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INFLAMMATION

1.
A 40-year-old man has the recent onset of right-sided chest pain, difficulty breathing,
and fever. On auscultation he has crackles, decreased respiratory sounds, and evidence of a
right-sided pleural effusion. Which of the following best describes the expected type of
inflammatory process involving the lung?
A)
B)
C)
D)
E)

Fibroblasts, collagen deposition, replacement of intrinsic tissue


Macrophages, lymphocytes, increased concentrations of immunoglobulins
Mast cells, histamine, smooth muscle contraction
Neutrophils, increased vascular permeability, edema
Vascular budding, fibroblasts, edema, proteoglycans

5.
A 57-year-old man receives a sintered titanium oxide implant during total hip
arthroplasty following traumatic injury. During the first 6 weeks following surgery, bone
ingrowth anneals to the bone-metal interface in both the femur and acetabulum, thus
securing the prosthesis in position. Type I collagen secretion in the first stage of matrix
formation is mediated by which of the following cell types?
A)
B)
C)
D)
E)
F)
G)

Chondroblasts
Chondrocytes
Endothelial cells
Macrophages
Osteoblasts
Osteoclasts
Osteocytes

23. In the diagram of a blood vessel, what is the principal site of nitric oxide action in
producing vasodilation?

a)

b)

c)

d)

e)

f)
1

CELL INJURY
39.
In reversible hypoxic cell injury, cellular swelling results from intracellular accumulation
of
A)
cholesterol
B)
glycogen
C)
phospholipid
D)
potassium
E)
sodium

CELL INJURY
22.
An 18-year-old man attempts suicide by taking 15 g of acetaminophen. Four hours
after the overdose, high levels of acetaminophen are found in the plasma. The most
appropriate therapy is
A)
hemodialysis
B)
oral administration of aspirin
C)
oral administration of N-acetylcysteine
D)
respiratory support and watchful waiting
E)
urinary alkalinization and forced diuresis

CELL INJURY
36.
An adult's hemoglobin is 98% saturated with oxygen, but arterial oxygen content is
decreased. The most likely cause of this condition is
A)
anemia
B)
an arteriovenous shunt
C)
hemoglobinopathy
D)
high-altitude hypoxia
E)
pulmonary diffusion defect

MUSCULOSKELETAL
9.
A 61-year-old woman has a 10-year history of progressive pain in the hips, knees, and
hands. She has symmetric swelling and formation of nodules in the distal interphalangeal
joints of her hands and pain on movement of both knees. There is no increased warmth or
tenderness. The most likely cause of her joint pain is
A)
B)
C)
D)
E)

gout
Lyme disease
osteoarthritis
pseudogout
rheumatoid arthritis
2

COAGULATION
10.
A 3-year-old boy with cystic fibrosis is evaluated for the acute onset of an
uncontrollable nosebleed. There is no family history of a bleeding disorder. A few large
bruises are seen on the legs; no other abnormalities are noted. Prothrombin and partial
thromboplastin times are prolonged. The patient's abnormalities are likely to improve with
treatment using a cofactor for which process?
A)

Carboxylation of prothrombin

B)

Conversion of homocysteine to methionine

C)

Farnesylation of ras

D)

Hydroxylation of procollagen

E)

Phosphorylation of pyruvate dehydrogenase

LYMPHOPROLIFERATIVE
13.
A 16-year-old boy is brought to the emergency department because of respiratory
distress. Examination shows a large mediastinal mass and 3-cm firm cervical lymph nodes
bilaterally. Examination of tissue obtained on cervical lymph node biopsy shows small
lymphocytes interspersed with binucleate cells with clear chromatin and large eosinophilic
nucleoli. The most likely diagnosis is
A)

Burkitt's lymphoma

B)

diffuse noncleaved cell lymphoma

C)

follicular lymphoma

D)

Hodgkin's disease

E)

lymphoblastic lymphoma

29.
A 65-year-old man with inguinal adenopathy undergoes a lymph node biopsy. Light
microscopy shows replacement of nodal tissue by cells that form well-defined, uniform
glandular structures. The nuclei are relatively small and nucleoli are inconspicuous. An
immunohistochemical stain for prostate-specific antigen is positive. These findings are most
consistent with which of the following?
A)
B)
C)
D)

High-grade, high-stage neoplasm


High-grade, low-stage neoplasm
Low-grade, high-stage neoplasm
Low-grade, low-stage neoplasm
3

GASTRO
15.
A 45-year-old woman has a 7-month history of moderate abdominal pain that is
exacerbated by eating. She has used alcohol heavily for the past 10 years. X-ray films of the
abdomen show diffuse retroperitoneal calcifications. The most likely diagnosis is
A)
B)
C)
D)
E)

cholangitis
chronic pancreatitis
pancreatic islet cell neoplasm
perforated gastric ulcer
ulcerative colitis

GASTRO
28.
A 20-year-old man has gastrointestinal bleeding due to Meckel's diverticulum.
Histologic evaluation of the resected diverticulum is most likely to show
A)
B)
C)
D)
E)

acute bacterial inflammation


carcinoid tumor
gastric mucosa
an impacted enterolith
varices at the neck of the diverticulum

RENAL
19.
A 68-year-old woman is admitted to the hospital for evaluation of gross hematuria.
Two days after admission she develops aphasia and right hemiplegia, followed shortly by
coma and death. The cut surface of one of her kidneys as seen at autopsy is shown. Which
of the following was the most likely cause of the hematuria?

A)
C)
E)

Metastatic cancer
Polycystic kidney disease
Renal cell carcinoma

B)
D)
F)

Papillary necrosis
Renal abscess
Renal infarct
4

ENDOCRINE
A 3-year-old boy has a mutation in the calcium receptors on cell surfaces of his parathyroid
gland and on the basolateral (blood) side of the thick ascending limb of the loop of Henle.
Which of the following patterns is expected with a mutation that leads to activation of this
receptor in the absence of binding of its ligand, calcium?

Ca2+

Serum PTH

Urine Ca2+

a) Hypercalcemia
b) Hypercalcemia
c) Hypercalcemia
d) Hypercalcemia
e) Hypocalcemia
f) Hypocalcemia
g) Hypocalcemia
h) Hypocalcemia

high
high
low
low
high
high
low
low

high
low
high
low
high
low
high
low

DERMATOLOGY
1. A 9-year-old boy has had the lesions shown for several months. Which of the
following histologic changes would be most likely if this lesion were biopsied?

A)
B)
C)
D)
E)

Cytoid bodies and loss of adhesion to adjacent cells


Epidermal acanthosis with subepidermal blister
Epidermal thinning with marked inflammatory dermal infiltrate
Marked squamous cell dysplasia with thinned stratum corneum
Thickened stratum corneum and epidermis and vacuolated squamous cells

GASTRO IIMUNO
32.
A 45-year-old woman who has acute diverticulitis develops severe hypotension,
tachypnea, and tachycardia. She subsequently develops cyanosis and hypoxemia
unresponsive to oxygen therapy. X-ray films of the chest show a diffuse alveolar infiltrate.
Blood culture grows Escherichia coli. A major factor in the pathogenesis of this syndrome is
A)
degranulation of mast cells
B)
delayed (type IV) hypersensitivity to bacterial products
C)
increased surfactant production by type II pneumocytes
D)
production of antibodies to alveolar basement membranes
E)
release of oxygen free radicals from sequestered neutrophils

INFLAMMATION
35.
Basic fibroblast growth factor is applied to an experimentally induced dermal wound. A
histologic section is prepared 72 hours later. Compared with an untreated wound, the most
likely alteration in this wound is
A)

decreased numbers of fibroblasts

B)

increased breakdown of matrix

C)

increased numbers of blood vessels

D)

increased numbers of eosinophils

E)

Increased numbers of giant cells

CARDIO
38.
A 50-year-old woman comes to the physician because of a fever, cachexia, and
malaise for the past 6 months. Auscultation discloses a low-pitched, early to mid-diastolic
murmur. Echocardiography shows a left atrial mass that prolapses into the mitral valve orifice
during diastole. Which of the following findings is most likely on microscopic examination of
this mass?
A)

Amorphous extracellular matrix

B)

Glycogen-containing polygonal cells

C)

Malignant lymphoid cells

D)

Malignant spindle cells

E)

Mature adipose cells

CARDIO
41.
A 56-year-old man with extensive coronary artery atherosclerotic disease has
evidence of coronary vasoconstriction and myocardial ischemia. The most likely cause of the
vasoconstriction is failure of the endothelial cell layer of the diseased coronary arteries to
produce a substance with which of the following actions?
A)

Activation of Na+ channels

B)

Closure of K+ channels

C)

Opening L-type Ca2+ channels

D)

Stimulation of ATP accumulation

E)

Stimulation of cyclic GMP accumulation

NEOPLASIA
42.
Over a period of 3 weeks, a 60-year-old woman develops anorexia, restlessness,
irritability, and confusion. Serum sodium concentration is 125 mEq/L; urine osmolality is
increased. Assuming the patient's disorder represents a paraneoplastic syndrome, which of
the following diagnostic procedures is most likely to result in an abnormal finding?
A)

Examination of bone marrow

B)

Liver scan

C)

Mammography

D)

Measurement of urinary excretion of 5-hydroxyindoleacetic acid

E)

X-ray film of the chest

NEUMO
43.
A 29-year-old patient has a 3-week history of persistent cough and intermittent flushing
and diarrhea. An x-ray film of the chest and bronchoscopy show a 2-cm, solitary, well-defined
mass that projects into the lumen of the mainstem bronchus. The mucosa of the bronchus is
intact. These findings are most characteristic of
A)
B)
C)
D)
E)

bronchial carcinoid tumor


hamartoma
mesothelioma
metastatic adenocarcinoma
squamous cell carcinoma of the lung

GASTRO
50.
A 3-year-old boy has a 5-week history of weight loss and bulky, frothy, foul-smelling
stools. Dietary modification results in clinical improvement. Which of the following is the most
likely finding on examination of a biopsy specimen from the small intestine?
A)
B)
C)
D)
E)

Atrophy of villi and microvilli


Degenerative changes of the myenteric plexus
Multiple outpouchings through the muscle coat
Numerous ulcerations and pseudopolyps
Pseudomembrane covering the luminal surface

NEURO
2.
A 38-year-old man comes to the physician because of involuntary movements of the
arms and legs for the past month and progressive facial twitching and grimacing over the
past year. Neurologic examination shows athetoid and choreiform movements of the arms
and legs, dystonic movements of the tongue, dysarthria, impairment in immediate and shortterm memory, and dyscalculia. Which of the following is the most likely diagnosis?
A)
B)
C)
D)
E)
F)
G)

Amyotrophic lateral sclerosis


Dementia, Alzheimer's type
Huntington's disease
Korsakoff's syndrome
Multi-infarct dementia
Parkinson's disease
Wernicke's encephalopathy

ENDOCRINE
8.
A 16-year-old girl has generalized weakness and nocturnal leg cramps. She is not
taking any medications. Laboratory studies show:
Serum
Na+ 135 mEq/L
Cl
108 mEq/L
K+
2.8 mEq/L
HCO3
21 mEq/L
Urine pH
7.0
Which of the following is the most likely diagnosis?
A)
B)
C)
D)
E)

Adrenal insufficiency
Hyporeninemic hypoaldosteronism
Nephrogenic diabetes insipidus
Renal tubular acidosis
Syndrome of inappropriate ADH (vasopressin
8

MALE PART
17.
A 20-year-old man has a painless 2-cm nodule in his right scrotum. The nodule is
difficult to distinguish from the right testis and does not transilluminate. There is no additional
swelling or inguinal adenopathy. The most likely diagnosis is
A)

cryptorchidism

B)

hydrocele

C)

scrotal cyst

D)

testicular cancer

E)

testicular torsion

F)

varicocele

NEURO
18. An 83-year-old woman dies after having progressive memory loss, apraxia, and aphasia
for 4 years. A photomicrograph of brain tissue obtained on autopsy is shown. Which of the
following is the most likely cause of these findings?

A)
B)
C)
D)
E)

Creutzfeldt-Jakob disease
Dementia, Alzheimer's type
Hypothyroidism
Vascular dementia
Vitamin B12 (cyanocobalamin) deficiency
9

ENDOCRINE
19.
A 38-year-old woman has noticed the gradual development of a goiter. Thyroid
function studies show serum thyroxine (T4) and triiodothyronine (T3) concentrations to be
within the reference range. Serum concentration of thyroid-stimulating hormone is slightly
increased. The serum contains a high level of antimicrosomal (antiperoxidase) antibodies, but
no thyroid-stimulating hormone receptor antibodies are detected. The most likely diagnosis is
A)

autoimmune (Hashimoto's) thyroiditis

B)

diffuse toxic goiter (Graves' disease)

C)

primary atrophy of the thyroid gland

D)

Riedel's struma

E)

subacute thyroiditis

NEUMO
20.
A 34-year-old woman comes to the physician's office because she has had a cough,
fatigue, low-grade fever, mild dyspnea, and aching joints for the past month. Physical
examination shows no abnormalities. X-ray film of the chest shows bilateral hilar adenopathy
with mild diffuse parenchymal infiltrates. Examination of tissue obtained by transbronchial
biopsy during bronchoscopy shows noncaseating granulomas. Which of the following is the
most appropriate therapy?
A)

Azathioprine

B)

Methotrexate

C)

Prednisone

D)

Rifampin

E)

Zidovudine (AZT)

NEURO
21.
An 18-year-old man has multiple bilateral angiomyolipomas. Which of the following
lesions is most likely to be found within the central nervous system?
A)
B)
C)
D)
E)

Adenocarcinoma
Cortical hamartoma
Glioblastoma multiforme
Metastatic angiomyolipoma
Subependymal meningioma
10

CARDIO
22.
A 58-year-old man develops an acute coronary thrombosis with resultant myocardial
infarction. The swelling of the myocardial cells bordering the infarct is most likely to be due to
A)

depletion of ATP

B)

efflux of Ca2+

C)

efflux of Na+

D)

increase of intracellular pH

E)

production of H2O2

NEUMO
23.
A 45-year-old man develops a fever, a cough productive of rusty sputum, and chest
pain. Sputum cultures are positive for Streptococcus pneumoniae. He is treated with
antibiotics and recovers uneventfully. Which of the following cell types is most likely
responsible for regeneration of the injured tissue?
A)

Clara cell

B)

Fibroblast

C)

Macrophage

D)

Type I pneumocyte

E)

Type II pneumocytes +++

FEMALE PART- GENETICS


25.
A 16-year-old girl is evaluated because she has not yet had a menstrual period. She is
147 cm (4 ft 10 in) tall and weighs 42 kg (93 lb). Breast development is Tanner stage 1 of 5
and pubic hair growth is Tanner stage 2 of 5, respectively. She has a low hairline, short 4th
metacarpals bilaterally, and multiple pigmented nevi. A cervix is seen on pelvic examination.
Laboratory studies show an increased serum follicle-stimulating hormone concentration.
Serum thyroid-stimulating hormone concentration and serum prolactin concentration are
within the reference ranges. Which of the following is the most likely diagnosis?
A)
B)
C)
D)
E)

Androgen insensitivity syndrome


Gonadal dysgenesis 45,X (Turner's syndrome)
Gonadotropin-secreting pituitary tumor
Isolated gonadotropin deficiency
Paramesonephric (mllerian) aplasia

11

MUSCULOSKELETAL
29.
A 30-year-old woman is brought to the emergency department because of pain in her
upper arm after falling off a horse. X-ray films show a closed simple fracture of the upper
humerus. Serum studies 3 weeks later are most likely to show an increased concentration of
A)

alkaline phosphatase

B)

calcium

C)

creatine kinase

D)

-glutamyltransferase

E)

phosphorus

MALE PART
30.
An 18-year-old man has nausea, vomiting, headache, a temperature to 39.4 C (103 F),
and painful swelling of the parotid glands. He is at increased risk for
A)

appendicitis

B)

arthritis

C)

cystitis

D)

episcleritis

E)

orchitis

FEMALE PART
31.
A 28-year-old woman is undergoing evaluation at 37 weeks' gestation. Blood pressure
is 120/75 mm Hg sitting, 115/70 mm Hg standing, and 90/60 mm Hg supine. The most likely
explanation for these findings is
A)

compression of the vena cava

B)

gestational diabetes mellitus

C)

peripartum cardiomyopathy

D)

preeclampsia

E)

uterine contraction

12

ENDOCRINE
32.
A 45-year-old man who is undergoing dialysis for chronic renal failure starts receiving
erythropoietin therapy. He has a history of type 1 diabetes mellitus, peripheral neuropathy,
and well-controlled hypertension. Exacerbation of which of the following is most likely to
occur in this patient?
A)

Chronic renal insufficiency

B)

Diabetes mellitus

C)

Hypertension

D)

Osteitis fibrosa cystica

E)

Peripheral neuropathy

NEURO
34.
A 2-year-old boy has brittle depigmented hair, cerebral atrophy, delayed myelination,
motor delay, and mental retardation. Lysyl oxidase activity is decreased. The function of
which of the following substances is most likely to be defective in this patient?
A)

Albumin

B)

Ceruloplasmin

C)

Chondroitin sulfate

D)

Collagen

CARDIO
36.
A 45-year-old woman has a 3-month history of a persistent cough and increasing
shortness of breath. She denies chest pain or other illnesses. Blood pressure is 110/70 mm
Hg, and pulse is 110/min. She has diffuse basilar crackles and an S3 gallop, but no murmur.
ECG shows sinus tachycardia and nonspecific ST-T wave changes. Echocardiography
shows a dilated left ventricle and a diffusely hypokinetic heart. The most likely diagnosis is
A)
B)
C)
D)
E)

acute pericarditis with effusion


dilated cardiomyopathy
hypertrophic cardiomyopathy
severe mitral valve prolapse
silent subendocardial infarct

13

GENETICS
37.
A 2-year-old boy has a unilateral cleft lip and cleft palate. He has no other
malformations and is otherwise healthy. He has no family history of birth defects. His
parents are not related. Which of the following genetic mechanisms is most likely to have
caused these congenital abnormalities?
A)

Autosomal dominant inheritance

B)

Autosomal recessive inheritance

C)

Chromosome aneuploidy

D)

Chromosome deletion

E)

Mitochondrial DNA mutation

F)

Multifactorial inheritance

G)

X-linked recessive inheritance

HEMATO
38.
A 40-year-old woman has a fever and petechiae. Laboratory studies show:
Hemoglobin 9 g/dL
Leukocyte count
5000/mm3
Neutrophils 10%
Lymphocytes
20%
Blasts
70%
Platelet count
20,000/mm3
A peripheral blood smear shows Auer rods. The most likely diagnosis is
A)

acute lymphoid leukemia

B)

acute myeloid leukemia

C)

chronic lymphocytic leukemia

D)

chronic myelogenous leukemia

E)

leukemoid reaction

14

ENDOCRINE
40.
A 5-month-old male infant develops lethargy, somnolence, hypothermia, feeding
problems, and persistent jaundice. After several days, he develops a hoarse cry and
hypotonic muscles. The tongue is large and protruding, and an umbilical hernia is noted.
Hematologic evaluation shows no abnormalities. Which of the following abnormalities is most
consistent with these findings?
A)
B)
C)
D)
E)

Agenesis of the parathyroid glands


Congenital adrenal hyperplasia
Maternal diffuse toxic goiter (Graves' disease)
Thyroid hypoplasia
Trisomy 21 (Down's syndrome)

CELL INJURY
44.
A 59-year-old man undergoes repair of an abdominal aortic aneurysm. During the
procedure the distal abdominal aorta is clamped, occluding blood supply to the legs for 45
minutes. The period of ischemia is short enough that no permanent damage is done to the
affected tissues. Examination of tissue obtained on biopsy of the gastrocnemius muscle at
the end of the period of ischemia is most likely to show
A)

coagulation necrosis

B)

erythrophagocytosis

C)

hydropic swelling

D)

karyolysis

E)

karyorrhexis

PNEUMO
45.
Alveolitis with interstitial edema, inflammatory cell accumulation, and type II epithelial
cell hypertrophy and hyperplasia is believed to be an early and central event in the
pathogenesis of
A)
B)
C)
D)
E)

anthracosis
asthma
centriacinar emphysema
chronic bronchitis
pulmonary fibrosis

15

MALE G-U
2. Benign prostatic enlargement causes a characteristic impression on the urinary bladder in
which area of the cystogram?

a)

b)

c)

d)

GASTRO- OB-GYN
3.
A healthy 25-year-old woman who is at 24 weeks' gestation develops heartburn within
an hour after eating. Which of the following is the most likely cause?
A)
Decreased competency of the lower esophageal sphincter
B)
Decreased esophageal motility
C)
Increased gastric acid production
D)
Increased gastric emptying
E)
Increased gastric motility
ENDOCRINE
6.
A 64-year-old woman comes to the physician's office because of gradually worsening
abdominal cramps, nausea, diarrhea, flushing of the skin, and heart palpitations. Twenty-four
hour urinary 5-hydroxyindoleacetic acid excretion is increased. The most likely cause of these
findings is a neoplasm originating in which of the following structures?
A)
Adrenal gland
B)
Esophagus
C)
Kidney
D)
Small intestine
E)
Spleen
F)
Thyroid
16

GENETICS FEMALE
10.
A female neonate has an enlarged clitoris. Pregnancy and delivery were uneventful.
Laboratory studies on blood taken at 7 days of age show hyponatremia and hyperkalemia.
Microscopic examination of the adrenal cortex is most likely to show which of the following
features?
A)

Dysplasia

B)

Hyperplasia

C)

Hypoplasia

D)

Metaplasia

E)

Neoplasia

MUSCULO SKELETAL
11.
An elderly woman has had generalized bone pain and a loss of height over the last 5
years. Complete blood count is normal. Serum calcium, phosphate, and creatinine
concentrations and serum alkaline phosphatase activity are within the reference range.
Serum protein electrophoresis shows no abnormalities. X-ray films of the spine show
generalized loss of bone density and a compression fracture of T-8. Which of the following is
most likely to be seen in tissue obtained on biopsy of the iliac crest?
A)
Cysts filled with fibroblasts and giant cells
B)
Disorderly osteoblastic and osteoclastic activity
C)
Sheets of plasma cells
D)
Thin trabeculae with low osteoclastic activity
RENAL
19.
A 46-year-old man is killed in an automobile accident. The photograph shows a kidney
at autopsy. Which of the following would have been expected in this patient?

A)
C)
E)

Cerebral arterial aneurysms


Multiple hepatic cysts
Vesicoureteral reflux

B)
D)

Hypertensive heart disease


Normal renal function

17

RENAL
25.
An afebrile 8-year-old girl is evaluated for mild edema and a "puffy" face. She
recovered from an untreated sore throat and fever 3 weeks ago. Urinalysis shows moderate
proteinuria and hematuria with occasional red cell casts. A photomicrograph of renal tissue
obtained on biopsy is shown. Which of the following is most likely responsible for the cellular
infiltrate shown?

A)

Bradykinin

B)

C5a

C)

Histamine

D)

N-formylated peptides

E)

Serotonin

GINECO
29.
A 21-year-old woman comes to the physician because of a vaginal discharge for the
past 2 weeks. She has had 3 sexual partners in the past 6 months. Examination shows
tenderness with cervical motion. The discharge is mucopurulent and the cervical os is
erythematous and edematous. This patient is at greatest risk for the development of which of
the following?
A)
B)
C)
D)
E)
F)
G)

Aortic aneurysm
Endocarditis
Endometrial carcinoma
Infertility
Multiple births
Ovarian carcinoma
Rheumatoid arthritis
18

CARDIODIET
31.
A 67-year-old man is admitted to the hospital because of worsening dyspnea over the
past 6 hours. He was diagnosed with hypertension 10 years ago. Temperature is 36 C (96.8
F), pulse is 100/min, respirations are 22/min, and blood pressure is 136/87 mm Hg. Physical
examination shows an S3 gallop by cardiac auscultation and bilateral coarse rales halfway up
the lungs bilaterally. Which of the following is the most appropriate dietary order for this
patient?
A)
B)
C)
D)
E)
F)
G)
H)
I)

Clear liquid diet


Enteral feeding via a nasoenteric tube
Full liquid diet
High-fiber diet
Low-residue diet
Parenteral nutrition via a central venous access
Protein-restricted diet
Regular hospital diet
Sodium-restricted diet

CELL INJURY
39.
A 19-month-old girl dies after ingesting a bottle of her mother's iron sulfate
supplements. At autopsy, microscopic examination of hepatic tissue shows lysosomal
degradation. Which of the following is the most likely mechanism of this finding?
A)
B)
C)
D)

Activation of glutathione peroxidase activity


Inhibition of glutathione-S-transferase activity
Peroxidation of DNA
Peroxidation of membrane lipids

PHARMACO
40.
After sampling red wine and cheese, a 55-year-old man has a severe pounding
headache. Pulse is 110/min, and blood pressure is 230/145 mm Hg. He is most likely taking
which of the following drugs?
A)
B)
C)
D)
E)

Diphenhydramine
Enalapril
Imipramine
Nitroglycerin
Tranylcypromine

19

CARDIO
44.
A 12-year-old girl is admitted to the hospital because of marked shortness of breath,
an erythematous rash, and painful, swollen hip and knee joints. Antistreptolysin O titer is
abnormally high. X-ray film of the chest shows an enlarged heart. She develops intractable
congestive heart failure and dies on the second hospital day. Which of the following cardiac
abnormalities is most likely to be seen at autopsy?
A)

Granulomatous pericarditis with caseous necrosis

B)

Multiple microabscesses in the myocardium

C)

Myocardial edema with Aschoff bodies

D)

Stenosis of the aortic valve

E)

Stenosis of the mitral valve

CARDIO
46.
A 55-year-old man being treated for congestive heart failure becomes confused about
his medications and takes an overdose of digoxin. Five hours later, he reports anorexia,
nausea, vomiting, and visual disturbances. Serum digoxin concentration is 10 ng/mL (toxic >
2.5 ng/mL); serum potassium concentration is 7.2 mEq/L. Which of the following is the most
likely cause of the hyperkalemia?
A)

Hyporeninemic hypoaldosteronism

B)

Increased renal tubular absorption of potassium

C)

Inhibition of Na+-K+ ATPase

D)

Intravascular hemolysis

E)

Rhabdomyolysis

20

Head
A 50-year-old woman comes to the physician because of swelling of her left cheek for 2
weeks. An elevation with a small opening in the area shown by the arrow is noted on
examination of the oral mucosa. This area is most likely the opening of which of the following
structures?

A)

Draining abscess

B)

Fistula

C)

Parotid gland duct

D)

Sublingual gland duct

E)

Submandibular gland duct

HEMATO
49.
A 34-year-old woman has had fatigue, irritability, intermittent lightheadedness, and
heavy menstrual periods for the past 6 months. Laboratory evaluation is most likely to show
which of the following?
A)

Decreased serum vitamin B12 (cyanocobalamin) concentration

B)

Hypercalcemia

C)

Hypocalcemia

D)

Increased serum vitamin B12 (cyanocobalamin) concentration

E)

Megaloblastic anemia

F)

Microcytic anemia

21

RENAL
1.
After 6 hours of excruciating pain, a 26-year-old man passes a 3-mm calculus. The
calculus is most likely to be composed primarily of
A)
bilirubin
B)
calcium salts
C)
cystine
D)
triple phosphate
E)
urate

MUSCULOSKELETAL >REUMATO
4.
In a student laboratory session, a male medical student finds erythrocytes in his urine.
This finding is confirmed by the hospital laboratory. He denies any history of renal problems
or recent illness. Vital signs are within normal limits. Antistreptolysin O titer is less than
1:100. Microscopic examination of urine is unremarkable except for rare red cell casts. There
is no proteinuria. The most likely diagnosis is
A)
B)
C)
D)
E)

diabetic glomerulosclerosis
IgA nephropathy
lupus nephritis
membranous glomerulonephritis
poststreptococcal glomerulonephritis

NEUMO
7.
A 41-year-old woman remains hospitalized and in bed for 10 days because of
complications following a hysterectomy for uterine leiomyomas. On the tenth day, she
suddenly develops severe respiratory distress and collapses. She is resuscitated, but dies
2 days later. A lung as seen at autopsy is shown. Which of the following is the most likely
diagnosis?

A)
C)
E)

Bronchopneumonia
Lung abscess
Pulmonary metastases

B)
D)

Interstitial pneumonia
Pulmonary infarct
22

GASTRO
8.
A 15-year-old girl has fever, nausea, and acute abdominal pain and tenderness.
Laboratory studies show a neutrophilic leukemoid reaction. A laparotomy and appendectomy
are done. Which of the following histologic findings will establish the diagnosis of acute
appendicitis?
A)

Follicular lymphoid hyperplasia

B)

Histiocytic infiltrate of the lamina propria

C)

Lymphoid infiltrate of the mucosa

D)

Mucosal ulceration

E)

Neutrophilic infiltrate of the muscularis

ENDOCRINE
9.
A 45-year-old man has frequent headaches, diffuse arthralgias and generalized
weakness, pain in both hands, pain in the temporomandibular joint that is worse on chewing,
and increasing shoe size. He has difficulty picking up small objects. Which of the following is
the most likely diagnosis?
A)

Acromegaly

B)

Cushing's disease

C)

Hypothyroidism

D)

Prolactinoma

E)

Seminiferous tubule dysgenesis (Klinefelter's syndrome)

MUSCULOSKELETAL
18.
A 3-year-old girl has multiple bone fractures, mild hearing loss, and blue sclerae. Her
mother also has blue sclerae and has near-total bilateral hearing loss. These findings are
most likely to be due to a defect in which of the following proteins?
A)

Dystrophin

B)

Elastin

C)

Fibrillin

D)

Myosin

E)

Type I collagen
23

ENDOCRINE
20.
A 50-year-old woman has myalgias, nervousness, a pounding heart, difficulty falling
asleep, and decreased appetite. She had a thyroidectomy 6 months ago and is taking
levothyroxine. Pulse is 120/min, and blood pressure is 140/70 mm Hg. Serum thyroidstimulating hormone concentration is 0.1 U/mL. Which of the following is the most
appropriate therapy?
A)

Add diazepam to her regimen

B)

Add fluoxetine to her regimen

C)

Add imipramine to her regimen

D)

Add verapamil to her regimen

E)

Decrease the dose of levothyroxine

F)

Increase the dose of levothyroxine

ENDOCRINE
21. A 12-year-old boy is brought to the emergency department because of vomiting and
rapid breathing. Over the past 2 weeks, he has been drinking fluids and urinating
excessively. He has lost weight. He is thin, afebrile, and drowsy. Respirations are rapid and
deep, and there is a fruity odor on his breath. Laboratory studies show:
Arterial blood pH
Serum
Glucose
Urea nitrogen (BUN)
Creatinine

7.0
575 mg/dL
74 mg/dL
2.0 mg/dL

Which of the following is most likely to be increased in this patient's blood?


A)

Ammonia

B)

Carnitine

C)

-Hydroxybutyrate

D)

Isovaleric acid

E)

Sodium

HEMATO
24

22. A previously healthy 32-year-old woman has the onset of recurrent headaches. She
develops nausea, vomiting, weakness, abdominal pain, and easy bruisability. Her
temperature is 38.5 C (101.3 F). Laboratory studies show:
Hemoglobin
Leukocyte count
Mean corpuscular volume
Platelet count

6.9 g/dL
15,000/mm3
78 m3
30,000/mm3

She is immediately admitted to the hospital. Over the next few days, she develops
progressive lethargy and lapses into a coma. A peripheral blood smear is most likely to show
A)

macrocytes

B)

schistocytes

C)

sickle cells

D)

spherocytes

E)

target cells

FEMALE PART GYN


23.
A 42-year-old woman has a 3-month history of an intermittent reddish-brown discharge
from the nipple of her right breast. No masses are palpable in either breast. There is no pain
or tenderness. Which of the following is the most likely diagnosis?
A)

Fibroadenoma

B)

Fibrocystic disease

C)

Intraductal papilloma

D)

Lobular carcinoma

E)

Mastitis

F)

Traumatic fat necrosis

ENDOCRINE
25

24.
A 55-year-old man with diabetes mellitus has burning dysesthesias over the lateral
aspect of his left lower leg. Capsaicin-containing cream is effective in alleviating the
symptoms. The substance most likely to have caused the dysesthesias is
A)

ADH (vasopressin)

B)

angiotensin II

C)

dopamine

D)

inositol

E)

neuropeptide Y

F)

nitric oxide

G)

norepinephrine

H)

substance P

CARDIO
25.
A 2-day-old male neonate is transferred to the neonatal intensive care unit because of
tachypnea and intense cyanosis. There is a prominent lift and a soft, systolic murmur is heard
along the left sternal border. S1 is loud at the lower left sternum. X-ray film of the chest
shows a normal heart size and pulmonary vascular pattern. Echocardiography shows the
aorta lying anterior and to the right of the pulmonary artery. Which of the following is the most
likely diagnosis?
A)

Aortic coarctation

B)

Kartagener's syndrome

C)

Patent ductus arteriosus

D)
Transposition of the great vessels
E) Ventricular septal defect

26

NEUMO- ENVIRONMENT
29.
The photomicrograph is of lung tissue as seen at autopsy of a patient with an
occupational exposure to

A)

asbestos

B)

beryllium

C)

coal dust

D)

iron

E)

silica

NEUMO
30.
In patients with bronchial asthma, which of the following eosinophil products is most
likely to be responsible for damage to the epithelium?
A)

Heparin

B)

Leukotriene C4

C)

Major basic protein

D)

NADPH oxidase

E)

Platelet activating factor

LYMPHOPROLIFERATIVE
27

31.
A 15-year-old girl has had a sore throat and temperatures to 37.7 C (100 F) for 3 days.
Physical examination shows erythematous pharyngeal mucosa and cervical
lymphadenopathy. Leukocyte count is 12,000/mm3 with 60% lymphocytes. A slide
agglutination test is positive for antibodies against Epstein-Barr virus. This virus is most likely
to replicate initially in which of the following cells?
A)

Peripheral blood B lymphocytes

B)

Peripheral blood monocytes

C)

Peripheral blood T lymphocytes

D)

Pharyngeal B lymphocytes

E)

Pharyngeal monocytes

F)

Pharyngeal T lymphocytes

CARDIO
32.
A 53-year-old obese woman who has hypertension is brought to the emergency
department after collapsing. Prior to admission, she had severe excruciating stabbing-like
chest pain radiating to her left shoulder. She is anxious and in severe pain. Pulse is 110/min,
and blood pressure is 160/80 mm Hg. On auscultation, heart sounds are distant; pulsus
paradoxus is present. ECG shows low voltage and ST-T wave changes. An x-ray film of the
chest shows widening of the mediastinum. The most likely diagnosis is
A)
B)
C)
D)
E)

aortic dissection with cardiac tamponade


hypertensive crisis
massive pulmonary thromboembolism
myocardial infarct with congestive failure
rupture of the papillary muscle

NEURO
33.
An 82-year-old woman has become increasingly disoriented over the past year. She is
pleasant and attempts to be cooperative. She performs poorly on a Mini-Mental State
Examination. Pulse is 80/min, and blood pressure is 160/90 mm Hg. MRI of the head shows
small lacunar lesions predominantly in the lenticulostriate arteries of the internal capsules and
in other widely disparate regions of both cerebral cortices. Which of the following is the most
likely explanation for these findings?
A)
B)
C)
D)
E)

Dementia, Alzheimer's type


Huntington's disease
Multi-infarct dementia
Multiple sclerosis
Parkinsonism

28

RENAL / IMMUNO
34.
A 58-year-old man comes to the physician because of blood in his urine. He had a
nephrectomy 10 years ago because of injuries sustained in a motor vehicle collision.
Evaluation shows renal cell carcinoma in his remaining kidney and pulmonary metastases.
Interleukin-2 (IL-2) therapy is started. Three weeks later, CT scan confirms regression of the
tumor. Which of the following most likely caused the regression?
A)

An effect of IL-2 on tumor vascularization

B)

Cytotoxic effects of IL-2 on tumor cells

C)

Increased natural killer cell activity

D)

Induction of antitumor antibodies by IL-2

E)

Induction of B-lymphocyte proliferation

F)

Spontaneous remission

MUSCULOSKELETAL
35.
A mother reports that her 1-year-old male infant is less active. Weakness is
progressive. The mother says that even though her son is weak, his muscles appear larger
than before. The most likely diagnosis is
A)

central core disease

B)

Duchenne's muscular dystrophy

C)

limb-girdle dystrophy

D)

myotonic dystrophy

E)

nemaline myopathy

CARDIO/INFLAMMATION
44.
A 45-year-old man has a myocardial infarction. A coronary stent restores blood flow,
but reperfusion causes a paradoxical increase in damage. Which of the following is the most
likely mechanism of the new myocardial damage?
A)
Direct poisoning of mitochondrial enzymes
B)
Increase in lipid peroxidation of membranes
C)
Inhibition of ATPase-dependent transport
D)
Loss of intracellular amino acids
E)
Prevention of cross-linking of labile amino acids

29

NUTRITION
45.
A 7-month-old female infant is brought to the physician's office after having a tonicclonic seizure. Findings include ataxia, hypotonia, hearing loss, hair loss, and a rash.
Laboratory studies show normal plasma amino acid concentrations but abnormal urinary
organic acid concentrations consistent with multiple carboxylase deficiency. The
administration of which of the following is the most appropriate treatment of this patient?
A)

Biotin

B)

Vitamin B2 (riboflavin)

C)

Vitamin B6 (pyridoxine)

D)

Vitamin B12 (cyanocobalamin)

E)

Vitamin C

CELL INJURY POISONING


49.
A 25-year-old man swallows 100 mL of carbon tetrachloride in a suicide attempt.
Which of the following is the most likely outcome?
A)

Central nervous system failure as a consequence of DNA damage in neurons

B)

Gastric toxicity related to erosive gastritis

C)

Heart failure as a result of lipid peroxidation of cardiac myocytes

D)

No toxicity because the kidneys will excrete the carbon tetrachloride

E)

Severe hepatotoxicity as a consequence of damage to the plasma membranes

GENETICS
3. A neonate has ambiguous genitalia. In the first 48 hours of life, the neonate feeds poorly
and becomes dehydrated. Which of the following is the most likely diagnosis?
A)

Androgen insensitivity syndrome

B)

5-Reductase deficiency

C)

17-Hydroxylase deficiency

D)

21-Hydroxylase deficiency

E)

True hermaphroditism

ENDOCRINE
30

4. A 27-year-old man is found to have a solitary thyroid nodule during a routine health
maintenance examination. A thyroid scintiscan shows uptake of radioactive iodine by the
nodule. Which of the following is the most likely diagnosis?
A)

Chronic autoimmune (Hashimoto's) thyroiditis

B)

Follicular adenoma

C)

Granulomatous thyroiditis

D)

Medullary carcinoma

E)

Papillary carcinoma

DERMATO
11.
A 55-year-old man has had patchy leukoplakia of the anterior floor of his mouth for 4
years. He now has a raised, firm white lesion in the same area. Examination of tissue
obtained on biopsy of this new lesion is most likely to show
A)
B)
C)
D)
E)
F)
G)

aphthous ulcer
Burkitt's lymphoma
Candida infection
Kaposi's sarcoma
mixed tumor of the parotid gland
squamous cell carcinoma
Warthin's tumor

CARDIO
12.
A 55-year-old man with a long history of poorly controlled hypertension suddenly
develops severe retrosternal chest pain that radiates into the upper back between the
scapulae. On examination he has diaphoresis and severe shortness of breath. Pulse is
125/min and regular, and blood pressure is 130/60 mm Hg in the left arm and 80/50 mm Hg
in the right arm. There are diffuse, wet, inspiratory crackles in both lung fields, distant heart
sounds, and a previously undetected grade 2/6, blowing, early diastolic murmur in the second
right and third left intercostal spaces adjacent to the sternum. The most likely diagnosis is
A)
B)
C)
D)
E)
F)

dissecting aortic aneurysm


myocardial infarction
pericarditis with tamponade
pulmonary embolism
ruptured chordae tendineae
ventricular septal rupture

NEURO
31

13.
A 65-year-old man dies of bronchopneumonia. He has a 6-year history of progressive
loss of facial expression, tremors, rigidity, and slowing of voluntary movement. At autopsy,
loss of pigmented cells is noted in the substantia nigra. Which of the following additional
abnormalities is most likely to be present?
A)

Eosinophilic inclusions (Lewy bodies) in neurons of the substantia nigra

B)

Loss of neurons in the caudate nuclei

C)

Microglial nodules and multinucleated giant cells in the white matter

D)

Neurofibrillary tangles in the cortical neurons

E)

Viral inclusions in the oligodendrocytes

NEUMO
16.
A 31-year-old woman is admitted to the hospital in labor at 28 weeks' gestation.
Administration of which of the following will most likely enhance production of surfactant by
fetal type II alveolar cells?
A)

Corticosteroids

B)

Glucagon

C)

Growth hormone

D)

Insulin

E)

Somatostatin

NEUMO
18.
A homeless 38-year-old man has a 3-month history of decreased appetite, generalized
wasting, a low-grade fever, and worsening cough productive of bloody, mucopurulent sputum.
He has a 3-year history of alcohol abuse. X-ray films of the chest show consolidation and
cavitary lesions in the apices of the lungs. Which of the following is the most likely
inflammatory and/or immune response in the lung?
A)

Endothelial cell proliferation, vascular budding, fibroblasts

B)
C)
D)

Epithelioid cells, multinucleated giant cells, caseation necrosis


Fibroblasts, collagen deposition, replacement of intrinsic tissue
Macrophages, lymphocytes, hypergammaglobulinemia

E)

Neutrophils, vascular congestion, exudates

GASTRO
32

20.
A 45-year-old man has a 6-month history of burning pain that begins in the epigastric
area and ascends into the chest. Episodes occur most frequently after large meals and at
night. Endoscopic examination shows moderately severe inflammation in the distal 3 cm of
the esophagus. Which of the following is the most likely cause of this condition?
A)

Diffuse spasm of the esophageal musculature

B)

Failure of the lower esophageal sphincter to relax after a swallow

C)

Helicobacter pylori infection

D)

Hypersecretion of gastric acid

E)

Inappropriate relaxation of the lower esophageal sphincter

LYMPHOPROLIF
21.
A 70-year-old woman has increasing weakness, weight loss, generalized lymph node
enlargement, and hepatosplenomegaly. Laboratory studies show absolute lymphocytosis
with the majority of cells being CD5+. The patient also has a mild antiglobulin-positive
hemolytic anemia. Karyotype is normal. Which of the following is the most likely diagnosis?
A) Acute lymphoblastic leukemia
B)
Acute promyelocytic leukemia
C)
Chronic lymphocytic leukemia
D)
Chronic myeloid leukemia
E)
Fanconi's anemia
F)
Hairy cell leukemia
G)
Myelodysplastic syndrome
H)
Myeloid metaplasia with myelofibrosis
I)
Polycythemia vera

GASTRO
22.
A 50-year-old woman is evaluated for occult blood in the stool. Colonoscopy shows a
5-cm sessile mass with a velvety surface that projects about 2 cm above the mucosa of the
rectosigmoid. Microscopic examination of tissue obtained on biopsy of the mass shows
papillae composed of delicate fibrovascular cores covered by dysplastic columnar epithelium.
This patient is at increased risk for which of the following colonic neoplasms?
A)
B)
C)
D)
E)
F)

Adenocarcinoma
Carcinoid
Fibrosarcoma
Leiomyosarcoma
Lymphoma
Squamous carcinoma

MUSCULOSKELETAL / ENDOCRINE
33

23.
A 25-year-old woman has had generalized bone pain for 9 years. She has frequent
episodes of loose bulky stools. Examination shows muscle weakness and a distended
abdomen. X-ray films show generalized demineralization of bones, absence of the lamina
dura, and fracture-like lines in the bones of the feet. Which of the following sets of findings in
serum is most likely in this patient?
Calcium/Phosphorus/Alkaline phosphatase/Parathyroid hormone
A)

B)

C)

D)

E)

CARDIO / INFLAMMATION
29.
A 45-year-old woman has an acute coronary occlusion. Within seconds, the ischemic
region shows mitochondrial swelling and depletion of glycogen granules. Which of the
following metabolic events is the most likely cause of these cellular changes?
A)
B)
C)
D)
E)

Accumulation of free fatty acids


ATP depletion
Degradation of membrane phospholipid
Efflux of K+
Influx of Na+

RENAL
30.
A 4-year-old girl is brought to the emergency department because of a 5-day history of
fever, diffuse abdominal pain, nausea, vomiting, and diarrhea. Examination shows petechiae,
hepatomegaly, and splenomegaly. Hemoglobin concentration is 8.7 g/dL and platelet count is
60,000/mm3. A peripheral blood smear shows erythrocyte fragmentation. Which of the
following renal findings is most likely to be associated with her condition?
A)
B)
C)
D)
E)

Glomerular crescent formation


IgG-associated glomerular basement membrane antibody
Membranoproliferative glomerulonephritis
Narrowing of the capillary wall by fibrin deposition
Periglomerular granuloma with giant cells

GASTRO
34

A 48-year-old man with a long history of alcohol abuse has painless vomiting of large
amounts of bright red blood. Heart rate is 110/min and blood pressure is 80/0 mm Hg. He
dies despite rapid transfusion of packed erythrocytes. At autopsy, the source of the
hemorrhage is found in the lower esophagus. A photograph of the site is shown. Which of
the following mechanisms most likely caused the hemorrhage?

A)

Alcohol-induced esophagitis

B)

Deficiency in hepatic synthesis of vitamin K-dependent coagulation proteins

C)

Mechanical tearing of the esophageal mucosa during vomiting

D)

Peptic ulceration of esophageal mucosa due to reflux of gastric acid

E)

Transmission of portal hypertension to esophageal veins

CARDIO
40.
A 67-year-old woman has the sudden onset of dyspnea and chest pain and dies within
minutes. Stage IV ovarian cancer was diagnosed 1 year ago, and she has been bedridden for
2 months. Which of the following is most likely to be found on autopsy?
A)
B)
C)
D)
E)

Acute myocardial infarction


Deep venous thrombosis
Dissecting aortic aneurysm
Renal papillary necrosis
Ruptured berry aneurysm

35

IMMUNO
41.
A 4-month-old boy is admitted to the hospital with disseminated candidiasis. He has
had several episodes of upper respiratory viral infections and has a history of tetany. Two
months ago, his serum calcium concentration was 2.0 mg/dL. Truncus arteriosus was
diagnosed. He was given vitamin D and calcium supplements and was discharged at 1
month of age. Which of the following sets of laboratory findings is most likely at this time?
Gamma globulins

Peripheral lymphocytes

Mediastinal shadow on x-ray films

A) Decreased

decreased

narrowed

B) Normal

decreased

widened

C) Normal

decreased

narrowed

D) Increased

increased

widened

E) Increased

increased

narrowed

FEMALE PART
A sexually active 18-year-old woman comes to the physician's office because of fever, lower
abdominal pain, and a purulent vaginal discharge for the last 3 weeks. A tender mass is
palpated in the right lower quadrant on bimanual examination. Which of the following is the
most likely site of the mass?
A)

Ovary

B)

Fallopian tube

C)

Uterine fundus

D)

Uterine body

E)

Vagina

F)

Bladder

G)

Rectum

36

CARDIO
A 72-year-old man comes to the physician because of an 8-month history of feeling lightheaded when he stands up. Blood pressure is 130/85 mm Hg while supine and 94/64 mm Hg
while standing. High-dose fludrocortisone therapy is started. After 5 days of treatment,
laboratory studies are most likely to show which of the following changes?
Serum
K+
Renin

Urine
K+ excretion

A)

B)

C)

D)

E)

F)

MUSCULOSKELETAL/ ACTIONS
A 61-year-old man has a 3-month history of dull, aching pain on the left side of his chest.
Which of the following is the most appropriate next step in evaluation of this patient?
A)

Ask him about his past medical history

B)

Ask him about his family history

C)

Ask him for additional details about his chest pain

D)

Order an exercise stress test

E)

Perform a cardiovascular examination

37

11.

DERMATO

A 35-year-old woman has had twelve 0.5 to 1.5-cm lesions on her neck, trunk, and limbs for
the past 5 years. A lesion on her arm is shown. Which of the following is the most likely
diagnosis?
A)

Chronic hepatic disease

B)

Cushing's syndrome

C)

HIV infection

D)

Melatonin excess

E)

Neurofibromatosis

NEUMO
12.
A 74-year-old man has a cough. On auscultation of the right posterior chest, the
patient's spoken "ee" sounds more like "ay." Which of the following conditions on the right is
most likely?
A)

Bronchopleural fistula

B)

Lower lobe consolidation

C)

Middle lobe atelectasis

D)

Pleural effusion

E)

Pleural plaque

F)

Pneumothorax

G)

Sequestration

GASTRO
38

16.
A 2-year-old child has a hemorrhage in the lower gastrointestinal tract. A Meckel's
diverticulum is surgically resected. What kind of ectopic tissue is most likely to be present in
the diverticulum?
A)

Biliary

B)

Colonic

C)

Duodenal

D)

Gastric

E)

Splenic

ENDOCRINE
18.
A neonate with swelling of the neck has a decreased serum thyroxine (T4)
concentration and an increased serum thyroid-stimulating hormone concentration. Which of
the following agents chronically ingested by the mother during the pregnancy is the most
likely cause of these findings?
A)

Corticosteroids

B)

Propranolol

C)

Propylthiouracil

D)

Thyroxine (T4)

E)

Triiodothyronine (T3)

CARDIO/NEUMO/INFLAMM
20.
A 56-year-old man has had fever and pleuritic chest pain for 1 day. He was admitted to
the hospital 3 weeks ago because of an acute transmural anterior myocardial infarction. He
has taken a -adrenergic blocking agent and aspirin since being discharged. A friction rub is
heard over his precordium. Which of the following is the most likely cause of the current
findings?
A)
B)
C)
D)
E)

Adverse drug effect


Aortic dissection
Autoimmune reaction
Postviral inflammation
Recurrent ischemia

ENDOCRINE_RENAL
39

22.
A 35-year-old woman has had type 1 diabetes mellitus for 20 years and
microalbuminuria for 3 years. Which of the following findings is most likely on examination of
tissue obtained on renal biopsy?
A)

Corticomedullary cysts

B)

Diffuse glomerulosclerosis

C)

Endothelial cell proliferation

D)

Glomerular crescents

E)

Glomerular leukocytic infiltration

MUSCULOSKELETAL
23.
A 26-year-old woman has a 3-week history of joint pain and a photosensitive rash on
her face and other exposed parts of her body. Which of the following tests is most useful in
confirming the diagnosis?
A)

Antibodies against native DNA (double-stranded DNA)

B)

Antibodies against rubella virus

C)

Erythrocyte sedimentation rate

D)

Leukocyte count

E)

Rheumatoid factor assay

F)

Serologic test for syphilis

G)

Total hemolytic complement concentration

MALE PART
27.
A 72-year-old man has difficulty initiating urination. Digital rectal examination shows
an enlarged, firm prostate. An assay for serum prostate-specific antigen is 3.5 g/L
(reference range = 05). Examination of tissue obtained on biopsy of the prostate is most
likely to show
A)
B)
C)
D)
E)

adenocarcinoma
chronic prostatitis
epithelial dysplasia
glandular hyperplasia
leiomyoma

CARDIO
40

Nine months ago, a 60-year-old man had a myocardial infarction of his left anterior ventricular
wall. Recovery was uneventful. A photomicrograph of the area of infarction is shown. Which
of the following macrophage products is primarily responsible for the dominant feature in the
area surrounding the X?
A)
Fibroblast growth factor
B)
Formylated peptides
C)
Interferon-
D)
Leukotriene D4
E)
Neutral proteases
F)
Nitric oxide

INFLAMMATION/ NEUMO
A 42-year-old man with pneumococcal pneumonia has acute fibrinous pleuritis. Which of the
following proteolytic enzymes is required to eliminate the exudate and restore normal pleural
anatomy?
A)

Collagenase

B)

Plasmin

C)

Stromeolysin

D)

Thrombin

E)
Trypsin
NUTRITION/VITAMINS/ LYMPHOPROLIF
41

35.
Several clinical trials have suggested that retinoic acid can induce remission in
patients with acute promyelocytic leukemia. Such remission is related to the ability of retinoic
acid to promote which of the following?
A)

Differentiation of leukemic cells

B)

Differentiation of monocytes into macrophages

C)

Generation of cytotoxic T lymphocytes

D)

Production of interferon

E)

Repair of DNA damage

COAGULATION
40.
A 32-year-old man has a family history of bleeding. Partial thromboplastin and
bleeding times are prolonged, aggregation of platelets with ristocetin is absent, and factor VIII
(antihemophilic factor) concentration is decreased. The most likely diagnosis is
A)

deficiency of antithrombin III

B)

disseminated intravascular coagulation

C)

hemophilia A

D)

hepatic failure

E)

von Willebrand's disease

ENDOCRINE
41.
A 23-year-old woman has had intermittent amenorrhea since the birth of her first child
5 years ago. She received 10 units of blood during her delivery. Her skin is thick and doughy.
She has no energy and is depressed. Which of the following is the most likely cause of her
symptoms?
A)

Adrenocortical insufficiency

B)

Chronic fatigue syndrome

C)

Hemochromatosis

D)

HIV infection

E)

Pituitary necrosis

HEMATO
42

49.
A 25-year-old woman, gravida 1, para 0, who is Rh-negative, delivers a full-term Rhpositive neonate. The mother is given prophylactic anti-Rho(D) immune globulin immediately
post partum. During her second pregnancy 3 years later, she is screened each trimester for
Rho(D) antibodies. An indirect antiglobulin test done during the third trimester indicates the
presence of anti-Rho(D) antibodies in her serum. Which of the following is the most likely
mechanism for the occurrence of these maternal antibodies?
A)

Anamnestic production of maternal anti-Rho(D) immunoglobulin

B)

Intrauterine transplacental fetal-maternal hemorrhages during the second pregnancy

C)

Residual circulating prophylactic anti-Rho(D) immunoglobulin

D)

Transplacental passage of fetal IgG anti-Rho(D) antibodies

NUTRITION
5. Compared with a person who follows a lacto-ovo vegetarian diet, a person whose
vegetarian diet does not permit intake of milk or eggs is most likely to have a deficiency of
A)
B)
C)
D)
E)

folate
vitamin A
vitamin B12 (cyanocobalamin)
vitamin C
Vitamin D

NEUMO
12. A 49-year-old man has a 1-week history of shortness of breath without fever, chills, or
cough. Breath sounds are decreased in the left lower lobe, and there is decreased vocal and
tactile fremitus and dullness to percussion in this area. The most likely diagnosis is
A)
bronchiectasis
B)
bronchospasm
C)
emphysema
D)
interstitial infiltrate
E)
lobar consolidation
F)
pleural effusion
G)
pneumothorax

43

ENDOCRINE
16.
A 50-year-old woman comes to the physician because of a visible painless lump in her
neck for the past 6 months. Her pulse is 80/min, respirations are 14/min, and blood pressure
is 120/70 mm Hg. She has an enlarged, nontender thyroid gland. Initial thyroid function
studies are normal. Her serum thyroid-stimulating hormone (TSH) concentration is 15 U/mL,
and serum thyroxine (T4) concentration is 3.5 g/dL. Which of the following describes the
most likely pathologic findings in her thyroid gland?
A
)
Absence of thyroglobulin
B
)
Heavy lymphocyte infiltrate with germinal center formation
C
)
Noncaseating granulomas
D
)
Presence of an antibody that simulates the action of TSH
E
)
Regenerative nodules with lakes of excess thyroid proteins

GENETICS
22.
Mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) protein
alter which of the following ion transport mechanisms?
A
B
C
D
E

)
)
)
)
)

Ca2+-activated Cl secretion
Ca2+-activated Cl uptake
Cyclic AMP (cAMP)-stimulated Cl secretion
cAMP-stimulated Na+ secretion
cAMP-stimulated Na+ uptake

CARDIO
23.
A 70-year-old man has severe atherosclerotic disease of the abdominal aorta that
obstructs the ostia of the superior and inferior mesenteric arteries. He has intermittent
episodes of abdominal pain and bloody diarrhea. Which of the following regions of the bowel
is likely to be most severely affected?
A
B
C
D
E

)
)
)
)
)

Ascending colon
Descending colon
Hepatic flexure
Splenic flexure
Transverse colon

DERMATO
44

24.
A 73-year-old woman has a 1-cm, scaly, raised lesion on the right side of the face. A
photomicrograph of tissue obtained on biopsy of the excised lesion is shown. Use of which of
the following is most likely to have prevented the development of this lesion?

A
B
C
D
E
F
G

)
)
)
)
)
)
)

Conjugated estrogen
Isoniazid
Sunscreen
Tretinoin cream
Triamcinolone cream
Vitamin C
Vitamin E cream

NEUMO
26.
Examination of the lungs at autopsy shows nodular areas of chronic pneumonitis with
necrotizing arteritis and focal collections of epithelioid histiocytes. The most likely diagnosis is
A
B
C
D
E
F
G

)
)
)
)
)
)
)

desquamative interstitial pneumonia


Goodpasture's syndrome
histiocytosis X
idiopathic pulmonary fibrosis
pulmonary alveolar proteinosis
sarcoidosis
Wegener's granulomatosis

RENAL
47.
A 40-year-old woman has recurrent calcium-containing renal calculi. Which of the
following strategies is most likely to decrease her risk for forming additional calculi?
A
)
Administration of a thiazide diuretic
B
)
Alkalinization of the urine
C
)
Ingestion of a high-oxalate diet
D
)
Ingestion of a high-protein diet
E
)
Restriction of fluid intake
45

RENAL
30.
A 39-year-old woman with rheumatoid arthritis develops proteinuria after treatment
with penicillamine. Examination of tissue obtained on renal biopsy shows diffuse fine granular
deposits of IgG and C3 in the glomerular basement membrane. The most likely diagnosis is
A)
focal segmental sclerosis
B)
Goodpasture's syndrome
C)
IgA nephropathy
D)
membranous glomerulonephritis
E)
minimal change disease

FEMALE/GYNECO
31.
An asymptomatic 65-year-old woman comes to the gynecologist for a routine
examination. Physical examination shows a left adnexal enlargement that was not present 1
year ago. Which of the following is the most likely diagnosis?
A
B
C
D
E

)
)
)
)
)

Endometriosis
Leiomyoma
Ovarian tumor
Polycystic ovarian disease
Ruptured luteal cyst

LYMPHO
32.
Latent infection with which of the following viruses is associated with expression of
some (but not all) viral genes in B lymphocytes?
A
B
C
D
E

)
)
)
)
)

Epstein-Barr virus
Hepatitis B virus
Measles virus
Simian virus 40
Varicella-zoster virus

MUSCULOSKELETAL
34.
A full-term male neonate is born with a 4x4-cm mass posterior to the right
sternocleidomastoid muscle. Delivery was uncomplicated and Apgar scores were 9 and 9 at 1
and 5 minutes, respectively. The mass is unilocular and filled with watery fluid; no other
abnormalities are present. The most likely diagnosis is
A
B
C
D
E

)
)
)
)
)

branchial cyst
cystic hygroma
preauricular sinus
thyroglossal duct cyst
Zenker's diverticulum
46

LYMPHO
A 32-year-old man has had malaise, a low-grade fever, and a 4.5-kg (10-lb) weight loss over
the past 3 months. He has unilateral cervical lymphadenopathy. Laboratory studies show:
Hemoglobin
Hematocrit
Mean corpuscular volume
Reticulocyte count
Serum iron
Total iron-binding capacity

11 g/dL
33%
80 m3
0.5%
25 g/dL
150 g/dL (N=250460)

Examination of tissue obtained on biopsy of a lymph node shows Hodgkin's disease, nodular
sclerosing type. The most likely cause of the anemia is
A
)
abnormal utilization of iron
B
)
extravascular hemolysis
C
)
folate deficiency
D
)
iron deficiency
E
)
marrow aplasia

NEURO
36.
A 35-year-old woman at 18 weeks' gestation has an increased serum -fetoprotein
concentration. Which of the following has the greatest influence in determining the predictive
value of this test for neural tube defects?
A
B
C
D
E

)
)
)
)
)

Concentration of -fetoprotein in maternal serum


Maternal history of monozygotic twin pregnancies
Prevalence of neural tube defects in the population in question
Sensitivity of the test
Specificity of the test

GASTRO
37.
A 45-year-old man has nausea, vomiting, and abdominal pain. He has tachycardia,
absent bowel sounds, and involuntary guarding and rebound tenderness of the abdomen.
The most likely cause of these findings is
A
B
C
D
E

)
)
)
)
)

cholecystitis
gastritis
gastroenteritis
peritonitis
small bowel obstruction

47

NEUMO
38.
A 40-year-old man is brought to the emergency department after being exposed to
ozone and nitrogen dioxide at a factory. He dies shortly thereafter. At autopsy, examination of
tissue taken from a lung biopsy suggests damage to his alveolar epithelium. If he had
survived, this layer would have likely been regenerated within several weeks by which of the
following cells?
A
B
C
D
E

)
)
)
)
)

Clara cells
Endothelial cells
Reticular cells
Type I pneumocytes
Type II pneumocytes

NUTRITION- GASTRO
42.
A 47-year-old man undergoes resection of his entire stomach for intractable bleeding
from a gastric ulcer. After recovery, he is at increased risk for which of the following?
A
)
Copper deficiency
B
)
Vitamin A deficiency
C
)
Vitamin B6 (pyridoxine) deficiency
D
)
Vitamin B12 (cyanocobalamin) deficiency
E
)
Vitamin C deficiency

CARDIO
47.
A 65-year-old woman develops a proximal deep venous thrombosis 1 week after an
elective total hip replacement. What is the mechanism of intravenous heparin in treating this
disorder?
A
B
C
D
E

)
)
)
)
)

Activation of plasmin
Facilitation of inactivation of thrombin by antithrombin III
Inhibition of activation of tissue plasminogen
Inhibition of vitamin K-dependent coagulation factors
Reversible inhibition of protein C and protein S activity

48

DERMATO

A neonate is born with the abnormality shown. Abnormally robust activity of which of the
following processes is the most likely cause of this malformation?
A

Angiogenesis

Cell adhesion

Cell migration

Gastrulation

Somitogenesis

ENDOCRINE
3.
A 30-year-old woman has a 10-month history of a whitish discharge from both breasts.
Her last menstrual period was 9 months ago. She had a bilateral tubal ligation 4 years ago
after the birth of her third child. Palpation of the breasts discloses no masses. Whitish fluid is
expressed bilaterally on compression of the nipples. The most likely diagnosis is
A
)
bilateral mastitis
B
)
intraductal carcinoma of the breast
C
)
metastatic carcinoma of the breast
D
)
pituitary adenoma
E
)
premature menopause

49

ENDOCRINE
5.
Over the past 6 months, a 54-year-old woman has had several episodes of
nervousness in which her heart pounds and her skin becomes clammy. She has also had
difficulty sleeping and recently developed hypertension. The most likely cause is a neoplasm
in which structure labeled on the cross-sectional drawing of the abdomen at the level of T-12
to L-1?

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

CARDIO
An 85-year-old woman who was admitted to the hospital 3 days ago for myocardial infarction
has a radionuclide scan that shows damage to the anterior wall of the left ventricle. Which of
the following coronary vascular structures was most likely occluded?
A)
B)
C)
D)
E)
F)

Circumflex artery
Coronary sinus
Left anterior descending artery
Posterior descending artery
Right coronary artery
Right marginal artery

50

HEMATO
A 10-year-old girl has fever, fatigue, and easy bruising. Laboratory studies show:
Hemoglobin
Hematocrit
Leukocyte count
Platelet count

6.6 g/dL (N=11.815)


20% (N=3645%)
1300/mm3
12,000/mm3

A photomicrograph of bone marrow obtained on biopsy is shown. The most likely diagnosis is
A)
B)
C)
D)
E)

aleukemic leukemia
aplastic anemia
immune thrombocytopenic purpura
myelofibrosis
vitamin B12 (cyanocobalamin) deficiency

MUSCULOSKELETAL
17.
A 20-year-old man has had increasingly severe muscle weakness and incapacitation.
He has used a wheelchair for ambulation since he was 10 years of age. Examination of
tissue obtained on biopsy of a calf muscle when he was 6 years old showed a mixed pattern
of muscle fiber necrosis alternating with hypertrophy and regeneration of residual muscle
fibers. At age 18 years, biopsy findings showed virtually complete replacement of muscle by
fibrofatty tissue. Which of the following cellular proteins is most likely to be missing from this
patient's muscles?
A
B
C
D
E

)
)
)
)
)

Actin
Desmin
Dystrophin
Spectrin
Vimentin

51

GASTRO
A 32-year-old woman who is an editor for a publishing company comes to the physician
because of intermittent diarrhea for the past 10 years, which occurs three to four times per
year, lasts 2 to 4 days, and is associated with deadlines at work. During these episodes, the
stool is loose and contains no melena or bright blood. Between episodes of diarrhea, she
occasionally has one bowel movement every 4 to 7 days; the stool is hard and "pellet-like."
She drinks one glass of wine daily. Physical examination shows no abnormalities. Laboratory
studies show:
Hemoglobin
14.3 g/dL
Hematocrit
43%
Leukocyte count
8100/mm3
Erythrocyte sedimentation rate (Westergren)
7 mm/h
Which of the following is the most likely diagnosis?
A)
Crohn's disease
B)
Colon cancer
C)
Diverticulitis
D)
Irritable bowel syndrome
E)
Small bowel lymphoma
F)
Ulcerative colitis

NEURO
Over a period of 3 years, a 40-year-old man develops generalized dystonic, hyperkinetic
movements and progressive dementia. His mother and one sister have a similar disease, but
his father and another sister are healthy. Which of the following lesions is most likely to be
present in the central nervous system of the patient and his affected family members?
A)
Atrophy of the caudate nuclei
B)
Loss of pigmented cells in the substantia nigra
C)
Microglial nodules and multinucleated giant cells in the white matter
D)
Neurofibrillary tangles in the cortical neurons
E)
Spongiform changes in the cerebral cortex

NUTRITION
A 5-year-old girl from sub-Saharan Africa is brought to the health clinic by her mother
because of diarrhea for the past 4 weeks. Her pulse is 150/min, and blood pressure is 80/40
mm Hg. Physical examination shows edema of the face, abdomen, and legs. She is listless
and has reddish hair. Serum albumin concentration is 1.2 g/dL. Compared with a healthy
child, which of the following findings is most likely in this girl?
A)
Decreased interstitial fluid volume
B)
Decreased interstitial hydrostatic pressure
C)
Decreased plasma oncotic pressure
D)
Increased capillary hydrostatic pressure
E)
Increased plasma volume
MUSCULOSKELETAL
52

32.
A 63-year-old woman has pain in the back. An x-ray film of the spine shows a vertebral
compression fracture. Measurement of bone mineral density is markedly below the reference
range. Serum concentrations of calcium, phosphorus, albumin, and creatinine, and activity of
alkaline phosphatase are all within the reference range. Urine calcium and protein
concentrations are normal. The most likely diagnosis is
A)
Fanconi's syndrome
B)
hyperparathyroidism
C)
osteitis deformans (Paget's disease)
D)
osteomalacia
E)
osteoporosis
ENDOCRINE
8.
A 22-year-old woman is concerned about her risk for developing diabetes because her
mother has type 2 diabetes mellitus. Which of the following is the primary defect thought to
predispose individuals towards the development of type 2 diabetes mellitus?
A)
Anti-insulin receptor antibodies
B)

Autoimmune destruction of pancreatic cells

C)

Dysregulation of pancreatic cells

D)

Increased peripheral insulin resistance

E)

Suppressed hepatic glycogen synthesis

ENDOCRINE
33.
A 42-year-old woman reports fatigability, nervousness, irritability, and heat intolerance.
She has a diffuse goiter, exophthalmos, and pretibial edema. Circulating antibodies to which
of the following are most likely to be found in this patient?
A)
Microsomal protein
B)
Reverse triiodothyronine (rT3)
C)
Thyroglobulin
D)
Thyrotropin
E)
Thyrotropin receptor
CARDIO
A 68-year-old man has heterozygous familial hypercholesterolemia. Which of the following
agents will decrease plasma VLDL and LDL concentrations but will cause cutaneous
vasodilation that subsides with repeated doses?
A)
Niacin
B)
Nitric oxide
C)
Prostacyclin (PGI2)
D)
Prostaglandin E2
E)
Substance P
F)
Thyroxine (T4)
G)
Vasoactive intestinal polypeptide
H)
Vitamin B6 (pyridoxine)
CARDIO
53

A 55-year-old man with a 10-year history of poorly controlled hypertension has had increasing
dyspnea for the past 3 days. Last night he slept sitting in a chair. Vital signs are:
Pulse: 110/min
Respirations: 30/min and regular
Blood pressure, sitting: 120/80 mm Hg
The apical impulse is felt 2 cm lateral to the midclavicular line in the sixth intercostal space.
Over the apex, there is an early diastolic low-frequency sound after S2. This sound is most
likely
A)

a midsystolic click

B)

an opening snap

C)

a pericardial rub

D)

a splitting of S2

E)

an S3

54