NBME CBSE ACTUAL EXAM 200 QUESTIONS AND ANSWERS LATEST (usmle step 1)MEDICAL EXAMINATION, SCORED AN A!!!

1. 70yo M dies in a motor vehicle collision. Was undergoing evaluation for occult blood in the stool. Photo of transverse colon shown. Dx? Tubular adenoma 2. 38yo M with 1-week hx of watery, itchy eyes and a runny nose. Physical shows inflamed nasal mucosa. No congestion in lower lung. Pharmacotherapy? Loratadine 3. 16yo girl with 3-day hx of fever, nonproductive cough, and fatigue. T 38.3, P 88/min, BP 102-70. PE shows pale conjunctivae. CXR shows bilateral interstitial infiltrates. Blood spontaenously agglutinates while awaiting transport to the laboratory. Antibody isotypes causing agglutination? IgM 4. 24yo M with small tender blisters on his penis 3 days after unprotected sex. Photograph shown. Causal agent? HSV-2 5. 42yo F with 3-year hx of an intermittent facial rash, including the forehead, eyelids, nose, and cheeks. Rash seems to be getting worse since she moved from New York to Florida last year. Spicy foods precipitate a flushing reaction that seems to exacerbate the rash. PE shows erythema over the nose and cheeks, with scattered telangiectasias and a few papules. Dx? Rosacea 6. 53yo M returned from Africa, has fever, headache, and abdominal discomfort. Received appropriate vaccinations prior to the trip. T 39.4C. A wright-stained peripheral smear shown. Dx? Malaria 7. 68yo F with T2DM and hypertension that has been poorly controlled despite hydrochlorothiazide treatment. BP 150/96, Labs show serum glucose concentration of 130 and proteinuria. In addition to current Rx, which is most appropriate pharmacotherapy? Lisinopril 8. 66yo M with stage IV colon cancer with 3-day hx of severe diarrhea after receiving chemotherapy with fluorouracil, leucovorin, and Irinotecan. prescribed opioid antidiarrheal agent with no CNS effects. Which med? Loperamide 9. 35yo M in ED with 2-hour hx of sever fatigue and dizziness. Had profuse, watery diarrhea for 8 hours despite a lack of oral intake. Recently returned from a medical relief trip to a remove village in Honduras. T 36.7 C, P 122/min, BP 90/50. PE shows dry skin and decreased capillary refill. Stool for occult blood is negative; stool is gray and turbid. Gram stain shows gram-negative, comma-shaped bacteria; no erythrocytes of leukocytes. MOA of toxin? Activation of adenylyl cyclase 10. 59yo F with gradual onset of lack of muscle control in her left arm and leg. Sx 1 mo ago after dx with metastatic breast cancer. PE shows ataxia of left upper and lower extremities. Muscle strength, DTR, sensation, proprioception normal. Metastatic tumor in which location? cerebellum 11. Newborn delivered at 38 weeks' gestation weighs 1800 g. PE shows petechial rash, microcephaly, and hepatosplenomegaly. Serologic test for CMV: IgG + in mother, + in newborn; IGM - in mother, + in newborn. Explanation? Congenital cytomegalovirus infection 12. Female newborn is delivered at 38 weeks' gestation. Apgar 8 and 8 at 1/5 min. PE shows a bulging, fluod0filled mass approximately 5 cm in diameter in the midline over the lumbosacral region. No spontaneous movements of the lower extremities. Abnormality most likely occurred because of abnormal development during which periods of postconception (in days)? 15 to 40 13. 64yo M in ED 3 hours after SOB with exertion and extreme fatigue. Has ischemic heart disease. P 125/min, BP 105/60. ECG shows atrial fibrillation. Intravenous ibutilide is administered. Ten minutes later, ECG shows normal sinus rhythm. Risk for which drug effect in the next 6 hours? torsades de pointes 14. 65yo F with 20-year hx of osteoarthritis of the hands now has pain radiating down the distal anterior thigh, knee, medial leg, and food. Bony outgrowth of vertebrae compressing one of the spinal nerves is suspected. Nerve root in which intervertebral foramina is effected? L3 to L4 15. 38yo M with 3-year hx of T2DM. Taking an oral antihyperglycemic agent, he has tried diet and exercise. BMI 32. PE normal. Hb A1c is 10%. Physician recommends initiation of insulin injections. Responds, "I know that insulin would help control my blood sugar. But a lot of people in my family have diabetes, and insulin made them really sick at times. Patient is at which stage of change? contemplation 16. 24yo M with 2-day history of an itchy rash on his arms and legs. Returned from a camping trip in the woods 5 days ago. PE shows edematous, erythematous rash with linear vesicles. Cause is activation of which cell types? T lymphocytes 17. 70yo M from china with poorly differentiated monoclonal carcinoma of the nasopharynx. DNA probes of neoplastic cells are most likely to detect genome of which virus? EBV 18. Epidemiologic study of aniline dye, 500 workers with bladder cancer and 200 workers without. Exposed to aniline dyes/Have Bladder cancer: Yes/Yes (250), Yes/No (50), No/Yes (250), No/No (150). Odds ratio? 3 19. 24yo M with hx of IVDA could not be aroused. Friend reports that the patient injected himself with a drug 6 hours ago. Labs show drug concentration of 0.3. Assuming first-order one-compartment kinetics, has a half-life of 2 hours, and a volume of distribution of 200 L in this patient. What is quantity of drug (in mg) injected? 480 20. Compound is taken up by bacterial cells. No energy is necessary for uptake, and the compound is not concentrated in the cell. Which describes this mechanism of transport? carrier-mediated diffusion 21. Newborn has male genital ducts but female external genitalia. Cytogenetic analysis shows a 46,XY karyotype, and genetic testing shows a mutation of the gene encoding 5alpha-reductase. In absence of this mutation, labia majora would have been? scrotum 22. Study designed to evaluate the efficacy of coenzyme Q10 in improving cardiac output in patients with CHF. Sixty patients with CHF are recruited. Each assigned by coin toss to one of two groups. Design? randomized clinical trial 23. 12yo boy immersed up to his neck in 60F water for 20 minutes. Physiological changes? Central blood volume INCREASED, ADH (vasopressin) DECREASED, Atrial Natriuretic Peptide INCREASED? C (block3, q23) 24. Randomized controlled study of 2000 patients with insomnia is conducted to evaluate the efficacy of a new medication to treat this condition. Ten subjects from both the control and treatment groups do not complete the study are not included in the analysis. Treatment group able to fall asleep 5 minutes faster than control (p=0.001). Neither group report an improvement in quality of life. Conclude that new med is efficacious in treating insomnia. Type of error? Failure to distinguish between statistical significance and clinical significance 25. 18mo girl. Separation of the umbilical cord was delayed after birth. Has had four severe skin infections Staphylococcus aureus; No pus formation at infection sites. Persistent leukocytosis in absence of infection. Mechanisms impaired? leukocyte adhesion and transmigration 26. 50yo M with increasing cough for 6 month and hemoptysis for 1 week. Smoked 1 pack per day for 32 years. Plays squash, swims. CXR shows a 3 x 4-cm hilar mass. Cytologic examination of sputum shows a non-small cell carcinoma. Tells patient he has lung cancer. The patient responds, "How can this be happening to m? I eat right and exercise." Appropriate response? "It must be difficult for you to accept this diagnosis when you feel healthy." 27. 32yo M with 6-month hx of low back pain and stiffness, worse in morning and improve during the day; the pain radiates to his buttocks but not down his legs. Back stiffness if he sits for prolonged periods. Which to confirm diagnosis? X-rays of the sacroiliac joints 28. 17yo boy with 8-kg weight gain during the past year. No medical illness. BMI is 32. He asks, "Do you think that my weight gain is inherited from my father?" Appropriate response? "Yes, your weight gain can be caused by genes and environment combined." 29. 52yo M neighbors have reported that he has been confused and not taking care of himself. 4-mo Hx of diarrhea. PE shows extreme muscle wasting, stomatitis, and a diffuse rash that is worse in sun-exposed areas. Diagnosis? pellagra 30. 80yo F with suspected temporal arteritis (TA). ESR is 100, Pretest probability for TA is 50% in this patient. In the evaluation of TA, ESR has a sensitivity of 99% and specificity of 60%. Based on the results of the ESR testing, most appropriate next step? Additional testing to confirm the diagnosis of TA 31. Sequence surrounding the first two exons of the human beta-globin gene shown, with exons in bold. Translation start codon is underlined. A mutation from G--A at position 355 is most likely to lead to beta-thalassemia by which mechanism? Disruption of normal splicing by creation of a new 3' splice site? 32. 42yo M in ED because of a 10-day history of progressive fever, SOB, and nonproductive cough. 20-kg weight loss. Immigrated to USA from the Ivory Coast 4 years ago. Temp 38C. Lungs clear, CXr shows diffuse interstitial infiltrate. Silver stain obtained via bronchoscopy shows Pneumocystis jiroveci (formerly P. carinii). High dose prednisone and trimethoprim-sulfamethoxazole is initiated, and workup for HIV infection is done. HIV ELISA positive, HIV western blot positive, CD4 22; HIV viral load 50. Explanation? Infection with HIV-2 33. 27yo F with vaginal bleeding for 3 weeks. First pregnancy ended with a spontaneous abortion 8 months ago. No Rx since dilatation and curettage at that time. PE shows enlarged uterus, beta-hCG markedly increased. Ultrasonagraphy of pelvis shows material within the endometrial cavity and no intrauterine pregnancy. CT scan shows a necrotic intrauterine mass and metastatic nodules in the lungs. Site of Origin? trophoblastic tissue 34. 65yo M emigrated from Brazil with 8-month history of shortness of breath and fatigue, edema of lower ext. CXR shows cardiomegaly. endomyocardial biopsy specimen shows myofiber necrosis with a mixed inflammatory infiltrate of PMNs, T lymphos, s, and eosinophils. Causal org? Trypanosoma cruzi 35. 40yo F with mole on her back that has increased in size during past 4 months. PE shows raised irregular lesion with variegated black-tan pigmentation and ill-defined margins. Pleomorphic, hyperchromatic cells within clear islands that tend to collapse. Extends from epidermis into papillary dermis. Dx? melanoma 36. 42yo farmer has a 7-mm red scaly plaque on helical rim of left ear. Photomicrograph shown. Dx? actinic keratosis 37. 30yo F training for a marathon, running 20 miles/day. Fasting glucose is 60. After her glucose stores have been depleted, which organ, in addition to liver, releases glucose? kidney 38. Male newborn at 28 weeks'. Given ventilatory support with up to 80% oxygen for the next 72 hours, but dies of resp. failure. Cause is inadequate secretion from which labeled cell types? D. type II pneumocyte (produces surfactant) 39. 9yo girl with poor growth during the past year. 3rd %ile for height and at 10th percentile for weight. PE normal. Visual field testing shows bitemporal hemianopia. Labs show GH deficiency. MRI shows calcified cystic mass in suprasellar region. Tumor derived from? Diverticulum of the roof of the embryonic oral cavity 40. 28yo F G1P1 with 2-day history of a painful mass in her right breast. Delivered healthy female newborn 3 weeks ago, and been breast-feeding since. T 37C, PE shows 3-cm tender mass surrounded by an area of erythema beneath the right areola. Causal org? staph aureus 41. 3yo boy with bacterial colitis caused by Salmonella enterica serovar arizonae. Which factor accounts for recruitment of PMNS to inflammatory site by intestinal epithelial cells? IL-8 42. 27yo F with fever, malaise, abdominal pain, and vaginal d/c for 4 days. LMP 5 days ago. Had ectopic 1 year ago. T 38.3 C, bilateral lower quadrant tenderness with rebound and guarding. Pelvic exam with cervical motion tenderness and bilateral adnexal tenderness WBC 18k. Pregnancy test neg. Dx? Gonorrhea (PID) 43. 20M with 3-month hx of progressive thirst (drinking a lot of fluids) and urinary frequency during past 3 days. U/A shows specific gravity less than 1.006. Most likely has dysfunction of which endocrine structure? posterior pituitary gland (ADH) 44. 21yo M in ED with excruciating anal pain for 4 hours. Exam shows 15-mm, blue tinged rounded mass at anal margin. Represents thrombus in a tributary of which blood vessel? inferior rectal vein 45. 6-week-old girl with 6-day hx of vomiting small amount of milk 2 to 3 times daily. 50%ile for length and weight. Cause? Immature lower esophageal sphincter 46. 37yo M with 4-day hx of diarrhea and abdominal pain, worse in past 24h, with watery-brown stools. Completed a 10-day course of amoxicillin for a sinus infection 5 days ago. Stool shows: Fecal fat negative; ova and parasites negative; Cx for infx negative; C. Diff toxin positive. Which pathologic findings present in intestinal tract? Pseudomemnbranes of fibrin and inflammatory debris 47. 28yo M in ED 30 minutes after SOB. 3-year hx of cocaine abuse. T 38.1, P 100/min, BP 150/45. PE: diminished pulses in left upper extremity. Crackles heard over all lung fields. 2/6 diastolic murmur at left sternal border. CXr shows a widened aortic arch. Dx? Dissecting aneurysm 48. 1-week-old girl. screening showed a possible defect in fatty acid oxidation. PE normal. Next step? Measurement of serum acylcarnitine concentrations 49. 79yoM 30 minutes after LOC for 30 seconds. Alert, but dizzy. No urinary or fecal incontinence. Pulse 40/min, BP 92/56. PE shows no tongue biting. Lungs clear, Variable intensity S1. Oriented X3. ECG shows a third-degree atrioventricular block. Next step? Insertion of transvenous pacemaker 50. 55yo M with chronic bronchitis in ED after being unresponsive. Found bottles of albuterol, ampicillin, codeine, and theophylline bedside. T 37.2 C, p 112/min, respirations are 6/min, BP 95/60. Acute Rx should include? naloxone 51. 50yo man has persistent cough for 2 months. He has had a 5 kg (11 lb) weight loss. He is a farmer and on itraconazole 4 weeks for histoplasmosis from chicken coops. Medications: hydrochlorothiazide, enalapril, atenolol, omeprazole, and metoclopramide for hypertension and gastroesophageal reflux. Thin. Physical exam otherwise normal. Itraconazole interacts with which drug and account for lack of effect of itraconazole? omeprazole 52. 20yo man with 6-hour difficulty breathing and vomiting. 10-year history of type 1 diabetes on insulin. Pulse 90, respirations 30 and deep, bp 90/60. Physical shows dehydration. Labs: Na+ 130, K+ 6.5, HCO3 5, glucose 500, pH 7.2, pCO2 25 mm Hg. Which compound stimulated hormone-sensitive lipase in adipocytes causing accumulation of metabolites causing acidosis? epinephrine 53. Physician sad to inform patient of progression of carcinoma to the terminal phase. Physician's face makes patient cry and ask, "It's bad news, isn't it?" Which is best response? "Yes, it is." 54. 75yo man 2-year history of decreased force of urinary stream, urinate several times throughout night. BUN 55, Cr 5.0. Ultrasound shows bilateral hydronephrosis and dilated ureter. Mechanism of renal failure? Increased hydrostatic pressure in Bowman space 55. 4yo boy two bacterial urinary tract infections past year. Physical exam normal. Radiologic studies show dilation of left ureter and renal pelvis, minimal left-sided renal function. Left nephrectomy done. Photo: dilated renal pelvis and ureter. Which is cause of renal disease? congenital urethral obstruction 56. 45yo man poorly controlled type 2 diabetes 1-month low-grade fever. Getting hemodialysis for end-stage renal disease. T 37 C (98.6 F), pulse 72, bp 144/92. Physical subclavian catheter below right clavicle. Lungs clear. Cardiac exam no murmurs. Blood cultures grow nonhemolytic, catalase-negative, gram-positive cocci in pairs and chains. Which organism? Enterococcus faecalis 57. 3yo boy sickle cell disease with fever and pain over left foot 3 weeks. Hematocrit stable. Leukocyte count 15,000 predominance of neutrophils. Which is most likely explanation for findings? osteomyelitis 58. 10yo girl well-child examination. No menstrual period. 50th percentile height and weight. Physical exam absence of breast bud development and no pubic or axillary hair. It is most appropriate to tell mother that first objective sign of puberty will be which? Breast bud development 59. 45yo woman follow-up exam after 8 weeks tamoxifen therapy for estrogen and progesterone positive invasive ductal carcinoma of breast. 50yo sister also hormone-sensitive breast cancer. Physical exam normal. Serum decreased concentrations of endoxifen, active metabolite of prodrug tamoxifen. Genetic analysis shows homozygous cytochrome P450 2D6*4 alleles. Likelihood patient's sisters has same alleles? 25% 60. 60yo man progressive shortness of breath past 3 months. Worked in shipyard. Respirations 25. Bilateral basilar crepitant crackles. Xray chest reticulonodular pulmonary infiltrates consistent with interstitial fibrosis. Picture: sputum sample of elongate structures (ferruginous body). Fibrosis initiated by interaction of structures with which cell? Alveolar macrophages 61. 30yo woman 20 weeks gestation, uncomplicated pregnancy. Fundal height is greater than expected for gestational age. Ultrasound shows increased amniotic fluid. Which abnormality is cause? Tracheoesophageal atresia 62. 43yo woman for health maintenance exam. Physician 30 minutes late for appointment because of emergency, when enters, patients checks watch. Which is best initial response? "I'm sorry I got delayed. I hope I haven't made you late somewhere else." 63. 27yo woman 12-hour history of fever and abdominal pain. History of recurrent urinary tract infections. Temperature is 39 C (102.2 F). Physical exam tenderness of right flank. Abdominal xrays bilateral staghorn renal calculi. Urinalysis pH 8, many RBCs, WBC, bacteria. Calculi composed of? struvite 64. 48yo nulligravid woman with excessive uterine bleeding for 3 months. Bleeding during menses and at irregular intervals. Menses were regular before. BMI 27. Pelvic exam: adnexae are nonpalpable. Endometrial curettage shows abundant tissue. Which is cause of symptoms? Endometrial hyperplasia 65. 65yo woman surgical repair of aneurysm right internal carotid artery in cavernous sinus. Three days later on physical exam, right pupil larger than left pupil. Weakness of eye movement. Diagram of coronal section through middle cranial fossa shown. Which nerve is damaged? A (CN III) 66. 55yo woman 6-week history low energy, irritability, crying spells, difficulty falling asleep, wakes up during night, cannot focus. Taking lorazepam for 15y for generalized anxiety disorder. Taking estrogen replacement therapy for postmenopausal symptoms. Vital signs normal. Physical exam normal. Mental status shows constricted affect. Mood is "testy." Speech is slowed. No psychosis. Wishes she wouldn't wake up but doesn't plan to harm herself. Cause of symptoms? Major depressive disorder 67. 10yrs after total gastrectomy, 60yo man difficulty walking. Diffuse spasticity in arms and legs, impaired proprioception in his feet, increased muscle stretch reflexes in arms and knees, absence of muscle stretch reflexes in ankles, bilateral extensor plantar responses. Which vitamin is deficient? B12 (cobalamin) 68. 80yo man type 2 diabetes 2-month history severe constipation. Laxatives haven't relieved symptoms. Abdominal exam shows distention. Colonoscopy shows no abnormalities. Patient has dysfunction of which nerve? Pelvic splanchnic 69. 34yo man lightheaded after running 12 miles of marathon hot day. Pulse 130 bp 80/60. Which changes to autonomic nervous system occurred? B. Sympathetic efferent activity increased, parasympathetic efferent activity decreased 70. 6-Mercaptopurine (6-MP) used to treat acute lymphoblastic leukemia (ALL). 6-MP acted on by enzymes to make 6-thioguanine nucleotides (6-TGN). Efficacy and toxicity of 6-MP correlated with 6-TGN. 6-MP acted on by xanthine oxidase (XO), thiopurine methyltransferase (TPMT), leading to inactive metabolites. Which are clinical consequences of ALL patients homozygous for low-activity alleles of TPMT? They may be given normal doses of 6-MP (?) 71. Ten human subjects given new oral drug to monitor drug effect and toxicity. Blood analyzed for human pharmacokinetics of drug for first time. Which trial type? Phase 1 72. 15yo girl health maintenance exam. Mother dx squamous cell carcinoma face, maternal grandfather died of metastatic melanoma. In patient this age, which factor most predicts compliance with photoprotection? Use of sunscreen by her peers 73. 34yo AIDS patient with pulmonary tuberculosis. No CD4+ T lymphocytes in peripheral blood. Which cellular components most likely to have deficient function in tuberculous lesions in lungs? Macrophages 74. 44yo woman follow-up after two Pap smears showing atypical squamous cells of undetermined significant. Test shows viral E6 protein of human papillomavirus. This protein promotes cell growth and malignancy by causing cellular p53 protein degradation. This degradation begins when p53 protein targeted to which type of cell enzymes? ubiquitin ligase 75. 40yo woman hx of 6 month episodic sinusitis with 2-week intermittent headaches, fatigue, and generalized joint pain, worsening cough productive of blood-tinged sputum. Failed antibiotics, decongestants and nasal corticosteroids. Physical exam: erythema in nasal mucosa, two small ulceration. Lungs scattered crackles. X-ray patchy bilateral opacities. Labs: Hemoglobin 13, ESR 70, leukocyte 10,500, antineutrophil cytoplasmic antibody increased. Dx? Wegener granulomatosis 76. 25yo woman 6-month history of joint pain poorly responsive to aspirin. Physical exam: bilateral swelling of proximal interphalangeal joints, metacarpophalangeal joints, and wrists; weakness of grasp. Small nodules palpated beneath skin around joints of fingers. Dx? Rheumatoid arthritis 77. 50yo woman 1-year hx of hot flashes and irregular menses. Decreased bone mineral density. Alendronate prescribed. Mechanism of drug? Inhibition of osteoclast-mediated bone resorption 78. Female newborn at 36 weeks gestation has respiratory distress. Apgar 3 and 5 at 1 and 5 minutes. Physical shows cyanosis. Endotracheal and NG tubes placed. Xray shows nasogastric tube in left hemithorax, mediastinum displacement to right, absence bowel gas in abdomen. Which embryological event led to these findings? Incomplete formation of pleuroperitoneal membrane 79. 65yo women progressive vulva itching past 2 months; miconazole for yeast infections ineffective. Exam: atrophy of labia minora and thin, parchment-like skin over vulva and anus. Dx? Lichen sclerosus 80. 75yo man 2-day ear ringing, nausea, fatigue. Temp 37 C (98.6 F), pulse 100, respirations 24, bp 140/85. Physical: mild epigastic tenderness. ABG: pH=7.42 pCO2=30 pO2=95 HCO3=19. Dx? Salicylate poisoning 81. 15yo girl 1-day hx redness and painful skin following sunbathing. She used sunblock. No medications. Physical exam: severe erythema of back and extremities, no blisters. Dx? First-degree burn 82. 58yo man supraventricular tachyarrhythmia refractory to pharmacotherapy gets ablation of accessory excitatory pathway in atrial endocardium. Which area should be avoided to leave sinoatrial (pacemaker) node intact? The junction of the superior vena cava and the right atrium 83. 81yo woman massive pulmonary embolism from deep venous thrombosis. Platelet count 160,000. Appropriate pharmacotherapy is started. One week later, platelets 55,000. Thrombocytopenia most likely caused by a drug with which of the following mechanism of action? Potentiates the action of antithrombin III 84. 22yo woman, g1p1, 2-day hx of fever, severe vaginal bleeding. four days ago delivered healthy male newborn. Temp 38.1 C (100.6 F). Pelvic exam: open cervix, heavy vaginal bleeding. US shows uterus with no placental tissue or thrombi. If operation required to control bleeding, ligation of branch of which artery required? Internal iliac 85. 35yo woman abnormal Pap smear. Cervical biopsy shows microinvasive cervical carcinoma. Which microscopic features led to dx? Neoplastic cells in sub-basement membrane connective tissue 86. 17yo girl 1-day shortness of breath, weakness and muscle tenderness. Did triathlon previous day. BMI 19. Temperature 38 C (100.4 F), respirations 20, bp 150/90. Physical bilateral crackles lower lobes, muscle tenderness. Creatinine 4. Urinalysis 3+ protein, 4+ hemoglobin. Patient's condition is from increased release of which substance? Myoglobin 87. 16yo boy with no signs of puberty. Sex development Tanner stage 2. Physical exam: circumcised penis, soft small tests 5 mL, prostate firm, nontender, no discharge or lesions. Testosterone low. Which hormone is cause of decreased serum testosterone and lack of pituitary hormone stimulus? Luteinizing hormone 88. 28yo woman wants to lose weight. She binges on high-carbohydrate foods 2 to 3 times a week, forcing herself to vomit after. BMI 23. Which physical finding is likely? Parotid gland enlargement 89. 15yo girl emigrated from India and with several lesions on neck for 2 weeks. Physical exam shows hypopigmented, hypoesthetic area on left side of forehead and 4-cm lesions on neck. Biopsy shows acid-fast bacilli. Best explanation why the organism results in dermal rather than visceral infections? Temperature sensitivity 90. 59yo man has total thyroidectomy for 4-cm follicular carcinoma of thyroid. Twelve hours after procedure, has paresthesias of hands and feet. Vitals stable, carpal spasm on inflammation of bp cuff. Lab findings? Decreased parathyroid hormone, decreased calcium 91. 41yo man with asthma and allergy to grass pollen wheezes and difficulty breathing 10 min after mowing lawn. Drug for immediate relief of acute symptoms? Albuterol 92. 14yo boy daily headaches for 2 months. Headaches are bilateral aching in temples. "Has not been himself" for months. Confused, forgetting names, dates, places, clumsy, frequent falls. School performance declined. Physical exam: broad-based ataxic gait. Slow to answer questions. Chronic abuse of which substance? Inhaled glue 93. 40yo African American woman 2-week hx fever, malaise, dyspnea. Temperature 36.7 C (98 F), respirations 20. Physical exam: erythema nodosum, parotid enlargement, hepatosplenomegaly. Calcium 16. CT chest bilateral hilar adenopathy. Increase of which in serum? 1,25-Dihydroxycholecalciferol 94. 56yo woman with restrictive cardiomyopathy, proteinuria, renal failure. 35-year history of rheumatoid arthritis. Renal biopsy shows glomerular deposition of eosinophilic hyaline material. Congo red stain: birefringent pattern under polarized light. Structure of material? beta-pleated sheet structure 95. 63yo man 3-month hx difficulty sleeping. Sleeps better upright. HR 90, bp 110/60. Physical exam: increased jugular venous pressure, mild ankle edema. Cause of edema? Increased capillary hydrostatic pressure 96. 14yo boy come to ER 1 hour after colliding with teammate playing soccer. Physical exam: edematous tissues of left eye, mild depression of left zygomatic bone. Skin between eye and upper lip numb. Double vision look upward. Nerve damaged causing sensory loss? Maxillary division of trigeminal nerve 97. 35yo man becomes increasingly depressed, impulsive and difficult over past year. Grimaces intermittently with rapid, jerking, purposeless movements of fingers. Historical factor relevant in dx? Family history of a similar illness 98. 18yo man Crohn disease 1-day hx severe abdominal pain and intermittent bloody diarrhea. Temperature 38 C (100.4 F), pulse 98, respirations 18. Physical exam: draining anal fistula. Treatment with antibiotics and prednisone over next 3 weeks recovers. Mechanism of pharmacotherapy is suppression of which? T-lymphocyte function 99. 34yo woman with pyelonephritis treated with bactericidal antibiotic 4 days no improvement. Antibiotic added that inhibits binding to 30S ribosome, blocking protein synthesis intracellularly. Antibiotic? Gentamicin (aminoglycosides) 100. 3yo boy and his 5yo brother with recurrent hemarthroses. Both parents healthy, but mother with two younger brothers with same sx and maternal uncle who died at 8 of mild head trauma. Partial thromboplastin time is prolonged. Defect? Factor VIII (antihemophilic factor) 101. 6yo boy from Russia with unstable gait and incoordination for 2 weeks. Pale, bulky stools for 4 years and two episodes of bacterial pneumonia and chronic cough since age 1 year. 3%ile for height/weight. Neuro exam shows ataxia, no DTRs, loss of proprioception. Stool shows inc fat concentration. Vitamin deficient? Vitamin E 102. 54yo F 1 week after sudden loss of vision in left eye, returned within 1 day. 3-month hx of progressive SOB with exertion. Echocardiography shows mass in the left atrium of the heart. Lesion is resected, photomicrograph of it is shown. Which describes the lesion? myxoma 103. 27yo primigravid woman at 34 weeks' with nausea and vomiting, and abdominal pain for 12 hours. Everything's been normal. BP is now 164/102, and right upper quadrant tenderness. Labs show Hb 7.4, HCT 24%, Platelets 72k, Cr 1.2, total bili 2.3, AST 112, ALT 126. Peripheral blood smear will show? Schistocytes 104. 60yo F 3 hours after sudden onset ankle pain. 4-year Hx of increasing serum creatinine concentrations. Began furosemide 1 month ago, also takes glipizide. P 120/min, resp 25/min, BP 150/100. Joint fluid shows negatively birefringent crystals. Increased risk of which complications of underlying process causing joint findings? Nephrolithiasis 105. 56yo F follow-up 8 weeks after recovering from pneumococcal pneumonia. Chest X-rays normal. Which allowed this resolution to occur? Maintenance of basement membrane integrity 106. 29yo F with 5-week hx of fatigue and 4-day hx of heart palpitations and anxiety. Has primary hypothyroidism Rx with triiodothyronine, but she has doubled the dose because of fatigue. TFT will show which? TSH DECREASED, Free thyroxine DECREASED, Free triiodothyronine INCREASED 107. 20yo F has multiple neurofibromas. Mom, uncle, and brothers with similar lesions. Mode of inheritance? Autosomal dominant 108. 45yo M with yellow skin. Drinks eight to ten 12-ounce cans of beers daily for 10 days. Liver is tender. Serum: total bili 5.9, Alk Phos 210, AST 110, ALT 69, gamma-glutamyltransferase 25 (n = 0-30). Liver biopsy will show? Mallory hyaline 109. 50yo M smoked 2 packs per day for 34 years, with SOB on exertion, chronic cough, and wheezing. Increased AP diameter, diminished breath sounds, scattered rhonchi. Which Lab abnormalities is expected? Increased blood HCO3 110. 35yo M uses crack cocaine daily, with 2-hour Hx of substernal chest pain. T 37C, P 110/min, BP 160/100. Most appropriate next step? Admit the patient to the hospital for possible myocardial ischemia 111. 54yo F with hypertension and bilateral renal artery stenosis starts taking NSAIDS for back pain. Her Cr concentration increases from 1.0 to 5.0. Cause is due to inhibiting which? Vasodilating prostaglandins at the afferent arteriole 112. 83yo M brought to ED after being found at home bedridden and confused. No meds. P 100/min, BP 85/50. BP unchanged after 1L IV saline. Pulmonary artery catheter shows: Cardiac output high, PCWP low, systemic vascular resistance low. Cause of hypotension? Early septic shock 113. 32yo M with 3-month hx of swelling and breast tenderness. Receiving thyroid hormone and steroid replacements since removal of pituitary adenoma 2 years ago. Began hCG injections 4 months ago. Most likely binding site of hCG causing gynecomastia? Tissue: Testicle; Effect: estradiol production 114. 38yo F with 3-day hx of sore throat. Photo shown of throat. Which nerves is tested by saying "ah," elevating area at tip of the arrow? vagus 115. 8yo boy with disruptive behavior, interrupts, always moving, trouble completing tasks. Drug with which mechanism is appropriate? Increased release of dopamine and norepinephrine 116. 62yo M with alcohol-induced liver disease develops ascites. Infection ruled out. Most appropriate diuretic, in addition to loops, is which? Spironolactone 117. 72yo M with weakness and fatigue. Hemoglobin concentration is 9.2, WBC 5400, platelets 350k. Peripheral blood smear is shown. Cause? Gastrointestinal blood loss 118. 65yo F with widely metastatic breast cancer unresponsive to chemo. No family. "close friend," at all her visits and now she is moved to inpatient hospice after she decides she wants no further curative therapy. Says, "We can't bear to be apart. It would be cruel to separate us now.". Which response is appropriate? "The two of you seem to have a very important relationship. Of course you may stay together." 119. 46yo M treated with oral cyclosporine after cardiac transplant. Cyclosporine decreases likelihood of rejected by which actions? Suppressing the early response of T lymphocytes to activation 120. 30yo M in ED 15 minutes after found unconscious. Comatose, pupils 4 mm in diameter, not reactive to light. CT head shown. Cause of coma is bleeding from which structures? Middle meningeal artery 121. 68yo M with 6-month hx of erectile dysfunction. PE and labs normal. If pharmacotherapy is indicated, drug with which MOA? Inhibition of phosphodiesterase 122. 35yo M with recurrent sinusitis and bronchitis. Cardiac examination shows PMI at fourth intercostal space within the midclavicular line on the right. Hepatic margin is palpable on the left. Endoscopy shows nasal polyps. Biopsy shows thickened, ciliated, pseudostratified epithelium with small patches of squamous metaplasia and mild lymphoid infiltration. Which structure most likely to be absent on electron microscopic exam of epithelium? Dynein arms 123. 30yo primi at 22 weeks' gestation with 1-day hx of fever, chills, and muscle aches. T 39.4, P 114/min, resp 15/min, BP 104/72. PE shows uterus consistent with 22-week gestation. Fetal heart sounds are heard. WBC 12K, Blood cultures grow gram-positive rods. Causal organism? Listeria monocytogenes 124. 42yo M with multiple lesions over his body. PE shows flaccid bullous erosions involving upper and lower extremities and torso. Biopsy shows extensive epidermal acantholysis resulting in the formation of intraepidermal blister. Intact basal layer of keratinocytes adherent to basement membrane is identified. Which is related to pathogenesis? Development of autoantibodies against desmosomal proteins 125. 50yo M 3 days after his first generalized tonic-clonic seizure. 1-month hx of frequent episodes of pins-and-needles sensation around the mouth, hands, and feet, involuntary contraction of muscles. Neuro exam shows mild, diffuse hyperreflexia. Which serum electrolyte is abnormal? Calcium 126. 52yo F with hot flashes. Menses have been irregular for the past 6 months. Physiologic cause? Failure of the ovaries to secrete 17 beta-estradiol 127. 32yo F G2P1 at 7 weeks' gestation with vaginal bleeding for 3 days and increasingly severe left abdominal pain for 18 hours. Direct and rebound tenderness with guarding in left lower quadrant. Cervical os is closed. serum beta-hCG is 6000. U/S shows empty uterus. Dx? Ectopic pregnancy 128. 26yo F 5 weeks after birth of first child. Worries constantly that the infant is ill and wakes up to make sure he is well. Washes her hands 30 times per day. Worried about people braking into her house, checks lock 3-4 times a night. Not breast feeding. Rx? Sertraline 129. 10yo boy has had anemia since birth. Spleen is five times normal. Splenectomy is indicated if anemia is caused by which? Hereditary spherocytosis 130. 62yo F in ED for 2-day hx of fever, abdominal tenderness, and painful urination. Agitated. T 38.8C, Labs show WBC 14k. Admitted to hospital, nurses note she has torn up four breakfast menus because she is confused. Cause? Delirium 131. 60yo F with 3-year Hx of hyperlipidemia. Low-cholesterol diet and exercise program ineffective after 1 year. Lovastatin initiated, but unable to tolerate greater than 20 mg daily. Additional drug is added that inhibits transport of cholesterol through intestinal wall. Which drug? Ezetimibe 132. 48yo M with bronzing of his skin, weakness, and fatigue during the past 3 months. PE shows hepatomegaly, and small testes. Serum: AST INCREASED, ALT INCREASED, iron INCREASED, transferrrin sat INCREASED, ferritin INCREASED, testosterone DECREASED, LH DECREASED, FSH DECREASED. Explanation? Increased intestinal iron absorption 133. 45yo M with intermittent bloody diarrhea and abdominal pain. Sigmoidoscopy and rectal biopsy show IBD. Monoclonal antibody is begun, which is directed against what components? Tumor necrosis factor (anti-TNF alpha like infliximab) 134. 41yo F with increasingly severe headaches for 6 weeks. BP 160/100. bruit over left costovertebral angle. U/A normal. Angiogram of left renal artery shows alternating areas of stenosis and aneurysmal dilatation ("string of beads" sign). Dx? Fibromuscular dysplasia 135. 55yo M with sepsis. Appears anxious and confused. Rx with vancomycin and ceftriaxone initiated in ED. T 39.8, P 132/min, BP 85/48. PE shows warm, flushed skin. No edema. Administer which solutions? 0.9% Saline 136. 36yo M undergoes elective liposuction under general anesthesia. Operation is terminated when patient develops hyperthermia, tachycardia, and marked muscle rigidity. MOA of drug that should be administered? Decreases release of Ca from the sarcoplasmic reticulum (dantrolene) 137. In a survey of 100 households (average three residents per household), 45 with asthma are detected. Prevalence? 15% 138. While lifting weights, 24yo M swelling in right inguinal region. Photograph shown of small intestine resected. Dx? Strangulation 139. 24yo with second-degre burn. Two weeks after, tissue shows increased fibroblast migration and proliferation, increased collagen and fibronectin, and decreased metalloproteinases. Caused by production of which? Transforming growth factor-beta (TGF) 140. Protein found in brown adipose tissue of mice causes leak of H ions inward across inner mitochondrial membrane. Effect of this protein on oxidative phosphorylation and energy metabolism? Increased ratio of oxygen consumption to ATP generation 141. 57yo M with alcoholism has distended abdomen with shifting dullness, fluid wave, caput medusae, palmar erythema, spider angioma. Additional finding? Gynecomastia 142. 16yo girl with 2-year hx of fainting; increased in frequency during past 6 months. BP 110/80 supine and 60/40 standing. Neuro exam normal. Plasma shows undetectable norepinephrine and marked increase in dopamine concentration when standing. Deficiency of which? Dopamine beta-hydroxylase 143. 20yo M with suspected appendicitis has periumbilical burning and discomfort, localizes to RLQ 5 cm superomedial to anterosuperior ilica spine. This is because periumbilical region and appendix are both supplied by afferent fibers in dorsal root ganglia of which levels? T10 144. . 60yo M from china to USA with 1-month hx of confusion and swelling of abdomen and legs. Peanut farmer in china. Smoked 1 pack per day for 40 years. No alcohol. PE shows ascites and ankle edema. Liver palpable, spleen isn't. Serum: Albumin 4, total bili 2.5, Alk Phos 200, AST 45, ALT 60, IgG anti Hep A positive; Anti hep B negative, anti hep C negative. U/S shows 10 cm lesion. Biopsy shows dysplastic hepatocytes in small clusters and rows with no normal architecture. Exposure to which? Aflatoxin 145. 42yo M in ED for 5-hour hx of fever, chills, and severe pain and swelling of his left arm. Scratched his arm on a nail yesterday. Appears confused, T 40C, BP 71/38. Labs show Hb 14, HCt 42%, WBC 15K (35% PMNs, 40% bands, 25% lymphos), Platelets 50K, Serum BUN 28, Cr 2.8. Symptoms due to systematic release of which cytokines? IL-1 and tumor necrosis factor (TNF)-alpha 146. 62yo M dies suddenly while playing tennis. No cardiac risk factors, no hx of CAD. Autopsy, cardiac valve defect and concentric LVH. Which valve abnormalities is most likely involved? Aortic stenosis 147. 67yo M has urinary urgency after placement of urinary bladder catheter during transurethral resection of the prostate. Most appropriate Rx has which MOA? Inhibition of muscarinic receptors 148. Mouse embryos are produced with two pronuclei, both of same parental origin. When the pronuclei are maternal, produces have poorly developed extraembryonic structures. When both pronuclei are paternal, produces have poorly developed embryonic tissue. Which genetic mechanisms? Imprinting 149. 18-yo F with sepsis after an abortion. Within 24 hours she becomes dyspneic, oliguric, and develops petechiae, ecchymoses, and bleeding from venipuncture sites. Which lab finding? Decreased plasma fibrinogen concentration 150. 63yo M with 6-month hx of exertional chest pain relieved by rest. smoked for 45 years. Mild HTN, no meds. Which lesion in LAD is most likely cause? Calcified 80% stenosis