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Najeeb center-UCE
Endocrine, Reproductive and Musculoskeletal/skin/Connective tissue Organ systems Quiz #1

1- The continuous administration of gonadotropin-releasing hormone (GnRH) is most likely

to elicit which of the following long-term changes in the release of luteinizing hormone
(LH) and follicle-stimulating hormone (FSH)?
A- Decrease
B- Increase
C- Loss of cyclicity without a net increase or decrease
D- No change in net release or cyclicity
Continuous administration of leuprolide (GnRH analog) decreases FSH and LH release.
Pulsating administration of leuprolide increases their release and may be used to induce
ovulation.

2- A 27-year-old man has a painful, infected abscess on the posterior aspect of the scrotum.
Testes are normal on physical examination. Which of the following lymph nodes is most
likely to be tender and swollen?
A- External iliac
B- Internal iliac
C- Lumbar (aortic)
D- Sacral
E- Superficial inguinal
Remember: Lymph from anal canal below pectinate line, scrotum, lower 1/3 of vagina, all
lower limb (except lateral aspect of foot which drains to popliteal and then to deep
inguinal) drains to superficial inguinal nodes.
Lymph from testes, not scrotum drains to lumbar (aortic, paraaortic) lymph nodes.

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3- A 56-year-old woman with squamous cell carcinoma of the lung has had fatigue, right
flank pain, and constipation for 6 weeks. Examination shows hematuria and crystaluria.
The most likely cause of these symptoms is secretion of which of the following substances
by the carcinoma?
A- ACTH
B- Bombesin
C- Calcitonin
D- Erythropoietin
E- Human chorionic gonadotropin (HCG)
F- Nonsuppressible insulin-like activity
G- Parathormone-related protein (PTH-rp)
Squamous cell carcinomas may produce PTH-rp (may cause hyperparathyroidism, as in
this patient). Small cell carcinomas may produce ACTH (hypercorticolism with high
cortisol, high ACTH) and ADH (syndrome of inappropriate secretion of ADH, which causes
volume retention, hyponatremia, somnolence)
If it was an osteoblastic tumor (metastatic prostate adenocarcinoma, multiple myeloma),
there would be lytic lesions and probably hypercalcemia due to cytokine-induced bone
damage (not PTH-rp). REMEMBER, TUMORS DO NO USUALLY PRODUCE PTH,THEY
PRODUCE PTH-rp!).

4- 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 (Pagets disease of bone) is
made. Serum measurement of which of the following is most likely to support the
diagnosis?
A- Alkaline phosphatase activity
B- ALT activity
C- Calcitonin concentration
D- Calcium concentration
E- Lactate dehydrogenase activity
F- Parathyroid hormone concentration
G- Thyroxine (T4) concentration
Alkaline phosphatase is a marker of bone remodeling (formation Resorption). In
Pagets disease there are periods of excessive osteoclastic activity (resorption) followed by
periods of excessive osteoblastic activity (bone formation). There is usually pain. Ca++,
Phosphate, PTH, calcitonin, and vitamin D are all normal. Remember it may lead to heart
failure and osteosarcoma.

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5- A 75-year-old man has a painless mass in the left upper anterior neck. Examination of
tissue obtained on biopsy shows partial replacement of a lymph node by a neoplasm; the
neoplasm is composed of cohesive sheets of polygonal cells with granular eosinophilic
cytoplasm, prominent intercellular bridges, keratin pearls and pleomorphic round nuclei.
Immunocytochemical preparations show a strongly positive reaction of the neoplastic
cells to a high-molecular-weight keratin antibody. There is no reaction to antibodies
against vimentin and leukocyte common antigen (CD45). Serum S-100 marker is negative.
Which of the following is the most likely diagnosis?
A- Adenocarcinoma
B- Malignant lymphoma
C- Non-Hodgkin lymphoma
D- Sarcoma
E- Squamous cell carcinoma
S-100 is a marker of neuroblastoma and melanoma. Keratin pearls strongly suggest
squamous cell carcinomas. Remember in the case of melanomas, vertical growth is more
important than horizontal growth (determines prognosis and metastasis). Basal cell
carcinomas are more common than all the others, but present with pearly borders.

6- 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 patients condition and suggest a benign course?
A- Cardiolipin = antiphospholipid syndrome (along with lupus anticoagulant, remember
antiphospholipid syndrome in a woman with increased PT and PTT and recurrent
abortions)
B- Centromere: specific for CREST syndrome (milder and more localized form of
systemic sclerosis or scleroderm)
C- Double-stranded DNA = Lupus (most specific along with anti-smith
D- Histone = drug-induced lupus
E- Scl-70= systemic and most severe form of this disease, so not the right choice
F- Sm = Lupus (most specific along with anti dsDNA)
G- SS-A (Ro)= Sjogrens
H- SS-B (La)= Sjogrens

7- A 9-year-old girl has had polyuria, polydipsia, and weight loss for the past 3 weeks. She is
alert, her breath has a fruity odor, and she has tachypnea. Laboratory studies show:
Serum Na+: 130 mEq/L
Serum Cl-: 100 mEq/L
Serum K+: 5.8 mEq/L
Serum HCO3-: 6.0 mEq/L
Serum glucose: 700 mg/dL
Arterial pH: 7.0
Arterial PCO2: 16 mm hg
Which of the following sets of additional findings in serum is most likely?
-hydroxybutyrate
A
B
C
D
E

Osmolarity

Anion gap

This is diabetic ketoacidosis! Know it well!

8- 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?
A- Free thyroxine (FT4)
B- Iodine/iodide
C- Thyroid-stimulating hormone (TSH)
D- Total thyroxine (T4)
E- Total triiodothyronine (T3)
T4 and T3 levels may be confusing some times, but TSH is always revealing.

9- 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?
A- Adenocarcinoma of the cervix: not important
B- Adenocarcinoma of the endometrium
C- Adenocarcinoma of the ovary: Almost inexistant
D- Leiomyosarcoma of the uterus: Female in reproductive ages, with anemia, pelvic
heaviness, menstrual irregularities, difficulties with pregnancies.
E- Squamous cell carcinoma of the cervix
F- Squamous cell carcinoma of the vagina: HPV!
Painles bleeding in any postmenopausal female should make you suspect either
endometrial hyperplasia or its major consequence, endometrial carcinoma!
You wont see adenocarcinoma of the ovary. Squamous cell carcinoma of cervix may be
asymptomatic or be associated with post-coital bleeding.

10- Immediately after vaginal delivery of a male newborn at 35 weeks gestation, a 35-yearold 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?
A- Abruptio placentae: Severe lower abdominal pain with hypertonic uterus, MCC is
hypertension. May be caused by trauma or cocaine. May lead to DIC, fetal death,
Sheehans syndrome. Occurs during 3rd trimester of pregnancy.
B- Placenta accreta
C- Placenta percreta: deeper invasion (if invasion involves the serosa, it is increta)
D- Placenta previa: painless bleeding during the 3rd trimester of pregnancy
E- Placental infarction: may be a complication of preeclampsia
11- 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?
A- Anserine bursa: pain over the superior-medial area of the tibia.
B- Ischial bursa: pain on sitting over the buttocks.
C- Psoas bursa: No pain after direct palpation over lateral aspect of hip
D- Sacroiliac joint:
E- Sciatic nerve: Pain on posterior aspect of thigh, lateral leg, plantar foot. Pain worsens
with straight-leg raising maneuver. Due to L4-L5 and L5-S1 herniation.
F- Trochanteric bursa: pain only over the lateral aspect of the hip! Major trochanter.

12- A 20-year-old man comes to the physician because of a 2-month history of persistent pain
in his right knee. He is a college football player. Physical examination shows a stable right
knee with tenderness to palpation. An x-ray of the right knee is shown; the arrow
indicates an abnormality. The most likely cause of this patients pain is ossification of
which of the following?
A- Lateral collateral ligament: next to
fibula
B- Lateral meniscus
C- Medial collateral ligament
D- Medial meniscus
E- Tendon of adductor magnus

13- 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 except for 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?
A- Decreased synthesis and release of ADH (vasopressin): is going to be increased
instead of decreased because of the hyperosmolarity
B- Disruption of the transverse gradient in the loop of Henle: the gradient is unaltered.
C- Increased glomerular filtration rate
D- Increased osmolarity in the tubular lumen: glucose behaves as an osmotic diuretic in
hyperglycemia.
E- Inhibition of the Na+/glucose transporter (SGLT-1) in the proximal tubule

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14- A 35-year-old man is brought to the emergency department 1 hour after he sustained a
fracture of his left radius in a fall. He has end-stage renal disease and has been receiving
hemodialysis for 10 years. An x-ray of the left upper extremity shows osteopenia. The
most likely cause of the osteopenia is decreased synthesis and secretion of which of the
following substances?
A- Calcitonin
B- 1,25-Dihydroxycholecalciferol: 1 alpha hydroxylase is only in the kidney!
C- Erythropoietin
D- Parathyroid hormone (PTH, Parathormone): is going to be increased
E- Renin
15- A 5-year-old girl is brought to the physician by her parents for an initial physical
examination. They recently moved to town, and they failed to bring any medical records.
They state that the child was behind in most of her developmental milestones, and that
her teeth erupted late. During the last 3 years, she has sustained fractures of both
upper extremities as well as her left lower extremity. The physician notes a distinct nasal
quality to the childs voice. Her height is at the 10th percentile, and her weight is at the
30th percentile. Physical examination shows frontal bossing of the skull. X-rays confirm
the healed fractures and show generalized increase in bone density, and widening of
the metaphyses and diaphysis of the long bones. Which of the following are most likely
to be defective in this patient?
A- Chondroblasts
B- Chondrocytes
C- Myocytes
D- Osteoblasts
E- Osteoclasts: this is osteopetrosis (marble bone disease), a disease in which bones are
thicker but weaker.
F- Osteocytes

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16- A 69-year-old man is brought to the physician because of a 2-day history of pain of his
right knee. During the past 3 years, he also has had recurrent episodes of pain of the left
great toe and one episode of pain and swelling of the left elbow. These episodes
improved following use of over-the-counter ibuprofen, he has hypertension,
gastrointestinal reflux disease, and hypercholesterolemia. Current medications include
hydrochlorothiazide, ranitidine, and atorvastatin. Physical examination shows erythema
and warmth over the right knee. Nodules are present on the helix of the left ear, chin,
right shoulder, middle back, and lower back. Which of the following nodules is most likely
a tophus (due to hyperuricemia)?
A- Chin
B- Ear: gout tophi appear in hands and ears mainly.
C- Lower back
D- Middle back
E- Shoulder
17- A 42-year-old woman has the sudden onset of abdominal pain 1 day after undergoing
abdominal hysterectomy because of leiomyomata uteri. Her temperature is 38.3 C (101
F). Abdominal examination shows tenderness over the right lower quadrant. Retrograde
pyelography shows contrast in the left renal pelvis and none in the right renal pelvis. A
structure that passes inferior to which of the following was most likely severed during the
operation?
A- Ovarian artery
B- Ovarian ligament
C- Mesosalpinx
D- Round ligament of the uterus
E- Uterine artery: Very important! The ureters pass below the uterine arteries in pelvis
and can be damaged during pelvic surgeries such as this. The pyelography shows that
no contrast media are passing through right ureter because it has been cut.
18- A 25-year-old man is brought to the emergency department because of confusion and
stupor for 1 hour. He is a nurse. This is his fourth similar episode within the past 4
months; he is asymptomatic between the episodes, which are not related to meals.
Physical examination shows no abnormalities. Laboratory studies show a serum glucose
concentration of 30 mg/dL. Serum glucose concentrations during his previous episodes
have ranged from 20 mg/dL to 40 mg/dL. Dextrose resolved the symptoms during his
previous visits. In addition to stabilizing the patient, which of the following is the most
appropriate next step in establishing a diagnosis?
A- 24-hour urine collection for measurement of ACTH
B- Measurement of serum C-peptide concentration: this is the only way for you to know
if this insulin comes from a pancreatic insulinoma or from exogenous sources
(factitious or surreptitious administration). If peptide C is high, then you order the CT
scan.
C- Measurement of serum cortisol concentration
D- CT scan of the pancreas
E- Prednisone therapy

19- A 30-year-old man with HIV infection comes to the physician because of a rash for 3
weeks. The rash is not pruritic or painful. He has not had fevers or chills, and there have
been no recent changes in the soaps and detergents that he uses. He takes no
medications. He does not smoke cigarettes or drink alcohol. His vital signs are within
normal limits. Physical examination shows diffuse lesions on his chest, back, and arms
similar to those shown in the photograph. There are no lesions on the palms or soles.
Which of the following is the most likely diagnosis?
A- Herpes simplex: painful, burning
B- Human papillomavirus infection
C- Kaposis sarcoma
D- Molluscum contagiosum: look at the
central dimpling!
E- Rickettsia ricketsii infection: maculopapular rash (no dimpling)
F- Syphilis: maculo-papular rash (no
dimpling)

20- A 31-year-old woman has her pituitary stalk (which includes the dopaminergic tuberoinfundibular tract) inadvertently transected during an operation to remove a tumor
adjacent to the hypothalamic area. Secretion of which of the following pituitary
hormones is most likely to be increased in this patient as a result of the transection?
A- ACTH
B- Growth hormone
C- Luteinizing hormone
D- Prolactin: If you destroy the stalk, dopamine and all releasing hormones decrease.
Only prolactin will increase as a consequence. All other pituitary hormones will
decrease.
E- Thyroid-stimulating hormone

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21- A 52-year-old woman dies 9 months after being diagnosed with well-differentiated ductal
carcinoma of the right breast metastatic to the brain, lung and liver. Her mother and one
of her sisters also have died of breast cancer. Which of the following molecular
abnormalities is most likely to be found in this patient?
A- Amplification of the HER2 gene in somatic cells: no heredity
B- Amplification of the N-myc gene in neoplastic cells: neuroblastoma
C- Deletion of the Rb locus in healthy somatic cells: Retinoblastoma
D- Fusion of the BCR and C-ABL genes in neoplastic cells: Philadelphia chromosome, AML
E- Germline inactivation of the BRCA1 gene: autosomal-dominant familial breast cancer
22- A previously healthy 47-year-old woman comes to the physician because of a 3-week
history of easy fatigability, proximal muscle weakness, pruritus, constipation, and lower
abdominal pain. Her mother, who is still alive, had a tumor in her thyroid gland and
another one in her adrenal gland surgically removed. The patient is found to have renal
calculi and a parathyroid adenoma. Follow-up genetic testing is recommended. Which of
the following genes should be tested?
A- BRCA1: breast and ovarian cancers
B- BRCA2
C- CFTR
D- P53 tumor suppressor gene: all cancers, but RET is more specific for MEN 2
E- Ret protooncogene: this is MEN 2A
23- A 65-year-old woman comes to the clinic 8 weeks after she found a lump in her right
breast on self-examination. Physical examination shows dimpling over the mass.
Mammography of the breast shows a 4-cm mass in the lower lateral quadrant of the right
breast. The dimpling of the skin is most likely due to traction of the tumor on which of the
following structures?
A- Branches of the cutaneous pectoral nerves
B- Lactiferous ducts
C- Mammary arteries and veins
D- Mammary lymphatics
E- Suspensory (Cooper) ligaments: very important! Dimpling is not only caused by
cancer.
24- A 52-year-old woman has had slowly progressive weakness and weight loss of 9 kg (20 lb)
for 4 months. She has never traveled outside of the USA. Her blood pressure is 82/50 mm
Hg. Her skin shows diffuse hyperpigmentation. Plasma concentration of ACTH is markedly
increased, and the serum concentration of cortisol is decreased. CT scans of the chest and
abdomen disclose no mass lesions. Which of the following is the most likely etiology of
this patients disease?
A- Autoimmune: MCC of Addisons disease is autoimmune destruction of adrenal cortex
B- Congenital
C- Infectious
D- Metabolic
E- Neoplastic

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25- A 25-year-old woman is evaluated for infertility. She has a history of pelvic inflammatory
disease due to Neisseria gonorrhoeae infections. Based on history alone, the most likely
cause of this patients infertility is the effect of her infection on which of the following
structures?
A- Cervical glands
B- Endometrium
C- Fallopian tube: fibrosis induced by pelvic inflammatory disease
D- Myometrium
E- Ovary
26- A 65-year-old man comes to the physician because of increasingly severe pain in his right
leg during the past month. The pain occurs after walking 2 blocks and resolves with rest.
He has no numbness, tingling, weakness or swelling. He has type 2 diabetes mellitus,
hypertension, and hypercholesterolemia. Current medications include metformin,
hydrochlorothiazide, and pravastatin. He has smoked 1 packs of cigarettes daily for 40
years. His pulse is 80/min, and blood pressure is 140/90 mm Hg. Physical examination
shows no tenderness or edema of the lower extremities. The dorsal pedal and posterior
tibial pulses are 1+ (decreased) on the right and 2+ (normal) on the left. Patellar and
Achilles deep tendon reflexes are 1+ bilaterally (hyporreflexia). Which of the following is
the most likely cause of this patients condition?
A- Deep venous thrombosis: pain in one side with edema
B- Diabetic neuropathy: symmetric peripheral neuropathy with tingling, numbness
C- Osteoarthritis: pain over weight-bearing joints
D- Peripheral vascular disease: This man has claudication, a sign of vascular
insufficiency. Probably associated with atherosclerosis.
E- Spinal stenosis: paraparesis
27- A 42-year-old man with hypertension, gout, and type 1 diabetes mellitus undergoes renal
transplantation. His immunosuppressive regimen includes azathioprine, prednisone, and
cyclosporine. The dose of azathioprine would have to be adjusted if he is taking which of
the following drugs?
A- Allopurinol: allopurinol inactivates xanthine oxidase, the enzyme that in turn
inactivates azathioprine. Remember azathioprine is converted ty 6-MP.
B- Atenolol
C- Diltiazem
D- Glyburide
E- Urecholine

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28- A 16-month-old girl is brought to the physician for a routine examination. Physical
examination shows hypertension, rapid eye movements, and a firm, nodular midline
abdominal mass. Laboratory studies show increased urine concentrations of homovanillic
acid and vanillylmandelic acid. Which of the following is the most likely cause of the
findings in this patient?
A- Aldosterone-secreting adenoma
B- Hepatoblastoma
C- Medulloblastoma
D- Nephroblastoma
E- Neuroblastoma
29- A 40-year-old primigravid woman at 8 weeks gestation comes to the physician for a
routine prenatal visit. Her blood pressure is 150/90 mm Hg. Ultrasonography of the
abdomen shows echogenic tissue without the presence of a fetus. A dilation and
curettage is performed, and the tissue removed is shown. This patient is at greatest risk
for which of the following complications?
A- Choriocarcinoma
B- Eclampsia
C- Ectopic pregnancy
D- Placenta accreta
E- Placenta extrachorialis
F- Placenta previa
G- Placental site trophoblastic tumor
H- Villitis of unknown cause

30- A 67-year-old man with small cell carcinoma of the lung develops antibodies directed
against the P/Q-type Ca++ channel (this is lambert-Eaton syndrome). He is at increased
risk for developing a neurologic syndrome that most closely resembles that produced by
which of the following toxins?
A- Botulinum: flaccid paralysis
B- Diphtheria
C- Organophosphate: fasciculations
D- Strychnine: tetany
E- Tetanus : tetany

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31- A 54-year-old woman comes to the physician for a routine examination. She has had
symptoms of menopause for approximately 15 months. She inquires about the risks and
benefits of combined hormone replacement therapy. She says she has obtained some
information from a web site on the internet and understands the effects of estrogen.
However, she is unsure of the purpose of progesterone in the therapy regimen. She is
provided with literature from the Womens health initiative trial and the heart and
Estrogen/Progestin replacement study. After fully explaining the results of the research,
which of the following is the most appropriate response by the physician regarding the
beneficial effects of progesterone?
A- Decreases thromboembolic disease
B- Decreases vaginal atrophy
C- Increases serum HDL-cholesterol concentration
D- Prevents endometrial hyperplasia: this is why you use progesterone
E- Prevents osteoporosis
32- A 16-year-old girl comes to the physician because of a 10-year history of a lesion on her
left arm. Physical examination shows a 1-cm pigmented lesion on the left forearm.
Following excision, the edges of the defect are opposed (brought together), and the
wound is sutured. Increased mitotic activity of which of the following cells is most likely
to reestablish epidermal continuity in this patient by replacing dead epidermal cells?
A- Basal cells: reepitelization
B- Corneocytes
C- Langerhans cells
D- Macrophages
E- Melanocytes
F- Merkel cells
33- A 25-year-old woman comes to the physician because she has not had a menstrual period
for 1 year. Menses began at age 14 years, and until the past year have occurred every 28
days and lasted 5 days. She does not have any children but would like to start a family.
Examination is unremarkable. A pregnancy test is negative. Laboratory studies show an
increased serum prolactin concentration and normal serum thyroid-stimulating hormone
(TSH) and thyroxine (T4) concentrations. Cranial imaging shows a pituitary
microadenoma. Which of the following agents is likely to be most effective in achieving
fertility?
A- Dopamine agonist: dopamine is prolactin-inhibitory factor (such as bromocriptine)
B- Estrogen agonist
C- Gonadotropin agonist
D- Progesterone agonist
F- Testosterone agonist

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34- The binding of a ligand to a membrane-bound receptor can result in a conformational
change in the receptor leading to activation of an enzyme such as adenylyl cyclase, which
uses ATP to generate AMP. This conformational change is initiated by a series of events
that requires the binding of which of the following nucleotides in order to activate
adenylyl cyclase?
A- ADP
B- AMP
C- ATP
D- GDP: binds G protein when it is inactive
E- GTP: Hormone Receptor G-protein GTP binds G protein G protein alpha
activates adenylyl cyclase cAMP increases and stimulates protein kinase A
35- A 75-year-old woman begins treatment with several drugs for osteoporosis. 2 weeks
later, she develops a burning sensation in her chest and throat daily approximately 2
hours after taking her medications. Which of the following medications is the most likely
cause of the development of the burning sensation in this patient?
A- Alendronate: this is an adverse effect of this drug group (erosive esophagitis)
B- Calcitonin
C- Raloxifene
D- Sodium fluoride
E- Vitamin D
36- A 2-month-old girl has asymmetric gluteal folds. Physical examination reveals a palpable
"clunk" present when the hip is reduced in and out of the acetabulum. If untreated, the
underlying pelvic condition will most likely progress to an erosive arthropathy. Which of
the following is the most likely diagnosis?
Diagnosis: congenital dysplasia of the hip joint (congenital dislocation of hip joint)
ABCDEF-

Dislocation: if the condition is not treated, the child will walk with a limp
Fasciitis
Ganglion
Myositis ossificans
Sprain
Strain

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37- A 36-year-old man comes to the physician because of pain in his right lower leg for 3
days. He recently increased his running routine from 12 to 24 miles per week. Physical
examination shows tenderness of the right lower extremity. An x-ray of the lower
extremity shows a stress fracture of the right lower tibia. Which of the following is most
likely increased in this patient?
A- Osteoblast activity at the fracture: they are supposed to become osteocytes in order
to repair bone
B- Serum Ca++ concentration: Ca++ concentration does not change during fracture
repair
C- Serum magnesium concentration
D- Serum parathyroid hormone concentration: no change, could worsen fracture
E- Serum phosphorus concentration: no change
F- Serum vitamin D concentration: will change if you give supplements
38- Which of the following labeled curves best describes the variation in blood estradiol
concentration during the menstrual cycle?
A- LH
B- FSH
C- Progesterone
The answer is D.

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39- A 55-year-old man comes to the emergency department 2 hours after he fell on his right
wrist. He has a 1-year history of coronary artery disease and a 2-year history of
heartburn. Examination of the right wrist shows exquisite tenderness to palpation and
swelling. The patient asks, Do you think you could prescribe celecoxib for the pain? Ive
heard that it wont upset my stomach like aspirin does. The physician is reluctant to
prescribe this drug because other drugs in the same category have been associated with
increased risk for myocardial infarction, associated with increased thrombogenesis. This
increased risk is most likely caused by which of the following mechanisms?
A- Greater inhibition of cyclooxygenase-1 (COX-1) than COX-2 enzymes
B- Inhibition of COX-2 enzyme in gastric epithelial cells
C- Inhibition of lipoxygenase preventing the formation of leukotrienes D4 and C4
D- Inhibition of prostacyclin (PGI2) formation without inhibition of thromboxane A2 in
platelets
E- Inhibition of prostaglandin E2 formation
PGI2 is antithrombotic, Thromboxane A2 is thrombogenic!

40- A male newborn has an abnormal blood thyroid-stimulating hormone (TSH)

concentration at birth. Physical examination shows an anterior cervical mass high in the
neck; the thyroid gland is not palpable. Serum studies show a TSH concentration of 30
U/mL (N < 5), thyroxine (T4) concentration less than 3 U/mL ( N = 4-12), and
triiodothyronine (T3) concentration of 65 ng/dL (N = 80-100). Which of the following is
the most likely cause of these findings?
A- Anti-TSH receptor antibody
B- Lingual thyroid
C- Negative iodine balance
D- Sodium/iodine symporter gene mutation
E- Thyroid carcinoma

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41- A 26-year-old man who was stabbed in the right side of the neck has a nerve injury. The
physician is unable to detect a muscle stretch reflex in the right biceps. This injury most
likely affected the function of which of the following nerves?
A- Axillary: weak abduction, flexion, extension of arm, anesthesia in shoulder
B- Median: weak opposition of thumb, anesthesia in thenar region, weak flexion of
digits, Benedict hand (MCC of lesion: carpal tunel syndrome, may be damaged in
suicide attempts when they cut on the wrist)
C- Musculocutaneous
D- Radial: wrist drop, weak extension of digits, lost triceps reflex, anesthesia in dorsal
skin of upper limb (Most important cause of damage: fracture of mid shaft of
humerus)
E- Ulnar: weak adduction and abduction of fingers, claw hand, anesthesia in little finger
( Most important lesion is in medial epicondyle of humerus)
Nerve lesions are high-yield! Remember the clinical findings will depend on the specific site where the
nerve is damaged! Dont expect to see loss of triceps reflex if the radial nerve is damaged on the
elbow!

42- A 15-year-old girl has virilizing adrenal hyperplasia. Increased serum concentrations of
11-deoxycorticosterone have resulted in hypernatremia, hypokalemia, and hypervolemia.
Serum ACTH concentration is increased, but serum aldosterone concentration is
decreased. Administration of dexamethasone normalizes ACTH, 11-deoxycorticosterone,
aldosterone, and androgen concentrations. Which of the following labeled enzymes is
most likely to be defective in this
patient?

The answer is F.
E will result in hypovolemia, hypotension,
hyperkalemia and pseuedohermaphroditism
present at birth,

B will result in delayed sexual maturation,

hypertension, hypokalemia, hypervolemia,
increased aldosterone.

18

43- A 52-year-old woman comes to the physician because of pain in her right knee. The knee
is red, warm, and swollen. Serum uric acid concentration is 11.4 mg/dL. Joint fluid
aspirate shows negatively birefringent crystals. Indomethacin therapy is started and she
begins a purine-restricted diet. One week later, her 24-hour urinary acid excretion is 800
mg/day N = 300-600 mg/day). Which of the following is most appropriate to decrease
the serum uric acid concentration in this patient?
A- Allopurinol
B- Aspirin: may increase uric acid excretion (not decrease production) at high doses
C- Colchicine: Drug of choice for acute attacks! Doesnt affect production, it is a
microtubular inhibitor, so it prevents macrophage invasion and further inflammation
D- Probenecid: Increases uric acid elimination, and may decrease the elimination of
many other agents and drugs.
E- Sulfinpyrazone: uricosuric (increases excretion)
44- A 43-year-old woman has hyporreflexia and a hoarse voice. She has a decreased plasma
thyroid-stimulating hormone concentration that increases after she is given thyrotropinreleasing hormone. The most likely diagnosis is hypothyroidism caused by which of the
following?
A- Abnormality in the hypothalamus: TRH is produced by hypothalamus, and Is deficient
here. It induces the anterior pituitary to release TSH.
B- Abnormality in the pituitary gland: TSH responds to TRH. If it didint, then it would be
pituitary.
C- Abnormality in the thyroid gland: no response to TRH or TSH administration.
D- Dietary iodine deficiency: no response to TRH or TSH administration.
E- Resistance to thyroid hormone
45- A 45-year-old man comes to the emergency after inadvertently taking an overdose of
metoprolol. His pulse is 40/min and blood pressure is 80/50 mm Hg. Glucagon is
administered intravenously. 5 minutes later, his pulse is 70/min and blood pressure is
130/80 mm Hg. Which of the following best describes the mechanism of action of
glucagon in this patient?
A- Inhibition of cardiac muscarinic 2 (M2) receptors
B- Inhibition of phosphodiesterase
C- Opening of K+ channels
D- Potentiation of drug-induced hypoglycemia
E- Stimulation of adenylyl cyclase: glucagon stimulates Gs protein

19
46- A 19-year-old woman with a 5-year history of poorly controlled type 1 diabetes mellitus
gives birth to a plethoric, macrosomic male newborn who weighs 5 kg (11 lb). 12 hours
later the newborn has hypoglycemia. Which of the following is the most likely cause of
these findings in the newborn?
A- Increased fetal pancreatic secretion of insulin: maternal hyperglycemia causes fetal
hyperglycemia Fetal insulin secretion Macrosomia an hypoglycemia
B- Increased fatal production of cortisol
C- Increased fetal production of growth hormone
D- Maternal anti-insulin antibodies, which cross the placenta
E- Maternal insulin, which crosses the placenta
47- A 27-year-old woman has had menses once every 4-6 months since age 16 years.
Menarche occurred at age 12 years, and she had regular 28-day cycles until she joined
the high school track team at age 16 years. She now runs 30-40 miles weekly. She eats a
healthy diet. She is 170 cm (5 ft 7 in) tall and weighs 61 kg (135 lb). BMI is 21 kg/m2. This
woman has an increased risk for developing which of the following?
A- Anorexia nervosa
B- Endometriosis
C- Osteoporosis: Sports decrease GnRH release, therefore decrease FSH and and this
may cause menstrual irregularities. The less estrogen, the higher the risk of
osteoporosis!
D- Ovarian cancer
E- Vitamin B12 deficiency
48- A 49-year-old man undergoes radical neck dissection for a malignancy. All four
parathyroid glands are removed. He has hypocalcemia postoperatively. Calcium
concentration returns to the reference range with calcium and vitamin D
supplementation. Which of the following best describes the result of loss of parathyroid
hormone on vitamin D metabolism?
A- Decreased cutaneous synthesis of vitamin D from steroid precursors
B- Decreased hepatic conversion of vitamin D to 25-hydroxycholecalciferol
C- Decreased intestinal absorption of dietary vitamin D
D- Decreased number of 1,25 dihydroxycholecalciferol receptors
E- Decreased renal conversion of 25-hydroxycholecalciferol to 1,25dihydroxycholecalciferol: 1 hydroxylase, induced by PTH!
F- Increased hepatic catabolism of vitamin D

20
49- After being given an infusion of mannitol, a healthy person is most likely to have which of
the following changes in plasma osmolarity and plasma ADH (vasopressin) concentration?
The answer is A: ADH will increase because of
the increased osmolarity.

50- A 68-year-old man comes to the emergency department because of chest pain for 30
minutes. An ECG shows a regular rate and rhythm and inverted T waves. While laboratory
studies are being done, he is given oxygen and aspirin. Aspirin is most appropriate in the
treatment of this patient because of the inhibition of which of the following enzymes?
A- Cyclooxygenase
B- Lipoxygenase
C- Phospholipase A2
D- Prostacyclin (PGI2) synthase
E- Thromboxane A2 synthase
51- A 30-year-old woman is being treated for leuprolide for estrogen-dependent breast
cancer. After 2 months of continuous treatment, which of the following is the most likely
effect on the secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH)
from the pituitary gland?

ABCDE-

LH

FSH
: same as question #1!
(no change)

21
52- A 20-year-old woman comes to the physician for an examination prior to participating on
the college varsity volleyball team. She has a 1-month history of mild facial acne. Physical
examination shows no other abnormalities. Treatment with a topical agent is begun. 3
weeks later, she returns to the physician because of leg swelling and weight gain. Physical
examination shows severe facial acne and acne on the chest and back. There is 2+ pitting
edema of the lower extremities. Laboratory studies show a mildly increased serum direct
bilirubin concentration and serum transaminase activity, suggesting cholestasis.
Hematocrit s 52% (N = 35-45% in females). The most likely cause of her condition is selfadministration of which of the following substances?
A- ACTH
B- Ethinyl estradiol: estrogen, unlikely to cause this
C- Growth hormone: may cause all these except increased red blood cells, acne and
cholestasis. Testosterone is a steroid hormone.
D- Hydrocortisone
E- Methandrostenolone: androgen. May cause all these and eve aggressive behavior
and changes in voice.
53- A 70-year-old man comes to the physician because of a 2-year history of urinary hesitancy
and frequency. He states that he wakes 2-3 times a night to void and that during the past
year he has had intermittent pain with urination. Physical examination shows no
abnormalities. Results of urinalysis are within the reference range. Ultrasonography of
the abdomen shows bilateral dilation of the renal collecting system. Which of the
following is the most likely diagnosis?
A- Adenocarcinoma of the prostate: involves peripheral lobe, palpable hard nodule
B- Benign prostatic hyperplasia: Involves the periurethral lobe, causes urethral
obstruction
C- Nephroblastoma
D- Renal cell carcinoma
E- Ureterolithiasis
F- Ureteropelvic junction stricture
G- Urethral valves
H- Urothelial carcinoma of the bladder
54- A 27-year-old woman has a suprasellar craniopharyngioma, which leads to pressureinduced atrophy of the posterior pituitary. Which of the following responses is most likely
in the kidney?
A- Decreased production of 1,25-dihydroxycholecalciferol
B- Decreased Na+ reabsorption in the proximal convoluted tubule
C- Increased Ca++ reabsorption in the proximal tubule
D- Increased water reabsorption by the thick limb of the loop of Henle
E- Production of a hypotonic urine

22
55- A 60-year-old woman comes to the physician because of vaginal bleeding. Menopause
occurred at age 52; she has not had vaginal dryness or hot flashes and has not been on
hormone replacement therapy. She has type 1 diabetes mellitus and weighs 114 kg (250
lb). Physical examination shows absence of vaginal atrophy and scant blood from the
cervix. An increase in the serum concentration of which of the following hormones most
likely accounts for these findings?
A- Cortisol
B- Dehydroepiandrosterone sulfate
C- Estrone: most important estrogen after menopause!
D- Progesterone
E- Prolactin
56- A 31-year-old woman has an enlarged right ovary detected on pelvic examination and
confirmed on endovaginal ultrasonography. At laparoscopy, an 8-cm cyst filled with thick
brown material is removed. Histologic sections show that the cyst is lined by
macrophages containing abundant hemosiderin. Which of the following is the most likely
diagnosis?
A- Adenomyosis
B- Benign cystic teratoma
C- Endometrioma: chocolate cysts!
D- Polycystic ovary
E- Struma ovarii
57- A 29-year-old primigravid woman at 22 weeks gestation has anxiety and poor
concentration. She has gained 2.3 kg 95 (5 lb) during the pregnancy. Her pulse is 110/min
and blood pressure is 132/65 mm Hg. She has a fine tremor and warm, moist skin. She
has had intermittent palpitations and 3 loose bowel movements per day for the past 6
weeks. Findings on prenatal visits up to this time have been unremarkable. Hemoglobin
and serum glucose levels are within the reference ranges. The most appropriate next step
is to assess the function of which of the following?
A- Central nervous system
B- Gastrointestinal tract
C- Heart
D- Kidney
E- Liver
F- Thyroid gland

23
58- During an investigational study, a newly synthesized drug (Drug X) is found to selectively
block the effects of inhibin. A researcher administers Drug X to an experimental animal.
Which of the following is most likely to occur?
A- Decreased serum FSH concentration
B- Decreased serum GnRH concentration
C- Increased serum FSH concentration: Inhibin has negative feedback effects over FSH,
so if you block it, FHS will increase!
D- Increased serum GnRH concentration
E- Leydig cell atrophy
F- Leydig cell hypertrophy
59- Which of the following best describes peptide hormones?
Receptor location
A- Cell membrane
B- Cell membrane
C- Cell membrane
D- Cell membrane
E- Nucleus or cytosolic
F- Nucleus or cytosolic
G- Nucleus or cytosolic
H- Nucleus or cytosolic

Onset of action
Rapid
Rapid
Slow
Slow
Rapid
Rapid
Slow
Slow

Examples
Aldosterone
Insulin
Aldosterone
Insulin
Aldosterone
Insulin
Aldosterone
Insulin

60- An 81-year-old man with urinary frequency and incomplete bladder emptying undergoes
a transurethral resection. A photomicrograph of the resected specimen is shown.
Metastasis of the neoplasm will most characteristically involve which of the following
organs?
A- Adrenal gland
B- Bone: prostate adenocarcinoma, osteolytic
/osteoblastic metastasis
C- Brain
D- Liver
E- Lung

24
61- Which of the following best describes plasma and urine osmolarity in a 27-year-old
woman who has nephrogenic diabetes insipidus?

Plasma osmolarity
A
B
C
D

Urine Osmolarity
After mild H2O deprivation
After administration of ADH

Remember, in nephrogenic diabetes insipidus, ADH is normally produced, the problem is in

the kidneys! So dont expect any response after giving ADH! If it is central DI, then there
will be increased urine osmolarity.
62- A 16-year-old girl is brought to the physician by her mother because she has never had a
menstrual period. She is 140 cm (4 ft 7 in) tall and weighs 45 kg (100 lb); BMI is 23 kg/m2.
Physical examination shows little development of secondary sexual characteristics. Which
of the following findings is most likely on examination of the ovaries?
A- Atrophy: Streak gonads in Turners! LH and FSH
B- Corpora lutea
C- Gonadoblastoma
D- Polycystic ovarian disease
E- Teratoma
63- A 20-year-old woman has had progressive weakness, anorexia, intermittent vomiting, and
a 6-kig (13.2 lb) weight loss over the past 6 months. She is thin, her blood pressure is
88/60 mm Hg, and there is diffuse brown darkening of the elbow creases and in an old
appendectomy scar. Which of the following sets of laboratory findings is most likely in
this patient?
ACTH
Serum Cortisol
Serum Aldosterone
Urine Na+
Urine K+
A-

B-

C-

D-

E-

Addisons disease. MCC is autoimmne destruction of adrenal cortex. Cortisol,

aldosterone, sex hormones will decrease. If aldosterone decreases, Na+ reabsorption
decreases and therefore increases in urine, K+ secretion deceases and therefore it
increases in blood. As cortisol cannot exert its negative feedback on anterior pituitary
for ACTH release, ACTH will increase. Option A could be caused by anterior pituitary
destruction.

25
64- An 18-year-old man has an appendectomy. 2 weeks later, the abdominal incision has
healed well and has a pink, shiny, granular appearance. Which of the following findings is
most likely on examination of tissue obtained from the healing area?
A- Granulation tissue with angiogenesis: Granulation tissue with type III collagen!
B- Chronic inflammation with epithelioid cells
C- Fibrinoid necrosis: only vasculitis!
D- Granulomatous inflammation
E- Ischemic injury
65- Embryonic chondrogenesis requires the formation of mesenchymal condensations at the
sites of future cartilage. During this developmental step, cAMP concentrations in the cells
comprising the condensation increase significantly. Treatment with a membranepermeable form of cAMP allows individual mesenchymal cells to differentiate into
chondrocytes without first forming these condensations. Inhibition of which of the
following enzymes would most directly inhibit cAMP-mediated induction of
chondrogenesis from mesenchyme?
A- Guanylyl cyclase: converts GTP to cGMP
B- Phosphodiesterase: degrades cGMP and cAMP, inhibited by sildenafil and milrinone.
C- Proteasome: destroys defective proteins and muscle protein during starvation.
Requires polyubiquination to target defective or normal muscle proteins.
D- Protein kinase A
E- Tyrosine kinase: insulin, PDGF, FGF, IGF, VEGF (growth factors!)
66- A 45-year-old woman comes to the physician because of a 6-month history of mouth
ulcers, thickening of the skin, and throbbing pain in her hands when they are exposed to
the cold. She also has had a 1-month history of severe headaches and difficulty
swallowing. Physical examination shows small red lesions around the mouth and
generalized muscle weakness. Laboratory studies show a high titer of anti-Scl 70 (antitopoisomerase I) antibody. A biopsy specimen of the skin shows thinning of the
epidermis, hyalinization and obliteration of arterioles, and dermal thickening. These
dermatologic changes are caused primarily by the release of chemokines from which of
the following inflammatory cell types?
A- Endothelial cells
B- Eosinophils
C- Lymphocytes
D- Mast cells
E- Platelets
F- Segmented neutrophils

26

67- A 19-year-old man has had continuous pain in his left knee since a motorcycle collision 10
days ago. Physical examination shows excessive posterior movement of the tibia relative
to the femur. Flexion and extension are normal, and there is no evidence of anterior,
medial, or lateral instability. Injury of which of the following labeled structures in the
sagittal MRI of a normal knee is most likely associated
with these findings?
The answer is E: posterior cruciate ligament.
D is anterior cruciate ligament.
A is skin above patellar ligament which looks black.
C is fat.
B is transverse ligament.

27
68- A 68-year-old woman is brought to the emergency department by her husband 3 hours
after the onset of severe pain in the middle of her lower back after carrying groceries. She
takes no medications and has never received hormone replacement therapy. Physical
examination shows tenderness over the lumbosacral spine. Neurologic examination
shows no focal findings. Which of the following findings is most likely on an x-ray of the
spine?
A- Compression fracture of L4: MC fracture in people with osteoporosis usually
associated with straining such as in this case!
B- Facet joint dislocation at L3-L4
C- Fracture of lateral process of L1
D- Herniation of the L5-S1 intervertebral disc: pain would be felt lumbar region,
radiating to posterior thig, lateral leg and plantar foot. Positive straight-leg rising
test. Not usually sudden.
E- Spinal stenosis at T12
69- A 22-year-old woman who is a marathon runner has a stress fracture of the tibia. She
participates in a study in which bone density is measured and is found to have decreased
bone density. Which of the following is the most likely cause?
A- Calcitonin deficiency
B- Cortisol deficiency
C- Estrogen deficiency: exercise decreases GnRH, this decreases FSH and LH, which
results in decreased estrogen production and bone resorption will be greater than
bone formation.
D- Growth hormone deficiency
E- Insulin deficiency
F- Parathyroid hormone deficiency
G- Parathyroid hormone excess: nothing here suggests this
H- Thyroid hormone deficiency
I- Thyroid hormone excess
70- A 55-year-old woman comes to the physician because of a 3-month history of chronic
back pain and difficulty walking. Neurologic examination shows tenderness of the spine
and footdrop. Lumbar myelograms are shown. As the lumbar disc herniates into the
spinal canal, which of the following ligaments is pushed into the spinal root nerves?
A- Anterior longitudinal ligament
B- Cruciform ligament
C- Interspinous ligament
D- Posterior longitudinal ligament
E- Supraspinous ligament

28

71- In a 24-year-old woman, which of the following is most likely to induce a shift in the
normal balance of bone accretion (formation) and resorption toward net bone loss?
A- Bodybuilding and use of anabolic steroids: this would shift the normal balance toward
bone formation! Androgens are anabolic!
B- Eating a high-calcium diet: no effect
C- Living on a space station for the past 6 months: your body will no longer need those
bones!
D- Metabolic alkalosis and chronic vomiting: no effect
E- Running 1-2 miles, 3 times weekly : same as A, unless it is a woman in which
estrogens may decrease.
72- A 60-year-old woman has the sudden onset of midthoracic back pain while doing
housework. She has had diffuse aches and pains for 3 months. She had a renal calculus 1
year ago. Physical examination shows kyphosis with tenderness in the midthoracic region.
The remainder of the examination shows no abnormalities. Laboratory studies show:
Hemoglobin: 12.9 g/dL (N = 12-15.6 g/dL)
Hematocrit: 38.9% (N = 35-46%)
Serum Ca++: 11.5 mg/dL (N = 4.5-5.6 mg/dL)
Serum BUN: 12 mg/dL (N = 7-30 mg/dL)
Serum Creatinine: 0.9 mg/dL (N = 0.7-1.2 mg/dL)
Serum phosphorus: 2.9 mg/dL (N= 2.5-4.5 mg/dL)
Total protein: 7.2 g/dL (N= 6.0-8.5 g/dL)
Which of the following is the most likely diagnosis?
A- Ankylosing spondylitis
B- Hyperparathyroidism
C- Osteitis deformans (Pagets disease)
D- Osteomalacia
E- Osteoporosis

29
73- A 27-year-old woman is brought to the emergency department 30 minutes after being
involved in a motor vehicle collision. Physical examination shows exquisite tenderness of
the left upper extremity. An x-ray of the affected area is shown. This patient is at greatest
risk for injury of which of the following nerves?
A- Medial cutaneous: Klumpkes paralysis
B- Median: carpal tunnel or anterior wrist
(or Erbs paralysis)
C- Musculocutaneous
D- Radial
E- Ulnar: medial epicondyle or near the hook of
the hamate bone of the wrist.

In this question they might ask you about which

artery instead of which nerve is most likely
damaged. The answer would be deep brachial
(humeral) artery.

74- A 25-year-old man has bilateral arthritis of the sacroiliac joints, inflammation of the
shoulder joints, and early involvement of the lumbar spine. There is no rash,
subcutaneous nodules or urethritis. Which of the following is the most likely diagnosis?
A- Ankylosing spondylitis: bilateral sacroiliac pain + lumbar spine in a young man, pain
improves with exercise!
B- Gouty arthritis: podagra, single joint.
C- Juvenile rheumatoid arthritis: symmetric joint involvement, morning stiffness.
D- Osteoarthritis: in old people, affecting weight-bearing joints.
E- Psoriatic arthritis: stiffness, single joint, probably migratory, probably with skin
lesions.

30
75- A 22-year-old woman participates in a clinical study of a putative protein hormone that is
synthesized in the liver in response to a decrease in the blood platelet concentration.
Injection of the hormone causes an increase in platelet production. Which of the
following is the most likely location of the receptor that accounts for the increase in
platelet count?
A- In the cytoplasm of hepatocytes: what for?
B- In the cytoplasm of megakaryocytes: this is not a steroid or thyroid hormone!
C- In the nucleus of hepatocytes: this hormone is not fat-soluble
D- On the cell membrane of hepatocytes: what for?
E- On the cell membrane of megakaryocytes

31
76- A 37-year-old man comes to the physician because of severe back pain for 2 days. The
pain radiates down to the buttock, posterior thigh, and posterolateral leg. He also has
numbness on the side of his left foot. On physical examination, sensation to pain is
decreased over the lateral side of the left foot. Deep tendon reflexes are absent at the
left ankle, and there is weakness of dorsiflexion of the left foot. Compression of which of
the following nerve roots is the most likely cause of these findings?
A- T12
B- L2
C- L4
D- S1: this is disk herniation, MC in L4-L5 and L5-S1
E- S3

32
77- A 17-year-old boy is stabbed in the anterior axilla. He has loss of sensation on the
anterolateral surface of the forearm and loss of the biceps reflex. Which of the following
nerves is most likely to be damaged?
A- Axillary
B- Intercostobrachial
C- Lateral pectoral
D- Long thoracic
E- Medial antebrachial cutaneous
F- Medial brachial cutaneous
G- Medial pectoral
H- Median
I- Musculocutaneous : this is a repeated question.
78- A 16-year-old boy has pain in the right knee immediately after twisting it while playing
soccer. Examination shows excessive posterior sliding of the tibia when it is pushed
backward with the knee flexed (posterior drawer sign). Which of the following ligaments
is most likely injured?
A- Anterior cruciate: damage would be associated with positive anterior drawer sign.
B- Posterior cruciate
C- Coronary
D- Lateral collateral: positive varus (medial) stress test
E- Medial collateral: positive valgus (lateral) stress test
Remember the unhappy knee triad!

79- A 49-year-old man comes to the physician because of increasingly severe pain in his right
thumb during the past 2 days. He has a 10-year history of type 2 diabetes mellitus.
Physical examination shows swelling and erythema of the thumb. X-rays of the right
thumb show osteomyelitis at the arrows shown. Which of the following structures is most
likely affected by the pathologic process?
A- Adductor pollicis brevis muscle
B- Adductor pollicis muscle
C- Extensor pollicis longus tendon: posterior/dorsal
D- Flexor pollicis longus tendon: the arrows point toward
anterior/ventral aspect of phalanges
E- Muscular branch of median nerve

33

80- An 80-year-old woman comes to the physician because of a 10-year history of slowly
worsening pain in both knees. She has a 20-year history of hypertension and worked as a
housekeeper most of her adult life. Physical examination shows irregular bony
prominences around the tibial plateau at the knee joint line bilaterally and moderate
bilateral knee joint effusions. X-rays of the knees show thinned cartilage and extensive
osteophyte formation. Which of the following is the earliest stage in the development of
this condition?
A- Cracking of the cartilaginous surface
B- Marginal osteophyte proliferation: occurs after the cartilaginous cracking
C- Neovascularization
D- Seepage of articular fluid into the bone
E- Subchondral bone cyst formation: this is true, but occurs after the cracking
81- A 37-year-old man has numbness of the thenar eminence. Which of the following
findings will confirm the most likely diagnosis?
A- Atrophy of the interosseous muscles of the hand
B- Decreased strength during extension of the thumb
C- Decreased strength of opposition of the thumb: median nerve!
D- Loss of sensation to the skin covering the dorsum of the hand
E- Loss of sensation to the skin of the little finger: ulnar (+ loss of sensation in
hypothenar area, inability to adduct and abduct fingers and claw hand)
82- A 16-year-old boy participates in a study of exercise and muscle hypertrophy. After a pretraining biopsy of the quadriceps muscle is obtained, he begins a weight-lifting program
to increase the mass and strength of the quadriceps muscle. After 3 months of training, a
second muscle biopsy specimen is taken for histologic assessment of skeletal muscle
characteristics. Compared to the pre-training sample, the post-training sample is most
likely to show which of the following findings?
# of mitochondria
A- Increased
B- Increased
C- Increased
D- Increased
E- No change
F- No change
G- No change
H- No change

Amount of actin per myocyte

Increased
Increased
No change
No change
Increased
Increased
No change
No change

Total # of myocytes
Increased
No change
Increased
No change
Increased
No change
Increase
No change

Skeletal and cardiac myocytes are permanent cells, they can never replicate through
mitosis! Remember hypertrophy is due to increased number of actin and myosin.

34
83- A 25-year-old man is brought to the emergency department after falling and dislocating
his shoulder. Physical examination shows markedly extensible skin and hypermobile
joints. He is at increased risk for development of which of the following?
A- Acanthosis nigricans
B- Colonic angiodysplasia and hemorrhage
C- Hepatolenticular degeneration
D- Malignant melanoma
E- Osteopetrosis
F- Progressive multifocal leukoencephalopathy
G- Rupture of the colon and large arteries: Ehlers Danlos!
84- A 35-year-old man comes to his physician because of a 2-week history of muscle
weakness and a facial rash. Examination shows periorbital edema and red-blue
discoloration of the upper eyelids. There is bilateral proximal muscle weakness causing
the patient difficulty getting up from a chair and climbing steps. An antinuclear antibody
test is positive. Muscle biopsy shows perifascicular inflammation and muscle atrophy.
Which of the following is the most likely diagnosis?
A- Dermatomyositis: anti jo-1 antibodies
B- Polyarteritis nodosa: hepatitis B association, affects GI, brain, heart, skin, not lung
C- Polymyositis: anti jo-1 ANA antibodies, similar to dermatomyositis but no skin
involvement!
D- Systemic lupus erythematosus: no muscular weakness unless it is a mixed connective
tissue disorder (lupus + polymyositis +/- scleroderma)
E- Systemic sclerosis (scleroderma)
85- A molecular defect in the basement membrane components of skin will cause which of
the following skin conditions?
A- Chronic blistering: bullous pemphigoid!
B- Dry scaling skin: psoriasis (+ stratum corneun hyperplasia)
C- Keloid formation: excessive type III collagen production
D- Proliferation of cutaneous nevi
E- Thick cornified skin

35
86- A 17-year-old boy has anesthesia of the little finger and atrophy of the interosseous
muscles 3 weeks after receiving a violent blow to the anterior axilla while playing football.
Based on the diagram of the brachial plexus, which of the following labeled sites is most
likely to be injured?
The answer is D. There is ulnar nerve involvement, and D
is the origin of the ulnar nerve.

87- Which of the following structures are most likely found with the structures labeled I in
the photomicrograph?
A- Adhesion plaques
B- Gap junctions: the arrows point toward intercalated junctions, exclusive of cardiac
muscle cells that allow myocytes to behave as one single syncytium, which provide
electrical coupling/communication between cells.
C- Hemidesmosomes: skin and mucosa, help bind epidermis to dermis (integrin, collagen)
D- Myosin filaments
E- Tight junctions (zonulae occludens)

36
88- A 54-year-old man with alcoholism is brought to the emergency department because of a
10-day history of weakness, confusion, and shortness of breath. He drinks approximately
3 fourths of a liter of liquor daily. He appears wasted, and there is an odor of alcohol on
his breath. His respirations are 32/min. physical examination shows jaundice, abdominal
distention, spider angiomata, and tanner stage 2 gynecomastia. Laboratory studies show
hypoalbuminemia and an increased serum estrogen-to-androgen ratio. The development
of gynecomastia in this patient is mediated primarily by which of the following signal
transduction pathways?
A- Activation of phospholipase A2 and generation of arachidonic acid
B- Activation of phospholipase C and generation of inositol 1,4,5-triphosphate
C- G protein-coupled activation of adenylyl cyclase
D- Receptor dimerization and autophosphorylation of tyrosine residues
E- Transmembrane diffusion and binding of signaling molecule to transcription factor:
this is the mechanism for fat-soluble vitamins (A and D), thyroid hormones and steroid
hromones.
89- A 30-year-old woman has cervical pap smears showing cytopathic changes indicative of
human papilloma virus type 16 infection. Which of the following is the most likely longterm consequence?
A- Endometrial carcinoma
B- Papillary adenocarcinoma
C- Serous carcinoma
D- Small cell carcinoma
E- Squamous cell carcinoma
90- In this metabolic pathway a single enzyme catalyzes each step. Which of the following
enzymes is inhibited by aspirin?
The answer is B (COX 1/COX 2).
C would be zileuton (lipoxygenase
inhibitor)

37

91- A 20-year-old woman with anorexia nervosa lives at home with her parents. She has
secondary amenorrhea. Which of the following is the most important step in restoring
reproductive and endocrine function to normal?
A- Benzodiazepine therapy
B- Discouraging her parents involvement in her life
C- Encouraging her to gain weight: this would improve estrogen synthesis by increasing
FSH and LH release (via GnRH)
D- Helping her resolve conflicts over adult sexuality
E- Short course of estrogen replacement therapy: this will not resolve the problem.
92- Which of the following substances increases the secretion of insulin from the pancreas by
closing ATP-sensitive K+ channels and leading to cell depolarization, Ca++ channel
opening and insulin release?
A- Clonidine: central alpha2 agonist
B- Glyburide: sulfonylurea
C- Metformin: inhibits gluconeogenesis and increases glycolysis in liver, improves insulin
resistance. May lead to lactic acidosis.
D- Prednisone
E- Somatostatin: inhibits everything. Remember octreotide is its analog.
93- Clomiphene citrate, FSH, and menopausal gonadotropins are administered to a 32-yearold woman to induce folliculogenesis for an in vitro fertilization procedure. The oocytes
with responding antral follicles reinitiate meiotic development as they are released from
which of the following stages of meiotic arrest?
A- 1st meiotic prophase: diplotene (dictiotene) phase!
B- 1st meiotic metaphase
C- 1st meiotic telophase
D- 2nd meiotic prophase
E- 2nd meiotic metaphase (secondary oocyte, just after ovulation. Meiosis II is finished
after fertilization occurs)
F- 2nd meiotic telophase
94- Which of the following signaling mechanisms is used to transmit the effects of
triiodithyronine (T3)?
A- T3 binding activates a cell-surface adenylyl cyclase receptor
B- T3 binding activates a cell-surface guanylyl cyclase receptor: Natriuretic peptides
C- T3 binding activates the DNA binding activity of an intracellular receptor
D- T3 binds a G protein-coupled receptor on the cell surface: water-soluble
(hydrophobic) hormones
E- T3 binds a tyrosine kinase-linked receptor on the cell surface

38
95- A 52-year-old woman has menstrual irregularities, hot flashes, and emotional liability. In
this patient, decreased follicular hormone production has most likely resulted in an
increased serum concentration of which of the following substances?
A- Estrogen: this is supposed to be decreased, this is the cause of the symptoms!
B- Follicle-stimulating hormone (FSH): FSH decreases > than LH becase of decrease
negative feedback from estrogen!
C- Human chorionic gonadotropin (HCG)
D- Inhibin
E- Oxytocin
F- Progesterone
G- Prolactin
96- A state-mandated blood screening test conducted on day 2 of life in a healthy full-term
newborn shows a decreased serum total thyroxine (T4) concentration and a normal
serum thyroid-stimulating hormone (TSH) concentration. Tests on venous blood confirm
these findings. The venous free T4 concentration is normal. Which of the following is the
most likely explanation for these findings?
A- Dysgenesis of the thyroid gland: Total and free T4 will be decreased. TSH increased.
B- Hypopituitarism
C- Inborn error of thyroxine synthesis
D- Iodine deficiency
E- Thyroxine-binding globulin deficiency: always think about this option when total T4
is decreased but free T4 is normal. This could also occur in liver cirrhosis. Increased
total T4 with normal Free T4 is seen in pregnancy.
97- An increase in the serum concentration of which of the following is the most conclusive
sign that ovulation has occurred?
A- Androstenedione
B- Estradiol
C- Estriol
D- Luteinizing hormone: this is the answer If they ask you what hormone precipitates
ovulation! LH surge.
E- Progesterone
98- A 45-year-old man with hypertension is diagnosed with primary hyperaldosteronism.
Which of the following sets of physiologic changes is most likely in this patient?
Plasma renin activity
A-
B-
C-
D-
E-
F-
G-

Plasma K+ concentration

Extracellular fluid volume

39

99- During the differentiation of mammary gland alveolar cells in late pregnancy, the
hormone that acts synergistically with estrogen is which of the following?
A- ADH
B- Human chorionic gonadotropin
C- Human placental lactogen: estrogen is also synergistic
D- LH
E- Oxytocin: oxytocin is synergistic only after delivery of the baby! Works in milk
ejection by contracting areolar smooth muscle via Gq receptors.

100- This motif of a steroid hormone receptor binds specifically to which of the following
compounds?
A- ATP
B- cAMP
C- DNA: this is a zinc finger
motif, present in steroid
hormone intracellular
receptors. It is a
transcription factor!
D- RNA
E- Steroid hormone

101- A newborn has external genitalia that appear to be female. However, the vagina ends as a
blind pouch. Chromosomal analysis shows a 46, XY karyotype. Which of the following is
the most likely explanation for the physical findings?
A- Abnormal androgen receptors
B- Absence of the sex-determining region on the Y chromosome: if this was true, this
individual would have internal female genitalia.
C- Gonadal dysgenesis
D- Increased fetal concentration of estrogen
E- Increased fetal concentration of testosterone

40
102- A 55-year-old woman comes to the physician because of increased facial hair growth
over the past 8 years. Menopause occurred at age 45. Laboratory studies of serum
show:
Testosterone: 80 ng/dL (N= 20-90 ng/dL)
Dehydroepiandrosterone sulfate: 320 g/dL (N = 60-350 g/dL)
Estradiol: 20 pg./mL
Progesterone: decreased
Which of the following is the most likely cause of the increased facial hair growth?
A- Decreased 5alpha-reductase activity
B- Decreased adrenal androgen production
C- Decreased androstenedione peripheral conversion
D- Decreased inhibin production
E- Increased ovarian androgen production
F- Increased testosterone/estrogen ratio: androgens produced by adrenals and hilar
cells of ovary. Estrogen production severely deceased. Although some androgens may
be aromatized to be converted to estrogens.
103- A 19-year-old man is brought to the emergency department after hitting his head on
the pavement when he fell off his motorcycle. An MRI of his head shows a
transection of the pituitary stalk (which includes the dopaminergic tuberoinfundibular tract). Which of the following patterns best describes the secretion of
pituitary hormones in this patient?
ACTH
A-
B-
C-
D-
E-
F-

FSH

Growth hormone

Prolactin

TSH

This is a repeated question. If you destroy the stalk (or the hypothalamus), all
pituitary hormones will decrease, except for prolactin, because its dopaminergic
inhibition will be cut.

41
104- A 62-year-old woman is found to have a 3-cm, asymptomatic, cystic adnexal mass on
routine examination. Ultrasonography shows a simple cyst. Which of the following values
measured in serum is most likely to aid in determining the management of this patient?
A- CA-125: marker of ovarian neoplasms
B- CEA: marker of intestinal neoplasms, colon
C- Estradiol
D- Alpha-fetoprotein: marker of embryonal and yolk sac testicular/ovarian tumors and
hepatocarcinoma.
E- HCG: marker of choriocarcinoma, embryonal testicular tumor
105- A 68-year-old man experiences increasing urinary frequency and difficulty starting and
stopping his flow of urine. Examination of tissue obtained on biopsy of the enlarged
prostate confirms benign prostatic hyperplasia. Which of the following is the most likely
complication of his basic disease state?
A- Acute bacterial pyelonephritis: less likely than cystitis
B- Bacteremia
C- Bacterial cystitis: thats the closest thing to the prostate!
D- Chronic renal failure
E- Malignant transformation: never!
106- Four days after sexual intercourse, a 25-year-old man develops dysuria and a
mucopurulent urethral discharge. The urethral meatus is congested and edematous.
Examination of the discharge shows gram negative diplococci within neutrophilic
leukocytes. If this infection is not treated, which of the following is the most likely
complication?
A- Hemorrhagic cellulitis
B- Cystitis
C- Epididymitis
D- Orchitis: more likely with mumps infection
E- Pyelonephritis

42
107- A 12-year-old boy has had slowly progressive renal failure for the past 2 years. He is short
and pale. Blood pressure is 150/92 mm Hg. Serum Ca++ concentration is decreased, and
serum phosphate, BUN and creatinine concentrations are increased. X-rays of the bones
show subperiosteal erosions of the phalanges, osteopenia, and coarsening trabeculae.
Which of the following sets of laboratory findings in serum is most likely in this patient?
25-Hydroxycholecalciferol
1,25-dihydroxycholecalciferol
PTH
A

B (normal)

In renal failure, phosphate is retained causing hyperphosphatemia, which binds free

ionized Ca++ and causes hypocalcemia. The hypocalcemia induces PTH release which
damages bone. Failing kidneys produce less vitamin D.

108- A 40-year-old woman comes to the physician because of a 1-year-history of chronic low
back pain. Exercises to strengthen the abdominal muscles are recommended. Straight-leg
rising consists of raising both lower extremities while lying flat on her back. Which of the
following muscles is most directly involved in this exercise?
F- Erector spinae
G- Iliopsoas: most important flexor of the thigh.
H- Latissimus dorsi
I- Quadratus lumborum
J- Vastus medialis
109- A 55-year-old man comes to the physicians office because of a 2nd episode of acute
severe pain in his right big toe. Examination shows an erythematous, swollen, and
exquisitely tender right first metatarsophalangeal joint. Administration of which of the
following drugs is the most appropriate initial therapy?
A- Allopurinol: maintenance treatment
B- Colchicine: acute attacks! Indomethacin is another good choice.
C- Methotrexate
D- Probenecid: maintenance treatment
E- Propoxyphene
F- Tramadol

43
110- An 18-year-old woman, gravida 1, para 1, comes to the physician for a routine
postpartum examination. She says that she often has mild leakage even when she is not
ready to breast-feed her 6-week-old son. She reports that this symptom is particularly
severe whenever he begins to cry. The physician reassures her that this is an entirely
normal response. This reaction is most likely caused by psychogenic stimuli that promote
secretion of which of the following mediators?
A- Dopamine
B- Luteinizing hormone
C- Oxytocin
D- Progesterone
E- Prolactin
111- A 20-year-old woman who has had oligomenorrhea for 3 years has the sudden onset of
heavy vaginal bleeding. She is moderately obese and has increased amounts of hair on
the face, arms and legs. Examination of an endometrial biopsy specimen shows
hyperplasia without atypia. Laboratory studies show increased serum concentrations of
LH, androgens and estrogens; FSH concentration is decreased. Histologic examination of
the ovaries is most likely to show which of the following?
A- Mucinous cystadenomas
B- Multiple persistent corpora lutea
C- Multiple subcortical cysts lined by granulosa cells: polycystic ovarian syndrome!
D- Normal histology
E- Serous cystadenomas
112- Which of the following drugs given for the treatment of diabetes mellitus may result in
cardiotoxicity and lead to heart failure?
A- Ascarbose
B- Glyburide: hypoglycemia
C- Metformin: lactic acidosis
D- Repaglinide
E- Rosiglitazone
113- A 56-year-old man with alcoholism comes to the emergency because he is unable to raise
the fingers of his left hand (this is the same as finger extension). He is afraid that he has
had a stroke. He tells the physician that he fell asleep the night before at his favorite bar
with his arm across the arm of the chair. Which of the following nerves is most likely
affected in this patient?
A- Brachial
B- Median
C- Musculocutaneous
D- Radial
E- Ulnar

44
114- An experimental animal is treated with an agent that disrupts desmosomes (maculae
adherens). Which of the following is most likely to be decreased?
A- Cohesion of epidermal cells to the basal lamina: hemidesmosomes, bullous
pemphigoid
B- Cohesion between adjacent keratinocytes: pemphigus vulgaris
C- Number of melanocytes
D- Proliferation of keratinocytes
E- Thickness of the stratum corneum
115- A 12-year-old boy has had persistent pain in the arm since he fell while playing basketball
2 weeks ago. His left deltoid muscle is paralyzed, and he is unable to hold his left arm in
abduction against resistance. Which of the following bones is the most likely site of a
fracture?
A- Acromion
B- Clavicle
C- Coracoid process
D- Deltoid tuberosity
E- Radius
F- Shaft of the humerus
G- Surgical neck of the humerus: there is damage to the axillary nerve!
H- Ulna
116- An obese 52-year-old woman comes to the physician because of vaginal bleeding. Her
last normal menstrual period occurred 6 months ago. Biopsy shows endometrial
hyperplasia. This endometrial stimulation is most likely due to peripheral aromatization
of which of the following hormones?
A- Aldosterone
B- Androstenedione
C- FSH: cannot be aromatized
D- LH: same as FSH
E- Progesterone: progesterone is not aromatized to estrogens!
117- A 56-year-old woman comes to the physicians office for her 1st health maintenance
examination in the past 5 years. She has a 2 x 2.5 cm lesion 4cm from the nipple in the
outer upper quadrant of her left breast. The lesion is nontender and nonmobile and has
ill-defined borders. There is no discharge on compression of the nipple. Which of the
following is the most likely explanation for these findings?
A- Adenocarcinoma
B- Benign lymph node enlargement: no lymph nodes over there.
C- Fibroadenoma: mobile, grows during menstrual cycles, single breast. Common during
reproductive ages.
D- Fibrocystic disease: multiple, bilateral masses that enlarge and become painful during
menstrual cycles.
E- Metastatic carcinoma

45

118- A 54-year-old woman comes to the physician because she has noticed that the front of
her neck appears swollen. Serum thyroxine (T4) concentration is 16 g/dL (N = 4.5-12),
and serum thyroid-stimulating hormone (TSH) concentration is 0.1 U/mL (N = 0.5-4.7).
Which of the following is the most likely diagnosis?
A- Cretinism
B- Diffuse toxic goiter (Graves disease)
C- Myxedema
D- Simple goiter
E- Thyroiditis
119- Female pseudohermaphroditism is most often due to a deficiency of which of the
following enzymes involved in cortisol biosynthesis?
A- 20,22-desmolase
B- 17alpha-hydroxylase
C- 18-hydroxylase
D- 21-hydroxylase
E- 3beta-hydroxysteroid dehydrogenase
120- Norepinephrine stimulation of Gq proteins results in an increased intracellular
concentration of Ca++. Which of the following is the most likely cause of the increased
intracellular calcium concentration?
A- Arachidonic acid
B- cAMP
C- cGMP
D- 1,2-Diacylglycerol
E- Inositol 1,4,5-triphosphate: Ca++ and diacylglycerol activate protein kinase C