NBME Questions + Answers Part 2

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62. A 20-year-old woman comes to the physician because of a 5-year history of heavy bleeding with menses that often requires her to change her sanitary pads three times hourly. Menses occur at regular 28-day intervals. She recently sustained a minor cut to her finger, and the bleeding took longer to stop than usual. She has not had easy bruising or change in weight. She only takes an oral contraceptive, but she has not been sexually active for the past 6 months. Her temperature is 37.5°C (99.5°F), pulse is 72/min, respirations are 12/min, and blood pressure is 120/66 mm Hg. Physical examination shows mildly pale conjunctivae. Pelvic examination shows no abnormalities. Laboratory studies show:
Hemoglobin
Hematocrit
Mean corpuscular hemoglobin concentration Mean corpuscular volume
Leukocyte count
Platelet count
Platelet aggregation studies
Prothrombin time
Partial thromboplastin time
10.5 g/dL 31.3%
28% Hb/cell 70 μm3 5500/mm3 275,000/mm3 normal
10.5 sec (INR=1.0) 28 sec
A Pap smear shows no abnormalities. Which of the following hematologic disorders is the most likely cause of this patient's menorrhagia?
(A) Afibrinogenemia
(B) Hemophilia A
(C) Intravascular coagulation
(D) Vitamin K deficiency
(E) von Willebrand disease
63. A 32-year-old man is brought to the emergency department 30 minutes after being struck by a car while driving his motorcycle. He reports severe pelvic pain. On examination, there is bruising of the perineum and pain is elicited with motion of his pelvis. Blood is noted at the urethral meatus. There is no other penile trauma. A plain x-ray shows a fracture of the superior pubic ramus and retrograde urethrography is done to evaluate for a urethral disruption. Which of the following portions of the urethra would be at greatest risk for injury in this patient?
(A) Intramural (pre-prostatic)
(B) Membranous
(C) Prostatic
(D) Spongy
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64. A 63-year-old man is brought to the emergency department 1 hour after police found him unresponsive. His respirations are 30/min. Crackles are heard over the left upper and the entire right lung fields. Despite appropriate lifesaving measures, he dies. A photomicrograph of a section of the right lung obtained at autopsy is shown. Which of the following mediators is the most likely cause of the position of the cell indicated by the arrow?
(A) Bradykinin
(B) C5a
(C) Histamine
(D) Nitrous oxide
(E) Prostaglandins
65. A 25-year-old woman comes to the office because of a 6-month history of increasingly severe low back pain and heavy menses. Her temperature is 37.1°C (98.8°F), pulse is 75/min, respirations are 13/min, and blood pressure is 115/79 mm Hg. Physical examination shows no abnormalities. An endometrial biopsy specimen shows regular tubular endometrial glands with abundant mitotic figures in the endometrial glands and stroma. Which of the following proteins or enzymes regulate the progression of cells into this phase of this patient's menstrual cycle?
(A) AMP-dependent kinases
(B) Cyclin-dependent kinases
(C) Hexokinases
(D) Lipid kinases
(E) Urokinases
66. A 29-year-old woman is prescribed carbamazepine for trigeminal neuralgia. She has a strong family history of osteoporosis. As a result, the physician also advises her to increase her intake of vitamin D. The most likely reason
for this
recommendation is that carbamazepine may affect which of the following pharmacokinetic processes?
(A) Absorption
(B) Distribution
(C) Excretion
(D) Metabolism
(E) Protein binding
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67. An 18-year-old woman is brought to the emergency department because of a 1-day history of fever, dizziness, weakness, rash, nausea, and vomiting. She has been using synthetic sanitary pads and tampons since her last menstrual period began 2 days ago. She has a history of recurrent urinary tract infections treated with trimethoprim- sulfamethoxazole. Current medications also include aspirin and an herbal supplement for menstrual cramps as needed. Her temperature is 39°C (102.2°F), pulse is 100/min, and blood pressure is 85/55 mm Hg. Physical examination shows injected conjunctivae and a fine, erythematous rash over the trunk, palms, and soles of the feet. Oral and pelvic examinations show erythema of the mucous membranes. Laboratory studies show:
Leukocyte count Segmented neutrophils Bands
Eosinophils Lymphocytes Monocytes
Platelet count Serum
AST ALT
The patient's use of which of the following most likely increased her
(A) Aspirin
(B) Herbal supplement
(C) Sanitary pads
(D) Tampons
(E) Trimethoprim-sulfamethoxazole
15,000/mm3 75%
5%
1%
15%
4% 100,000/mm3
100 U/L 80 U/L
risk for this condition?
68. A 53-year-old man comes to the physician because of a 6-month history of intermittent blood in his stool. He has had no pain with defecation. Physical examination shows a 1-cm, visible anal mass located below the dentate line. A biopsy of the mass is scheduled. If the mass is found to be malignant, it is most appropriate to evaluate which of the following lymph nodes for possible metastasis?
(A) Internal iliac
(B) Popliteal
(C) Sacral
(D) Superficial inguinal
(E) Superior rectal
69. A 14-year-old boy is brought to the physician for a physical examination prior to participating in sports. He appears reluctant to remove his shirt for the examination, and says that he is embarrassed because he has grown breasts during the past year. He is at the 50th percentile for height and weight. Physical examination shows bilateral 1.5-cm fibroglandular masses located beneath the nipple-areolar complex and normal penis and testes. Pubic hair development is Tanner stage 3. Serum concentrations of gonadotropic hormones, estrogens, and testosterone are within the reference ranges. Which of the following is the most likely cause of this patient's breast enlargement?
(A) Breast adenocarcinoma
(B) Estradiol-secreting Leydig cell tumor
(C) Peutz-Jeghers syndrome
(D) Seminiferous tubule dysgenesis (Klinefelter syndrome)
(E) Normal development
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70. A 24-year-old man is brought to the emergency department by paramedics 30 minutes after he was involved in a motor vehicle collision in which his face struck the steering wheel. He was the unrestrained driver. On arrival, he has moderate facial pain and double vision on upward gaze. He has no history of serious illness and takes no medications. Vital signs are within normal limits. Examination of the left eye shows periorbital ecchymoses and infraorbital edema. Ocular movement is restricted vertically. Examination of the right eye shows no abnormalities. Visual acuity is 20/20 bilaterally. CT scan of the orbits is shown. The remainder of the examination is most likely to disclose impairment of which of the following on this patient's left side?
(A) Hearing
(B) Lacrimation
(C) Pupillary reflex
(D) Saliva production
(E) Sensation over the upper lip
71. A 23-year-old woman is brought to the medical tent 2 minutes after she collapsed at the finish line of a marathon. She has not lost consciousness; she is alert and coherent and says she feels dizzy and light-headed. She does not have headache or nausea. She has no history of major medical illness and takes no medications. Her pulse is 120/min, and blood pressure is 85/50 mm Hg; other vital signs are within normal limits. Physical examination shows no other abnormalities. She is placed on a cot, her feet are elevated, and an infusion of 0.9% saline is begun. Thirty minutes later, her pulse is 70/min, and blood pressure is 110/70 mm Hg. She says she feels well and begins eating
orange slices. Which of the following best describes this patient’s condition?
(A) Autonomic dysfunction
(B) Hypokalemia
(C) Hyponatremia
(D) Myocardial inflammation
(E) Orthostatic hypotension
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72. A 27-year-old man comes to the emergency department because of a 3-hour history of pain around his navel. He also has had nausea and one episode of vomiting 1 hour ago. During the past year, he has had multiple episodes of dark stools, which last for 2 to 3 days and resolve spontaneously. He underwent an appendectomy 2 years ago. The patient says that his current symptoms are similar to those he had during the appendicitis episode. His temperature is 39.0°C (102.2°F), pulse is 94/min, respirations are 22/min, and blood pressure is 114/78 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Physical examination shows rebound tenderness localized over the right lower quadrant. Results of laboratory studies are shown:
Hemoglobin Hematocrit Leukocyte count Platelet count Serum
Urea nitrogen Creatinine
12 g/dL
36% 18,000/mm3 350,000/mm3
20 mg/dL 0.7 mg/dL
CT scan of the abdomen shows fat stranding in the mesentery of the small bowel with an area of inflammation in a segment of the small bowel. Urgent laparotomy shows a segment of inflamed small bowel in the terminal ileum; there is a 2 x 2-cm bulge in the antimesenteric border of the inflamed segment. Histologic examination of a biopsy specimen of this bulging area is most likely to show which of the following in this patient?
(A) Choristoma
(B) Ciliary epithelium
(C) Endothelial cells
(D) Gastric mucosa
(E) Striated muscle
73. A 14-year-old girl is brought to the physician after her mother learned that she began having sexual intercourse with various partners 1 month ago. She does not use condoms or other contraception. The mother is concerned about her behavior. The patient's parents separated 3 months ago. She had been an honor student and excelled in sports and leadership positions at school before the separation. Since the separation, however, she has become sullen, defiant, and rebellious. She has begun smoking cigarettes, disobeying her curfew, and being truant from school. This patient
is most
(A) (B) (C) (D) (E)
likely using which of the following defense mechanisms?
Acting out Displacement Projection Reaction formation Sublimation
74. A 38-year-old woman, gravida 3, para 2, at approximately 36 weeks' gestation, comes to the emergency department because of a 4-hour history of contractions. She has received no prenatal care but reports two uncomplicated vaginal deliveries 5 and 8 years ago. She is in mild distress because of pain that she rates as a 7 on a 10-point scale. Abdominal examination is consistent with a uterus at full term. Ultrasonography shows oligohydramnios and a full- term fetus with a large left kidney and an empty right renal fossa. It is most appropriate to obtain specific additional history regarding maternal use of which of the following during pregnancy?
(A) ACE inhibitors
(B) Antiepileptic drugs
(C) Marijuana
(D) Oral contraceptives
(E) Stimulants
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75. A 65-year-old woman with asthma is brought to the emergency department because of shortness of breath and light- headedness since taking her first dose of aspirin 30 minutes ago for primary prevention of coronary artery disease. She had a similar reaction 5 years ago after taking ibuprofen. Her pulse is 120/min, respirations are 25/min, and blood pressure is 90/60 mm Hg. Bilateral wheezing is heard over all lung fields. The most likely underlying cause of this patient’s condition is accumulation of which of the following mediators?
(A) Endoperoxides
(B) Leukotrienes
(C) Prostacyclin (PGI2)
(D) Prostaglandins
(E) Thromboxane
76. A 19-year-old man with asthma comes to a new physician for an initial examination. He has been treated in the emergency department multiple times during the past 7 months because of acute exacerbations of asthma. The patient says that he has received care only from emergency department physicians on an almost monthly basis during the past 4 years, and he has managed his symptoms with inhaled β2-adrenergic agonists. The patient says, "All the doctors I've seen just don't understand me. They keep prescribing inhalers that don't work, including that steroid inhaler they gave me recently." He has no other history of major medical illness. He does not appear to be in respiratory distress. Mild end-expiratory wheezing is heard over all lung fields. Which of the following is the most appropriate statement by the physician at this time?
(A) "Are you sure that you're taking your medications appropriately?"
(B) "I'm confident that I can help you with your asthma. I will order pulmonary function tests to see exactly
what the problem is."
(C) "Tell me what you know about the steroid inhalers and how they are supposed to work."
(D) "Your asthma seems particularly difficult to control. I'd like to refer you to an asthma specialist."
(E) "You're probably allergic to something at your home, so we'll need to figure out what that is before your
asthma can get better."
77. A healthy 22-year-old man participates in a study of glucose metabolism. At the beginning of the study, his serum glucose concentration is within the reference range. He consumes an 800-calorie meal consisting of protein, fat, and carbohydrates. He then sleeps through the night without additional food or drink. Twelve hours later, his serum glucose concentration remains within the reference range. Which of the following mechanisms is most likely involved in maintaining this man's serum glucose concentration?
(A) Continued gut absorption of calories from the ingested meal
(B) Glucose release from skeletal muscle
(C) Glycogenolysis in the liver
(D) Increased leptin release from adipose tissues
(E) Inhibition of glucagon release by the pancreas
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78. A 30-year-old man is admitted to the hospital for evaluation. He has a 6-week history of colicky abdominal pain and diarrhea with occasional blood. Three days after admission, he suddenly develops peritonitis and sepsis. Despite appropriate care, he dies. At autopsy, examination shows a fibrinous exudate over the peritoneal and serosal surfaces, and a punctate opening is seen in the wall of a thickened loop of small intestine. Several lengths of the small and large intestines are also thickened and adherent to one another, with marked areas of narrowing. Photomicrographs of a section of the colon are shown. Which of the following is the most likely diagnosis?
(A) Colon cancer
(B) Crohn disease
(C) Diverticulitis
(D) Ischemic necrosis
(E) Ulcerative colitis
79. A 3-month-old boy is brought to the emergency department because of a 2-hour history of respiratory distress. His pulse is 120/min, respirations are 40/min, and blood pressure is 80/50 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 82%. Physical examination shows cyanosis. Cardiac examination shows no murmur. A chest x- ray shows no abnormalities. A blood sample appears brown. The most likely cause of this patient’s condition is which of the following abnormalities?
(A) Decreased activity in the enzyme that reduces Fe3+ to Fe2+
(B) Decreased erythrocyte production
(C) Inability of the porphyrin ring to stay attached to hemoglobin
(D) Increased iron in the body
(E) Mutation of one of the codons for hemoglobin
80. A 68-year-old woman comes to the emergency department because of a 1-day history of fever and pain and swelling of her left leg. She has a history of chronic lower extremity edema. Physical examination shows dry, scaly skin over the lower extremities, and a swollen, erythematous, hot, and tender left calf. One day later, blood cultures grow gram-positive, catalase-negative cocci that exhibit clear zones of hemolysis on blood agar plates. There is no growth when bacitracin is added to the plate. Which of the following species of Streptococcus is the most likely causal organism?
(A) S. agalactiae (group B)
(B) S. mitis
(C) S. pneumoniae
(D) S. pyogenes (group A)
(E) Viridans streptococcus
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USMLE STEP 1 SAMPLE TEST QUESTIONS
BLOCK 3, ITEMS 81-119
81. A 62-year-old woman comes to the physician because of low back pain for 1 week. Menopause occurred 10 years ago. Physical examination shows localized tenderness over the lumbar spine after movement. X-rays of the spine show a compression fracture of L1-2. A DEXA scan shows decreased bone mineral density. Serum calcium and phosphorus concentrations and serum alkaline phosphatase activity are within the reference ranges. A bisphosphonate drug is prescribed. The expected beneficial effect of this drug is most likely due to which of the following actions?
(A) Decreased insulin-like growth factor-1 concentration
(B) Decreased osteoclast activity
(C) Decreased osteoprotegerin production
(D) Increased 1,25-dihydroxycholecalciferol concentration
(E) Increased osteoblast activity
(F) Increased receptor activator of NF-κB ligand (RANKL) production
82. In a cohort study of elderly women, the relative risk ratio for hip fractures among those who exercise regularly is 1.2 (95% confidence interval of 1.1 to 1.8). Which of the following is the most appropriate conclusion about the effect of regular exercise on the risk for hip fracture?
(A) Statistically nonsignificant increase in risk
(B) Statistically nonsignificant overall decrease in risk
(C) Statistically significant overall decrease in risk
(D) Statistically significant overall increase in risk
83. A 52-year-old man is brought to the emergency department 30 minutes after he had an episode of chest pain radiating to his jaw while shoveling snow. His pulse is 80/min, and blood pressure is 130/70 mm Hg. The lungs are clear to auscultation. Cardiac examination shows an S4. While undergoing an ECG, the patient says that he feels the chest pain returning. The most appropriate immediate treatment is a drug with which of the following mechanisms of action?
(A) Increases cAMP concentration
(B) Increases nitric oxide concentration
(C) Inhibits potassium flux
(D) Inhibits sodium flux
84. A 24-year-old woman comes to the physician for a follow-up examination. One week ago, she was treated in the emergency department after she accidentally spilled hot grease on her left leg while working at a fast-food restaurant. Examination of the left lower extremity shows a 7-cm, pink, soft, granular, edematous wound. The formation of this tissue was most likely caused by increased activity of which of the following?
(A) Complement C3b
(B) Glycosylation-dependent cell adhesion molecule-1
(C) P-selectin
(D) Stromelysin
(E) Vascular endothelial growth factor
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85. A 27-year-old man is admitted to the hospital 45 minutes after being involved in a motor vehicle collision. Physical examination shows a sluggish response to stimuli. Neurologic examination shows no other abnormalities. A skull x- ray shows a linear, nondepressed basal skull fracture. Two weeks later, the patient develops polyuria and polydipsia. Laboratory studies show a serum glucose concentration within the reference range, increased serum osmolality, and decreased urine osmolality. Following the administration of desmopressin, urine osmolality increases. The beneficial
effect of
(A) (B) (C) (D) (E)
this drug is most likely due to activation of which of the following?
Adenylyl cyclase Ca2+ channels Janus kinase Serine kinase Tyrosine kinase
86. A 10-month-old boy is brought to the physician because of a 4-day history of fever and cough. His illness began with low-grade fever and copious, clear nasal discharge. Two days ago he developed a moist, nonproductive cough and rapid breathing. He has received all scheduled childhood immunizations. He attends a large day-care center and has three school-aged siblings. His temperature is 38°C (100.4°F), pulse is 101/min, respirations are 38/min, and blood pressure is 85/60 mm Hg. Physical examination shows nasal flaring and rhinorrhea. Chest examination shows intercostal retractions along with bilateral, diffuse wheezes and expiratory rhonchi. The infectious agent of this patient's condition most likely has which of the following properties?
(A) DNA genome
(B) Double-stranded nucleic acid genome
(C) Mature virion lacking viral polymerase
(D) Mediation of cell entry via a fusion protein
(E) Viability on surfaces for several weeks
87. A 17-year-old girl is brought to the emergency department 15 minutes after being stung by a bee. She has mild light- headedness but no difficulty swallowing. Her temperature is 37.1°C (98.8°F), pulse is 100/min, respirations are 30/min, and blood pressure is 115/70 mm Hg. Physical examination shows no urticaria. Bilateral wheezing is heard on auscultation of the chest. Which of the following types of drugs is the most appropriate pharmacotherapy for this patient?
(A) α1-Adrenergic agonist
(B) α2-Adrenergic agonist
(C) α1-Adrenergic antagonist
(D) β2-Adrenergic agonist
(E) β2-Adrenergic antagonist
88. A 14-year-old boy is brought to the physician because of a 2-day history of a sore throat and fever that peaks in the late afternoon. He also has a 1-week history of progressive fatigue. He recently began having unprotected sexual intercourse with one partner. He appears ill. His temperature is 39°C (102.2°F). Physical examination shows cervical lymphadenopathy and pharyngeal erythema with a creamy exudate. Which of the following is the most likely diagnosis?
(A) Candidiasis
(B) Herpangina
(C) Infectious mononucleosis
(D) Mumps
(E) Syphilis
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89. A 57-year-old man receives radiation therapy for a squamous cell carcinoma of the lung. Despite therapy, the tumor progressively increases in size, and he dies 6 months later. His tumor cells contain a point mutation in the p53 gene (TP53), leading to an inactive gene product. Based on this finding, the progressive tumor growth despite irradiation therapy is most likely to be related to a defect in cell cycle arrest in which of the following phases of the cell cycle?
(A) G0 (B) G1 (C) G2 (D) M (E) S
90. A 28-year-old man comes to the physician because of a 1-year history of pain with urination that has increased in severity during the past month. He also has had episodes of blood in his urine during the past 5 years. He lived in sub-Saharan Africa until he came to the USA 6 months ago for graduate school. His temperature is 38°C (100.4°F), pulse is 80/min, respirations are 16/min, and blood pressure is 110/84 mm Hg. Physical examination shows suprapubic tenderness. Laboratory studies show:
Hemoglobin Hematocrit Leukocyte count
Segmented neutrophils Bands
Eosinophils Lymphocytes Monocytes
Serum
Urea nitrogen Creatinine
Urine Blood
RBC WBC RBC casts WBC casts
12.3 g/dL 37% 13,400/mm3 65%
5% 5% 22% 3%
75 mg/dL 3.8 mg/dL
3+ 200/hpf 100/hpf absent absent
Imaging studies show bilateral hydroureter and hydronephrosis and foci of calcification in the region of the bladder. A biopsy specimen of the bladder shows marked chronic inflammation with fibrosis and scattered granulomas. Which of the following best explains the biopsy findings?
(A) Exposure to a chemical toxin
(B) Interstitial cystitis
(C) Malacoplakia
(D) Schistosomiasis
(E) Vesicoureteral reflux
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91. A couple comes for preconceptional genetic counseling because they both have a family history of α-thalassemia. The woman has a minimally decreased hemoglobin concentration. Genetic studies show a single gene deletion. The man has microcytic anemia and a two-gene deletion. If the two-gene deletion is in trans (one deletion on the maternal gene and one deletion on the paternal gene), which of the following percentages of their offspring will have a two-gene deletion?
(A) 0% (B) 25% (C) 50% (D) 75% (E) 100%
92. A previously healthy 40-year-old woman is brought to the emergency department by her husband because of a 2-day history of fever, lethargy, and confusion. Her temperature is 38°C (100.4°F), pulse is 80/min, respirations are 18/min, and blood pressure is 140/90 mm Hg. Physical examination shows scattered petechiae and ecchymoses over the lower extremities. Neurologic examination shows moderate generalized motor weakness. She is oriented to person but not to place or time. Laboratory studies show:
Hemoglobin
Hematocrit
Leukocyte count
Platelet count
Prothrombin time
Partial thromboplastin time Serum
Urea nitrogen
Lactate dehydrogenase
9 g/dL
27%
8000/mm3 with a normal differential 15,000/mm3
12 sec (INR=1.1)
30 sec
25 mg/dL 1000 U/L
A peripheral blood smear shows 3+ polychromasia and 3+ schistocytes. Urine and blood cultures grow no organisms. A chest x-ray shows no abnormalities. Which of the following is the most likely diagnosis?
(A) Acute myeloid leukemia
(B) Autoimmune hemolytic anemia
(C) Thrombotic thrombocytopenic purpura
(D) Toxic shock syndrome
(E) von Willebrand disease
93. A 16-year-old boy is admitted to the emergency department because of a knife wound to the left side of his chest. An x-ray of the chest shows an air-fluid level in the left side of the chest, partial collapse of the left lung, and elevation of the stomach bubble. The mediastinum is in the midline. Which of the following is the most likely diagnosis?
(A) Hemopneumothorax, not under tension
(B) Hemothorax, not under tension
(C) Pneumothorax, not under tension
(D) Tension hemopneumothorax
(E) Tension hemothorax
(F) Tension pneumothorax
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94. A 49-year-old woman comes to the physician for a follow-up examination. She has a strong family history of coronary artery disease. Her blood pressure has ranged from 150/95 mm Hg to 130/85 mm Hg during the previous three visits within the past 2 months. Her blood pressure today is 140/90 mm Hg. Physical examination shows no other abnormalities. Laboratory studies show:
Cholesterol, total HDL-cholesterol LDL-cholesterol
Triglycerides
Treatment with atorvastatin and losartan is initiated. Which of the following serum findings is most likely to occur
in this
(A) (B) (C) (D) (E)
patient?
HDL-cholesterol
Decreased Decreased Increased Increased No change
Triglycerides
decreased increased decreased increased no change
290 mg/dL 40 mg/dL 190 mg/dL 350 mg/dL
95. A 73-year-old woman comes to the physician because of a 2-month history of diffuse weakness and tingling of her arms and legs. Neurologic examination shows weakness of the extensor and flexor muscles of the lower extremities. Knee and ankle deep tendon reflexes are exaggerated. Sensation to vibration and position is decreased in all extremities, but the decrease is more prominent in the lower extremities than in the upper extremities. This patient most likely has a deficiency of which of the following vitamins?
(A) Niacin
(B) Vitamin B1 (thiamine)
(C) Vitamin B2 (riboflavin)
(D) Vitamin B6 (pyridoxine)
(E) Vitamin B12 (cyanocobalamin)
96. A 15-year-old girl comes to the physician because of a 3-month history of acne. Breast and pubic hair development began at the age of 12 years. Menarche occurred at the age of 14 years. Physical examination shows scattered open and closed comedones over the cheeks and forehead. Breast and pubic hair development are Tanner stage 5. Which of the following is the most likely underlying cause of this patient's acne?
(A) Decreased parasympathetic stimulation to the sebaceous glands
(B) Increased estrogen stimulation of the sebaceous glands
(C) Increased responsiveness of the sebaceous glands to follicle-stimulating hormone
(D) Increased sympathetic stimulation to the sebaceous glands
(E) Stimulation of the sebaceous glands by androgens
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97. A 4-year-old boy from Brazil is brought to the physician because of a 1-week history of painless swelling of his jaw and pressure around his eyes. He is at the 80th percentile for height and weight. Physical examination shows a single 12 × 10-cm lesion in the right side of the jaw with diffuse limits and irregular edges. Photomicrographs of an incisional biopsy specimen of the lesion are shown. Based on these findings, which of the following processes is most likely occurring in the region indicated by the arrows?
(A) Apoptosis (B) Necrosis (C) Oncosis (D) Ostosis (E) Symptosis
98. A 51-year-old man comes to the office because of a 6-month history of a lump on his tongue that is interfering with his speech and eating; he also has had a 6.8-kg (15-lb) weight loss during this period. He has smoked 1 pack of cigarettes daily and has consumed six 12-oz bottles of beer on weekend nights during the past 30 years. His vital signs are within normal limits. Physical examination shows a 1.5-cm mass on the apex of the tongue. Further evaluation of the mass confirms squamous cell carcinoma. It is most appropriate to evaluate which of the following lymph nodes first for evidence of metastasis in this patient?
(A) Inferior deep cervical
(B) Parotid
(C) Retropharyngeal
(D) Submental
(E) Superior deep cervical
99. A 15-year-old boy is brought to the emergency department by his parents because of a 2-hour history of confusion and agitation. He also has had fever, headache, stiff neck, and vomiting since he returned from summer camp 2 days ago. His parents say he does not use illicit drugs. On arrival, he is combative and there is evidence of hallucinations. His temperature is 40°C (104°F), pulse is 80/min, respirations are 17/min, and blood pressure is 100/70 mm Hg. A lumbar puncture is performed. Results of cerebrospinal fluid analysis show cysts and trophozoites. The most likely portal of pathogen entry into this patient's central nervous system is which of the following?
(A) Cavernous sinus
(B) Facial nerve
(C) Frontal sinus
(D) Mastoid sinus
(E) Olfactory nerve
(F) Trigeminal nerve
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100. A 17-year-old boy is brought to the emergency department 30 minutes after being found with a "blank stare" and flat facial expression at a party. His pulse is 72/min, and blood pressure is 104/68 mm Hg. He is sitting upright and appears catatonic. Physical examination shows rigidity. During the examination, he becomes hostile and attempts to assault the physician. This patient most likely ingested which of the following drugs?
(A) Cocaine
(B) Diazepam
(C) Methamphetamine
(D) Oxycodone
(E) PCP (phencyclidine)
101. A placebo-controlled clinical trial is conducted to assess whether a new antihypertensive drug is more effective than standard therapy. A total of 5000 patients with essential hypertension are enrolled and randomly assigned to one of two groups: 2500 patients receive the new drug and 2500 patients receive placebo. If the alpha is set at 0.01 instead of 0.05, which of the following is the most likely result?
(A) Significant findings can be reported with greater confidence
(B) The study will have more power
(C) There is a decreased likelihood of a Type II error
(D) There is an increased likelihood of statistically significant findings
(E) There is an increased likelihood of a Type I error
102. A 17-year-old girl is brought to the physician by her mother because she has not had a menstrual period for 6 months. The patient is unconcerned about the lack of menses. Menarche occurred at the age of 12 years, and menses had occurred at regular 28-day intervals until they became irregular 1 year ago. She is a member of her high school gymnastics team. She appears emaciated. She is 163 cm (5 ft 4 in) tall and weighs 40 kg (88 lb); BMI is 15 kg/m2. Her pulse is 54/min, and blood pressure is 80/50 mm Hg. Which of the following is the most likely cause of this patient's amenorrhea?
(A) Hyperthyroidism
(B) Hypogonadotropic hypogonadism
(C) Hypothyroidism
(D) Polycystic ovarian syndrome
(E) Prolactinoma
103. A male stillborn is delivered at 32 weeks' gestation to a 30-year-old woman. The pregnancy was complicated by oligohydramnios. Examination of the stillborn shows the absence of a urethral opening. Which of the following additional findings is most likely in this stillborn?
(A) Congenital diaphragmatic hernia
(B) Intralobar sequestration
(C) Pulmonary hypoplasia
(D) Situs inversus
(E) Tracheoesophageal fistula
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104. A 6-day-old breast-fed boy is brought to the emergency department by his mother because of poor weight gain and irritability since delivery, and a 2-hour history of vomiting. Physical examination shows jaundice and hepatomegaly. A reducing substance test result of the urine is positive, and a glucose oxidase test result is negative. The concentration of which of the following metabolites in liver is most likely increased in this patient?
(A) Fructose 1,6-bisphosphate
(B) Galactose 1-phosphate
(C) Glucose 1-phosphate
(D) Glucose 6-phosphate
105. A 25-year-old man is brought to the emergency department because of a 6-day history of fever, severe muscle pain, and diffuse, painful swelling of his neck, underarms, and groin area. The symptoms began after returning from a camping trip in New Mexico. He appears ill and lethargic and can barely answer questions. His temperature is 39.2°C (102.5°F), pulse is 120/min, respirations are 22/min, and blood pressure is 110/70 mm Hg. Physical examination shows generalized scattered black maculae. Examination of the right upper extremity shows an erythematous, solid, tender mass on the underside of the upper extremity just above the elbow; the mass is draining blood and necrotic material. The most effective antibiotic for this patient’s disorder will interfere with which of the following cellular processes or enzymes?
(A) Cell wall synthesis
(B) DNA helicase
(C) Glucuronosyltransferase
(D) Proteasomal degradation
(E) Ribosomal assembly
(F) Tetrahydrofolate reductase
106. A 45-year-old man is brought to the clinic by his wife because of a 6-month history of progressive weakness; he also has had dysphagia and a 4.5-kg (10-lb) weight loss during this period. He has had to use a wheelchair during the past 3 weeks because of the weakness. He has no other history of major medical illness and takes no medications. He is a former financial analyst and has no known toxin exposures. He does not smoke or drink alcoholic beverages. He is 183 cm (6 ft) tall and now weighs 68 kg (150 lb); BMI is 20 kg/m2. His temperature is 37.0°C (98.6°F), pulse is 88/min, respirations are 18/min, and blood pressure is 138/78 mm Hg. He is mentally alert. Physical examination shows muscle fasciculations of the upper extremities and weakness of the lower extremities. The remainder of the
physical
(A) (B) (C) (D) (E)
examination is most likely to show which of the following additional findings in this patient?
Atrophy
Decreased visual acuity
Loss of proprioception Presence of palmomental reflex Ptosis
107. A new severe respiratory illness caused by a newly identified virus is discovered. Which of the following properties of a killed vaccine relative to a live vaccine is the most appropriate rationale for developing a killed vaccine for this illness?
(A) Avoids the concern for reversion to virulence
(B) Develops more rapid protective immunity
(C) Is less likely to require subsequent boosters for lifelong immunity
(D) Is most likely to generate mucosal immunity
(E) Requires little safety monitoring to ensure inactivation
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108. A 33-year-old woman comes to the physician because of a 2-day history of mild nausea, increased urinary urgency and frequency, and constipation. She also has had a 4.5-kg (10-lb) weight loss during the past 2 weeks and a 3-week history of vaginal bleeding. Pelvic examination shows a nodular cervix with an irregular, friable posterior lip, and a rock-hard, irregular, immobile pelvic mass that extends across the pelvis. Examination of biopsy specimens from the cervix and anterior wall of the vagina show well-differentiated keratinizing squamous cell carcinoma. Which of the following best describes the pathogenesis of this patient's disease?
(A) Inactivation of cellular p53
(B) Insertion of viral promotors adjacent to cellular growth factor genes
(C) Specialized transduction
(D) Transactivation of cellular growth factor genes by TAX
(E) Translocation of CMYC to an Ig gene promoter
109. A 54-year-old woman with a 40-year history of type 1 diabetes mellitus comes to the office for a follow-up examination. She is receiving hemodialysis for end-stage renal disease while awaiting a kidney transplant. As part of her regimen, she also receives regular injections of a drug that induces reticulocyte release from the bone marrow and stimulates a cytokine receptor that signals via the JAK/STAT pathway. This patient is most likely receiving which of the following drugs?
(A) Erythropoietin
(B) Filgrastim
(C) Interleukin-2 (IL-2)
(D) Platelet-derived growth factor
(E) Sargramostim
110. During
during a 15-minute session on a treadmill. The average pulse for the last 2 minutes of the session is 175/min. During the last minute of exercise, various measurements are taken. Compared with the measurement before the session, which of the following is most likely to be decreased?
(A) Cardiac output
(B) Oxygen consumption
(C) Pulse pressure
(D) Stroke volume
(E) Systolic blood pressure
(F) Total peripheral resistance
111. An 8-year-old boy is brought to the office by his mother because of a 3-day history of fever, sore throat, and itchy eyes. He just returned from a weeklong summer camp that included hiking trips and swimming lessons in the camp- owned swimming pool. He has no history of major medical illness and receives no medications. He appears tired. His temperature is 39.4°C (102.9°F); other vital signs are within normal limits. Physical examination shows conjunctival injection and discharge and oropharyngeal erythema. The public health department reports an outbreak of similar symptoms among the other campers and camp volunteers. Which of the following is the most likely cause of this patient’s symptoms?
(A) Adenovirus
(B) Cytomegalovirus
(C) Epstein-Barr virus
(D) Influenza virus
(E) West Nile virus
a clinical study examining the effects of exercise, men between the ages of 20 and 30 years are evaluated
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112. A 44-year-old woman comes to the office because of a 10-month history of wide red streaks over her lower trunk and significant weight gain in her face and abdomen. Although her appetite has increased, she has noticed that her arms and legs have become thinner. Which of the following additional findings are most likely in this patient?
(A) Hyperkalemia and numerous bruises
(B) Hypertension and muscle weakness
(C) Hypocalcemia and hyperglycemia
(D) Hypoglycemia and fat pads between the scapulae
(E) Jaundice and thinning of the skin
113. A 12-year-old boy is brought to the physician by his mother because of a 1-month history of pain below the left knee. His mother says, "He can usually walk around, but he hasn't been able to play in any of his soccer games since
this all Which
(A) (B) (C) (D) (E) (F)
began." Examination of the left knee shows warmth, swelling, and tenderness. An x-ray of the knee is shown. of the following structures is attached to the abnormal anterior tibial area?
Anterior cruciate ligament Gastrocnemius muscle Patellar ligament Popliteus muscle
Posterior cruciate ligament Soleus muscle
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114. A 65-year-old retired man comes to the office for a health maintenance examination. He has no history of major medical illness and takes no medications. He lives in a single-family home with his cat and dog. He spends much of his time in his basement woodworking shop. He does not smoke. His temperature is 37.0°C (98.6°F), pulse is 84/min, respirations are 12/min, and blood pressure is 138/88 mm Hg. Physical examination shows no cyanosis. The lungs are clear. Cardiac examination shows no abnormalities. Extremity examination shows no edema. The patient wishes to mitigate his risk for pulmonary disease. This patient is at increased risk for lung cancer because of which of the following environmental exposures?
(A) Indoor cleaning chemicals
(B) Pet dander
(C) Polyurethane
(D) Radon
(E) Sawdust
115. A 54-year-old man comes to the physician for a follow-up examination 10 days after undergoing a stereotactic brain operation to remove a small tumor. The operation was successful. During the procedure, he was under conscious sedation. The patient recalls that at one point during the operation he experienced a sudden, intense feeling of overwhelming fear. Which of the following areas of the brain was most likely stimulated at that time?
(A) Amygdala
(B) Hippocampus
(C) Mammillary body
(D) Prefrontal cortex
(E) Thalamus
116. A 30-year-old woman comes to the physician because of a 2-day history of abdominal pain. She has a history of recurrent upper respiratory tract infections, sinusitis, and pancreatitis. She has thick nasal secretions. She says that her sweat is salty and crystallizes on her skin. Her vital signs are within normal limits. Physical examination shows epigastric tenderness. Genetic testing for the 36 most common mutations shows a detectable mutation (G551D) in one allele of the CFTR gene. Which of the following best explains this patient's clinical phenotype?
(A) Loss of heterozygosity of the CFTR gene has occurred in the pancreas
(B) Only one G551D allele is needed in CFTR
(C) The patient is a CFTR obligate carrier
(D) The patient's CFTR mutation is unrelated to her clinical phenotype
(E) The second CFTR mutation was not detected by the testing obtained
117. A 74-year-old man with mild chronic obstructive pulmonary disease comes to the physician for a follow-up examination. Current medications include a short-acting β2-adrenergic agonist by metered-dose inhaler as needed. Physical examination shows no abnormalities. At the end of the examination, he tells the physician, "I enjoy coming to see you because you remind me of my daughter. She died 35 years ago this month." He has been a patient of this physician for 5 years. Which of the following is the most appropriate response by the physician?
(A) "I may have to refer you to another physician who doesn't remind you of your daughter so you can focus more on your medical condition and its treatment."
(B) "I'd like to refer you to a grief counselor so that you can work out your unresolved feelings about your daughter's death."
(C) "I'm sorry you lost your daughter. Unfortunately, since we only have a limited amount of time, we must now move on to your medical condition."
(D) "That makes me feel a little uncomfortable. I hope you understand."
(E) "You must miss your daughter very much. Tell me about her."
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118. A 9-month-old boy is brought to the office by his mother for a well-child examination. He was born at 32 weeks’ gestation because of spontaneous rupture of membranes. Growth and development are appropriate for age. His mother says he can sit without support and is interactive. She is concerned that he still takes two to three 1-hour naps daily. He goes to sleep at 7 PM and awakens at 7 AM. She says he also awakens and cries at least once nightly and settles back to sleep after drinking a bottle of formula. Physical examination shows no abnormalities. Which of the following is the most likely explanation for this patient’s sleep pattern?
(A) Gastroesophageal reflux
(B) Hypoglycemia
(C) Obstructive sleep apnea
(D) Parasomnia
(E) Normal development
119. A 32-year-old man comes to the office because of a 2-year history of abnormal movements of his hands that are worse when he feels angry or depressed. His maternal grandmother and mother, both now deceased, had similar symptoms with onset at the ages of 53 years and 42 years, respectively. Neurologic examination shows normal muscle strength, bulk, and tone. There is no intention tremor or dysmetria. Sensation is intact. He is unable to fix his gaze on one point or protrude his tongue for more than 30 seconds. Deep tendon reflexes are hyperactive. Mental status examination shows no abnormalities. This patient most likely has an anatomic abnormality in which of the following locations?
(A) Basal ganglia
(B) Cerebellum
(C) Dorsal spinal column
(D) Frontal lobe
(E) Lateral spinal column