uric acid
Researching new cancer drug, effective at killing rapidly dividing cells, in mice caused profound myelosuppression. In patients, most appropriate to follow
which when at risk for infectious complications?
- Neutrophil counts

- Neutrophil counts

C. Neutrophil counts

Neutrophils make up the majority of WBC! A part

of the first responding innate immunity.

Myelosuppression means no Myeloid cells like

monocytes, macrophages, neutrophils, basophils,
eosinophils, erythrocytes, dendritic cells, and
megakaryocytes or platelets.
67-year-old man with 3 months fatigue and shortness of breath. Vitals HR 90, RR 15, bp 150/98. PE conjunctival pallor. Labs: hb 8.5, hct 26%, MCV 90, RDW
14.4% (N=13-15%), Cr 2.9, Ferritin 144, Iron 24, Transferrin saturation 23% (N=20-50%). Besides iron supplementation, most appropriate tx?
- Erythropoietin
39-year-old man with polycystic kidney disease has 6-month history intermittent blood in urine. T 98.6 F HR 100 RR 24 BP 160/90. Urea nitrogen 100,
creatinine 8. UA shows blood. Arterial blood gas shows?
pH/pCO2/HCO3-
- 7.22/28/11

- 7.22/28/11

Increase in creatinine and BUN --> renal failure

Consequence of renal failure = Metabolic acidosis so Bicarb will be <20 and PCO2 will be decreased too due to hyperventilation.
4-year-old male with recurrent UTIs, left kidney found small and non functional; right is normal. Nephrectomy is done, and the picture shown (dilated ureter
and renal calyx). Microscopic exam of kidney will show which?
- Tubular atrophy

- Tubular atrophy

Tubular atrophy
(hint: dilated ureter/calyx in
image)
↓
Posterior urethral valves is the
#1 cause of bladder obstruction
in males

Diagnosed
by hydronephrosis and thick-
walled bladder
A previously healthy 20-year-old woman has had palpable lump in right breast 4 months. No pain, swelling, nipple discharge. Lump = smooth, firm, round, mobile, nontender, and well delineated from underlying tissue. No changes in skin around lesion.
- Fibroadenoma
To decrease risk for cv disease 24 yo man begins diet. 1.53 95 kg BMI 32, Intends to lose 16 kg by limiting caloric intake to 2000 cal. to maintain the
recommended protein intake (56g day); a balanced decreased in carbs and fat is required (caloric radio of fat and carbs is 30:55). which best describes
number of calories that should be provided by fat in this its diet each day?
- 630

- 630
65-year-old man with 4-hour history of intermittent severe pain in flank area radiating to genital region. History of hypercalciuria and renal calculi. Drug
decrease the urinary excretion of calcium?
- Hydrochlorothiazide

- Hydrochlorothiazide
48-year-old man 2-month increasing abdominal girth and inability to achieve erection. Smoked 1 pack cigarettes for 20 years and drug 1 pint of liquor daily.
Vitals normal. PE shows scleral icterus, spider angiomata, gynecomastia, ascites and prominent umbilical venous pattern. Tests small. Cause of
gynecomastia?
- Failure of liver to degrade estrogen

- Failure of liver to degrade estrogen

Randomized controlled trial evaluating tx of acute otitis media. No statistically significant differences found between infants receiving the antibiotic and
those with standard tx. Which aspect results in type II error?
- Number of subjects in the study
18-month-old girl with 2 day progressive cough and hoarseness. T 102.2F, HR 88, RR 24, bp 100/70. Oxygen saturation 95%. PE mild erythema of
oropharyngeal and laryngeal mucosa no exudate, harsh, barking cough heard. Improves within 4 days. Cause?
- Parainfluenza
34-year old man is brought to the ER semiconscious and combative. In addition to sedation , a short-acting neuromuscular blocking agent is administered for
intubation to prevent aspiration. Within a few seconds after admin of the drug, he has transient muscle fasciculations in his face ; he develops generalized
paralysis within 1 minute. Forty five minutes after completion of the procedure , he is still paralyzed. A genetic abnormality of which of the following
enzymes is the most likely cause of his unusually slow recovery from paralysis?
- Pseudocholinesterase

Pseudocholinesterase deficiency is a condition in which a person's body is abnormally slow at breaking down a certain
class of drugs used for surgical anesthesia. Known as choline esters, the most commonly used of these drugs is called
succinylcholine (suxamethonium).

Different from malignant hyperthermia where person presents w/ fever and muscle contractions and its due to mutation
in voltage sensitive ryanodine receptor causing an increase in Ca release from sarcoplasmic reticulum
67-year-old man who eight months ago dx with primary lung carcinoma involving adrenal glands, liver, and bone. Had 17.6-lb weight loss during 3 months.
PE shows cachexia and significant muscle wasting. Intracellular components increased in patient's muscle cells?
- Autophagic vacuoles
83-year-old with arteriosclerosis undergoes repair of infrarenal abdominal aortic aneurysm. Graft extends just below the renal arteries to the bifurcation of
the aorta. Which organ will lose primary blood supply and rely on collateral circulation?
- Descending colon

Branches off the abdominal aorta (Superior to inferior)

Celiac trunk
SMA
Renal
Gonadal (on left side)
IMA
Bifurcation at L4 in to Left and Right common illiacs

IMA supplies (Hindgut) Distal 1/3 of transverse colon to upper portion of the rectum.
25-year-old woman with fatigue for 3 wks and intermittent fever for 7 days, had teeth cleaned a month ago, no abx for prophylaxis, and had rheumatic
fever as child and endocarditis 4 y ago. PE shows 2/6 murmur, ultrasound shows abnormal mitral valve. Photo of growth from blood cultures shown (GP
cocci in chains). Characteristic of causal organism?
- Greening reaction on blood agar

- Greening reaction on blood agar

The “greening reaction” is another

name for Alpha-hemolysis on
blood agar.
38-year-old man 1-week shortness of breath with exertion, light palpation of carotid artery shows upstroke is abnormally brisk and downstroke falls
precipitously. Cause of finding?
- Aortic Regurgitation
45-year-old man comes to the physician because of an enlarging face shoulders and trunk and thinning of his arms and legs. Physical examination shows a
large plethoric face, fat pad over the upper thoracic spine and purple striae on the abdomen. Serum studies show undetectable ACTH and an increased
cortisol concentration. Administration of low dose dexamethasone would most likely result in which of the following sets of serum findings?
- ACTH no change, cortisol no change

- ACTH no change, cortisol no change

In a normal person, Dexamethasone provides negative feedback to pituitary, thus ↓ ACTH secretion which then ↓ cortisol production.
It NOT making a change means this process is outside the normal axis.

In our patient, ACTH is undetectable so therefore it is likely an ACTH independent Cushing’s syndrome (meaning it doesn’t involve the anterior pituitary)

So this is most likely either exogenous glucocorticoids or an adrenal tumor.

55-year-old woman who is a physician has fractured femur during motor vehicle collision. 2 days after admission, has tachycardia, restlessness, diaphoresis,
anxiety, seeing "vague shapes" on walls. Dx?
- Alcohol withdrawal
58-year-old man comes to the physician because of a 4-year history of recurrent cough productive of increased sputum. Use of over-the-counter cough
suppressants has not resolved his symptoms. He has smoked 2 packs of cigarettes daily for 35 years. He has no family history of lung disease. His
temperature is 37°C (98.6°F), pulse is 72/min, and respirations are 18/min. Physical examination shows cyanosis. Diffuse wheezing is heard on auscultation.
Which of the following pulmonary cell types is most likely to be abnormal in this patient?
- Pseudostratified columnar epithelial cells
17-year-old boy with syncopal episode, fever, nausea, muscle aches, progressive confusion. T 103.5F, palpable bp 80. PE rash on lower extremities. WBC
26,000. Blood and CSF cultures grow oxidase positive, gram negative diplococcus. Brother with similar infection at same age. Immune disorder?
- Late component of complement deficiency
56-year-old exposed to possible chemical attack. Respirations labored, diaphoresis, excessive lacrimation, increased salivation, muscle strength 2/5, urinary
and fecal incontinence. Besides atropine, another tx?
- Pralidoxime

- Pralidoxime
Section 2
44-year-old woman 15 weeks' gestation with uterus consistent size with gestational age. Amniocentesis shows increased alpha-fetoprotein (AFP). Fetus at
greatest risk for which defect?
- Spina bifida
33-year-old woman who three weeks ago, underwent oophorectomy for epithelial ovarian cancer. Recommends adjuvant chemotherapy with paclitaxel.
Mechanism?
- Inhibits microtubule disassembly
Heart of 76-year-old woman shows concentric enlargement of left ventricle. Micro exam shows enlarged myocardial cells with large nuclei. Dx that causes
this cardiac enlargement?
- Hypertension
14-year-old girl with 4 months of heavy menstrual flow. Menarche at 13 with regular intervals. History of frequent nosebleeds and easy bruisability. Father
has problems with nosebleeds and clotting. PE shows mild gum bleeding and ecchymoses. Labs: hb 8.2, hct 24.6, platelet 250,000, bleeding time 10, PT 14
(INR 1.5), PTT 60. Dx?
- von Willebrand disease
45-year-old woman with joint pain due to rheumatoid arthritis comes for infective treatment with over-the-counter agents. Initiate disease-modifying
antirheumatic drug (DMARD). Delayed onset of action of DMARD, so physician prescribes another until DMARD is effective. Drug?
- Prednisone
45-year-old woman dx with cholelithiasis. She asks why abdominal pain is intermittent and not constant. Pain is produced when gallbladder contracts
against gallstone obstructing cystic duct. Where is hormone released from that causes gallbladder contraction?
- Enteroendocrine cells of the small intestine (CCK)

- Enteroendocrine cells of the small intestine (CCK)

CCK (Cholecystokinin) is a Gut Peptide.

CCK is released from I enteroendocrine cells

(meaning that these cells act on neural muscarinic
pathways) found in the upper small
intestine (duodenum and jejunum).

CCK delays gastric emptying, stimulates gall

bladder contraction and pancreatic secretion,
and reduces food intake, all of which optimize
digestive capacities.
35-year old man w several episodes of squeezing chest pain gets angiogram... gets IV NE. Question shows a graph of coronary blood flow with a drop after
the NE and then a rise. Which substance causes increased total coronary blood flow 1-2 mins after NE?
- Adenosine

- Adenosine

Dilated coronary crown: adenosine causes coronary dilation (mediated by A2 receptors)

8-year-old boy with persistent disruptive behavior. Teacher says he's in "constant motion" and never completes assignments. Treated in ER several times
because of skateboarding injuries. Tx?
- Methylphenidate
65-year-old man with cancer of cecum found to have metastatic lesion to liver. Venous route of mets?
- Ileocolic --> superior mesenteric --> portal --> right hepatic branch of portal

FA 2016 pg. 344

- Ileocolic --> superior mesenteric --> portal --> right hepatic branch of portal
67-year-old woman comes to the physician because of a 1-month history of low back pain. She has hypertension well controlled with a thiazide diuretic. Her pulse is 140/min, and blood pressure is 140/85 mm Hg. Physical examination shows tenderness to palpation over the L2-3 vertebrae. Laboratory studies show:
Hemoglobin 13.5 g/dL
Hematocrit 41%
Leukocyte count 10,500/mm3
Segmented neutrophils 65%
Eosinophils 1%
Basophils 1%
Lymphocytes 30%
Monocytes 3%
Platelet count 250,000/mm3
Serum electrophoresis shows a monoclonal spike of IgG kappa. A chest x-ray shows cardiomegaly with bilateral pleural and pericardial effusions. An x-ray of the spine shows a lytic lesion. Echocardiography shows an echodense thickened left ventricle and poor diastolic compliance. A photomicrograph of a specimen obtained on myocardial biopsy is shown. Which
of the following is the most likely cause of the cardiac findings in this patient?
- Amyloid infiltration
4-year-old boy with fatigue and irritability for 2 months. Family visited rural Louisiana 5 months ago and ran around barefoot. Conjunctivae are pale. Labs
shows normal wbc with 15% eosinophils. Stool prep shows parasite egg (picture). Cause of fatigue?
- Microcytic anemia (Necator americanus/Ancylostoma duodenale)
2-year-old girl with febrile seizure. PE shows nuchal rigidity and bacterial meningitis suspected. LP and immediate abx therapy planned, but parents
unavailable for consent. Next step?
- Initiate the procedure and treatment without consent
35yo F has congestive cardiomyopathy and pitting edema. Her serum urea nitrogen concentration is 25mg/dl and serum creatinine is 1.8mg/dl. Furosemide therapy is started. After 5 days, labs show:
Na 130
K 4.5
Cl 90
HCO 30
BUN 85
Creatinine 2.2
Albumin 3
Urine specific gravity 1.023, rbc 0 wbc0 sediment none
Urinary fractional excretion of sodium is less than 1%. Explanation?
- Prerenal azotemia

- Prerenal azotemia

Loop diuretic like furosemide is used to treat edematous states because it inhibits the ascending loop of Henle which
prevents concentration of urine.

But in this case it doesn’t work in stopping kidney injury and BUN/ Creatinine increases so it’s most likely:

Prerenal Azotemia due to decrease in renal blood flow which decreases GFR. Na/H2O and BUN held on to by kidney in
attempt to conserve volume (kidney thinks there isn’t enough due to lack of blood flow) --> increase BUN/ Creatinine
ratio (BUN is reabsorbed but creatinine is not) and decrease in fractional excretion of Na.
57-year-old man with alcoholism dies of klebsiella pneumonia. Abscess cavities filled with purulent exudate on autopsy. Pattern of necrosis in lung tissue?
- Liquefaction

- Liquefaction

Associated with bacterial abscesses and brain

infarcts!

Caseous is associated with ischemia and infarcts in

most tissue except the brain.

Fibrinoid is associated with immune reaction in

vessels

Gangrenous is associated with distal extremity after

chronic ischemia
4-month-old boy with 1-day respiratory distress. Has progressive weakness and difficulty feeding for a month. RR 50/min. PE shows enlarged tongue and
generalized hypotonia. Increased lactate, pyruvate, glucose, and uric acid. CXR shows cardiomegaly. Biopsy of skeletal muscle shows increased glycogen.
Enzyme impaired?
- alpha-1,4-Glucosidase

- alpha-1,4-Glucosidase
34-year-old man burned hands firing pots 3 months ago. He has no pain during or after burn. PE shows mild atrophy of arms and hands, absence of deep
tendon reflexes in upper extremities, and decreased pain and temperature sensations in C4 to T1 dermatomes. Touch is preserved. Dx?
- Syringomyelia

- Syringomyelia
22-year-old nulligravid woman has menses that occur at irregular 26- to 32-day intervals. Height 5 ft 4 in and weighs 187 lb. BMI 32.
PE shows mild hirsutism and velvety brown, thickened skin at the base of the neck and around axillae. Patient has which condition?
- Hyperinsulinemia
35-year-old man with several episodes of dizziness and fainting during the past 2 months. Father and several paternal uncles died suddenly. PE and lipid
studies normal. Angiography shows no coronary artery blockage. ECG shows prolonged QT. Decreased activity in which of following causes this?
- Outward (delayed) rectifying potassium channel

- Outward (delayed) rectifying potassium channel

A study is conducted to compare the incidence of myocardial infarction in patients undergoing two different types of angioplasty or an operative procedure
to manage single-vessel coronary artery disease. A total of 1000 patients are enrolled. Through a chance process, 500 are assigned to undergo the operative
procedure, 250 are assigned to undergo one type of angioplasty, and 250 are assigned to undergo a second type of angioplasty. All patients are followed for
3 years to determine the incidence of myocardial infarction. Which of the following best describes this study design?
- Randomized clinical trial

Randomized clinical trial (not prospective cohort study)

36-year-old woman diagnosed with HIV. Two months ago, started antiretroviral therapy with efavirenz, emtricitabine, and tenofovir. Labs: CD4 352 and
undetectable HIV viral load. Two months ago, CD4 count was 158 and plasma HIV viral load was 5500. Next step?
- Continue efavirenz, emtricitabine, and tenofovir with no changes

- Continue efavirenz, emtricitabine, and

tenofovir with no changes

Don't take anything out. HIV patients should be kept on thier HAART
regimen, which includes 2 NRTIs and one other drug PI/NNRTI/etc).

By keeping these same medications we are not allowing the virus to

become resistant against them directly. The virus has mutated in a
“different” direction and we can try to add another drug to combat that
new mutation.
45-year-old man comes to physician for follow up after appendectomy. There is mild scleral icterus and well healing surgical incision. Lab values show
Total bilirubin 3.2
Direct: 0.2
Indirect 3 mg/dL
Dx?
- Gilbert
35-year-old with Chagas disease and 2-hour history of moderate chest pain. 4.4 lb weight loss in 2 months. Vitals stable. Barium swallow shows dilated
esophagus with beak-like narrowing at lower esophageal sphincter (LES). Biopsy shows?
- Loss of neurons in myenteric plexus
 A transcription factor that activates expression of HMG coA reductase is identified, this TF is initially synthetized as a large precursor protein, with 2
membrane spanning domains. The transcriptional domain is released by proteolysis when the membrane has a decreased cholesterol concentration. The
precursor protein is mot likely initially produced in which of the following labeled area on this labeled diagram of a hepatocyte?
- F, Rough Endoplasmic Reticulum (ER)
Labeled organelle is the rough endoplasmic reticulum, site of protein synthesis
23-year-old woman g1p1, not felt well since delivery 2 weeks ago; ongoing fatigue, inability to breast-feed, light-headedness in upright position. Pregnancy
complicated by preeclampsia and required cesarean delivery, after she required blood transfusions because of hypotension. PE appears lethargic. HR 80, BP
100/50, HR standing 85, BP standing 86/44. Hb 11.6, hct 36%. Serum hormone concentrations?

Prolactin/ACTH/TSH/Aldosterone
- decreased, decreased, decreased, increased
Sheehan syndrome occurred, so all anterior pituitary hormones (and whatever they induce those are
also down)

Aldosterone is up because blood delivery is decreased to juxtaglomerular cells ---> renin ---> ang
II ---> incr aldo.
5-year-old girls with severe leg pain 1 day after fell off sled. Immigrate to USA from Iceland. Has had three bone fractures since birth. Parents are vegan and
don't give diary products. PE shows tenderness, swelling, and limited range of motion of left lower extremity. Xray shows fracture of fibula. Pt has vitamin
deficiency that affects which of the following?

- Intestinal calcium
absorption
Man comes to doc for cast removal. Fracture of left humerus that required open reduction, internal fixation, cast immobilization. Muscle strength is 2/5
with extension of elbow and 1/5 with extension of wrist and fingers. Patient most likely sustained a fracture at (which location in humerus)?

Radial groove (radial N. is the extensors of

arm, wrist and fingers)
Prevalence of high-grade cervical intraepithelial neoplasia in unscreened population is 5%. Prevalence in population with negative Pap smear results is as
high 0.2%. Prevalence decreases, which also decreases?

- Predictive value of a positive test result

36-year-old F with 2 week history of fatigue, bleeding of the gums, and bone pain. Physical examination shows pallor, hepatosplenomegaly, and ecchymotic lesions over extremities. Labs:
Hb 8g/dl
Ht 25%
Leukocytes: 36,000
segm neutr 4%
eosinophils 4%
lymph 6%
mono 6%
promyelo 80%
platelets 25,000
Polymerase chain reaction test shows an mRNA corresponding to the retinoic acid receptor- alfa/promyelocytic leukemia fusion gene resulting from a reciprocal translocation of chromosomes 15 and 17. Treatment w/ all-trans retinoic
acid is started. In response to the therapy, the fusion protein will most likely attract which of the following proteins to form a pre-transcriptional complex?

- Histone acetylase

Tx APL with Vit A derivative that can bind mutated receptors of cells stuck in blast stage
(promyelocytes) and allow them become PMNs.
3-year-old boy 7 days after dx with severe chronic diarrhea due to Giardia. Immunological studies show peripheral leukocytes that express both CD3 and
CD4 and fail to express CD40 ligand. Based on this, the immunoglobulin isotype that predominates has which biological properties?

- Complement activation
21-year-old woman with 2-days history of urinary frequency and pain with urination. T 39 C (102.2 F), pulse 125, bp 96/60. Urine grows gram-negative
bacteria. Virulence factor for adherence to bladder?
- Fimbriae
62-year-old woman with 3-day hx of fever, shaking chills, and left flank pain. Dx acute pyelonephritis and treated with ciprofloxacin. Five days after, sudden
onset watery diarrhea and lower abdominal cramps. T 100.9 F, pulse 80, rr 18, bp 124/88. PE moderate tenderness to palpation in lower quadrants
especially on right and increased bowel sounds. Stool is brown and occult blood negative. Next step?
- Test of the stool for Clostridium difficile toxin
18-year-old woman comes 12 hours after ingesting 100 aspirin tablets in suicide attempt. PE shows tachypnea. Labs?
pH/pCO2/HCO3-
- 7.32/15/8

Aspirin = Salicylates! Can cause and increased anion gap

metabolic acidosis with immediate hyperventilation as
compensatory response.

Primary disturbance= decreased HCO3-

Also have decreased PCO2 (from hyperventilation)

Metabolic acidosis: Both HCO3 and PCO2 is decreased

48yo man with possible hypertension. based on 20 measurements, his average diastolic pressure is 94mmHg, SD is 8mmHg. If only four measurements were
made rather than 20, which of the following statements would best describe the width of the 95% CI with regard the mean blood pressure?
- Larger

SEM = standard error of the mean = An estimate of how much variability

exists between the sample mean and population mean. Increases as the sample
# (n) decreases.

So sample n decreased-> increased SEM and made CI larger!

An investigator conducts a meta-analysis of three genome-wide association studies of Crohn Disease. The studies encompassed 3200 cases and 4800
controls, all of European descent. The initial studies identified 11 significant loci with odds ratios above 1.3 and 1.5; the combined meta-analysis identified
an additional 21 loci with odd ratio of 1.1 to 1.3. It is estimated that the 32 loci identified explain about 10% of the variance in disease risk with 2 loci
accounting for 2% of the variance. Previous studies of twins indicated a 50% heretability rate for Crohn's disease. Which of the following best explains these
results?
- The identified loci account for a relatively small part of the variance
68-year-old man with 3 days of increasingly severe chest pain, shortness of breath, stridor, hoarseness, difficulty swallowing and nonproductive cough.
Long-standing hx of hypertension. Smokes 2 packs of cigarettes for 45 years. T 99 F, pulse 80, rr 15, bp 160/94. PE shows visible pulsation above the
manubrium of the sternum and displacement of the trachea to the right. Murmur second right intercostal space. Dx? - Aortic aneurysm

- Aortic aneurysm

Aortic aneurysm (not pneumothorax)

long standing HTN + visible pulsation are the clues
6-year-old boy with 5-day history of intermittent vomiting and 3-month hx of progressive clumsiness. Can no longer ride bicycle and difficulty getting out of
car. Funduscopic exam shows bilateral papilledema. Neuro exam shows impaired upward gaze and pupil response to light. Walks shuffling gait. CT shows
enlarged lateral and third ventricles and a 2-cm mass. Location of mass?
- Pineal gland
66-year-old man with 1-month hx of nonproductive cough and 6 months shortness of breath. Bilateral end-inspiratory crackles heard. CT chest shows
diffuse reticular opacities at periphery and bases of lungs. Micro exam of biopsy shows patchy interstitial fibrosis, several fibroblastic foci and no
granulomas. Dx?
- Idiopathic pulmonary fibrosis
73-year-old man has poor appetite and lost 25 lb over 4 months. Labs show normochromatic normocytic anemia. Xray of chest shows 2-cm perihilar mass.
Biopsy shows small cell carcinoma of lung. Which is responsible for weight loss?
- Cytokine effect

- Cytokine effect

Cytokine effect (not renal failure)

Cachexia: weight loss, muscle atrophy, fatigue in chronic disease (cancer, AIDS, heart failure, COPD)
- Mediated by TNF-alpha, IFN-gamma, IL-1, and IL-6
54-year-old man with normal renal functions gets a heart transplantation. One year later, bp 170/110 and serum creatinine 2.1. Which drug caused these
findings?

- Cyclosporine
3-year-old boy with progressive fever and skin lesions during 24 hours. T 102.9 F, pulse 120, RR 20, bp 110/60. PE shows large, flaccid, bullous lesions over
trunk and abdomen. Another finding in pt?

- Positive nares culture for toxin-

producing Staphylococcus aureus
28-year-old man infertility, weight lifter and takes anabolic steroids. Mechanism of infertility?
- Suppression of gonadotropins
Investigator studying immune response to fungi. Fungi express beta-glucans on cell surface and that triggers innate immune response. Which tx decreases
glucan expression?
- Caspofungin
72-year-old woman comes to the physician because of a 6-month history of increased bruising on her forearms. She appears alert and well nourished. Physical examination shows extensive wrinkling, scaly erythematous patches on the face, and irregularly shaped brown macules on the face and forearms. There are
ecchymoses in various stages of healing on both forearms; the ecchymoses are more numerous on the right side. Laboratory studies, including a complete blood count and coagulation studies, are within the reference ranges. She has noticed no bleeding from her gums after brushing her teeth. Which of the following is
the most likely cause of the ecchymoses in this patient?

- Extensive solar elastosis – Solar

Don’t get confused with Actinic Keratosis

Actinic keratosis: atypia or dysplasia of the keratinocytes in
the basal layers of the epidermis accompanied by
parakeratosis, thinning of the granular layer, buds of atypical
epidermis extending toward the papillary dermis, dermal solar
elastosis, and inflammation.
98-year-old woman who lives with daughter and grandson comes for routine exam with type 2 diabetes and hypertension but no complaints. She has had
14-lb weight loss since last visit 3 months ago. BMI 15. PE shows multiple ecchymoses in various stages of healing upper extremities and torso. Physician
should ask?
- "Are you safe at home?"
51-year-old with Graves disease develops ulcerating pharyngitis after 6 months of propylthiouracil. What's the underlying cause of ulcerative pharyngeal
disease?
- Agranulocytosis
50-year-old man with pulmonary embolus. Treated with intravenous heparin. 24 hours later, warfarin added. Day 2, partial thromboplastin time is 52
seconds (control 26 sec), and prothrombin time is 12 seconds (control 12.1 sec; INR = 1). Best explanation for normal prothrombin time and INR?
- Long half-life of factor II (prothrombin) (?)
24-year-old woman overdose on drug X and has serum concentration of 32. Drug X follows first-order kinetics. 6 hours later, the serum concentration is 16.
Cannot be moved from intensive care unit until concentration 1.1 or lower. Which is minimum number of hours from first blood sample (32) that patient
must remain in icu?
- 30 hours (5 half lives)

5 half lives * 6 hours = 30

10-day-old male newborn 1-day history red eyes with discharge. Pregnancy uncomplicated but no prenatal care in third trimester. PE bilateral conjunctival
injection with water discharge. Cause?
- Chlamydia trachomatis (gonorrhea occurs earlier and is more purulent)
34-year-old man with herniated lumbar intervertebral disc. Laminectomy and removal of hernia scheduled. CT scan of vertebrae shown, which is surgical
entrance location into neural canal?

- D (the lamina - called a laminectomy)

18-year-old woman get general anesthesia for wisdom teeth extraction. After 5 minutes, gets hypertonicity of skeletal muscles and increased body
temperature. The treatment is a drug that decreases? - Sarcoplasmic Ca release

- Sarcoplasmic Ca release
Section 3
45-year-old homeless man found unconscious. Breath smells of alcohol. Vitals stable. PE shows bronzed skin and spider angiomata on chest. Labs: hemoglobin 10,
hematocrit 30%, MCV 110, WBC 9000, platelets 160,000, ferritin 200, b12 500, folate 20. Blood smear shows hypersegmented neutrophils and 3+ oval macrocytes. Labs?
You are also going to see an elevation of Homocysteine levels in Folate Deficiency. This is
because B12 needs to receive a methyl group from Folate so it can pass it on to
Homocysteine to create Methionine. Less Folate means B12 doesn’t have a methyl group to
pass on and Homocysteine builds up. Unlike B12 deficiencies, Folate deficiency does not
result in a buildup of Methylmalonic Acid or neurological symptoms.

Folate and B12 work closely together handing off methyl groups to each other. It is sort of
like a game of hot potato. Folate doesn’t “want” the methyl group so it passes it on to B12.
B12 doesn’t “want” it either so it passes it off to methionine. In effect, B12 helps recycle
methyltetrahydrofolate back into tetrohydrofolate which can be used to create DNA. This
means that a deficiency of B12 can cause a deficiency of Folate as less Folate is being
recycled into its “active” form. Therefore, B12 deficiency present very similarly to Folate
deficiency. You get Macrocytic/Megaloblastic Anemia with Hypersegmented
Neutrophils and increased Homocysteine levels.
Methylmalonic Acid normal and Homocysteine increased.

Alcoholic with a Folate Deficiency!

Folate and B12 needed for: Homocysteine -> Methionine -> DNA synthesis

B12 only needed for:

Methylmalonic acid -> Succinic acid -> Myelin synthesis

- Methylmalonic acid: normal, Homocysteine: increased

The key pathway for the development of these neurological symptoms is odd chain fatty
acid breakdown. Odd chain fatty acids are broken down to eventually give Methylmalonyl
CoA. B12 is a cofactor in the process that converts methylmalonyl CoA into Succinyl CoA
which can then be used in the TCA cycle to generate energy. If there is not enough B12 this
reaction is slowed and Methylmalonic Acid builds up. This Methylmalonic Acid build up
is toxic to neurons and leads to demyelination in the posterior and lateral columns of the
spinal cord. This is called Subacute Combined Degeneration and presents with peripheral
numbness/tingling, spasticity, and loss of vibration and proprioception.
http://www.stomponstep1.com/folate-b12-deficiency-megaloblastic-anemia-hypersegmented/
35-year-old woman with 2-day history of blistering lesions on sun-exposed face, arms and hands. Recurrent episodes of skin lesions
over several years. Taking oral contraceptives for 15y. PE shows fluid-filled vesicles and bullae. Labs: AST increased, ALT increased,
total porphyrin increased, urine uroporphyrin III increased. Precursor to uroporphyrin?
- Succinyl CoA

Why it’s the right answer: Dx is porphyria, which

describes a group of disorders, resulting in defective
heme synthesis. The most common type of porphyria is
porphyria cutanea tarda. The deficient or defective
enzyme is uroporphyrinogen decarboxylase. At the start
of heme synthesis, succinyl CoA and glycine combine to
form ALA (via ALA synthase), the very start of heme
synthesis.

Take home point: Porphyria is a group of disorders that

result in defective heme synthesis and the buildup of
uroporphyrin, an intermediate compound. The very
beginning of heme synthesis starts with succinyl CoA and
glycine.
32-year-old woman brought in after 10-foot fall from ladder. PE suggests severe hemorrhage and shock. Xray shows fracture of left
ninth and tenth ribs. Organ injured?
- Spleen
34-year-old man with a 3 month history of a progressive rash on his feet. Rash is not itchy or painful. A photograph of feet is shown.
HIV+. In addition to HAART, which of the following pharmacotherapy is most appropriate?
- Antineoplastic
Newborn is found to have a cervical rib. Transformation of seventh cervical segment to thoracic identity. Which is
true of HOX gene alteration?

- Expression of a HOX gene normally expressed only caudal to C7

A sexually active 32-year-old woman has vaginal pain with urination. Pelvic examination show bilateral vesicoulcerative lesions of
introitus. Tx?
- Acyclovir
3-week-old male newborn with recurrent vomiting after feeding since birth, and eager to feed after vomiting. Abdominal exam shows
firm, mobile mass in epigastrum to right of midline. Dx description?
- Single primary development defect
63-year-old man with abnormal blood pressure. 6 months ago, bp was 135/85. Today bp 170/98. Bruit heard over left renal artery. CT
angio shows left arterial stenosis. Labs?
- Total peripheral resistance increased, plasma renin activity increased, serum aldosterone concentration increased

Why it’s the right answer: The board examiners love these up and down
arrow questions, and they are not something to be intimidated by because
they are usually pretty straight forward as long as you’re able to break down
the clinical vignette.

Here, there’s a guy that had good, well-controlled blood pressure 6 months
ago, but now has very high blood pressure that is a result of gradual onset
- Total peripheral resistance increased, renal artery stenosis. When there is a blockage of one or two renal arteries,
- Plasma renin activity increased the kidney(s) are starved by blood. In reaction the kidneys think blood
- Serum aldosterone concentration increased
pressure is low, so they release factors to increase the pressure in the form
of the RAAS cascade (silly little kidneys). One factor/hormone they release is
renin (from the juxtaglomerular cells). Renin then causes a cascade of other
hormones to be released, including aldosterone, which increases blood
pressure so the kidneys are happy and no longer starved. In other words,
total peripheral resistance (TPR) is increased. The other important thing to
remember is the columns do not go in order necessarily– they should really
in fact be reversed to show first increases renin, which increases aldosterone,
which increases TPR, so don’t be fooled by that.

Take home point: Low kidney perfusion (from things like renal artery stenosis
or fibromuscular dysplasia) leads to activation of the RAAS cascade and an
overall increase in BP/TPR.
5-year-old boy with motion sickness. Planning vacation to Australia, and wants diphenhydramine for motion sickness. Mechanism of
action for motion sickness?

- Antagonist at muscarinic-3 (M3) receptors

63 yo man with mild emphysema has smoked 1 pack for 45 years sudden headache, myalgia and rising temperature. A dry cough
develops, with chill and chest pain. Examination of gram stain of sputum disclose neutrophils, but bacteria are not evident. An X-ray
of the chest is consistent with severe pneumonia. A culture of sputum is negative, but culture of bronchoscopy specimen on a highly
specialized bacteriologic medium yields gram negative rods. The identity of these bacteria is confirmed by staining with specific
fluoroscent antibodies. The patient respond therapy with macrolide Ab. Mechanism?
- Inhalation of aerosol from an environmental source (Legionella)

(Legionella)
67-year-old man with 1 year progressive difficulty writing and walking. Pt is stooped and talks slowly. PE shows bland facial
expression, fine resting tremor in both hands, no tremor when moves, walks with difficulty starting and stopping, cogwheel rigidity.
Brain tissue histology shown as well as gross cross sections of midbrain both normal and diseased. Substance referred to by arrow?
- Alpha-synuclein
Patient making sexual advances towards physician. Appropriate measure?
- Have a chaperone join them
Child with XXY karyotype, genetic studies showed he received the extra "x" from his father. An error of chromosome segregation
occurred during anaphase at which of the following stages of spermatogenesis in the patient's father?
- Primary spermatocyte

Primary spermatocyte (division of X and Y occurs at end of Meiosis I)

Persons are at risk of influenza are vaccination every year because of antigenic variation, which can be drift (minor)
or shift (major). Mechanism of antigenic shift?
- Reassortment
10-year-old boy with 4 days nosebleeds and easy bruising. Three weeks ago, upper respiratory tract infection. PE
ecchymoses on upper and lower extremities. Labs shows hemoglobin and leukocyte count normal, and decreased
platelet count. Bone marrow smear shows increased megakaryocytes. Mechanism of dz? - Antibodies against
glycoprotein (Gp) IIb/IIIa complex

- Antibodies against glycoprotein (Gp) IIb/IIIa complex

28-year-old man with ulcerative colitis, history of partial colectomy, and improved rectal bleeding and diarrhea since then. Meds include mesalamine,
hydrocodone and acetaminophen. He says, "I've been taking so much of my opiate prescription that I ran out and stole some from my job." Next step?
- Discuss treatment options and a referral for detoxification program
52 yo man is brought to er 30min after the onset of chest pain and shortness of breath. He had played tennis all day and he does not
remember how much fluid he had consumed. His temperature is 36.7 oC, pulse 122min, respirations 28min and BP 90/50 mmHg. PE
shows dry skin and decreased capillary refill. An ECG and evaluation of cardiac enzymes show no abnormalities. Which of the
following findings in the nephron best describes the tubular osmolarity, compared with serum in this patient?
PT //macula densa //medullary collection duct
- Isotonic, hypotonic, hypertonic (?)

Macula Densa (combo of cells from ascending loop of henle and distal tubule)
= reabsorption of all of the Na, H2O, HCO3--Dilute tubular fluid-->
Hypotonic

Medullary collection duct: draws H2O and urea out to create a hypertonic
interstitium
45-year-old man with hypertension not compliant with medications. bp 160/100. Cardiac exam shows apical impulse displaced
laterally, loud S2 and S4 gallop. Echo shows thickening of left ventricular wall. Mechanism of change in cardiac muscle?
- Transcription factor c-Jun: increased, beta-myosin heave chain: increased, endothelin: increased

C-jun = Increase transcription

↓
Increased cell size and/or number of cells
↓
increase LV hypertrophy

Endothelin is increased because it causes

vasoconstriction. Plays a role in
pulmonary hyptertension and cor
pulmonale.
(Take knowledge of Primary Pulmonary
HTN and apply it here - in pulmonary
hypertension there is an over production
of endothelin which obliterates the
pulmonary capillaries and thus we give
bosentan (endothelin antagonist)
30-year-old woman with 2-years of numbness, blanching, and bluish color to ears, fingers and toes after emotional upset or cold
exposure. Vitals and PE normal. Avoid taking which drug?
- Phenylephrine

Why it’s the right answer: Dx is Raynaud’s

phenomenon, which is vasospasm of arteries and
arterioles, impairing circulation and resulting in color
changes in extremities, commonly the hands. The
mechanism of vasoconstriction is alpha agonism, so
you would absolutely at all costs avoid drugs that act
as agonists on alpha receptors. The only drug listed
that is an alpha agonist is phenylephrine, specifically a
selective alpha1-adrenergic receptor agonist.

Take home point: Avoid alpha agonists in Raynaud’s

phenomenon.
65-year-old with sudden onset generalized tonic-clonic seizures. Personality change last 6 months; used to be mild mannered and
now verbally abusive. CT shows single mass enhances with contrast in right frontal lobe and crosses to left hemisphere through
corpus callosum. Dx?
- High-grade fibrillary astrocytoma

Why it’s the right answer: It is pretty clear from the question that this is cancer, and that is why the rest of the answer
choices are also all cancers, and we need to figure out which type of cancer this patient has. The key tip-offs to knowing
this is an astrocytoma are the location and characteristic crossover from one hemisphere to the other. Astrocytomas love
the supretentorial region, specifically the frontal lobe, and therefore present with personality changes. Furthermore, the
classic ‘butterfly lesion’ that goes from one hemisphere to the other is also characteristic of astrocytomas.

Why the others are wrong: A meningioma usually presents with localized neurological deficits since it normally has a
mass effect and pushes on the cerebral hemispheres. It also is described on imaging as a mass with a tail, since it is
“sprouting” from the meninges (or at least that’s how I remember it). A schwannoma is classically located in the
cerebellar-pontine junction (know where this is on imaging), and therefore intratentorial, and also will come with other
s/s of hearing loss, tinnitus, ect. Metastasis is typically 2+ lesions, not just the one, but this could have easily been mets
as well, its just that astrocytoma is a better fit for the clinical picture presented.

Take home point: Astrocytomas are single lesions that are often in the frontal lobe, presenting with personality changes
therefore, and “butterfly” from lobe to the other through the corpus callosum.
68-year-old man with creatinine 2.3 due to chronically increased hydrostatic pressure in Bowman space. Cause?

- Benign prostatic hyperplasia

30-year-old woman with a long-standing history of pelvic inflammatory disease has surgical resection of a scarred segment of a
fallopian tube. Which of the following inflammatory cells is most likely to be found in the resected specimen?
- Macrophages
25-year-old woman with polycystic kidneys and 3-month history of weakness, fatigue, headaches, hypertension, loss of appetite and
itching. Cr 4. Labs?
- bicarb (HCO3-) decreased, inorganic phosphorous (PO4) increased, parathyroid hormone increased

Chronic renal disease

↓
(Renal osteodystrophy) secondary hyperparathyroidism
↓
Hypocalcemia, hyperphophatemia, failure of Vitamin D hydroxylation (decreased ca intestinal absorption)

Renal failure: Metabolic acidosis (decrease in bicarb) and renal osteodystrophy

70-year-old woman comes to the physician because of increasingly severe pain in the right knee over the past 3 months. She has
fallen repeatedly. She has a 10 year history of symptomatic osteitis deformans. She has bowed tibia and tenderness of the proximal
right tibia. an X ray shows a fracture of the proximal tibia with elevated periostium and sunburst pattern. an xray of lungs shows
pulmonary nodules of various sizes. which of the following findings is most likely on biopsy.
- Pleomorphic neoplastic cells producing new woven bone
55-year-old man with elevated LDL cholesterol is prescribed lovastatin. This treatment would result in which adaptive responses at
the cellular level? - Increased transcription of HMG-CoA reductase

- Increased transcription of HMG-CoA reductase

(Make sure to read the question properly)
- The inhibition of HMG-CoA reductase
would cause refractory increase in
transmission
7-year-old boy is about undergo an appendectomy. An intravenous catheter needs to be inserted, but the patient is fearful of being stuck with needle. The most appropriate anesthesia administered by mask to anesthetize this patient quickly would have which of the following characteristics?
- Low blood solubility
39-year-old man with 1-week of red spots on shins, joint pain and fatigue. PE shows purpura over lower extremities. Liver palpated 4 cm below costal margin. Labs: WBC 10,000, AST 142, ALT 154, hepatitis C virus RNA positive, anti-hepatitis C virus antibody positive, cryoglobulins positive, C4 120 (N=350-600),
urine protein 4+, urine RBC numerous. Hypersensitivity reaction? - Type III (immune complex-mediated)

- Type III (immune complex-mediated)

Dx is cryoglobulinemia secondary to hepatitis C. And

what do cryoglobulins do to the kidney? Cause
nephrotic syndrome by settling in the kidney and
causing an immune response. So, whenever you have
circulating immune complexes, that is always a type III
hypersensitivity reaction. The boards LOVES the
association between hep C and vasculitis and nephrotic
syndrome secondary to cryoglobulinemia. This question
goes a step further by asking for the type of
hypersensitivity reaction. Also, the 4 types of reactions
are also very high-yield so know all of them and how to
tell the difference between them.
A new antiplatelet agent is developed for the prevention of recurrence of stroke. In a large randomized clinical trial with equal numbers of men and women, the rates of stroke are lower in patients receiving the new agent than in patients receiving the standard treatment. Results are shown:
Recurrent Stroke Rates per 1000 Person-Years
Standard Treatment vs. New Antiplatelet Drug
Women .12 .04
Men .24 .08
Overall .18 .06
Based on these results, which of the following is the relative risk reduction in women?
- 67%

Relative risk reduction= portion or risk reduction attributable to the intervention as

compared to the control= 1-RR
RR= risk of developing dz in exposed group/risk of developing dz in unexposed group
or standard treatment

.04/.12 = .3333
1-0.333 = .67
- Concentration of cAMP
70-year-old man with early morning awakening, decreased energy, difficulty concentrating, anhedonia, psychomotor retardation,
depressed mood for 3 months. He had myocardial infarction and nonsustained ventricular tachycardia 2 years ago. Tx?

- Paroxetine
66-year-old man dies 7 days after myocardial infarction. Gross of heart shown (perforated interventricular wall). Histology? -
Erythrocytes, cellular debris, macrophages, and early granulation tissue

- Erythrocytes, cellular debris, macrophages, and early granulation tissue

56-year-old man comes with vague right-sided flank pain and 7-lb weight loss over past 6 weeks. No recent trauma or back strain.
Urine is darker than usual over 2 weeks. Renal ultrasound shows 1.5-cm solid mass in upper portion of right kidney. Urine shows
50 erythrocytes, 6 leukocytes, no bacteria. Dx?
- Renal cell carcinoma

Why it’s right: This is a patient with recent weight loss, flank pain and hematuria, which at his age, is 100% renal cell carcinoma
(RCC) until proven otherwise. The typical triad is the latter two symptoms (flank pain, hematuria) plus palpable mass. But the
triad doesn’t always need to be completed, and they even further support the dx of RCC by sharing the ultrasound results – a
solid mass. Cystic mass is more favorable for a benign process, and here the word “solid” directs the test-taker towards
malignancy.

Why the others are wrong: Metastasis from another cancer wound not have such prominent urinary findings, and they would
have to give other signs/symptoms (s/s) of another malignancy elsewhere in the body. An abscess is less likely to be a solid
mass – similarly, a hematoma would also not be a solid mass, but a combination of cysts, fluid, etc. An abscess would also
present with fever and have an acute onset with bacteria and WBCs (more than just 6, which is borderline normal) in the urine.
Finally, transitional cell carcinoma is referring to cancer of the ureter or pelvis, located either in the ureter or in the inner portion
of the kidney (the pelvis). The cancer described is not only typical of RCC but also is located on the upper portion of the kidney,
or in the cortex, and therefore must derive from the renal cortex parenchyma itself.

Take home point: Patient >50 YO with weight loss, hematuria, and flank pain is RCC until proven otherwise.
During a clinical study of calcium and phosphorus metabolism, a 50-year-old man undergoes series of
lab studies. His serum Ca, PO4 and PTH are normal. He is given infusion 2 g Calcium chloride over 2
hours. His serum Ca concentration now is 11.5mg/dl. Compared with pre infusion levels, the serum
concentration of which of the following substances is likely to be increased at this time? - 24,25-
Dihydroxycholecalciferol

Why it’s the right answer: First off, it is important to know the sequence of vitamin D metabolism for step 1 because this concept incorporates
not only physiology, biochemistry, and nutrition, but also high-yield diseases like kidney disease (problem with alpha-1-hydroxylase), crohn’s
colitis (issue with vitD absorption), and sarcoidosis (elevated Ca++). So lets take a look:

1) So we start with Vitamin D3 (AKA cholecalciferol, from diet like fortified dairy products and fish oils; or synthesized from 7-
dehydrocholesterol in the skin when exposed to UV rays) à (via the liver) à
- 24,25-Dihydroxycholecalciferol 2) 25-hydroxyvitamin D3à (via the kidney) à
3) (a) 1,25-dihydroxyvitamin D3 (by enzyme 1-alpha-hydroxylase located in the kidney and gets positive feedback from PTH)

(b) 24,25-dihydroxyvitamin D3 (by enzyme 24-alph-hydroxylase also in the kidney)

Now, the question is asking about negative feedback. When there is a high level of calcium, there is negative feedback on the amount of PTH
released (because PTH leads to increased calcium). PTH increases the enzymatic activity of 1-alpha-hydroxylase, an enzymes that converts 25-
Vitamin D3 to 1,25-Dihydroxycholecalciferol. Conversely, low PTH does not activate 1-alpha-hydroxylase when calcium levels are high (such as
in the clinical scenario above). So 25-Vitamin D3 is shunted to the other pathway and converted to 24,25-Dihydroxylase (by another enzyme
that is not important for purposes of the boards). The other choices are ruled out based on the above explanation. This is one of the most
difficult questions on NBME 18 because it requires that you not only know the metabolism of vitamin D as well as the back of your hand, but it
also requires that you know the concept of enzyme kinetics, positive and negative feedback, and specifically where Vitamin D3 goes if its not
being converted to 1,25-Vitamin D and shunted to the other pathway.

Take home point: PTH gets positive feedback from low Ca++ and negative feedback from high Ca+. PTH increases Ca++, and does so in part by
increasing the activity of enzyme 1-alpha-hydroxylase, which converts vitamin D3 to 1,25-Vitamin D, the active form of vitamin D that increases
Ca++ absorption from the gut. When vitamin D3 isn’t being converted to 1,25-Vitamin D, it’s being shunted to its other pathway that forms
24,25-Vitamin D.

For more information, and a great schematic on what I said above in words regarding vit D metabolism, follow this
link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2879391/
16-year-old boy who frequently thinks about sex, daydreams about girls before going to sleep, and masturbates one to two times
daily. After counseling about safe sex, best next step?
- Schedule next routine examination
68-year-old man with alcoholism comes for fever, chills and productive cough of purulent sputum for 3 days. Blood cultures positive.
Gram stain: gram-positive, lancet-shaped diplococci. Vaccine is against which bacterial component?
- Capsular polysaccharide
8-year-old boy with pain on back and head since he fell off swing. Tender 2.5cm swollen mass over right occiput. CT
shows osteolytic and soft-tissue mass in skull with inward displacement of dura. Biopsy shows sheet-like infiltrate of
pale eosinophilic cells with bean-shaped nuclei. Cells positive for CD1a. Electron microscopy of cells shows Birbeck
granules. Abnormal cell type?
- Langerhans cells
29-year-old woman comes to the physician because of irregular menstrual periods since menarche at the age of 12.
She is 5.3Ft and weighs 86kgs. BMI 34. She is evaluated and a diagnosis of PCOS is made. After explaining the
diagnosis, the physician discusses behavioral changes, including dietary modification and exercise as part of her
treatment. Which of the following will ensure adherence?

- Provide follow ups to monitor progress in attaining her goal

60-year-old man 1 day of fever, chills, confusion and memory loss. Returned from Gulf coast where he walked barefoot. Hx of severe cirrhosis and portal
hypertension. T 39C (102.2 F), RR 22, bp 90/48. Physical shows early blister formation on right lower extremity. Blood culture: gram-negative, lactose-
fermenting organism. Bug?
- Vibrio vulnificus

V. vulnificus can cause a wound infection from contact with contaminated water or shellfish.

Salmonella is not a lactose fermenting organism

Haemophilus influenzae is a respiratory gram negative that lactose fermenting doesn’t test for.
50-year-old woman with COPD comes with 3 months of progressive shortness of breath. Physical shows JVD, loud
pulmonary component of S2. Pulmonary function tests show FEV1:FVC ratio of 20% and decreased diffusing capacity
for carbon monoxide. Which is decreased in pulmonary vascular smooth muscle?
- Endothelial nitric oxide synthase production

- Endothelial nitric oxide synthase production

COPD
↓
Hypoxemia
↓
Alveoli constrict in attempt to send blood to more diffused part of lung
↓
High pressure in pulmonary circuit
↓
Atherosclerosis of pulmonary trunk, smooth muscle hypertrophy of pulmonary arteries, & intimal fibrosis so less vasodilation happening and
less endothelial nitric oxidase synthase production
An experimental animal is created that has a defect in an innate gastrointestinal defense mechanism.
Organism is found to have decreased HCl prod. After 2 months on biopsy gastric fundus and body show
decreased mucosal thickness and hyperplasia of enterochromaffin like cells. This closely resembles?
- Chronic gastritis
22-year-old man who is a professional cyclist undergoes extensive physiologic testing as part of his training regimen. His resting pulse
is 33/min, and blood pressure is110/62 mm Hg. Echocardiography shows dilated ventricles with normal function and a left ventricular
ejection fraction of 75%. Which of the following best describes the findings in this patient?
- Eccentric hypertrophy

Why it’s the right answer: “Dilated ventricles” is the key phrase in the stem. A
dilated heart is built from eccentric hypertrophy, or in-line (or in-series)
building and enlargements of muscle cells/fibers. In contrast, a thick heart of
normal size (not dilated) is built from concentric hypertrophy, or parallel
building and enlargement of muscle cells. This is a key concept for the boards
that is repeatedly tested. Furthermore, this patient doesn’t necessarily have
anything wrong with him. He is a professional athlete and works his heart to
the max, so much so that it has become big, and not in a pathological way,
since his EF is still preserved and actually more than it should be at 75%
(normal is ~55-65%).

Why the others are wrong: All of the other choices are suggestive of a
pathological process. Congestive cardiomyopathy would have a decreased
EF. Diastolic dysfunction is incorrect because although in diastolic
dysfunction there is preserved EF with impaired relaxation, the ventricles are
not dilated but usually hypertrophied and thicker; the same reason why
also hypertrophic cardiomyopathy and increased myocardial stiffness are
incorrect – both may have a normal to increased EF, but the ventricles would
be thick not dilated.

Take home point: Eccentric hypertrophy results in dilation, concentric

hypertrophy results in thickening.
20-year-old woman at 27 weeks' gestation is admitted to the hospital because of a 12-hour history of intense uterine
contractions occurring every 8 minutes. Her membranes ruptured 32 hours ago. Her temperature is 39.1°C(102.4°F),
and pulse is 115/min. Physical examination shows tenderness of the uterus. Pelvic examination shows a closed cervix
that is not effaced. The fetal heart rate is 210/min. Which of the following is the primary stimulus for her uterine
muscle contractions? - Inflamed maternal decidua release of prostaglandin

- Inflamed maternal decidua release of prostaglandin

Inflamed maternal decidua release of prostaglandin (not stressed fetal

production and release of oxytocin)

Prostaglandins and oxytocin cause contractions

26-year-old man comes in 2 hours after injuring arm skiing. Sensation to pinprick absent over lateral
aspect of shoulder. Xray of right shoulder shown (fracture of surgical neck of humerus). Nerve
damaged?
- Axillary
18-year-old man comes with cracked lips and peeling sunburned skin. Works as lifeguard. PE shows desquamation of
sunburned skin. Lips are dry and cracked. Petrolatum to lips may reduce lip symptoms by which of following effects
of the compound?
- Barrier
63-year-old woman with 2-week history of daily episodes of severe, lancinating, left-sided facial pain. Pain lasts 30 to 60 seconds and shoots down ear along jawline. Precipitated by chewing or brushing teeth. Dx?
- Trigeminal neuralgia
A previously healthy 35-year-old woman who comes to the physician. Shortness of breath w/ exertion. Jugular Venous Distenstion w/ A wave. Lungs clear. Loud pulmonary S2 and right-sided S4 gallop.

- Endothelin-1
Why it’s the right answer: Dx is pulmonary hypertension secondary to pulmonary fibrosis. An important
point I want to bring up here is that the boards don’t always follow the demographic rules we know and
love – i.e. a middle-aged woman is the classic demographic category for idiopathic pulmonary fibrosis.
However, the board examiners know that everyone is going to get the answers right if they put that there,
so they try to make the question harder (sometimes) by changing it up and maybe giving you a 40-50-
year-old MAN with pulmonary fibrosis. So again, don’t be tripped up. This clinical vignette is still pretty
obvious sans the demographics of the patient based on physical exam alone. And one of the factors that
is upregulated in pulmonary fibrosis is endothelin-1. Another KEY point is that the lungs is the ONLY
organ system, that when starved for blood, vasoconstricts instead of vasodilating. Vasodilation is a
normal response to decreased blood flow à to let more blood flow in!! However, the vessels in the lungs
CONSTRICT and mainly do so through endothelin-1. And the reason they constrict? To not promote
further deoxygenation through a V/Q or shunt defect. Finally, know the drug to treat this condition, which
decreases pulmonary hypertension by antagonizing the endothelin receptor: Bosentan. It could be on
your test (wink wink).

Take home point: Pulmonary artery hypertension (PAH) results from increase in release of endothelin-1.
PAH is a consequent of pulmonary fibrosis. Bosentan is a medication frequently used to treat PAH
through antagonization of the endothelin receptor.
30-year-old man in bicycle collision and hits right shoulder forcefully. Unable to flex right elbow with decreased sensation to pinprick
over right lateral forearm. Brachial plexus lesion?
- E (musculocutaneous nerve)
4-day-old boy with vomiting after breastfeeding. PE shows lethargy and dry mucous membranes. Labs: Na 139, Cl 90,
K 7, HCO3 17, Glucose 42, BUN 25, Cr 0.4, 17-hydroxyprogesterone increased. Enzyme deficiency?
- 21-hydroxylase
67-year-old woman with atrial fibrillation with sudden onset severe abdominal pain. Ex-lap shows embolus in superior mesenteric
artery with complete occlusion of middle colic artery. Ischemic changes where?
- Small intestine, ascending colon, and part of the transverse colon
70-year-old man comes with skin blistering for 1 week. No oral lesions. Physical shows tense bullae in joint folds of upper and lower
extremities. Biopsy shows subepidermal blister formation. Immunofluorescence microscopy shows antibodies against proteins at the
dermal-epidermal junction. Target by antibodies?
- Hemidesmosome

Why it’s the right answer: This is a pretty basic question on bullous pemphigoid, which is the dx
presented in the vignette. In this autoimmune disease, antibodies are directed against the
hemidesmosomes, which link the dermis to the overlying epidermis. You either know this one or you
don’t, basically.

Take home point: Bullous pemphigoid is a disease of the hemidesmosomes and characterized by a
linear immunofluorescent pattern that highlights the dermal and epidermal junction. Conversely,
pemphigus vulgaris, the other high-yield autoimmune skin disease that’s tested on the boards, is a
disease in which autoantibodies target desmosomes, creating a circular immunofluorescence pattern
INTRAdermally.

Bullous pemphigoid: Layer - deep, age - elderly, blisters - tense/firm, oral lesions - rare, Nikolsky's sign -
negative, Immunofluorescence - Basement membrane, target antigen - hemidesmosome, blister
content - hemorrhagic

Pemphigus vulgaris: Layer - superficial, age - middle-age (not always), blisters - flaccid, easily rupture,
oral lesions - common, Nikolsky's sign - positive, Immunofluorescence - intraepidermal, circular, target
antigen - desmosome, blister content - fluid-filled
Section 4
33-year-old man dx with epilepsy age 10 years. Most recent generalized tonic-clonic was 5 years ago. Medication was adjusted.
Current meds include carbamazepine. He's never had any collisions while driving his motor vehicle. Patient's status with respect to
driving?

- He is medically qualified to drive

45-year-old woman with 4-month joint pain, muscles aches and fatigue. Had a renal calculus 6 months ago and had cholecystectomy
1 year ago. Appears fatigue, depressed, there is mucosal pallor. No masses palpated in neck. Labs: erythrocyte count 3 million, K+ 4,
Cl- 106, Ca2+ 13, phosphorous 2.7, alk phos 125. Technetium-99m scan shows 1.2 cm nodule in neck. Mutation?
52-year-old with chronic pancreatitis is deficient in which enzymes that causes inability to digest triglycerides?

- Colipase
25-year-old woman comes for counseling prior to conception. Has seizure disorder on valproic acid. Fetus at greatest risk for drug-
related adverse effect during which pregnancy stage? - 3 to 8 weeks

- 3 to 8 weeks
Study designed to test the effectiveness of a new drug in the treatment of endometriosis, 100 women randomly assigned to one of
two groups. 48 of women receive new drug, 52 receive standard therapy. The primary purpose of this method of assigning patients to
different groups is to create which of the following ?
- Two groups with similar underlying characteristics
45-year-old man bmi 26, total cholesterol 200, HDL 50, triglycerides 550. Which drug to prescribe?

- Fenofibrate

Upregulates LPL -> increase in triglyceride clearence and

it will activate PPAR-A to induce HDL synthesis

Colestipol = Bile acid resin which actually slightly

increases triglycerides and predominately used to decrease
LDL by preventing intestinal reabsorption of bile acids;
liver must use cholesterol to make more
4-year-old boy (pedigree shown) has clumsy gait for past year. Exam calf hypertrophy and proximal muscle
weakness. Creatine kinase increased. Muscle biopsy shows loss of muscle tissue, regenerating muscles fibers and
fibrosis. Maternal uncle had similar findings and died at 15 years. Patient's sister is pregnant. Ultrasound identifies
male fetus. Probability fetus has disorder? - 1/4

- 1/4
32-year-old woman has operation for hyperparathyroidism. Three parathyroid glands found but one does not appear
in normal superior location on right side. Embryologic event that led to this?

- Abnormal migration of endoderm from fourth pharyngeal pouch

27-year-old man for psychiatric eval sent by employer because he is "very odd." Is a computer repair specialist and
lives alone. Refuses to socialize and has no friends. Extremely preoccupied with science fiction, occult, afterlife.
Personality disorder?
25-year-old-man who has a history of facial flushing and rapid heart rate each time he consumes a small amount of alcohol
participates in study of alcohol intolerance. Molecular analysis shows presence of a lysine (K487, oriental variant) for glutamate
(E487, native variant) substitution in aldehyde dehydrogenase. Kinetic characteristics of the enzyme variants shown:
Enzyme Km (NAD+) microM Kcat (min-1)
E487 37 180
K487 5600 9.5
based on these findings, which of the following is the most likely cause of this man's condition?
35-year-old woman pain in left leg 2 days. PE shows deep venous thrombosis. Labs: platelet 200,000, PT 12 (INR 1),
PTT 37. Heparin started. Five days later, platelet 120,000. Reason for decreased platelets?
- Drug-related antibodies

- Drug-related antibodies
21-year-old man loses 15% total blood volume 2 minute after motor vehicle collision. Finding most likely? - Increased
sympathetic nerve traffic to sinoatrial node

- Increased sympathetic nerve traffic to

sinoatrial node
19-year-old woman 2-day history of pain in left index finger. Injured it when catching a ball. PE shows erythema of
left index finger. Unable to flex the distal phalanx when proximal interphalangeal joint metacarpophalangeal joints
restratined. Xray normal. Injured structure?
- Flexor digitorum profundus tendon

- Flexor digitorum profundus tendon

(don’t read the question wrong)
65-year-old woman with 6 hour Hx fever and shaking chills. 4 hours ago, she took 325 mg aspirine tablets. Temp 39.4 C, pulse 96/m, respiration 18/m and blood pressure 102/60 mmHg. Physical examination shows marked tenderness bilaterally in the costovertebral areas. Lab studies show :

Hb 13 g/dl
Ht 39%
Leukocyte count 32.000/mm3
Urine ph 6
Nitrites 4+
Leukocyte esterase 4+
A photograph of wright stained peripheral blood smear, which the most likely cause this patient leukocytosis ?
 55-year-old man northern European descent with 2-month weakness, altered skin color, bilateral knee pain. Siblings have type 2
diabetes and cirrhosis. PE bronzed skin, hepatomegaly, arthritis. Increased saturation of transferrin and ferritin. Liver biopsy
increased iron content and cirrhosis Greatest risk?
- Hepatocellular carcinoma

Hemochromatosis!

From multiple blood transfusions or hereditary HFE

mutation (can result in heart failure, "bronze
diabetes," and increase risk of hepatocellular
carcinoma

Classic triad = cirrhosis, DM, and skin pigmentation

2-year-old boy 2-day history of fever, sore throat, rash. T 101.7 F (38.7 C). Widespread, red, sandpaper-like rash on extremities.
Purulent exudate over tonsils. Dx streptococcus pyogenes (group A) infection. Cause of skin findings?
- Erythrogenic toxin
27-year-old primigravid woman at 18 weeks gestation comes to physician for routine prenatal examination. The
uterus consistent in size with 18 week gestation. Ultrasonography shows a male fetus. The collecting system and
pelvis of the left kidney is dilated and the renal cortex appears compressed. The left and right ureters are not dilated.
The right kidney appears normal. Amniotic fluid volume is normal. Which causing renal finding in this fetus ?
- Incomplete recanalization of proximal ureter
A 70-year-old woman comes to the physician for a routine pelvic examination. During speculum examination of the
vagina and cervix, the Valsalva maneuver causes a bulge of the anterior vaginal wall. Which of the following is the
most likely cause of this finding?
- Cystocele
Workbench wiped down with alcohol, successfully inactivates viruses with which characteristic?
- Enveloped virion

Alcohol denatures proteins and disrupts cell membranes.

52-year-old female with a history of breast cancer who received 4week course of radiations 6 months ago comes for
followup. Exam shows no cancer recurrence. rr 26/min. CT chest shows b/l atelectasis in upper lung fields. Primary
pathophysiological cause?
- Contraction (secondary to radiation)

- Contraction (secondary to radiation)

Atelectasis = loss of lung volume due to inadequate expansion of air space.

Contraction Atelectasis: radiation causes local or general fibrotic changes in lung or pleura which makes full
expansion not possibly and causes and increase in elastic recoil during expiration (stiffer lungs).
17-year-old boy brought by mother with concern that puberty is delayed. When mother leaves room, patient states,
"I'm fine. I don't know what's the matter with her. She wants me to be tall like my dad." Patient is 175 cm (5 ft 9 in)
tall and weighs 70 kg (155 lb); BMI 23. Sex development is Tanner stage 4. Most appropriate next statement to
mother?
- "Tell me more about your concerns about your son's height."
82-year-old woman comes to the physician because of constant severe lower abdominal pain and fever for 24 hours.
Laproscopic examination shows severe diverticulosis and perforated diverticulitis. In spite of appropriate therapy she
dies 2 days later. Liver autopsy shown. Which of the following is the primary component of the material shown on
the hepatic surface?
- Fibrin

- Fibrin
1-3 days after: yellow pallor on liver lots of neutrophils! Fibrinous so material
shown on hepatic surface is made up of fibrin
35-year-old woman with infertile, receive injection of contrast material into cervix. On hysterosalpingogram (shown), contrast
material (indicated by arrows) also seen in peritoneal cavity, which explain this finding?
- Spillage of contrast which normal
69-year-old woman with 3-week history of muscle cramps, weakness, abdominal pain, and constipation. Hypertension treated with
metoprolol and hydrochlorothiazide for past 4 months. Labs show hypokalemia. Which drug should be added?
- Triamterene (potassium-sparing)
60-year-old man for routine health examination. Has had normal blood pressure measurements. BP today
170/95mmHg. Physical examination shows no other abnormalities. Serum show hypokalemia and metabolic
alkalosis. Plasma renin activity and serum aldosterone concentrations are increased. Following the administration of
captopril, there is a marked increase in plasma renin activity. Which of the following is the most likely cause of the
findings in this patient?
- Renal artery stenosis

- Renal artery stenosis

45 yr old man with SOB on exertion x 6 months, nosebleeds since adolescence, 2 pics: clubbing + hemorrhagic lesions
in tongue, inhaled albuterol doesn't improve his symptoms. Cause of symptoms?
- Pulmonary AV shunting
Disease is osler weber rendu

- Pulmonary AV shunting - Disease is osler weber rendu

1-year-old boy with rash for 2 weeks. 10th percentile for height and weight. PE scaly, seborrheic eruption over scalp,
palms, back, diaper region and soles of feet. Generalized lymphadenopathy and hepatosplenomegaly. Xray of skull
shows osteolytic lesions. EM biopsy of skin shows tennis racket-shaped bilamellar granule in cytoplasm. Immuno
studies show CD1a antigen expression. Abnormal cells in patient are derived from which cell?
- Dendritic cells
63-year-old man 2-week sensation of fullness in left upper quadrant. Has lethargy and shortness of breath. 20-lb
weight loss during 3 months. PE shows pallor. Spleen tip palpated. Labs: hb 9, hct 27%, wbc 4000, serum uric acid 15.
Peripheral blood smear numerous erythrocytes with abnormal shapes and sizes, nucleated erythrocytes and
myelocytes. Aspiration of bone marrow dry tap. Biopry shows thickened bony trabeculae with increased reticulum.
Dx?
- Myelofibrosis
After operation, 65-year-old patient has lung region that is underventilated but well perfused. Which increases?
- Physiologic shunt

- Physiologic shunt
58-year-old woman with 6-month shortness of breath and chronic nonproductive cough. 2-year history difficulty swallowing, joint
stiffness, diffuse tightening of skin on face, neck, shoulders, arms, fingers. Sensitivity to cold weather, turn white. Hx of esophageal
reflux. Biopsy showed atrophy of epidermis and deposition of collagen throughout dermis with loss of dermal appendages. PE
cutaneous ulceration, clawlike flexion deformity, decreased joint mobility. At risk for which pulmonary disorder?
- Pulmonary hypertension (dx: systemic sclerosis/CREST)
A 25-year-old woman comes to the physician because of a 2-year history of intermittent, diffuse, cramping lower abdominal pain. The pain is usually associated with2 to 6 days of loose, watery stools, and is typically relieved with defecation. Between these episodes, her
stools are normal. Her vital signs are within normal limits. Physical examination shows no abnormalities. Laboratory studies, including complete blood count, metabolic panel, and thyroid function tests show no abnormalities. A drug targeting which of the following
mechanisms of action is most appropriate for this patient?
- Accentuation of μ-opioid myenteric plexus receptor
48-year-old woman with gradual onset back pain past 2 weeks. No trauma. Doesn't smoke cigarettes,
drink alcohol or use drugs. Hemogram, serologic studies and urinalysis unremarkable. Xray of spine
shows two lytic lesions, in T-10 and L-1. Dx?
- Metastatic carcinoma of the breast

- Metastatic carcinoma of the breast

Bone Mets (most to least common): Prostate, breast>lung, thyroid, kidney
A 68-year-old man comes to the physician because of a 1-month history of light-headedness and tightness in his chest with exertion. He adds that the pain is worse after arguing with his wife, and the symptoms resolve with rest. He has a past history of lower
gastrointestinal bleeding; evaluation at that time was negative on upper endoscopy and colonoscopy. His temperature is 37°C (98.6°F), pulse is 85/min, respirations are 15/min, and blood pressure is 110/75 mm Hg. Physical examination shows no abnormalities. His
hemoglobin concentration is 8.2 g/dL, and hematocrit is 24%. Test of the stool for occult blood is positive. An ECG shows no abnormalities. Repeat colonoscopy shows no abnormalities. Which of the following is the most likely cause of this patient's gastrointestinal
symptoms?
- Angiodysplasia

- Angiodysplasia
1-year-old has numerous infection of skin and oral mucosa since birth. Infections slow to respond to antibiotic therapy. T 100.4F. PE
multiple erythematous lesions of skin some with superficial ulceration. WBC 21,000 77% segmented neutrophils, 6% bands, 14%
lymphocytes and 3% monocytes. Biopsy shows no neutrophils in dermis or epidermis. Culture of lesion grows Staphylococcus aureus.
Defective
- An integrin

Integrin= membrane proteins that maintain the integrity of basolateral

membrane by binding to collagen and laminin in basement membrane

Leukocyte adhesion deficiency Type 1 (AR)

Defect in LFA-1 integrin (CD18) protein found on phagocytes--> impaired

migration and chemotaxis

Increase in neutrophils but no neutrophils at lesions

Leads to recurrent bacterial skin and mucosal infections with absent pus
formation, impaired wound healing, and delayed separation of umbilical
cord (>30 days)
58-year-old man comes to physician for benzodiazepine prescription for situation at work. Feels anxious and thinks
he can complete last 2 years of work if anxiety decreases. Gives 1-month regimen of benzodiazepine. Wife calls, "My
husband got fired! I know it was because he was taking too much of that drug you gave him. Didn't you know he had
history of alcoholism?" Initial action?
- Contact the patient to discuss the situation
35-year-old from group home comes for worsening behavior for 2 weeks. He believes CIA is spying on him through television set.
Reports hearing voices in hall outside and that CIA now plans to kill him. Appears disheveled with unkempt hair and poor hygiene,
difficulty answering questions because listening to internal stimuli. Mental status exam will show which?
- Flattened affect

- Flattened affect
32-year-old man with X-linked recessive disease has deafness, hematuria and progressive renal failure. Protein
abnormality?
- Type IV collagen
25-year-old man just returned from work as worker from Africa begins oral chloroquine therapy for malaria caused by Plasmodium
vivax. His initial therapeutic response is good, but he develops recurrent parasitemia 2 months later. Which of the following best
explains the recurrence ?
- Chloroquine is ineffective on the exoerythrocytic malaria tissue stages
21-year-old woman with 10-days difficulty walking. Two years ago had loss of vision in left eye which improved. Neuro exam shows
decreased visual acuity in left eye with pallor of optic disc. Has past-pointing on a finger-nose test. Broad-based gait. MRI shows brain
lesions in white matter of cerebellum. Pathogenesis?
- CD4+ T lymphocytes are activated by myelin basic protein
46-year-old woman with 1-week low-grade fever and joint pain. Has chronic headaches and takes ibuprofen several
times. PE diffuse maculopapular rash. UA 2+ protein, 10-20 WBC and eosinophils. Renal biopsy would show what?
- Inflammatory infiltrates in the interstitium

- Inflammatory infiltrates in the interstitium

8-year-old girl is brought to the physician by her mother because of a 3 week history of poor feeding chronic diarrhea and pale foul
smelling stools. Mother says the symptoms began with colicky abdominal pain following introduction of solid food to the infant's
diet. History of gluten sensitivity. 60th percentile for length and 25th percentile for weight. Which cell is dysfunctional?
- Enterocyte

- Enterocyte
68-year-old man with a 10-month history of shortness of breath and swelling of his feet, family history of
cardiovascular disease. He smoked 2 packs of cigarettes daily for 50 years. Pulse 80/min, rr 24/min, BP 150/80. PE:
3+pitting edema of lower extremities. Diffuse, scattered wheezes are heard bilaterally on auscultation of the chest.
Grade 2/6 pansystolic mumur heard best at lower left sternal border, which increases on inspiration. Maximal
impulse palpated in sub-xiphoid area. S1 and S2 sounds are distant. Liver span 14 cm. Diagnosis?
- Cor pulmonale

Cor pulmonale, as pulmonary hypertensive heart disease is frequently called, constitutes right ventricular hypertrophy,
dilation, and potentially failure secondary to pulmonary hypertension caused by disorders of the lungs or pulmonary
vasculature and is the right-sided counter part of left-sided (systemic) hypertensive heart disease. Although quite
common, right ventricular thickening and dilation caused either by congenital heart diseases or by diseases of the left
side of the heart and the resultant pulmonary venous hypertension owing to postcapillary obstruction to blood flow are
excluded from this definition of cor pulmonale.

http://www.score95.com/blog/blog/usmle-pulmonary-right-sided-hypertensive-heart-disease-cor-pulmonale/
2-month-old boy well child exam, mother with no concerns. 25th percentile for length and 30th percentile for weight. Cardiac exam
shows blowing holosystolic murmur best heard at lower left sternal border. Cause?
- Ventricular septal defect
47-year-old woman with irregular, raised, multicolored dark lesion on left forearm with frequent sunlight exposure.
Biopsy shows malignant pigmented cells. Worst prognosis with involvement of which layer?
- Subcutaneous tissue

- Subcutaneous tissue
Deepest layer/ deeper the tissue involvement is the worse the prognosis
6-year-old girl with 15-minute history of severe shortness of breath. Diagnosed with throat tumor 3 years ago. RR 32.
PE nasal flaring. Laryngoscopy shows multiple raised, finger-shaped lesions from vocal cords and epiglottis. Lesions
excised and shows finger-shaped fibrovascular cores lined with benign squamous epithelium. Causal virus?
- Human papillomavirus, type 6
 32-year-old man with HIV infection follow up examination, has been treated with HAART for the past 6 years HIV plasma viral load
has been undetectable. HIV viral load now increase, antiretroviral resistance suspected. HIV genotype analysis confirms that the virus
has resistance mutations, which of the following most likely mutated?
- Reverse transcriptase and protease (the two targets of HAART therapy, therefore if therapy stopped working, must be these two
target proteins of virus mutated)

- Reverse transcriptase and protease

- The two targets of HAART
therapy, therefore if therapy
stopped working, must be these
two target proteins of virus
mutated)
35-year-old primigravid woman 36 weeks' gestation with 6-hour history of heavy vaginal bleeding. No prenatal care.
Ultrasound shows placenta over cervical os. Can't stop bleeding and has cesarean. Dx?
- Placenta previa
17-year-old boy in septic shock unresponsive to ADH (vasopressin). Treat is discontinued, and high-dose dopamine in started. Which
receptors are stimulated?
- alpha1-adrenoreceptors

A1 (Gq protein linked phosphlipase C receptor)

when stimulated VASCONSTRICTS

Dopamine is a sympathomimetic!

At high doses: provides vasoconstriction due A1

effects!

At low doses: inotropic (modify force or speed of

contraction of heart muscle) and chronotropic
effects ( change heart rate and rhythm by
affecting heart's conduction system and the
nerves that influence it)