Basic Science Flashcard

A 24-year-old man, a new immigrant to the UK from Eastern Europe, who had worked in his own country as a demolition contractor, undergoes a medical examination and is found to have glycosuria. His blood lead concentration is high. Which of the following findings would suggest that he has a generalised disorder of proximal tubular function?

E- Metabolic acidosis

A 47-year-old man with a long history of alcohol abuse is admitted to hospital with acute abdominal pain and is diagnosed clinically as having acute pancreatitis. This is confirmed by finding a high serum amylase activity and by the results of an ultrasound scan. He has not had a similar illness before. His serum is seen to be lipaemic: serum triglyceride concentration is 26 mmol/l. Which of the following is the most likely cause of the hypertriglyceridaemia?

E- Increased synthesis of VLDL (very low-density lipoprotein)

A patient undergoes respiratory function tests. Which of the following are normal readings for a 70-kg man?

E- Inspiratory reserve volume of 2 litres

Angelman's and Prader-Willi syndromes both involve defects in the same chromosome region. What is the best molecular explanation for differences in the phenotypes in these two conditions?

E- It is due to the differential expression of genes depending on parental origin

Botulinum toxin has which of the following features?

E- It may be used in the treatment of blepharospasm

You are teaching molecular biology to a group of medical students, and one asks you about how reverse transcriptase works. How does reverse transcriptase work?

E- It transcribes DNA from RNA

Which of the following adverse food reactions is mediated by IgE-dependent mechanisms and hence can be ascertained by skinprick testing?

E- Kiwi fruit

A 35-year-old man presents with severe hypertension and is found to have a unilateral phaeochromocytoma. His father died from metastatic renal-cell carcinoma aged 48 and previously had surgery for a brain tumour. What is the most likely underlying genetic condition?

C- von Hippel-Lindau syndrome

Only IgE-mediated allergic reactions can be formally tested by skinprick testing. Adverse reactions to which of the following substances can be tested in this manner?

E- Latex

An 81-year-old, nursing-home resident is admitted to hospital in an unconscious state. His blood sugar is measured as 1.5 mmol/l (normal 3-6 mmol/l). You administer glucagon. Which of the following best describes one of the main actions of glucagon?

E- Increased glycogenolysis and gluconeogenesis

A 58-year-old man develops generalised oedema. He has heavy proteinuria and his serum albumin concentration is 24 g/l (35-50). Which of the following additional findings would most suggest a specific cause for this condition?

A- Bence Jones protein in urine

A patient receives too many infusions after an operation resulting in a 20% increase in hisblood volume. What is the physiological process that is most likely to correct this abnormality?

D- Atrial natriuretic peptide (ANP) release

An infant, seen in the ER, presents with a fever and persistent cough. Physical examination and a chest x-ray suggest pneumonia. Which of the following is most likely the cause of this infection?

D. Respiratory syncytial virus

Traditional vaccination for the common cold is virtually impossible because there are multiple serotypes of which one of the following viruses?

D. Respiratory syncytial virus

Which of the following is a leading cause of pneumonia primarily in infants?

D. Respiratory syncytial virus

Pain referred to the right side of the neck and extending laterally from the right clavicle to the tip of the right shoulder is most likely to involve which of the following?

D. Right phrenic nerve

A man presents with an eczematous rash on his hands suggestive of contact dermatitis, possibly related to wearing latex gloves at work. He requests confirmatory tests. Which of the following tests is most likely to be helpful establishing the diagnosis?

C- Patch testing

A pregnant woman in her second trimester presents with a recent onset of a bullous rash on her lower anterior abdominal wall. She has no other clinical features. Which of the following bullous conditions is the most likely diagnosis?

C- Pemphigoid gestationis

Susceptiblity to Pneumocystis jiroveci can be associated with high levels of:

1- IgM

A 42-year-old, atopic, health-care worker presents with red weals and itchy hands within 20 minutes of wearing latex gloves. Which of the following mechanisms is most likely to be relevant?

E- IgE-mediated sensitivity

An anaesthetist performs a successful block of the median nerve at the elbow. Which neurological sign is likely to be present on examination?

E- Inability to abduct the thumb

A 20-year-old woman complains of an immediate intense itching in her throat when eating apples, but says that she can eat cooked ones. She mentions that she has allergic rhinitis but the current symptoms occur in April and May and not the typical June/July period associated with grass pollen. What is the most likely diagnosis?

A- Birch-associated oral allergy syndrome

In a 21-year-old female with systemic lupus erythematosus, which of the following investigations/statements is true?

A- CRP is typically normal in non-infected patients with active disease

Fatty acids transported from adipose tissue to the muscle. Which enzyme is essential for this process?

A- Carnitine acyltransferase I

You are asked to review a 17-year-old who suffers from leprachaunism. You understand that this occurs due to a mutation associated with the insulin receptor. Where is the insulin receptor located?

A- Cell membrane

A 54-year-old woman presents with longstanding tinnitus and evidence of a unilateral fifth (trigeminal nerve) palsy. Her MRI scan shows evidence of an acoustic neuroma. Where is compression of the trigeminal nerve most likely to be occurring?

A- Cerebellopontine angle

A 76-year-old patient is admitted to the acute admission unit with septic shock. Pulse is 106 and BP 90/40 mmHg. Urinary catheterisation produces 75 ml of concentrated urine. Which of the following principles applies to the choice of an appropriate intravenous fluid for resuscitation?

A- Certain intravenous solutions, which would be hypo-osmolar, have dextrose added to ensure they are iso-osmolar

A young woman is admitted to A&E having taken an aspirin overdose. The plasma concentration of salicylate is 550 mg/l (4.0 mmol/l). What clinical feature would most suggest that another drug has been taken in addition to aspirin?

A- Coma

The accumulation of gangliosidic GM2 in the central nervous system of individuals with Tay-Sachs disease is attributed to:

A- Decreased lysosomal hydrolysis

A patient presents with hypocalcaemic tetany. He has abnormal ears, hypertelorism and an absent thymus. What is the most likely diagnosis?

A- DiGeorge syndrome

Which of the following respiratory physiology tests would be consistent with a diagnosis of moderately established cryptogenic fibrosing alveolitis?

A- Diffusion capacity decreased, FEV1/FVC normal, total lung capacity reduced

Osteoporosis is most reliably diagnosed by which one of the following techniques?

A- Dual-energy X-ray absorptiometry (DEXA)

Which of the following is the most important causative factor in the development of obesity in the majority of patients?

A- Energy intake in excess of expenditure

A 25-year-old woman presents with primary hyperparathyroidism. It emerges that she has been treated previously for a prolactinoma. What is your diagnosis?

A- Familial parathyroid hyperplasia

A patient has been diagnosed with Marfan's syndrome. Which gene mutation is responsible for this condition?

A- Fibrillin

A 19-year-old man from a family of travellers presents to the Emergency department. He has suffered a sudden deterioration in vision. Additional past medical history of note includes bilateral shoulder dislocation. On examination he is tall and thin with a high arched palate. He appears to have suffered a lens dislocation Which of the following genes is most likely to be abnormal?

A- Fibrillin-1

A patient undergoes excision of the left submandibular salivary gland for sialectasia. Unfortunately, his hypoglossal (XII) nerve on that side is damaged. What is the most likely outcome?

D- All the intrinsic muscles of the left side of the tongue are paralysed

You are called to see a 12-hour-old male infant who was born to a 19-year-old G1 woman with no prenatal care. She presented to the emergency room completely dilated and crowning. The baby was born minutes later. On examination, the baby is febrile and tachypneic. A CXR confirms the presence of pneumonia. What is the most likely infectious agent?

A. group B Streptococcus (GBS)

A patient who had a myocardial infarction 6 months ago is diagnosed as having gingival hypertrophy. Which drug is most likely to be responsible for this?

D- Amlodipine

A 41-year-old man has a body mass index of 38 kg/m2. He is normotensive and a non-smoker. A fasting blood glucose concentration is normal. His mortality in comparison with an otherwise comparable individual of normal body weight is increased primarily because of an increased risk of which one of the following?

B- Cardiovascular disease

A 48-year-old woman presents to the clinic complaining that her left foot drags and gets caught when she tries to climb the steps athome. On examination there is weakness of the foot and ankle dorsiflexors and she has a so-called steppage gate. She has sensory loss over the lateral portion of the leg extending onto the dorsum of the foot. Which of the following is the most likely location of neurological injury?

B- Common peroneal nerve injury

You are working in the Emergency Department and notice that a tall and thin 19 year old student has attended for the second time with spontaneous pneumothorax. He displays clear signs of hyperflexibility and on further questioning it appears he has also had problems with shoulder dislocation. He also has a reduced upper to lower body segment ratio. You suspect he may have Marfan's. Which of the following correctly describes the mutation associated with Marfan's syndrome?

A- Fibrillin-1 (FBN-1) gene mutation

Degranulation of eosinophils allows which of the following cellular processes?

A- Fusion of the lysosomal membrane with the plasma membrane

Pulmonary gas exchange occurs under which of the following physiological principles?

A- Gas exchange can occur in the final seven branches of the bronchoalveolar tree

A 39-year-old man presents with recurrent episodes of early morning dizziness, which resolve rapidly when he has his breakfast. Which of the following metabolic pathways is most likely to be functioning abnormally?

A- Gluconeogenesis

A 48-year-old man is referred by his GP with suspected acromegaly. Which of the following would be the most useful investigation to establish the diagnosis?

A- Glucose tolerance test with measurement of growth hormone

You are examining some strategies for research into a possible metabolic defect. You think this involves an abnormality of pyruvate kinase. In which of the following processes is pyruvate kinase the rate limiting step?

A- Glycolysis

The mean lower oesophageal sphincter pressure is reduced in which of the following situations?

A- Grade III oesophagitis

In a 20-year-old man, recurrent and/or severe infections with which of the following organisms would make you suspect immunodeficiency associated with hypogammaglobulinaemia?

A- Haemophilus influenzae

High titres of antithyroid microsomal and antithyroglobulin antibodies would suggest which of the following diagnoses in a patient presenting with a complaint of tiredness?

A- Hashimoto's thyroiditis

Which enzyme breaks base pairs in a double-stranded DNA molecule?

A- Helicase

A 25-year-old patient suffered recurrent deep vein thromboses and also one pulmonary embolism. She was extensively investigated and diagnosed with protein C deficiency. What pathological process is most likely to be responsible for her venous thromboembolisms?

A- Reduced degradation of factors Va and VIIIa

Following an apparent transient ischaemic attack, a patient is demonstrated to have asmall left homonymous hemianopia with partial sparing of central vision. Which of the following is the most likely anatomical site of the lesion responsible?

A- Right occipital cortex

You have performed a liver biopsy, and shortly after the procedure the patient develops pain on the tip of his right shoulder. Which nerve is most likely to be responsible for his pain?

A- Right phrenic nerve

The oxygen-haemoglobin dissociation curve is shifted to the left by which of the following factors?

A- Rise in pH

Cholera is a toxicogenic dysenteric disease common in many parts of the world. In the treatment of patients who have cholera, the use of a drug that inhibits adenylcyclase would be expected to

E. Block the action of cholera toxin

Patients with Cushing's syndrome often show osteoporotic changes. Which of the following is involved in the etiology of osteoporosis induced by Cushing's syndrome?

E. Bone fragility resulting from excess bone resorption

A 42-year-old man with type-1 diabetes mellitus, which was diagnosed 23 years ago, is admitted to hospital with diabetic ketoacidosis. He is complaining of abdominal pain. Which of the following findings on admission would most suggest an acute event has preciptated his DKA?

A- Serum amylase activity of 1244 U/l (upper limit of normal, 150 U/l)

The substitution of the amino acid valine instead of the normal glutamic acid at position6 of the b-globin chain is the genetic abnormality encountered in which one of the following types of congenital haemolytic anaemia?

A- Sickle cell anaemia

A 64-year-old man is admitted with a severe haematemesis. Upper GI endoscopy identifies a posterior gastric ulcer. Bleeding is most likely to having occurred from which main vessel?

A- Splenic artery

A patient presents with facial abnormalities that may include abnormal ears, a shortened philtrum, micrognathia and hypertelorism. Which cells is this patient lacking?

A- T lymphocytes

A 38-year-old woman is sent as an emergency to you with an acute-onset headache and deteriorating conscious level. Her husband mentions that her brother has recently had a kidney transplant, although he is not sure why. What condition may be running in the family?

C- Polycystic kidney disease

An 82-year-old woman with atrial fibrillation develops a sudden arterial occlusion of her right arm due to a brachial embolism. Which statement pertaining to the arterial system of the upper limb best accords with usual clinical findings?

A- The brachial artery bifurcates into the ulnar and radial arteries at the level of the head of the radius

A patient has her inferior laryngeal nerve inadvertently divided during a partial thyroidectomy. Which clinical features are likely to result from this?

A- The larynx is anaesthetic inferior to the vocal cord on the affected side

A cerebral angiogram is performed on a 37-year-old woman, following a suspected aneurysmal bleed. Which anatomical feature should be considered when interpreting the angiogram?

A- The middle cerebral artery is the largest single component of the circle of Willis

Which of the following features applies to acetylcholine-mediated transmission at the motor endplate?

A- The synaptic fusion complex is made of synaptobrevin, syntaxin and synaptosome-associated protein

What is the main feature of DNA sequence polymorphisms that differentiates them from mutations?

A- They are common in the population

Which of the following structures is located in the anterior mediastinum on computed tomography (CT)?

A- Thymus

A 20-year-old woman presents with hypothyroidism. On further questioning it transpires she has primary amenorrhoea. She is also of relatively short stature compared to her sisters. What is the most likely diagnosis?

A- Turner's syndrome

In patients with systemic lupus erythematosus which of the following statements is correct?

A- Up to 80% of patients have anti-dsDNA antibodies

Which one of the following is higher at the apex of the lung than at the base when a person is standing?

A- V/Q ratio

A patient presents with eczema, thrombocytopenia and recurrent infections.​What is the most likely diagnosis?

A- Wiskott-Aldrich syndrome

V. cholerae, the causative agent of cholera, is best described as

A. "String-test"-positive isolate; three serotypes—Ogawa (AB), Inaba (AC), Hikojima (ABC)

You are called to see a newborn in the nursery because the nurse is concerned that the baby may have Down syndrome. If you were to perform an abdominal x-ray, what is the most likely finding that would be seen?

A. "double-bubble" sign

Select an appropriate measure of frequency that describes the number of deaths between the ages of 28 days and 11 months per 1000 live births in 1 year.

E. Post neonatal mortality

A39-year-old obese female presents with irregular menstrual periods, mild acne and hirsutism, and acanthosis nigricans on the nuchal fold, axilla, and intertriginous areas (inner upper thighs). You suspect PCOS. Which of the following laboratory tests would be most important to perform to rule out a likely confounding diagnosis?

A. 2-hour oral glucose tolerance test

A 50 year old woman comes for her periodical health examination. Her body mass index is 29 kg/m2. Her blood pressure is 120/80. She has no family history of cardiovascular disease. Her total cholesterol is 200 mg/dL (5.2 mmol/L), her HDL is 35 mg/dL (0.9 mmol/L), and her LDL is 100 mg/dL (2.6 mmol/L). The most appropriate initial intervention for weight loss is

A. Exercise

Which one of the following markers is closely associated with HBV infectivity and DNA polymerase activity?

A. HBeAg

A colleague asks for your help in designing a new diagnostic molecular assay where small amounts of DNA need to be accurately amplified and analysed. Which would be your technique of choice?

C- Polymerase chain reaction (PCR)

Infection with hepatitis D virus (HDV; delta agent) can occur simulta- neously with infection with hepatitis B virus (HBV) or in a carrier of hepati- tis B virus because HDV is a defective virus that requires HBV for its replicative function. What serologic test can be used to determine whether a patient with HDV is an HBV carrier?

A. HBsAg

Which of the following is the most cost-effective and safe public health measure today to prevent dental caries?

A. Water fluoridation

Rabies, psittacosis, salmonellosis. Select the most common described mode of transmission with the above disease

A. Water or foodborne transmission

A 45-year-old male has received intravenous contrast dye prior to CT scan of the abdomen. Twenty minutes later the patient reports severe pruritus. He denies respiratory distress, syncope, or palpitations. His blood pressure is 98/54, pulse is 90, and respiratory rate is 22. On physical examination, he has widespread urticaria. His lungs are clear to auscultation. The next appropriate step would be which of the following?

A. administration of 0.5 mL of 1:1000 epinephrine subcutaneously

A 22-year-old woman with partial lipodystrophy presents with a 3- month history of increasing swelling of her legs, which is now up to her knees. Urinalysis shows heavy proteinuria but no haematuria. A diagnosis of nephrotic syndrome is therefore made. Which investigation is most likely to help in the definition of the underlying renal pathology?

B- Complement studies

A 74-year-old man receives an acyclovir shingles treatment pack from his GP. He is a retired chemist and is interested in asking you about how acyclovir works. Which of the following best describes the step required for acyclovir activation?

B- Conversion to monophosphate form by viral thymidine kinase

A19-year-old college student is found to have an elevated serum calcium on routine physical examination. She has a family history of hypercalcemia that has not resulted in any known symptoms. Further workup reveals a slightly elevated serum parathyroid hormone with depressed levels of serum phosphate. A 24 hour urine calcium excretion is obtained and is low. Which of the following is the correct diagnosis?

A. familial hypocalciuric hypercalcemia (FHH)

A 48-year-old man went up in a hot air balloon without sufficient clothes to keep him warm. In the evening he presents with acute renal failure and a purpuric/vasculitic rash on his legs. Which of the following investigations is likely to be most helpful in identifying the process leading to the above?

B- Cryoglobulins

A 54-year-old man with a long history of excessive alcohol ingestion develops a blistering skin eruption. His urine tests positive for porphyrins. What is the most likely diagnosis?

B- Cutaneous hepatic porphyria

Which of the following should be considered in the management of haemophilia A?

B- Desmopressin may be useful

By which process are particles moved along a concentration gradient across a selectively permeable membrane?

B- Diffusion

A 7-year-old boy who came from India presented with fever, maculopapular rash and pharyngitis with greyish membranes surrounding the tonsils. There is regional lymphadenopathy. What is the most likely diagnosis?

B- Diphtheria

The primary neurochemical disturbance in idiopathic Parkinson's disease involves

B- Dopamine

Which of the following is typically the earliest lesion to develop in diabetic retinopathy?

B- Dot haemorrhages

The secretion of growth hormone is increased by?

B- Exercise

In Duchenne's muscular dystrophy, which of the following statements applies?

B- Exon deletion or duplication in the dystrophin gene occurs in 60% of patients

Which protein defect is responsible for Marfan's syndrome?

B- Fibrillin

A 48-year-old male truck driver presents for evaluation of bright red rectal bleeding with bowel movements. He also has the feeling that something protrudes through his anus while he strains to move his bowels but that it withdraws into the bowel when he relaxes. He has no abdominal pain, weight loss, or other symptoms. A colonoscopy reveals no polyps or tumors but does note internal hemorrhoids. Which of the following is the best initial treatment for him?

A. high fiber diet, frequent sitz baths, and topical steroid ointment

Lethargy, malaise, and fatigue are observed in a patient 2 weeks after eating raw hamburger at a restaurant. The most likely infectious cause is

C. E. coli

Bupivacaine is a local anesthetic agent that is much more potent and the duration of action of which is considerably longer than procaine. Possible reasons for this difference include which of the following?

A. higher partition coefficient for bupivacaine than for procaine

A 72-year-old woman undergoes a sigmoid colectomy for diverticulitis. Postoperatively, she develops a wound infection for which she is transferred to the ICU for 2 days because of hypotension. Which of the following would have had the most effect on reducing her risk of developing complications?

A. preoperative treatment of her concomitant urinary tract infection

A40-year-old woman presents with headaches and visual disturbances for the past 6 months. She suddenly developed amenorrhea 2 years ago. One year ago, she noticed milky discharge from her left breast. The most likely diagnosis is which of the following?

A. prolactinoma

When planning the radiotherapy dosage for solid tumours, it has to be remembered that the division of cells is governed by the cell cycle, the mechanism of which is disrupted by radiation. Which of the following is true concerning the cell cycle?

B- G1 is a gap phase under the influence of the p53 gene

A 20-year-old man is referred to the endocrinology clinic because of delayed puberty. On examination, he has a preadolescent body habitus and no evidence of the development of secondary sexual characteristics. Serum testosterone, LH (luteinising hormone) and FSH (follicle-stimulating hormone) concentrations are all in the prepubertal range. The LH and FSH concentrations increase only slightly following a single injection of GnRH (gonadotrophin-releasing hormone) but a normal response iselicited after GnRH is given daily for seven consecutive days. Which of the following is most likely to be the cause of his delayed puberty?

A- A hypothalamic disorder

You are asked to see a patient who had a chest drain removed 4 days ago. There appears to be some infection. What are the stages in the cell biology of normal wound healing?

B- Maturation and remodelling can continue for up to a year

A 20-year-old man presents with mild jaundice following a flu-like illness. Following review by a gastroenterologist, he has been told that a diagnosis of Gilbert's syndrome is probable. Which of the following laboratory tests is most likely to confirm this diagnosis?

A- Absence of bilirubin in the urine

A 49-year-old postmenopausal woman of Southern Asian origin complains of muscle weakness. She is found to have hypocalcaemia, and X-ray examination reveals two Looser's zones in her left upper femur. A defect in which of the following physiological processes is most likely to be the cause of her illness?

A- Absorption of calcium from the gut

A 19-year-old woman has been diagnosed as having acute intermittent porphyria. How is she most likely to have presented?

A- Acute abdomen

You are asked to review a 45-year-old obese woman who is jaundiced. Which of the following best fits the metabolism of bile acids?

B- Their production is catalysed by cholesterol 7a-hydroxylase

A 25-year-old man is admitted to hospital with persistent vomiting. He is clinically dehydrated and hypotensive. His serum sodium concentration is 124 mmol/l, potassium 4.9 mmol/l, urea 9.8 mmol/l, creatinine 96 m mol/l. Urine sodium concentration in a specimen passed on admission is 62 mmol/l. Which of the following is the most likely cause of the hyponatraemia?

A- Adrenal failure

Some 4 hours after sustaining major trauma in a road traffic accident, a 22-year-old man, notknown to have diabetes, is found to have a high blood glucose concentration. Increased secretion of which of the following substances is most likely to be responsible?

A- Adrenaline (epinephrine)

An overweight 32-year-old woman presents with a short history of painless jaundice. There is no previous history of illness and, apart from the jaundice, she has no signs of chronic liver disease. Initial investigations reveal a haemoglobin of 12.7 g/dl, MCV 105 fl, serum bilirubin 162 mmol/l, AST 145 U/l, alkaline phosphatase 224 U/l, gamma-glutamyltransferase 200 U/l. Which of the following is the most likely diagnosis?

A- Alcoholic liver disease

Haemolytic disease of the newborn is typically restricted to the presence of Rhesus antigens on red cells rather than ABO antigens. Predominantly, such anti-Rh antibodies cross the placenta during the third trimester. Which of the following statements best explains the background physiology?

A- Antibodies to ABO blood groups are IgM, whereas antibodies to Rhesus, antigens are IgG2- Antibodies to ABO blood groups are IgG, whereas, antibodies to Rhesus antigens are IgM

You review a 19-year-old man who is referred to the clinic with recurrent nose bleeds. On examination you notice that he has multiple telangiectases on his body and you are concerned that he may have an underlying genetic disorder. On further questioning you understand that one relative had a similar skin appearance and unfortunately died of a GIhaemorrhage, and another suffered from a stroke. What is the likely mode of inheritance for this condition?

A- Autosomal dominant

A young pregnant girl would like to know the risk of having a child with genetic abnormalities. Her father and two brothers are affected by haemophilia, which is inherited as an X-linked disease. She is herself completely asymptomatic. She knows from her last ultrasound test that her baby is a boy. What is the chance for her son to be genetically affected by the same condition?

A- 1 in 2

A patient has the following urea and electrolytes results: Sodium 140 mmol/l Potassium 4 mmol/l Chloride 105 mmol/l Bicarbonate 20mmol/l Calculate the anion gap.

A- 19 meq/l

A 36-year-old man presents to his family doctor complaining of excessive sweating. Thyroid function tests are performed: serum TSH concentration is normal, but the concentrations of both free thyroxine and free triiodothyronine are elevated. Which of the following is the most likely explanation for these results?

A- A TSH-secreting pituitary tumour

In a healthcare worker with a proven natural rubber/latex allergy, which of the following foods is most commonly associated with this condition?

A- Bananas

A 45-year-old woman with type-2 diabetes is making an apparently good recovery 7 days after a partial resection of the small intestine following trauma sustained in a stabbing incident. She is receiving parenteral nutrition with additional 'normal' saline and, because of a history of deep vein thrombosis some 10 years previously, is on prophylactic heparin. Before her admission she was well, with no ongoing medical problems and taking no regular medication. Serum electrolyte results are as follows: sodium 129 mmol/l, potassium 6.5 mmol/l, bicarbonate 24 mmol/l, urea 8.5 mmol/l, creatinine 120 mmol/l, glucose 10.2 mmol/l. Her potassium concentration has risen over the past 3 days. The potassium content of the parenteral feed has been reduced from 60 to 20 mmol/24 h during this period. Urine output is appropriate to her fluid input. Her red cell, white cell and platelet counts are all normal. What is the most likely cause of the hyperkalaemia?

A- Heparin treatment

A 52 year old man is being treated in hospitalfor digoxin toxicity. Which of the following biochemical abnormalities, if present, would be most likely to exacerbate the digoxin?

A- Hypokalaemia

A 55-year-old diabetic patient complains of soreness of his tongue, he has also noticed white plaques on his tongue. Which antibody in the saliva is the most important host defence in preventing further spreading of the disease?

A- IgA

Which immunoglobulin can fix complement via the alternative pathway?

A- IgA

Which of the following is true concerning immunity to viruses?

A- IgA can offer protection at mucosal surfaces

A 19-year-old woman is found in the desert following an accident 7 days earlier. She is severely dehydrated, drowsy and confused. On examination she looks very dry and has a BP of 90/65 mmHg. Investigations: Hb 14.9 g/dl, WCC 6.0 x 109/L, PLT 190 x 109/L, Na+ 145 mmol/l K+ 5.4 mmol/l, Creatinine 198 μmol/l, Urea 21.0 mmol/l Which of the following is the adaptive mechanism which has prevented her from dying from dehydration?

A- Increase of aquaporin-2 in collecting duct

What is the importance of the P1 receptor?

A- Inducing apoptosis

During the last trimester, IgG is actively transported across the placenta to supply passive immunity to the fetus. Which disease occurring during pregnancy is most likely to lead to the neonate having low immunoglobulin levels and hence being prone to bacterial infections?

A- Intestinal lymphangiectasia

A 75-year-old man with prostatism has a serum prostate-specific antigen (PSA) concentration of 15 ng/l. Which of the following statements is true with regard to this result?

A- It could be explained by prostatitis

Which of following is true regarding gamma-glutamyl transferase (GGT)?

A- It is increased in patients with fatty liver disease

You identify an IgAk paraprotein in an elderly male and need to decide whether this is part of an underlying malignancy such as myeloma, or a monoclonal gammopathy of underdetermined significance. Which of the following tests most supports a malignant process?

A- Kappa light chains in the urine (Bence Jones protein)

A 16-year-old boy presented with absence of pubertal development. He had no other symptoms of note. On examination he was tall, his voice was unbroken, testes were undescended and there was only scanty pubic hair. The remainder of the examination was unremarkable. What is the most likely diagnosis?

A- Klinefelter's syndrome

A 20-year-old man is referred for investigation of hypogonadism and infertility. He went through normal puberty and there is no significant family history. On examination he is tall with gynaecomastia and small testes. He has a normal sense of smell. Which condition would be high on your list of differential diagnoses?

A- Klinefelter's syndrome

A 36-year-old man presents to his GP with a feeling of numbness in his left leg. On examination, he has decreased position sense and light touch and vibration sensation affecting his left leg to the upper part of the thigh. No other neurological deficit is demonstrable. Which of the following is the most likely cause of this presentation?

A- Left dorsal column lesion

In an adult patient with cirrhosis, which of the following findings is the most reliably diagnostic of hereditary haemochromatosis as the cause?

A- Liver biopsy

A patient has been investigated for loose joints. He also complains of reduced vision. On examination he has very thin extremities and arachnodactyly. What is the most likely diagnosis?

A- Marfan's syndrome

In a patient developing anaphylaxis, which of the following is true?

A- May be exacerbated by exercise

A young woman with known systemic lupus erythematosus, complicated by an autoimmune neutropenia, is referred for consideration of her therapeutic options. The initial choice of treatment would have been azathioprine; however, monitoring of the drug therapy is likely to be highly problematic since this patient is neutropenic. A cytotoxic agent selective for lymphocytes is therefore preferable, to circumvent such problems. Which agent best fits her requirements?

A- Mycophenolate mofetil

Patients with xeroderma pigmentosum have a high risk of developing skin cancer.What kind of genetic deficiency do those patients have?

A- Nucleotide excision repair

A dental surgeon carries out a block of the inferior alveolar nerve by infiltrating local anaesthetic at the mandibular foramen. Which clinical feature may result from this procedure?

A- Numbness of the lower lip on the injected side

A 27-year-old woman presents with worsening back pain. As a child, she and her sister had several admissions to hospital with bone fractures following minor trauma and she has recently developed bilateral hearing loss. Apart from some teeth discoloration and mild joint laxity, examination was normal. A vertebral X-ray showed partial collapse of L3. What is the most likely diagnosis?

A- Osteogenesis imperfecta

The 3' to 5' exonuclease activity possessed by some DNA polymerases that enables the enzyme to replace misincorporated nucleotide is called what?

A- Proofreading

A patient presents with mononeuritis multiplex affecting the oculomotor nerve (III). What clinical feature is likely to be present on examination?

A- Ptosis of the upper eyelid on the affected side

A 22-year-old female (G3P0020) presents to your office for an initial obstetric visit in her third pregnancy. She reports a sure LMP date approximately 6 weeks ago, with a history of regular cycles. Her two previous pregnancies ended in spontaneous abortions. She denies any significant medical or surgical history. She denies use of alcohol, tobacco, or illicit drugs, though she does report a history of IV drug use as a teenager. She is a full-time student. She reports that twins run in her family, but she does not have any family history of diabetes, hypertension, or congenital anomalies. On review of her prenatal labs that have already been drawn, you find that her human immunodeficiency virus (HIV) antibody test (enzyme-linked immunosorbent assay [ELISA]) is positive. Her test results are otherwise normal Which of the following is recommended to reduce the risk of perinatal transmission of HIV from mother to infant?

A. A scheduled cesarean delivery can reduce the risk of transmission if the maternal viral load is greater than 1000 copies/mL.

Which one of the following would be the treatment of choice for HSV infection?

A. Acyclovir

A1-month-old female presents after an episode of bilious emesis. She became irritable 12 hours ago, began vomiting 6 hours ago, and is now lethargic. She had one small stool that was somewhat bloody 2 hours ago. Which of the following statements is true?

A. An upper GI contrast study should be obtained immediately.

C. trachomatis can be distinguished from C. psittaci by which of the following criteria?

A. C. trachomatis is sensitive to sulfonamides

What the most appropriate specimen is for the detection of Cytomegalovirus

A. Cervical tissue

What the most appropriate specimen is for the detection of Human papillomavirus

A. Cervical tissue

Comparison of the prevalence of hepatitis B surface antigen (HBsAg) in medical and dental students. Select an appropriate statistical test to analyze the data that match above description

A. Chi-square analysis

A 25yearold man presents with blurred vision, dysphagia, and dry mouth. Select the correct etiologic agent that match the descriptions above

A. Clostridium botulinum

Which of the following is characteristic of Hirschsprung's disease?

A. Constipation is the most frequent presenting feature.

A 39-year-old HIV-positive male presents for routine follow-up. He is on highly active antiretroviral therapy. A CD4 count is 250/L. His vital signs are within normal limits and his examination is normal. One month later, a repeat measurement of the patient's CD4 count is 225/L. Which of the following interventions would be the most appropriate at this time?

A. Continue the current regimen without change.

A child has mononucleosis-like symptoms yet the test for mononucleosis and the EBV titers are negative. One of the causes of heterophile- negative mononucleosis is

A. Cytomegalovirus

A45-year-old man undergoes a distal esophagectomy for Barrett's esophagus. During his hospital course, a left chest tube is placed for an effusion. Milky white fluid is found to come out through the tube. Which of the following statements is most accurate about this condition?

A. Diagnosis can be confirmed by checking the lymphocyte count and triglyceride level in the fluid.

Apatient with a known family history of multiple endocrine neoplasia (MEN) I, now presents with intractable ulcer disease. Which of the following statements about his condition is most accurate?

A. Diarrhea is a frequent complaint.

Which of the following interventions is the most effective in the prevention and control of injuries?

A. Education

A young man with severe learning difficulties and congenital heart disease is referred to you for a cardiac assessment. He is accompanied by his carer who says he has a chromosome abnormality. What type of abnormality is most likely to cause such a severe phenotype?

B- Unbalanced autosomal translocation

A28-year-old male, well known to your clinic, presents for management of swelling, pain, and tenderness that has developed in his left ankle and right knee. It has persisted for 1 month. Your patient reports that he developed severe diarrhea after a picnic 1 month prior to the onset of his arthritis. During the interval between the diarrhea and onset of arthritis, he developed a "pink eye" that lasted for 4 days. He denies any symptoms of back pain or stiffness. You remember that he was treated with ceftriaxone and doxycycline for gonorrhea 2 years ago, which he acquired from sexual activity with multiple partners. Since that time, he has been in a monogamous relationship with his wife and has not had any genitourinary symptoms. He promises that he has been faithful to his wife and has not engaged in unprotected sexual activity outside his marriage. His physical examination is notable for a swollen left ankle, swollen right knee, and the absence of penile discharge or any skin lesions. The patient's symptoms do not respond to your initial therapeutic management. You suspect that his condition is refractory to treatment. Which of the following should you consider at this time?

A. He may have human immunodeficiency virus (HIV) infection and should be tested.

IgM antibody to the viral particle is the method of choice for laboratory diagnosis of which one of the following hepatitis viruses?

A. Hepatitis A

A54-year-old man without significant past medical history presents to his primary care physician complaining of epigastric discomfort and early satiety. He subsequently undergoes an endoscopic procedure revealing an ulcerated mucosal lesion. The biopsy of this lesion is interpreted as a welldifferentiated lymphoma. Which of the following statements regarding his treatment and prognosis is most accurate?

A. His prognosis is poorer than if he were diagnosed with a gastric adenocarcinoma.

Apatient you see routinely in the clinic has elevated liver function tests. ALT is 89, AST is 75, and the total bilirubin and alkaline phosphatase are normal. The patient has no past history of hepatitis, taking medications, or excessive drinking. You order hepatitis serologies. The results are as follows: Positive: HBsAg and anti-HBc. Negative: anti-HBs, anti-HBc IgM, anti-HAV, and anti-HCV Which statement best describes this clinical situation?

A. If the patient was found to be HBe antigen positive, he would be considered highly infectious to spread hepatitis B.

A 59-year-old White male with a 40 pack-year history of smoking presents to your clinic complaining of three prior episodes of a "shade passing over his left eye" over the last 2 months. He reports that last week he experienced some weakness in his right arm, which resolved after 5 minutes. Appropriate management and counseling for this patient includes which of the following?

A. Initial management of this patient should include bilateral cerebral vessel duplex ultrasonography.

You perform an upper endoscopy on a patient and find changes suggestive of Barrett's esophagus. How do you explain this to the patient and his family?

A. Is a condition where the normal esophageal lining is replaced by columnar epithelium.

Trachoma is one of the leading causes of blindness. Which of the fol- lowing best typifies the disease?

A. It is caused by C. trachomatis

Scabies is caused by a small mite that burrows into the skin. The disease is best described by which one of the following statements?

A. It is caused by a species of Sarcoptes

A 58-year-old male presents to your office for a well-male examination. It has been several years since he last visited a doctor, but he states that he has been in "excellent health." He denies any history of drinking, smoking, or using illegal drugs. He maintains a diet low in sodium and fat. An avid sports enthusiast, he also spends at least 2 hours per day engaged in some type of outdoor physical activity. On physical examination, you discover a translucent waxy papule with raised borders on the posterior aspect of his left shoulder. Which of the following is true of this patient's skin condition?

A. It is the most common malignancy in the United States.

A24-year-old female presents to your office for excision of a nevus. After obtaining consent and prepping the site, you anesthetize the area with 1% lidocaine. However, as you start the procedure, you note that the patient is not sufficiently anesthetized. Your partner suggests the use of lidocaine with epinephrine. The addition of epinephrine with local anesthetics is useful because of which of the following properties?

A. It prolongs and increases the depth of local anesthesia.

Which of the following mycoplasmas has been implicated as a cause of nongonococcal urethritis (NGU)?

A. Mycoplasma hominis

A 21-year-old college student complained of malaise, low-grade fever, and a harsh cough, but not of muscle aches and pains. An x-ray revealed a diffuse interstitial pneumonia in the left lobes of the lung. The WBC count was normal. The student has been ill for a week.Based on the information given, the most likely diagnosis is

A. Mycoplasma pneumonia

Which of the following measures is used frequently as a denominator to calculate the incidence rate of a disease?

A. Number of cases observed

A 72-year-old man with a diagnosis of prostate cancer was recently seen in the clinic for restaging and reevaluation. His bone scan showed development of widespread osseous metastases and his PSA was rising. He was started on leuprolide acetate, a gonadotropin releasing-hormone (GnRH) agonist. He now returns to the clinic complaining of new severe mid-thoracic back pain, which is worse with recumbency and worse with Valsalva maneuver. He also reports that he has a brief but intense electric shock sensation in his lower extremities when he bends over to tie his shoes. On physical exam, he had localized tenderness over the mid-thoracic spine, but his motor strength, sensation, and deep tendon reflexes are all intact. What is the most appropriate next step?

A. Obtain an MRI of the thoracic spine.

The use of oral contracep tives will have the most impact on gynecological mortality by reduc ing the risk for which of the follow ing cancers?

A. Ovarian

The antibiotic of choice for streptococcal pharyngitis is

A. Penicillin

A 72-year-old diabetic is transferred to your hospital for fever and altered mental status in the late summer. Symptoms started in this patient 1 week prior to admission. On physical examination, the patient was disoriented. There were no focal neurologic findings. There was a fine rash on the patient's trunk. On oral examination, there were tongue fasciculations. A lumbar puncture was performed which showed a glucose of 71 and a protein of 94; microscopy of the cerebrospinal fluid (CSF) revealed 9 RBC and 14 WBC (21 P, 68 L, 11 H). The creatinine phosphokinase was 506. An electroencephalogram and MRI of the brain were normal. What further diagnostic test is the most appropriate?

A. Perform a West Nile virus IgM on the CSF.

Broad-spectrum penicillin with antipseudomonas activity is

A. Piperacillin

A woman, recently returned from Africa, complains of having paroxysmal attacks of chills, fever, and sweating; these attacks last a day or two at a time and recur every 36 to 48 h. Examination of a stained blood specimen reveals ring-like and crescent-like forms within red blood cells. The infecting organism most likely is

A. Plasmodium falciparum

Which of the following causes a fatal encephalitis for which a vaccine is available?

A. Rabies

Which of the following is the most common cause of pediatric gastroenteritis? It is difficult to grow in cell culture but can be detected easily by immunologic methods (ELISA).

A. Rotavirus

Culture of the menstrual fluid in the case cited would most likely reveal a predominance of

A. S. aureus

A 28-year-old menstruating woman appeared in the emergency room with the following signs and symptoms: fever, 104°F (40°C); WBC, 16,000/μL; blood pressure, 90/65 mmHg; a scarlatiniform rash on her trunk, palms, and soles; extreme fatigue; vomiting; and diarrhea.The patient described in the case above most likely has

A. Scalded skin syndrome

S. aureus has a distinctive appearance on which one of the following media?

A. Sheep blood agar

A primary procedure for diagnosis of fecal parasites is a stained smear of feces. For some parasitic infections, however, other specimens may be more productive. G. lamblia is best diagnosed by

A. Sigmoidoscopy and aspiration of mucosal lesions

E. histolytica infection is best diagnosed by

A. Sigmoidoscopy and aspiration of mucosal lesions

The most common portal of entry for C. tetani, the cause of tetanus, is the

A. Skin

A 63-year-old male presents to your office with palpitations for the past 3 weeks. He has had no chest pains or dyspnea. He has no significant medical history and takes no medications. He does not smoke cigarettes and a recent lipid panel was normal. On examination, he is in no apparent distress. His pulse is 115 bpm and irregular. His BP is 125/77. His lungs are clear and his cardiac examination reveals an irregularly irregular rhythm with no murmurs, rubs, or gallops. An abnormal result of which of the following laboratory tests would be most likely to explain the cause of this condition?

A. TSH

The cerebral cortex forms from which of the following?

A. Telencephalon

A 64-year-old male with a history of hypertension and tobacco abuse presents for follow-up after a routine physical during which he was found to have 45 red blood cells (RBCs) per high-power field (HPF) on a screening urinalysis. The urinalysis was negative for leukocytes, nitrites, epithelial cells, and ketones. The patient denies any complaints and the review of systems is essentially negative. In detecting microscopic hematuria, which of the following is true?

A. The office urine dipstick is 91100% sensitive and 6599% specific for detection of RBCs, Hgb and myoglobin.

A survey of 100 healthy adults reveals that 80% have IgG antibodies to Toxoplasma. Which one of the following statements would help to explain this finding?

A. The potential for Toxoplasma infection is widespread and the disease is mild and self-limiting

A bacterium is examined and is found to lack superoxide dismutase, catalase, and peroxidase. Which of the following statements best describes this bacterium?

A. This bacterium is an anaerobe

A fur trapper complains of sore muscles, has swollen eyes, and reports eating bear meat on a regular basis. He is at risk for

A. Trichinosis

A 4-year-old is brought to your office by his mother for evaluation. She is concerned because the child has been spiking fevers and pulling on his left ear. Your examination reveals a bulging and erythematous tympanic membrane (TM). You determine that the child should receive antibiotics. The initial antibiotic of choice should be?

A. amoxicillin

A 64-year-old male has been suffering from lower back pain for over 10 years. You have been following him for this period. You have prescribed stretching exercises and, occasionally, an anti- inflammatorymedication to alleviate his pain. Although he has had no neurologic deficits in the past, today he has shown up in your office unexpectedly, complaining of bilateral lower back pain with numbness and tingling over the dorsal aspect of both feet. His symptoms have become progressively worse over the past 2 weeks and he is now unable to stand for more than 5 minutes without developing extreme pain and numbness. His symptoms are much improved by sitting down or kneeling over a chair. Climbing stairs seems to be tolerated well, but walking greatly exacerbates the pain. He denies bladder or bowel incontinence or retention, point tenderness or anesthesia in the lower back along the spinal cord or in the saddle area. Which of the following imaging studies would be most helpful to confirm the diagnosis?

A. an MRI of the lumbosacral spine

You see a 31/2-year-old child in the emergency department who has had fever for the past week. The parents relate that their son has some swollen glands, fever, and now seems to be getting a rash on his arms. On examination, you find an uncomfortable appearing young boy whose vital signs are normal with the exception of a temperature of 104°F. You note t hat he has a red posterior oropharynx with dry, cracked lips. His TMs are normal. He has mild conjunctival injection bilaterally without any discharge. His chest is clear, and his heart sounds are normal. He does not have any hepatosplenomegaly. His has a lacy, confluent macular rash on his chest and upper arms, with mild peeling of the tips of his fingers.Which laboratory result would be most consistent with the diagnosis?

A. an elevated platelet count

Gastrin secretion is enhanced by which of the following?

A. antral distention

A 16-year-old sexually active woman is being seen in the emergency department. She is complaining of vaginal discharge. She has a temperature of 99.5°F, but is otherwise well. On pelvic examination, you see a mucopurulent cervical discharge with scant blood. Samples of the discharge are sent to the laboratory for culture. There are no cervical ulcers noted. She does not have any medical allergies. For this patient, what is the most appropriate regimen for initial therapy?

A. azithromycin (Zithromax) 1 g orally once and ceftriaxone (Rocephin) 125 mg intramuscular (IM) once

While working in the emergency department in the winter, you examine a 3-week-old female infant. The baby is accompanied by her mother and father. They report that the baby has been congested for the past 24 hours. The parents have been taking the infant's temperature rectally and report that it has been normal. The infant was a born at 35 weeks' gestation and was delivered by caesarian due to preeclampsia. On examination, you see a well-appearing infant with a respiratory rate (RR) of 46 and a heart rate (HR) of 112. The TMs are normal and the lung fields are clear to auscultation. The mother relates that she has had a "cold" for the past few days. The father reports that he smokes, but only outside. As part of your evaluation you perform a nasopharyngeal swab for RSV antigen, which comes back positive. The best course of action for this infant is which of the following?

A. full sepsis workup with empiric intravenous antibiotic

A 50-year-old man comes to the emergency room (ER) with a history of vomiting of 3 days' duration. His past history reveals that for approximately 20 years he has been experiencing epigastric pain that lasts for 23 weeks during spring and autumn. He remembers getting relief from pain by taking milk and antacids. Physical examination showed fullness in the epigastric area with visible peristalsis, absence of tenderness, and normal active bowel sounds. What is the most likely diagnosis?

A. gastric outlet obstruction

A 46-year-old female presents to your office with rectal bleeding, itching, and irritation. On examination, a 3-cm ulcerating lesion is seen in the anal canal. Biopsy of the lesion reveals squamous cell carcinoma (SCC). Which of the following is the most appropriate treatment?

A. chemotherapy and pelvic radiation protocol

A 45-year-old male receives a cadaveric liver transplant for alcoholic cirrhosis. Postoperatively, the patient is taken to the surgical intensive care unit (SICU). There is concern for primary nonfunction of the allograft. Which of the following is a sign of this?

A. coagulopathy with an INR of 2

A37-year-old woman (gravida 3, para 3) presents with a 4-month history of postcoital spotting On pelvic examination, you visualize a 2-cm friable lesion on the anterior lip of the cervix. The next most appropriate step is which of the following?

A. colposcopy

A15-year-old female presents to the emergency room (ER) with acute onset right lower quadrant pain and nausea. She recently became sexually active and is "in the middle" of her menstrual cycle. Physical examination is notable for generalized guarding, rebound, and 8/10 pain in both lower quadrants. A pelvic examination shows no vaginal discharge, a normal appearing cervix, and general pelvic tenderness, but the examination is limited by the patient's guarding. Her complete blood count is notable for a borderline elevated white blood cell (WBC) count, and a urinary -hCG is negative. Pelvic ultrasound shows a 2-cm simple appearing cyst on the right ovary and a mild amount of fluid in the cul-de-sac. Acomputed tomographic (CT) scan cannot definitively visualize the appendix, confirms the presence of a 2-cm cystic structure in the right ovary, and otherwise notes normal anatomy. Which of the following is the most appropriate next step?

A. diagnostic laparoscopy

Which of the following structures can be found outside of the spermatic cord during a hernia repair?

A. direct hernia sac

A 70-year-old male is seen in the office for chest pain. He reports that he is getting substernal chest pain, without radiation, when he mows his lawn. The pain resolves with 1015 minutes of rest. He has never had pain at rest. He has no other cardiac complaints and his review of systems is otherwise negative. He has an unremarkable medical history and takes only a baby aspirin a day. On examination, his blood pressure is 160/70, pulse 85, and respiratory rate 16. His cardiac examination is notable for a harsh, 3/6 systolic ejection murmur along the sternal border that radiates to the carotid arteries. His carotid pulsation is noted to rise slowly and is small and sustained. His lungs are clear. The remainder of his examination is normal. Which of the following would be the most appropriate test to order next?

A. echocardiogram

A35-year-old woman with two prior term pregnancies presents for her first prenatal visit at 12 weeks' gestation. She recalls having had hypertension near the end of her first pregnancy. She believes her blood pressure has been normal since, but admits that she rarely seeks preventive health care visits, and that her last examination by a physician was more than 2 years ago. Today, you find her blood pressure to be 160/100. Her blood pressure comes under good control after initiating medication and remains well controlled until the 36th week, when her blood pressure is noted to have risen again to 170/110. She is also noted to have 3+ proteinuria on urine dipstick testing. For which of the following complications is she at risk?

A. eclampsia

A64-year-old man with a long history of smoking but no significant past medical history presents to his physician's office complaining of a 12 week history of worsening dyspnea, facial swelling, and discoloration. He has also had swelling and discomfort of his right arm. Physical examination reveals edema with plethora of the face and right arm, with prominent collateral veins over the chest wall. Following the establishment of a diagnosis, what is the most appropriate initial therapy?

A. elevation of the head and monitoring for airway obstruction

On a Monday morning you see a 12-year-old otherwise healthy boy in the emergency department. The parents brought the boy in because they noticed that he started to have an abnormal gait in the past few days. He seems to be shuffling his feet. The boy complains that his legs feel heavy and are tingling. He relates that his arms feel fine. His past history is significant for attention deficit/hyperactivity disorder (ADHD) for which he is taking methylphenidate. He denies trauma or taking any other medicines or drugs. On examination, he is afebrile with normal vital signs. His entire physical examination is normal with the exception of the examination of is lower extremities. He has 3/5 strength throughout both of his lower extremities with a normal muscle mass. His all joints have a full range of motion, without any pain or swelling. His reflexes are absent and he describes some paresthesias of his feet and ankles Which of the following is the most appropriate initial management plan?

A. hospitalization and close observation for progression of his weakness

A32-year-old female presents for her first pap smear in more than 10 years. She has a history of heavy alcohol use and IV drug use and has performed sexual acts for drugs on numerous occasions. Testing performed today reveals her to have chlamydia cervicitis and trichomonas vaginalis and to be seropositive for hepatitis B and hepatitis C. HIV testing is negative. Her pap smear subsequently returns with carcinoma in-situ of the cervix. Infection with which of the following agents is most likely to have resulted in her cancer?

A. human papillomavirus type 16

A well-appearing 6-year-old presents to your office with a chief complaint of bruising. The parents report that the child had a cold 2 weeks ago but completely recovered. The child is sitting on the examining table, in no distress, discussing her favorite cartoons. On examination, you find mucosal bleeding and bruises on the child's arms and chest. You order a complete blood count (CBC) that has the following results: WBC 12,000, hemoglobin 11 g/dL, and a platelet count of 45,000. What is the most likely cause of this child's bleeding and bruising?

A. immune thrombocytopenic purpura (ITP)

A 35-year-old woman schedules an appointment in an outpatient clinic for evaluation and treatment of a "mouth problem." She says that she has white spots in her mouth that have been present for a few weeks. In response to your questioning, she states that she has been experiencing fatigue and a 20-lb weight loss over the past several months, although she attributes these symptoms to a dramatic increase in work hours at her job over the same period of time. She denies having any other chronic medical issues and does not use any prescription or OTC medications. As you examine her, you note the presence of white plaques on her buccal mucosa, palate, and tongue. Scraping of the plaques with a tongue depressor elicits pain as well as a small amount of bleeding. Nontender generalized cervical and submandibular lymphadenopathy is present. Which of the following immunizations is safe to administer to this patient?

A. inactivated influenza vaccine

A mother brings her 15-year-old son in for a preparticipation sports physical examination. She feels that her son has not yet undergone pubertal changes and that makes her concerned. Which of the following physical examination findings is usually the first sign of the onset of puberty in males?

A. increased testicular volume

A 54-year-old male with uncontrolled type II diabetes and well-controlled hypertension presents with complaints of erectile dysfunction. The patient requests Viagra (sildenafil), as his friends have used it with success. However, he is concerned as he was told by someone that Viagra can be fatal if used with some blood pressure medications. You would advise the patient that the use of which of the following is contraindicated in patients taking sildenafil?

A. isosorbide mononitrate

You are asked to perform a high school physical examination for a 16-year-old female patient. She is on the track team. By history, she is healthy except for the fact that she has been amenorrheic for 4 months. She denies current or past sexual activity. On examination, she is 5 ft 9 in. tall and weighs 115 lbs. Her heart rate is 50 bpm. She has dry skin with lanugo. She has several sores in her mouth and obvious dental caries. She has several scratches on the backs of her hands. She is tanner stage III on breast examination. Her pelvic examination is remarkable for findings of urogenital atrophy. Her urine -hCG is negative. At this point in time, appropriate management of this patient would include which of the following?

A. laboratory assessment of electrolytes and an electrocardiogram

A19-year-old male who moved to your city 3 months ago comes to your office complaining of dry cough for the past 23 months. Along with the cough, he has had some shortness of breath with exertion. He denies fever, chills, nausea, vomiting, wheezing, and sneezing. The cough occurs mostly in the morning and improves as the day goes on. He denies similar complaints in the past and has no history of allergies. He says that his father had eczema and an allergy to eggs. You order a CXR. Which of the following are you most likely to find?

A. normal

Several days following an uneventful laparoscopic cholecystectomy, the pathology report reveals gallbladder cancer that is invasive into the submucosa of the specimen. The most appropriate management is which of the following?

A. observation and close follow-up

A 34-year-old male undergoes an uneventful excision of a parathyroid adenoma. The following postoperative day, he complains of numbness around his lips. Which of the following is the most appropriate intervention?

A. oral calcium gluconate

A 54-year-old male presents to the ED with acute onset of severe abdominal pain. His history is significant for gnawing epigastric pain that radiates to the back for several months. Physical examination demonstrates mild hypertension and tachycardia as well as a rigid "board like" abdomen with generalized rebound tenderness and hypoactive bowel sounds. Rectal examination reveals dark hemoccult positive stools without gross blood. Which of the following would be the next appropriate step in management?

A. order upright chest and abdomen x-rays

A newborn male is brought to you in the neonatal intensive care unit (NICU). On physical examination, you notice that the infant has deficient abdominal musculature and undescended testes. Your suspicion is high for a certain condition. Upon further imaging, what associated finding would be expected?

A. posterior urethral valves on a voiding cystourethrogram (VCUG)

A 32-year-old woman presents with complaints of irritability, heat intolerance, hyperdefecation, and frequent palpitations. She has lost 20 lb over the past six months. She has always been in good health and does not take any prescription or OTC medications. She denies any prior history of thyroid disease or exposure to head/neck irradiation, but she states that one of her relatives was diagnosed with a thyroid disorder at roughly the same age. Vital signs are as follows: BP 138/78, HR 112, RR 22, temp. 98.8°F. On examination, her thyroid is diffusely enlarged and smooth. Auscultation of the thyroid reveals a bruit. Her hair is fine in texture, and she has warm velvety skin. She has hyperactive deep tendon reflexes. There is a fine tremor in her outstretched hands. Which of the following interventions is most appropriate at this time?

A. propylthiouracil

You are called to the ER to assist with a series of trauma patients who arrived following a multiple vehicle accident. You are assigned to a 22-year-old male who was an unrestrained driver involved in a head-on collision. After you confirm the presence of an adequate airway and equal breath sounds bilaterally, you address his hypotension and tachycardia by giving 2 L of lactated Ringer's solution. His pulse remains elevated at 130 and his blood pressure is 92/55. His pelvic x-ray returns and demonstrates a widening of the pubic symphysis. In addition to continued fluid resuscitation, what is your next step in management?

A. reduce the pelvic volume with a sheet or pneumatic compression garment

Biopsy of a 4-cm sessile polyp of the cecum during a routine screening colonoscopy reveals it to be a villous adenoma with atypia. Attempt at piecemeal snare polypectomy through the colonoscope is unsuccessful. Which of the following is the most appropriate management?

A. right hemicolectomy

A20-year-old male has had a recent wide local excision of a 1.5 mm melanoma from the right ankle. There is no evidence of metastatic disease. The most important prognostic factor for this patient is which of the following? Which of the following interventions is most appropriate in addition to wide local excision of the patient's melanoma?

A. sentinel lymph node biopsy

A32-year-old female presents for her first pap smear in more than 10 years. She has a history of heavy alcohol use and IV drug use and has performed sexual acts for drugs on numerous occasions. Testing performed today reveals her to have chlamydia cervicitis and trichomonas vaginalis and to be seropositive for hepatitis B and hepatitis C. HIV testing is negative. Her pap smear subsequently returns with carcinoma in-situ of the cervix. Subsequent work-up confirms the presence of micro-invasive cervical carcinoma [Stage Ia]. What would be the most appropriate treatment?

A. simple hysterectomy

A 35-year-old woman presents to your office complaining of fatigue and global achiness. She states that she has "not been myself" since she developed a bad whiplash after a motor vehicle accident. Her health has otherwise been good. About 3 years ago, she saw a cardiologist for chest pain. A full evaluation ensued including heart catheterization that showed no coronary disease, although her cholesterol levels were elevated and a statin was prescribed. She sleeps poorly and notes that she has gained a considerable amount of weight. She has seen a gastroenterologist who has told her that her abdominal pain and alternating constipation and diarrhea are because of irritable bowel syndrome. Physical examination shows that her height is 5 ft 2 in. and her weight is 240 lb. Blood pressure is 126/78. Pulse is 86 and regular. Heart and lung examinations are completely normal. Her pharynx is normal and she has no lymphadenopathy. Abdominal examination shows diffuse mild tenderness, but no masses, rebound, guarding, or organomegaly. Rectal and pelvic examinations are normal. Muscular strength is 4/5 distally and proximally, but there is a considerable give way secondary to pain. She is tender bilaterally at the occiput across the trapezius, iliac crest at the greater trochanteric, anserine bursae bilaterally, and at the second intercostal space bilaterally. In this patient, which of the following conditions may also be exacerbating her symptoms?

A. sleep apnea

Parents bring you a 9-month-old boy they recently have adopted from western Russia. They have sparse medical records of the child's past. They do know that the boy was the result of a sexual assault on the mother and was given up at birth. The child has been in a "baby home" for 5 months. The records which accompanied the boy indicate that there had been some testing done. These tests include HIV, hepatitis B and C serologies, and a rapid plasma reagin (RPR), all of which are negative at 8 months of age. There is what appears to be a Russian immunization record as well. It seems to indicate that the child has had three diphtheria, tetanus, pertussis (DTP), three oral polio, and three hepatitis B vaccinations. There is also an indication that BCG (Bacille Calmette-Guérin) was given. The parents are concerned about fetal alcohol syndrome (FAS). Which physical feature is most consistent with FAS?

A. smooth philtrum

A20-year-old male has had a recent wide local excision of a 1.5 mm melanoma from the right ankle. There is no evidence of metastatic disease. The most important prognostic factor for this patient is which of the following?

A. the Breslow depth of the tumor

Avascular necrosis is most likely to occur in fracture dislocations involving which of the following?

A. the femoral head

A 10-year-old male has a history of seizures which are controlled with dilantin. The child also has asthma and often uses an albuterol inhaler. Which of the following asthma medications can lower the seizure threshold in children?

A. theophylline

A27-year-old female whose father had a colon resection for adenocarcinoma undergoes her first colonoscopy. Over 100 small polyps are seen distributed mainly in her sigmoid and rectum. Multiple polyps are removed and histologic review reveals tubular adenomas with no evidence of atypia or dysplasia. The most appropriate next step in her management is which of the following?

A. total proctocolectomy with ileoanal J pouch reconstruction

A patient presents with a new neck mass. On examination, she has a palpable thyroid nodule and a palpable cervical lymph node on the same side. Needle biopsy of the thyroid nodule shows amyloid in the stroma. The treatment for this patient is which of the following?

A. total thyroidectomy and modified neck dissection

A mobile mass is found on rectal examination in a 77-year-old male with complaints of blood in his stool. On workup, he is found to have a stage I (Dukes' A), well differentiated adenocarcinoma. The most appropriate intervention is which of the following?

A. transanal excision

A38-year-old woman presents to the ER with heavy vaginal bleeding. A pelvic examination using a speculum to visualize the cervix reveals a large, friable, fungating cervical mass. On bimanual examination, the mass extends to the right pelvic sidewall. A biopsy from a recent gynecologic visit reveals invasive squamous cell carcinoma of the cervix. An abdominal/pelvic CT scan shows enlarged pelvic lymph nodes and right hydronephrosis. Her hematocrit (HCT) in the ER is 24%, but she is hemodynamically stable with a BP of 124/70 and a pulse of 73. The cervical mass is actively bleeding. Which of the following is the most appropriate immediate management of the vaginal bleeding in the ER?

A. vaginal packing soaked with Monsel solution

A 48-year-old woman complaining of dysuria is diagnosed with a UTI by urinalysis. Urine culture and sensitivities reveal that the causative organism belongs to the genus Klebsiella and is resistant to multiple antibiotics. Based upon the results available, you decide to begin therapy with gentamicin. Which of the following irreversible complications is also associated with gentamicin use?

A. vestibular dysfunction

A 48-year-old woman with metastatic breast cancer presents to the Emergency Center complaining of a 4 day history of nausea, anorexia, and generalized weakness. Her husband reports that she has been more somnolent, sleeping 1214 hours per day, and at times she seems confused. CT scan of the brain revealsno abnormalities. Initial laboratory evaluation reveals a normal CBC, but her BUN is elevated at 32 mg/dL with a slight elevation of serum creatinine above her baseline. Her serum calcium is elevated at 15 mg/dL. What is the most appropriate initial therapy for the patient's hypercalcemia?

A. volume resuscitation with normal saline

Which one of the following organisms normally inhabits the healthy human oral cavity?

B. M. orale

A motor cyclist involved in a road traffic accident sustained an injury to the brachial plexus on the right side. He is found to have weakness of right shoulder abduction and forearm flexion, as well as some sensory loss over the lateral aspect of his upper arm. The right biceps and brachioradialis reflexes are absent. What is the likely level of maximal plexus injury?

B- C5,6 root

Which of the following tumour-associated antigens is linked with the correct cancer?

B- CA 19-9: Pancreatic cancer

You review a 16-year-old boy who has a history of Type 1 diabetes. He is doing a project at his school on aspects of the human immune system and asks about the function of T lymphocytes and how they interact with other cells in the body. Which of the following fits best with the action of the immune system?

B- CD4 T cells interact with B cells via MHC class II

A middle-aged woman is referred to you by her GP with a 6-month history of increasing breathlessness on exertion. Her son is affected with Duchenne's muscular dystrophy, as was her brother. What would you be concerned about in her?

B- Cardiomyopathy

In estimating the physiological clearance of 10 ml of an intravenous substance which has been administered at 10 mg/ml, the plasma concentration at equilibration is 15 mg/litre, the urine concentration is 150 mg/litre and the subject produces 1440 ml of urine during aIn estimating the physiological clearance of 10 ml of an intravenous substance which has been administered at 10 mg/ml, the plasma concentration at equilibration is 15 mg/litre, the urine concentration is 150 mg/litre and the subject produces 1440 ml of urine during a24h collection. The substance is not actively secreted or absorbed by the kidney. What is the clearance of the substance?

B- 10 ml/min

You are asked to see a 45-year-old man who is haemodynamically compromised and plan to insert a right subclavian line. He has a body mass index (BMI) of 38, where is the correct position for central venous cannulation?

B- 2 cm under the mid-point of the clavicle and 1 cm laterally

A man who has autosomal recessively inherited common variable immunodeficiencywould like to start a family. His partner does not have the disease. What is the percentage that his children will inherit his disease?

B- <5%

You are asked to review a young man with short stature, short fifth metacarpals, subcutaneous calcification, intellectual impairment and hypocalcaemia. Given the likely clinical diagnosis, mutation resulting in the dysfunction of what structure is most likely?

B- A G-protein linked to the PTH receptor

A 25-year-old man is referred to a dermatologist with fleshy nodules on the backs of his elbows. He also has yellow linear deposits in his palmar creases. His fasting serum lipids are: cholesterol 14.2 mmol/l, triglycerides 16 mmol/l. Fasting plasma glucose and thyroid function tests are normal. In addition to dietary and lifestyle advice, what would be the most appropriate treatment?

B- A fibrate

Which of the following takes place during inspiration?

B- A negative pressure of 1-3 mmHg is created

Antibodies to which of the following are found in patients with myasthenia gravis?

B- Acetylcholine receptors

You review a 21-year-old man with albinism. He is from Central/ South America and you believe that he has Hermansky-Pudlak syndrome (HPS). You believe that this is due to a defect in the transport of glycoproteins from the Golgi body. Which of the following best fits the position of the Golgi body within the cell?

B- Adjacent to the endoplasmic reticulum

Which one of the following statements BEST describes a patient with Wilson's disease?

B- An alternative diagnosis should be considered if chorea occurs with no evidence of Kayser-Fleischer rings

You are researching a new agent for the management of hypoxia related to acute pneumonia. Part of the assessment includes changes in the pulmonary vasculature in response to hypoxia. When considering acute hypoxia, which of the following is true of the pulmonary vasculature?

B- An area of lung unaffected by pneumonia is likely to experience vasodilatation

A patient with type 1 diabetes presents to clinic for review and says he has read about cloning as a cure for diabetes mellitus. He asks you about the mechanism. Which of the following best describes the mechanism currently used for cloning?

B- An enucleated oocyte is fused with the nucleus from a donor cell

Which one of the following features in an adult patient presenting with porphyrinuria would most suggest lead poisoning rather than acute intermittent porphyria as a cause?

B- Anaemia

A dental practice nurse is admitted for an elective operation. During induction with a general anaesthetic she develops tachycardia, rash and diffuse wheeze. She had mentioned that she has had rashes when assisting with anaesthetics at work. What is the likely diagnosis?

B- Anaphylaxis

A 56-year-old woman sustains a myocardial infarction. ST elevation and Q waves are present in leads V4-V6 , I and AVL. Which of the following aspects of the heart is most likely to have been involved in the infarct?

B- Anterolateral

A medical SHO is required to give a blood sample to check his HepB status. He received a course of vaccinations nine months ago. What is his blood test likely to show?

B- Anti-HBsAb

A 36-year-old woman with an eight month history of Raynaud's phenomenon presents to the emergency room with new onset precordial chest pain. Physical examination reveals a pericardial friction rub and her CPK is elevated 5 times above the upper normal limit, but the MB isoenzyme is negative. The immunology profile reveals a positive ANA test at 1:640 with a speckled staining pattern. The MOST appropriate immunology test at this stage is?

B- Anti-ribonucleoprotein (anti-RNP antibody)

A 50-year-old man is referred by his GP with general ill health. An autoimmune screen reveals high titres of anti-smooth muscle antibodies. Which of the following conditions is suggested by this autoantibody profile?

B- Autoimmune hepatitis

Which of the following statements is most consistent with the Crigler-Najjar syndrome?

B- Autosomally inherited, severe unconjugated hyperbilirubinaemia

A 61-year-old patient who suffered a humeral fracture after falling off a ladder presents for review after being in a cast for the past 8 weeks. He presents with weakness in the deltoid, and sensory loss over the deltoid region. Which of the following is the most likely underlying lesion?

B- Axillary nerve injury

Which of the following statements is true concerning immunity to bacteria?

B- Bacteria opsonised by antibodies and complement are more effectively phagocytosed than those opsonised by antibodies alone

You are reviewing a man who has paid privately for HLA tissue typing. He is found to be HLA B5-positive on typing.Which of the following diseases is most closely associated with HLA B5?

B- Behçet's syndrome

A 71-year-old man presents with fatigue and breathlessness. The results of initial investigations include a serum creatinine concentration of 654 mmol/l. Which of the following best suggests a specific cause for his renal failure?

B- Bence Jones proteinuria

A 21-year-old male medical student who has been feeling non-specifically unwell for several days is noticed to have slightly icteric sclerae by his girlfriend and has liver function tests performed. The results of these are normal apart from a serum bilirubin concentration of 44 mmol/l (3-17). His urine does not contain bilirubin. Which of the following is the most likely diagnosis?

B- Gilbert's syndrome

A 68-year old man undergoes a routine health check-up, which includes various laboratory investigations. He has abnormal results as follows: fasting blood glucose 5.6 mmol/l; urea 7.2 mmol/l; alkaline phosphatase activity 176 U/l (upper limit of reference range 150); TSH 9.1 mU/l; creatinine clearance (calculated) 70 ml/min. Which one of the following parameters can be regarded as a normal result of ageing?

B- Glomerular filtration rate

A 21-year-old man is alarmed to find that his urine has become unusually dark 2 days before he is to leave on a backpacking holiday in South-East Asia . He consults his GP, who observes that he is slightly jaundiced. Deficiency of which of the following enzymes could best explain these clinical features?

B- Glucose 6-phosphate dehydrogenase

A 45-year-old man presents with prognathism and interdental separation. Which of the following is the most appropriate investigation?

B- Glucose tolerance test including growth hormone measurement

Which of the following definitely excludes IgG subclass deficiency?

B- Good IgG antibody responses to immunisations

A 25-year-old man is found to have a fasting serum triglyceride concentration of 4.2 mmol/l at a routine examination for life insurance. His serum cholesterol concentration is 5.4 mmol/l; liver function tests are normal apart from a g-glutamyltransferase activity of 74 U/l (upper limit of normal, 55 U/l). He claims to be in good health but has a history of epilepsy for which he is taking sodium valproate. His body mass index is 24 kg/m2. What is the most likely cause of the abnormal findings?

B- Hepatic steatosis secondary to alcohol

A 40-year-old man presents with a purpuric rash on his lower limbs. You request cryoglobulin screening. The report indicates a moderate amount of a mixed cryoglobulin, having both a monoclonal and a polyclonal component. With what are these typically associated?

B- Hepatitis C

A 72-year-old woman is found to have a serum calcium concentration of 3.12 mmol/l.Which of the following clinical features, if present, would most direct you towards a specific cause?

B- Hilar lymphadenopathy

A 38-year-old woman with type-1 diabetes reports at her regular clinic review that she has been experiencing frequent episodes of hypoglycaemia during the previous 6 months, despite reducing her overall dose of insulin by almost 50%. Her Hb A1c in the clinic is 5.6%, having been 6.8 % a year previously. She also says she has lost some weight and that her periods are becoming scanty and irregular, and wonders if she is having an early menopause. Gonadotrophin concentrations are in the normal early follicular range. What is the most likely cause of the reduction in her insulin requirement?

B- Hypopituitarism

Which of the following is not typically a cause of hypercalcaemia?

B- Hypothyroidism

A 38-year-old builder's labourer sustained a severe fracture of his left elbow, which damaged the ulnar nerve behind the medial epicondyle of the humerus. A month later, he still has a total ulnar nerve paralysis. Which clinical sign is most likely to be present on examination?

B- Inability to grip a sheet of paper between his fingers when the hand is placed flat on the table

You are asked to assess the cardiovascular risk status of a man with the insulin-resistance syndrome. Which of the following pathophysiological changes are most strongly associated with increased insulin resistance?

B- Increased levels of Plasminogen activator inhibitor-1 PAI-1

A 32-year-old man is referred to a dermatologist with soft, fleshy lumps over his elbows. Examination also reveals that he has yellow fat deposits in his palmar creases. His (fasting) serum cholesterol concentration is 12.4 mmol/l, triglyceride 14.2 mmol/l. Which of the following groups of lipoprotein particles is likely to be present in excess?

B- Intermediate-density lipoproteins (IDL)

A 56-year-old woman with known metastatic breast cancer presents to A&E with a calcium concentration of 3.22 mmol/l. Which of the following is the most appropriate initial management?

B- Intravenous infusion of 0.9% sodium chloride ('normal saline')

Which one of the following statements best applies to renal tubular acidosis type 4?

B- It is a recognised complication of diabetes mellitus

Which of the following is true of the Churg-Strauss syndrome?Which of the following is true of the Churg-Strauss syndrome?

B- It is likely to be associated with a history of asthma and atopy over a few years before the diagnosis is made

You are reviewing a 45-year-old woman whois suffering from multiple sclerosis and are considering prescribing beta-interferon for her. Which of the following best describes the action of beta-interferon?

B- It leads to increased MHC class-I expression

Which one of the following inherited diseases is due to mutation in mitochondrial DNA?

B- Leber's optic neuropathy

Multiple members from a large family suffer from an autosomal-dominant disorder. Although the gene for the condition is known, a mutation has not been found in the family. One of the family members wants to know if he will develop the disease as his father is affected. Blood samples are available from both affected and unaffected members. Which molecular technique is most useful in this situation?

B- Linkage analysis

A 28 year old man, who is a keen bodybuilder, presents with a short history of left upper limb discomfort and difficulty in moving his shoulder. On examination he is noticed to have winging of the left scapula. There is no wasting of the shoulder girdle muscles. With stabilisation of the scapula, he has a full range of movement and is able to elevate the shoulder. Sensory testing is normal, as are upper limb reflexes. What is the likely anatomical origin of his problem?

B- Long thoracic nerve

What would be consistent with femoral nerve damage in a patient with pelvis trauma?

B- Loss of sensation over the anterior-lateral aspect of the thigh

A 21-year-old man takes advantage of his employer's health benefits and undergoes a private health screen. Urinalysis is positive for protein on two occasions, once at the health screen and a later repeated sample at the GP. His serum urea and creatinine concentrations are normal.Which of the following would be the most important investigations to perform next?

B- Measurement of urine protein immediately on getting out of bed in the morning

A 49-year-old woman has been complaining of a tingling feeling in her right hand at night and is under the impression that her hand is swollen although there is no obvious oedema. In the last few days she has noticed numbness in her right index finger and the tip of her thumb, especially while working. Which nerve is most likely to be responsible for her symptoms?

B- Median nerve

You review a 28-year-old man with a family history of early thyroid carcinoma and phaeochromocytoma. Your patient has been searching on the internet and has found information about the RET proto-oncogene. The proto-oncogene RET causes which thyroid cancer?

B- Medullary

A 24-year-old, unconscious man is admitted to A&E. No history is available. The results of arterial blood gas analysis are: [H+] 80 nmol/l (pH 7.1), p(CO2) 7.0 kPa, p(O2) 8.2 kPa, [HCO3-] 17.1 mmol/l. These results indicate which one of the following acid-base disturbances?

B- Mixed metabolic and respiratory acidosis

You are investigating a 24-year-old woman with pyrexia of unknown origin, and a diagnosis of systemic lupus erythematosus (SLE) may need to be excluded. What negative test virtually excludes the condition?

B- Negative ANA and negative anti-Ro antibodies

A 19-year-old woman is referral to you with a blood pressure of 180/130 mmHg. On examination she has cafè-au-lait patches and some axillary freckling. She required surgery for scoliosis as a child. What is the most likely underlying diagnosis?

B- Neurofibromatosis type 1

In an elderly patient found to have a large IgM-kappa paraprotein, which of the following helps to decide that it is related to Waldenstrom's macroglobulinaemia?

B- No isotype suppression (normal IgG and IgA levels)

Where does RNA splicing occur?

B- Nucleus

In a patient with suspected hereditary angio-oedema (HAE), which of the following is most likely to be helpful in identifying this clinical condition?

B- Persistently low C4 levels, including between attacks

A 32-year-old, 6 ft 7 inch (2.01 m) man is admitted via ambulance from Heathrow airport after a flight from Australia. He is ataxic with double vision and complains of facial numbness. On examination there is left-sided facial numbness, nystagmus, ataxia and Horner 's syndrome. There appears to be some loss of pain and temperature sensation on the right-hand side. Which artery is most likely to be occluded in this case?

B- Posterior inferior cerebellar artery

A 65-year-old smoker with a history of transient ischaemic attacks presents with loss of co-ordination of his right side. On examination there is decreased skin sensation in the right half of his face and the left half of his body. In addition he has a right Horner syndrome. Which vessel is most likely to be involved?

B- Posterior inferior cerebellar artery

Genomic imprinting is seen in which of the following conditions?

B- Prader-Willi syndrome

You are reviewing a young woman who presents with intermittent abdominal pain, depression and anxiety. She has a diagnosis of acute intermittent porphyria. Which of the following statements best fits the production of haem?

B- Protoporphyrin is formed as the penultimate step before haem formation

A 54-year-old Afro-Caribbean man consults his family doctor because of the chest discomfort he first noticed 4 days ago after a session digging in his garden, but which he says is now resolving. He has previously been well, but is being treated with a statin for hypercholesterolaemia, and a thiazide and a calcium-channel antagonist for hypertension. Serum creatine kinase activity is 425 U/l (normal up to 150 U/l); serum troponin-T concentration is normal. What is the most likely explanation for the elevated creatine kinase?

B- Racial variant

A patient with liver cirrhosis develops metabolic alkalosis.What is the most likely pathological mechanism?

B- Reduced urea synthesis

A 72-year-old man presents to A&E with acute retention of urine. He has a serum creatinine concentration of 522 mmol/l. Which of the following features, if present, would help most to identify possibleaetiologies for his renal failure and suggest that it is longstanding?

B- Small kidneys on ultrasound examination

A patient with AIDS develops Pneumocystis jiroveci pneumonia. He is deficient of what immunological component?

B- T cells

A 50-year-old woman, who is a non-smoker, presents with bilateral claudication of her arms when performing tasks such as using a paint-roller when decorating. She is noted to have absent radial pulses and be normotensive. Investigations reveal a raised ESR of 80 mm/h and a CRP of 30 mg/l. What is the most likely diagnosis?

B- Takayasu's arteritis

A hypertensive, heavy smoking, 73-year-old man suffers a massive cardiac infarct following occlusion of his anterior interventricular artery, (anterior descending artery). Angiography is performed to demonstrate the coronary vessels.Which anatomical relationship of these vessels should be borne in mind?

B- The anterior interventricular artery supplies almost all of the left ventricle

Which of the following physiological characteristics relates to the lining of the respiratory tract?

B- The cilia are under the control of a physiological motor, dynein

In the clinical examination of the chest, accurate knowledge of the surface markings of the lungs is essential. Which of the following corresponds to the clinical situation?

B- The oblique fissure of the lung corresponds to the medial border of the scapula when the arm is fully abducted

Regarding the clinical physiology of the adrenal gland in Cushing's disease, which of the following pertains?

B- The zona fasciculata is predominantly controlled by ACTH and is often hypertrophied

A 50-year-old man with a long-standing history of alcohol abuse was admitted to hospital because he was difficult to rouse. On examination he is confused and ataxic. Examination of the eyes reveals nystagmus and ophthalmoplegia. Deficiency of which vitamin is most likely to have caused his symptoms?

B- Vitamin B1

A patient with hypoalbuminaemia is suspected of having a protein-losing enteropathy.Measurement of which of the following in a sample of faeces would be most appropriate to prove this?

B- α1-antitrypsin

A 25-year-old adopted man consults for review. He is interested in having children and is concerned about the possibility of inheritance of genetic disease. Which of the following is most prevalent in northern Caucasians?

B- α1-antitrypsin deficiency (A1AT)

The incidence rate of lung cancer is 120/100,000 person years for smokers and 10/100,000 person years for nonsmokers. The prevalence of smoking is 20% in the community. What is the relative risk of developing lung cancer for smokers compared with nonsmokers?

B. 12

A new test for chlamydial infections of the cervix is introduced. Half of the women who are tested have a positive test. Compared with the gold standard of careful cultures, 45% of those with a positive test are infected with chlamydia, and 95% of those with a negative test are free of the infection. Match with the correct percentage with the epidemiologic terms, Prevalence of chlamydial infection in that community. A new test for chlamydial infections of the cervix is introduced. Half of the women who are tested have a positive test. Compared with the gold standard of careful cultures, 45% of those with a positive test are infected with chlamydia, and 95% of those with a negative test are free of the infection. Match with the correct percentage with the epidemiologic terms, Predictive value of a positive test.

B. 45%

A 25-year-old nulligravid woman presents as a new patient to your gynecology practice. She has recently moved to the area. She is a healthy woman with no medical problems and is currently using oral contraceptives without problems. She informs you that she and her husband are planning to start a family within the next year. On review, you find her family history is unremarkable, but she informs you that her husband's sister has cystic fibrosis. Given that the husband's sister has cystic fibrosis, what is the likelihood that he is a carrier?

B. 67% (2 in 3) chance of being a carrier

Mycoplasmas differ from chlamydiae in that they are

B. Able to grow on artificial cell-free media

Finding HBsAg positive, HBeAg positive, and IgM core antibody pos- itive reflects

B. Acute infection (acute phase)

A 32yearold farmer presents to the emergency room with a crushing injury of the index finger and thumb that occurred while he was working with machinery in his barn. Records show that he received three doses of Td in the past, and that his last dose was given when he was 25 years old. In addition to proper wound cleaning and management, which of the following is the most appropriate prevention intervention?

B. Administration of tetanus toxoid

A22-year-old male presents to an acute care clinic in order to have two genital lesions evaluated. He first noticed the lesions about 2 weeks ago, but delayed seeking medical care because he believed they were harmless due to the lack of any discomfort. He states that he does engage in unprotected sexual intercourse, with the most recent time being 1 month ago. On examination, the glans penis features two distinct nontender papules with elevated edges surrounding ulcerated craters. They each measure 1 cm in diameter. There is also nontender bilateral inguinal lymphadenopathy. Six hours after treating this patient, he calls your office with complaints of new-onset headache, myalgia, and malaise. He also states that he felt feverish immediately prior to calling and measured his temperature, which was 99.8°F. Which of the following is most appropriate at this time?

B. Advise use of acetaminophen and provide reassurance.

The best method for the detection of Strongyloides larvae is

B. Baermann technique

You are working in a community clinic on a Native American reservation. A mother brings in her 8- year-old son for an ophthalmic evaluation. On examination, you find bilateral corneal ulceration and decreased visual acuity. What is the most common infectious cause of blindness in the world?

B. C. trachomatis

Death occurs in 10% of cases of meningococcal meningitis. Choose statement below that match rate above.

B. Case fatality rate

A broad-spectrum antibiotic in the general class of thienamycins is

B. Cefoperazone

Which of the following types of cancer is the most frequent cause of gynecologic cancer deaths?

B. Cervical

Malaria is a significant worldwide public health problem. Which one of the following control methods for malaria is currently effective?

B. Chemoprophylaxis

The treatment of choice for a patient with C. jejuni enterocolitis is

B. Ciprofloxacin

Which of the following organisms may be ingested with raw fish, affects the liver, and has an operculated egg?

B. Clonorchis

A 20yearold patient presents to the office for contraception counseling. Her history reveals no past medical problems. Her physical and pelvic examination is normal. She is sexually active with the same partner for 9 months. Which of the following contraceptive methods would be most appropriate?

B. Combined oral contraceptives

A 50 year old woman comes for her periodical health examination. Her body mass index is 29 kg/m2. Her blood pressure is 120/80. She has no family history of cardiovascular disease. Her total cholesterol is 200 mg/dL (5.2 mmol/L), her HDL is 35 mg/dL (0.9 mmol/L), and her LDL is 100 mg/dL (2.6 mmol/L). This patient is at highest risk for developing which of the following conditions?

B. Coronary artery disease

A research team wishes to investigate a possible association between smokeless tobacco and oral lesions among professional baseball players. At spring training camp, they ask each baseball player about current and past use of smokeless tobacco, cigarettes, and alcohol, and a dentist notes the type and extent of the lesions in the mouth. What type of study is this?

B. Cross sectional

The incidence of H. influenzae meningitis in the general population is less than 1%. If during an epidemic the incidence rose to 3%, the negative predictive value of the LA test would

B. Decrease

A 34-year-old male presents with a penile lesion. Your history, physical examination, and serology confirm a diagnosis of syphilis. The patient reports that his mother told him he was "allergic" to penicillin. He does not recall any personal history of anaphylaxis or rash to antibiotics however he has never been "sick." How would you manage this patient?

B. Do skin testing for penicillin allergy.

A 50 year old woman comes for her periodical health examination. Her body mass index is 29 kg/m2. Her blood pressure is 120/80. She has no family history of cardiovascular disease. Her total cholesterol is 200 mg/dL (5.2 mmol/L), her HDL is 35 mg/dL (0.9 mmol/L), and her LDL is 100 mg/dL (2.6 mmol/L). This patient's weight increases the risk for which of the following cancers?

B. Endometrium, breast, and colon

E. coli causes disease by a variety of different methods. Which one of the following E. coli types is characterized by the presence of LT (heat-labile) and ST (heat-stable) proteins?

B. Enterotoxigenic (ETEC)

Analysis of the metabolites produced by an organism's fermentation of glucose reveals small amounts of 6-phosphogluconic acid. This fermentation organism is most likely to be

B. Escherichia

Which of the following groups of risk factors has been associated with endometrial cancer?

B. Family history, obesity, and null parity

Shigellosis is common in travelers to developing countries. Infection is commonly acquired through the

B. Gastrointestinal tract

Afather and son come to your office because of persistent diarrhea. They relate the presence of watery diarrhea for over 2 weeks. They noted that the diarrhea began after returning from a Boy Scout camping trip in the Rocky Mountains. The diarrhea has waxed and waned for 2 weeks. It is nonbloody and foul smelling. They have had increased flatulence and mild abdominal cramping. What is the most likely etiology of their diarrhea?

B. Giardia lamblia

Vaccination for this hepatic disease is with viral surface antigen and usually provides immunity.

B. Hepatitis B

A64-year-old man with hypertension presents for routine follow-up of his blood pressure. His home blood pressure log reveals readings in the 150/70 range. His home monitor had previously been verified by clinic BP readings. He denies any complaints. His current medications include HCTZ 25 mg daily, metoprolol 100 mg twice daily, enalapril 20 mg twice daily, and amlodipine 10 mg daily. He states he is adherent to his medication, drug, and exercise regimen as you recommended. At this time, how would you advise the patient?

B. I need to order some tests to look for secondary causes of high blood pressure.

Select an appropriate measure of frequency that describes the number of deaths under the age of 1 year per 1000 live births in 1 year.

B. Infant mortality

A 42-year-old man presents to your clinic with a 1-week history of pain and inflammation involving his right first metatarsophalangeal (MTP) joint. He describes the pain as sudden in onset and worse at night. He denies experiencing any fever or traumatic injury to the joint and states that he has never had this type of pain before. He denies any chronic medical conditions, any prior surgery, and any current medication use. Besides an erythematous and exquisitely tender right first MTP joint, the remainder of his physical examination is unremarkable. Which of the following is true of the patient's condition?

B. It commonly presents as a monoarticular arthritis.

Which of the following is the most prevalent microorganism in the vagina that may also be protective?

B. Lactobacillus

Human infection with the beef tapeworm, Taenia saginata, usually is less serious than infection with the pork tapeworm, T. solium, because

B. Larval invasion does not occur in beef tapeworm infection

C. diphtheriae may be difficult to isolate from the nasopharynx with- out the use of special media. The medium of choice is

B. Löffler's medium

A 5-year-old girl presents for evaluation of breast development, history of multiple bone fractures, and vaginal bleeding. Physical examination is notable for "café au lait" spots on her skin, tanner stage 2 breasts, and she appears tall for her age. What is the most likely cause of precocious puberty in this child?

B. McCune-Albright syndrome

Ideally, an antibiotic should focus on a microbial target not found in mammalian cells. By this standard, which of the following antibiotic agents would be expected to be most toxic to humans?

B. Mitomycin

A 58-year-old male presents to your office for a well-male examination. It has been several years since he last visited a doctor, but he states that he has been in "excellent health." He denies any history of drinking, smoking, or using illegal drugs. He maintains a diet low in sodium and fat. An avid sports enthusiast, he also spends at least 2 hours per day engaged in some type of outdoor physical activity. On physical examination, you discover a translucent waxy papule with raised borders on the posterior aspect of his left shoulder. The treatment modality associated with the lowest recurrence rate is which of these?

B. Mohs micrographic surgery

Choose the type of measurement scale for Type of medical specialty.

B. Nominal scale

A 10-year-old boy presents to your clinic with right knee pain for 2 weeks. He is physically active at school and plays soccer and basketball. He describes pain in his knees when he runs or jumps. He denies any recent trauma. His physical examination is normal except for mild edema and tenderness over the right tibial tubercle. What is the most likely diagnosis?

B. Osgood-Schlatter disease

You are called to the trauma bay to evaluate a 42-year-old male who suffered a blow to his knee at the construction site where he works. He is awake, alert, and his vital signs have been stable in transport. After completing your primary survey, you continue with your secondary survey and determine that his only injury is to his right leg. It is clear that he has suffered a posterior knee dislocation. As part of your examination, you determine that you cannot feel a pulse in his right foot. Realizing that there is compromised blood supply to the patient's right foot, you immediately do which of the following?

B. Relocate the knee into anatomical position and re-examine the pulse.

A previously healthy 34-year-old man, a lifelong nonsmoker, sought medical care at an Urgent Care Center for an upper respiratory infection. A chest x-ray was obtained, which revealed a peripherally located right lower lobe lung nodule. A follow-up CT of the chest showed the 1.8 cm nodule with multiple nonspecific calcifications, and no associated hilar or mediastinal adenopathy. What is the most appropriate next step?

B. Repeat the CT chest in 3 months to assess for stability of the nodule.

A vaccine is available for one of the most common causes of infantile gastroenteritis. However, it has recently been recalled. The virus is

B. Rotavirus

Human plague can be bubonic or pneumonic. The primary epidemiologic difference between the two clinical forms of plague is

B. Route of infection

Inhalation of fungal spores can cause primary lung infections. Of the following organisms, which one is most likely to be associated with this mode of transmission?

B. S. schenckii

A student from Phnom Penh has had abdominal pain for 2 years; he is used to swim in Sekong/Stung Treng river. Which of the following should you be in your differential diagnosis?

B. Schistosomiasis

Treating a pregnant woman infected with syphilis. Select the most appropriate level of prevention that match with description above.

B. Secondary prevention

Using condoms during sexual intercourse. Select the most appropriate level of prevention that match with description above.

B. Secondary prevention

You see a 3-week-old infant in your office for an acute visit. She was born via spontaneous vaginal delivery following a term, uncomplicated prenatal course. The parents are concerned because they have seen some streaks of blood in her diaper over the past few days. The infant's stools have been soft and not difficult to pass. The parents relate that she is eating 2 oz every 2 hours of a cow's milk based formula. What is the carbohydrate source in most infant formula?

B. lactose

A term infant male is born after an uncomplicated vaginal delivery. The mother's prenatal labs were negative with the exception of being GBS positive at 36 weeks' gestation. The mother received two doses of ampicillin prior to delivery and did not have a fever. The infant had APGAR scores of 9 at 1 minute and 9 at 5 minutes. The infant was brought to the newborn nursery and appears well The father tells you that he has hemophilia. His wife neither has hemophilia nor is a carrier. What does this mean for the baby?

B. The baby neither has hemophilia nor is a carrier of the hemophilia gene.

The time interval between entry of an infectious agent into a host and the onset of symptoms is called

B. The incubation period

Amebae that are parasitic in humans are found in the oral cavity and the intestinal tract. Which one of the following statements best describes these intestinal amebae?

B. They can cause peritonitis and liver abscesses

Edema, neuropathy, and myocardial failure. Select the dietary deficiency that match each set of symptoms and signs.

B. Thiamine deficiency

A 24-year-old G1 presents to you for initiation of obstetric care. She informs you that she is on a medication that was prescribed for acne. The drug is listed as category X in your pharmacy book. The pregnancy risk factor category X for a drug indicates which of the following?

B. This drug should never be used by a pregnant female under any circumstances.

A28-year-old male, well known to your clinic, presents for management of swelling, pain, and tenderness that has developed in his left ankle and right knee. It has persisted for 1 month. Your patient reports that he developed severe diarrhea after a picnic 1 month prior to the onset of his arthritis. During the interval between the diarrhea and onset of arthritis, he developed a "pink eye" that lasted for 4 days. He denies any symptoms of back pain or stiffness. You remember that he was treated with ceftriaxone and doxycycline for gonorrhea 2 years ago, which he acquired from sexual activity with multiple partners. Since that time, he has been in a monogamous relationship with his wife and has not had any genitourinary symptoms. He promises that he has been faithful to his wife and has not engaged in unprotected sexual activity outside his marriage. His physical examination is notable for a swollen left ankle, swollen right knee, and the absence of penile discharge or any skin lesions. What would be the appropriate management for this patient's arthritis?

B. Treat with daily indomethacin (150200 mg daily).

Apatient you see routinely in the clinic has elevated liver function tests. ALT is 89, AST is 75, and the total bilirubin and alkaline phosphatase are normal. The patient has no past history of hepatitis, taking medications, or excessive drinking. You order hepatitis serologies. The results are as follows: Positive: HBsAg and anti-HBc. Negative: anti-HBs, anti-HBc IgM, anti-HAV, and anti-HCV What is the most appropriate next step for this patient?

B. Vaccinate the patient with hepatitis A vaccine.

Which of the following vaccines is CONTRAINDICATED during pregnancy?

B. Varicella vaccine

A28-year-old woman presents for evaluation of primary infertility. She has had fewer than four periods per year since menarche at age 14, facial hirsutism, acne, and weight gain. On examination, she has a BP 150/100. Her body mass index (BMI) is 40. Acanthosis nigricans is noted along the posterior surface of her neck. How would you counsel this patient?

B. Weight loss is key to her management.

A 48-year-old woman complaining of dysuria is diagnosed with a UTI by urinalysis. Urine culture and sensitivities reveal that the causative organism belongs to the genus Klebsiella and is resistant to multiple antibiotics. Based upon the results available, you decide to begin therapy with gentamicin. Which of the following would lead to the classification of this patient's infection as "complicated?"

B. a diagnosis of type II DM

On a Monday morning you see a 12-year-old otherwise healthy boy in the emergency department. The parents brought the boy in because they noticed that he started to have an abnormal gait in the past few days. He seems to be shuffling his feet. The boy complains that his legs feel heavy and are tingling. He relates that his arms feel fine. His past history is significant for attention deficit/hyperactivity disorder (ADHD) for which he is taking methylphenidate. He denies trauma or taking any other medicines or drugs. On examination, he is afebrile with normal vital signs. His entire physical examination is normal with the exception of the examination of is lower extremities. He has 3/5 strength throughout both of his lower extremities with a normal muscle mass. His all joints have a full range of motion, without any pain or swelling. His reflexes are absent and he describes some paresthesias of his feet and ankles. What is the most likely diagnosis?

B. acute inflammatory demyelinating polyneuropathy (Guillain-Barré syndrome)

A 62-year-old man undergoes transplantation of a kidney from a cadaveric donor. The surgery is uncomplicated and his recovery proceeds well for the first week postoperatively. In the second postoperative week, he develops hypertension, peripheral edema, and decreased urinary output. He states that he has been taking his medications as ordered. What is the most likely cause of this condition?

B. acute organ rejection

A 72-year-old man comes to your clinic for the first time, accompanied by his wife. His wife states that she is concerned because he has been growing increasingly forgetful over the past year. Within the past month, he has forgotten to turn off the stove and has got lost while walking to the post office one block away from their home. His past medical history is significant for well-controlled diabetes and chronic lower back pain. He has no history of falls or traumatic injury to the head. Examination of the patient is significant for a score of 18 on a Mini Mental Status Examination (MMSE). During the administration of the MMSE, the patient blurts out that his wife brought him to the doctor because she is having an extramarital relationship. Use of which of the following medications would be the most likely to lead to worsening of symptoms in this patient?

B. amitriptyline

What is the most sensitive indicator of pneumonia in a child?

B. tachypnea

A19-year-old male who moved to your city 3 months ago comes to your office complaining of dry cough for the past 23 months. Along with the cough, he has had some shortness of breath with exertion. He denies fever, chills, nausea, vomiting, wheezing, and sneezing. The cough occurs mostly in the morning and improves as the day goes on. He denies similar complaints in the past and has no history of allergies. He says that his father had eczema and an allergy to eggs. What is the single best treatment for preventing symptoms in this patient?

B. an inhaled steroid

A 55-year-old male is brought to the ED, by ambulance, because of crushing chest pain radiating to his left shoulder and arm that started 1 hour ago. He has a history of hypertension, high cholesterol, and has smoked a pack of cigarettes a day for 30 years. He has never had symptoms like this before. Fortunately, the patient survives this episode. As part of his long-term treatment, which of the following would be an appropriate therapeutic intervention to initiate due to its proven effect on survival rate?

B. captopril

A mother brings her 21/2-year-old daughter to your office for evaluation of frequent urination. The mother relates that the daughter seems to be urinating more frequently, up to 810 times in a day, over the past week. The girl complains of pain when she urinates, but the urine does not have any different odor to it. The mother says that the girl otherwise seems fine and still loves to take her bubble bath at night. The girl does not have a fever, weight loss, diarrhea, or vomiting What is the most likely diagnosis?

B. chemical urethritis

A 16-year-old sexually active woman is being seen in the emergency department. She is complaining of vaginal discharge. She has a temperature of 99.5°F, but is otherwise well. On pelvic examination, you see a mucopurulent cervical discharge with scant blood. Samples of the discharge are sent to the laboratory for culture. There are no cervical ulcers noted. She does not have any medical allergies. Which of the following is the most common sexually transmitted infection in adolescents?

B. chlamydia

A57-year-old male presents for annual examination. On history, you note a history of colon cancer that was successfully surgically resected 2 years ago. He had a negative postoperative colonoscopy 6 months later and another negative colonoscopy last year. Which of the following would be the most appropriate colon cancer screening regimen for this patient?

B. colonoscopy in 3 years

Parents bring their 12-year-old son to your clinic for evaluation. The child states that he gets teased a lot in school because of his short stature. His weight and height are below the 10th percentile for his age. His parents are of average height. Following your physical examination, you determine that he has tanner stage 1 development and his bone age is that of a 9-year-old male. His examination is otherwise normal. What is the most likely diagnosis?

B. constitutional growth delay

You are asked to perform a high school physical examination for a 16-year-old female patient. She is on the track team. By history, she is healthy except for the fact that she has been amenorrheic for 4 months. She denies current or past sexual activity. On examination, she is 5 ft 9 in. tall and weighs 115 lbs. Her heart rate is 50 bpm. She has dry skin with lanugo. She has several sores in her mouth and obvious dental caries. She has several scratches on the backs of her hands. She is tanner stage III on breast examination. Her pelvic examination is remarkable for findings of urogenital atrophy. Her urine -hCG is negative. Which of the following would be the most likely diagnosis for this patient?

B. eating disorder

A 48-year-old woman with metastatic breast cancer presents to the Emergency Center complaining of a 4 day history of nausea, anorexia, and generalized weakness. Her husband reports that she has been more somnolent, sleeping 1214 hours per day, and at times she seems confused. CT scan of the brain reveals no abnormalities. Initial laboratory evaluation reveals a normal CBC, but her BUN is elevated at 32 mg/dL with a slight elevation of serum creatinine above her baseline. Her serum calcium is elevated at 15 mg/dL. What is the most likely cause of her hypercalcemia?

B. ectopic production of a parathyroid hormone-related protein

A 50-year-old female presents to your office for evaluation of solid food dysphagia without weight loss. Symptoms have been present for 6 months and are progressive. The patient has had two episodes of near impaction, but copious water ingestion and repeated swallows allowed the food bolus to pass. She has never had to present to the ER for disimpaction. She drinks five to six beers per day, loves spicy foods, and smokes a pack of cigarettes daily with a total lifetime history of 30 pack-years. She has had intermittent heartburn symptoms for years and has not sought treatment. She takes hydrochlorothiazide for hypertension. Review of symptoms reveals chronic cough. Physical examination is unremarkable. Upper endoscopy reveals a distal esophageal stricture with inflammatory changes. Esophageal biopsies reveal benign mucosa with chronic inflammation. Gastric biopsies are unremarkable. Helicobacter pylori testing is negative. The patient is at increased risk for which of the following illnesses?

B. esophageal adenocarcinoma

A 56-year-old thin, White woman, who has recently undergone a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy for a stage IB, grade 1, endometrioid tumor of the uterus, presents to your office complaining of hot flashes and vaginal dryness. She wants advice about the use of estrogen replacement in women treated for endometrial cancer. Which of the following is the best treatment for this woman?

B. estrogen replacement therapy

A 50-year-old man presents to your office with fatigue and weakness. He first noticed it a few weeks ago while trying to hang pictures with his wife. His legs have begun to ache as he walks up stairs. He has lost about 20 lbs in the last 3 months. Most recently, he has found that he is more constipated and has trouble rising from the commode. Your physical examination reveals modest proximal weakness, no articular swelling, rash, or any other pertinent findings. Blood work from a recent insurance examination revealed: Sodium 142 meq/L; potassium 3.8 meq/L; chloride 107 meq/L; bicarbonate 29 meq/L; BUN 30 mg/dL; Cr 1.6 mg/dL; WBC 6.8; Hgb 13.6 g/dL; HCT 40%; MCV 88.0 m3; platelets 240,000/mm3; AST 200 U/L; ALT 250 U/L; alkaline phosphatase 70 U/L; bilirubin 0.3 mg/dL; ESR 40 mm/h. Along with a creatine phosphokinase (CPK), which of the following tests should be ordered first?

B. gamma glutamyl transferase (GGT)

A 45-year-old male with type II diabetes, hypertension, and hyperlipidemia presents to your clinic as a new patient. He has been out of his cholesterol medications and came to your office requesting a refill. The patient brought his most recent lipid profile (done after he was off his cholesterol medication for 3 months) which revealed: Cholesterol (total): 242 mg/dL HDL cholesterol: 38 mg/dL Triglycerides (TGs): 660 mg/dL, LDL cholesterol = unable to calculate due to high TGs He also had recent liver function tests that were normal. Based on Adult Treatment Panel (ATP) III guidelines, which of the following medications should be the initial pharmacologic treatment for this patient?

B. gemfibrozil

A61-year-old man comes to your office for a checkup. He currently feels well and has no focal complaints. He has a past medical history significant for wellcontrolled hypertension, and his gallbladder was removed 3 years ago in the setting of acute cholecystitis. He does not smoke and drinks one to two alcoholic beverages per day. Family history is remarkable for colon cancer in his mother at age 45 and a brother at age 49. He has a sister who developed endometrial cancer at age 53. He has never undergone colon cancer screening and is interested in pursuing this. The patient's family history is strongly suggestive of which of the following?

B. hereditary nonpolyposis colorectal cancer (HNPCC) syndrome

A 74-year-old male with gout, osteoporosis, and type II diabetes presents for routine followup. As you review his medication list you note that he is on insulin, vitamin D, glypizide, quinidine, and allopurinol. You now diagnose him with hypertension that requires pharmacologic management. Which of the following medications would be contraindicated in this patient?

B. hydrochlorothiazide

A 19-year-old woman begins chemotherapy for an acute leukemia. Although you determine that her renal function is unimpaired prior to the initiation of treatment, you feel that she may be at high risk for development of tumor lysis syndrome given her condition's typically good response to chemotherapy. Which of the following is typically seen as a feature of tumor lysis syndrome?

B. hypocalcemia

Vitamin D supplementation can be helpful in treating which disease?

B. hypoparathyroidism

You are called to see a newborn in the nursery because the nurse is concerned that the baby may have Down syndrome. After confirming that the child does indeed have Down syndrome, the parents ask you what problems their baby may have in the future. With which of the following is the infant most likely to have problems?

B. hypothyroidism

A 64-year-old male with a history of hypertension and tobacco abuse presents for follow-up after a routine physical during which he was found to have 45 red blood cells (RBCs) per high-power field (HPF) on a screening urinalysis. The urinalysis was negative for leukocytes, nitrites, epithelial cells, and ketones. The patient denies any complaints and the review of systems is essentially negative.

B. image the upper and lower urinary tracts

A 65-year-old man presents to your office for evaluation of abdominal pain. The patient states that he has epigastric pain that radiates to his back. The pain is worse with eating and improves with fasting. The pain has been present for 6 months and is gradually worsening. The patient has lost 15 lbs but feels his oral intake has been adequate. He complains of greasy stools and frequent thirst and urination. Examination reveals a thin male with temporal wasting and oderate abdominal pain with palpation. The patient consumes approximately 1015 beers per day and smokes a pack of cigarettes per day for the past 20 years. On further evaluation, the patient is found to be diabetic. He has an elevated HgbA1C and fasting hyperglycemia. The patient is sent for diabetic teaching sessions and begun on insulin therapy, but is unable to achieve euglycemia. He experiences frequent bouts of symptomatic hypoglycemia requiring ER visits. What is the most likely cause for these episodes?

B. impaired glucagon production

A 17-year-old male presents for evaluation of shortness of breath. He has episodes where he will audibly wheeze and have chest tightness. His symptoms worsen if he tries to exercise, especially when it is cold. He has used an OTC inhaler with good relief of his symptoms, but he finds that his symptoms are worsening. He now has episodes of wheezing on a daily basis and will have nighttime wheezing and coughing, on average, five or six times a month. You suspect a diagnosis of asthma. Which of the following would confirm your suspicion of the diagnosis of asthma?

B. increase in FEV1 of 15% after giving inhaled albuterol

A 23-year-old pregnant woman with type 1 diabetes was admitted to the Obstetrics service for DKA. The DKA was appropriately treated and has resolved. You were consulted for medical management of the diabetes, as her sugars have been labile throughout the hospital stay. Your history and review of records reveals that the patient has a long-standing history of noncompliance with diet and medication regimens. She currently uses any insulin she can get and does not eat regular meals. She has fluctuating blood sugars with episodes of hypoglycemia. You counsel the patient extensively, order nutrition and diabetic teaching consults, and discuss keeping home glucose logs. Assuming the patient will follow your advice, which regimen would you recommend to minimize fluctuating glucose readings?

B. insulin glargine once daily and insulin lispro before meals

A woman complains of amenorrhea for several months following a dilation and curettage. Which of the following is the most likely reason?

B. intrauterine scarring

A 61-year-old female is diagnosed with osteoporosis by a screening dual-energy x-ray absorptiometry (DEXA) scan. Which of these is a risk factor for postmenopausal osteoporosis?

B. lack of exercise

You see a 2-month-old infant in the emergency department for vomiting. The mother says that the baby has been spitting up more over the past few days and has become more irritable. She denies any fever, diarrhea, or change in formula. The mother tells you that there is a family history of heartburn and that her other children have all spit up. The infant has some emesis in the emergency department that seems to be formula mixed with some bile. The infant is intermittently irritable and sleepy. What is the most concerning diagnosis that this could be?

B. malrotation

A 48-year-old woman complaining of dysuria is diagnosed with a UTI by urinalysis. Urine culture and sensitivities reveal that the causative organism belongs to the genus Klebsiella and is resistant to multiple antibiotics. Based upon the results available, you decide to begin therapy with gentamicin. Before doing so, you explain to the patient that antibiotics such as gentamicin are often associated with which of the following?

B. nephrotoxicity

A father and son come to your office because of persistent diarrhea. They relate the presence of watery diarrhea for over 2 weeks. They noted that the diarrhea began after returning from a Boy Scout camping trip in the Rocky Mountains. The diarrhea has waxed and waned for 2 weeks. It is non-bloody and foul smelling. They have had increased flatulence and mild abdominal cramping. What would be the most appropriate treatment?

B. oral metronidazole

A24-year-old male medical student is admitted to the hospital for the evaluation of a 3-month history of bloody stools. The patient has approximately six blood stained or blood streaked stools per day, associated with relatively little, if any, pain. He has not had any weight loss, and he has been able to attend classes without interruption. He denies any fecal incontinence. He has no prior medical history. Review of systems is remarkable only for occasional fevers and the fact that the patient quit smoking approximately 8 months ago. A colonoscopy is performed and reveals a granular, friable colonic mucosal surface with loss of normal vascular pattern from the anal verge to the hepatic flexure of the colon. Biopsies reveal prominent neutrophils in the epithelium and cryptitis with focal crypt abscesses, and no dysplasia. The patient is diagnosed with ulcerative colitis. Which of the following is the best initial treatment for this patient?

B. oral prednisone

A mildly mentally retarded 9-year-old girl is brought to your office for acne. On examination, she does not actually have acne but has small flesh colored papules along her nasolabial fold. Her past history is significant for having had a first (afebrile) seizure last year. The mother reminds you that she has a faint birthmark on her hip that is pale and becomes more prominent in the summer, when the child's skin tans. Examination of this area reveals a 5-cm oval patch that is hypopigmented. Which condition would she most likely have? In evaluating her first seizure, a head CT was performed. Which finding would be most consistent with her diagnosis?

B. periventricular "tubers"

A 24-year-old White (G1P1001) female presents to your office 6 weeks after a normal spontaneous vaginal delivery at term. She reports that she has been unable to breast-feed her baby despite helpfrom her pediatrician and a lactation consultant. On further questioning, you elicit that she has also experienced nausea, weakness, and weight loss. In addition, she reports dizziness when getting out of bed in the morning. On your examination, she has a waxy texture to her skin and periorbital edema. You also note decreased axillary and pubic hair, which she reports is a change for her. This condition is most commonly associated with which of the following?

B. postpartum hemorrhage

A 28-year-old White G1 woman presents to your office for an initial obstetric visit. Her LMP is certain and allows you to estimate a 9-week gestational age today. She denies bleeding, cramping, or other symptoms of concern. She is excited about being pregnant. She has already started taking her prenatal vitamins with folic acid. She reports no significant past medical history. In fact, she states that she has not been to a doctor in many years because she has not had any problems. She has had no surgeries. She does not smoke. She drank alcohol socially prior to pregnancy but has not consumed any alcohol since she became pregnant. She has family history of hypertension, but no other significant history is elicited. On physical examination, her blood pressure is 110/60. She is healthy appearing, and there are no significant findings on examination. Your pelvic examination confirms uterine size consistent with stated dates. As part of a routine laboratory evaluation, you decide to check a thyroid-stimulating hormone (TSH). The TSH is 0.4 IU/mL (normal range 0.55.5) and a free T4 of 1.8 ng/dL (normal range 0.72.0). What is the most appropriate management of this condition?

B. prescription for propylthiouracil (PTU)

A72-year-old African American male presents for a routine health examination. He states that he would like to have a "screening for cancer." In the United States, based on his sex, race, and age, what is the most likely malignancy for this patient?

B. prostate cancer

A 62-year-old man undergoes transplantation of a kidney from a cadaveric donor. The surgery is uncomplicated and his recovery proceeds well for the first week postoperatively. In the second postoperative week, he develops hypertension, peripheral edema, and decreased urinary output. He states that he has been taking his medications as ordered What is the most appropriate management at this time?

B. pulse steroid dose and increase immunosuppresion

An 8-month-old boy is brought to the clinic by his mother because he has been lethargic, fussy, and not feeding well over the past several days. The mother has been working two jobs so the baby has been cared for by her boyfriend for the past month. She is very worried because he has not been smiling and vocalizing as much as he normally does and he has not been able to lift his head. Which of the following findings on physical examination is suggestive of child abuse?

B. retinal hemorrhages visualized on funduscopy in a 4 month old

A42-year-old man without prior significant medical history comes to your office for evaluation of chronic diarrhea of 12 months duration, although the patient states he has had loose stools for many years. During this time he has lost 25 lbs. The diarrhea is large volume, occasionally greasy, and nonbloody. In addition, the patient has mild abdominal pain for much of the day. He has been smoking a pack of cigarettes a day for 20 years and drinks approximately five beers per day. His physical examination reveals a thin male with temporal wasting and generalized muscle loss. He has glossitis and angular cheilosis. He has excoriations on his elbows and knees and scattered papulovesicular lesions in these regions as well What is the most serious long-term complication this patient could face?

B. small bowel cancer

An 18-year-old female presents for evaluation of facial acne. On examination, she has multiple comedones, papules, and pustules on her forehead, nose, cheeks, and chin. She also has several distinct nodules, each greater than 5 mm in diameter. After 6 months of appropriate treatment, the severity of your patient's acne remains essentially unchanged. You rule out several potential causes for the patient's recalcitrant acne and decide that more aggressive therapy is warranted. As you discuss this option with your patient, which of the following side effects of the proposed treatment necessitates extensive counseling prior to initiation of therapy?

B. teratogenicity

You are trialing a new antihypertensive agent, 'Wonderone'. As part of the drug-development programme you must assess the half-life of Wonderone. Some results are sent to you for calculation of the half-life:, 15 mins after iv injection - Wonderone level 150, 2 h 15 mins after iv injection - Wonderone level 37.5, 4 h 15 mins after iv injection - Wonderone level 9.4. Which of the following stems fits best with the half-life of this agent?

C- 1 h

A 24-year-old woman visits her GP complaining that she is tired and lethargic. He arranges some routine blood tests including FBC, U&E, LFT, TFT, viscosity and immunoglobulins. The only abnormality is elevated IgE levels to 1.2 times the upper limit of normal. Raised IgE levels are a normal finding in what % of the population?

C- 2.5%

You suspect that a 48-year-old man is suffering from Cushing's syndrome. At what time of day is a random cortisol test most likely to be abnormal?

C- 2400 h

A 72-year-old man presents with weight loss, low-grade fever, mononeuritis and hypertension. You consider the diagnosis of polyarteritis nodosa (PAN) and request certain immunological investigations. Which one of the following would best support your clinical diagnosis?

C- ANCA-negative

A 19-year-old man is admitted by ambulance after falling into a river. He is pulled out by two friends but is thought to have inhaled a significant quantity of water. On examination in the Emergency room his saturation is 90% on O2 by mask. He is drowsy but conscious, with bradycardia and a temperature of 34.8oC. Auscultation of his chest reveals wheeze and crackles consistent with fluid inhalation. Which of the following is the most likely biochemical imbalance to be seen?

C- Acidosis on ABG measurement

A 25-year-old accountant is admitted to hospital with severe abdominal pain, vomiting and postural hypotension. She has had similar attacks in the past. A mid-stream urine sample shows the presence of high levels of aminolaevulinic acid (ALA) and porphobilinogen (PBG). What is the most likely diagnosis?

C- Acute intermittent porphyria

A patient with familial hypercholesterolaemia has a total cholesterol concentration of 10.2 mmol/l, LDL-cholesterol 8.1 mmol/l, HDL-cholesterol 1.2 mmol/l and fasting triglycerides 1.9 mmol/l. He has a strong family history of premature myocardial infarction. He is a non-smoker and normotensive. He is given lifestyle and dietary advice and prescribed a statin. Some 2 months after being on the maximum dose of the statin, his total cholesterol concentration is 6.8 mmol/l, LDL-cholesterol 5.2 mmol/l, HDL-cholesterol 1.3 mmol/l and fasting triglycerides 1.0 mmol/l. What would be the most appropriate next step in his management?

C- Adding ezetimibe to his medication

Which of these are well-recognised late complications of trisomy 21 (Down's syndrome)?

C- Alzheimer's dementia

A 70-year-old patient has become more forgetful, in that he has lost his day-to-day memory and is unable to learn new tasks. What kind of pathological deposits are most likely to be present in his brain?

C- Amyloid

A 50-year-old woman presents with symptoms and signs of cerebellar ataxia and an abdominal mass that on ultrasound is suggestive of ovarian cancer. You consider the possibility of a paraneoplastic syndrome and request some immunological investigations. Which antibody test would best support your clinical diagnosis?

C- Anti-Yo antibodies

A male patient age 33 presents with depression, weight loss and choreiform movements. He informs you that his father had similar symptoms aged 50, his grandfather at aged 75, and both deteriorated in terms of mobility and mental state and eventually died. What is the phenomenon described here known as?

C- Anticipation

In the investigation of a woman presenting with jaundice and itching, which one of the following would most strongly support the diagnosis of primary biliary cirrhosis (PBC)?

C- Antimitochondrial antibodies (M2 pattern)

A 27-year-old Jewish man attends the clinic with his wife. They are keen to start a family but are worried because his brother developed jaundice during teenage years and was given a diagnosis of Dubin Johnson syndrome. He asks for advice as to the chance of his children inheriting the condition. Which of the following most accurately represents the mode of inheritance for Dubin Johnson syndrome?

C- Autosomal recessive

A 24-year-old woman is admitted with dysarthria, tremor and parkinsonian symptoms. On examination you notice yellow brown rings on examination of the eyes, seen at the limbus of the corneae. Given the most likely diagnosis, which part of the brain is predominantly affected by her underlying condition?

C- Basal ganglia

A 62-year-old man presents with lower back pain radiating into the posterior part of the tops of both legs. He also reports trouble with difficulty starting and stopping his stream of urine and difficulty making it to the toilet when he wants to pass stool. On examination he has local tenderness to palpation over the lower back. There is diminished light touch in the perianal region and decreased anal tone. Where is the most likely cause of his symptoms?

C- Cauda equina syndrome

Which of the following statements is most accurate with regards to the chemoreceptor control of breathing?

C- Central chemoreceptors are sensitive to the H+ content of the CSF

A 55-year-old-woman presents with the clinical features of Cushing's syndrome. She is on no medication. The results of routine biochemical investigations are normal. Her 0900-h cortisol concentration is 800 nmol/l (normal 150-650) and ACTH 80 ng/ml (normal < 50). Following dexamethasone 1 mg theprevious evening, a repeat 0900-h cortisol concentration is 720 nmol/l. Which of the following is the most likely diagnosis?

C- Cushing's disease (pituitary adenoma)

Which of the following statements regarding the eukaryotic cell cycle is correct?

C- DNA is made in the S phase

A 25-year-old man, previously rather sedentary in his habits but alarmed by his increasing weight, is persuaded by his girlfriend to join a gym, and begins an exercise programme. Although there are several similar people enrolled in the programme, he finds that he is unable to keep up with them because of muscle pain, particularly in his legs. Within a few minutes of resting, however, the pains resolve. Investigation revealed a slight fall in blood lactate concentration during exercise. Which of the following is most likely to be the cause of his complaint?

C- Decreased muscle glycogenolysis

A 77-year-old man presents with a history of vomiting undigested food. Routinebiochemistry shows a serum bicarbonate concentration of 38 mmol/l. Which of the following findings would most strongly suggest that he had a chronic metabolic alkalosis?

C- Elevated arterial p(CO2)

A 71-year-old man with known chronic obstructive pulmonary disease is admitted to A&E with severe shortness of breath. Blood gas analysis shows: arterial [H+] 55 nmol/l (pH 7.26), p(CO2) 9.4 kPa, p(O2) 9.1 kPa, derived [HCO3-] 31 mmol/l.Which of the following types of acid-base disturbance is most likely?

C- Exacerbation of chronic respiratory acidosis

Intervertebral disc prolapse in the lumbar spine most often affects the L4/l5 and L5/S1 discs. In a man presenting with acute back pain following an episode of lifting a heavy weight, reduced force of which of the following movements would most suggest an L5/S1 (L5 root) rather than an L4/5 disc lesion (L4 root)?

C- Extension of great toe

A man in his mid-60s is referred to you because he is worried about his family history of ischaemic heart disease. His father was a non-smoker and died of a myocardial infarction aged 39 years. His maternal grandfather and a paternal uncle both had myocardial infarcts in their 40s. What is his history most suggestive of?

C- Familial hypercholesterolaemia

Insulin binds to a 400-kDa glycoprotein, which straddles the cell membrane of many cells and exerts much of its peripheral effects through action at this receptor. The expression of which glucose transporter (GLUT) is upregulated by insulin binding at this receptor site?

C- GLUT-4

A 58-year-old man presents with progressively worsening indigestion and weight loss. His GP can feel an epigastric mass and arranges upper gastrointestinal (GI) endoscopy. Biopsy of a suspicious lesion in the stomach reveals numerous signet ring cells. Which of the following is the most likely underlying diagnosis?

C- Gastric adenocarcinoma

In a patient presenting acutely with severe abdominal pain presumed to be related to previously diagnosed hereditary angioneuritic oedema, which of the following treatment strategies would be optimal?

C- Give an intravenous C1-inhibitor concentrate

A 25-year-old patient presents with anaemia and jaundice. A blood film showspolychromasia, bite cells, reticulocytosis and Heinz bodies. What is the most probable diagnosis?

C- Glucose-6-phosphate dehydrogenase deficiency

An 18-year-old woman presents with mild polyuria and polydipsia; her fasting blood glucose concentration is 14 mmol/l. Her father and two of her three sisters have diabetes. She responds well to treatment with insulin, and is stabilised on a total dose of 14 units per 24 h. A mutation in which of the following is likely to be responsible for her condition?

C- Hepatic nuclear factor-1a

Which of the following features most reliably suggests that a patient presenting with diabetes has type 1?

C- History of recent weight loss

In which of the following genetic diseases is DNA analysis useful?

C- Huntington's disease

A 55-year-old, chronic heavy smoker is brought to A&E with a 2-day history of polyuria, polydipsia, nausea and altered sensorium. On examination, he is lethargic and confused. A chest X-ray shows a round shadow in the right mid-zone with enlarged hilar lymph nodes on the right side. An ECG is normal except for a narrowed QT interval. What is the most likely metabolic abnormality in this case?

C- Hypercalcaemia

An elderly man with a history of prostatism presents with acute retention of urine. His serum creatinine concentration is 520 mmol/l. Which of the following additional abnormal serum biochemistry test results is most suggestive of a chronic component to his renal failure?

C- Hypocalcaemia

A 24-year-old woman undergoes resection of the terminal ileum with fashioning of an ileostomy for Crohn's disease. Some 2 weeks after surgery, she is making a good recovery, and is eating a high-energy, low-residue diet, but has a high ileostomy volume, necessitatingintravenous fluid replacement. Her serum calcium concentration is 1.82 mmol/l, phosphate 1.28 mmol/l, alkaline phosphatase 82 U/l (normal < 150), albumin 30 g/l, creatinine 80 m mol/l. Prior to surgery, her serum calcium concentration was 2.18 mmol/l, albumin 36 g/l. What is the most likely cause of her hypocalcaemia?

C- Hypomagnesaemia

Gluten-sensitive enteropathy (GSE) can be associated with low levels of:

C- IgA

Selective IgA deficiency is often discovered incidentally in the investigation of a patient, however you will need to explain to the patient the clinical significance of such a finding. Hence which of the following statements is relevant?

C- IgG2 deficiency leading to recurrent bacterial infections

When is a gene mutation causing a particular genetic disorder said to be highly penetrant?

C- Individuals with the mutation invariably develop the phenotype

An 8-year-old child is admitted to hospital having ingested some of her mother's iron tablets (ferrous fumarate) 4 hours earlier. Her serum iron concentration is 182 mmol/l. Plain abdominal X-ray is unremarkable. What would be the most useful therapeutic measure?

C- Intravenous infusion of desferrioxamine

You are reviewing an 18-year-old woman with cystic fibrosis. How would the genetic inheritance of this condition best be described?

C- It has an autosomal-recessive mode of inheritance

What is the most likely diagnosis in a 30-year-old man with tall stature, gynaecomastia and azoospermia?

C- Klinefelter's syndrome

A 19-year-old man presents with clinical features suggestive of malabsorption. Which of the following investigations has the potential to indicate a single cause for this?

C- Lactose tolerance test

A 24-year-old woman attends the neurological clinic for review of multiple sclerosis, diagnosed 2 years before. She had presented with blurring of vision and mild pain in her left eye, which had resolved over a period of 3 months and had not recurred. On examination now, the following observations are made: light shone in the left eye causes constriction of the left and right pupils; light shone into the right eye causes constriction of the right and left pupils but when the light is shone back into the left eye, the left pupil dilates slightly. Which of the following is the most likely site of the lesion responsible?

C- Left optic nerve

A 25-year-old patient presents with yellow papules on the extensor surfaces of the arms, legs, buttocks and back. His triglycerides are grossly elevated. On questioning he admits that there is a family history. What kind of deficiency is the patient most likely to have?

C- Lipoprotein lipase

In metabolic alkalosis associated with prolonged nasogastric aspiration in postoperative ileus, what is the most important cause of the acid-base disturbance?

C- Loss of gastric acid

Blood is circulated through the arteries by which of the following physiological mechanisms?

C- Maintenance of diastolic pressure in the arteries and arterioles

A 65-year-old man consults his family doctor complaining of feeling 'tired all the time'. His haemoglobin is 11.5 g/dl (13-17); mean cell volume (MCV) is 105 fl (82-102). Bone marrow examination does not indicate megaloblastic changes.Which of the following investigations is most important to determine the cause of the anaemia?

C- Measurement of serum TSH (thyroid-stimulating hormone) concentration

A 40-year-old woman patient has been referred to hospital with jaundice. On examination there is hepatosplenomegaly. She does not take any medication nor drinks alcohol. Her sister, who is 10 years older, had similar problems. Following serum testing, antibodies to which antigen are most likely to be detected in her serum?

C- Mitochondria

In which of the following hereditary conditions will affected males have a significant risk of fathering affected sons?

C- Myotonic dystrophy

A 40-year-old man comes to see you because he is worried about his family history of Huntington's disease. His 45-year-old sister is known to be affected and has been given a molecular diagnosis, but neither parent is affected and both have had a normal gene test. What is the most likely reason for this inheritance pattern?

C- Non-paternity

A 32-year-old woman on nasogastric aspiration for paralytic ileus following surgery develops a metabolic alkalosis. Which of the following intravenous fluids would be the preferred treatment for the alkalosis?

C- Normal (0.9%) saline

A 19-year-old patient presents with gradual worsening myopia and decreased night vision. On examination there is atrophy of the retina. What enzyme deficiency is this patient most likely to have?

C- Ornithine aminotransferase

A 75-year-old man is given a routine health check by his family doctor. He has no specific complaints and is not on any regularmedication. Biochemical tests reveal a serum alkaline phosphatase activity of 550 U/l (upper limit of normal (ULN) 150 U/l); serum creatinine concentration is 132 mmol/l, calcium 2.42 mmol/l, phosphate 1.21 mmo l/l, albumin 41 g/l. Which of the following is the most likely cause of the high alkaline phosphatase?

C- Paget's disease of bone

A teenager presents with excess hair and amenorrhoea. She is normotensive. Her prolactin levels are normal but she has a raised 17a-hydroxyprogesterone level. What is her diagnosis?

C- Partial 21-hydroxylase deficiency

A 13-year-old boy of Spanish descent has suffered from recurrent sinus infections for the past 2 years and has a history ofintermittent diarrhoea. As an infant he had many episodes of otitis media and at the age of 10 years was hospitalised with tonsilitis. His mother has coeliac disease and his sister autoimmune haemolytic anaemia. His full blood count is normal. What is his most likely diagnosis?

C- Selective IgA deficiency

A 16-year-old girl presents to the Emergency Department complaining of an urticarial skin rash. There is a history of recent ingestion of peanut butter, although she is not known to be allergic to peanuts. Measurement of peanut specific IgE on RAST testing is in the normal range. Which of the following fits best with this clinical situation?

C- Skin prick testing may be useful

A patient collapses during induction with a general anaesthetic. Which of the following investigations will be most useful in subsequently establishing an IgE-mediated process (anaphylactic mechanism)?

C- Skin-prick tests to anaesthetic agents

You are asked to help identify whether the child of a woman with a neuromuscular disorder is affected by the condition. A specific DNA sequence associated with the mutation which causes the disorder has been identified. Which of the following methods is a technique to identify a particular DNA sequence?

C- Southern blot

An 18-year-old suffers recurrent, proven bacterial chest infections requiring regular antibiotic treatment. Which of the following is the best way to exclude antibody deficiency?

C- Specific antibodies to haemophilus and pneumococci

Which one of the following is MOST likely to increase during exercise?

C- Stroke volume

Anti-Ro antibodies in isolation (negative ANA) occur in which of the following conditions?

C- Systemic lupus erythematosus (SLE)

Which organ lies anterior in direct contact with the left kidney without separation by visceral peritoneum?

C- Tail of the pancreas

Following a rock-climbing accident in which a foothold gave way, leaving him suspended by one arm, a young man develops weakness of his right hand. He can manoeuvre his arm into any position but cannot use the hand effectively. What structure is most likely to have been damaged in this accident?

C- The T1 nerve root

Which of the following is true concerning complement activation?

C- The alternative, but not the classical C3, convertase enzyme involves C3b

Whilst treating a diabetic patient who is controlled with insulin you perform fundoscopy and find new vessel disease in the macula lutea. Which of the following is true of ocular physiology?

C- The central portion of the macula is known as the fovea centralis

You review a 54-year-old man with a history of alcoholism; you are concerned that there may be evidence of portal hypertension. Which of the following stems best describes blood flow to the liver?

C- The portal vein supplies 75% of liver blood flow

You are called to see a 56-year-old man 2 h after a cardiac catheterisation. He is actively bleeding from his catheter site and his dressings and bedclothes are soaked with blood. Which of the following statements is true?

C- The pulse can remain normal in patients with grade I shock

In performing a lumbar puncture, the operator needs to be familiar with the anatomy involved. Which anatomical feature is relevant to this procedure?

C- The spinal cord in the normal adult terminates anywhere from opposite the body of T12 to the body of L3; however, the commonest level is at the disc space between L1 and L2

Parents of a boy with suspected peanut allergy want answers to many questions, including prediction of the severity of future reactions and whether he will grow out the allergy. Which of the following is a valid statement?

C- The weal size resulting from the skinprick test is an excellent predictor of a positive food challenge to peanuts

Concerning monoclonal free light chains, which of the following statements is true?

C- They are found in isolation in 20-30% of cases of myeloma

Which of the following is a feature of restriction fragment length polymorphisms (RFLPs)?

C- They may be used to diagnose Huntington's disease

A 15-year-old boy presents with fever, rash and arthralgia. He has ++ protein and + blood on urinalysis. Investigations reveal the following: erythrocyte sedimentation rate 32; C-reactive protein 12; full blood count normal; and U+Es normal. Antistreptolysin-O titres are raised. What immunological phenomenon is taking place?

C- Type-III hypersensitivity reaction

A 44-year-old woman presents complaining that she has trouble opening jars and holding a pencil. On examination she has weakness of the adductor pollicis muscle. There is also sensory loss over the volar surface of the hypothenar eminence. Which of the following is the likely site of the lesion which has caused this clinical picture?

C- Ulnar nerve

A 58-year-old female patient goes into anaphylactic shock in the operating theatre soon after induction. She has been previously patch tested for severe asthma, and was found to be allergic to cats, dogs, trees and pollens. She received vecuronium and propofol on induction. Which of the following is the most likely cause?

C- Vecuronium

During the assessment of a stroke, a middle-aged man undergoes detailed neurological examination. Which of the following physical signs would most suggest a pyramidal lesion?

C- Weakness of knee flexion

A 49-year-old woman presents to her gynaecologist with CIN-3 changes. She has been reading on the Internet about how the human papillomavirus interferes with the programmed death of defective cells and may predispose to cancers. Which of the following protein names best identifies the DNA-binding protein with which the papillomavirus interferes?

C- p53

Cells from a patient with severe combined immunodeficiency disease (SCID) lack the adenosine deaminase enzyme. This will have a direct effect on?

C- purine salvage

A 35-year-old woman schedules an appointment in an outpatient clinic for evaluation and treatment of a "mouth problem." She says that she has white spots in her mouth that have been present for a few weeks. In response to your questioning, she states that she has been experiencing fatigue and a 20-lb weight loss over the past several months, although she attributes these symptoms to a dramatic increase in work hours at her job over the same period of time. She denies having any other chronic medical issues and does not use any prescription or OTC medications. As you examine her, you note the presence of white plaques on her buccal mucosa, palate, and tongue. Scraping of the plaques with a tongue depressor elicits pain as well as a small amount of bleeding. Nontender generalized cervical and submandibular lymphadenopathy is present. Which of the following questions would potentially yield the most useful information in this patient's diagnosis and treatment?

C. "Have you engaged in unprotected sexual intercourse?"

Following tubal ligation what percentage of pregnancies are ectopic?

C. 30%

A 35-year-old 80-kg male was transported to the regional burn center at your hospital after suffering second- and third-degree burns from the eruption of a brush fire fueled with gasoline. He was intubated by EMS to secure his airway for transport. On arrival, he is found to have burns across his face, anterior neck, chest, and anterior abdomen, as well as bilateral circumferential upper extremity burns. What do you estimate the total body surface area (TBSA) of his burns to be?

C. 40%

A new test for chlamydial infections of the cervix is introduced. Half of the women who are tested have a positive test. Compared with the gold standard of careful cultures, 45% of those with a positive test are infected with chlamydia, and 95% of those with a negative test are free of the infection. Match with the correct percentage with the epidemiologic terms, Specificity of the test.

C. 63%

A 25-year-old woman presents to your office complaining of cold hands. She describes them turning white as she reaches for orange juice in the frozen food section of the supermarket. It seems to be getting worse lately. She has no other symptoms but does note that she and her husband are contemplating pregnancy. Her examination today is unremarkable. In this patient, which of the following studies would be most likely to describe an increased risk of future systemic disease?

C. ANA

A parasite resembling malaria that infects both animals and humans and is carried by the same tick that transmits B. burgdorferi (the bacterium that causes Lyme disease) would most likely be observed in

C. Blood

What the most appropriate specimen is for the detection of Enterovirus

C. Blood

A concerned mother brings in her 18-monthold infant girl. The baby's developmental milestones have been normal. The mother states that there is a "funny glint" in her baby's eyes. She also states that sometimes the infant's eyes look crossed. Which of these supports the diagnosis of a serious life- threatening disease?

C. Bright red reflex in one eye, a white reflex in the other.

A 65-year-old man presents to your office for evaluation of abdominal pain. The patient states that he has epigastric pain that radiates to his back. The pain is worse with eating and improves with fasting. The pain has been present for 6 months and is gradually worsening. The patient has lost 15 lbs but feels his oral intake has been adequate. He complains of greasy stools and frequent thirst and urination. Examination reveals a thin male with temporal wasting and oderate abdominal pain with palpation. The patient consumes approximately 1015 beers per day and smokes a pack of cigarettes per day for the past 20 years. What would be the best initial test to do in this patient?

C. CT scan of the abdomen

"Third-generation cephalosporin with primary activity against Pseudomonas aeruginosa is"

C. Ceftriaxone

Third-generation cephalosporin with good activity against Borrelia burgdorferi is

C. Ceftriaxone

Pathogenic mechanisms involved in tuberculosis can be primarily attributed to which of the following?

C. Cell-mediated hypersensitivity

Apatient undergoes a gastrectomy following a gunshot injury. How would you counsel him about postgastrectomy syndromes?

C. Cholestyramine is a treatment for postvagotomy diarrhea.

Which one of the following viruses is the leading cause of congenital malformations?

C. Cytomegalovirus

A 68yearold man with controlled hypertension complains of gradual impairment of vision. His history further reveals that he was recently diagnosed with mild adult onset diabetes that is also well controlled. He is a retired fisherman. The most likely cause of his visual impairment is

C. Diabetic retinopathy

A 60-year-old morbidly obese man presents with complaints of fatigue, worsening exertional dyspnea, three-pillow orthopnea, lower extremity edema, and cough occasionally productive of frothy sputum. He has a long-standing history of type II diabetes and hypertension. On examination, you note the presence of bibasilar rales, an S3 gallop, jugular venous distention, and 2+ pitting edema in both legs up to the knees. There does not appear to be an arrhythmia present. A transesophageal echocardiogram (TEE) is performed which reveals a left ventricular ejection fraction (LVEF) of 30%. Which of the following accurately describes this patient and his condition?

C. Digoxin would be an appropriate choice in attempting to control symptoms.

Ascaris are best observed in human specimens by which one of the following?

C. Dilution followed by egg count

A20-year-old male has had a recent wide local excision of a 1.5 mm melanoma from the right ankle. There is no evidence of metastatic disease. The most important prognostic factor for this patient is which of the following? Which of the following is true regarding melanoma?

C. Elevated serum LDH suggests metastatic melanoma.

A 39-year-old HIV-positive male presents for routine follow-up. He is on highly active antiretroviral therapy. A CD4 count is 250/L. His vital signs are within normal limits and his examination is normal. He has a PPD placed and follows up in 48 hours. At the site of the injection you find 6 mm of induration. A CXR is normal. He has never been treated for tuberculosis or a positive PPD before. Which management option is most appropriate?

C. Empirically start isoniazid daily for 9 months.

Malaise and fatigue with increased "atypical" lymphocytes and a reactive heterophil antibody test is most commonly caused by

C. Epstein-Barr virus

The life cycle of this parasite consists of two stages: the cyst and the trophozoite, as shown in the figure below. The most likely identification of this organism is

C. Giardia

A patient with dyspepsia has a positive serologic test for Helicobacter pylori and is concerned that he could have an ulcer. Which of the following statements about H. pylori and ulcer disease would be most accurate?

C. H. pylori is associated with both gastric and duodenal ulcers.

This virus belongs to the family of flaviviruses and its reservoir is strictly human. Transmission is blood-borne so the blood supply is routinely screened for this virus.

C. Hepatitis C

Select the most effective or principal means of control for Tetanus.

C. Immunization

Select the most effective or principal means of control for Typhoid fever.

C. Immunization

Patients should be vaccinated annually for influenza with which of the following vaccines?

C. Inactivated virus vaccine

The vaccine for measles is best characterized as a

C. Inactivated virus vaccine

An immunocompromised patient is suspected of having an infection with A. fumigatus. Which of the clinical conditions is most likely to occur?

C. Invasive aspergillosis causing thrombosis and infarction

You see a 31/2-year-old child in the emergency department who has had fever for the past week. The parents relate that their son has some swollen glands, fever, and now seems to be getting a rash on his arms. On examination, you find an uncomfortable appearing young boy whose vital signs are normal with the exception of a temperature of 104°F. You note t hat he has a red posterior oropharynx with dry, cracked lips. His TMs are normal. He has mild conjunctival injection bilaterally without any discharge. His chest is clear, and his heart sounds are normal. He does not have any hepatosplenomegaly. His has a lacy, confluent macular rash on his chest and upper arms, with mild peeling of the tips of his fingers. What is the most likely diagnosis?

C. Kawasaki disease

A 52 year old woman presents to your office for her annual gynecological examination. She stopped menstruating about 6 months ago and is getting some hot flashes. Her history reveals that she drinks one glass of wine per day and smokes about 10 cigarettes per day. She does not exercise much and is overweight. Her most important risk factor for developing osteoporosis is

C. Lack of physical activity

A 2-year-old child was admitted to the hospital with acute meningitis. The Gram stain revealed Gram-positive short rods, and the mother indicated that the child had received "all" of the meningitis vaccinations. What is the most likely cause of the disease?

C. Listeria

Which one of the following organisms causes primary atypical pneumonia in humans?

C. M. pneumoniae

Children between the ages of 1 and 5 have an average of eight colds per year. Choose statement below that match rate above.

C. Morbidity rate

Public health efforts to pre vent injuries have been particularly successful in reducing deaths from

C. Motor vehicle accidents

Which of the following is a common cause of epidemic gastroenteritis, particularly aboard cruise ships and in summer camps? It may be detected by ELISA methods or electron microscopy.

C. Norwalk virus

A 25-year-old woman with acute myelocytic leukemia is undergoing induction chemotherapy and presents to the Emergency Center complaining of a 1-day history of fever to 102º F with no other symptoms. Other than having a fever, her vital signs and physical examination are normal. Laboratory evaluation reveals pancytopenia, with a WBC count of 0.3 k/L, hemoglobin concentration of 9.2 mg/dL, and platelet count of 23,000/L. What is the most appropriate initial management?

C. Obtain blood culture, urine culture, a chest x-ray, and admit the patient to the hospital for empiric broadspectrum antibiotics with Gram-negative coverage.

A mother brings her 4-year-old son to your office, relating that he fell earlier that morning while at the playground. She says that the boy tripped over another child and landed on his outstretched hands. On examination, the boy has some mild swelling around his left wrist, and he says that it hurts when you palpate it. What is the most appropriate next step?

C. Perform anterior-posterior (AP) and lateral x-rays of the left wrist and elbow.

There are millions of cases of leprosy (Hansen's disease) worldwide, but predominately in Asia and Africa. The clinical spectrum of Hansen's disease is best characterized by

C. Peripheral neuritis

Measles, tuberculosis, influenza. Select the most common described mode of transmission with the above disease

C. Persontoperson direct contact transmission

A "parasite" that may be a fungus is the initial clinical manifestation in up to 60% of patients with AIDS. This organism is

C. Pneumocystis

This virus is the leading cause of bronchiolitis and community- acquired pneumonia in infants.

C. Respiratory syncytial virus

The most common way in which tuberculosis is acquired is via the

C. Respiratory tract

A term infant male is born after an uncomplicated vaginal delivery. The mother's prenatal labs were negative with the exception of being GBS positive at 36 weeks' gestation. The mother received two doses of ampicillin prior to delivery and did not have a fever. The infant had APGAR scores of 9 at 1 minute and 9 at 5 minutes. The infant was brought to the newborn nursery and appears well. The most appropriate management of the infant would be which of the following?

C. Routine care.

Flukes (trematodes) have a great impact on worldwide public health, causing both morbidity and mortality. Which of the following organisms penetrates skin, is endemic in Africa and Latin America, and has a large lateral spine on its eggs?

C. S. mansoni

C1 deficiency has three subcomponents, of which the most common is deficiency of C1q. Most of those patients will have clinical and serologic findings typical of which of these?

C. SLE

A 22-year-old female (G3P0020) presents to your office for an initial obstetric visit in her third pregnancy. She reports a sure LMP date approximately 6 weeks ago, with a history of regular cycles. Her two previous pregnancies ended in spontaneous abortions. She denies any significant medical or surgical history. She denies use of alcohol, tobacco, or illicit drugs, though she does report a history of IV drug use as a teenager. She is a full-time student. She reports that twins run in her family, but she does not have any family history of diabetes, hypertension, or congenital anomalies. On review of her prenatal labs that have already been drawn, you find that her human immunodeficiency virus (HIV) antibody test (enzyme-linked immunosorbent assay [ELISA]) is positive. Her test results are otherwise normal. Which of the following indicates how you counsel the patient?

C. She will require an additional, confirmatory test to determine whether or not she has HIV.

A 24-year-old White (G1P1001) female presents to your office 6 weeks after a normal spontaneous vaginal delivery at term. She reports that she has been unable to breast-feed her baby despite helpfrom her pediatrician and a lactation consultant. On further questioning, you elicit that she has also experienced nausea, weakness, and weight loss. In addition, she reports dizziness when getting out of bed in the morning. On your examination, she has a waxy texture to her skin and periorbital edema. You also note decreased axillary and pubic hair, which she reports is a change for her. She most likely has which of the following diagnoses?

C. Sheehan syndrome

Each individual of the total group has an equal chance of being selected. Select the correct term that match above description of a sampling procedure.

C. Simple random sampling

Schistosomiasis is a disease characterized by granulomatous reac- tions to the ova or to products of the parasite at the place of oviposition. Clinical manifestations include which one of the following?

C. Splenomegaly

To isolate specific bacteria from clinical specimens, it is necessary to use a variety of artificial media, some of which is selective, others of which are nonselective. N. gonorrhoeae is a fastidious pathogen and found in sites often con- taminated with normal flora. The best medium for isolation is

C. Thayer-Martin agar

A70-year-old White woman has been faithful about taking 1200 mg of calcium, 400 IU of vitamin D supplements, and performing weight-bearing exercise on a daily basis. Her hip T score from her current DEXA scan has changed from -2.0 SDs to -2.55 SDs compared with last year's test. Which of the following is associated with a reduced risk of osteoporotic fractures?

C. body mass index of greater than 23

A 72-year-old diabetic is transferred to your hospital for fever and altered mental status in the late summer. Symptoms started in this patient 1 week prior to admission. On physical examination, the patient was disoriented. There were no focal neurologic findings. There was a fine rash on the patient's trunk. On oral examination, there were tongue fasciculations. A lumbar puncture was performed which showed a glucose of 71 and a protein of 94; microscopy of the cerebrospinal fluid (CSF) revealed 9 RBC and 14 WBC (21 P, 68 L, 11 H). The creatinine phosphokinase was 506. An electroencephalogram and MRI of the brain were normal. What is the best interpretation of these findings?

C. The patient may have West Nile virus.

A 29-year-old woman complains of fatigue and decreased exercise tolerance. She takes no medications and denies changes in the color of the stool. Physical examination is significant for pale skin and conjunctivae. Stool was negative for blood. Laboratory evaluation revealed Hgb of 7.8 g/dL, reticulocytopenia, microcytosis, and hypochromia. In vitamin B12 or folate deficiency, which of the following statements is correct?

C. The peripheral smear in patients with cobalamin deficiency is identical to that found in folate deficiency.

A butcher, who is fond of eating raw hamburger, develops chorioretinitis; a Sabin-Feldman dye test is positive. This patient is most likely infected with

C. Toxoplasmosis

A 25-year-old nulligravid female, whose LMP was 4 weeks ago, is seen by her OB/GYN for a left breast mass. The patient discovered it 2 weeks ago while in the shower. Her maternal aunt died of breast cancer at age 60, and the patient is very worried about this new finding. On examination, a mobile, nonerythematous, 3-cm nonsolid feeling mass is palpated in the left upper outer quadrant of her left breast. There is no nipple discharge, and the axillary lymph nodes are nonpalpable. Her right breast examination is normal. The patient wants you to schedule a mammogram that same day. Your response is which of the following?

C. Ultrasound would be a better imaging modality for her situation.

Chicken pox is a common disease of childhood. It is caused by which of the following viruses?

C. Varicella-zoster virus

Excluding influenza, which one of the following viruses is a common cause of acute respiratory disease?

C. Varicella-zoster virus

35yearold woman presents to your office complaining of hair loss, bone pain, and dryness and fissures of the lips. She tells you that she has been taking large amount of vitamins in hopes of pre venting cancer and infections. Her symptoms are most likely caused by an excess of

C. Vitamin C

A 63-year-old male presents to your office with palpitations for the past 3 weeks. He has had no chest pains or dyspnea. He has no significant medical history and takes no medications. He does not smoke cigarettes and a recent lipid panel was normal. On examination, he is in no apparent distress. His pulse is 115 bpm and irregular. His BP is 125/77. His lungs are clear and his cardiac examination reveals an irregularly irregular rhythm with no murmurs, rubs, or gallops. Which of the following is most likely to be found on an ECG?

C. absent P waves

A 43-year-old patient presents with his fourth episode of culture-proven shingles in a T7 distribution. What is the most likely associated underlying condition?

C. acquired immunodeficiency syndrome (AIDS)

An 8-year-old male presents to your office complaining of a 1-week history of painful knee and elbow joints. On examination, you find a painful, hot, and swollen knee. He also has multiple erythematous macules with pale centers on his trunk and extremities. The laboratory work you order reveals elevated antistreptococcal antibodies. What is the most likely diagnosis?

C. acute rheumatic fever (ARF)

A 60-year-old woman arrives at your office for a routine physical examination. During the course of her examination she asks you about osteoporosis. She is concerned about her risk for osteoporosis, as her mother suffered from multiple vertebral compression fractures at the age of 60. Your patient reports that she still smokes cigarettes ("although I know they are bad for me") and has one alcoholic beverage a week. She reports having had menopause 5 years ago and experiencing a deep venous thrombosis approximately 20 years ago. She is proud of the fact that she regularly exercises at the local fitness center. She has been taking 1500 mg of calcium with 800 IU of vitamin D every day. You suspect that she is at risk for osteoporosis. After a thorough discussion with your patient, you determine that pharmacologic intervention would be beneficial given the severity of her osteoporosis. Which of the following is most appropriate for your patient?

C. alendronate

A 19-year-old woman begins chemotherapy for an acute leukemia. Although you determine that her renal function is unimpaired prior to the initiation of treatment, you feel that she may be at high risk for development of tumor lysis syndrome given her condition's typically good response to chemotherapy. Which of the following is an appropriate medication to use as a preventative measure prior to and during her treatment for leukemia?

C. allopurinol

A 17-year-old female presents with primary amenorrhea. On physical examination, she has normal secondary sexual characteristics, scant pubic and axillary hair, and a blind ending vaginal pouch. Apelvic MRI indicates inguinal gonads and no uterus. Her karyotype is 46,XY. Which of the following is the most likely etiology of primary amenorrhea in this patient?

C. androgen insensitivity

A54-year-old Asian female with no significant medical history presents with frontal headache, eye pain, nausea, and vomiting. Her abdominal examination shows mild diffuse tenderness but no rebound or guarding. Her mucous membranes are dry. Her vision is blurry in both eyes, her eyes are injected but her extraocular muscles are intact. Her pupils are mid-dilated and fixed Which of the following is the most likely diagnosis?

C. angle closure glaucoma

A 72-year-old previously healthy woman was diagnosed with Stage II breast cancer and was initiated on FAC chemotherapy (5-fluorouracil, doxorubicin, cyclophosphamide) 3 months ago. She now presents to the emergency room complaining of exertional dyspnea, orthopnea, and lower extremity edema. Her vital signs are normal, her EKG is normal, and her chest x-ray shows cardiomegaly and pulmonary vascular congestion. What is the most likely cause of the patient's new symptoms?

C. anthracycline-induced cardiomyopathy

A 22-year-old White female (gravida 2, para 1, abortus 1) comes to your office with a 3-week history of lower abdominal pain and increased vaginal discharge. She has a prior history of an ectopic pregnancy at age 16. Her last menstrual period (LMP) was 7 days ago, and she has had unprotected vaginal intercourse with a new sexual partner several times over the past few weeks. Her temperature is 38.0°C; her vital signs are stable. She has bilateral lower quadrant tenderness but no peritoneal signs. On speculum examination, she has foul smelling green discharge emanating from her cervix. She has cervical motion tenderness on bimanual examination and is tender in both adnexae. Her wet mount shows copious white cells. Her urine - hCG is (-). Which of the following would be the most appropriate treatment regimen for this patient?

C. ceftriaxone intramuscular (IM) plus doxycycline PO for 14 days

A 60-year-old woman arrives at your office for a routine physical examination. During the course of her examination she asks you about osteoporosis. She is concerned about her risk for osteoporosis, as her mother suffered from multiple vertebral compression fractures at the age of 60. Your patient reports that she still smokes cigarettes ("although I know they are bad for me") and has one alcoholic beverage a week. She reports having had menopause 5 years ago and experiencing a deep venous thrombosis approximately 20 years ago. She is proud of the fact that she regularly exercises at the local fitness center. She has been taking 1500 mg of calcium with 800 IU of vitamin D every day. You suspect that she is at risk for osteoporosis. After performing the appropriate imaging study, you determine that your patient has osteoporosis. Of the following choices, which is risk factor most likely contributing to her osteoporosis?

C. cigarette smoking

A 60-year-old male with a history of hypertension and hyperlipidemia undergoes an evaluation for angina. He states that he routinely experiences dyspnea, fatigue, and retrosternal chest discomfort when performing activities such as walking around the block on which his house is located or climbing the flight of stairs within his home. Besides taking medications for his blood pressure and cholesterol, he uses nitroglycerin which successfully alleviates his symptoms. Which of the following best describes the severity of this patient's angina?

C. class III

You are asked to see a 74-year-old man who has been admitted for evaluation of abdominal pain. During his workup, he was found to have hemoccult positive stool and a CT scan that was concerning for a mass in his sigmoid colon. Which should be the next step in his treatment?

C. colonoscopy to biopsy the mass and rule out synchronous lesions

A22-year-old nulliparous woman who desires future fertility is found to have a pap smear consistent with high-grade squamous intraepithelial lesion (HGSIL). Initial management should be which of the following?

C. colposcopy

You see a 3-week-old infant in your office for an acute visit. She was born via spontaneous vaginal delivery following a term, uncomplicated prenatal course. The parents are concerned because they have seen some streaks of blood in her diaper over the past few days. The infant's stools have been soft and not difficult to pass. The parents relate that she is eating 2 oz every 2 hours of a cow's milk based formula. What is the most likely cause of the blood in her stool?

C. cow's milk protein intolerance

A 63-year-old male presents to your office with palpitations for the past 3 weeks. He has had no chestpains or dyspnea. He has no significant medical history and takes no medications. He does not smoke cigarettes and a recent lipid panel was normal. On examination, he is in no apparent distress. His pulse is 115 bpm and irregular. His BP is 125/77. His lungs are clear and his cardiac examination reveals an irregularly irregular rhythm with no murmurs, rubs, or gallops. Which of the following studies would be most appropriate to order at this time?

C. echocardiogram

A38-year-old woman presents to the ER with heavy vaginal bleeding. A pelvic examination using a speculum to visualize the cervix reveals a large, friable, fungating cervical mass. On bimanual examination, the mass extends to the right pelvic sidewall. A biopsy from a recent gynecologic visit reveals invasive squamous cell carcinoma of the cervix. An abdominal/pelvic CT scan shows enlarged pelvic lymph nodes and right hydronephrosis. Her hematocrit (HCT) in the ER is 24%, but she is hemodynamically stable with a BP of 124/70 and a pulse of 73. The cervical mass is actively bleeding. Your initial treatment of the vaginal bleeding in the ER only partially controls the bleeding, and she is requiring frequent retreatment. The best definitive treatment to control the bleeding at this time is which of the following?

C. emergency high-dose radiation therapy

A35-year-old woman with two prior term pregnancies presents for her first prenatal visit at 12 weeks' gestation. She recalls having had hypertension near the end of her first pregnancy. She believes her blood pressure has been normal since, but admits that she rarely seeks preventive health care visits, and that her last examination by a physician was more than 2 years ago. Today, you find her blood pressure to be 160/100. Which of the following antihypertensive agents would be contraindicated for management of her hypertension during pregnancy?

C. enalapril

A42-year-old man without prior significant medical history comes to your office for evaluation of chronic diarrhea of 12 months duration, although the patient states he has had loose stools for many years. During this time he has lost 25 lbs. The diarrhea is large volume, occasionally greasy, and nonbloody. In addition, the patient has mild abdominal pain for much of the day. He has been smoking a pack of cigarettes a day for 20 years and drinks approximately five beers per day. His physical examination reveals a thin male with temporal wasting and generalized muscle loss. He has glossitis and angular cheilosis. He has excoriations on his elbows and knees and scattered papulovesicular lesions in these regions as well Which of the following is the best test toconfirm the suspected diagnosis?

C. esophagogastroduodenoscopy with small bowel biopsy

A 60-year-old morbidly obese man presents with complaints of fatigue, worsening exertional dyspnea, three-pillow orthopnea, lower extremity edema, and cough occasionally productive of frothy sputum. He has a long-standing history of type II diabetes and hypertension. On examination, you note the presence of bibasilar rales, an S3 gallop, jugular venous distention, and 2+ pitting edema in both legs up to the knees. There does not appear to be an arrhythmia present. Which of the following medications should be given initially?

C. furosemide

A 50-year-old female presents to your office for evaluation of solid food dysphagia without weight loss. Symptoms have been present for 6 months and are progressive. The patient has had two episodes of near impaction, but copious water ingestion and repeated swallows allowed the food bolus to pass. She has never had to present to the ER for disimpaction. She drinks five to six beers per day, loves spicy foods, and smokes a pack of cigarettes daily with a total lifetime history of 30 pack-years. She has had intermittent heartburn symptoms for years and has not sought treatment. She takes hydrochlorothiazide for hypertension. Review of symptoms reveals chronic cough. Physical examination is unremarkable. Upper endoscopy reveals a distal esophageal stricture with inflammatory changes. Esophageal biopsies reveal benign mucosa with chronic inflammation. Gastric biopsies are unremarkable. Helicobacter pylori testing is negative.What is the most likely etiology of the patient's stricture?

C. gastroesophageal reflux

A28-year-old woman presents for evaluation of primary infertility. She has had fewer than four periods per year since menarche at age 14, facial hirsutism, acne, and weight gain. On examination, she has a BP 150/100. Her body mass index (BMI) is 40. Acanthosis nigricans is noted along the posterior surface of her neck. Which of the following laboratory studies is most likely to be abnormal in this patient?

C. glucose tolerance test

A28-year-old woman presents for evaluation of primary infertility. She has had fewer than four periods per year since menarche at age 14, facial hirsutism, acne, and weight gain. On examination, she has a BP 150/100. Her body mass index (BMI) is 40. Acanthosis nigricans is noted along the posterior surface of her neck. Which of the following would be her most likely fasting lipid profile?

C. high TGs, low HDL

A 34-year-old male undergoes an uneventful excision of a parathyroid adenoma. The following postoperative day, he complains of numbness around his lips. Which of the following is the most likely cause of this symptom?

C. hypocalcemia due to hungry bone syndrome

A 32-year-old woman presents with complaints of irritability, heat intolerance, hyperdefecation, and frequent palpitations. She has lost 20 lb over the past six months. She has always been in good health and does not take any prescription or OTC medications. She denies any prior history of thyroid disease or exposure to head/neck irradiation, but she states that one of her relatives was diagnosed with a thyroid disorder at roughly the same age. Vital signs are as follows: BP 138/78, HR 112, RR 22, temp. 98.8°F. On examination, her thyroid is diffusely enlarged and smooth. Auscultation of the thyroid reveals a bruit. Her hair is fine in texture, and she has warm velvety skin. She has hyperactive deep tendon reflexes. There is a fine tremor in her outstretched hands. Which of the following is a common finding in this condition?

C. infiltrative ophthalmopathy

A22-year-old male presents to an acute care clinic in order to have two genital lesions evaluated. He first noticed the lesions about 2 weeks ago, but delayed seeking medical care because he believed they were harmless due to the lack of any discomfort. He states that he does engage in unprotected sexual intercourse, with the most recent time being 1 month ago. On examination, the glans penis features two distinct nontender papules with elevated edges surrounding ulcerated craters. They each measure 1 cm in diameter. There is also nontender bilateral inguinal lymphadenopathy. The drug of choice for treating this patient works by which of the following mechanisms?

C. inhibiting bacterial cell wall synthesis

A 5-year-old male is admitted to the hospital following a 3-week history of spiking fevers and fatigue. Your examination reveals pale mucous membranes and skin. You also find splenomegaly. You are concerned about a possible malignancy. What is the most common malignancy of childhood?

C. leukemia

A 32-year-old woman presents with complaints of irritability, heat intolerance, hyperdefecation, and frequent palpitations. She has lost 20 lb over the past six months. She has always been in good health and does not take any prescription or OTC medications. She denies any prior history of thyroid disease or exposure to head/neck irradiation, but she states that one of her relatives was diagnosed with a thyroid disorder at roughly the same age. Vital signs are as follows: BP 138/78, HR 112, RR 22, temp. 98.8°F. On examination, her thyroid is diffusely enlarged and smooth. Auscultation of the thyroid reveals a bruit. Her hair is fine in texture, and she has warm velvety skin. She has hyperactive deep tendon reflexes. There is a fine tremor in her outstretched hands. Which of the following sets of laboratory results would be consistent with this patient's presentation? TSH free T3 free T4

C. low high high

Which of the following agents is considered the first-line therapy for prevention of eclamptic seizures?

C. magnesium sulfate

A 32-year-old woman complains of episodic confusion in the morning for the past 6 months. During one of these episodes, she was brought to the ER and her serum glucose was found to be 40 mg/dL. She was given intravenous dextrose and her symptoms resolved within 15 minutes. She has gained approximately 25 lbs during the past year. Which of the following would be the most appropriate next step?

C. measure insulin, C-peptide, and sulfonylurea level on the initial blood sample in ER

A 52-year-old female has been referred to you for consultation following a core biopsy of an area of calcifications seen on a screening mammogram. She has no family history of breast or ovarian cancer. She has not been taking hormone replacement therapy and has no reproductive risk factors. On physical examination, there is no palpable mass. The core biopsy results demonstrate atypical ductal hyperplasia. What should be the next step in her treatment?

C. needle localized excisional biopsy

A 44-year-old female has a history of endometriosis resulting in chronic pelvic pain. She presents to you 6 months after her total abdominal hysterectomy and bilateral salpingooophorectomy. She reports continued pelvic pain. Which of the following would be your most appropriate recommendation for medical management?

C. oral progestins

A41-year-old woman, recently diagnosed with a 2-cm, stage IB1 cervical cancer, undergoes a radical hysterectomy, bilateral salpingooophorectomy, and retroperitoneal pelvic lymph node dissection. Her surgery and postoperative course are uncomplicated. Four weeks postoperatively, she presents to the ER complaining of left leg swelling and left lower quadrant abdominal pain. On physical examination, she is afebrile, has a normal WBC count, and you palpate a 5 4 cm mass in the left lower quadrant. You order a pelvic ultrasound that shows a 5 5 cm simple cyst in the left lower quadrant. Which of the following is the most likely diagnosis?

C. ovarian cyst

A 14-year-old nulligravid female is brought to the ER by her parents with a 12-hour history of severe, intermittent left lower quadrant pain. She has had nausea and vomiting for the past 2 hours. On history, the patient experienced menarche at age 12 and denies past or current contact with a sexual partner. Her last normal menstrual period was 3 weeks ago. On examination, she is afebrile, pulse 100, BP 110/70, respiratory rate (RR) 20. She is visibly uncomfortable. She has no costovertebral tenderness, has diminished bowel sounds, her abdomen is nondistended, and exhibits rebound and guarding in both lower quadrants. She is unable to tolerate a pelvic examination due to pain. Laboratory values are as follows: WBC 13, HCT 39, -hCG (-), UA (-). Apelvic ultrasound shows a normal nonpregnant uterus, normal right adnexa, and an 8-cm left adnexal mass with a 3-cm solid component The most likely etiology of this patient's pain is which of the following?

C. ovarian torsion

Which anatomic location is the most common site of extra-adrenal pheochromocytomas?

C. paraaortic area

A43-year-old Black female (gravida 3, para 3) with a previous tubal ligation, presents to your office complaining of increasing menorrhagia, dysmenorrhea, and fatigue over the past 6 months. On examination, her vital signs are normal, and on abdominal examination you palpate a firm, mobile mass just below the umbilicus. On pelvic examination, there is a moderate amount of old blood coming from the cervical os. A urine pregnancy test is negative, her last pap smear was normal and her spun HCT today is 28%. Which diagnostic test would be most costeffective in confirming a diagnosis?

C. pelvic ultrasound

A 24-year-old male presents with sore throat, subjective fever, abdominal pain, and bad breath. He says that a neighbor's child is currently being treated for strep throat. On examination, his temperature is 101.1° F and his other vital signs are normal. He appears well. His throat is erythematous and his tonsils are enlarged, but there are no pharyngeal or tonsillar exudates. He has no cervical adenopathy. He has an occasional cough but his lungs are clear. His abdominal examination is normal. The presence of which of the following findings is a clinical predictor for the diagnosis of streptococcal pharyngitis? Which of the following is the recommended first-line agent for the treatment of group A streptococcal pharyngitis?

C. penicillin

Which of the following risk factors has the strongest association with the development of malignant melanoma?

C. pigmented lesion with asymmetric irregular borders, color variegation, and diameter 8 mm

A 19-year-old (G2P1001) female at 354/7 weeks EGA presents for a routine prenatal visit. Her pregnancy has been uncomplicated. She reports good fetal movement and denies vaginal bleeding, loss of fluid, or contractions. She is excited about the arrival of her baby and is planning to breast-feed. Her past medical history is significant for chlamydia that was treated approximately 1 year ago. She is otherwise healthy. Her blood pressure today is 110/60. Fundal height is appropriate. UA is negative. The patient would like to discuss options for postpartum birth control. Which of the following would be an appropriate and effective option for postpartum birth control for this patient?

C. progesterone-only pill

A28-year-old male, well known to your clinic, presents for management of swelling, pain, and tenderness that has developed in his left ankle and right knee. It has persisted for 1 month. Your patient reports that he developed severe diarrhea after a picnic 1 month prior to the onset of his arthritis. During the interval between the diarrhea and onset of arthritis, he developed a "pink eye" that lasted for 4 days. He denies any symptoms of back pain or stiffness. You remember that he was treated with ceftriaxone and doxycycline for gonorrhea 2 years ago, which he acquired from sexual activity with multiple partners. Since that time, he has been in a monogamous relationship with his wife and has not had any genitourinary symptoms. He promises that he has been faithful to his wife and has not engaged in unprotected sexual activity outside his marriage. His physical examination is notable for a swollen left ankle, swollen right knee, and the absence of penile discharge or any skin lesions. Which of the following is the most likely diagnosis?

C. reactive arthritis

A well-appearing 6-year-old presents to your office with a chief complaint of bruising. The parents report that the child had a cold 2 weeks ago but completely recovered. The child is sitting on the examining table, in no distress, discussing her favorite cartoons. On examination, you find mucosal bleeding and bruises on the child's arms and chest. You order a complete blood count (CBC) that has the following results: WBC 12,000, hemoglobin 11 g/dL, and a platelet count of 45,000. After discussing various options with a regional pediatric hematologist and the patient's parents, your most appropriate initial management would be which of the following?

C. reassurance to the parents with close outpatient follow-up

A 74-year-old male with a history of hypertension, type II diabetes, myopia, and cataract surgery 2 weeks ago presents with the sudden onset of severe flashes of light and multiple new floaters in his right eye. He denies photophobia, ocular trauma, or diplopia. He also states that he feels as if there is a curtain lowering over his right eye. Your examination and a stat ophthalmology consultation confirm your clinical diagnosis. Of the choices listed below, what would be the most appropriate next step to provide definite treatment for this patient?

C. removal of vitreous humor (posterior vitrectomy)

A 32-year-old man comes to the office for his annual checkup. He is asymptomatic and his physical exam is normal. He reports that his father died of colon cancer at age 46 and his older brother was recently diagnosed with colon cancer at age 37. His paternal aunt was previously diagnosed and treated for endometrial cancer. He is concerned about his family history of malignancy and wants to discuss cancer screening. What would be the most appropriate recommendation at this time?

C. screening colonoscopy

A23 year old female presents to the emergency department (ED) with "abdominal cramping" nausea, and vaginal bleeding. Ahuman chorionic gonadotropin (hCG) level returns 5150 mIU/mL. A vaginal probe ultrasound is performed and notes no evidence of an intrauterine pregnancy, normal appearing ovaries, a mild amount of fluid in the cul-de-sac, and no evidence of ectopic gestation. The ED physician can exclude which diagnosis from the differential?

C. singleton intrauterine pregnancy

A 64-year-old male has been suffering from lower back pain for over 10 years. You have been following him for this period. You have prescribed stretching exercises and, occasionally, an anti- inflammatory medication to alleviate his pain. Although he has had no neurologic deficits in the past, today he has shown up in your office unexpectedly, complaining of bilateral lower back pain with numbness and tingling over the dorsal aspect of both feet. His symptoms have become progressively worse over the past 2 weeks and he is now unable to stand for more than 5 minutes without developing extreme pain and numbness. His symptoms are much improved by sitting down or kneeling over a chair. Climbing stairs seems to be tolerated well, but walking greatly exacerbates the pain. He denies bladder or bowel incontinence or retention, point tenderness or anesthesia in the lower back along the spinal cord or in the saddle area. What is the likely diagnosis?

C. spinal stenosis of the lumbosacral area

A 26-year-old HIV-positive man is admitted to the hospital for treatment of a varicella-zoster infection. On the fourth day of treatment, he develops an acute renal insufficiency. What is the most likely treatmentrelated mechanism accounting for the patient's acute renal insufficiency?

C. the precipitation of acyclovir in renal tubules

A 24-year-old male presents with sore throat, subjective fever, abdominal pain, and bad breath. He says that a neighbor's child is currently being treated for strep throat. On examination, his temperature is 101.1° F and his other vital signs are normal. He appears well. His throat is erythematous and his tonsils are enlarged, but there are no pharyngeal or tonsillar exudates. He has no cervical adenopathy. He has an occasional cough but his lungs are clear. His abdominal examination is normal. The presence of which of the following findings is a clinical predictor for the diagnosis of streptococcal pharyngitis?

C. tonsillar exudates

A mildly mentally retarded 9-year-old girl is brought to your office for acne. On examination, she does not actually have acne but has small flesh colored papules along her nasolabial fold. Her past history is significant for having had a first (afebrile) seizure last year. The mother reminds you that she has a faint birthmark on her hip that is pale and becomes more prominent in the summer, when the child's skin tans. Examination of this area reveals a 5-cm oval patch that is hypopigmented. Which condition would she most likely have?

C. tuberous sclerosis

A42-year-old male with extensive Crohn's disease undergoes a near complete resection of the ileum. Adeficiency of which of the following vitamin is likely to result?

C. vitamin B12

Which of the following can induce menstrual bleeding in a 21-year-old anovulatory, amenorrheic woman with PCOS?

C. withdrawal of progestin therapy

You are consulted by a 55-year-old asymptomatic postmenopausal woman who has been on tamoxifen for 2 years following a diagnosis of breast cancer. She has no other risk factors for endometrial cancer but she was searching the Internet and found information about the risks of tamoxifen therapy. She inquires about endometrial cancer screening. You tell her that for asymptomatic woman on tamoxifen, the screening recommendations for endometrial cancer are which of the following?

C. yearly gynecologic examinations

When taking a history from a 61-year-old woman with disseminated sclerosis, you ascertain that she is intermittently incontinent for liquid stools. Which of the following pertains to the clinical physiology of faecal continence?

E- Incontinence may be associated with rectal prolapse

A 32-year-old woman with a history of Sjögren's syndrome gives birth to her second child. On examination the baby is noted to be bradycardic at 65 beats per minute during birth checks carried out by the on-call midwife. The baby's ECG shows that she appears to be in a junctional rhythm. Which of the following antibodies is most likely to be responsible for the child's heart block?

D- Anti-ro

A 40 year old woman, who is under investigation in the medical out-patient department for symptoms of fatigue, proves to have weakly positive serum anti-nuclear antibodies (ANAs). Other blood tests are all normal. Which of the following is the most likely explanation for her ANA positivity?

D- Age-related

A 25-year-old woman is referred to you for treatment of her asthma. She is otherwise well and there is no significant previous medical history. During the consultation it transpires that her sister died of cystic fibrosis and she is worried about having a child affected with the same disease. Her chest X-ray is normal. Assuming a population carrier frequency of 1 in 25, what is the chance of her having an affected child?

D- 1 in 150

You see a healthy 20-year-old man in your clinic. There is no significant past medical history and he plays rugby for Saracens rugby club. He tells you that his brother died at the age of seven years with cystic fibrosis. What are his chances of being a carrier?

D- 2 in 3 (67%)

You are consenting a 19-year-old man, who is thought to have a congenital neurological degenerative disorder, for collection of genetic material. He tells you he has heard about the human genome project. Which of the following statements is true concerning the project?

D- 3.7 million human single nucleotide polymorphisms (SNPs) were mapped

A 60-year-old man presents to the emergency team with dramatic swelling of his tongue and lips. He has hypertension and type-2 diabetes mellitus. His drug therapy has been unchanged for 5 years and comprises lisinopril, low-dose aspirin and metformin. Which of the following diagnoses is most likely?

D- ACE inhibitor-associated angioedema

Which enzyme in serum is increased in Gaucher's disease?

D- Acid phosphatase

A 25-year-old woman with systemic lupus erythematosus (SLE) has dsDNA antibodies and a grade III glomerulonephritis. Which is the most likely immunopathological process?

D- Activation of the classical complement pathway

A 17-year-old boy with a history of type 1 diabetes mellitus, sensorineural high tone deafness and colour blindess presents for review in the genetics clinic. You learn from his mother that other members of the family are affected, including a daughter aged 21 who also suffers from Type 1 diabetes. Which of the following represents the usual mode of inheritance for the likely genetic syndrome?

D- Autosomal recessive

Regarding B cells and plasma cells, which of the following is true?

D- B cells can undergo isotype switching

A woman presented with diarrhoea that has persisted up to 2 weeks after cholecystectomy. What is the most likely cause of the diarrhoea?

D- Bile acid malabsorption

A 17-year-old adolescent complains of intermittent face swelling. It varies in severity but sometimes he has difficulty breathing. His brother has similar symptoms. What protein is most likely to be responsible for his condition?

D- C1 esterase inhibitor

A 22-year-old woman presents to Accident & Emergency with an acute hereditary angioedema involving the larynx. What is the optimum immediate management?

D- C1 inhibitor concentrate

A 78-year-old man had poliomyelitis as a child, which left him with total paralysis of the left deltoid muscle. Which feature is most likely to be present on clinical examination?

D- Detectable weakness in drawing the arm forward and internally rotating the shoulder when this is compared with the right side

A 24-year-old man is being provided with long-term parenteral nutrition for Crohn's disease. His energy requirement is estimated to be approximately 597 J (2500 kcal)/24 h. Which of the following combinations of lipid emulsion and dextrose solutions would bemost appropriate to provide his energy requirements?

D- Dextrose 50% 750 ml, lipid emulsion 20% 500 ml

Which of the following disorders may have an autosomal recessive mode of inheritance?

D- Ehlers-Danlos syndrome Type IV

A 30-year-old man is found to have 3 adenomatous polyps in the sigmoid colon at colonoscopy. He mentions that his father died at 45 with colon cancer, his paternal aunt was treated for rectal cancer at 45 and his paternal grandfather was treated for colon cancer at 50. What is the most likely diagnosis?

D- Hereditary non-polyposis colon cancer (HNPCC)

A 20-year-old man presents with pes cavus, distal weakness and wasting of his leg muscles, absent knee and ankle jerks and reduced sensation to touch and vibration in his feet and legs. His father is said to havesimilar problems. Nerve conduction studies show absent sensory potentials from his sural nerve and reduced motor nerve conduction velocities in his common peroneal nerve. What is the most likely diagnosis?

D- Hereditary sensory and motor neuropathy type 1 (HMSN1)

A patient in the intensive care unit following liver transplant surgery has a metabolic alkalosis. Which of the following biochemical abnormalities is most specifically indicative of this?

D- High plasma bicarbonate concentration

A 35-year-old man presents with a one-year history of choreiform movements, personality changes and mild memory loss. His father died with similar problems at the age of 50. What is the most likely diagnosis?

D- Huntington's disease

A patient on total parenteral nutrition (TPN) regimen presents with drowsiness and abnormal serum electrolytes. What is the most likely cause?

D- Hypophosphataemia

Which of the following immunoglobulin isotypes has the highest concentration in serum?

D- IgG

What is the mechanism of action of erythropoietin when used as a performance-enhancing drug?

D- Improvement of exercise tolerance

You review a young man with hypocalcaemia and notice on review of his hands that he has a shortened fourth and fifth digit on each hand. You wonder if he may have pseudohypoparathyroidism, caused by a G-protein abnormality. Which of the following best describes the location of G-proteins?

D- In the cytoplasm

A patient on enteral nutrition develops constipation.What could explain the underlying clinical physiology?

D- Inadequate fluid replacement

How is the Mantoux test administered?

D- Intradermal

Which of the following statements concerning hyperacute rejection after renal transplantation is correct?

D- Is mediated by preformed circulating antibodies

Antibodies to which of the following are most frequently present in the serum of patients with type-1 diabetes at diagnosis?

D- Islet cells

You review a 39-year-old sportsman who complains of knee pain. Arthroscopy reveals damage to the cartilage. Which of the following stems best describes a property of hyaline cartilage?

D- It is avascular

Which of the following statements about prostaglandin synthesis is correct?

D- It is mediated by cyclooxygenase

A 70-year-old man with symptoms of prostatism has a serum prostate specific antigen (PSA) concentration of 20 mg/l (normal value, < 4 mg/l). Which one of the following statements about the clinical importance of this result is the most likely?

D- It is more likely to reflect prostatic cancer than benign prostatic hypertrophy

Which of the following statements pertains to a resting neurone?

D- It is positively charged externally

A 27-year-old woman presents with global weakness, lethargy and numbness of her extremities, which has worsened over the past 6 weeks. She admits to intermittent diarrhoea. On examination in the Emergency Department she is markedly underweight with a body mass index (BMI) of only 19. Blood testing reveals hypokalaemia, raised chloride levels, low serum bicarbonate and pH of 7.31. Which of the following diagnoses seems most likely in this case?

D- Laxative abuse

Which of the following is a feature of the early asthma response?

D- Mast-cell degranulation is seen in response to the B-cell production of IgE

A 75-year-old woman is being followed by her GP for suspected developing primary hypothyroidism. Which of the following biochemical changes would you most expect to occur first?

E- Increase in serum TSH

A 22-year-old golfer presents for review. He has noticed a decrease in his grip strength over the past few weeks and pain over his elbow. On examination he has pain over his elbow which is worse on wrist flexion and resisted forearm pronation. There is weakness of the adductor policis muscle and loss of pinch grip and loss of sensation over the lateral fingers of the hand. Which of the following is the most likely cause for his injury?

D- Medial epicondylitis

A 22-year-old man presents with a long history of intermittent abdominal discomfort and diarrhoea. On examination, he has a body mass index of 19 kg/m2 and is clinically anaemic. Coeliac disease is suspected. Which of the following investigations will most reliably diagnose this condition?

D- Microscopic examination of a small bowel biopsy specimen

A 74-year-old-man is seen in the preoperative assessment clinic prior to a right total hip replacement scheduled in eight weeks time. He had a recent chest infection and suffered chronic joint pain and prostatism for many years. On examination there were few chest signs and the musculoskeletal examination revealed evidence of severe arthritis in the right hip and base of the thumb. The prostate is firm and enlarged. It was thought that he was fit to have the operation. However, the blood tests showed raised immunoglobulins and the immune electrophoresis identified an M-protein of the IgG type at 2.5 g/dl. Further tests reveal no lytic bone lesions on skeletal survey and no Bence-Jones proteinuria. The bone profile and the prostate specific antigen were within normal limits. The MOST likely underlying disease is?

D- Monoclonal gammopathies of undetermined significance (MGUS)

A 29-year-old man is referred to you with lethargy, constipation and generalised bone pain. Some 5 years ago he had pituitary surgery for a prolactinoma. He mentions that his father had required surgery to his parathyroid a few years ago and his brother is currently in hospital with kidney stones. What is the most likely diagnosis?

D- Multiple endocrine neoplasia type 1

A 40-year-old man is referred to you with breathlessness and bradycardia. During the consultation you notice that he has a bilateral ptosis. He is estranged from his family and never knew his father, but he does know that his sister has a muscle problem and lost a child in infancy. What diagnosis might you suspect in this man?

D- Myotonic dystrophy

A couple attends genetic screening for an inherited condition that has been observed in the husband's family. More severe cases of so-called 'anticipation' have been observed. What is the most likely condition?

D- Myotonic dystrophy

You are reviewing a man with significant early arterial disease. The brachial artery response postocclusion is severely diminished and confirms a diagnosis of endothelial dysfunction.The successful production of which compound is best linked to vascular smooth muscle cell relaxation?

D- Nitric oxide

A patient with colon cancer presents with cafè au lait spots around the nose and mouth, hand and feet and within the oral cavity. What is the most likely diagnosis?

D- Peutz-Jeghers' syndrome

Which one of the following porphyrias can be both acquired and inherited?

D- Porphyria cutanea tarda (cutaneous hepatic porphyria)

A 20-year-old female presents with the following blood gases: pH 7.48 p(CO2) 3.9 mmHg HCO3- 22 mmol/l H+ 35mmol/l. What is the most likely reason for these results?

D- Pregnancy

A 52-year-old woman undergoes investigation for jaundice. She first noticed this symptom 2 months ago, but for 4 months prior to that, she had been experiencing generalised pruritus. The results of liver function tests are as follows: serum bilirubin 325 mmol/l, aspartate aminotransaminase 55 U/l (15-42), alkaline phosphatase 436 U/l (80-150),gamma-glutamyltransferase 82 U/l (11-51), albumin 36 g/l, total protein 82 g/l. Which of the following is the most likely diagnosis?

D- Primary biliary cirrhosis

Which of the following findings would most suggest that fluid loss from the body was primarily hypotonic (water depletion) rather than isotonic (sodium depletion)?

D- Production of a highly concentrated urine

A 70-year-old Irish man is diagnosed with haemochromatosis. Subsequently, his son is also diagnosed with the condition. Both are homozygous for the common Northern European mutation. What is the most likely explanation?

D- Pseudo-dominant inheritance

A 42-year-old Afro-Caribbean man sustains a myocardial infarction. He is discharged from hospital 4 days later. His medication is aspirin, simvastatin and a β-blocker. A month later, he is well and has routine blood tests in the outpatient clinic. His serum creatine kinase(CK) activity is reported as being 400 U/l. His CK 24 h after admission had been 620 U/l and had fallen to 415 U/l after a further 48 h. Which of the following is the most likely cause of the high CK when he was reviewed in outpatients?

D- Racial variant

Phase 0 of the cardiac action potential relates to a:

D- Rapid influx of sodium

You are asked to review an 80-year-old woman who has suffered previous neurological damage. You note that she has a lower homonymous quadrantanopia affecting the temporal side of the left visual field and the nasal side of the right visual field. Where is the most likely site of her brain lesion?

D- Right parietal lobe

Where would you visualise the azygous lobe on an antero-posterior (A-P) chest X-ray?

D- Right upper zone

A young man is admitted to the emergency room unconscious and hyperventilating. His breath smells of alcohol. Which of the following findings would suggest a specific cause for his condition?

D- Serum calcium concentration (corrected) 1.62 mmol/l

In relation to the nutritional physiology of patients, which of the following would represent appropriate nitrogen requirements (g N/kg per day) and calorie requirements (kcal/kg per day)?

D- Severe injury: nitrogen requirement 0.3 g N/kg per day, calorie requirement 35 kcal/kg per day

A 55-year-old male is brought to the ED, by ambulance, because of crushing chest pain radiating to his left shoulder and arm that started 1 hour ago. He has a history of hypertension, high cholesterol, and has smoked a pack of cigarettes a day for 30 years. He has never had symptoms like this before. Which of the following would be most likely to be seen on an ECG?

D. S-T segment elevation in anterior leads with reciprocal S-T segment depression in inferior leads

A 44-year-old pharmacist presents with a history of recurrent episodes of faintness, sweating and tremor, occurring particularly in the late morning or late afternoon. An insulinoma is suspected. The patient is admitted for 3 days' consecutive overnight fasting with blood glucose measurements in the morning. She remains asymptomatic during her admission and the lowest blood glucose concentration is 4.4 mmol/l. On discharge from hospital, she reports that her symptoms have recurred. What would be the most useful investigation to establish the diagnosis?

D- Simultaneous measurement of glucose and C-peptide when symptomatic

An 82-year-old woman, who is not on drug therapy, presents with a bullous skin rash on her arms. Which of the following tests is most likely to supply the definitive diagnosis?

D- Skin biopsy for examination by immunofluorescence

A 49-year-old man presents with an acutely red and painful eye. Following ophthalmalogical assessment, a diagnosis of anterior uveitis is made. Further investigations are to be undertaken to examine the possible underlying systemic cause. Which of the following underlying diagnoses would the least likely in his case?

D- T-cell lymphoma

A 42-year-old man with a history of road traffic accident and injury to his back and neck presents with global muscle wasting of the left hand. Which is the nerve or nerve root most likely to be involved?

D- T1 nerve root

In the selection of an optimum agent to prevent rejection postrenal transplantation, which of the following cell biological principles is correct?

D- Tacrolimus is a calcineurin inhibitor

A 45-year-man sustains a myocardial infarction. His serum cholesterol concentration is 9.6 mmol/l. Which of the following physical signs would most suggest a diagnosis of familial hypercholesterolaemia?

D- Tendon xanthomas

Which of the following statements is true in the epidemiology of disease associated with a-1-antitrypsin deficiency?

D- The disorder is an indication for liver transplantation in a child

A 75-year-old man has gangrene of the left hallux. There are no pulses to feel below the rather weak femoral pulse on that side. A duplex scan reveals a block in the superficial femoral artery. Which statement pertaining to the arterial system of the lower limb best accords with usual clinical findings?

D- The popliteal artery lies against the popliteal surface of the femur deep to the popliteal vein, which itself lies deep to the tibial nerve

A 42-year-old man consulted his family doctor because of a 2-3 month history of lethargy and feeling generally unwell. The history was otherwise unremarkable. His urine tested positive for glucose, and a random venous plasma glucose concentration was 8.3 mmol/l. The family doctor arranged an oral glucose tolerance test: glucose concentration at baseline 5.6 mmol/l, 9.3 mmol/l at 120 minutes. Which of the following statements is correct?

D- The result of the OGTT indicates impaired glucose tolerance

A 50-year-old woman has a suspected right renal artery stenosis. A transfemoral aortogram has been performed. Which one of the following is likely to be correct?

D- The right and left renal arteries lie in the transpyloric plane at the level of the first lumbar vertebra

Following a stroke, a patient is found to have a left homonymous inferior quadrantic visual field defect. Which one of the following structures is most likely to have been affected by the stroke?

D- The right parietal lobe

A 41-year-old patient complains of tinnitus. Which of the following statements is correct regarding the clinical physiology of the ear?

D- The scala media contains the organ of Corti

Which of the following statements is true concerning kinins?

D- They are proteins that attract phagocytes

You are reviewing a man with familial hypertriglyceridaemia who has presented to the surgeons with pancreatitis. He asks about why he suffers from this condition. Which of the following best describes the metabolism of VLDL (predominant triglyceride) particles?

D- They are synthesised continuously in the liver

A woman has von Willebrand's disease and so does her partner. They wish to have childrenand seek genetic counselling. How would the risk of disease transmission to her offspring be best described?

D- Three-quarters of the children will have the disease

In a patient with chronic hyponatraemia (sodium concentration 112 mmol/l), which of the following findings would most suggest a diagnosis of the syndrome of inappropriate [secretion of] antidiuretic hormone (SIADH)?

D- Urinary osmolality 350 mOsmol/kg

A 70-year-old man presents in an acute confusional state. His plasma sodium concentration is 108 mmol/l, his creatinine is 106 micromol/l, urea of 5.0 mmol/l. Which of the following findings would be most suggestive of the hyponatraemia being due to inappropriate secretion of vasopressin (antidiuretic hormone, ADH)?

D- Urine osmolality 510 mosmol/kg

Which of the following is an acute porphyria?

D- Variegate porphyria

A 75-year-old woman undergoes total gastrectomy for carcinoma of stomach. With which of the following nutrients is she most likely to require parenteral replacement?

D- Vitamin B12

Absent immune deposits on immunohistochemical analysis of renal tissue is characteristic of which one of the following renal disorders?

D- Wegener's granulomatosis

You are working on your PhD project into the underlying basis for an inherited neurological condition. Part of your project involves identifying a protein expressed in an abnormal cell line. Which of the following is the appropriate method for identifying such a protein?

D- Western blot

Among women aged 18 to 34 in a community, weight is normally distributed with a mean of 52 kg and a standard deviation of 7.5 kg. What percentage of women will have a weight over 59.5 kg?

D. 16%

In order to prevent unintended pregnancy following an episode of unprotected intercourse, by when is it recommended that "emergency" oral contraception should be initiated?

D. 72 hours

Which of the following organisms penetrates skin, is endemic in Asia, and has a small lateral spine on its eggs?

D. S. japonicum

A 35-year-old 80-kg male was transported to the regional burn center at your hospital after suffering second- and third-degree burns from the eruption of a brush fire fueled with gasoline. He was intubated by EMS to secure his airway for transport. On arrival, he is found to have burns across his face, anterior neck, chest, and anterior abdomen, as well as bilateral circumferential upper extremity burns. Over the first 8 hours of his resuscitation, you estimate that he will require which of the following?

D. 800 mL/h of isotonic fluid

A new test for chlamydial infections of the cervix is introduced. Half of the women who are tested have a positive test. Compared with the gold standard of careful cultures, 45% of those with a positive test are infected with chlamydia, and 95% of those with a negative test are free of the infection. Match with the correct percentage with the epidemiologic terms, Sensitivity of the test.

D. 90%

Which of the following is a cause of mild gastroenteritis? It can be transmitted by the fecal-oral route but not by food consumption.

D. Astrovirus

Which of the following forms from paraxial mesoderm?

D. Biceps brachii

Certain parasites are found most commonly in particular body contents. A helminth that is naturally transmitted by ingestion of pork, bear, or walrus meat could be detected in

D. Biopsied muscle

A 10-month-old infant has a dysplastic right external ear, some preauricular tags, and a small notch (coloboma) in the iris and lower lid. Which condition does he likely have?

D. CHARGE association

In a study of the cause of lung cancer, patients who had the dis ease were matched with controls by age, sex, place of residence, and social class. The frequency of cigarette smoking was then compared in the two groups. What type of study was this?

D. Casecontrol

Quinolone antibiotic with broad Gram-negative and Gram-positive activity is

D. Ciprofloxacin

Which of the following types of diets may reduce the risk of developing cancer?

D. Diet rich in vitamin C and βcarotene

In order to recognize abnormal bacteria, it is necessary to know which bacteria are predominant normal flora of certain body sites. The bowel contains many microorganisms but the most prevalent bacterium is

D. E. coli

A 2-year-old infant is brought to the emergency room with hemolytic uremic syndrome and thrombocytopenia. Which one of the following bacteria would most likely be isolated from a stool specimen?

D. E. coli 0157/H7

The diagnostic characteristics of Plasmodium falciparum are best described by which one of the following statements?

D. Except in infections with very high parasitemia, only ring forms of early tropho- zoites and the gametocytes are seen in the peripheral blood

A person who contracts gonorrhea is most likely to have acquired it via the

D. Genital tract

Based on the information given, which of the following laboratory tests would most rapidly assist you in making the diagnosis?

D. Gram stain of sputum

This hepatitis virus is a defective virus in that it cannot replicate independently without the presence of hepatitis B virus.

D. Hepatitis D

You see a 31/2-year-old child in the emergency department who has had fever for the past week. The parents relate that their son has some swollen glands, fever, and now seems to be getting a rash on his arms. On examination, you find an uncomfortable appearing young boy whose vital signs are normal with the exception of a temperature of 104°F. You note t hat he has a red posterior oropharynx with dry, cracked lips. His TMs are normal. He has mild conjunctival injection bilaterally without any discharge. His chest is clear, and his heart sounds are normal. He does not have any hepatosplenomegaly. His has a lacy, confluent macular rash on his chest and upper arms, with mild peeling of the tips of his fingers.What is the most appropriate treatment at thispoint?

D. IVIG

A 29-year-old woman complains of fatigue and decreased exercise tolerance. She takes no medications and denies changes in the color of the stool. Physical examination is significant for pale skin and conjunctivae. Stool was negative for blood. Laboratory evaluation revealed Hgb of 7.8 g/dL, reticulocytopenia, microcytosis, and hypochromia. Which of the following is the most appropriate next step in the management of the anemia in this woman?

D. Identify the cause of the anemia with a thorough history and physical examination.

A 31-year-old female health care worker presents to your clinic after a needlestick injury from a patient who subsequently left against medical advice prior to laboratory analysis for HIV or hepatitis. You advise your colleague that:

D. If the patient had HIV, her risk of seroconversion is 0.3%.

Finding antibodies to HBsAg reflects

D. Immunization

Symptoms of C. botulinum food poisoning include double vision, inability to speak, and respiratory paralysis. These symptoms are consistent with

D. Ingestion of a neurotoxin

Choose the type of measurement scale for Year of birth.

D. Interval scale

While visiting a neighbor, a 14-year-old girl is bitten on the left hand by the neighbor's pet cat. The cat is an indoor pet and has had all of the required routine vaccinations. You see the girl in the office approximately 1 hour after the injury. On the dorsum of the left hand you see two shallow puncture wounds that are not actively bleeding. She has full range of motion of her hand, normal capillary refill, and sensation. You see in the chart that the patient had a diphtheria/tetanus (dT) booster vaccine last year. What is the most appropriate management at this time?

D. Irrigate the wounds and prescribe oral amoxicillin/clavulanic acid (Augmentin).

A 4-year-old boy returns for his second visit to the emergency room. Three days ago he was brought in with a 4-day history of fever up to 102°F. At that time, his physical examination was significant for injection of the oropharynx and an enlarged left anterior cervical lymph node. His left TM was nonbulging and nonerythematous. He was sent home on amoxicillin with a diagnosis of streptococcal pharyngitis. He returns today with a persistent fever, edema of both hands, bilateral conjunctivitis, and a polymorphous truncal rash. What is the most likely diagnosis?

D. Kawasaki disease

Which one of the following organisms normally inhabits the female genital tract but may cause acute respiratory illness?

D. M. fermentans

Select an appropriate measure of frequency that describes the number of deaths in the first 28 days of life per 1000 live births in 1 year.

D. Neonatal mortality

A37-year-old White executive secretary comes to you after she found a lump in her right breast while she was showering. She describes a lesion beneath her right nipple. You question her about her personal and family history. She began menarche at age 12, and she is still having regular menstrual periods. She has had two children; the first was born when she was 25 years old. She has no family history of breast, ovarian, or colon cancer on either her maternal or paternal side. You perform a physical examination including a careful examination of her breasts. You note that her breasts contain many small cysts bilaterally. However, you also palpate a localized, firm, nontender mass below the right areola. You also describe a peau d'orange appearance of the areola. Amammogram is performed; however, the mammogram demonstrates no abnormality involving either breast. What next should be done?

D. Order an ultrasound of the right breast and lymph node basin.

Parents bring you a 9-month-old boy they recently have adopted from western Russia. They have sparse medical records of the child's past. They do know that the boy was the result of a sexual assault on the mother and was given up at birth. The child has been in a "baby home" for 5 months. The records which accompanied the boy indicate that there had been some testing done. These tests include HIV, hepatitis B and C serologies, and a rapid plasma reagin (RPR), all of which are negative at 8 months of age. There is what appears to be a Russian immunization record as well. It seems to indicate that the child has had three diphtheria, tetanus, pertussis (DTP), three oral polio, and three hepatitis B vaccinations. There is also an indication that BCG (Bacille Calmette-Guérin) was given. You place a purified protein derivative (PPD) and the parents come back in 48 hours to have it read. The response is 15 mm of induration. The boy does not have any respiratory symptoms at this time. What is the most appropriate response to this information?

D. Perform a CXR and begin isoniazid (INH) for 9 months if the x-ray is negative.

A 30yearold patient presents to your office for contraceptive counseling. She is divorced and has just started a new relationship. She wishes to use oral contraceptives because of their effectiveness. Her examination is normal. Which of the following factors would be considered a contraindication to their use?

D. Polycystic breast disease

A 52yearold patient with chronic cough and shortness of breath is diagnosed with chronic obstructive lung disease. Which of the following factors is the most important contributor to this finding?

D. Repeated childhood respiratory tract infections

Which of the following conditions usually causes hypoglycemia at birth?

E. Beckwith-Wiedemann syndrome

You are working in the emergency department and are called to perform a lumbar puncture on a 3-month-old infant who presented with fever and lethargy. The spinal fluid that you obtain is turbid. The laboratory reports that there are 200 WBCs and 5 RBCs per high-power field (HPF). Ninety-five percent of the WBCs in the spinal fluid are neutrophils. Which of the following is the most probable cause of this illness?

D. S. pneumoniae

In people who have sickle cell anemia, osteomyelitis usually is associated with which of the following organisms?

D. Salmonella

A 25-year-old woman presents to your office complaining of cold hands. She describes them turning white as she reaches for orange juice in the frozen food section of the supermarket. It seems to be getting worse lately. She has no other symptoms but does note that she and her husband are contemplating pregnancy. Her examination today is unremarkable. Which of the following antibodies can cross the placenta and cause the syndrome of neonatal lupus?

D. Sjögren syndrome antibodies (SSA/SSB)

What the most appropriate specimen is for the detection of Varicella-zoster virus (VZV)

D. Skin

What the most appropriate specimen is for the detection of Adenovirus 40/41

D. Stool

Analysis of a patient's stool reveals small structures resembling rice grains; microscopic examination shows these to be proglottids. The most likely organism in this patient's stool is

D. T. saginata

A 39-year-old HIV-positive male presents for routine follow-up. He is on highly active antiretroviral therapy. A CD4 count is 250/L. His vital signs are within normal limits and his examination is normal. Which of the following management options is most appropriate at this time?

D. Test the patient for IgG antibody to Toxoplasma gondii if such a test has not yet been done.

A22-year-old male presents to an acute care clinic in order to have two genital lesions evaluated. He first noticed the lesions about 2 weeks ago, but delayed seeking medical care because he believed they were harmless due to the lack of any discomfort. He states that he does engage in unprotected sexual intercourse, with the most recent time being 1 month ago. On examination, the glans penis features two distinct nontender papules with elevated edges surrounding ulcerated craters. They each measure 1 cm in diameter. There is also nontender bilateral inguinal lymphadenopathy. Which of the following is true about this patient's condition?

D. There is a latent phase in which patients are asymptomatic.

V. cholerae, the causative agent of cholera, is best isolated using

D. Thiosulfate citrate bile salts sucrose medium

A23-year-old male is brought by ambulance to the ER after being found in a house fire. He was in a closed room with a large amount of smoke and has sustained burns to his face, torso, arms, and legs. His pulse is 120, BP 110/55, and SpO2 92% on 2 L of oxygen by nasal cannula. Which of the following statements is true?

D. This patient meets criteria for transfer to a dedicated burn center.

The antibiotic of choice for pneumococcal pneumonia is

D. Vancomycin

The therapy of choice for pseudomembranous enterocolitis is

D. Vancomycin

A teenager who works in a dog kennel after school has had a skin rash, eosinophilia, and an enlarged liver and spleen for 2 years. The most likely cause of this infection is

D. Visceral larva migrans

You are a second-year surgery resident and have just left work after a 30-hour shift. On your way home you witness a recent collision where there is an obviously injured pedestrian. Several bystanders are providing care for the injured victim. You elect to keep driving. Awitness at the scene recognizes you as a physician and reports you to the authorities for neglecting to stop to provide care. As a consequence of your actions, which of the following will most likely happen?

D. You will have no legal action taken against you.

A 17-year-old male presents for evaluation of shortness of breath. He has episodes where he will audibly wheeze and have chest tightness. His symptoms worsen if he tries to exercise, especially when it is cold. He has used an OTC inhaler with good relief of his symptoms, but he finds that his symptoms are worsening. He now has episodes of wheezing on a daily basis and will have nighttime wheezing and coughing, on average, five or six times a month. You suspect a diagnosis of asthma. Which of the following is the most appropriate pharmacologic regimen for this patient?

D. a scheduled long-acting beta agonist, a scheduled inhaled steroid, and a shortacting inhaled bronchodilator as needed

A well-appearing 6-year-old presents to your office with a chief complaint of bruising. The parents report that the child had a cold 2 weeks ago but completely recovered. The child is sitting on the examining table, in no distress, discussing her favorite cartoons. On examination, you find mucosal bleeding and bruises on the child's arms and chest. You order a complete blood count (CBC) that has the following results: WBC 12,000, hemoglobin 11 g/dL, and a platelet count of 45,000. Following your initial evaluation and treatment, you see the child for follow-up in 1 week. She continues to appear well but still has obvious purpura and her platelet count is now 17,000. All other cell lines are normal. Of the options listed below, what is your most appropriate management at this time?

D. admission to the children's hospital for IVIG and steroids

A 35-year-old man is referred to you with altered bowel habit and weight loss. One of his sisters had a hysterectomy for uterine cancer aged 42, another sister had colorectal cancer aged 44 and his father died from colorectal cancer in his fifties. Colonoscopy shows a few polyps and a caecal mass. Which genetic condition might be running in the family?

E- Hereditary non-polyposis colorectal cancer

A 45-year-old male has received intravenous contrast dye prior to CT scan of the abdomen. Twenty minutes later the patient reports severe pruritus. He denies respiratory distress, syncope, or palpitations. His blood pressure is 98/54, pulse is 90, and respiratory rate is 22. On physical examination, he has widespread urticaria. His lungs are clear to auscultation. The next appropriate step would be which of the following This intervention works well in cases such as this due to activity directed toward which of these receptors?

D. adrenergic receptors

A 31-year-old female presents to her physician complaining of rapid onset of hirsutism, deepening of the voice, irregular menses, clitoral enlargement, and acne. Which of the following is the most likely cause of this clinical presentation?

D. androgen secreting tumor

A26-year-old female with recurrent pregnancy loss undergoes a laparoscopy and hysteroscopy. She is found to have a Müllerian anomaly with a heart-shaped uterus that has two uterine horns but one common cervix. What is the name of the uterine anomaly?

D. bicornuate

A 60-year-old morbidly obese man presents with complaints of fatigue, worsening exertional dyspnea, three-pillow orthopnea, lower extremity edema, and cough occasionally productive of frothy sputum. He has a long-standing history of type II diabetes and hypertension. On examination, you note the presence of bibasilar rales, an S3 gallop, jugular venous distention, and 2+ pitting edema in both legs up to the knees. There does not appear to be an arrhythmia present. Which test would be most sensitive for diagnosis of this condition?

D. brain natriuretic peptide (BNP)

A 60-year-old morbidly obese man presents with complaints of fatigue, worsening exertional dyspnea, three-pillow orthopnea, lower extremity edema, and cough occasionally productive of frothy sputum. He has a long-standing history of type II diabetes and hypertension. On examination, you note the presence of bibasilar rales, an S3 gallop, jugular venous distention, and 2+ pitting edema in both legs up to the knees. There does not appear to be an arrhythmia present. Which of the following has been shown to prolong survival in patients with this condition?

D. carvedilol

A22-year-old nulliparous woman who desires future fertility is found to have a pap smear consistent with high-grade squamous intraepithelial lesion (HGSIL). The test you performed above was inadequate. What would be your next step in management?

D. cold knife cervical conization

A 14-year-old nulligravid female is brought to the ER by her parents with a 12-hour history of severe, intermittent left lower quadrant pain. She has had nausea and vomiting for the past 2 hours. On history, the patient experienced menarche at age 12 and denies past or current contact with a sexual partner. Her last normal menstrual period was 3 weeks ago. On examination, she is afebrile, pulse 100, BP 110/70, respiratory rate (RR) 20. She is visibly uncomfortable. She has no costovertebral tenderness, has diminished bowel sounds, her abdomen is nondistended, and exhibits rebound and guarding in both lower quadrants. She is unable to tolerate a pelvic examination due to pain. Laboratory values are as follows: WBC 13, HCT 39, -hCG (-), UA (-). Apelvic ultrasound shows a normal nonpregnant uterus, normal right adnexa, and an 8-cm left adnexal mass with a 3-cm solid component. Which of the following would be the next appropriate step in managing this patient?

D. consultation for immediate surgical intervention

A19-year-old male who moved to your city 3 months ago comes to your office complaining of dry cough for the past 23 months. Along with the cough, he has had some shortness of breath with exertion. He denies fever, chills, nausea, vomiting, wheezing, and sneezing. The cough occurs mostly in the morning and improves as the day goes on. He denies similar complaints in the past and has no history of allergies. He says that his father had eczema and an allergy to eggs. The pulmonary function test that is most likely to be diagnostic in this patient is which of these?

D. decreased forced expiratory volume in 1 second (FEV1)

A 60-year-old woman arrives at your office for a routine physical examination. During the course of her examination she asks you about osteoporosis. She is concerned about her risk for osteoporosis, as her mother suffered from multiple vertebral compression fractures at the age of 60. Your patient reports that she still smokes cigarettes ("although I know they are bad for me") and has one alcoholic beverage a week. She reports having had menopause 5 years ago and experiencing a deep venous thrombosis approximately 20 years ago. She is proud of the fact that she regularly exercises at the local fitness center. She has been taking 1500 mg of calcium with 800 IU of vitamin D every day. You suspect that she is at risk for osteoporosis. Which of the following tests is best to detect and monitor osteoporosis?

D. dual-energy x-ray absorptiometry (DEXA)

You are called to see a newborn in the nursery because the nurse is concerned that the baby may have Down syndrome. The infant begins to have progressively large amounts of bilious emesis. The infant feeds well and has only a small amount of abdominal distention. What is the most likely diagnosis?

D. duodenal atresia

A 4-year-old boy is brought to the emergency room by his mother after the child spontaneously admitted to swallowing part of a toy. The child is unable to describe what he ate further, although he appears to be in no distress. His vital signs are normal and his respiratory and abdominal examinations are unremarkable. The child is hungry and is demanding to eat something. ACXR reveals what appears to be a watch battery ("button battery") in the patient's esophagus. What is the best course of action in this situation?

D. emergency endoscopy

A21-year-old Asian female, with past medical history of exertional asthma, comes to your office complaining of mild low back pain. It started after her working out in the gym 3 days ago. The pain is 24 out of 10 in intensity, has no radiation, increases with bending or lying down for a long time, and improves with warm showers. You examine the patient, diagnose her with paravertebral muscle spasm, and give her prescriptions for cyclobenzaprine and naproxen to use as needed for pain and stiffness. You receive a call from your patient 2 hours later. She is having generalized itching, dizziness, and swelling of the tongue and lips. She is having difficulty breathing. She tells you that she took the first dose of the medication you prescribed about 30 minutes ago. The most beneficial immediate intervention for this patient would be which of the following?

D. epinephrine

A CT scan in a patient with a temperature of 102.1°F and a history of an abdominal aortic graft reveals fluid around the graft. Which of the following is the most appropriate treatment?

D. exploration with graft excision and construction of axillobifemoral graft

A34-year-old woman was found to have a 2-cm right thyroid nodule at the time of a well woman examination. The remainder of the thyroid was palpably normal and there were no lymph nodes palpable. There was no history of thyroid disease or radiation therapy to her head or neck. She was clinically euthyroid. Thyroid-stimulating hormone (TSH) was normal. Which of the following tests would be the most useful in establishing a specific diagnosis?

D. fine needle aspiration of the nodule

Which of the following are currently recommended for all children for every well-child visit?

D. full physical examination

A 32-year-old man who is HIV-positive was found to have Burkitt's lymphoma with diffuse bulky abdominal disease. He now reports to the hospital and is scheduled to begin chemotherapy. Admission laboratory studies show elevations of his uric acid at 15 mg/dL, serum phosphorus at 8.5 mg/dL, creatinine at 2.9 mg/dL, and potassium at 6.1 mEq/L. What therapy is most likely to reverse the patient's metabolic abnormalities?

D. hemodialysis

A 48-year-old woman presents for evaluation of progressively worsening dyspnea. She relates the onset of symptoms to a "walking pneumonia" that she had a year ago. Her breathing has worsened progressively since that time. She has a "smoker's cough" productive of some clear or white phlegm, for which she frequently sucks on cough drops. She started smoking regularly at the age of 18. She currently smokes about a pack of cigarettes a day, down from as much as two packs per day. She is not on any medications regularly. She has no history of heart disease and has always had normal blood pressure Which of the following is most likely to be found on a CXR?

D. hyperinflation of the lungs

A45-year-old male presents to the hospital for acute abdominal pain and is found to have acute pancreatitis. He has no past medical history but recently has noticed urinary frequency and muscle weakness. He takes no medications. He denies alcohol use. His liver function tests during the episode are normal and magnetic resonance cholangiopancreatography study (MRCP) demonstrates an absence of stones in the biliary tree as well as a normal pancreatic duct. His serum calcium is found to be markedly elevated during this episode. The patient recovers clinically, and repeat serum calcium is also found to be elevated 1 month after hospital discharge. What is the most likely cause of his hypercalcemia?

D. hyperparathyroidism

A 19-year-old woman who is 2 months postpartum complains of palpitations, heat intolerance, tremulousness, weight loss, and fatigue. Her thyroid is prominent and firm but nontender. Serum TSH level was undetectable. A nuclear medicine radioactive iodine uptake is performed and shows no uptake of iodine in the neck. Which of the following is the most appropriate next step?

D. initiate propranolol therapy

A 64 year old woman presents with bilateral symmetric arthralgias and morning stiffness for several years. She says that she has been worked up for RA in the past. On review of her records as well as the examination you note subcutaneous nodules, positive rheumatoid factor, and radiographs of the hands that revealed joint erosions. Which of her findings has the highest positive likelihood ratio (LR) for the diagnosis of RA?

D. joint erosions of the hand on xray

A 70-year-old male is seen in the office for chest pain. He reports that he is getting substernal chest pain, without radiation, when he mows his lawn. The pain resolves with 1015 minutes of rest. He has never had pain at rest. He has no other cardiac complaints and his review of systems is otherwise negative. He has an unremarkable medical history and takes only a baby aspirin a day. On examination, his blood pressure is 160/70, pulse 85, and respiratory rate 16. His cardiac examination is notable for a harsh, 3/6 systolic ejection murmur along the sternal border that radiates to the carotid arteries. His carotid pulsation is noted to rise slowly and is small and sustained. His lungs are clear. The remainder of his examination is normal. Which of the following would be most likely to be seen on an ECG?

D. left ventricular hypertrophy pattern

A 50-year-old man presents to your office with fatigue and weakness. He first noticed it a few weeks ago while trying to hang pictures with his wife. His legs have begun to ache as he walks up stairs. He has lost about 20 lbs in the last 3 months. Most recently, he has found that he is more constipated and has trouble rising from the commode. Your physical examination reveals modest proximal weakness, no articular swelling, rash, or any other pertinent findings. Blood work from a recent insurance examination revealed: Sodium 142 meq/L; potassium 3.8 meq/L; chloride 107 meq/L; bicarbonate 29 meq/L; BUN 30 mg/dL; Cr 1.6 mg/dL; WBC 6.8; Hgb 13.6 g/dL; HCT 40%; MCV 88.0 m3; platelets 240,000/mm3; AST 200 U/L; ALT 250 U/L; alkaline phosphatase 70 U/L; bilirubin 0.3 mg/dL; ESR 40 mm/h His CPK is 2400 and an EMG shows fibrillation potentials, positive sleep waves, and myotonic discharges. In addition to addressing his myositis, diagnostic testing should be performed to evaluate for the possibility of which of these?

D. lung cancer

A 17-year-old male presents for evaluation of shortness of breath. He has episodes where he will audibly wheeze and have chest tightness. His symptoms worsen if he tries to exercise, especially when it is cold. He has used an OTC inhaler with good relief of his symptoms, but he finds that his symptoms are worsening. He now has episodes of wheezing on a daily basis and will have nighttime wheezing and coughing, on average, five or six times a month. You suspect a diagnosis of asthma. Your diagnostic workup confirms the diagnosis of asthma. What clinical classification of asthma does this patient have?

D. moderate persistent asthma

A 63-year-old woman with a grade 2 endometrioid adenocarcinoma of the uterus diagnosed by endometrial biopsy is taken to the operating room for surgical treatment with a total abdominal hysterectomy, bilateral salpingooophorectomy, and pelvic and paraaortic lymphadenectomy. No complications are noted intraoperatively. On postoperative day 1, the patient complains of numbness in her medial thigh. Your neurologic examination suggests absence of cutaneous sensation to the medial thigh and an inability to adduct her hip. Which of the following is the most likely etiology for this clinical presentation?

D. obturator nerve injury

An 18-year-old female presents for evaluation of facial acne. On examination, she has multiple comedones, papules, and pustules on her forehead, nose, cheeks, and chin. She also has several distinct nodules, each greater than 5 mm in diameter. Which of the following is most appropriate for initial inclusion in a regimen to treat this patient's acne?

D. oral tetracycline

In January, you see an 18-month-old boy in the middle of the night in the pediatric emergency department. The father relates that 1 hour ago his son started coughing. The father describes the cough as barking ("seal" like). The child has mild stridor at rest, but otherwise is not in respiratory distress. His RR is 45 breaths per minute. He has a temperature of 103.4°F . What is the most common etiology of this illness in children?

D. parainfluenza, types 1 and 2

A 29-year-old woman complains of fatigue and decreased exercise tolerance. She takes no medications and denies changes in the color of the stool. Physical examination is significant for pale skin and conjunctivae. Stool was negative for blood. Laboratory evaluation revealed Hgb of 7.8 g/dL, reticulocytopenia, microcytosis, and hypochromia.The U.S. Preventive Services Task Force (USPSTF) recommends screening for iron deficiency in which of the following?

D. pregnant women

A 42 year old male admitted for pulmonary embolus was placed on heparin, dosed by a weight based protocol. However, later in the day, you receive a call from the floor nurse stating that the patient had spontaneous epistaxis and a very high aPTT. Use of which of the following would be best at this time?

D. protamine sulfate

A 60-year-old male with a history of hypertension and hyperlipidemia undergoes an evaluation for angina. He states that he routinely experiences dyspnea, fatigue, and retrosternal chest discomfort when performing activities such as walking around the block on which his house is located or climbing the flight of stairs within his home. Besides taking medications for his blood pressure and cholesterol, he uses nitroglycerin which successfully alleviates his symptoms. The patient undergoes a cardiac catheterization and is found to have 70% narrowing of the left anterior descending and proximal left circumflex arteries. Which of the following would be the most appropriate management of this condition?

D. referral for coronary artery bypass grafting (CABG)

A 45-year-old male comes to your office for his first annual checkup in the last 10 years. On first impression, he appears overweight but is otherwise healthy and has no specific complaints. He has a brother with diabetes and a sister with high blood pressure. Both of his parents are deceased and his father died of a stroke at age 73. He is a long-standing heavy smoker and only drinks alcohol on special occasions. On physical examination, his blood pressure is 166/90 in the left arm and 164/88 in the right arm. The rest of the examination is unremarkable. He is concerned about his health and does not want to end up on medication, like his siblings In the initial evaluation of a patient such as this, which of the following should be routinely recommended?

D. renal function tests (serum creatinine and blood urea nitrogen [BUN])

A67-year-old female with past medical history of rheumatoid arthritis on chronic steroid treatment and past surgical history (PSH) of complete hysterectomy secondary to fibroids presents for routine visit. Patient states that she has had multiple arthralgias worsening over the last 2 years. She had a DEXA scan done that showed a T score of -1.5. She has been taking calcium + vitamin D, and even started an exercise program at her local gym. She was started on bisphosphonates, which she has tolerated well. Prior to discharging the patient, how soon would you counsel her to repeat the DEXA scan?

D. repeat in 2 years

A 74-year-old male with a history of hypertension, type II diabetes, myopia, and cataract surgery 2 weeks ago presents with the sudden onset of severe flashes of light and multiple new floaters in his right eye. He denies photophobia, ocular trauma, or diplopia. He also states that he feels as if there is a curtain lowering over his right eye. What is the most likely cause of his symptoms?

D. retinal detachment

A 55-year-old woman presents to your office with painful hands, causing difficulty opening jars and turning the key in the ignition of her car. She is fatigued and she notices joint stiffness, but limbers up by lunch. She has trouble getting her rings off because of enlarging knuckles. About a year ago, she tried some OTC ibuprofen, which seemed to help, but led to the development of a bleeding ulcer severe enough to require transfusion and ICU care. Otherwise, her health is good, and her review of systems is negative. Your physical examination reveals tenderness and swelling at the index proximal interphalangeal and metacarpophalangeal joints bilaterally. There are small effusions on both knees. She has tenderness to lateral compression of the forefoot area bilaterally. Which of the following tests is most likely to result in a diagnosis?

D. rheumatoid factor

A74-year-old male with a history of hypertension, CAD, and a 50 pack-year history of smoking presents with complaints of pain and cramping sensation of the thigh and buttock areas for the past 2 months. On detailed history, patient reports that the pain is usually during ambulation and relieves with sitting down. The pain does not change with respect to sitting or supine position. He denies any recent trauma, weakness of the legs, or paresthesias. He takes his prescription medications regularly and denies using alcohol, drugs, or any herbs/ supplements. Which of the following should be performed as an initial test to help confirm your clinical impression? Which of the following measures should be implemented for the management of this patient's condition?

D. smoking cessation and walking program

A19-year-old male who moved to your city 3 months ago comes to your office complaining of dry cough for the past 23 months. Along with the cough, he has had some shortness of breath with exertion. He denies fever, chills, nausea, vomiting, wheezing, and sneezing. The cough occurs mostly in the morning and improves as the day goes on. He denies similar complaints in the past and has no history of allergies. He says that his father had eczema and an allergy to eggs. Which of the following properties of albuterol makes it a more appropriate choice than epinephrine for relief of acute episodes of bronchoconstriction?

D. specificity for beta-2 receptors

A20-year-old male has had a recent wide local excision of a 1.5 mm melanoma from the right ankle. There is no evidence of metastatic disease. The most important prognostic factor for this patient is which of the following? One year after his initial diagnosis and treatment, the patient develops a palpable right inguinal lymph node. Inguinal lymph node dissection reveals one node positive for metastatic melanoma; the remaining nodes are negative. Acomplete restaging workup shows no evidence of any additional metastatic disease. What is the correct stage for this patient?

D. stage III

A 16-year-old youth presents with lethargy and abdominal bloating. He has lost 5 kg in weight over the last 6 months. Examination confirms a thin teenager with obvious pallor. Which is the most appropriate serological test to investigate possible malabsorption?

E- IgA antiendomysial antibodies

A 63-year-old Black female presents to your office complaining of leaking urine. She gets up at night five times to urinate and occasionally loses urine en route to the toilet. During the daytime, she urinates every 45 minutes "to help prevent the leakage." She denies loss of urine with coughing or sneezing. She has not had dysuria or any other pelvic floor complaints. She has a family history of diabetes. She drinks several caffeinated beverages throughout the day. On examination, her postvoid residual urine is normal, and a urine dipstick shows 3+ glucose but is otherwise negative. Her abdominal and pelvic examinations are normal. Which of the following do you recommend?

D. timed voids, decrease in caffeine intake, and screening for diabetes

A 65-year-old man presents to your office for evaluation of abdominal pain. The patient states that he has epigastric pain that radiates to his back. The pain is worse with eating and improves with fasting. The pain has been present for 6 months and is gradually worsening. The patient has lost 15 lbs but feels his oral intake has been adequate. He complains of greasy stools and frequent thirst and urination. Examination reveals a thin male with temporal wasting and oderate abdominal pain with palpation. The patient consumes approximately 1015 beers per day and smokes a pack of cigarettes per day for the past 20 years. On further questioning, the patient reports that he recently had a motor vehicle accident at night because he felt he could not see clearly. The most likely cause of this symptom is which of the following?

D. vitamin A deficiency

You are asked to review a 15-year-old boy with abnormal weight gain and learning difficulties. As part of your assessment you arrange for an assessment of peptide hormones to assess if a deficiency may be involved in the pathogenesis of his condition. Elevated levels of which of the following may be involved in the pathogenesis of his condition?

E- Gherelin

Which of the following is associated with the correct disease?

E- HLA Cw6 - psoriasis

Periodic fever can be associated with high levels of:

E- IgD

Which of the following fluids would be the most appropriate to replace the fluid being lost in a patient with a paralytic ileus draining 2 litres of fluid a day through a nasogastric tube?

E- 0.9% sodium chloride ('normal saline')

A 20-year-old woman, who was prescribed the oral contraceptive pill a week earlier, develops central abdominal pain, vomiting and weakness in both lower limbs. Blood tests show an elevated white cell count. What is the most probable diagnosis?

E- Acute intermittent porphyria

A 40-year-old lady presents with numbness and tingling in little finger of her right hand, and a diagnosis of ulnar neuropathy is made. Which muscle of her hand is most likely to be affected?

E- Adductor pollicis

Which of the following statements is true about the matrix metalloproteinases, which play a major role in pathological processes, including rheumatoid arthritis, periodontitis, vascular disease as well as tumour invasion and metastasis?

E- All share sequence homologies

Immunological investigations in a patient with renal disease are important in the diagnostic work-up, which of the following statements is correct?

E- Antiglomerular basement-membrane antibodies are associated with Goodpasture's disease

Where is the immune defect in chronic lymphocytic leukaemia situated?

E- B cells

When taking a history from a patient with suspected vasculitis, clinical determination of the size of vessel involved is important in the identification of the underlying vasculitic condition. Which of the following statements is true?

E- Behçet's disease is a postcapillary venulitis

A young boy has his second episode of Neisseria meningitis. You suspect he may have complement deficiency.Which of the following deficient complement factors is particularly associated with Neisseria infection?

E- C5

Glucokinase exists in brain, pancreas and liver, and responds differently in different locations. In the brain, response is governed merely by different glucose levels, while in liver glucokinase activity increases after meals. Downregulation of glucokinase activity in the liver is an example of which of the following?

E- Co-repression

Which of the following diseases is correctly matched to the immunodeficiency?

E- DiGeorge syndrome - absent T-cell function

You are asked to see a 19-year-old man who has had recurrent pneumothoraces. He is tall with pes planus and has an increased arm span to height ratio and upper segment to lower segment body ratios. Which other feature would be most helpful in making a diagnosis of Marfan's syndrome?

E- Early diastolic murmur

In a patient with nickel-associated contact dermatitis which of the following statements is true?

E- Elimination of the responsible agent is the most important goal

A 15-year-old youth with haemophilia A has suffered recurrent bleeding episodes into his joints. As a consequence he has arthropathies in his knees, elbows and wrists. What is the most likely coagulation deficiency causing his bleeding tendency?

E- Factor VIII

A 35-year-old woman is referred by her GP because she has been feeling unwell and has pain, stiffness and tenderness in her joints which have gradually worsened over the last 6 months. She has a detectable rheumatoid factor. What is the most likely structure that these antibodies are targeted against?

E- Fc portion of immunoglobulins

A 26-year-old teacher of Ashkenazi Jewish descent presents with long-standing bone pain. On examination there is marked hepatosplenomegaly. Which genetic disorder should be included in the list of differential diagnoses?

E- Gaucher's disease

A patient presents with distal weakness and muscle wasting. Myotonic dystrophy is confirmed by which investigation?

E- Genetic testing

A 55-year-old woman is diagnosed with type 2 diabetes mellitus. Her weight is 76 kg, body mass index 34 kg/m2. After 3 months' trial of dietary modification, she has lost 2 kg in weight, but her Hb A1c, which was 10.2% at diagnosis, is 9.6%. The most appropriate treatment would now be which of the following?

E- Metformin

Which of the following statements in relation to skin disease is true?

E- Nasal swabs should be routinely checked in patients with recurrent staphylococcal abscesses

A couple aged in their early 30s come to the genetics clinic. They have one 6-year-old son who has gross obesity and mild mental impairment, diagnosed as Prader Willi syndrome and they are concerned about the possibility of further children being affected. Which of the following most accurately describes the mode of inheritance of Prader Willi?

E- Non-mendelian

Which of the following patterns of serum lipids is most characteristic of diabetes mellitus?

E- Normal LDL-cholesterol, low HDL-cholesterol, elevated triglycerides

A 68-year-old man is admitted to hospital for elective femoral angioplasty. On examination, he is found to have widespread lymphadenopathy. Blood is taken for 'group and save'. His cells are not agglutinated by either anti-A or anti-B; his serum does notcause agglutination of cells of blood group A or B. Based on these data, which of the following is most likely to be his genotype?

E- OO

What is the medical treatment of choice for the majority of patients with carcinoid syndrome?

E- Octreotide

A patient has been diagnosed with a fast-growing pituitary adenoma. Magnetic resonance image (MRI) scanning reveals suprasellar extension. Which structure is most likely affected?

E- Optic chiasm

A 71-year-old-man is given a health check by his doctor. He has no complaints, apart from pain in his hip, which he attributes to arthritis. He has blood taken for a panel of routine biochemical and haematological tests. The only abnormality is a serum alkaline phosphatase activity of 822 U/l. Which of the following is the most likely cause of this abnormality in his case?

E- Paget's disease

A 45-year-old man has severe pulmonary emphysema. A diagnosis of α1-antitrypsin deficiency is being considered. What is the genotype most typically associated with this condition?

E- PiZZ

A 54-year-old woman has undergone some blood tests as part of an employment health screen. She reports she is in good health and, being very health conscious, takes regular vitamin and mineral supplements. She is taking bendrofluazide 2.5 mg for hypertension and her blood pressure is 132/82 mmHg. The only abnormality is a serum calcium concentration of 2.94 mmol/l. Which of the following is the most likely cause?

E- Primary hyperparathyroidism

A 34-year-old immigrant of African origin is prescribed ciprofloxacin for an infection. He suffers problems with acute haemolysis. You suspect G6PD deficiency. Given this, what is the likely underlying cause of haemolysis?

E- Reduced levels of NADPH

Which of the following is the initial treatment of choice for the hyponatraemia in the majority of patients with the syndrome of inappropriate [secretion of] ADH (antidiuretic hormone, vasopressin)?

E- Restriction of water intake

The polymerase chain reaction (PCR) is becoming widely used in both research and clinical medicine. Which of the following statements is correct?

E- Reverse transcriptase-PCR (RT-PCR) is able to identify the transcripts of a given gene by detecting the messenger (m) RNA coding for the gene

An 18-year-old army recruit undergoes preliminary health screening and is found to have a haemoglobin of 11.5 mg/dl (13-17). Spherocytes are present in the peripheral blood film. Investigation of his siblings reveals that one of his two brothers also has spherocytic anaemia. A defect in which of the following is most frequently responsible for this condition?

E- Spectrin

Hypercalcaemia in malignant disease secondary to the secretion of parathyroid hormone-related peptide by the tumour ismost frequently associated with which one of the following?

E- Squamous-cell carcinoma of the bronchus

Concerning the respiratory cell biology of an asthmatic individual, which of the following is true?

E- T cells are mobile and contribution to asthma is via cytokine production

Which of the following is a feature of the Sézary disease?

E- T-cell malignancy

A 48-year-old woman with known renal disease presents to A&E, and admission biochemistry profile shows a serum potassium concentration of 5.9 mmol/l. Her ECG is abnormal. Which ECG abnormality is most likely to have occurred earliest as her hyperkalaemia developed?

E- Tall, tented T wave

A patient undergoes a radical parotidectomy for a malignant parotid tumour, at which time it is found necessary to perform a total division of the left facial (VII) nerve. Postoperatively, which is the most likely sequel?

E- Tendency for food and fluids to collect in the buccal sulcus after meals

In patients with severe oral and genital ulceration, therapy with agents having clinically significant anti-TNF- a activity can bebeneficial, which of the following is used for this indication?

E- Thalidomide

A 17-year-old phenotypic female with no clinical evidence of dysmorphism is referred to the Endocrine Clinic for the investigation of primary amenorrhoea. On examination, breast development is normal, the external genitalia are normal female in appearance but pubic hair is sparse. Her karyotype is found to be 46XY. A defect in which of the following hormonal processes is most likely to be the abnormality causing this presentation?

E- The androgen receptor

A 52-year-old hypertensive man presents with a right hemisphere stroke. Neuroimaging demonstrates the presence of a recent infarction of the right internal capsule. Which anatomical features of this region should be borne in mind?

E- The internal capsule receives its arterial supply from the lenticulostriate vessels derived from the roots of the middle and anterior cerebral arteries

A young man sustains a skull-base fracture at the middle cranial fossa which injures his right abducent (VI) nerve. Which signs are most likely to be present on clinical examination?

E- The patient is unable to deviate his right eye laterally

You are reviewing a 52-year-old man who has suffered a myocardial infarction. You suspect occlusion of the posterior descending coronary artery. In this case, which region of myocardium would you expect to be most affected?

E- The posterior portion interventricular septum and the posterior left ventricular wall

Why can trinucleotide repeat disorders become worse in successive generations?

E- The repeat can expand from one generation to the next

A 62-year-old woman with type-2 diabetes being treated with a thiazide, β-blocker and ACE inhibitor for hypertension is found to have a serum potassium concentration of 3.1 mmol/l. Her blood pressure is 156/94 mmHg; serum creatinine concentration is 115 mmol/l. What is the most likely cause of the hypokalaemia?

E- The thiazide diuretic

An otherwise well, 62-year-old woman with hypertension is referred to an outpatient clinic for assessment. Despite treatment with a thiazide diuretic, a beta-adrenergic antagonist (beta-blocker) and an angiotensin-converting enzyme (ACE) inhibitor, her blood pressure is 158/92 mmHg. Investigations show serum sodium concentration is 138 mmol/l, serum potassium concentration 3.2 mmol/l, serum creatinine concentration 108 mmol/l. What is the most likely cause of the hypokalaemia?

E- The thiazide diuretic

A 28-year-old man presents with a septic cavernous sinus thrombosis, with high fever, orbital oedema and proptosis. The primary source of infection would most likely arise from which site?

E- The upper lip

Immunoglobulin structure - which of the following regions forms the antigen binding site?

E- The variable region of one heavy and one light chain

A young man is admitted to A&E having taken an overdose of an unknown drug. On examination, he is hyperventilating and has a tachycardia. Results of arterial blood gas analysis (breathing room air) are: [H+] 30 nmol/l (pH 7.56); p(CO2) 3.5 kPa; p(O2) 14.2 kPa; [HCO3-] 21 mmol/l. Which of the following drugs is he most likely to have taken?

E- Theophylline

Which of the following statements applies to the physiology of the normal menstrual cycle?

E- There is a large rise in GnRH just before ovulation

Which of the following statements best characterises low-density lipoproteins (LDL)?

E- They contain apolipoprotein B-100

A 40-year-old man develops jerky movements affecting various parts of his body. His fatherdied at the age of 55 and had been diagnosed as having Huntington's disease. Which of the following genetic abnormalities is responsible for this condition?

E- Triplet-repeat mutation

A 16-year-old girl presents with primary amenorrhoea. On examination, her height is 145 cm and weight 45 kg. What is the most likely diagnosis?

E- Turner's syndrome

An 84-year-old man had his left sciatic nerve completely transected just inferior to the buttock crease by a piece of shrapnel during the D-day landings in 1944. Which sign is likely to be present on current neurological examination?

E- Unimpaired hip abduction

A 20-year-old woman presents with tremor and dysarthria, she is also noticed to be slightly jaundiced; clinically, Wilson's disease is considered to be the most likely diagnosis. Which of the following investigations will most reliably confirm this diagnosis?

E- Urinary copper excretion after penicillamine challenge

Some 24 hours after sustaining severe skeletal and soft tissue trauma in a road traffic accident, a 19-year-old man becomes oliguric. Which of the following would be LEAST likely to present if acute tubular necrosis were the likely diagnosis?

E- Urinary sodium concentration less than 10 mmol/l

Sickle-cell anaemia is characterised by which of the following?

E- Vaso-occlusive crises

A 34-year-old woman with a body mass index of 44 kg/m2 seeks medical help for her obesity. Which one of the following treatments offers her the highest probability of achieving a long-term reduction in weight?

E- Vertical banded gastroplication

Where is the antibody targeted in Lambert-Eaton syndrome?

E- Voltage-gated calcium channels

A 45-year-old lady is referred to you with a diagnosis of renal cell carcinoma. She tells you that she had surgery for phaeochromocytoma at the age of 25 years. What is the most likely diagnosis?

E- Von Hippel-Lindau disease

The predicted length of the follicular phase of a patient with a consistent 34-day menstrual cycle is which of the following?

E. 20 days

In nine families surveyed, the numbers of children per family were 4, 6, 2, 2, 4, 3, 2, 1, and 7. The mean, median, and mode numbers of children per family are, respectively,

E. 3.4, 3, 2

A new test for chlamydial infections of the cervix is introduced. Half of the women who are tested have a positive test. Compared with the gold standard of careful cultures, 45% of those with a positive test are infected with chlamydia, and 95% of those with a negative test are free of the infection. Match with the correct percentage with the epidemiologic terms, Predictive value of a negative test

E. 95%

Which patient is most likely to become a chronic carrier following an acute episode of hepatitis B?

E. A 40yearold HIVinfected male with a CD4 cell count of 200

This is a double-stranded DNA virus. It is responsible for 15% of pediatric respiratory infections and 10 to 15% of acute diarrhea in children.

E. Adenovirus

A21-year-old Asian female, with past medical history of exertional asthma, comes to your office complaining of mild low back pain. It started after her working out in the gym 3 days ago. The pain is 24 out of 10 in intensity, has no radiation, increases with bending or lying down for a long time, and improves with warm showers. You examine the patient, diagnose her with paravertebral muscle spasm, and give her prescriptions for cyclobenzaprine and naproxen to use as needed for pain and stiffness. You receive a call from your patient 2 hours later. She is having generalized itching, dizziness, and swelling of the tongue and lips. She is having difficulty breathing. She tells you that she took the first dose of the medication you prescribed about 30 minutes ago. What should you do at this time?

E. Ask her to call 911 immediately.

A 65-year-old man presents to your office for evaluation of abdominal pain. The patient states that he has epigastric pain that radiates to his back. The pain is worse with eating and improves with fasting. The pain has been present for 6 months and is gradually worsening. The patient has lost 15 lbs but feels his oral intake has been adequate. He complains of greasy stools and frequent thirst and urination. Examination reveals a thin male with temporal wasting and oderate abdominal pain with palpation. The patient consumes approximately 1015 beers per day and smokes a pack of cigarettes per day for the past 20 years. The patient's abdominal pain worsens and his weight loss progresses despite therapy, and you suspect that he may have a malignancy. If a malignancy was present, which tumor marker would be most likely to be elevated in this patient?

E. CA-19-9

Households are selected at random, and every person in each household is included in the sample. Select the correct term that match above description of a sampling procedure.

E. Cluster sampling

Approximately 9 people die each year in a country for every 1000 estimated to be alive. Choose statement below that match rate above.

E. Crude mortality

Eighty percent of susceptible household contacts of a child with chicken pox develop this disease. Choose statement below that match rate above.

E. Crude mortality

Influenza can be treated; therefore, specific detection of the virus becomes much more important. Which of the following would be best for detection of influenza?

E. Culture of respiratory secretions on monkey kidney cells

A 19-year-old female presents to the ED complaining of swelling in her left lower extremity. She reports that she had arthroscopy of the right knee about a week ago for a torn meniscus. The swelling started last night and is uncomfortable. Which of the following statements most accurately describes the situation?

E. Directed lytic therapy is indicated for this patient if her lower extremity becomes bluish and has evidence of vascular compromise.

The medical evaluation of a 25yearold intravenous drug user reveals elevated liver enzymes and a positive antiHBsAg. The most likely cause of the abnormal liver profile is hepatitis

E. E

A newborn male is brought to you in the neonatal intensive care unit (NICU). On physical examination, you notice that the infant has deficient abdominal musculature and undescended testes. Your suspicion is high for a certain condition. You presumptively diagnose the child with which of the following?

E. Eagle-Barrett syndrome

You are called to the trauma bay to evaluate a 42-year-old male who suffered a blow to his knee at the construction site where he works. He is awake, alert, and his vital signs have been stable in transport. After completing your primary survey, you continue with your secondary survey and determine that his only injury is to his right leg. It is clear that he has suffered a posterior knee dislocation. As part of your examination, you determine that you cannot feel a pulse in his right foot. Later that night after the patient had been treated and stabilized, you are called to the patient's room to evaluate severe pain in his right lower leg. Upon examining the patient, you determine that he has a bounding pulse in his right foot. However, the patient does state that he has a tingling sensation in his foot and he is in excruciating pain when you flex his foot. Which of the following should be the next step in his treatment?

E. Emergently take the patient to the OR.

A mother relates seeing worms in her 3-year-old's stool. She describes them as 1-cm long white threads that seemed to be moving. What is the most likely infectious etiology for this finding?

E. Enterobius vermicularis

This virus may be detected by the polymerase chain reaction (PCR) in a variety of cells of patients with nasopharyngeal carcinoma.

E. Epstein-Barr virus

A 28-year-old White G1 woman presents to your office for an initial obstetric visit. Her LMP is certain and allows you to estimate a 9-week gestational age today. She denies bleeding, cramping, or other symptoms of concern. She is excited about being pregnant. She has already started taking her prenatal vitamins with folic acid. She reports no significant past medical history. In fact, she states that she has not been to a doctor in many years because she has not had any problems. She has had no surgeries. She does not smoke. She drank alcohol socially prior to pregnancy but has not consumed any alcohol since she became pregnant. She has family history of hypertension, but no other significant history is elicited. On physical examination, her blood pressure is 110/60. She is healthy appearing, and there are no significant findings on examination. Your pelvic examination confirms uterine size consistent with stated dates. As part of a routine laboratory evaluation, you decide to check a thyroid-stimulating hormone (TSH). The TSH is 0.4 IU/ mL (normal range 0.55.5) and a free T4 of 1.8 ng/dL (normal range 0.72.0). What is the most likely cause of this patient's hyperthyroidism?

E. Grave's disease

Finding HBsAg positive and HBeAg positive reflects

E. HBV carrier state

A 64-year-old male with a history of hypertension and tobacco abuse presents for follow-up after a routine physical during which he was found to have 45 red blood cells (RBCs) per high-power field (HPF) on a screening urinalysis. The urinalysis was negative for leukocytes, nitrites, epithelial cells, and ketones. The patient denies any complaints and the review of systems is essentially negative. What would be your initial approach in the workup of this patient with asymptomatic microscopic hematuria?

E. repeat urinalysis

A 4-year-old child is brought to your office because of a sudden onset of irritability, weakness, and pallor. The mother tells you that both of her children have been experiencing episodes of vomiting and diarrhea. Your physical examination reveals a blood pressure of 115/80, dry mucus membranes, petechiae, and diffuse abdominal pain. The following laboratory work is obtained: Urinalysis: microscopic hematuria and proteinuria Blood urea nitrogen (BUN)/creatinine (Cr): 20/1.0 mg/dL Hemoglobin: 7 g/dL Peripheral blood smear: fragmented RBCs Prothrombin time (PT), partial thromboplastin time (PTT): normal Coombs' test: negative What is the most likely diagnosis?

E. HUS

A 4yearold girl presents with sore throat, fever, hoarseness, and drooling. Select the correct etiologic agent that match the descriptions above

E. Haemophilus influenza B

Trypanosoma cruzi initially penetrates through the mucous mem branes on the skin and then multiplies in a lesion known as a chagoma. In the chronic stage of the disease, the main lesions are often observed in the

E. Heart and liver

Which of the following acts as a cofactor in duodenal ulcer?​

E. Helicobacter pylori

This hepatitis virus is a calicivirus. The reservoir is in pigs, and humans acquire it via the fecal-oral route.

E. Hepatitis

Which of the following is transmitted by the fecal-oral route; can be acquired from shellfish; and often causes acute jaundice, diarrhea, and liver function abnormalities?

E. Hepatitis A virus

Which of the following is the most important risk factor for developing cervical cancer?

E. Human papillomavirus type 16

A70-year-old White woman has been faithful about taking 1200 mg of calcium, 400 IU of vitamin D supplements, and performing weight-bearing exercise on a daily basis. Her hip T score from her current DEXA scan has changed from -2.0 SDs to -2.55 SDs compared with last year's test. At this time, which of the following do you recommend?

E. IM testosterone

A 48-year-old woman presents for evaluation of progressively worsening dyspnea. She relates the onset of symptoms to a "walking pneumonia" that she had a year ago. Her breathing has worsened progressively since that time. She has a "smoker's cough" productive of some clear or white phlegm, for which she frequently sucks on cough drops. She started smoking regularly at the age of 18. She currently smokes about a pack of cigarettes a day, down from as much as two packs per day. She is not on any medications regularly. She has no history of heart disease and has always had normal blood pressure You recommend smoking cessation to your patient. She asks why, at this point, she should quit. Which of the following statements is true?

E. If she is able to stay off of cigarettes, the rate of worsening of her lung function will slow.

Which of the following public health interventions has been the most successful in preventing initiation of smoking or reducing the prevalence of smoking?

E. Increases in cigarette prices through taxes

A 72-year-old man comes to your clinic for the first time, accompanied by his wife. His wife states that she is concerned because he has been growing increasingly forgetful over the past year. Within the past month, he has forgotten to turn off the stove and has got lost while walking to the post office one block away from their home. His past medical history is significant for well-controlled diabetes and chronic lower back pain. He has no history of falls or traumatic injury to the head. Examination of the patient is significant for a score of 18 on a Mini Mental Status Examination (MMSE). During the administration of the MMSE, the patient blurts out that his wife brought him to the doctor because she is having an extramarital relationship. Which of the following accurately describes this patient's condition?

E. It is one of the most common terminal illnesses in developed nations.

You are preparing a report to present to the MoH on the declining rates of gonorrhea in your province in both men and women over the last 10 years. Which type of graph would best illustrate the data?

E. Line graph

Environmental tobacco smoke (ETS) is a major public health issue, particularly for children. Which of the following conditions is most affected by ETS?

E. Lung cancer

M. tuberculosis can be found in the sputum of patients with tuberculosis. After digestion of the sputum, isolation is best accomplished using

E. Löwenstein-Jensen medium

Y. enterocolitica, formerly a Pasteurella, is best described by which of the following statements?

E. Manifests different biochemical and physiologic characteristics, depending on growth temperature, and causes a spectrum of human disease, most commonly mesenteric lymphadenitis

Orchitis, which may cause sterility, is a possible manifestation of which of the following?

E. Mumps

An 18yearold sexually active college student presents with complaints of lower abdominal pain and irregular bleeding for five days. She has no fever. She uses oral contraceptives as method of birth control. Upon examination, the cervix is friable; there is cervical motion tenderness and adnexal tenderness. The pregnancy test is negative. Which is the most likely etiologic agent responsible for these findings?

E. Mycoplasma hominis

Dermatitis, diarrhea, and delirium. Select the dietary deficiency that match each set of symptoms and signs.

E. Niacin deficiency

A 55-year-old woman presents to your office with painful hands, causing difficulty opening jars and turning the key in the ignition of her car. She is fatigued and she notices joint stiffness, but limbers up by lunch. She has trouble getting her rings off because of enlarging knuckles. About a year ago, she tried some OTC ibuprofen, which seemed to help, but led to the development of a bleeding ulcer severe enough to require transfusion and ICU care. Otherwise, her health is good, and her review of systems is negative. Your physical examination reveals tenderness and swelling at the index proximal interphalangeal and metacarpophalangeal joints bilaterally. There are small effusions on both knees. She has tenderness to lateral compression of the forefoot area bilaterally. The test ordered above is negative and an anticyclic citrullinated peptide (anti-CCP) antibody is strongly positive (600). Which of the following is the probable source of her symptoms?

E. RA

The presence of Negri inclusion bodies in host cells is characteristic of

E. Rabies

Choose the type of measurement scale for Birth Weight.

E. Ratio scale

Which of the following best describes the presently available vaccine for hepatitis B?

E. Recombinant viral vaccine

Which of the following is available and effective for hepatitis A?

E. Recombinant viral vaccine

The association between low birth weight and maternal smoking during pregnancy can be studied by obtaining smoking histories from women at the time of the first prenatal visit and then subsequently assessing and assigning birth weight at delivery according to smoking histories. What type of study is this?

E. Retrospective cohort

Which of the following organisms penetrates skin, is endemic in Africa and the Middle East, has large terminal spines on its eggs, and is found in urine samples?

E. S. haematobium

A 4-year-old is brought to your office by his mother for evaluation. She is concerned because the child has been spiking fevers and pulling on his left ear. Your examination reveals a bulging and erythematous tympanic membrane (TM). Which of the following is most likely to be the cause of his illness?

E. S. pneumoniae

Perilymph is located in which of the following structures?

E. Scala tympani

A tissue-dwelling trematode that may be found in feces can also be detected in

E. Sputum

In the study of the cause of a disease, the essential difference between an experimental study and an observational study is that in the experimental investigation

E. The investigators determine who is and who is not exposed to the suspected causal factor

Which one of the following organisms is associated with nongonococcal urethritis in humans?

E. U. urealyticum

A 45-year-old male comes to your office for his first annual checkup in the last 10 years. On first impression, he appears overweight but is otherwise healthy and has no specific complaints. He has a brother with diabetes and a sister with high blood pressure. Both of his parents are deceased and his father died of a stroke at age 73. He is a long-standing heavy smoker and only drinks alcohol on special occasions. On physical examination, his blood pressure is 166/90 in the left arm and 164/88 in the right arm. The rest of the examination is unremarkable. He is concerned about his health and does not want to end up on medication, like his siblings. Regarding your initial recommendations, which of the following would be most appropriate?

E. You should screen him for diabetes and evaluate him for other cardiovascular risk factors before proceeding any further.

A 31-year-old (gravida 1, para 1) female had a forceps-assisted vaginal delivery 3 months ago. Her infant weighed 4250 g. During the delivery she sustained a fourth degree perineal injury that was repaired. She now complains of fecal incontinence and foul vaginal discharge when her stools are loose, which happens several days a week. The most likely etiology for her fecal incontinence and foul vaginal discharge would be which of the following?

E. a rectovaginal fistula

A 52-year-old man presents to the ED with a complaint of rectal bleeding and hematuria. He has a medical history significant for atrial fibrillation diagnosed 10 years ago and states that he takes metoprolol as well as warfarin for this condition. Upon examination, you find that his blood pressure is 122/78, his pulse is 84, his respiratory rate is 18, and his O2 saturation is 98% on room air. He has an irregularly irregular heart rhythm, gingival bleeding, and some bruises on his extremities. He has a positive fecal occult blood test, and laboratory studies return showing an international normalized ratio (INR) of 16.5. You order that the patient's warfarin be held. Which of the following is the most appropriate additional intervention at this time?

E. administer vitamin K1 and fresh frozen plasma

A64-year-old female with no significant medical history presents with vague complaints of progressive generalized muscle weakness and fatigue. She denies any history of trauma or drug use and does not take any prescription, OTC or herbal medications. This is a new complaint and she has not had any prior workup. There is no evidence of trauma and a recent TSH was normal. On examination, you find mild muscle tenderness and atrophy. She has difficulty standing from a chair unless she pushes up with her arms at the same time. Her neurologic examination is normal. Which of the following tests would be most helpful in confirming your clinical diagnosis?

E. aldolase

A 76-year-old alcoholic male with hypertension, type II diabetes, and a history of congestive heart presented with cough, fever, malaise, and chills. His initial vitals were: HR 110, T: 102°F, RR: 25, B P 90/60, O2 saturation 93% on 4L/NC. The patient decompensated in the ER and was intubated. Intubation was achieved after three attempts secondary to patient vomiting during the initial attempts. Patient was admitted to the ICU with a diagnosis of sepsis and respiratory failure secondary to suspected pneumonia. After obtaining blood and sputum cultures, the initial empiric antibiotic coverage should be which of the following?

E. ampicillin/sulbactam and gatifloxacin

You are asked to see a 64-year-old man with left lower quadrant abdominal pain that was admitted to the medicine service after a CT scan demonstrated diverticulitis of the sigmoid colon. There was no evidence for gross perforation and no abscess was identified. He had been admitted 6 months ago for the same problem and had an uneventful recovery. Which treatment do you recommend?

E. antibiotics, interval colonoscopy, and subsequent sigmoidectomy

A 70-year-old male is seen in the office for chest pain. He reports that he is getting substernal chest pain, without radiation, when he mows his lawn. The pain resolves with 1015 minutes of rest. He has never had pain at rest. He has no other cardiac complaints and his review of systems is otherwise negative. He has an unremarkable medical history and takes only a baby aspirin a day. On examination, his blood pressure is 160/70, pulse 85, and respiratory rate 16. His cardiac examination is notable for a harsh, 3/6 systolic ejection murmur along the sternal border that radiates to the carotid arteries. His carotid pulsation is noted to rise slowly and is small and sustained. His lungs are clear. The remainder of his examination is normal. Subsequent workup confirms the diagnosis of critical aortic stenosis. Which of the following treatments would be most appropriate at this time?

E. aortic valve replacement

A 28-year-old woman presents to your clinic complaining of feeling "on edge." Upon further questioning, you discover that she has also noticed problems with irritability, insomnia, fatigue, and restlessness. She also has a history of worrying about things that seem to not bother those around her. She states these symptoms have been present for years but have recently become worse. When you try to gather more information, she interrupts to say that she cannot stay much longer because she is afraid that she will lose her new job as a machinist. Which of the following medications would be most appropriate in this patient?

E. buspirone

A 55-year-old male is brought to the ED, by ambulance, because of crushing chest pain radiating to his left shoulder and arm that started 1 hour ago. He has a history of hypertension, high cholesterol, and has smoked a pack of cigarettes a day for 30 years. He has never had symptoms like this before. The patient's rhythm converts to asystole. What is the most appropriate first action to take?

E. check a second monitor lead

A24-year-old male medical student is admitted to the hospital for the evaluation of a 3-month history of bloody stools. The patient has approximately six blood stained or blood streaked stools per day, associated with relatively little, if any, pain. He has not had any weight loss, and he has been able to attend classes without interruption. He denies any fecal incontinence. He has no prior medical history. Review of systems is remarkable only for occasional fevers and the fact that the patient quit smoking approximately 8 months ago. A colonoscopy is performed and reveals a granular, friable colonic mucosal surface with loss of normal vascular pattern from the anal verge to the hepatic flexure of the colon. Biopsies reveal prominent neutrophils in the epithelium and cryptitis with focal crypt abscesses, and no dysplasia. The patient is diagnosed with ulcerative colitis. In addition to an increased lifetime risk of colon cancer, the patient is also at increased risk for which of the following tumors?

E. cholangiocarcinoma

A32-year-old female presents for her first pap smear in more than 10 years. She has a history of heavy alcohol use and IV drug use and has performed sexual acts for drugs on numerous occasions. Testing performed today reveals her to have chlamydia cervicitis and trichomonas vaginalis and to be seropositive for hepatitis B and hepatitis C. HIV testing is negative. Her pap smear subsequently returns with carcinoma in-situ of the cervix. What should be the next step in her work-up?

E. colposcopy and directed cervical biopsy

In your internal medicine clinic you are caring for a 42-year-old woman with hereditary nonpolyposis colon cancer (HNPCC), Lynch syndrome II, which is a hereditary, autosomal dominant, cancer syndrome that results from a mutation in a mismatch deoxyribonucleic acid (DNA) repair gene. These patients have a lifetime risk of colon cancer nearly 6080%, but are also at risk for several other malignancies. For which gynecologic malignancy is this woman most at risk?

E. endometrial cancer

A 54-year-old male presents to the ED with acute onset of severe abdominal pain. His history is significant for gnawing epigastric pain that radiates to the back for several months. Physical examination demonstrates mild hypertension and tachycardia as well as a rigid "board like" abdomen with generalized rebound tenderness and hypoactive bowel sounds. Rectal examination reveals dark hemoccult positive stools without gross blood. While you are in the process of working up the patient he becomes hypotensive and tachycardic. Bright red blood per rectum is now noted. The most likely explanation for his condition is which of the following?

E. erosion of the gastroduodenal artery

A 50-year-old female presents to your office for evaluation of solid food dysphagia without weight loss. Symptoms have been present for 6 months and are progressive. The patient has had two episodes of near impaction, but copious water ingestion and repeated swallows allowed the food bolus to pass. She has never had to present to the ER for disimpaction. She drinks five to six beers per day, loves spicy foods, and smokes a pack of cigarettes daily with a total lifetime history of 30 pack-years. She has had intermittent heartburn symptoms for years and has not sought treatment. She takes hydrochlorothiazide for hypertension. Review of symptoms reveals chronic cough. Physical examination is unremarkable. Upper endoscopy reveals a distal esophageal stricture with inflammatory changes. Esophageal biopsies reveal benign mucosa with chronic inflammation. Gastric biopsies are unremarkable. Helicobacter pylori testing is negative. What is the next best step in therapy for this patient?

E. esophageal dilation with PPI inhibitor therapy

A 58-year-old male presents to your office for a well-male examination. It has been several years since he last visited a doctor, but he states that he has been in "excellent health." He denies any history of drinking, smoking, or using illegal drugs. He maintains a diet low in sodium and fat. An avid sports enthusiast, he also spends at least 2 hours per day engaged in some type of outdoor physical activity. On physical examination, you discover a translucent waxy papule with raised borders on the posterior aspect of his left shoulder. Which of the following is the most important risk factor for development of this skin condition?

E. exposure to short-wavelength ultraviolet radiation

A43-year-old morbidly obese woman presents to your office with a 3-week history of increasing vulvar burning. She has had no new sexual partners or practices. She has not noticed any change in her vaginal discharge. She has attempted to medicate herself with over-thecounter antifungals, herbal creams, and old antibiotics, none of which have provided relief. On examination, her entire labia majora and minora are markedly erythematous and tender to the touch. Her vaginal mucosa appears to have normal rugae. Her vaginal pH is normal and whiff test is negative. The wet mount shows a few WBCs and normal squamous cells. What is the most likely diagnosis?

E. lichens sclerosis et atrophicus

An amenorrheic 17-year-old female is diagnosed with Kallmann syndrome. Blood testing of this patient would indicate which of the following results?

E. low FSH, low LH, low estradiol

You are called to see a newborn in the nursery because the nurse is concerned that the baby may have Down syndrome. What is the most common central nervous system (CNS) complication of Down syndrome?

E. mental retardation

You are working in the emergency department and are called to perform a lumbar puncture on a 3-monthold infant who presented with fever and lethargy. The spinal fluid that you obtain is turbid. The laboratory reports that there are 200 WBCs and 5 RBCs per high-power field (HPF). Ninety-five percent of the WBCs in the spinal fluid are neutrophils If the laboratory result showed that 98% of the WBCs in the spinal fluid were lymphocytes, what would be the most likely etiology of the infection?

E. nonpolio enteroviruses

A mother brings her baby girl for a 9-month well child visit. You have been following her since birth. Her growth chart is shown in Figure. Her vital signs and examination are otherwise normal. The growth pattern is most consistent with which of the following?

E. nutritional failure to thrive (FTT)

A22-year-old nulliparous woman who desires future fertility is found to have a pap smear consistent with high-grade squamous intraepithelial lesion (HGSIL). The final pathology report indicates a single focus of squamous carcinoma invasive into the cervical stroma to a depth of 2.0 mm. An ECC is negative. There is no lymphvascular space invasion, and the cone margins are negative. The most appropriate therapy for this patient is which of the following?

E. observation with close follow-up

A 5-year-old male is admitted to the hospital following a 3-week history of spiking fevers and fatigue. Your examination reveals pale mucous membranes and skin. You also find splenomegaly. The best course of care for this young man would be which of the following?

E. obtain EBV serologies (IgM and IgG) and treat symptomatically with comfort measures

A39-year-old woman with a long-standing history of normal pap smears undergoes a total abdominal hysterectomy for a large uterine fibroid and menorrhagia. Six months after her hysterectomy she had a negative vaginal pap smear from the vaginal apex. She presents to your clinic today for a routine physical examination. Based on the American College of Obstetricians and Gynecologists recommendations, when should this patient have pap smears?

E. only if she develops risk factors

A62-year-old female with a history of a recent pulmonary embolus presents to your office for follow- up on anticoagulation treatment. She takes warfarin on a daily basis. She reports that for the last week she has noticed mild rectal bleeding and multiple bruises over the extremities with minimal trauma. She is comfortable appearing with normal vital signs and is not orthostatic. You ordered a stat CBC and PT/INR which revealed a mildly decreased Hgb at 11 g/dL and an elevated INR of 7. Which of the following would be the most appropriate intervention?

E. oral vitamin K

A 30-year-old (G2P0101) female presents to the clinic for a new obstetric visit. She has an unknown LMP. She reports that she discovered she was pregnant when she took a urine pregnancy test at home a month ago. She vaguely recalls having a period about 2 months ago, but is not sure exactly when that occurred. She reports that she is generally healthy. She had a previous delivery at 36 weeks EGA, though she reports her doctor was not really sure about her due date in that pregnancy. She reports that she had a normal spontaneous vaginal delivery in her previous pregnancy, and the child is healthy. Her postpartum course was complicated by depression, which has since resolved and not recurred. She denies history of sexually transmitted diseases or abnormal pap smears. She has no surgical history. She does not smoke, drink alcohol, or use illicit drugs. She does not have any family history of hypertension, diabetes, twins, or congenital anomalies. She does report that her mother has a history of depression. Which of the following tests will provide the most useful information to determine this patient's EDD?

E. pelvic ultrasound

An 82-year-old woman schedules an appointment to see you for neck and back pain. At age 50, she had an L4-L5 diskectomy and laminectomy. She also has long-standing hypothyroidism for which she takes levothyroxine 0.1 mg daily. Over the past few months, she has become more fatigued and describes pain in both of her arms, her low back, and the front of her thighs. She notes that the tops of her shoulders are also achy. She decided to call for an appointment because of worsening headache. She tells you that she has an appointment later this afternoon with her ophthalmologist, because she noticed some flickering of the vision in her left eye. Upon further questioning, she does acknowledge that she has cut her telephone conversation short with her daughter because her jaw begins to ache if she talks too long. Physical examination shows that she has normal vital signs. She has diffuse scalp tenderness. The oral mucosa is normal without aphthous ulcers and the salivary pool is normal. Her pupils are equal, round, and reactive to light and accommodation, and extraocular muscles are intact. The funduscopic examination appears normal for her age. Neck motion is slightly reduced to lateral flexion and rotation. Her trapezii are tender to palpation, but there is no significant loss of range of motion in her shoulders. Her supraspinatus and infraspinatus tendons appear intact. Her quadriceps are mildly tender, but her gastrocnemius muscles are normal. Her strength is normal for age. Her reflexes are normal and symmetrical. The most likely diagnosis is which of the following?

E. temporal arteritis

Use of which medication can result in enamel staining of primary teeth?

E. tetracycline

In January, you see an 18-month-old boy in the middle of the night in the pediatric emergency department. The father relates that 1 hour ago his son started coughing. The father describes the cough as barking ("seal" like). The child has mild stridor at rest, but otherwise is not in respiratory distress. His RR is 45 breaths per minute. He has a temperature of 103.4°F . What is the most common x-ray finding in this illness?

E. the "steeple" sign

A 54-year-old man presents with a 3-cm right thyroid nodule that was found incidentally by the patient while shaving. He denies any pain or discomfort. He denies any history of thyroid disease, any family history of thyroid disease, and any history of head/neck irradiation. He notes a 10-lb weight loss over the past 6 months. His examination is only remarkable for the firm right thyroid nodule. The remainder of the thyroid is not palpable. There is no adenopathy. Heart rate is 90/minute and regular. The skin is warm and moist, and a fine tremor is present when he holds his hands out. TSH level is <.02 U/mL. Which of the following is the most appropriate next step?

E. thyroid nuclear scan

Which of the following is the most appropriate treatment for a 32-year-old male with a toxic nodular goiter and compressive airway symptoms?

E. total lobectomy

A 12-month-old male child is brought to your office for a well-child examination and immunizations. You have been following the child since delivery and are aware that he has acquired immune deficiency syndrome (AIDS) and a markedly reduced T-cell count. Which of the following vaccinations should he not receive?

E. varicella

During the physical exam of a 52-year-old man you note internal hemorrhoids. He complains of blood in his stool. Which of the following arteries could be the source of his rectal bleeding?

A. Superior rectal artery off the inferior mesenteric artery B. Middle rectal artery off the internal iliac artery C. Inferior rectal artery off the internal pudendal artery

An HIV-positive patient prior to being treated with AZT, DDI, and saquinavir has a CD4 lymphocyte count and an HIV RNA viral load test done. Results are as follows: CD4: 50 CD4 lymphocytes per microliter, HIV RNA: 750,000 copies per ml. Which of the following statements best describes the above patient?

A. This patient is no longer in danger of opportunistic infection

Which of the following hematopoietic tissues or organs develops from endoderm?

A. Thymus

A 43-year-old man who recently returned from a trip to rural Peru presents with severe watery diarrhea, vomiting, and dehydration. He also has marked leg cramps and has lost 8 lb since his return from the trip. Fecal culture is positive for V. cholerae. How does this bacterium exert its effect?

A. Activation of enterokinase on the brush border of epithelial cells

Which of the following locations is optimal for fertilization of an ovulated egg by sperm to occur?

A. Ampulla of the oviduct

The clinical picture of arbovirus infection fits one of three categories: encephalitis, hemorrhagic fever, or fever with myalgia. One of the characteristics of arboviruses is that they

A. Are transmitted by arthropod vectors

An HIV-positive patient asks you if you can tell him the chances of him progressing to symptomatic AIDS. Which one of the following tests would be most useful?

A. CD4 lymphocyte count

A full-term male infant displays projectile vomiting 1 h after suck- ling. There is failure to gain weight during the first 48 hours. The vomitus is not bile-stained and no respiratory difficulty is evident. Examination reveals an abdomen neither tense nor bloated. Which of the following is the most probable explanation?

A. Congenital hypertrophic pyloric stenosis

A pituitary adenoma is likely to result in which of the following?

A. Cushing's syndrome

A 4-day-old boy weighing 7 lb, 6 oz is brought to the emergency room by his parents. The examining emergency room physician notes that his skin and sclerae are icteric. A blood test indicates elevated unconju- gated bilirubin in the serum. The elevated bilirubin levels in this patient are most likely the result of which of the following?

A. Deficiency of enzymes regulating bilirubin solubility

A 5-year-old boy sustains a tear in his gastrocnemius muscle when he is involved in a bicycle accident. Regeneration of the muscle will occur through which of the following?

A. Differentiation of satellite cells

The neural plate forms directly from which of the following?

A. Ectoderm

Which one of the following viruses may be human tumor virus?

A. Epstein-Barr virus (EBV)

Adults who have had varicella as children occasionally suffer a recurrent form of the disease, shingles. The agent causing these diseases is a member of which of the following viral families?

A. Herpesvirus

A hospital worker is found to have hepatitis B surface antigen. Subsequent tests reveal the presence of e antigen as well. The worker most likely

A. Is infective and has active hepatitis

Cytomegalovirus (CMV) infection is common. Which one of the fol- lowing statements best characterizes CMV?

A. It can be transmitted across the placental barrier

Hepatitis E, a recently characterized hepatitis virus, is best described by which of the following statements?

A. It is not a threat to the blood supply

Which of the following processes is responsible for fusion of the paired dorsal aortae?

A. Lateral folding

Which of the following is the function of the vestibular membrane?

A. Maintain the gradient between the endolymph and the perilymph

The asymmetry of the cell membrane is established primarily by which of the following?

A. Membrane synthesis in the endoplasmic reticulum

The intercostal neurovascular bundle is particularly vulnerable to injury from fractured ribs because it is found in which of the following locations?

B. Beneath the inferior border of the ribs

Gallbladder pain often presents as epigastric pain that then migrates towards the patient's right side and can even wrap around to the posterior. The referred pain is not the site of the problem. Anatomically where is the gallbladder located?

B. Between the right and quadrate lobes of the liver

Fetal blood from the placenta is about 80% oxygenated. However, mix- ture with unoxygenated blood at various points reduces the oxygen content. Which of the following fetal vessels contains blood with the highest oxygen content?

B. Common carotid arteries

The direction in which vestibular hair cell stereocilia are deflected is important for which of the following reasons?

B. Determines whether cells are depolarized or hyperpolarized

Cells that form the three primitive germ layers are derived from which of the following?

B. Epiblast

In the developing embryo, the edge of the ectoderm is continuous with which of the following?

B. Amniotic membrane

Which of the following is the primary regulator of salivary secretion?

B. Autonomic nervous system

Which of the following markers is usually the first viral marker detected after hepatitis B infection?

B. HBsAg

The most sensitive test for the diagnosis of herpes simplex (HSV) meningitis in a newborn infant is

B. HSV polymerase chain reaction (PCR)

Hepatitis C (HCV) is usually a clinically mild disease, with only minimal elevation of liver enzymes. Hospitalization is unusual. Which one of the following statements best characterizes HCV?

B. It often occurs in post transfusion patients

In dislocation of the jaw, displacement of the articular disk beyond the articular tubercle of the temporomandibular joint results from spasm or excessive contraction of which of the following muscles?

B. Lateral pterygoid

Which of the following occurs in diabetic retinopathy?

B. Microaneurysms

Atypical lymphocytosis is most likely to be found in which one of the following diseases?

B. Mononucleosis induced by Epstein-Barr virus

One of the most common sexually transmitted diseases that may lead to cervical carcinoma is caused by which of the following viruses?

B. Papillomavirus

The retinal pigment epithelium (RPE) is characterized by which of the following?

B. Phagocytosis of worn-out components of photoreceptor cells

The primary function of intermediate filaments is which of the following?

B. Provide mechanical stability

A 19-year-old teenager is brought to the emergency room after a single-car accident just 20 minutes earlier in which she lost control of her car on black ice and hit a retaining column of an overpass at about 45 miles per hour. She was wearing a seat belt but looks pale, has tachy- cardia and positional hypotension, is extremely nauseated, and is lying in the fetal position due to increasingly severe abdominal pain. She has no fractures and a cranial nerve test is normal. You order an abdominal CT because you suspect which of the following?

B. Ruptured spleen

In the developing human embryo/fetus, most of the internal organs begin to form in which month?

B. Second

The adrenal cortex influences the secretion of the adrenal medulla by means of which of the following?

B. Secretion of glucocorticoids into the intra-adrenal circulation

A patient has arthralgia, a rash, lymphadenopathy, pneumonia but no fever. Which of the following diseases is most likely based on these symptoms?

B. St. Louis encephalitis

Which of the following is the most direct route for spread of infection from the paranasal sinuses to the cavernous sinus of the dura mater?

B. Superior ophthalmic vein

Which structure is most susceptible to unintentional damage during a hysterectomy?

B. Ureter

The serum of a newborn infant reveals a 1:32 cytomegalovirus (CMV) titer. The child is clinically asymptomatic. Which of the following courses of action would be advisable?

B. Wait 6 months and obtain another titer on the baby

Which of the following viruses causes an acute febrile rash and produces disease in immunocompetent children but has been associated with transient aplastic crises in persons with sickle cell disease?

C. Parvovirus

There is considerable overlap of signs and symptoms seen in congenital and perinatal infections. In a neonate with "classic" symptoms of congenital cytomegalovirus (CMV) infection, which one of the following tests would be most useful in establishing a diagnosis?

C. CMV IgM titer on neonate's serum at birth and at 1 month of age

Which of the following is the function of the large subunit of the ribosome?

C. Catalyze peptide bond formation

The first (S1, or "lub") heart sound and the second (S2, or "dup") heart sound originate, respectively, from which of the following?

C. Closure of the atrioventricular valves followed by closure of the semilunar valves

Which of the following processes places the developing heart in the presumptive thoracic region cranial to the septum transversum?

C. Cranial folding

The primordial germ cells that eventually form the oogonia and sper- matogonia originate in which of the following?

C. Endodermal lining of the yolk sac

Infection with herpes simplex virus, a common human pathogen, is best described by which of the following statements?

C. It can be reactivated by emotional disturbances or prolonged exposure to sun-light

A 36-year-old male office worker comes to the clinic complaining of general weakness and shortness of breath. He also relates a rapid, throbbing pulse after climbing a flight of stairs. Cardiac auscultation reveals a diastolic rumbling murmur attributable to the mitral valve. The mitral valve is best heard where?

C. Left side in the midclavicular line in the fifth intercostal space

Meningitis is characterized by the acute onset of fever and stiff neck. Aseptic meningitis may be caused by a variety of microbial agents. During the initial 24 h of the course of aseptic meningitis, an affected person's cerebrospinal fluid is characterized by

C. Lymphocytosis

Eastern equine encephalitis virus is associated with a high fatality rate. Control of the disease could be possible by eradication of

C. Mosquitoes

Benign prostatic hypertrophy results in obstruction of the urinary tract. Patients present with weak urine flow, increased difficulty initiating urination, and increase frequency of urination since the bladder often is not fully emptied. Benign prostatic hypertrophy is associated with enlargement of which of the following?

C. Mucosal and submucosal regions

Which pair of venous structures contributes to the confluence of dural sinuses on the interior surface of the occipital bone?

C. Occipital and straight sinuses

Which virus is the leading cause of the croup syndrome in young children and, when infecting mammalian cells in culture, will hemabsorb red blood cells?

C. Parainfluenza virus

The major venous return system of the heart, the coronary sinus, empties into which of the following structures?

C. Right atrium

Like all endocrine glands, the thyroid is highly vascular. The thyroid gland normally receives its blood supply, in part, from branches off which of the following?

C. Subclavian artery

The stability and arrangement of actin filaments as well as their prop- erties and functions depend on which of the following?

D. Actin-binding proteins

Infectious mononucleosis, a viral disorder that can be debilitating, is Characterized by which of the following statements?

D. Affected persons respond to treatment with the production of heterophil antibodies

Delta hepatitis only occurs in patients who also have either acute or chronic infection with hepatitis B virus. The delta agent is

D. An incomplet

Structure(s) that normally transit the diaphragm by way of the esophageal hiatus include which of the following?

D. Anterior and posterior vagal trunk

Which of the following may be the only detectable serological marker during the early convalescent phase of HBV infection (window phase)?

D. Anti-HBc

A 65-year-old male presents with jaundice for 2-3 weeks, fatigue and increasing epigastric pain. He has no history of peptic ulcers and says the pain does not relate to eating in anyway. His epigastric pain is midline and he has had some recent back pain. His urinary bilirubinogen and serum bilirubin are elevated (serum bilirubin 5.8 mg/dl). Helical CT reveals a suspicious mass in the head of the pancreas adjacent to the descending duodenum. The gallbladder is significantly enlarged. Which of the following is the likely cause of the elevated bilirubin?

D. Blocked duodenal papilla

Which of the following is in direct contact with maternal blood in lacunae of the placenta?

D. Cells of the syncytiotrophoblast

Which one of the following groups of people may be at increased risk for HIV infection?

D. Foreign service employees who are hospitalized in Zaire for bleeding ulcers

A patient has all the gastrointestinal symptoms of infection with hepatitis A virus (HAV), yet all the tests for HAV-IgG and HAV-IgM are non- reactive. A possible cause of this infection is

D. Hepatitis E

Erythema infectiosum (fifth disease), a self-limited disease of children, is caused by

D. Human herpesvirus type 6

Elevated estrogen levels during the menstrual cycle result in which of the following?

D. Increase the ciliation of the epithelial cells of the oviduct

An 85-year old woman comes into your family practice office because she says she is losing weight and she is having trouble chewing. Which of the following muscles is a pure elevator of the jaw?

D. Medial pterygoid muscle

German measles virus (rubella), a common cause of exanthems in children, is best described by which of the following statements?

D. Onset is abrupt with cough, coryza, and fever

Which one of the following viruses would be most likely to establish a latent infection?

D. Parvovirus

A 26-year-old woman is in her last trimester of a normal pregnancy. Synthesis of milk by her mammary glands specifically requires which of the following?

D. Placental lactogen

Which of the following mechanisms is used to establish the mito- chondrial electrochemical gradient?

D. Proton-translocating activity in the inner membrane

Which of the following is the principal supply to the body and tail of the pancreas?

D. Splenic artery

A carcinoma in the medial portion of the lower lip is most likely to first metastasize via which of the following lymph nodes?

D. Submental

The course of the vertebral arteries is best described by which of the following statements?

D. They pass through the transverse processes of several cervical vertebrae

Endocytosis of low-density lipoprotein (LDL) differs from phagocytosis of damaged cells in which of the following?

D. Use of clathrin-coated pits

A 55-year-old woman arrives at the emergency room the day after St. Patrick's Day coughing up bright red blood. She has frequented your emergency room before. History includes excessive alcohol consumption. Using abdominal percussion you determine that her liver extends 5 cm below the right costal margin at the midclavicular line. You call in a gas- troenterologist because you suspect that the bright red blood is most likely the result of which of the following?

E. Esophageal varices

Monozygotic twins arise by means of which of the following?

E. Extra cleavage divisions of the zygote induced by the presence of a double chorion

Which of the following is independent of testosterone or other androgens?

E. Fetal testis development from an indifferent gonad

In a patient with diabetes mellitus of 30 years' duration, complica- tions related to kidney function may include which of the following?

E. Glycation of proteins in the basal lamina

A regimen that includes appropriately administered gamma globulin may be contraindicated in which one of the following diseases?

E. Infectious mononucleosis

Mumps virus accounts for 10 to 15% of all cases of aseptic meningitis in the United States. Infection with mumps virus

E. Is preventable by immunization

The ectoderm is derived directly from which of the following?

E. Nongastrulated epiblast

A 3-year-old child presents at the physician's office with symptoms of coryza, conjunctivitis, low-grade fever, and Koplik's spots. The causative agent of this disease belongs to which group of viruses?

E. Paramyxovirus

An immunocompromised person with history of seizures had an MRI that revealed a temporal lobe lesion. Brain biopsy results showed multinucleated giant cells with intranuclear inclusions. The most probable cause of the lesion is

E. Parvovirus

A 24-year old man was a passenger in an automobile broadsided by another vehicle. Although he was wearing a seat belt he felt "terrible," and had left sided abdominal, flank, and shoulder pain. During the ambulance ride into the emergency room his blood pressure kept dropping, he appeared pale, had a rapid heartbeat, with otherwise normal lung and heart sounds. Intravenous saline was started en route. Which of the following abdominal organs is most likely damaged?

E. Spleen

During a visit to her gynecologist, a patient reports she received vita- min A treatment for her acne unknowingly during the first 2 months of an undetected pregnancy. Which of the following organ systems in the developing fetus is most likely to be affected?

E. The skeletal and central nervous systems

A 23-year-old woman with a natural menstrual cycle is nearing ovulation. The oocyte of a mature follicle will be induced to undergo the first meiotic division as a result of which of the following hormonal stimuli?

E. The surge of luteinizing hormone (LH) initiated by high estrogen titers

Which of the following is found exclusively in the renal medulla?

E. Thin loops of Henle