1

1- A 19-year-old woman comes to the emergency department because of right lower

abdominal pain for 10hours. Her temperature is 39 C (102.1 F). Abdominal examination
shows rebound tenderness of the right lower quadrant. She is admitted to the hospital, and
an emergency exploratory operation is done. A photograph of the removed appendix is
shown. Which of the following best describes the process involved in her condition?
A- Acute inflammation
B- Catarrhal inflammation
C- Chronic inflammation
D- Granulomatous inflammation
E- Serous inflammation

2- 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, and
hepatosplenomegaly. Her hemoglobin concentration is 5.6 g/dL (N = 11.5=14.5), and serum
indirect bilirubin concentration is 3 mg/dL (Total bilirubin normal range = 0.1-1.3). A
peripheral blood smear shows hypochromia, nucleated erythrocytes, and microcytosis. DNA
analysis shows an A G point mutation within the TATA box of the beta-globin gene
promoter. Which of the following sets of additional laboratory findings is most likely in this
patient?
Hemoglobin F (22)
A-
B-
C-
D-
E-
F-
G-

Hemoglobin A2/hemoglobin A ratio

Reticulocyte count

2
3- 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 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 small anal 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?
A- Esophagus
B- Gastric antrum
C- Ileum
D- Pylorus
E- Rectum
F- Sigmoid colon
4- A 72-year-old woman comes to the physician because of an 8-month history of burning
chest pain and 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?
A- Atrophic gastritis
B- Helicobacter pylori infection
C- Impaired relaxation of the lower esophageal sphincter
D- Metaplasia of the esophageal epithelium
E- Spasm of the esophageal smooth muscle
5- A 47-year-old man comes to the emergency department because of a 2-hour history of
vomiting bright red blood. He has a 20-year history of alcoholism. Physical examination
shows jaundice and scleral icterus. Endoscopy shows esophageal bleeding from the mucosa.
The most likely cause of the bleeding is an indirect shunting of portal blood to the superior
vena cava via which of the following veins?
A- Hepatic
B- Inferior mesenteric
C- Left gastric
D- Right gastroepiploic
E- Splenic
F- Superior mesenteric

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6- A 32-year-old man is brought to the emergency department 20 minutes after having a
generalized tonic-clonic seizure. He has a 24-hour history of fever, headache, and
intolerance of light. He is alert. His temperature is 40 C (104 F), pulse is 140/min,
respirations are 24/min, and blood pressure is 90/45 mm Hg. He appears acutely ill.
Neurologic examination shows no focal findings. Intravenous fluids are administered, and
there is persistent bleeding around the intravenous site. Laboratory studies show:
Prothrombin time: 16 sec (N = 11-15 sec)
Partial thromboplastin time: 33 sec (N = 25-40 sec)
Fibrin degradation products: increased
D-Dimer (fibrin degradation product): increased
Which of the following changes is most likely in the blood coagulation process of this
patient?
A- Decreased fibrinolysis
B- Decreased microvascular thrombus formation
C- Decreased thrombin production
D- Increased circulating coagulation factors
E- Increased plasmin generation
F- Increased platelet count
7- A healthy 21-year-old man is undergoing initial screening for intestinal polyps.
Sigmoidoscopy shows multiple sessile and pedunculated (with stalk) polyps through the
rectum and sigmoid colon. Physical examination shows poor dentition and several osteomas
in the mandible and skin. Which of the following is the most likely diagnosis?
A- Cowden disease
B- Cronkhite-Canada syndrome
C- Gardner syndrome
D- Inflammatory mucosal polyps
E- Juvenile polyposis
F- Peutz-Jeghers syndrome
8- A 52-year-old woman comes to the physician because of nausea, intermittent bloating, and
diarrhea for 5 days. She underwent a gastric bypass operation 1 month ago and has had a 9kg (20 lb) weight loss since then. Abdominal examination shows mild distention. Which of
the following is the most likely cause of this patients symptoms?
A- Absence of functional parasympathetic ganglia in the large bowel
B- Hypersecretion of acid
C- Rapid emptying of hyperosmolar chime into the small bowel
D- Spasm of the pyloric sphincter
E- Surgical interruption of vagal fibers to the stomach

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9- A 20-year-old woman is admitted to the hospital because of weakness of the legs,
generalized severe abdominal pain, persistent vomiting, and port-wide-colored urine for 8
hours. She began taking an oral contraceptive 1 month ago. She has a history of 3 similar
episodes for which she did not seek medical attention. Physical examination shows
abdominal tenderness and guarding. There is weakness of the lower extremities and
decreased muscle stretch reflexes. Urine studies are most likely to show an increased
concentration of which of the following?
A- Bilirubin
B- Cystine
C- Homogentisic acid
D- Porphobilinogen
E- Uric acid
10- A healthy 24-year-old man is participating in a study of swallowing. The manometric
pressure changes that occur while this man swallows are shown. Which of the following best
represents the muscle activity in the upper esophageal sphincter, considering it opens to
allow the bolus enter the esophagus and then contracts to prevent it from regurgitating?

11- A 71-year-old man has a palpable, pulsatile mass just above the umbilicus. Transabdominal
ultrasonography shows a 6.5 cm infrarenal aortic aneurysm that extends to the iliac
bifurcation. Which of the following arteries is most likely involved in the aneurysm wall?
A- Inferior mesenteric
B- Inferior phrenic
C- Left gastroepiploic
D- Splenic
E- Superior mesenteric

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12- A 21-year-old woman has received numerous transfusions of packed erythrocytes for
treatment of homozygous beta-thalassemia. Laboratory monitoring of her iron stores is
necessary to avoid secondary iron overload. Which of the following laboratory
measurements is most sensitive in assessing her iron stores?
A- Ferritin
B- Haptaglobin
C- Iron saturation
D- Prealbumin
E- Transferrin
13- A 35-year-old man comes to the physician because of a painful perianal mass for 2 weeks.
His vital signs are within normal limits. Physical examination shows a 2-cm erythematous,
warm, swollen mass superior to the anal verge. Lancing of the mass releases a sanguineous
exudate. The wound is irrigated and bandaged, and antibiotics are administered. Which of
the following inflammatory mediators is most likely released form the aggregated platelets
in this patient?
A- Interleukin-1
B- Nitric oxide
C- Prostacyclin (PGI2)
D- Thrombin
E- Thromboxane A2
14- A 54-year-old woman comes to the physician because of a 2-week history of severe
heartburn and regurgitation of gastric contents at bedtime. Use of an over-the-counter
antacid decreased her symptoms but caused moderately severe diarrhea in the morning.
Which of the following ingredients in the antacid is the most likely cause of the diarrhea in
this patient?
A- Aluminium hydroxide
B- Calcium carbonate
C- Magnesium trisilicate
D- Simethicone
E- Sodium bicarbonate
15- A 45-year-old man who was diagnosed with small cell carcinoma of the lung 1 week ago
comes to the physician to discuss treatment. The physician recommends chemotherapy that
includes cyclophosphamide, doxorubicin, vincristine and cisplatin. He will be pretreated with
dexamethasone and ondansetron as antiemetics and mesna to help prevent cystitis. Which
of the following drugs has the greatest potential to produce both nephrotoxicity and
ototoxicity in this patient?
A- Cisplatin
B- Cyclophosphamide
C- Doxorubicin
D- Ondansetron
E- Vincristine

6
16- A 58-year-old man comes to the physician because of a 6-month history of a gurgling noise
in his throat as he eats, which often requires repeated coughing and throat clearing to
eradicate. He occasionally regurgitates undigested food 1 hour after eating. He has a 2-year
history of well-controlled type 2 diabetes mellitus and a 6-month history of intermittent mild
dysphagia and progressive halitosis. He has not had any weight loss. His vital signs are within
normal limits. Physical examination shows no abnormalities. Which of the following is the
most likely diagnosis?
A- Barrett esophagus
B- Diffuse esophageal spasm
C- Esophageal cancer
D- Gastroesophageal reflux disease
E- Zenker diverticulum
17- A 55-year-old man comes to the physician because of maroon-colored stool for 3 weeks.
Physical examination shows no abnormalities. Test of the stool for occult blood is positive.
Colonoscopy shows a 4-cm mass at the splenic flexure. A biopsy specimen of the mass shows
adenocarcinoma. This patients cancer is most likely to next spread to which of the following
organs?
A- Bone
B- Brain
C- Liver
D- Lung
E- Spleen
18- A previously healthy 55-year-old man comes to the emergency department because of a 3hour history of chest pressure. He states My chest is burning. I drank some whole milk, but
it didnt help. His father died suddenly at the age of 45 years. His pulse is 95/min, and
blood pressure is 156/96 mm Hg. Physical examination shows no jugular venous distention.
Crackles are heard one quarter of the way up both lung fields posteriorly. Cardiac
examination shows a soft S4 gallop most prominent at the apex. An ECG shows ST-segment
elevation in leads I, AVL, and V5-V6 without PR depression. Initial therapy with antiplatelet
agents administered prior to arrival fails to resolve the acute EC changes. Which of the
following agent is the most appropriate next pharmacotherapy?
A- Clopidogrel
B- Protein C
C- Simvastatin
D- Tissue plasminogen activator
E- Warfarin

7
19- A healthy 27-year-old woman comes to the physician for her first prenatal visit. She reports
feeling tired but otherwise feels well. She has followed a strict vegetarian diet for 5 years.
Laboratory studies show:
Hemoglobin: 9.1 g/dL
Hematocrit: 27%
Leukocyte count: 3200/mm3
Platelet count: 110,000/mm3
A wright-stained peripheral blood smear is shown. The
nutrient deficiency most likely responsible for her
hematologic abnormalities significantly impairs which
of the following cellular processes?
A- Bilirubin conjugation
B- DNA synthesis
C- Fatty acid oxidation
D- Gluconeogenesis
E- Heme production
20- A 47-year-old woman comes to the physician because of 3 episodes of right-sided abdominal
pain during the past 2 weeks. She says that the pain is steady, radiates to the right shoulder,
and lasts 60-90 minutes. She has had an intentional 18-kg (40 lb) weight loss during the past
10 weeks. She has not had fever or chills. Current medications include gemfibrozil for
hypertriglyceridemia. She is 168 cm (5 ft 6 in) tall and weighs 93 kg (205 lb); BMI is 33 kg/m2.
Abdominal examination shows mild right upper quadrant tenderness. Serum studies show
an alkaline phosphatase activity of 85 U/L (N = 38-126) and amylase activity of 60 U/L (N =
30-110). Which of the following is the most likely diagnosis?
A- Acute pancreatitis
B- Cholelithiasis
C- Chronic pancreatitis
D- Crohn disease
E- Drug-induced hepatitis
F- Peptic ulcer
21- A patient with a peptic ulcer is treated with drug X. several weeks later, the patient is also
given diazepam for treatment of anxiety, tension and insomnia. The patient falls asleep
much more quickly and sleeps for a longer period of time than normally experienced with
diazepam. Drug X is most likely to be which of the following?
A- Atropine
B- Cimetidine
C- Omeprazole
D- Propantheline
E- Ranitidine

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22- A 32-year-old woman receives a dose of warfarin orally for a large deep venous thrombus of
the right leg. She is currently taking an oral contraceptive. Her prothrombin time is 12 sec (N
= 12-15 sec). Which of the following best explains why this patients prothrombin time did
not change?
A- The large thrombus increases the dose of warfarin required
B- Oral contraceptives accelerate the clearance of warfarin
C- Preexisting circulating coagulation factors have not been cleared
D- Prothrombin time is not a measure of the efficacy of warfarin
E- Warfarin should have been administered intravenously
23- Which of the following best describes the mechanism of action of vinblastine?
A- Alkylates DNA
B- Causes single-and double-stranded DNA breaks
C- Destroys asparagine
D- Inhibits dihydrofolate reductase
E- Prevents microtubule polymerization
24- A 41-year-old man has had diarrhea, weight loss, and diplopia for 3 months. Physical
examination shows hyperpigmentation and synovitis of the knees and ankles. Stool fat
content is increased. Small intestinal tissue stained with periodic acid-Schiff (PAS)shows
macrophages containing diastase-resistant PAS-positive sickle-form particles; electron
microscopy shows the particles to be rod-shaped bacilli. Which of the following is the most
likely diagnosis?
A- Amyloidosis
B- Bacterial overgrowth
C- Celiac sprue
D- Crohn disease
E- Hypogammaglobulinemia
F- Intestinal insufficiency
G- Systemic mastocytosis
H- Tropical sprue
I- Whipples disease
25- A 35-year-old man has had burning epigastric pain for 1 year. Initially, the pain occurred a
few hours after meals, but recently it has become persistent. The pain has not responded to
H2-receptor antagonists or antibiotic treatment for Helicobacter pylori. A CT scan of the
abdomen shows a mass in the head of the pancreas; the surgically removed mass is shown.
Which of the following pancreatic tumors is most likely?
A- Acinar carcinoma
B- Ductal adenocarcinoma
C- Gastrinoma
D- Glucagonoma
E- VIPoma

9
26- A 42-year-old man comes to the physician because of a 2-year history of heartburn, which is
worse at night. He has smoked 2 packs of cigarettes daily for the past 30 years. Upper
endoscopy shows esophageal erosions. Tissue obtained on biopsy of the lower esophagus is
shown. Which of the following is the most likely complication of his disease?
A- Adenocarcinoma
B- Kaposi sarcoma
C- Leiomyosarcoma
D- Malignant lymphoma
E- Squamous cell carcinoma

27- A 37-year-old man comes to the physician because of progressive heartburn over the past 6
months. The symptoms are most severe after eating large or spicy meals and are partially
relieved with antacid therapy. An endoscopic biopsy of the lower esophagus shows
esophagitis. The most likely cause of the esophageal changes is a substance secreted by
which of the following cell types?
A- Chief cells
B- G cells
C- Goblet cells
D- Mucous cells
E- Parietal cells
28- A 54-year-old man has acute pain several hours after rubber band ligation of a prolapsing
hemorrhoid. Which of the following is the most likely explanation for the pain?
A- The ligation involved the mucous lining of the anal canal
B- The ligation stopped blood supply to the hemorrhoid
C- The ligation was done at the level of the anal columns
D- The ligation was done inferior to the pectinate (mucocutaneous) line
E- The ligation

10
29- A 23-year-old woman has a 6-year history of intermittent episodes of fever, crampy
abdominal pain, and frequent, loose stools. A section of bowel resected after a recent
severe episode is shown. Which of the following is the most likely diagnosis?
A- Acute appendicitis
B- Adenocarcinoma
C- Celiac disease
D- Crohn disease
E- Ulcerative colitis

30- The condensation reaction between succinyl-CoA and glycine is the rate-limiting reaction in
the biosynthesis of which of the following compounds?
A- Cholesterol
B- Heme
C- Urea
D- Vitamin D
31- During a meal, the vagus nerve stimulates secretion of acetylcholine, which stimulates the
stomach to secrete HCl in a second-messenger pathway derived directly from membrane
phospholipids. Which of the following 2nd messengers is involved?
A- cAMP
B- cGMP
C- Choline
D- G protein
E- Inositol 1,4,5-triphosphate
32- A 37-year-old woman develops pancytopenia after exposure to a benzene-containing agent.
Tissue obtained on a bone marrow biopsy is most likely to show replacement of normal
hematopoietic cells by which of the following cells?
A- Adipocytes
B- Lymphocytes
C- Monocytes
D- Osteoblasts
E- Reticuloendothelial cells

11
33- A 60-year-old man with signs and symptoms of an obstruction in the large bowel undergoes
surgical resection. The presence of a malignant neoplasm is most strongly supported by
which of the following features seen in the photograph of the resected segment of the
colon?
A- Fibrosis of the wall
B- Invasion of the submucosa and muscular layer
C- Narrowing of the lumen
D- Sharp demarcation from the normal mucosa
E- Ulceration of the mucosa

34- A 50-year-old woman has a 1-year history of recurrent hemorrhages and thrombosis. She
has a bruise on the forehead secondary to minor trauma. Evaluation for underlying
inflammatory and neoplastic disease is negative. Laboratory studies show:
Hemoglobin: 12 g/dL
Leukocyte count: 7000/mm3
Segmented neutrophils: 60%
Band forms: 5%
Lymphocytes: 30%
Monocytes: 5%
Platelet count: 2,000,000/mm3 ( N = 150,000-400,000)
Erythrocyte morphology: normal
Which of the following is the most likely diagnosis?
A- Chronic myelogenous leukemia
B- Essential thrombocythemia (thrombocytosis)
C- Myelofibrosis
D- Polycythemia vera
E- Reactive thrombocytosis
35- In organ transplantation, graft-versus-host disease may be induced by donor T-lymphocytes.
Which of the following disease-specific organ transplants is most likely to derive some
benefit from this graft-versus-host response?
A- Bone marrow transplant for acute myelogenous leukemia
B- Heart transplant for viral cardiomyopathy
C- Islet cell transplant for type 1 diabetes mellitus
D- Kidney transplant for membranous glomerulonephritis
E- Lung transplant for primary pulmonary hypertension

12

36- A 27-year-old woman comes to the clinic because of a 7-day history of intermittent
headaches, abdominal pain and bloating, low back pain, diarrhea, pain during sexual
intercourse, decreased interest in sex, and difficulty with balance. She tells the physician
that she is so frustrated because she cannot work due to her symptoms. She has seen 12
physicians in the past 5 years, none of whom have been able to diagnose her condition. The
patient most likely has which of the following disorders?
A- Autoimmune vasculitis
B- Chronic cadmium toxicity
C- Factitious disorder
D- Crohn disease
E- Ulcerative colitis
F- Fibromyalgia
G- Paraneoplastic syndrome
H- Somatization disorder
I- Schizophrenia
J- Irritable bowel syndrome
37- A 60-year-old woman has had progressive weakness and back pain over the past 8 weeks.
Complete blood count shows:
Hemoglobin: 8.0 g/dL
Leukocyte count: 15,000/mm3
Segmented neutrophils: 65%
Lymphocytes: 25%
Monocytes: 10%
Erythrocytes: rouleaux present
Erythrosedimentation rate: 40 mm/hour
Platelet count: 60,000/mm3

60% of bone marrow cells have features similar to those shown. Which of the following
additional findings is most likely to be present?
A- Antinuclear antibodies
B- Heterophile antibodies
C- Increased leukocyte alkaline phosphatase activity
D- light chain proteinuria
E- reciprocal chromosomal translocations: 9;22

13

38- An 18-month-old boy who is chubby is brought to the physicians office for a routine
examination. His weight is above the 90th percentile. Laboratory studies show:
Hematocrit: 30% (low)
Leukocyte count: 9000/mm3
Mean corpuscular volume (MCV): 60 m3 (N = 78-102)
Platelet count: 650,000/mm3
Which of the following laboratory values is most likely to be abnormal?
A- Cholesterol
B- Folate
C- Iron
D- Vitamin B12
E- Vitamin E
39- A 33-year-old man who is seropositive for HIV comes to the physician because of a lesion on
his forehead for 4 weeks. He has a 10-year history of intravenous drug abuse. Physical
examination shows a 1-cm, irregularly shaped, raised, indurated lesion on the forehead. A
photomicrograph of a biopsy specimen of the lesion is shown. Which of the following is the
most likely causal organism of this lesion?
A- Aspergillus fumigatus
B- Cytomegalovirus
C- Herpesvirus type 8
D- Mycobacterium avium-intracellulare
E- Pneumocystis jiroveci
F- Toxoplasma gondii

14
40- A 10-year-old girl is brought to the emergency department 1 hour after she fell from her
bicycle. Physical examination shows a 2-cm deep laceration over the left forearm. As a result
of the tissue trauma, which of the following plasma proteins most likely bound clotting
factor XII (Hageman factor) and kininogen, allowing autocatalytic amplification of the
inflammatory system in this patient?
A- Bradykinin
B- Fibrinogen
C- Immunoglobulin
D- Kallikrein
E- Alpha-macroglobulin
F- Plasmin
G- Thrombin
H- von Willebrand factor
41- A 17-year-old girl is evaluated because of a boil on her left shoulder. Examination shows an
erythematous, painful, fluctuant lesion; a yellow-green liquid material is drained surgically.
The pain and erythema gradually subside. Which of the following cells contributes most to
the tissue changes present in the lesion 5 days after drainage?
A- Eosinophils
B- Lymphocytes
C- Neutrophils
D- Plasma cells
E- Mast cells
42- The erythrocyte is prone to injury by reduced oxygen metabolites that are produced after
spontaneous oxidation of oxyhemoglobin. Which of the following reactions or processes is
most critical in protecting the erythrocyte from injury by these oxidation products?
A- Dissociation of methemoglobin into metheme and globin chains
B- Glucose 6-phosphate dehydrogenase-catalyzed generation of NADPH
C- Inactivation of hydroxyl free radicals by beta carotene
D- Synthesis of ubiquinone
E- Vitamin C-dependent reduction of methemoglobin to hemoglobin
43- Prostacyclin (PGI2) produced by endothelial cells promotes which of the following?
A- Adhesion of platelets
B- Expression of selectins
C- Priming of leukocytes
D- Production of nitric oxide
E- Vasodilation

15
44- A 52-year-old man is admitted to the hospital because of an acute myocardial infarction.
Coronary catheterization shows a lesion in the left anterior descending coronary artery.
After a balloon angioplasty is performed, abciximab is administered. Blockade of which of
the following is most likely to occur in this patient?
A- Gamma-carboxylation of clotting factors
B- Factor Xa formation
C- Fibrinogen to fibrin conversion
D- Platelet glycoprotein IIb/IIIa receptor function
E- Platelet thromboxane A2 production
45- Which of the following agents inhibits both the production of interleukin-2 in resting T
lymphocytes and the production of gamma-interferon in activated T-lymphocytes?
A- Azathioprine
B- Cisplatin
C- Cyclophosphamide
D- Cyclosporine
E- Mercaptopurine
46- Which of the following is the most likely explanation for the emergence of HIV variants
resistant to antiviral drugs?
A- CD4 is expressed on many cells
B- HIV can bind many co-receptors
C- HIV reverse transcriptase is error-prone, and may produce completely new variants of
viral enzymes and other drug molecular targets
D- Nef is capable of decreasing cell-surface expression of many proteins
E- Rev efficiently exports viral mRNAs from the nucleus
47- 5-fluoruracil is effective as an antineoplastic agent because it prevents which of the
following?
A- Amidation of phosphoribosylpyrophosphate
B- Conversion of ribonucleotides to deoxyribonucleotides
C- Incorporation of a methyl group into N5, N10 tetrahydrofolate
D- Methyl group transfer to dUMP to form dTMP
E- Reduction of dihydrofolate to tetrahydrofolate

16
48- A 23-year-old man with sickle cell disease is admitted to the hospital because of acute vasoocclusive crisis and acute sickle chest syndrome. Oxygen and intravenous fluids are started,
and a blood transfusion and an analgesic are administered. Five days later, leukocyte count
is 6500/mm3 and a platelet count is 120,000/mm3, and he is discharged with a prescription
for a drug to decrease the frequency of acute crisis by increasing the synthesis of fetal
hemoglobin (HbF, 22). 6 weeks later, leukocyte count is 1800/mm3 and platelet count is
60,000/mm3. Which of the following drugs is most likely responsible for the decreased
leukocyte and platelet counts in this patient?
A- Erythropoietin
B- Folic acid
C- Hydroxyurea
D- Interferon-alpha
E- Meperidine
49- A 10-year-old boy has chronic iron-deficiency anemia. A test of stool for occult blood is
positive. A barium enema with air contrast shows no abnormalities. Findings on upper
endoscopy examination are normal. His condition improves with H2-receptor antagonist
therapy. Which of the following is the most likely cause of the bleeding?
A- Arteriovenous malformation
B- Congenital megacolon (Hirschsprung disease)
C- Esophageal reflux
D- Meckel diverticulum
E- Ulcerative colitis
50- A 60-year-old woman is admitted to the hospital with a pulmonary embolism. Treatment
with enoxaparin is begun. The patient says, Thats not the heparin my other doctor gave
me. Why am I getting this newfangled stuff? . Compared with heparin, which of the
following best explains the appropriateness of enoxaparin for this patient?
A- Available orally
B- Larger loading dose required
C- Less expensive for each days therapy
D- Less monitoring required

17
51- A 49-year-old woman comes to the physician because of a 1-year history of intermittent
blood-stained diarrhea with cramping in the lower abdomen. Results of sigmoidoscopy are
shown. Culture of stool and biopsy of mucosa show no evidence of bacterial, amebic or viral
infection. The most appropriate maintenance therapy includes administration of which of
the following drugs?
A- Ciprofloxacin
B- Dapsone
C- Doxycycline
D- Ethambutol
E- Gentamycin
F- Streptomycin
G- Sulfadiazine
H- Sulfasalazine

52- A 30-year-old woman who takes ibuprofen for arthritis has a marked increase in menstrual
cramping after starting a drug to prevent peptic ulcer. Which of the following drugs most
likely caused this adverse effect?
A- Aluminium hydroxide
B- Magnesium hydroxide
C- Methacoline
D- Misoprostol
E- Omeprazole
F- Ranitidine
G- Sodium bicarbonate
H- Sucralfate
53- Perforation of which of the following structures will produce retroperitoneal gas?
A- Ascending colon
B- Cecum
C- Jejunum
D- Terminal ileum
E- Transverse colon

18

54- A 38-year-old man comes to the physician 24-hours after vomiting coffee-ground like
material (hematemesis). He has a 6-month history of intermittent, dull epigastric pain that is
temporarily relieved with the use of antacids. Physical examination shows mild epigastric
tenderness. Upper gastrointestinal endoscopy shows a duodenal ulcer. Serum studies show
markedly increased circulating concentrations of gastrin. Gastrin-mediated hyperstimulation
of which of the following cell types has contributed the most to the development of a
duodenal ulcer in this patient?
A- Acinar cells of Brunner glands
B- Centroacinar cells
C- Enteroendocrine cells
D- Gastric chief cells
E- Mucous neck cells
F- Paneth cells
G- Parietal cells
H- Surface mucous cells
55- A healthy 25-year-old man has a sample of blood drawn 1 hour after he eats a baked potato.
The concentration of which of the following substances is most likely increased in the blood
sample?
A- Amylose
B- Glucose
C- Limit dextrin
D- Pectin
E- Sucrose
56- A 67-year-old woman with pernicious anemia has absent gastric parietal cells. An increase in
which of the following is the most likely additional finding?
A- Gastrin in blood
B- Protein digestion in the stomach
C- Secretin in blood
D- Secretion of gastric acid
E- Secretion of intrinsic factor
57- An 8-year-old boy is brought to the emergency department by his mother because he has
had intermittent abdominal pain for the past 24 hours. Within the past 2 hours the pain has
become more severe and constant, and he has developed a temperature of 38 C (100.4 F).
Physical examination shows tenderness and guarding in the right lower quadrant. A
diagnosis of acute appendicitis is made and a laparotomy is performed. The appendix is
found to be normal; however, an inflamed ileal diverticulum is removed. Which of the
following developmental defects is most likely responsible for this finding?
A- Abnormal fixation of the intestinal mesentery
B- A defect in the longitudinal layer of the intestinal muscularis
C- Failure of normal recanalization leading to duplication of the intestinal lumen
D- Failure of the midgut loop to rotate as it enters the abdomen

19
E- Persistance of a remnant of the proximal portion of the yolk sac
58- A newborn is evaluated by a pediatrician because of jaundice. His serum total bilirubin
concentration is 2.5 mg/dL, with a direct component of 2 mg/dL. His feces are acolic and his
urine looks very dark. An ultrasound confirms the diagnosis of biliary atresia. If left
untreated, deficiency of which of the following compounds is more likely?
A- Vitamin B12
B- Vitamin B6
C- Vitamin B1
D- Folic acid
E- Vitamin E
59- A 13-year-old boy is brought to the physician because he developed jaundice 2 days ago
following a Boy Scout survival outing in which he was required to fast for 30 hours. He has
had intermittent mild jaundice since early childhood. There is no history of medication use
or substance abuse. Physical examination shows jaundice and mild scleral icterus. There is
no hepatosplenomegaly. His serum total bilirubin concentration is 3.8 mg/dL with a direct
component of 0.5 mg/dL. Imaging studies of the liver show no abnormalities. Which of the
following is the most likely diagnosis?
A- Autoimmune hemolytic anemia
B- Chronic familial nonhemolytic jaundice
C- Dubin-johnson syndrome
D- Gilbert syndrome
E- Beta-thalassemia
60- Malformation of the embryonic cloaca may lead to which of the following congenital
malformations?
A- Congenital hemorrhoids and rectal prolapse
B- Imperforate anus and rectovesical fistula
C- Double ureter and posterior urethral valves
D- Bifid clitoris and absent vestibular bulbs
E- Pelvic arteriovenous malformations
61- A 24-year-old woman is admitted to the hospital because of a temperature of 40 C (104 F),
generalized rash, and altered mental status. On admission, her platelet count, prothrombin
time (PT) and partial thromboplastin time (PT) are within the reference ranges. During the
next 24 hours, her blood and cerebrospinal fluid cultures grow Neisseria meningitidis.
Despite therapy, she becomes comatose and begins bleeding from all venipuncture sites and
from mucous membranes. Her PT and PTT are now markedly prolonged and platelet count is
less than 20,000/mm3. Which of the following plasma values is most likely to be increased in
this patient?
A- Activated protein C
B- D-dimer
C- Factor VII
D- Fibrinogen

20
E- Plasminogen
62- The graph shows gastric acid secretion response versus concentration of histamine
administered before (solid curve) and after (dashed curve) the administration of drug X.
Drug X is most likely which of the following?
A- Atropine
B- Cimetidine
C- Diphenhydramine
D- Misoprostol
E- Omeprazole
F- Sucralfate

63- The sickling of erythrocytes in patients with sickle cell disease results from which of the
following?
A- Aggregation and polymerization of the sickle cell hemoglobin (HbS)
B- Inability of HbS to bind heme
C- Inability of HbS molecules to form a tetramer
D- Instability of the HbS molecules
64- A 77-year-old man has had repeated episodes of difficulty speaking, facial numbness, and
clumsiness of the left hand. Doppler ultrasonography of his carotid arteries shows no
abnormalities. Which of the following drugs is the most appropriate therapy to prevent
future episodes?
A- Aspirin
B- Diflunisal
C- Methyl salicylate
D- Olsalazine
E- Salicylic acid
F- Salsalate
G- Sodium salicylate
H- Sulfasalazine

21
65- A 74-year-old man with a 5-year history of pernicious anemia develops a gastric ulcer on the
lesser curvature of the fundus. Biopsy of the lesion shows adenocarcinoma. Microscopic
examination of the adjacent gastric mucosa is most likely to show absence of which of the
following cells?
A- Chief cells
B- Mucous neck cells
C- Parietal cells
D- Small B lymphocytes
E- Transformed B lymphocytes
66- A 65-year-old woman with chronic constipation comes to the emergency department
because of a 3-day history of abdominal pain. Abdominal examination shows distention with
tenderness in the left lower quadrant. Sigmoidoscopy shows no tumors, but the scope
cannot be inserted beyond 15 cm because of abrupt luminal narrowing. Which of the
following is the most likely diagnosis?
A- Appendicitis
B- Diverticulosis
C- Small bowel obstruction
D- Volvulus of the cecum
E- Volvulus of the sigmoid colon
67- A 32-year-old man dies after an episode of massive upper gastrointestinal bleeding. He had
episodes of facial flushing, diarrhea and bronchospasm for the past year. A yellow
submucosal nodule is identified in the terminal ileum. The liver as seen at autopsy is shown.
Which of the following features of the neoplasms stage is demostrated?
A- Blood-borne metastases
B- Direct seeding
C- Lymphatic spread
D- Peritoneal implants
E- Size of the primary tumor

22
68- An 11-year-old boy has a mass in the jaw and cervical lymphadenopathy. A peripheral blood
smear shows abnormal vacuolated lymphoid cells. Tissue obtained on biopsy of the jaw mas
is shown. A karyotype suggests an 8;14 chromosomal reciprocal translocation. Which of the
following is the most likely diagnosis?
A- Burkitt lymphoma
B- Chronic lymphocytic leukemia
C- Hodgkin lymphoma
D- Mycosis fungoides
E- T-cell lymphoblastic leukemia
F- Waldestrom
macroglobulinemia

69- A 75-year-old man has intermittent pain in his right groin. Examination shows a large
inguinal hernia that extends to the scrotum. Repair is recommended because the hernia may
be incarcerated or strangled. During the operation, which of the following arteries is the
most useful landmark for locating the deep inguinal ring?
A- External iliac
B- Femoral
C- Inferior epigastric
D- Obturator
E- Superior mesenteric
70- A 25-year-old woman brings her 1-month-old son to the physician because he has been
vomiting with increasing forcefulness during or immediately after his findings for the past
week. The infant has no fever and seems relatively content but hungry after vomiting. He
has not had a bowel movement for the past 2 days. The mother is concerned because the
infants father had a similar problem at his age and had to have an operation. Physical
examination shows normal chest sounds and a palpable ovoid mass in the upper abdomen.
Which of the following is the most likely cause of his condition?
A- Achalasia
B- Congenital duodenal or jejunal atresia
C- Congenital megacolon (Hirschsprung disease)
D- Congenital tracheoesophageal fistula
E- Diaphragmatic herniation
F- Pyloric stenosis

23
71- A 17-year-old boy comes to the physician because of early satiety when eating, intermittent
nausea and vomiting of undigested, bile-stained food for the past 3 months. He has a 10year history of type 1 diabetes mellitus. Findings on physical exam are unremarkable.
Hemoglobin A1C is 18%, and fasting serum glucose concentration is 180 mg/dL. Which of the
following is the most likely cause of his symptoms?
A- Autonomic dysfunction
B- Chronic gastritis
C- Gastric carcinoma
D- Microangiopathy
E- Peptic ulcer disease
72- As part of the digestive process in the human, pancreatic proteinases within the small
intestine are normally activated. Which of the following substances from the duodenal
epithelium triggers this activation?
A- Calcium ion
B- Carboxypeptidase
C- Elastase
D- Enteropeptidase
E- Secretin
F- Trypsin
73- A 70-year-old man has easy fatigability, malaise, and an ataxic gait. He is pale and has a sore
tongue, absent vibratory sense up to his knees, and bilateral plantar reflexes. A peripheral
blood smear is shown. Which of the following is the most likely cause of this patients
disorder?
A- Acquired deficiency of intrinsic factor
B- Carcinoma of the colon
C- Congenital absence of transcobalamin II
D- Congenital malabsorption of vitamin B12
E- Hookworm infestation

24
74- An 18-year-old woman has had pharyngitis, fever, and lethargy for 3 days. Leukocyte count
is 11,500/mm3. The photomicrograph shows the type of cell that is predominant in her
peripheral blood smear. Which of the following is the most likely diagnosis?
A- Acute lymphoblastic leukemia
B- Acute monocytic leukemia
C- Acute myelogeous leukemia
D- Bacterial pharyngitis
E- Infectious mononucleosis
75- A 1-day-old newborn has bilious vomiting that began 1 hour after birth. Physical
examination shows upward slanting eyes, short small fingers, and a wide space between the
1st and 2nd toes. Peristaltic waves are seen, but no abdominal distention. Which of the
following is the most likely additional finding in this patient?
A- Congenital aganglionic megacolon
B- Duodenal atresia
C- Meconium ileus
D- Pyloric stenosis
E- Tracheoesophageal fistula
76- A 30-year-old woman has a 12-hour history of chills and abdominal pain. Her last menstrual
period was 2 weeks ago. Her temperature is 38.8 C (101.8 F), pulse is 120/min, respirations
are 18/min, and blood pressure is 132/82 mm Hg. Abdominal and pelvic examinations show
tenderness on palpation of the right lower quadrant, pain in the right lower quadrant after
pressure is quickly released from the left lower quadrant, pain in the lower quadrant when
the right hip is flexed against resistance (psoas sign), and tenderness in the right rectal wall.
Bowel sounds are absent. Test of stool for occult blood is negative. Which of the following is
the most likely diagnosis?
A- Appendicitis
B- Cystitis
C- Diverticulitis
D- Ectopic pregnancy
E- Pelvic inflammatory disease
77- A 57-year-old man comes to the physician because of a 3-month history of increased
abdominal girth, hemorrhoids, and swelling of his feet after periods of standing or sitting. He
has a 20-year history of alcoholism and hypertension. Current medications include
hydrochlorothiazide. Physical examination shows scleral icterus and jaundice. The abdomen
is round and distended, with a fluid wave and palpable spleen tip. Which of the following
best explains the patients splenomegaly?
A- Ascitis
B- Blockade of afferent splenic lymphatics
C- Decreased osmotic pressure in the hepatic veins
D- Hyperactivity of splenic macrophages
E- Hyperplasia in the periarterial lymphoid sheaths
F- Hyperplasia in the peripheral white pulp

25
G- Increased hydrostatic pressure in the splenic vein
H- Stenosis of the splenic artery
78- A 45-year-old woman has increasing dyspnea and fatigue. She is pale. Hemoglobin
concentration is 7.5 g/dL, leukocyte count is 4,500/mm3, and platelet count is 89,000/mm3.
A peripheral blood smear is shown. Based on these
findings, which of the following additional findings is most
likely?
A- Antiparietal cell antibodies in serum
B- Decreased serum concentration of iron
C- Increased hemoglobin A2 on hemoglobin
electrophoresis
D- Increased osmotic fragility of the erythrocytes
E- Positive direct antiglobulin test

79- An 85-year-old woman has a malignant neoplasm in the wall of the sigmoid colon. To which
of the following groups of lymph nodes is the neoplasm most likely to metastasize initially?
A- Celiac
B- Inferior mesenteric
C- Inguinal
D- Internal iliac
E- Lateral lumbar (aortic)
F- Superior mesenteric

26
80- A 16-year-old girl is brought to the physician because of sore throat, fever, and malaise. She
has cervical lymphadenopathy, and a tender, slightly enlarged spleen. Laboratory studies
show:
Hemoglobin: 14.4 g/dL
Hematocrit: 33.2%
Leukocyte count: 12,000/mm3
A peripheral blood smear is shown. Which of the following is the most likely diagnosis?
A- Acute lymphoblastic leukemia
B- Acute myelogenous leukemia
C- Hairy cell leukemia
D- Infectious mononucleosis
E- Follicular lymphoma

81- A 32-year-old man has dysphagia and odynophagia after ingesting drain cleaner containing
sodium hydroxide pallets. Which of the following is the most likely associated finding 3
months later?
A- Aspiration pneumonia
B- Blindness
C- Esophageal stricture
D- Gastric perforation
E- Hemolytic anemia
F- Renal failure
G- Systemic acid-base imbalance

27
82- A 49-year-old man comes to the physician because of fatigue, lightheadedness on standing
or sitting up rapidly, and dark-colored stools for the past 4 days. He moved to the USA from
southeastern Asia 2 years ago. His history includes chronic hepatitis B infection. Examination
shows pale mucous membranes, an enlarged liver, a prominent periumbilical venous
pattern, and nonbleeding internal hemorrhoids. Hemoglobin concentration is 7.8 g/dL.
Upper endoscopy shows circumferentially prominent tortuous veins with an adherent clot at
the gastroesophageal junction. Which of the following mechanisms best explains the blood
loss in this patient?
A- Acute inflammation of the gastroesophageal mucosa
B- Arteriovenous fistula at the gastroesophageal junction
C- Hepatic artery obstruction with increased celiac pressure
D- Increased flow through collateral hepatic veins
E- Increased pressure in submucosal esophageal veins
83- A 60-year-old woman develops anemia several years after a subtotal gastrectomy. Which of
the following is the most likely finding on a peripheral blood smear?
A- Basophilic stippling
B- Helmet cells
C- Macrocytosis of erythrocytes
D- Microcytosis of erythrocytes
E- Reticulocytosis
84- A 2-year-old boy with normal size, weight, and development is brought to the physician
because of a painful, swollen left knee for the past week. He has had 2 episodes of
asymptomatic hematuria during the past 6 months. Both parents are healthy. He has
achieved developmental milestones at appropriate ages. His height and weight are at the
70th percentile. Examination shows bruises and resolving hematomas on both elbows and
sighs of cutaneous hemorrhages at the site of a deep splinter. Laboratory studies show:
Hemoglobin: 12 g/dL (N= 13.8-17.2)
Erythrocyte count: normal
Leukocyte count: normal
Bleeding time: 4 min (N= 2-7 min)
Partial thromboplastin time: 30 sec (N = 15-40 sec)
Prothrombin time: 10 sec (N= 9-12.5 sec)
The most likely diagnosis can be proven by the therapeutic response to a single injection of
which of the following?
A- Vitamin K
B- Vitamin C
C- Folic acid
D- Factor VIII (Antihemophilic factor)
E- Factor I (Fibrinogen)

28
85- A 4-year-old girl requires a splenectomy after an automobile collision. Which of the
following is most likely to be a long-term complication in this patient?
A- Cytomegalovirus infection
B- Lymphopenia
C- Non-Hodgkin lymphoma
D- Streptococcal infection
E- Thrombocytopenia
86- A 73-year-old man is brought to the emergency department because of excruciating low
back pain that began while he was painting his garage 1 day ago. He visits the physician
every 6 months for monitoring of hypertension well controlled with a diuretic. An x-ray of
the spine shows several osteoblastic lesions in the vertebrae. A complete blood count shows
mild normocytic anemia. Immunoglobulin levels are within the normal reference values.
There is no lymphadenopathy. Which of the following is the most likely diagnosis?
A- Malignant lymphoma
B- Metastatic lung carcinoma
C- Metastatic prostate carcinoma
D- Multiple myeloma
E- Osteosarcoma
87- A 4-year-old boy has had recurrent watery diarrhea, abdominal distention, and increased
borborygmi (bowel sounds) for 3 months. The elimination of most dairy products form his
diet causes his symptoms to abate. In which of the following portions of the gastrointestinal
tract is an enzyme deficiency most likely?
A- Colon
B- Jejunum
C- Liver
D- Pancreas
E- Stomach
88- A 42-year-old man who is a resident of the USA comes to the physician because of greasy
foul-smelling stools and a 5.5 kg (12-lb) weight loss over the past 6 months. He has a 6-year
history of chronic abdominal and back pain. The epigastrium is tender on deep palpation. A
CT scan of the abdomen shows pancreatic atrophy and calcifications. Which of the following
is the most likely cause of his disease?
A- Alcohol dependence
B- Congenital pancreatic cyst
C- Diabetes mellitus
D- Gallstones
E- Heredity
F- Pancreas divisum
G- Protein-calorie malnutrition

29
89- Vitamin B6 (pyridoxine) is required for the enzyme that catalyzes the rate-limiting step in
heme synthesis. Which of the following labeled compounds in the diagram is synthesized in
this reaction?

90- A 1-year-old boy is brought to the emergency department because he is having difficulty
breathing after drinking water that contains nitrates. He is cyanotic. Blood drawn for
laboratory studies is chocolate-colored. His hemoglobin most likely has which of the
following properties?
A- Decreased glycosylation
B- Increased binding of 2,3-biphosphoglycerate
C- Increased proportion of Fe+++ (ferric)
D- Presence of beta subunits only
E- Sickle cell mutation
91- A 26-year-old man comes to the physicians office because he has had shortness of breath
and a cough for the past week. He received combination chemotherapy for testicular
carcinoma 4 months ago. Auscultation of the lungs discloses fine crackles at the bases. X-ray
of the chest shows diffuse pulmonary infiltrates. Which of the following chemotherapeutic
drugs is most likely responsible for his symptoms?
A- Bleomycin
B- Cisplatin
C- Cyclophosphamide
D- Daunorubicin
E- Etoposide
F- Ifosfamide
G- Paclitaxel
H- Vinblastine

30
92- A 10-month-old boy with hemoglobin SS disease is brought to the emergency department by
his parents because of severe pain in his feet for 2 hours. He appears acutely ill and is crying.
Vital signs are normal except for a pulse of 160/min. physical examination shows
splenomegaly and edematous, tender feet. Laboratory studies show a hemoglobin
concentration of 7 g/dL and a reticulocyte count of 12%. A peripheral blood smear shows
target cells, poikilocytes, and sickled erythrocytes. Which of the following processes most
likely caused the sickled erythrocytes in this patient?
A- Decreased interaction of hemoglobin S with spectrin upon deoxygenation
B- Inability of abnormal beta chains to form tetramers upon deoxygenation
C- Inability of abnormal beta chains to form tetramers upon oxygenation
D- Increased interaction of hemoglobin S with spectrin upon deoxygenation
E- Spontaneous polymerization of hemoglobin S upon deoxygenation
F- Spontaneous polymerization of hemoglobin S upon oxygenation
93- A 62-year-old man comes to the physician because of a 10-day history of mild, diffuse
abdominal pain and a rapidly progressive increase in abdominal girth. He has a 10-year
history of cirrhosis caused by hepatitis C and alcohol abuse. He stopped all alcohol
consumption 8 years ago has been well until recently. Examination of the abdomen shows
massive ascitis and a small liver with an irregular texture. A discrete 2-cm nodule is palpated
on the liver. Which of the following measurements in this patients serum is most
appropriate to establish a diagnosis?
A- GABA
B- CA-19-9
C- CA 125
D- CEA
E- Alpha-fetoprotein
F- PSA
94- Which of the following hormones, produced by the duodenal and proximal jejunal mucosa,
stimulates the release of pancreatic juice rich in digestive enzymes?
A- Cholecystokinin
B- Glucagon
C- Pancreatic polypeptide
D- Secretin
E- Vasoactive intestinal polypeptide
95- An asymptomatic 56-year-old woman has occult blood in her stool. Barium studies of her
transverse colon show an intraluminal mass. The surgical specimen is shown. Which of the
following is the most likely diagnosis?
A- Adenocarcinoma
B- Carcinoid tumor
C- Polypoid leiomyoma
D- Tubular adenoma
E- Villous adenoma

31
96- An asymptomatic 56-year-old woman has occult blood in her stool. Barium studies of her
transverse colon show an intraluminal mass. The surgical specimen is shown. Which of the
following is the most likely diagnosis?
A- Adenocarcinoma
B- Carcinoid tumor
C- Polypoid leiomyoma
D- Tubular adenoma
E- Villous adenoma

97- A 94-year-old man has been taking ibuprofen for osteoarthritis for the past 5 years. 2 years
ago, he developed renal failure, and serum creatinine concentration increased from 1.2 to 2
mg/dL. He recently developed gastrointestinal hemorrhage from a gastric ulcer. He wants to
continue taking the ibuprofen. Which of the following drugs is most likely to decrease this
patients risk for ibuprofen-induced gastric ulceration?
A- Ampicillin
B- Metronidazole
C- Misoprostol (PGE1)
D- Sucralfate
E- Vitamin B6
98- Which of the following antiemetic drugs may induce parkinsonian signs such as dystonia and
tardive dyskinesia?
A- Dronabinol
B- Dimenhydrinate
C- Metoclopramide
D- Ondansetron

32
99- A 25-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

100- The diagram shows a liver lobule. Long-term destruction of the hepatocytes, collapse of the
histologic architecture, and production of fibrous material in the areas indicated by the
arrow is most likely to result in which of the following?
A- Decreased intestinal motility
B- Gallstones
C- Increased central venous pressure
D- Increased hepatic venous pressure
E- Increased portal pressure
101- After several courses of treatment for non-Hodgkins lymphoma, a 33-year-old man
develops gross hematuria. Which of the following drugs is most likely to be responsible for
this adverse effect?
A- Carmustine
B- Cyclophosphamide
C- Daunorubicin
D- Methotrexate
E- Vincristine

33
102- A 20-year-old man has gastrointestinal bleeding due to Meckels diverticulum. Histologic
evaluation of the resected diverticulum is most likely to show:
A- Acute bacterial inflammation
B- Carcinoid tumor
C- Gastric mucosa
D- An impacted enterolith
E- Varices at the neck of the diverticulum
103- 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- Burkitts lymphoma
B- Diffuse non-cleaved cell lymphoma
C- Follicular lymphoma
D- Hodgkins lymphoma
E- Lymphoblastic lymphoma
104- A 3-year-old boy has a 5-week history of weight loss and bulky, frothy, foul-smelling stools.
Dietary modification including exclusion of gluten-containing foods from the diet results in
clinical improvement. Which of the following is the most likely finding on examination of a
biopsy specimen from the small intestine?
A- Atrophy of villi an microvilli
B- Degenerative changes of the myenteric plexus
C- Multiple outpouchings through the muscle coat
D- Numerous ulceration and pseudopolyps
E- Pseudomembrane covering the luminal surface
105- 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 patients 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

34
106- 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- Cholangitis
B- Chronic pancreatitis
C- Pancreatic islet cell neoplasm
D- Perforated gastric ulcer
E- Ulcerative colitis
107- The absorption of calcium from the intestinal tract results principally from the direct action
of which of the following?
A- Calcitonin
B- cAMP
C- 1,25-dihydroxycholecalciferol
D- 25-hydroxycholecalciferol
E- Parathyroid hormone
108- A 3-week-old infant has milk intolerance due to a defect in the enzymes that digest lactose.
This enzyme is located at which of the following sites in enterocytes?
A- At the apical surfaces
B- At the basolateral surfaces
C- Within the Golgi complex
D- Within lysosomes
E- Within peroxisomes
109- A 40-year-old woman has a fever and petechial. Laboratory studies show:
Hemoglobin: 9 g/dL (N = 12-15.6)
Leukocyte count: 5,000/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 (lymphoblastic)
leukemia
B- Acute myeloid (myeloblastic) leukemia
C- Chronic lymphocytic leukemia
D- Chronic myelogenous leukemia
E- Leukemoid reaction

35
110- In the previous case, treating the diagnosed condition appropriately is most likely to be
complicated by:
A- Metabolic acidosis with increased anion gap
B- Kernicterus
C- Disseminated intravascular coagulation
D- Thrombocytosis
E- Splenic infarction
111- A 34-year-old woman comes to the physicians 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 lymphadenopathy 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

112- Fetal and maternal erythrocytes have the same concentration of 2,3-biphosphoglycerate.
Whoever, compared with maternal hemoglobin (HbA), fetal hemoglobin (HbF) has a higher
affinity, which facilitates transplacental diffusion of oxygen. The presence of which of the
following polypeptide chains in HbF accounts for this finding?
A- Alpha chains alone
B- Beta chains alone
C- Gamma chains
D- Both alpha and beta chains

36
113- A 64-year-old woman comes to the physicians office because of gradually worsening
abdominal cramps, nausea, diarrhea, flushing of the skin and heart palpitations. 24 hour
urinary 5-hydroxyindolacetic acid excretion is increased. The most likely cause of these
findings is a neoplasm originating in which of the following organs?
A- Adrenal gland
B- Esophagus
C- Kidney
D- Small intestine
E- Spleen
F- Thyroid
114- A hyperactive 6-year-old girl develops microcytic anemia, cerebral edema, and ataxia.
Determination of which of the following serum enzyme activities is most likely to confirm
the diagnosis?
A- 5-aminolevulinic acid (-ALA) dehydrogenase (dehydratase)
B- Glucose 6-phosphate dehydrogenase
C- Glutathione transferase
D- Lactate dehydrogenase
E- Pyruvate kinase
115- An alcohol-dependent 40-year-old woman who is a health care worker has had episodic
symptoms of hypoglycemia for the past year. During one of those episodes, plasma glucose
concentration is decreased, plasma insulin concentration is increased, and serum C-peptide
concentration is not detectable. Which of the following is the most likely cause of the
hypoglycemia?
A- Acute hepatic failure
B- Ingestion of a sulfonylurea
C- Pancreatic beta cell neoplasm
D- Retroperitoneal fibrosarcoma
E- Surreptitious (factitious) use of insulin
116- 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, a finding consistent with a villous adenoma. This patient is at increased risk for
which of the following colonic neoplasms?
A- Adenocarcinoma
B- Carcinoid
C- Fibrosarcoma
D- Leiomyosarcoma
E- Lymphoma
F- Squamous cell carcinoma

37
117- A 55-year-old man has had patchy leukoplakia (a premalignant lesion) of the anterior floor of
his mouth for 4 years. He now has a raised, firm white lesion in the same area. Examination
of the tissue obtained on biopsy of this new lesion is most likely to show:
A- Aphthous ulcer
B- Burkitts lymphoma
C- Candida infection
D- Kaposis sarcoma
E- Mixed tumor of the parotid gland
F- Squamous cell carcinoma
G- Warthins tumor
118- 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: 11 g/dL
Hematocrit: 33%
Mean corpuscular volume: 80 M3
Reticulocyte count: 0.5%
Serum iron: 25 g/dL
Total iron binding capacity: 150 g/dL (N = 250-460)
Examination of tissue obtained on biopsy of a lymph node shows Hodgkins lymphoma,
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- Vitamin B6 deficiency
119- What is the mechanism of intravenous heparin in treating deep venous thrombosis?
A- Activation of plasmin
B- Facilitation of inactivation of thrombin by antithrombin III
C- Inhibition of activation of tissue plasminogen
D- Inhibition of vitamin K-dependent coagulation factors
E- Reversible inhibition of protein C and protein S activity
120- Which of the following cells share a common progenitor cell with macrophages?
A- Astrocytes
B- Ependymal cells
C- Microglia
D- Mullers fibers
E- Oligodendrocytes

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121- 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- Ascending colon
B- Descending colon
C- Hepatic flexure
D- Splenic flexure
E- Transverse colon
122- 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- Cholecystitis
B- Gastritis
C- Gastroenteritis
D- Peritonitis
E- Small bowel obstruction
123- 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 deficiency
D- Vitamin B12 deficiency
E- Vitamin C deficiency
124- Several clinical trials have suggested that retinoic acid (vitamin A) can induce remission in
patients with acute promyelocytic leukemia, evidenced by the decreased number of
myeloblasts in blood and bone marrow. 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
125- 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. Prothrombin time is normal. The most
likely diagnosis is:
A- Deficiency of antithrombin III
B- Disseminated intravascular coagulation
C- Hemophilia A
D- Hepatic failure

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E- von Willebrands disease
126- A 25-year-old woman, gravida 1, para 0, who is RH negative delivers a full-term RH positive
neonate. The mother is given prophylactic anti Rho (D) immune globulin immediately postpartum. During her 2nd pregnancy 3 years later, she is screened each trimester for RH (D)
antibodies. An indirect antiglobulin test done during the 3rd trimester indicates the presence
of anti Rh (D) antibodies in her serum. Which of the following is the most likely mechanism
for the occurrence of these maternal antibodies?
A- Anamnestic (due to previous stimulation) production of maternal anti Rh (D)
immunoglobulin
B- Intrauterine transplacental fetal-maternal hemorrhages during the 2nd pregnancy
C- Residual circulating prophylactic anti Rh (D) immunoglobulin
D- Transplacental passage of fetal IgG anti Rh (D) antibodies
127- 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- Lipase
128- A 10-year-old girl has fever, fatigue, and easy bruising. Laboratory studies show:
Hemoglobin: 6.6 g/dL
Hematocrit: 20%
Leukocyte count: 1,300/mm3
Platelet count: 12,000/mm3
A photomicrograph of the bone marrow obtained on biopsy is shown. The most likely
diagnosis is:
A- Aleukemic leukemia
B- Aplastic anemia
C- Immune thrombocytopenic purpura
D- Myelofibrosis
E- Vitamin B12 deficiency

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129- Actively dividing fibroblasts in culture are transferred from a 37 C incubator to a 0 C ice bath,
and colchicine is added to the culture medium. After 30 minutes, many cells have been
arrested in mitosis. Which of the following cytoskeletal proteins is most likely to be
involved?
A- Actin
B- Desmin
C- Dynein
D- Keratin
E- Kinesins
F- Lamins
G- Myosin
H- Neurofilament proteins
I- Tubulin
130- A 27-year-old man with recurrent peptic ulcer disease has a small pancreatic neoplasm that
produces large amounts of gastrin. While awaiting operation, the patient should be treated
with:
A- Chenodeoxycholic acid
B- Methacoline
C- Metoclopramide
D- Omeprazole
E- Sucralfate
131- 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 3-4 times per year, lasts
2-4 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 4-7 days, the stool is hard and pellet-like. She drinks 1 glass of
wine daily. Physical examination shows no abnormalities. Laboratory studies show:
Hemoglobin: 14.3 g/dL
Hematocrit: 43%
Leukocyte count: 8,100/mm3
Erythrocyte sedimentation rate: 7 mm/h
Which of the following is the most likely diagnosis?
A- Crohns disease
B- Colon cancer
C- Diverticulitis
D- Irritable bowel syndrome
E- Small bowel lymphoma
F- Ulcerative colitis

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132- An adults hemoglobin is 98% saturated with oxygen, PaO2 is normal, but arterial oxygen
content is decreased. The most likely cause of this condition is:
A- Anemia
B- Arteriovenous shunt
C- Hemoglobinopathy
D- High-altitude hypoxia
E- Pulmonary diffusion defect
133- A 58-year-old male is seen because of intermittent claudication in lower limbs. His doctor
prescribes Cilostazol, a drug that will inhibit platelet aggregation and cause arteriolar
vasodilation. Which of the following is the mechanism of this drug?
A- Inhibition of COX-2, deceasing Prostacyclin (PGI2)
B- Enhancement of insoluble fibrin monomer formation
C- Increased platelet release of ADP, increasing GP IIb/IIIa expression
D- Inhibition of phosphodiesterase III, increased AMP in platelets and blood vessels
E- Increasing the release of von-Willebrand factor
134- A 62-year-old female is found to have a bruit on her left carotid artery. Angiography
confirms atherosclerosis. Her physician explains to her that the best course of action would
be surgical removal of the atheroma because it increases her risk of stroke, and immediately
prescribes aspirin in combination with another anti-platelet agent with vasodilator
properties, dipirydamole, explaining to her that this will decrease such risk before surgery.
Which of the following describes the mechanism of dipyridamole?
A- Inhibits thromboxane synthase, phosphodiesterase 5, and adenosine deaminase
B- Inhibits COX-2 and nitric oxide synthase
C- Increases the expression of GP Ia and GP Ib
D- Decreases megakaryocyte production by the bone marrow
E- Activates anti-thrombin III and plasminogen