1-

A 71-year-old woman with temporal arteritis has had fever, malaise, and stiffness in her
shoulders and hips over the past 3 weeks. Which of the following Is the most likely
diagnosis?
A- Fibrositis
B- Polymyalgia rheumatica: commonly associated with temporal arteritis!
C- Polymyositis: Proximal muscle involvement + anti Jo1 ANAs
D- Rheumatoid arthritis: symmetrical, deforming joint pain (metacarpophalangeal,
proximal interphalangeal) with morning stiffness. Rheumatoid factor (anti Fc region
of IgG).
E- Sjgren syndrome: arthritis, parotitis, conjunctivitis.

2-

A 54-year-old man comes to the physician because of a 3-month history of severe pain
that radiates from his right thigh to the bottom of his right foot. He has a 1-year history of
chronic low back pain. Use of ibuprofen has not relieved the pain. Sensation to pinprick is
decreased over the lateral aspect and plantar surface of the right foot. There is
diminished strength of right foot plantar flexion. Which of the following is the most likely
cause of this patients condition?
A- Intervertebral disc herniation: sciatic nerve root impingement! This is a typical clinical
presentation!
B- Sacrococcygeal teratoma: sacral lump in a young child (baby). Derivative of the
primitive streak
C- Sacroiliitis: Ankylosing spondylitis (bilateral sacroiliitis + vertebral involvement), HLAB27!
D- Transverse myelitis: usually post-infectious, leads to spinal cord damage at many
levels.
E- Vertebral body compression fracture: this would appear suddenly with pain in
vertebral column, and would be most likely associated with strain.
F- Vitamin B12 deficiency

3-

A 65-year-old woman comes to the physician because of intermittent vaginal bleeding

during the past 3 months. Menopause occurred 10 years ago. She has one child, but she
had difficulty conceiving because of a history of polycystic ovarian disease. She is 163 cm
(5 ft 4 in) tall and weighs 91 kg (200 lb); BMI is 34 kg/m2. Pelvic examination shows a
normal-appearing cervix. Bimanual examination is limited by the patients obesity, but
there appears to be no abnormalities. This patient most likely has which of the following
types of cancer?
A- Cervical: may be asymptomatic, in young women, may lead to post-coital bleeding.
B- Endometrial: remember, painless bleeding in a postmenopausal woman! Endometrial
Hyperplasia or cancer!
C- Fallopian tube
D- Ovarian: not associated with bleeding, unless it is a granulosa tumor, which produces
estrogens which may precipitate hyperplasia.
E- Vaginal

4-

A 17-year-old girl comes to the physician because of severe abdominal pain and irregular
menstrual bleeding for 2 days. Menarche occurred at the age of 14 years. Her last regular
menstrual period was 4 weeks ago. She is sexually active and uses depot
medroxyprogesterone for contraception. She was treated for gonorrhea last year, and
she had an elective abortion 4 months ago. Abdominal examination shows tenderness,
decreased bowel sounds, and guarding. A diagnosis of ectopic pregnancy is considered.
Which of the following is the strongest predisposing risk factor for this condition?
A- Adolescent age
B- Congenital anomaly of the uterus
C- History of abortion
D- History of gonorrhea: this will cause fibrosis of fallopian ducts!
E- Use of depot medroxyprogesterone

5-

Which of the following is the role of Iodine in the biosynthesis of thyroxine (T4)?
A- It activates a membrane transporter that increases the import of tyrosine
B- It is added to tyrosine residues in thyroglobulin in the first step of T4 biosynthesis
C- It is covalently bond to free tyrosine to form T4
D- It is an essential cofactor for thyroid peroxidase

6-

Cyclic AMP-dependent protein kinases are activated by which of the following

mechanisms?
A- Association of the catalytic subunits to form active dimers on binding to cAMP
B- Association of the catalytic subunits with the regulatory subunits that are bound to
cAMP
C- Binding of cAMP to the regulatory subunits, which releases the catalytic subunits
D- Binding of cAMP to both the regulatory and catalytic subunits
The catalytic subunits of any enzyme only bind their substrates (hexokinase: glucose),
never regulatory (activator or repressor) molecules!

7-

A 67-year-old woman comes to the physician because of an 18-month history of

progressive persistent left hip pain. The pain is characterized as boring and aching. It is
not relieved by rest and worsens with ambulation. She walks with a limp because of the
pain. She has become hard of hearing (Cranial nerve impingement) over the past 5.
There is also pain and limited range of motion of the left hip with flexion and external
rotation. Serum Ca++, phosphate and PTH concentrations are within the reference range.
Serum alkaline phosphatase activity is markedly increased, and urinary hydroxyproline
excretion is increased. Which of the following is the most likely diagnosis?
A- Osteitis deformans (Pagets disease)
B- Osteoarthritis: Normal alkaline phosphatase, pain in weight-bearing joints that
worsens with use.
C- Osteomalacia: in this case, this woman would have a risk factor (steatorrhea)
D- Osteomyelitis: acute localized bone pain + fever
E- Osteoporosis : fractures, compression fractures (MC in vertebral column, sudden pain)

8-

A 17-year-old boy has chronic renal insufficiency. His serum BUN and creatinine
concentrations are increased, and his serum calcium is decreased. Which of the following
is most likely responsible for the development of hypocalcemia in this patient?
A- Decreased secretion of PTH: increases because of the hyopocalcemia
B- High concentration of PTH-rp: absent. Seen in paraneoplastic syndromes (squamous
cell carcinoma of lung)
C- Hyperphosphatemia: excess phosphate binds free ionized Ca++
D- Increased secretion of calcitonin: would lead to hypercalcemia
E- Vitamin D toxicity: Hypercalcemia

9-

Genetic screening shows that a newborn with a 46, XY karyotype has a disabling mutation
of the 5alpha-reductase gene. Which of the following best describes this newborns
genital system?
A- Female external genitalia and female genital ducts
B- Female external genitalia and male genital ducts: pseudohermaphroditism!
C- Female external genitalia and male and female genital ducts
D- Male external genitalia and female genital ducts
E- Male external genitalia and male genital ducts
F- Male external genitalia and male and female genital ducts

10- A 31-year-old man comes to the physician because of a decreased libido. He had a viral
orchitis 6 months ago. Physical examination shows gynecomastia and testicular atrophy.
Which of the following drugs is most appropriate for long-term management of this
condition?
A- Danazol: may have androgenic effects, but still inferior to testosterone.
B- Gonadotropin-releasing hormone: LH and FSH are already elevated due to testicular
atrophy, this would be useless, or could worsen the condition by increasing estrogen
synthesis.
C- Human chorionic gonadotropin: what for?
D- Sildenafil: would probably improve his erections, but would not increase his libido or
resolve the gynecomastia!
E- Testosterone

11- A 45-year-old man is diagnosed with a somatostatin-producing tumor. Which of the

following sets of physiologic changes is most likely in this man?
Insulin secretion
A
B
C
D
E
F
G
H

Gastric motility

Glucagon secretion

Remember, somatostatin decreases everything: in this case, Gastrin, insulin and

glucagon. This man has a pancreatic somatostatinoma (tumor of cells). There will be
achlorhydia (gastrin inhibition), hyperglycemia, diabetes (inhibition of GIP and
insulin), steatorrhea (secretin and cholecystokinin inhibition), and predisposition to
gallstones (cholecystokinin inhibition)
Other important pancreatic tumors:
Adenocarcinoma of head of pancreas: may obstruct bile duct and cause cholestasis
(conjugated hyperbilirubinemia, jaundice, acolic feces, dark urine, itching),
Courvoisier's sign: palpable, nontender gallbladder.
Pancreatic insulinoma: tumor of beta cells, Causes hyperinsulinemia (hypoglycemia,
tachycardia, sweating, anxiety) with increased C-peptide. Part of MEN I.
Pancreatic VIPoma: episodes of watery diarrhea, flushing, aclorhydria, hypokalemia,
normal anion gap metabolic acidosis.
Glucagonoma: tumor of alpha cells. Hyperglycemia, necrolytic migratory erythema

12- Triiodothyronine (T3) is more potent than thyroxine (T4) for the treatment of
hypothyroidism because of which of the following?
A- Active transport into target cells
B- Greater accumulation in mitochondria
C- Greater receptor affinity
D- Higher oral bioavailability
E- Longer plasma half-life

13- A 27-year-old man has a blood pressure of 160/98 mm Hg. He is not taking any
medications. Findings of physical examination are unremarkable. Laboratory studies
show hypokalemia. A form of secondary hypertension is suspected. Findings on urinalysis
and renal function tests are unremarkable. Which of the following types of drugs is the
most appropriate therapy for the hypertension and hypokalemia?
Dx: primary hyperaldosteronism (Conns syndrome)
ABCDEF-

Alpha-adrenergic blocking agent

Aldosterone antagonist: spironolactone (also has androgenic properties)
Calcium channel blocking agent
Sympatholytic agent
Thiazide diuretic
Vasodilator

14- A 45-year-old woman has weakness in the anterior thigh and is unable to extend her leg
at the knee. Flexion of the hip and knee is normal. Sensation is absent in the anterior
thigh and on the medial side of the leg. Which of the following nerves is most likely
injured?
A- Common peroneal: loss of sensation over the lateral aspect of the leg and foot, loss of
dorsiflexion and eversion of the foot, loss of dorsiflexion of toes, anesthesia over
dorsal foot, abnormal gait! MCC or lesion: trauma involving neck of fibula. Very high
yield!
B- Femoral: loss of patellar reflex
C- Lumbosacral trunk: forget about this one.
D- Obturator: anesthesia over medial thigh and knee.
E- Tibial: loss of plantar flexion of foot and toes, and inversion of foot. Probably absent
Achilles tendon reflex.
15- A 16-year-old boy is brought to the physician because he is much shorter than his peers.
He is proportionally develop and otherwise healthy. An x-ray of the wrist is
recommended to assess bone age. Which of the following radiographic findings will be an
indication that his growth is complete?
A- Absence of the epiphyseal cartilaginous plate
B- Absence of the primary ossification center
C- Presence of calcified material in the diaphysis
D- Presence of calcified material in the epiphysis
E- Presence of lines of arrested growth

16- An otherwise healthy 48-year-old woman comes to the physician because of a change in
her menstrual pattern. Her last normal menstrual period was 4 months ago, and she
noticed scant staining 3 weeks ago. Her history is otherwise unremarkable. Physical
examination shows vaginal dryness. Laboratory evaluation is most likely to show which of
the following changes in serum hormone concentrations?
A- Decreased FSH and LH
B- Decreased prolactin
C- Decreased thyroxine (T4)
D- Increased FSH and LH: this woman is having menopause. Decreased estrogens will
result in lost negative feedback over pituitary FSH and LH, and therefore, they will
increase!
E- Increased prolactin
17- A 1-year-old child has unilateral cryptorchidism. Even if this problem is surgically
corrected, the patient will be at increased risk for development of which of the following
in the cryptorchid testis?
A- Germ cell neoplasm: seminoma, for example!
B- Leydig cell tumor
C- Recurrent orchitis
D- Spermatocele
E- Testicular torsion
18- A 33-year-old woman, gravida 2, para 1, at term, gives birth to a 4167 g (9lb 3 oz) male
newborn by t spontaneous 30-minute vaginal delivery. Shortly after delivery of the
placenta, there is a brisk flow of blood from the uterus. Manual palpation of the uterine
cavity shows a large fragment of retained placental material. Curettage shows a fibrous
nodule of placental tissue that is firmly adherent to the uterine wall. Which of the
following is the most likely cause of the bleeding in this patient?
A- Abruptio placentae: painful bleeding during the 3rd trimester, the lower abdomen is
very stiff (hard uterus due to contractions) and tender. May lead to DIC.
B- Choriocarcinoma: malignant trophoblastic neoplasm, may be related to moles.
C- Factor XIII deficiency
D- Granulomatous endometriosis: foul-smelling vaginal discharge.
E- Placenta accreta: Placenta is attached to myometrium! It is not delivered, cannot be
removed, and leads to bleeding. Deeper invasion to myometrium: perccreta. Even
deeper invasion, involving or surpassing the serosa: inccreta.
F- Placenta previa: painless bleeding during 3rd trimester, before labor! Placenta is
attached near to or above the internal os.

19- A 55-year-old man has had decreasing interest in sex over the past 2 years and impotence
for the past 6 months. He has frequent headaches. Examination shows bitemporal visual
field defects, sparse facial and pubic hair, and testicular atrophy. MRI shows a 3-cm
pituitary tumor. Which of the following sets of serum hormone concentrations is most
likely?
Luteinizing hormone (LH)
A- Decreased
and this decreases LH and FSH
B- Decreased
C- Normal
D- Increased
E- Increased

Testosterone
Decreased: prolactinoma, prolactin GnRH
Increased
Normal
Decreased
Increased: testicular atrophy

20- A 6-month-old male infant is sluggish and appears edematous. He has coarse immature
facies, poor muscle tone, omphalocele and jaundice. Which of the following is the most
likely diagnosis?
A- Trisomy 13: cleft lip, cleft palate, rocker bottom feet.
B- Trisomy 18: clenched fists, rocker bottom feet
C- Congenital hypothyroidism
D- Physiologic neonatal jaundice: this is not a neonate!
E- Hydrops fetalis: this is not a fetus!
21- A 17-year-old boy is brought to the emergency after being injured in a football game. He
appears to have dislocated his elbow and is unable to adduct and abduct his fingers
(paralysis of interoseous muscles) . Which of the following nerves is most likely injured?
A- Axillary
B- Median
C- Musculocutaneous
D- Radial
E- Ulnar

22-

A 26-year-old woman who Is a marathon runner comes to the physician because of a 6month history of intermittent knee pain that is usually exacerbated by her participation in
a race. Physical examination shows no abnormalities. The structure indicated by the
arrow on the normal MRI shown is injured. Which of the following structures is most
likely injured?
A- Anterior cruciate ligament
B- Lateral meniscus
C- Medial meniscus
D- Popliteal artery
E- Popliteal vein
F- Posterior cruciate ligament

23- A 17-year-old girl has had general malaise and progressive intermittent pain in the knees
over the past 6 weeks. She has a history of mouth ulcers. She is using hydrocortisone
cream to treat a rash on her cheeks that extends to the bridge of her nose. She is not
sexually active. Physical examination is unremarkable. Laboratory studies show:
Hemoglobin: 7.2 g/dL
Hematocrit: 31%
Leukocytes count: 21,000/mm3
Platelet count: 37,000/mm3
Which of the following is the most likely diagnosis?
A- Gonococcal arthritis
B- Juvenile rheumatoid arthritis
C- Lyme disease
D- Psoriatic arthritis
E- Reiter syndrome
F- Systemic lupus erythematosus

24- A 25-year-old woman is attempting to conceive. A urinary LH kit detects a gonadotropin

(LH) surge on the 1st morning void of the 15th day of her menstrual cycle. How soon after
this event would it be feasible to detect human chorionic gonadotropin in her serum if
conception occurs?
A- That day
B- 2 days later
C- 4 days later
D- 8 days later: the blastocyst is implanted on the uterus 7 days after fertilization!
E- The 12th day of her next cycle
25- A 60-year-old post-menopausal woman comes to the physician because of back pain for 3
months. Her mother and her sister both had breast cancer. Physical examination shows
mild tenderness over the lumbar vertebrae. An x-ray of the spine is obtained and shows
evidence of a disease process. A photograph representative of a similar condition is
shown. To avoid stimulatory effect on the breast or endometrium, treatment of this
condition with which of the following drugs is most appropriate for this patient?
A- Danazol
B- Ethinyl estradiol
C- Mifepristone
D- Raloxifene: agonist in bone, antagonist in
breast and endometrium (uterus).
E- Tamoxifen: agonist on bone (good),
agonist in uterus (very bad, may lead to
hyperplasia), antagonist in breast: good.
So this is not the best choice at all!

26- A 2-year-old girl is brought to the physician for a routine examination. She is below the 5th
percentile for height and weight. Physical examination shows no other abnormalities.
Genetic screening shows a new mutation in the ADH-2 receptor. Water is restricted for
12 hours to test the functional significance of the mutation. At the end of the 12 hours,
which of the following sets of laboratory findings is most likely to confirm a loss of
function defect in the vasopressin-2 receptor?
Serum ADH
Serum Osmolarity (mOsmol/kg)
Urine osmolarity (mOsmol/kg)
A- Decreased
Decreased
200
B- Decreased
Decreased
600
C- Decreased
Increased
200
D- Decreased
Increased
600
E- Increased
Decreased
200
F- Increased
Decreased
600
G- Increased
Increased
200
H- Increased
Increased
600
No one answered this question right. If the ADH receptor 2 (Renal. V1 = vascular). This is a
case of neprogenic diabetes insipidus! If the receptor is insensitive to ADH (vasopressin),
then the individual is going to have a large volume of hypotonic (low osmolarity = low
solute concentration) urine. Therefore, plasma osmolarity increases. This increases ADH
release. As you are eliminating lots of hypotonic urine, your urine osmolarity must be
decreased (below 300, usually way below that).
Nephrogenic diabetes insipidus: due to Gs component of V2 ADH receptor. Kidneys are
insensitive to ADH. ADH: , Plasma osmolarity: , Urine osmolarity: . Water
deprivation test: no change in urine osmolarity. Response to ADH administration (nasal
desmopressin): no response. Causes: lithium, demeclocycline.
Central diabetes insipidus: Due to loss of ADH (hypothalamic damage). Kidneys are
normal. ADH: , plasma osmolarity: . Water deprivation test: no change in urine
osmolarity. Response to ADH administration: there is response (urine osmolarity
increases). Causes: Head trauma, tumors.

27- A 14-year-old boy with type 1 diabetes mellitus is brought to the emergency department
comatose. Despite administration of fluids and insulin, his blood pressure decreases, and
he goes into cardiac arrest. Laboratory studies at time of admission show:
Serum Na+: 145 mEq/L
Serum Cl-: 101 mEq/L
Serum k+: 3 mEq/L
Serum HCO3-: 12 mEq/L
Serum Glucose: 350 mg/dL
Serum Acetone: 3 mg/dL (N = 0)
Arterial pH: 7.2
Which of the following substances in the blood is most likely involved in the cardiac
arrest?
A- Acetone: only importance of this compound is the fruity odor in people with DKA.
B- ClC- HCO3D- K+
E- Na+

28- A 42-year-old woman has fatigue, arthralgias, and vague abdominal pain. She has a
history of recurrent kidney stones. Laboratory studies show:
Serum Ca++: increased
Serum phosphorus: decreased
Parathyroid hormone (PTH): increased
Alkaline phosphatase: normal
Urine Ca++: increased
Which of the following is the most likely site of the underlying pathologic process?
A- Breast
B- Hypothalamus
C- Kidney
D- Ovary
E- Parathyroid
F- Thyroid

29-

A 63-year-old woman with a 5-year-history of type 2 diabetes mellitus comes to the

physician for a routine examination. She notes that her blood glucose concentration has
been persistently higher over the past 4 months since she gained 9 kg (20 lb) during the
holidays. Her diabetes mellitus has been more difficult to control because weight gain
causes which of the following to occur?
A- Downregulation of insulin receptors: very important!
B- Increased activity of hepatic glucokinase
C- Increased expression of GLUT-4 transporters: on the contrary.
D- Inhibition of insulin release
E- Upregulation of insulin signaling

30- A 51-year-old man comes to the physician because of fatigue, weakness, and joint pain
for the past 5 days. For the past 9 months, he has been taking 10 mg of prednisone daily
for severe rheumatoid arthritis. He tells the physician that he misplaced his medication
last week and did not have it replaced. Which of the following mechanisms is most likely
responsible for the development of these symptoms in this patient?
A- Adrenal atrophy due to suppression of ACTH secretion: exogenous steroids inhibit
ACTH release in the same manner as endogenous steroids!
B- Decreased conversion of cortisone to hydrocortisone
C- Downregulation of glucocorticoid receptors in target cells
D- Increased clearance of endogenous adrenal steroids
E- Increased concentrations of plasma corticosteroid-binding globulin
31- The epidermal growth factor receptor and the platelet-derived growth factor receptor
are both classified as which of the following?
A- Calcium-dependent protein kinases
B- cGMP receptors
C- JAK/STAT kinases: cytokines, growth hormone.
D- Receptor guanylyl cyclases: Natriuretic peptides
E- Receptor serine/threonine kinases
F- Receptor tyrosine kinases: growth factors, insulin, IGF.

32- Following a traumatic injury, a 25-year-old man has loss of abduction (supraspinatum,
deltoid), lateral rotation (Infraspinatum), and flexion of the arm (deltoid); loss of flexion
at the elbow (biceps, brachial); and loss of supination of the forearm (biceps). X-rays
show no fractures. A lesion of
which of the following labeled
structures on the diagram best
explains these findings?
The answer is A: Median
(innervates anterior flexors of
forearm), musculocutaneous
(anterior flexors of arm), axillary
(deltoid) and suprascapular
nerves (infraspinatum and
supraspinatum muscles) affected.
This is Erb-duchenne paralysis.
E would damage the ulnar (anesthesia in hypothenar area, claw hand, inability to adduct
and abduct fingers) the median, the brachial and antebrachial medial cutaneous nerves
(anesthesia in medial arm and forearm)

33- Which of the following actions is most likely to be severely impaired if a nerve is injured
by a fracture at site X in the x-ray?
A- Dorsiflexion of the foot: remember, the common
peroneal (fibular) nerve is in contact with the neck of
the fibula!
B- Extension of the leg: femoral
C- Flexion of the leg: tibial division of sciatic nerve
D- Inversion of the foot: tibial
E- Plantar flexion of the foot: tibial

34- A 42-year-old woman has a 3-month history of an intermittent reddish-brown discharge

from the nipple of her right breast. No masses are palpable in either breast. There is no
pain or tenderness. Which of the following is the most likely diagnosis?
A- Fibroadenoma: unilateral, mobile mass that enlarges during menstrual cycles.
B- Fibrocystic disease: bilateral, multiple masses that enlarge and become painful during
menstrual cycles.
C- Intraductal papilloma
D- Lobular carcinoma: bilateral breast cancer.
E- Mastitis: irritation of nipple in a breast-feeding woman.
F- Traumatic fat necrosis
35- A 61-year-old woman has a 10-year history of progressive pain in the hips, knees and
hands. She has symmetric swelling and formation of nodules in the distal interphalangeal
joints of her hands and pain on movement of both knees. There is no increased warmth
or tenderness. The most likely cause of her joint pain is:
A- Gout: podagra, single joint involvement. Needle-shaped, negatively-birefringent
crystals on synovial fluid analysis.
B- Lyme disease: single joint, chronic pain.
C- Osteoarthritis: take a look at the age of this woman!
D- Pseudogout: large joints (knee), no nodules, no stiffness, no podagra. Positivelybiregringent rhomboid crystals on synovial fluid examination.
E- Rheumatoid arthritis: there is no morning stiffness! This condition doesnt involve
distal interphalangeal joints.
36-

An 18-year-old man has nausea, vomiting, headache, a temperature to 39.4 C (103 F), and
painful swelling of the parotid glands. He is at increased risk of:
A- Appendicitis
B- Arthritis
C- Cystitis
D- Episcleritis
E- Orchitis: parotitis may lead to orchitis.

37- A child born without limbs is found to have a mutation in a receptor for a fibroblast
growth factor. The absence of limbs most likely resulted from a disruption of the process
controlling which of the following?
A- Apoptosis
B- Differentiation
C- Epithelial-mesenchymal conversions
D- Proliferation

38- A 38-year-old woman has noticed the gradual development of a goiter. Thyroid function
studies show serum thyroxine (T4) and triiodothyronine (T3) concentrations to be within
the reference range. Serum concentration of thyroid stimulating hormone (TSH) is slightly
increased. The serum contains a high level of antimicrosomal (antiperoxidase) antibodies,
but no thyroid-stimulating hormone receptor antibodies are detected. The most likely
diagnosis is:
A- Autoimmune (Hashimotos) thyroiditis
B- Diffuse toxic goiter (Graves disease)
C- Primary atrophy of the thyroid gland
D- Riedels struma
E- Subacute thyroiditis
39- Which of the following enzymes acting on phosphatidylcholine will directly generate
diacylglycerol?
A- Hormone-sensitive lipase: Present in cytoplasm of adipocytes, degrades stored
triglycerides to release free fatty acids to bloodstream, which will be transported by
albumin. Activated by epinephrine and cortisol.
B- Lipoprotein lipase: present in adipose tissue capillaries, degrades triglycerides
transported by chylomicrons and VLDL
C- Pancreatic lipase: Pancreatic enzyme that degrades triglycerides
D- Phospholipase C: generates diacylglycerol and IP3
E- Sphingomyelinase: deficient in Nieman-Picks disease
F- Phospholipase A2: removes arachidonic acid from cell membranes
40- A 5-month-old male infant develops lethargy, somnolence, hypothermia, feeding
problems and a persistent jaundice. After several days, he develops a hoarse cry and
hypotonic muscles. The tongue is large and protruding, and an umbilical hernia is noted.
Hematologic evaluation shows no abnormalities. A karyotype is performed and results
are normal. Which of the following abnormalities is most consistent with these findings?
A- Agenesis of the parathyroid glands
B- Congenital adrenal hyperplasia
C- Maternal diffuse toxic goiter (Graves disease)
D- Thyroid hypoplasia: MCC (along with dysgenesis) of congenital hypothyroidism
E- Trisomy 21

41- An obese 62-year-old woman is brought to the emergency department in a coma by

emergency medical technicians. The technicians report that she said she had palpitations
and double vision before becoming unresponsive 10 minutes ago. A medic alert bracelet
shows that she has hypertension and type 2 diabetes mellitus. A number of prescription
drugs are found in her purse. Serum glucose concentration is 50 mg/dL. Which of the
following drugs is the most likely cause of the hypoglycemia?
A- Ascarbose
B- Captopril
C- Digoxin
D- Glyburide
E- Methyldopa
42- A 28-year-old woman is undergoing evaluation at 37 weeks gestation. Blood pressure is
120/75 mm Hg sitting, 115/70 mm Hg standing, and 90/60 mm Hg supine. The most likely
explanation for these findings is:
A- Compression of the vena cava: venous return decreases, stroke volume decreases.
B- Gestational diabetes mellitus
C- Peripartum cardiomyopathy
D- Preeclampsia
E- Uterine contraction

43- A 16-year-old girl is evaluated because she has not yet had a menstrual period. She is 147
cm (4ft 10 in) tall and weighs 42 kg (93 lb). breast development is Tanner stage 1 of 5 and
pubic hair growth is Tanner stage 2 of 5, respectively. She has a low hairline, short 4th
metacarpals bilaterally, and multiple pigmented nevi. A cervix is seen on pelvic
examination. Laboratory studies show an increased serum FSH concentration. Serum TSH
and prolactin concentrations are within the reference ranges. Which of the following is
the most likely diagnosis?
A- Androgen insensitivity syndrome: no internal female genitalia (no cervix), vagina ends
in a blind pouch, testes may be palpated in inguinal area.
B- Gonadal dysgenesis 45,X (Turners syndrome)
C- Gonadotropin-secreting pituitary tumor
D- Isolated gonadotropin deficiency
E- Paramesonephric aplasia

44- A 30-year-old woman is brought to the emergency department because of pain in the
upper arm after falling of a horse. X-ray films show a closed simple fracture of the upper
humerus. Serum studies 3 weeks later are most likely to show an increased concentration
of:
A- Alkaline phosphatase
B- Calcium: no change
C- Creatine kinase
D- Gamma glutamyltransferase: remember this is the enzyme that allows you to know if
the elevated levels of alkaline phosphatase are due to biliary tract/liver disease
instead of bone disease. Also very sensitive indicator of alcohol use.
E- Phosphorus

45- Eukaryotic proteins that exist as a nonmembrane-associated, glycosylated, disulfidelinked dimer in the mature form are generally found in which of the following?
A- Cytoplasm
B- Extracellular space: collagen
C- Mitochondrial matrix
D- Nuclear matrix
E- Nuclear pore
46- A 20-year-old man has a painless 2-cm nodule in his right scrotum. The nodule is difficult
to distinguish from the right testis and does not transilluminate. There is no additional
swelling or inguinal adenopathy. The most likely diagnosis is:
A- Cryptorchidism
B- Hydrocele
C- Scrotal cyst
D- Testicular cancer
E- Testicular torsion
F- Varicocele
47- A 62-year-old man develops numerous superficial blisters over the scalp, face, groin, and
trunk. New lesions develop over areas subjected to minimal trauma. Biopsy of one of the
lesions shows an intraepidermal blister with suprabasal acantholysis. Serologic studies
are likely to show an autoantibody directed against which of the following?
A- Anchoring filaments
B- Basement membrane proteins: same as D
C- Desmosomal proteins
D- Hemidesmosomal proteins: dermal-epidermal immunofluorescence
E- Integrins: same as D

48- A 14-year-old girl is brought to the physicians office by her mother who is concerned that
the girl has not begun to menstruate. Physical examination shows normal breast
development, no pubic hair, normal female external genitalia, bilateral inguinal hernias, a
vagina that ends in a blind pouch, and no palpable uterus or ovaries. Ultrasound
examination confirms the absence of internal female genitalia. The underlying problem in
this patient is related to which of the following?
A- Defective androgen receptors
B- Excess production of fetal estrogen
C- Excess production of fetal progesterone
D- Insufficient fetal testosterone production
E- Insufficient production of paramesonephric inhibitory factor during fetal life: in this
case, the individual would have internal female genitalia
49- A 10-year-old boy with asthma has been receiving oral hydrocortisone daily in increasing
doses for the past 2 years. He is obese and has growth retardation an edema of his lower
limbs. Which of the following is the most likely explanation for the edema?
A- The drug binds both glucocorticoid and mineralocorticoid receptors
B- The drug is converted to a mineralocorticoid in the liver
C- Pulmonary production of angiotensin is increased
D- Renin activity is increased because of stress
E- Secretion of ADH (vasopressin) is increased because of stress
50- Benign prostatic enlargement causes a characteristic impression on the urinary bladder in
which area of the cystogram?

The answer is B. That is the posteriorinferior aspect of the bladder, just

posterior to the prostate.
A is posterior upper border.
C is apex.
D is roof.

51- Sulfonylureas promote the release of insulin from pancreatic beta cells through which of
the following factors?
A- Inhibition of ATP-sensitive K+ channels
B- Inhibition of Na+/K+ ATPase: digitalis (glycosides)
C- Inhibition of voltage-sensitive Ca++ channels
D- Stimulation of guanylyl cyclase: Nitric oxide and natriuretic factors
E- Stimulation of phosphodiesterase
52- A 20-year-old man ingests 1 L of water over 1 hour. Which of the following sets of
changes is most likely at the end of the hour?
Plasma ADH (Vasopressin)
A- Increased
B- Increased
C- Increased
D- Increased
E- Decreased
F- Decreased
G- Decreased

Urine osmolarity
Increased
Increased
Decreased
Decreased
Decreased
Increased
Increased

Urine flow
Increased
Decreased
Decreased
Increased
Increased
Increased
Decreased

Only one person answered this question right. Drinking 1 L of water over 1 hour
increases plasma volume. This will inhibit ADH release, which will result in increased
diuresis (+free water clearance, hypotonic urine). Try that yourselves to see that it is
true.
53- A 72-year-old man comes to the physician because of an 8-month history of feeling lightheaded when he stands up. Blood pressure is 130/85 mm Hg while supine and 94/64
while standing. High-dose fludrocortisone (glucocorticoid with mineralocorticoid activity)
is started. After 5 days of treatment, laboratory studies are most likely to show which of
the following changes?
Serum K+
A- Decreased
B- Decreased
C- Decreased
D- Increased
E- Increased
F- Increased

Serum Renin
Increased
Increased
Decreased
Increased
Decreased
Decreased

Urine K+ excretion
Increased
Decreased
Increased
Decreased
Increased
Decreased

Glucocorticoid: cortisol
Mineralocorticoid: aldosterone (increases Na+ and H2O reabsorption, increases K+
and H+ secretion and excretion). Negative feedback over renin.

54- A neonate has ambiguous genitalia. In the first 48 hours of life, the neonate feeds poorly
and becomes dehydrated. Which of the following is the most likely diagnosis?
A- Androgen insensitivity syndrome
B- 5alpha reductase deficiency
C- 17-hydroxylase deficiency: hypervolemia with hypokalemia (instead of hypovolemia).
D- 21-hydroxylase deficiency
E- True hermaphroditism
55- A 25-year-old woman has had generalized bone pain for 9 years. She has frequent
episodes of loose, foul-smelling bulky stools. Examination shows muscle weakness and a
distended abdomen. X-ray films show generalized demineralization of bones, absence of
lamina dura, and fracture-like lines in the bones of the feet. Which of the following sets of
findings in serum is most likely in this patient?
Ca++
A-
B-
C-
D-
E-

Phosphorus

Alkaline phosphatase
(most likely normal)

PTH

This woman has steatorrhea (foul-smelling , floating stools), so she probably has
Vitamin A, D, E, K deficiencies. Deficiency of which of them would explain these
findings in bone? Vitamin D (this vitamin increases Ca++ and phosphate absorption in
GI, so if it decreases, both will decrease). Hypocalcemia stimulates PTH release.
56- A 42-year-old woman has dizziness and ringing in her ears 7 days after starting a new
drug. Which of the following drugs is the most likely cause?
A- Acetaminophen: liver toxicity ( due to free radical generation) and kidney toxicity (due
to decreased PGE2)
B- Aspirin: ototoxic drugs include aspirin, aminoglycosides, furosemide (especially when
combined with gentamycin), cisplatin (also nephrotoxic), and vancomycin.
C- Methotrexate: neural tube defects, blood cell abnormalities
D- Prednisone: Cushings, osteoporosis, Addisons If there is quick withdrawal
E- Acetazolamide: metabolic acidosis
57- Activation of T lymphocytes is initiated when processed antigen binds to the T
lymphocyte receptor on the cell membrane, and phospholipase C is activated. This results
in production of which of the following components of signal transduction?
A- cAMP
B- cGMP
C- Diacylglycerol: same question as before!
D- IL-2

58- The sulfonylureas exert their hypoglycemic effect by blocking which of the following
channels?
A- Ca++
B- ClC- K+: another repeated one!
D- Mg++
E- Na+
59- Which of the following hormones acts through receptors that contain tyrosine kinase?
A- ADH (Vasopressin): V1 and V1
B- Aldosterone: intracellular zinc-finger receptors (transcription factors that bind
response elements in DNA)
C- Calcitonin
D- 1,25-dihydroxycholecalciferol
E- Epinephrine: alpha and beta
F- Insulin
G- Parathyroid hormone (PTH): G protein-coupled, membrane-bound receptor
H- Thyroxine (T4): intracellular receptor similar to steroid hormone receptor
60-

A neonate is born with the abnormality shown. Which of the following statements best
applies to this malformation?
A- It is due to robust angiogenesis, and it
is most likely to spontaneously regress
B- It is due to abnormal cell adhesion
mechanisms, and it must be resected
C- It is due to excessive cell migration, and
its premalignant
D- It is related to abnormal gastrulation,
and its likely to grow as the child grows
E- It is caused by abnormal somitogenesis,
and may be related to
pheochromocytoma
This is a strawberry (capillary) hemangioma.

61- A 73-year-old white woman has a 1-cm, scaly, raised lesion on the right side of the face.
She worked as a lifeguard for 50 years. A photomicrograph of tissue obtained on biopsy
of the excised lesion is shown. Use of which of the following is most likely to have
prevented the development of this lesion?
A- Conjugated estrogen
B- Isoniazid
C- Sunscreen: this is a squamous cell
carcinoma of skin, look at that keratin
pearl on the right upper quadrant.
D- Tretinoin cream
E- Triamcinolone cream

62- A 50-year-old woman comes to the physician because of visible painless lump in her neck
for the past 6 months. Her pulse is 80/min, respirations are 14/min, and blood pressure is
120/70 mm Hg. She has an enlarged, nontender thyroid gland. Initial thyroid function
studies are normal. Now, her serum thyroid stimulating hormone (TSH) is 15 U/mL (N =
0.5-4.7), and serum total thyroxine (T4) concentration is 3.5 g/dL (N = 4.5-12.5). Which
of the following describes the most likely pathologic findings in her thyroid gland?
A- Absence of thyroglobulin
B- Heavy lymphocyte infiltrate with germinal center formation: type IV hypersensitivity
reaction
C- Noncaseating granulomas
D- Presence of an antibody that simulates the action of TSH: graves disease
E- Regenerative nodules with lakes of excessive thyroid protein
63-

A 35-year-old woman at 18 weeks gestation has an increased serum alpha-fetoprotein

concentration. Which of the following has the greatest influence in determining the
predictive value of this test for neural tube defects?
A- Concentration of alpha-fetoprotein in maternal serum
B- Maternal history of monozygotic twin pregnancies
C- Prevalence of neural tube defects in the population in question
D- Sensitivity of the test
E- Specificity of the test
Remember, the sensitivity and specificity of a test are not affected by disease prevalence,
but positive and negative predictive values are!
MCC of high levels of alpha-feto protein is wrong gestational age calculation.

64- A 36-year-old man has acute pain in the right upper arm and shoulder. Acute
supraspinatus tendinitis is suspected. Which of the following physical examination
maneuvers of the right shoulder is most likely to reproduce the pain, thus supporting the
diagnosis?
A- Abduction: know the rotator cuff. Supraspinatum is the least (blood) supplied muscle
among these, and it supports deltoid in abduction (first 15 degress). Infraspinatum
rotates laterally. Subscapular rotates medially and adducts arm.
B- Adduction
C- Extension
D- External rotation
E- Flexion
F- Internal rotation
65- Which of the following human cells is 1N and haploid?
A- Germinal epithelial cell
B- Primary spermatocyte: 4N diploid
C- Spermatid (also spermatozoa)
D- Type A1 spermatogonium
E- Type B spermatogonium
66- The binding specificity for extracellular matrix proteins, such as fibronectin and laminin to
cell membranes depends on which of the following classes of proteins?
A- Collagen
B- Elastin
C- Integrin
D- Microfibrillin
E- Proteoglycan
67- An asymptomatic 65-year-old woman comes to the gynecologist for a routine
examination. Physical examination shows a left adnexal enlargement that was not
present 1 year ago. Which of the following is the most likely diagnosis?
A- Endometriosis: dysmenorrhea
B- Leiomyoma
C- Ovarian tumor
D- Polycystic ovarian disease: many cysts, making the ovaries enlarge!
E- Ruptured luteal cyst: severe acute pain!
68- Patients taking metformin for the treatment of type 2 diabetes mellitus are at risk of
developing which of the following adverse effects?
A- Diabetic ketoacidosis: not usually seen in type II diabetes.
B- Lactic acidosis
C- Metabolic alkalosis
D- Renal tubular acidosis
E- Respiratory alkalosis

69- A 72-year-old man has difficulty initiating urination. Digital examination shows an
enlarged, firm prostate. An assay for serum prostate specific antigen (PSA) is 3.5 g/L (N =
0-5). Examination of tissue obtained on biopsy of the prostate is most likely to show:
A- Adenocarcinoma: single, hard as a rock, nodule.
B- Chronic prostatitis
C- Epithelial dysplasia
D- Glandular hyperplasia
E- Leiomyoma
70- During contraction of striated muscle, the thick and thin filaments alter their relationship
which each other, and the sarcomere shortens. Which of the following bands is most
likely to maintain a constant length during muscle contraction?
A- A: only one that doesnt change! Contains thin and thick filaments
B- H: This one in fact is not seen unless the muscle is completely relaxed. Becomes even
smaller during contraction.
C- I
D- M
71- A 60-year-old woman with osteoarthritis has recurrence of pain and stiffness in her joints.
She is afebrile. The most appropriate therapy is:
A- Allopurinol: this would worsen osteoarthritis by increasing bone resorption.
B- Aspirin
C- Colchicine
D- Estrogen
E- Probenecid
72- A 23-year-old woman has had intermittent amenorrhea since the birth of her first child 5
years ago. She received 10 units of blood during her delivery. Her skin is thick and doughy.
She has no energy and is depressed. Which of the following is the most likely cause of her
symptoms?
Remember the pituitary becomes hypertrophic during pregnancy, so any significant blood
loss may lead to necrosis! This woman has signs of LH and FSH loss and hypothyroidism.
A- Adrenocortical insufficiency
B- Chronic fatigue syndrome
C- Hemochromatosis
D- HIV infection
E- Pituitary necrosis

73- The concentration of sodium in the blood is affected by a hormone secreted by cells in
which of labeled zone in the photomicrograph?
The answer is B (zona glomerulosa).
C is zona fasciculata: produces glucocorticoids
D is zona reticularis: sex hormones
E is medulla

74- A 26-year-old woman has a 3-week history of joint pain and a photosensitive rash on her
face and other exposed parts of the body. Which of the following tests is most useful in
confirming the diagnosis?
A- Antibodies against native DNA (double stranded DNA)
B- Antibodies against rubella virus
C- Erythrocyte sedimentation rate
D- Leukocyte count
E- Rheumatoid factor assay
F- Serologic test for syphilis
G- Total hemolytic complement concentration

75- A neonate with swelling of the neck has a decreased serum thyroxine (T4) concentration
and an increased serum thyroid stimulating hormone concentration. Which of the
following agents chronically ingested by the mother during the pregnancy is the most
likely cause of these findigns?
A- Corticosteroids
B- Propranolol
C- Propylthiouracil: drugs for the treatment of hyperthyroidism may cause
hypothyroidism in mother and fetus.
D- Thyroxine (T4)
E- Triiodithyronine (T3)
76- As the result of a fall onto a hard surface, a 20-year-old woman sustains a fracture of the
medial humeral epicondyle, and a nerve is injured. Which action will be most affected by
this nerve injury?
A- Adduction of all digits: ulnar nerve
B- Extension of all digits: radial
C- Flexion of all digits: median
D- Pronation of the forearm: median
E- Supination of the forearm: musculocutaneous
77- Which of the following is the unique function of the central aggregate of particles
(marked by X) in the freeze-fracture image?
A- Adhesion
B- Communication: gap junction!
Formed by connexons, which can be
seen here.
C- Motility
D- Permeability

78- A 30-year-old woman has a 10-month history of a whitish discharge from both breasts.
Her last menstrual period was 9 months ago. She had a bilateral tubal ligation 4 years ago
after the birth of her 3rd child. Palpation of the breast discloses no masses. Whitish fluid is
expressed bilaterally on compression of the nipples (MILK!). The most likely diagnosis is:
A- Bilateral mastitis
B- Intraductal carcinoma of the breast
C- Metastatic carcinoma of the breast
D- Pituitary adenoma: Increased prolactin decreases GnRH activity, so FSH and LH
decrease.
E- Premature menopause
79- A 3-year-ol d boy has an abdominal cryptorchid testis that cannot be brought down into
the scrotal sac. The testis should be remover to decrease his risk for which of the
following?
A- Abnormal hormonal secretion
B- Infection
C- Intestinal obstruction
D- Malignancy
E- Psychological impairment
80-

A 42-year-old woman reports fatigability, nervousness, irritability, and heat intolerance.

She has a diffuse goiter, exophthalmos, and pretibial edema. Circulating antibodies to
which of the following are most likely to be found in this patient?
A- Microsomal protein
B- Reverse triiodithyronine (rT3)
C- Thyroglobulin
D- Thyrotropin (TSH)
E- Thyrotropin (TSH) receptor

81- A 22-year-old woman is concerned about her risk for developing diabetes because her
mother has type 2 diabetes mellitus. Which of the following is the primary defect thought
to predispose individuals towards the development of type 2 diabetes mellitus?
A- Anti-insulin receptor antibodies: important factor, but not present in everybody with
type II diabetes.
B- Autoimmune destruction of pancreatic beta cells
C- Dysregulation of pancreatic beta cells
D- Increased peripheral insulin resistance: most important factor
E- Suppressed hepatic glycogen synthesis

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