1. A 30-year-old woman comes to the physician for an initial health maintenance examination. Physical examination shows abnormalities.

Fasting serum lipid studies show: Cholesterol, total HDL-cholesterol LDL-cholesterol Triglycerides 300 mg/dL 35 mg/dL 232 mg/dL 165 mg/dL

Treatment with which of the following drugs is likely to be most effective to lower LDL-cholesterol in this patient? O O O O A) B) C) D) E) Colesevelam Ezetimibe Gemfibrozil Niacin Rosuvastatin

2. A 26-year-old man with moderate asthma comes to the physician for a routine examination. Current medications include albuterol. Wheezes are heard on auscultation of the chest. Spirometry shows a decreased FEV,. Treatment with a drug that blocks leukotriene receptors is begun. Administration of this drug prevents which of the following pulmonary events? O O O A) B) C) D) Bronchoconstriction Bronchodilation Vasoconstriction Vasodilation

3. A 42-year-old woman comes to the physician for a follow-up examination after she received two increased blood pressure readings different days. Her blood pressure now is 140/92 mm Hg. Physical examination shows no other abnormalities. In addition to considering pharmacotherapy, the physician recommends a low-sodium diet. Which of the following initial statements is the most appropriate approach to educating this patient about decreasing her sodium intake? O O O O A) B) C) D) E) "The Internet is a great way to learn about methods to decrease sodium in your diet." "Do you know what kinds of foods are high in sodium?" "I will send you a brochure outlining the low-sodium diet you will need to follow." "You must see a nutritionist to discuss decreasing your sodium intake." "You need to lower your intake to fewer than three grams of sodium daily."

4. A stillborn male newborn is delivered to a 32-year-old primigravid woman at 36 weeks' gestation. A photograph of the newborn is shown. Histologic examination of the sacrococcygeal tumor shows a haphazard arrangement of somatic tissues representing derivatives of ectoderm, mesoderm, and endoderm. The pathogenesis of this congenital neoplasm is most likely related to a defect arising during which of the following developmental processes? O O O O O O A) B) C) D) E) F) Head mesenchyme proliferation Hematopoiesis Neural crest formation Neural tube closure Primordial germ cell migration Somite development

5. A 35-year-old man is brought to the emergency department after ingesting an unknown quantity of his antidepressant medicine. He is comatose and having intermittent seizures. ECG shows a sinus tachycardia with 2:1 atrioventricular block and a prolonged QRS duration. Which of the following drugs is the most likely cause of these findings? O O O O A) B) C) D) E) Amitriptyline Buspirone Fluoxetine Haloperidol Lithium carbonate

6. A pharmacologist discovers a new fungal metabolite with unusual antimicrobial properties. It naturally concentrates in the endosomes, lysosomes, and phagolysosomes of cells and directly kills microorganisms (eg, Mycobacterium tuberculosis) that are normally resistant to degradation in the phagolysosomes. The metabolite has the undesirable effect of increasing the pH within phagolysosomes. Which of the following processes will be primarily affected? O O O A) B) C) D) Class IMHC molecule peptide loading Class II MHC molecule peptide loading Peptide binding to T-lymphocyte receptor ap Peptide binding to T-lymphocyte receptor y5

7. A 9-month-old girl is brought to the emergency department 30 minutes after she had a generalized tonic-clonic seizure. She has had failure to thrive and developmental delay since birth. She is at the 3rd percentile for length and weight. Physical examination shows microcephaly, tachypnea, and hypotonia. Laboratory studies show hypoglycemia, hyperalaninemia, and lactic acidosis. After intravenous glucose is administered, her serum glucose concentration returns to within the reference range. This patient most likely has a deficiency of which of the following enzyme activities? O O O O A) B) C) D) E) Glucokinase Glyceraldehyde-3-phosphate dehydrogenase Hexokinase Pyruvate carboxylase Triose-phosphate isomerase

8. A 2-month-old girl is brought to the physician by her mother because she is concerned that her daughter has not looked normal since birth. Physical examination shows coarse facial features, dislocation of the hips, an inguinal hernia, and generalized hypotonia. Serum studies show increased activities of lysosomal enzymes. Urine studies show no mucopolysaccharides. Microscopic examination of cultured skin fibroblasts shows dense inclusion bodies and deficient lysosomal enzymes. The most likely cause of this patient's disorder is a defect that occurs in which of the following? O O O O A) B) C) D) E) Golgi complex Mitochondrion Polyribosome Rough endoplasmic reticulum Smooth endoplasmic reticulum

9. A 50-year-old woman with poorly controlled hypertension comes to the physician for a follow-up examination. She says that she is concerned she will develop dementia, Alzheimer type, like her mother did. She says, "I don't want to end up like my mother at the end of her life." Which of the following is the most appropriate response by the physician? O O O O A) B) C) D) E) "Fortunately, medical research has led to significant advances in the treatment of dementia." "I understand your concern. Let's talk more about your specific worries." "I will give you some literature about dementia that should answer any questions you may have." "I'd like to address your hypertension first, since this is the most immediate threat to your health." "It's not helpful to focus on what could happen. It's probable that you'll live to a very advanced age without problems."

10. A 20-year-old woman has a 1-month history of double vision, a 2-week history of slurred speech and difficulty chewing and swallowing food, and a 1-week history of weakness in her neck. Her symptoms are most pronounced at night. Ptosis in both eyes is exacerbated with sustained upward gaze. Eye movements are limited in all directions. She is unable to hold her arms in place for more than 10 seconds when they are abducted at the shoulders. Which of the following is the most likely location of a lesion? O O O O A) B) C) D) E) Upper motoneurons Lower motoneurons Myelin in the peripheral nerves Myocytes in skeletal muscle Neuromuscular junction

11. The continuous administration of gonadotropin-releasing hormone is most likely to elicit which of the following long-term changes the release of luteinizing and follicle-stimulating hormones? O O O A) B) C) D) Decrease Increase Loss of cyclicity without a net increase or decrease No change in net release or cyclicity

12. A 55-year-old woman comes to the physician because of a 2-week history of intermittent heartburn. She has a 20-year history of significant sensitivity to cold weather. She states that her hands turn white when they are exposed to the cold. She also states that the skin on her fingers has become tighter over the past year. Physical examination shows tight, shiny, hyperpigmented skin of the face and hands. Several subcutaneous calcifications are present in the upper extremities. Joint mobility is normal. Renal and pulmonary function studies show no abnormalities. An autoimmune disorder is suspected. Autoantibodies directed against which of the following antigens demonstrate a high degree of specificity for this patient's condition and suggest a benign course? O A) B) O C) O D) O E) O F) OG) O H) Cardiolipin Centromere Double-stranded DNA Histone Scl-70 Sm SS-A(Ro) SS-B (La)

Hemoglobin Hematocrit Leukocyte count Reticulocyte count Platelet count

4.6 g/dL (N=12.1 14.9) 14% (N=37-44) 6500/mm3(N=4000 11,600) 0.5% of red cells (N=0.5 1.5) 200,000/mm3 (N=140,000-440,000)

A bone marrow aspirate smear is shown. Which of the following is the most likely causal organism of the patient's anemia? O A) O B) O C) D) O E) Adenovirus Histoplasma capsulatum Mycobacterium avium-intracellulare Parvovirus B19 Pneumocystis jiroveci (formerly P. carinii)

15. A 56-year-old woman with squamous cell carcinoma of the lung has had fatigue, weakness, right flank pain, anorexia, and constipation for 6 weeks. Examination shows hematuria. The most likely cause of these symptoms is secretion of which of the following substances by the carcinoma? O O O O O O A) B) C) D) E) F) G) ACTH Bombesin Calcitonin Erythropoietin Human chorionic gonadotropin Nonsuppressible insulin-like activity Parathormone-related protein

Lab Values

16. A 60-year-old man comes to the physician because of enlargement of his right knee during the past 2 years. Physical examination shows bony enlargement of the right proximal tibia. There is normal range of motion and no change in the length of the right lower extremity. The tentative diagnosis of osteitis deformans (Paget disease) is made. Serum measurement of which of the following is most likely to support the diagnosis? O O O O O O A) B) C) D) E) F) G) Alkaline phosphatase activity ALT activity Calcitonin concentration Calcium concentration Lactate dehydrogenase activity Parathyroid hormone concentration Thyroxine (T4 concentration )

17. A 74-year-old man who has dementia, Alzheimer type, is obtunded and no longer able to eat. He is 178 cm (5 ft 10 in) tall and weighs 50 kg (110 lb); BMI is 16 kg/m2 He is responsive to pain but completely uncommunicative. His serum albumin concentration is . 2.2 g/dL. He has been married to his wife for 50 years but has neither a living will nor durable power of attorney. His wife reports that he has expressed to her that no artificial means be used to prolong his life. He is expected to die within the next 2 months. He has had a nasogastric tube for enteral feeding but pulled it out on three occasions. Which of the following is the most appropriate next step? O O O O A) B) C) D) E) Discuss comfort care with the patient's wife Recommend feeding the patient with a syringe Suggest that a trial of haloperidol might prevent the patient from pulling out his nasogastric tube Begin total parenteral nutrition Schedule the patient for the placement of a percutaneous gastric feeding tube

!. 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 38C (100.4F), 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 Hemoglobin Hematocrit Leukocyte count Platelet count Prothrombin time Partial thromboplastin time Urea nitrogen Haptoglobin Lactate dehydrogenase A direct antiglobulin (Coombs) test result is negative. A chest x-ray shows no abnormalities. The patient is admitted to the hospital, and intravenous plasma exchange twice daily is started. Three days later, the patient is fully oriented. Her hemoglobin concentration is 11 g/dL, hematocrit is 33%, and platelet count is 85,000/mm3 A peripheral blood smear at the time of admission most likely showed . which of the following erythrocyte abnormalities? O O O O A) B) C) D) E) Cabot rings Hypochromic microcytes Pappenheimer bodies Schistocytes Teardrop forms 9 g/dL

19. A 1-year-old girl of Ashkenazi Jewish descent is brought to the physician because of a 2-month history of progressive twitching of both eyes. Since the age of 2 months, she has had a marked startle reaction and developmental delay. Physical examination shows cherry-red spots in the macular area of the eyes, hypotonia, and psychomotor retardation. A biopsy specimen of this patient's liver is most likely to show large quantities of which of the following in hepatocytes? O O O O A) B) C) D) E) Glucocerebroside GMj-ganglioside Heparan sulfate Lipofuscin Sialylated glycopeptides

A 7-year-old boy sits on the couch drinking cocoa and petting his cat. He watches his mother as she bakes fragrant cinnamon while the stereo plays a Mozart string quartet in the background. Which of the following sensory modalities is relayed directly to cortex without going through the child's thalamus?

21. During an experiment, 500 mg of both Drugs X and Y are simultaneously administered to a healthy human subject by bolus intravenous infusion. The serum concentrations immediately post-bolus of Drug X and Drug Y are 5 mg/L and 2.5 mg/L, respectively. Assuming there is no interaction between Drugs X and Y, which of the following findings regarding Drug Y is most likely compared with Drug X? O O O O O O A) B) C) D) E) F) Decreased clearance Decreased half-life Decreased volume of distribution Increased clearance Increased half-life Increased volume of distribution

22. A 57-year-old man with asthma comes to the emergency department 30 minutes after the onset of severe shortness of breath and left-sided chest discomfort while cross-country skiing. He has no history of similar symptoms. He also has major depressive disorder and hypertension. Current medications include albuterol, fluticasone inhaler, fluoxetine, and lisinopril. His temperature is 37C (98.6F), pulse is 110/min, respirations are 30/min, and blood pressure is 130/70 mm Hg. On auscultation, wheezes are heard that are more prominent on the right side than on the left. Cardiac examination shows normal heart sounds with no murmurs. A chest x-ray is shown. Which of the following conditions is the most likely cause of this patient's acute dyspnea? O O O O A) B) C) D) E) Asthma Myocardial ischemia Pleural effusion Pneumothorax Pulmonary infarction

23. Two months after a kidney transplant, a 32-year-old man who is taking immunosuppressive drugs develops an infection with cytomegalovirus. Which of the following is the most appropriate therapy? O O O O A) B) C) D) E) Acyclovir Famciclovir Ganciclovir Ribavirin Saquinavir

24. A 68-year-old man is brought to the emergency department 1 hour after the onset of nausea, sweating, and substernal chest pain radiating to his left arm. An ECG shows ST-segment elevation in precordial leads V, through Vd. Twenty minutes after arrival, the patient suddenly develops shortness of breath and diaphoresis. His temperature is 37C (98.6F), pulse is 80/min, respirations are 28/min, and blood pressure is 110/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 89%. Cardiac examination shows a regular rhythm. A grade 2/6 holosystolic murmur is heard best at the apex with the patient in the left lateral decubitus position. Which of the following is the most likely cause of this patient's shortness of breath? O O O O O O A) B) C) D) E) F) G) Aortic dissection Aortic stenosis Atrial fibrillation Cardiac tamponade Mitral regurgitation Pericarditis Ventricular septal defect

25. A healthy 54-year-old woman undergoes an exercise stress test. During the moderate phase of the exercise, her pulse is 140/min, respirations are 25/min, and blood pressure is 130/90 mm Hg. Which of the following is the relative proportion of coronary oxygen delivery during the rest and during the exercise times?

26. A male newborn delivered at 32 weeks' gestation dies of respiratory failure at the age of 2 days. A photomicrograph of lung tissue obtained at autopsy is shown. This patient most likely had a deficiency of which of the following substances? O O O O O A) B) C) D) E) F) a r Antitrypsin Elastase Lecithinase Serotonin Sphingomyelinase Surfactant

27. A 9-year-old girl has had polyuria, polydipsia, and weight loss for the past 3 weeks. She is alert, her breath has tachypnea. Laboratory studies show: 130 mEq/L 100 mEq/L 5.8 mEq/L 6.0 mEq/L 700 mg/dL 7.0 16 mm Hg

ClK* HCO3Glucose Arterial blood gases pH Pco2 Which of the following sets of additional findings in serum is most likely? O A) OB ) O C) O D) O E) p-Hydroxybutyrate Osmolality Anion Gap 1 * t * t t t * t t t * t t t

Lab Values

28. A 65-year-old man develops a temperature of 39.4C (103F) 5 days after undergoing a radical prostatectomy. An indwelling urinary catheter has been in place since the operation. Laboratory studies show pyuria, and a urine culture grows an oxidase-positive, nonlactose-fermenting, gram-negative bacillus 24 hours after inoculation. Which of the following is the most likely causal organism? O O O O A) B) C) D) E) Enterobacter aerogenes Escherichia coli Klebsiella pneumoniae Pseudomonas aeruginosa Serratia marcescens

29. A 27-year-old man comes to the physician because of back pain and muscle fatigue in his left lower leg for 6 months. He has not seen a physician for 10 years. He is 198 cm (6 ft 6 in) tall and weighs 68 kg (150 lb); BMI is 17 kg/m2 Cardiac examination shows . normal S, and S2. A midsystolic click is heard without murmur. Physical examination shows dental malocclusion, long fingers, joint hypermobility, and muscle hypotonia. There is scoliosis of the thoracic spine on the right. Which of the following is the most likely cause of this patient's cardiac finding? O O O O O A) B) C) D) E) F) Aortic insufficiency Aortic regurgitation Aortic stenosis Atrial septal defect Mitral valve prolapse Tricuspid regurgitation

30. A 15-month-old girl is brought to the physician because of a 6-month history of progressive weakness and fatigue. Physical examination shows tachycardia, scleral icterus, pallor, and hepatosplenomegaly. Her hemoglobin concentration is 5.6 g/dL (N=11.5 14.5), and serum indirect bilirubin concentration is 3 mg/dL. A peripheral blood smear shows severe hypochromia, nucleated erythrocytes, and microcytosis. DNA analysis shows an A-.G point mutation within the TATA box of the p-globin gene promoter. Which of the following sets of additional laboratory findings is most likely in this patient? Hemoglobin F O A) O B) OC) OD) OE) O F) OG ) t HemoglobinA2 :Hemoglobin A Ratio normal Reticulocyte Count t

31. A 6-year-old girl is brought to the emergency department because of difficulty breathing after being stung by a bee. She is in acute respiratory distress. Examination shows urticaria and edematous eyes and lips. Which of the following pharmacologic agents is most likely to promptly relieve the respiratory distress? O A) a r Adrenergic agonist O B) a r Adrenergic antagonist O O O O O C) D) E) F) G) H) arAdrenergic agonist arAdrenergic antagonist pr Adrenergic agonist pr Adrenergic antagonist prAdrenergic agonist prAdrenergic antagonist

32. A 2-year-old boy is brought to the physician by his mother for a well-child examination. He has a family history of hypothyroidism and thyroiditis. He is at the 60th percentile for height and 50th percentile for weight. He is alert and attentive to conversations around him, expresses interest in toys located in the waiting room, and has an appropriate vocabulary that he uses willingly. However, his mother is concerned that he is smaller than his siblings were at the same age. The mother insists that he be tested for thyroid disorder. Measurement of which of the following serum concentrations would provide the most definitive evidence for normal thyroid function in this patient? O O O O A) B) C) D) E) Free thyroxine (FTJ Iodine/iodide Thyroid-stimulating hormone Total thyroxine (T^ Total triiodothyronine (T3)

33. A 66-year-old nulligravid woman has had vaginal bleeding for 2 months; menopause occurred at age 53. She has type 2 diabetes mellitus and is moderately obese. Bimanual examination shows a slightly enlarged uterus; no other abnormalities are noted. Which of the following is the most likely diagnosis? O O O O O A) B) C) D) E) F) Adenocarcinoma of the cervix Adenocarcinoma of the endometrium Adenocarcinoma of the ovary Leiomyosarcoma of the uterus Squamous cell carcinoma of the cervix Squamous cell carcinoma of the vagina

34. A 69-year-old man with Parkinson disease has a progression of his tremor that is unresponsive to medications. A stereotactic operation is scheduled. To alleviate the tremor, the needle should be placed in which of the following locations? O A) OB) O C) O D) E) Cerebellar hemisphere Frontal lobe of the cortex Globus pallidus Inferior olivary nucleus Substantia nigra

35. A 14-year-old boy is brought to the physician because of persistent leg pain since he was kicked in the right shin while playing soccer 2 days ago. He also says that he trips over his right foot when he walks. Physical examination shows that the right lower extremity is edematous and tense. There is weakened toe extension, mildly weakened dorsiflexion, and decreased sensation between the first and second toes of the right foot. Compartment syndrome is suspected. Which of the following nerves is most likely affected? O O O O A) B) C) D) E) Deep fibular (peroneal) Femoral Saphenous Sural Tibial

36. Immediately after vaginal delivery of a male newborn at 35 weeks' gestation, a 35-year-old woman has heavy bleeding. The placenta cannot be delivered because it is attached to the uterine wall. Attempts to stop the bleeding are unsuccessful, and an emergency hysterectomy is done. Placental membranes are found to be superficially invading the myometrium. Which of the following is the most likely diagnosis? O O O O A) B) C) D) E) Abruptio placentae Placenta accreta Placenta percreta Placenta previa Placental infarction

37. A 27-year-old woman goes to the clinic for evaluation of worsening abdominal pain and diarrhea. For several months, she has had mild, intermittent abdominal pain that is often accompanied by watery diarrhea and a low-grade fever. In the last week, the abdominal cramps have worsened and she has seen streaks of dark blood in her watery-brown stools. She has lost 4.5-kg (10-lb) in the past 2 months. She denies changes in diet or recent travel. Physical examination shows mucosal ulcers in her mouth and a sm fissure. Endoscopic examination of the colon shows areas of mucosal ulceration with deep fissures. Microscopic examination of biopsies from the diseased area of bowel shows acute and chronic colitis with noncaseating granulomas. Which of the following sites in the gastrointestinal tract is the most common location of this disease process? O O O O O A) B) C) D) E) F) Esophagus Gastric antrum Ileum Pylorus Rectum Sigmoid colon

38. A study is conducted to assess the effectiveness of a new test to identify individuals at increased risk for lung cancer. Results are shown: Lung Cancer Present Absent 70 I 300 ~| 30 I 600 1 100 900 Total 370 630 1000

Test Result

Positive Negative Total

I I

Based on these results, which of the following is the predictive value of a positive test result to establish that an individual in this population has lung cancer? OA) O B) OC) D) O E) 0.10 0.19 0.33 0.70 0.81

39. A 45-year-old man with a long history of severe rheumatoid arthritis is being treated aggressively with gold salts. Over the past 6 weeks, he has gained 6.8 kg (15 lb) and has had progressive ankle swelling that has made it difficult to put on his shoes in the morning. He has generalized edema. Serum creatinine concentration is 1.0 g/dL. Urinalysis shows 4+ protein, numerous hyaline casts, and oval fat bodies, but no red cell casts. Urinary protein excretion is 8.4 g/24 h. The electron micrograph shows a glomerular capillary loop obtained on biopsy. Which of the following is the most likely diagnosis? O O O O A) B) C) D) E) Crescentic glomerulonephritis Focal segmental glomerulosclerosis Membranous nephropathy Minimal change disease Proliferative glomerulonephritis

40. A 19-year-old man is brought to the emergency department 45 minutes after collapsing at a party. He is agitated and disoriented. His temperature is 39.7C (103.5F), pulse is 138/min, respirations are 28/min, and blood pressure is 160/102 mm Hg. Physical examination shows hot, flushed skin; the pupils are dilated and responsive to light. Which of the following substances is the most likely cause of this patient's symptoms? O O O O A) B) C) D) E) Ecstasy (3,4-methylenedioxymethamphetamine) Ethanol Heroin Ketamine LSD

41. A 25-year-old woman comes to the physician because of increasingly severe pain of the right hip during the past week. She runs 5 miles daily and recently changed her route because of construction. She now runs on uneven ground rather than pavement. Range of motion of the hip is full. The pain is exacerbated by flexion and internal rotation of the hip and by direct palpation over the lateral aspect of the hip. Which of the following structures is most likely involved in her condition? O O O O O A) B) C) D) E) F) Anserine bursa Ischial bursa Psoas bursa Sacroiliac joint Sciatic nerve Trochanteric bursa

42. A 4-year-old boy has progressive muscle weakness and markedly increased serum creatine kinase activity. Additional laboratory studies show deletion of the gene for dystrophin. Which of the following patterns of inheritance should be explained during a counseling session? O O O O A) B) C) D) E) Autosomal dominant Autosomal recessive Mitochondrial X-linked dominant X-linked recessive

44. Two programs for the treatment of patients with newly detected hypercholesterolemia were tried in a community. Program A was used in one district of the community, and Program B was used in another. After four years, 40% of the 110 patients on Program A and 53% of the 95 patients on Program B had been successfully treated for hypercholesterolemia. The p-value for the difference was 0.3. Based on these data, the health officials decide not to change to program B in the first district. Which of the following best explains this decision? O O O A) B) C) D) They attributed the difference in success rates to chance alone They distinguished between statistical significance and clinical significance They felt the power was too high to justify a decision in favor of Program B They felt the p-value was too small to justify a decision in favor of Program B

45. A 29-year-old woman comes to the physician because of a 1-week history of nausea and vomiting in the mornings. Her last menstrual period was 8 weeks ago. Current medications include an oral contraceptive; she has not missed any doses during the past 2 years. Four months ago, she began taking an herbal preparation that was given to her by a friend, but she cannot remember the name of the herb. Physical examination shows a uterus consistent in size with an 8-week gestation. A urine pregnancy test result is positive. This patient has most likely been taking which of the following herbal preparations? O O O O A) B) C) D) E) Echinacea Ginkgo biloba Ginseng Saw palmetto St. John's wort

46. A 10-year-old boy is brought to the physician because of increased urination and progressive fatigue during the past 2 weeks. Vital signs are normal exceptfor a pulse of 120/min. Physical examination shows dry mucous membranes and dry skin. His fasting serum glucose concentration is 350 mg/dL. Which of the following mechanisms best explains the increased urine output in this patient? O O O O A) B) C) D) E) Decreased synthesis and release of ADH (vasopressin) Disruption of the transverse gradient in the loop of Henle Increased glomerular filtration rate Increased osmolarity in the tubular lumen Inhibition ofthe sodium-glucose transporter in the proximal tubule

47. A 42-year-old man needs a kidney allograft. His lymphocytes are examined by the mixed lymphocyte reaction with killed stimulator cells from himself and from each of 5 prospective donors. A donor with which of the following thymidine incorporation values (cpm) will be most compatible? (The patient has a thymidine incorporation value of 425/cpm.) A) O B) OC) OD) O E) 312 1542 2505 15,389 27,482

48. A 40-year-old man with hepatitis C is admitted to the hospital because of progressive confusion and disorientation during the past 3 days. He does not drink alcohol or use illicit drugs. He takes no medications. On arrival, the patient is agitated and confu Physical examination shows asterixis. Treatment with lactulose improves his confusion. Which of the following effects of lactulose in the colon is the most likely cause of this patient's improved mental status? O O O A) B) C) D) Acidification causing increased ammonium ion absorption Acidification causing increased ammonium ion excretion Alkalization causing increased ammonia absorption Alkalization causing increased ammonia excretion

49. A 72-year-old woman comes to the physician because of an 8-month history of burning chest pain and a bitter taste in her mouth; both symptoms occur at night when she lies down. The pain does not radiate and is not associated with shortness of breath. Physical examination shows no abnormalities. Which of the following is most likely to be associated with her symptoms? O O O O A) B) C) D) E) Atrophic gastritis Helicobacter pylori infection Impaired relaxation of the lower esophageal sphincter Metaplasia of the esophageal epithelium Spasm of the esophageal smooth muscle

50. A previously healthy 29-year-old man is brought to the emergency department because of a 24-hour history of intermittent, severe lower abdominal pain. The pain is sharp and intense, and each episode lasts approximately 10 minutes. He notes passage of reddish urine following each episode. Urinalysis shows: pH Specific gravity Blood Glucose Bilirubin Protein Ketones Leukocyte esterase Which of the following is the most likely cause of these findings? O O O O A) B) C) D) E) Escherichia coli infection Nodular prostatic hyperplasia Renal cell carcinoma Schistosomiasis Urolithiasis 6.5 1.013 4+ negative negative 1+ negative negative