Comlex High Yield Questions

Front 1

A 28-year-old male athlete complains of chest tenderness and tightness when training. Electrocardiogram rules out any heart involvement. Physical examination reveals that rib 2 is restricted in exhalation.

Which of the following would be the most effective in treating this dysfunction?
(A) Muscle energy to the anterior scalene
(B) Muscle energy to the posterior scalene
(C) Muscle energy to the middle scalene
(D) Muscle energy to the sternocleidomastoid
(E) Rib raising from T3-T6

Back 1

Ribs Muscle Attachments Used in Treatment
Rib 1 Anterior and Middle Scalene
Rib 2 Posterior Scalene
Rib 3-5 Pectoralis Minor
Ribs 6-9 Serratus Anterior
Ribs 10-11 Latissimus Dorsi (possibly Quadratus Lmborum)
Rib 12 Quadratus Lumborum

Front 2

A 14-year-old girl has cerebral palsy. Her muscles are rigid and she has uncontrollable spasms. To make her feel more comfortable, her physician prescribes baclofen.

Which of the following best describes the mechanism of action?
(A) Blocks the release of calcium from the sarcoplasmic reticulum
(B) It is a competitive inhibitor at the neuromuscular junction
(C) It blocks sodium channels
(D) It binds GABA-a receptors and opens chloride channels
(E) It binds GABA-b receptors and reduces the release of excitatory neurotransmitters

Back 2

Baclofen is a spasmolytic commonly used for cerebral palsy. It binds GABA-b receptors and reduces the release of excitatory neurotransmitters.

Front 3

A 30-year-old woman complains of diplopia when she looks down. She especially has trouble walking down a fight of stairs. MRI shows a lesion near the inferior colliculus.

Which of the following muscles is most likely paralyzed?
(A) Superior oblique
(B) Inferior oblique
(C) Superior rectus
(D) Inferior rectus
(E) Lateral rectus

Back 3

A lesion of cranial nerve IV (trochlear) causes diplopia when attempting to look down with an adducted eye. It innervates the superior oblique muscle.

Front 4

A 52-year-old Hispanic male complains of upper abdominal pain radiating to his back for the past few months. He also reports an unintentional weight loss. Physical examination is remarkable for scleral icterus.

Which of the following physical findings would be pathognomic for your suspected diagnoses?

(A) Battle sign
(B) Rovsing sign
(C) Courvoisier sign
(D) Murphy sign
(E) Homan sign

Back 4

Adenocarcinoma of the head of the pancreas is associated with Courvoiser 's sign which is an enlarged and palpable, but painless, gallbladder.

Front 5

A 45-year-old man was diagnosed with peptic ulcer disease. Urease breathe test was positive. After 2-weeks of being compliant with his drug therapy he complains of a rash. He states that his skin becomes red and itchy when he goes out in the sun.

Which of the following drugs is most likely responsible

(A) Omeprazole
(B) Cimetidine
(C) Sulfadiazine
(D) Chloramphenicol
(E) Doxycycline

Back 5

Tetracyclines are known to cause photosensitivity

Front 6

A 35-year-old African American male is brought in by ambulance for the acute onset of tachypnea and fatigue. He denies any past medical problems other than a current skin infection being treated with trimethoprim-sulfamethoxazole. Physical exam reveals tachycardia, tachypnea, mildly elevated blood pressure, and hepatosplenomegaly. This disorder is best described as

(A) autosomal recessive in inheritance
(B) transmitted by a retrovirus
(C) genetic inability to modulate oxidative stress
(D) a systemic effect of a skin infection
(E) caused by the Epstein-Barr virus

Back 6

G6PD deficiency results in an inability to effectively modulate oxidative stress.

Front 7

An 18-year-old obese female presents to the clinic with amenorrhea, acne and hirsutism. Lab results show elevated LH and normal FSH.

Which of the following is true concerning her most likely diagnosis?

(A) Increases the risk for ovarian cancer
(B) She has elevated corticosteroids
(C) Benign estrogen sensitive uterine tumors
(D) Increases the risk for type II diabetes
(E) Associated with blood-filled cysts on the ovaries

Back 7

Polycystic ovarian syndrome (PCOS) presents with amenorrhea, hirsutism. Labs show elevated LH, not FSH. Patients are at increased risk for type II diabetes.

Front 8

A 21-year-old female is brought via ambulance to the Emergency department for a suspected overdose. The patient is obtunded and her clothes are stained with vomit. The patient’s sister found her unconscious near an empty bottle of acetominophen.

Question 3 of 3 in set:

Which of the following is the most accurate concerning the action of this drug

(A) Reduces fever by reducing prostaglandin levels
(B) Inhibits the release of IL-1
(C) Inhibits the production of thromboxanes
(D) Inhibits the release of arachidonic acid
(E) Reduces the inflammatory repsonse

Back 8

Question Explanation:
The correct answer is A. Acetaminophen is a pain reliever and fever reducer. Fever reduction is achieved by reducing the production of prostaglandins which mediate the fever response. IL-1 activates the arachidonic acid pathway, which increases production of prostaglandins, thus stimulating a fever. Its release is not inhibited by acetaminophen (B). While aspirin (an NSAID) inhibits thromboxane production (thromboxane promotes platelet aggregation) which helpful for preventing clot formation, acetaminophen does not (C). Arachidonic acid is released from the membrane by phospholipases and these enzymes are not inhibited by acetaminophen (D). Unike NSAIDs, acetaminophen doesn't inhibit inflammation (E).

Bottom line: Acetaminophen is a pain reliever and fever reducer. It does NOT have anti-inflammatory or anti-platelet effects.

Front 9

A physician running a busy practice in an underserved area decides that he is too overwhelmed by his patient load. He instructs his office staff to refuse new patients into the practice but continues to see all members of his current patient population.

Which of the following statements most appropriately describes this decision?

(A) The physician is within his legal rights but his decision to refuse new patients is unethical
(B) The decision is illegal but ethically acceptable
(C) The decision is legal but only ethical if he arranges for referral to another practice
(D) The decision meets both ethical and legal criteria
(E) The decision to refuse new patients is illegal in underserved areas

Back 9

It is both legal and ethical for physicians to refuse new patients into their practice, even in underserved areas.

Front 10

An 8-year-old boy has a history of bleeding into his muscles and joints after minor trauma. His uncle also has a bleeding disorder due to a clotting factor deficiency. His blood pressure and other vital signs are within normal limits.

(A) Prolonged bleeding time
(B) Elevated PTT
(C) Prolonged extrinsic clotting pathway
(D) Thrombocytopenia
(E) Low ferritin

Back 10

The correct answer is B. This boy most likely has hemophilia A, an X-linked recessive bleeding disorder caused by a deficiency in factor 8. Bleeding into muscles and joints are common findings. Factor 8 is part of the intrinsic clotting pathway. Elongation of the intrinsic pathway manifests as an elevated PTT. Prolonged total bleeding time indicates platelet dysfunction or deficiency (A). Bleeing time is not affected by the levels of clotting factors. Prolonged extrinsic pathway manifests as elevated PT. It can be seen with warfarin, liver disease and DIC (C). Platelet count is not affected in hemophilia (D). Low ferritin suggests iron deficiency anemia (E).

Bottom line: Hemophilia causes a prolonged intrinsic pathway for clotting which manifests as an elevated PTT.

Front 11

A 3-year-old African American child is brought to the emergency room screaming and inconsolable. You are told that the child had an upper respiratory infection (URI) for the past week. On exam, the child has increased work of breathing, joint tenderness, splenomegaly, and appears mildly dehyradrated. Lung sounds are coarse over the right lower lobe.

(A) Aggressive transfusion, splenectomy
(B) Antibiotics alone
(C) Hydration, antibiotics, analgesia, respiratory support, and possible exchange transfusion
(D) Analgesia, hydration, splenectomy
(E) Observation

Back 11

The correct answer is C. Initial treatment for a sickle cell crisis includes hydration to help reduce sickling of red blood cells and maintain adequate perfusion of organ systems, antibiotics to treat an infectious source, respiratory support to keep oxygenation over 92%, possible exchange transfusion if the extent of sickling appears severe, and analgesia for the pain crisis. Splenectomy (A and D) is initial treatment for beta thallasemia major (in order to enhance survival of RBCs, but is rarely used for sickle cell disease, especially not as inital treatment. This is a serious and possibly fatal complication of sickle cell disease thus observation is not appropriate (E).

Bottom line: Intially treat a sickle cell crisis with hydration, antibiotics, analgesia, respiratory support, and possible exchange transfusion.

Front 12

A 3-year-old African American child is brought to the emergency room screaming and inconsolable. You are told that the child had an upper respiratory infection (URI) for the past week. On exam, the child has increased work of breathing, joint tenderness, splenomegaly, and appears mildly dehyradrated. Lung sounds are coarse over the right lower lobe.

A mutation of which chromosome causes this disorder

(A) 15
(B) 13
(C) 21
(D) 18
(E) 11

Back 12

The chromosomal mutation which causes sickle cell disease is located on chromosome 11.

Front 13

A 55-year-old IV drug user presents to the emergency department with spiking fevers, chills and fatigue for the past 3-hours. He complains of shortness of breath. Physical exam reveals petechiae on his arms and trunk and a new systolic murmur. Chest X-ray reveals pulmonary infarcts. Blood is collected for culture.

Which of the following is true concerning his most likely diagnosis?

(A) The cause is Streptococcus viridans
(B) The mitral valve is involved
(C) He has a pre-existing heart condition
(D) There is an increased risk for glomerulonephritis
(E) There is an increased risk for myocardial infarction

Back 13

IV drug users are at risk for infective endocarditis of the right-sided valves. The most common organism for the acute form is Staphylococcus aureus, SEQUELAE = KIDNEY DISEASE, CHF, STROKE, Etc. MI is NOT COMMON

Front 14

A homeless man with known HIV comes to the free clinic for an evaluation. He states that he has been coughing up phlegm and has found it hard to breath lately. The chest x-ray will show what gross diagnostic indication that he has PCP, Pneumocystis carinii Pneumonia?
(A) White infiltrate
(B) Cysts of varying sizes
(C) Caseating granulomas
(D) Non-caseating granulomas
(E) “Spaghetti and meatball” appearance

Back 14

The correct answer B. PCP manifests with varied sized cysts in the lung fields. (A) A non-PCP pneumonia may show lobar infiltrate, classically white on the films (C) Classic for TB (D) Classic for sarcoidosis (E) Classically Aspergillus flavus, a fungus.

Bottom Line: HIV patients have unique and specific infections such as PCP.

Front 15

A 46-year-old barber is complaining of muscle tension across his back at the level of his shoulder blades. Upon osteopathic physical examination you find that T4 is flexed, rotated right, sidebent right (FRrSr).
Which of the following best represents your findings?
(A) Left transverse process posterior, restricted in right translation, restricted in extension
(B) Right transverse process posterior, restricted in right translation, restricted in extension
(C) Right transverse process anterior, restricted in left translation, restricted in extension
(D) Right transverse process posterior, restricted in left translation, restricted in extension
(E) Right transverse process posterior, restricted in right translation, restricted in flexion

Back 15

The correct answer is B. The somatic dysfunction is flexed, rotated right and sidebent right (FRrSr). Somatic dysfunctions are named for the direction of ease. The direction of ease is flexion thus there will be restriction in extension (E). The physical finding for right rotation is a posterior transverse process on the right (A and C). The direction of ease is right sidebending thus there will be restriction in left sidebending. Left sidebending is induced by right translation, thus there will be restriction in right translation (C and D).

Bottom line: Somatic dysfunctions are named for the direction of ease thus restriction is found in the opposite direction.

COMLEX insight: Know not only how to name dysfunctions, but also know what your actual physical findings will be.

Front 16

A young breast cancer patient is recovering from a bilateral masectomy. During her first round of chemotherapy she suffers from excessive nausea and vomiting.

Which anti-emetic is recommended as first line?
A. Scopolamine
B. Meclizine
C. Promexerine
D. Odansetron
E. Diazepam

Back 16

The correct answer is D. Odansetron (Zofran) is 5-HT3 receptor antagonist anti-emetic shown best to stave nausea after chemotherapy and surgery. (A) Scopolamine is an anticholinergic best used to treat motion sickness. (B) Meclizine is an antihistamine used for motion sickness. (C) Promexerine (Phenergan) is both an anti-histamine and an anticholinergic. It may be employed if odansetron fails. (E) Benzodiazepines are used for anticipatory nausea and vomiting due to anxiety and stress.

Bottom line: Ondansetron works well for nausea caused by chemotherapy and/or surgery.

Front 17

A male infant is born to a 30 year old white mother. Upon physical exam, the pediatrician notices pronounced intrauterine growth restriction with microcephaly. Several craniofacial abnormalities along with hypoplastic growth of nails are noted. Mental retardation is also suspected. What medication was the mother on during the pregnancy?
(A) Ethosuximide
(B) Topiramate
(C) Valproic Acid
(D) Phenytoin
(E) Gabapentin

Back 17

The correct answer is D. This infant is suffering from fetal hydantoin syndrome which is caused by the teratogen phenytoin. Fetal hydantoin syndrome is marked by intrauterine growth restriction with microcephaly along with craniofacial abnormalities and hypoplastic growth of nails. Developmental delay or mental retardation may be noted later in life. Other features of the syndrome include heart defects and cleft lip. Ethosuximide is the first line treatment for absence seizures and it functions by blocking calcium channels. This epilepsy medication causes fatigue, urticaria, and Stevens-Johnson syndrome (A). Topiramate blocks sodium channels and may result in kidney stones and loss of weight (B). Valproic acid is the first line treatment for tonic-clonic seizures, but its use is contraindicated in pregnancy due to its potential to cause neural tube defects including spina bifida (C). Gabapentin has side effects that include both sedation and ataxia (E).

Bottom Line: Fetal hydantoin syndrome is caused by the teratogen phenytoin.

Front 18

An infant is born to a 25-year-old G2P2 mother at 40-weeks gestation. Apgar scores are 8 and 9 at one and five minutes after birth, respectively.

Which disease is not a part of the mandatory screen for newborns?
(A) Phenylketonuria
(B) Congenital hypothyroidism
(C) Maple syrup urine disease
(D) Human Immunodeficiency virus
(E) Cystic fibrosis

Back 18

The correct answer is D. HIV is capable of being vertically transmitted. However, it is not a part of the mandatory newborn screen. Phenylketonuria is caused by a congenital lack of phenylalanine hydroxilase. PKU is screened for in all states (A). Congenital hypothyroidism is screened for in all states (B). Maple syrup urine disease is a metabolic disorder that leads to a toxic build up of branched chains amino acids. It is screened for in all states (C). Cystic fibrosis is a congenital mutation of the chloride transport gene and is screened for at birth (E).

Bottom line: HIV infection may be transmitted to the child at birth; however, there is no mandatory screen as it is not a metabolic inherited disorder.

Front 19

A 36 year old G2P1 woman at 34 gestational weeks presents to her OB/GYN for her weekly obstetrical examination. The patient’s previous pregnancy was normal until week 38 of gestation when the patient’s blood pressure increased slightly. During this exam, the physician notes slight edema, 3+ protein on urine dipstick, and a blood pressure reading of 142/100 on two different blood pressure measurements. The patient has severe headache, abdominal pain, and physical exam shows hyperreflexia. What is the best treatment option for this patient to prevent morbidity and mortality to both herself and the fetus?
(A) Bed rest
(B) Change in diet including reducing salt intake
(C) Antihypertensive medication
(D) No medication or procedure is needed and let the pregnancy proceed
(E) Immediate delivery of the fetus

Back 19

The correct answer is E. This pregnant woman is suffering from preeclampsia. She has hypertension, protein in her urine, and edema upon physical exam. Another clue is the fact that during her last pregnancy, she had high blood pressure in the third trimester. The physical complaints of the patient, including headache, abdominal pain, and hyperreflexia are further indicators of hypertension. The best way to manage the patient is to deliver the fetus as soon as possible. An amniocentesis should be performed to ensure fetal lung maturity. Since the woman presented at 34 weeks of gestation the lungs should be mature. While bed rest (A), changing the diet to lower blood pressure (B), and providing antihypertensive meds will help to relive symptoms and by time until the lungs are mature, 34 gestational weeks allows for deliverer. Delivery is best to prevent both maternal and fetal morbidity and mortality. If no medication of procedures was offered to this patient she would be at a high risk due to death from cerebral hemorrhage or acute respiratory distress syndrome (D).

Bottom Line: Preeclampsia which is diagnosed based on hypertension, proteinuria, and edema is best treated with delivery of the fetus as soon as viably possible.

Front 20

Your patient is waiting to hear the results of her recent genetic test. She wants to know why the drugs are not working to treat her B-cell lymphoma. You have to tell her that certain genes in her body are building a resistance to the chemotherapy. The family of channel proteins that has a dual anti- and pro-apoptotic role is the

(A) lac operon family
(B) Bcl-2 family
(C) RAS family
(D) p53 family
(E) BRCA family

Back 20

The correct answer is B. The over-expression of the dually functioning Bcl-2 protein in lymphocytes leads to cancer. Rogue genes will establish channels and alter pH and Ca2+ flow. Pertains to the metabolism of lactose, not cell death or cancer. RAS is a signal transducer, not an apoptotic gene. p53 is a tumor suppressor that may trigger apoptosis, but it is not a channel protein. BRCA is a DNA repair gene, linked to breast cancer when mutated.

Bottom Line: Bcl-2 family contains channel proteins that add another source of cell regulation, anti- and pro-apoptosis.

Front 21

A 45-year-old AIDS patient has a CD4 count of 90/uL. He is currently taking lamivudine, indinavir, didanosine.

Which of the following drugs should be added for prophylaxis against meningitis?
(A) Trimethoprim-sulfamethoxazole
(B) Foscarnet
(C) Penicillin
(D) Fluconazole
(E) Ketoconazole

Back 21

The correct answer is D. This patient has a CD4 count below 100/uL. This increases his risk for Cryptococcal meningitis, for which fluconazole is the prophylactic drug of choice. Trimethoprim-sulfamethoxazole is prophylactic for Pneumocystis jiroveci pneumonia and the treatment for toxoplasmosis (A). Foscarnet is an anti-viral drug for cytomegalovirus and acyclovir-resistant herpes (B). Penicillin can be used to treat meningitis by Streptococcus pneumoniae but it is not given as prophylaxis (C). Ketoconazole doesn’t cross the blood-brain barrier (E).
Bottom line: Fluconazole is the prophylactic drug of choice for Cryptococcal meningitis in AIDS patients when the CD4 drops below 100/uL.

Front 22

The following chest x-ray and computed tomography (CT) scan is from a 35-year-old male

Which of the following does this gentleman most likely suffer from?
(A) Chronic obstructive pulmonary disease (COPD)
(B) Kartagener's syndrome
(C) Wegener's syndrome
(D) Cystic Fibrosis
(E) Adult polycystic kidney disease

Back 22

The correct answer is B. These radiographic images depict an individual with situs inversus totalis. As you can see, the heart and spleen are right sided while the liver is left sided. Situs inversus is commonly associated with the dynein arm defect causing immotile cilia, Kartagener's syndrome. The other answers are merely attractive distractors.

Bottom line: Be familiar with reading x-rays, CTs, and MRIs. By convention CT's are read as if you are looking at the patient in a supine position from their feet up.

Front 23

A 25-year-old woman woke up this morning unable to close her left eye. Physical examination reveals paralysis of the entire left side of her face. Her mouth is drooping on the left.

The nerve involved in the patient’s clinical presentation exits the skull through which neural foramen?
(A) Foramen rotundum
(B) Formaen ovale
(C) Jugular foramen
(D) Internal auditory meatus
(E) Foramen magnum

Back 23

The correct answer is D. The clinical presentation of unilateral facial drooping, inability to close the eye, and inability to move the face describes Bell’s palsy, which is due to a condition that affects the facial nerve, or CN VII. The facial nerve is responsible for closing the eyes, facial expression, taste and salivation. The facial nerve nuclei originates in the pons and exits the skull via the internal auditory meatus, along with the vestibulocochlear nerve, CN VIII, where it innervates areas of the face, tongue, and salivary glands. The foramen rotundum (A) is where the maxillary branch of the trigeminal nerve (V2) exits the skull which is involved in facial sensation, not facial movement. The foramen ovale (B) allows the mandibular branch of the trigeminal nerve (V3) to exit the skull and also provide facial sensation. The jugular foramen (C) as its name states, is the foramina that allows the jugular vein to course through the skull as well as an exit point for the glossopharyngeal, vagus, and accessory nerves. The foramen magnum (E), the largest of the foramina, allows the spinal roots of the accessory nerve, the brainstem and the vertebral arteries to exit the skull.

Bottom line: The facial nerve exits the skull via the internal auditory meatus. This nerve is important in facial expression and movement as well as taste and salivation. Paralysis of this nerve causes a clinical condition Bell’s palsy.

Front 24

A 55-year-old man has a 30-year history of diabetes. He states that despite his strong desire for sexual intercourse with his wife he has difficulty maintaining an erection. He denies depressed mood or marital difficulties.

Which of the following is true about the drug of choice
(A) It stimulates nitric oxide
(B) It increases intracellular cAMP
(C) It is useful for erectile dysfunction caused by nerve damage
(D) It blocks the activity of phosphodiesterase
(E) Aprostadil has the same mechanism of action

Back 24

The correct answer is D. This patient has erectile dysfunction (difficulty maintaining an erection despite strong desire for sex) which is likely caused by his long-standing diabetes. The drug of choice is sildenafil which inhibits phosphodiesterase-5 causing relaxation of the corpora cavernosa. Choice (A) describes the effects of nitrates, the most common of which is nitroglycerine. Phosphodiesterase-5 breaks down cGMP thus inhibition causes an increase in this secondary messenger (B). Increased cGMP relaxes the smooth muscle and promotes an erection. Parasympathetic innervation is needed to release nitric oxide and start the signaling pathway to increase cGMP. Once the pathway is active sildenafil can work to keep cGMP levels high. Thus the nerves must be intact in order for sildenafil to be useful (C). Alprostadil is a PGE1 analog used in patients that do not respond to sildenafil (E).

Bottom line: Sildenafil, the drug of choice for erectile dysfunction, inhibits phosphodiesterase-5 thus increasing cGMP and promoting erection.

Front 25

A 5-year-old girl has skin lesions exuding a honey-colored serous fluid. Culture reveals gram-positive cocci in chains with beta-hemolysis.

Which of the following sequelae is most likely?
(A) Thrombocytopenia
(B) Ascending paralysis that starts at the lower legs
(C) Red blood cell casts and smoky-colored urine
(D) Paralysis of the facial nerve
(E) Damage to the mitral valve

Back 25

Bottom line: Acute post-streptococcal glomerulonephritis can occur several weeks after a skin infection caused by Streptococcus pyogenes.

Front 26

A 55-year-old male presents to the emergency department with acute onset paralysis and numbness on the left side of his body. When the patient opens his mouth, the physician notices that the uvula deviates towards the patient’s left side.

Which of the following nuclei is most likely damaged?
(A) Nucleus solitaris
(B) Nucleus ambiguus
(C) Dorsal motor nucleus
(D) Inferior salivatory nucleus
(E) Superior salivatory nucleus

Back 26

The correct answer is B. This patient's lesion is in the right medulla and causing contralateral paralysis. The nuclei of cranial nerves IX, X, XI, and XII are located in the medulla of the brainstem. The nucleus ambiguus provides motor innervation of the pharynx, larynx and elevates the palate via the vagus nerve (CN X). Damage to it can cause contralateral deviation of the uvula due to failure to elevate the palate on the ipsilateral side. The nucleus solitarius (A) provides sensory information such as taste and gut distention. The dorsal motor nucleus (C) is responsible for providing parasympathetic innervation to the heart, gastrointestinal organs, and the lungs. The inferior salivatory nucleus (D) projects preganglionic fibers from the glossopharyngeal nerve (CN IX) to the parotid gland to control salivation. The superior salivatory nucleus (E) sends preganglionic fibers from the facial nerve (CN VII) to the submandibular and sublingual glands.

Bottom line: Each vagal nucleus located in the medulla of the brainstem corresponds to each type of vagal innervation. The nucleus solitarius provides visceral sensory innervation, the nucleus ambiguus provides motor innervation, and the dorsal motor nucleus functions in autonomic innervation.

Front 27

A 63-year-old female has a history of chronic renal failure. She has been receiving dialysis for the past 5-years. As part of her management creatinine, BUN, electrolytes, and glomerular filtration rate (GFR) are monitored.

Clearance of which of the following would most accurately determine her GFR?
(A) Glucose
(B) Inulin
(C) Creatinine
(D) Sodium
(E) PAH (para aminohippurate)

Back 27

The correct answer is B. Inulin is freely filtered by the kidney and is neither reabsorbed nor secreted, making it the gold standard in GFR calculation. Glucose is reabsorbed at the proximal tubule and under normal conditions, its concentration in the urine is zero making it worthless for determining GFR (A). Creatinine (C) is used more often in clinical practice to estimate GFR. It is less accurate than inulin because a small amount is secreted thus its clearance will slightly overestimate GFR. Sodium is reabsorbed at the proximal tubule and regulated by aldosterone at the collecting tubules thus its clearance cannot estimate GFR (D). PAH clearance estimates renal blood flow because it is freely filtered, secreted and not reabsorbed (E).

Bottom line: Inulin is freely filtered and is neither reabsorbed nor secreted, making its clearance the gold standard in GFR calculation.

Front 28

A 45-year-old man with chronic hepatitis B complains of abdominal pain. Ultrasound shows enlarged lymph nodes in the hepatoduodenal ligament. The structure at the highest risk for being affected is the
(A) remnant of the umbilical vein
(B) portal triad
(C) hepatic vein
(D) recurrent laryngeal nerve
(E) hepatic bile duct

Back 28

The correct answer is B. Enlarged lymph nodes in the hepatoduodenal ligament will most likely affect the portal triad because these are the structures closest to them. The portal triad, housed within this ligament, consists of the common bile duct, hepatic artery and portal vein. Remnant of the umbilical vein describes ligamentum teres of the liver found at the free end of the falciform ligament. The left recurrent laryngeal nerve is in close proximity to ligamentum arteriosum, the remnant of the ductus arteriosus that connects the aorta and pulmonary artery during fetal life.

Bottom Line: The portal triad, housed within the hepatoduodenal ligament, consists of the common bile duct, hepatic artery and portal vein.

Front 29

A 22-year-old football player is tackled during a practice, landing on his right shoulder. Immediately after, he notices pain and weakness in the shoulder with radiation into the thumb and second digit. On exam, no neurosensory deficits are appreciated. However, he is noted to have marked weakness in internal rotation of the right shoulder.
The injured structure is most likely the
(A) Deltoid
(B) Teres Major
(C) Teres Minor
(D) Infraspinatus
(E) Subscapularis

Back 29

The correct answer is E. The primary internal rotator of the shoulder is the subscapularis. The deltoid (A) serves as the primary flexor and abductor. The teres major (B) is a primary extensor, along with the latissimus dorsi and the posterior portion of the deltoid. Teres minor (C), like the infraspinatus (D), is an external rotator. Minor tears of the rotator cuff muscles are common sports injuries. While not tested in this question, the supraspinatus is the most is the most commonly injured muscle in the shoulder. Supraspinatus injuries would manifest with weakness in abduction, along with a positive drop arm test, pain at the acromion process, and positive empty can test. Treatment of all minor shoulder injuries involves rest, ice, and NSAIDs. OMM should target glenohumeral restrictions as well as dysfunction in the nearby clavicle, upper thorax, ribs, and ulnoradial joint. MRI and surgery may be indicted for complete tears.

Bottom line: The subscapularis is a rotator cuff muscle responsible for primary internal rotation of the shoulder.

Front 30

A 92-year-old woman presents to the emergency department with a chief complaint of severe dizziness for the past 2 days. She states that she has "passed out: 6 times. Upon questioning, she tells you she has a past medical history of "heart problems." Her blood pressure is 74/48 mm Hg. An ECG is obtained as shown in the exhibit.
Treatment?
(A) atropine
(B) an implanted pacemaker
(C) Valsalva maneuver
(D) immediate defibrillation
(E) to treat the underlying disorder

Back 30

Bottom Line: Definitive therapy for third degree AV block is placement of a pacemaker.

Front 31

A 35-year-old woman suffered severe hemorrhage during childbirth 6-months ago, requiring a blood transfusion. She states that she cannot breast feed because of lack of milk production. She also admits that she has not gotten her period since the delivery.

Which of the following additional findings is most likely?
(A) Hyperglycemia
(B) Hyponatremia
(C) Hyperthyroidism
(D) High estrogen levels
(E) Low serum cortisol

Back 31

Bottom line: Ischemic necrosis of the anterior pituitary (Sheehan syndrome) is a complication of massive blood loss during delivery. The clinical manifestation is hypopituitarism.

Front 32

A 7-year-old boy presents to the office complaining of a sore throat and fever. You obtain a throat culture which shows gram-positive cocci that are catalase negative with beta-hemolysis.
Tx?
(A) Amoxicillin
(B) Vancomycin
(C) Bactrim
(D) Erythromycin
(E) Penicillin VK

Back 32

The correct answer is E. This boy has strep throat caused by Streptococcus pyogenes (group A strep). All streptococcus species are catalase-negative, and Streptococcus pyogenes is beta-hemolytic (clear hemolysis). Penicillin VK is the drug of choice with little resistance. Erythromicin (D) is only recommended first line in penicillin allergic patients. Amoxicillin (A), vancomycin (B) and bactrim (C) are never first line treatment for group A strep.

Front 33

A 6-year-old boy presents to the Emergency room in severe respiratory distress. He is wheezing and his lips are blue. He mother states that exercise and cold weather have exacerbated similar symptoms in the past.
Tx for acute attack?
(A) Salmeterol
(B) Montelukast
(C) Intravenous steroids
(D) Theophylline
(E) Carvedilol

Back 33

Bottom line: An acute asthma attack should be treated with oxygen, short-acting beta agonists and IV steroids. Beta-blockers are contraindicated in asthma.

Front 34

A 29-year-old male is at your office today because he is traveling to Mexico and wants prophylaxis for traveler’s diarrhea. He has known inflammatory bowel disease and will be in Mexico for three weeks.
A. Ciprofloxacin
B. Metronidazole
C. TMP-SMX
D. Doxycycline
E. Erythromycin

Based on the above scenario, the most appropriate treatment would be

Back 34

The correct answer is choice B. Although prophylaxis for traveler’s diarrhea is not routinely recommended, they are prescribed in certain cases where the consequence of dehydration is greater than the risk of antibiotic use. Quinolones, such as ciprofloxacin or norfloxacin, are first line recommendations for prophylaxis and for the treatment of traveler’s diarrhea. Metronidazole, choice (A) is a good treatment for anaerobic and parasitic infections such as trichomoniasis. Choice (C), TMP-SMX was used as prophylaxis for traveler’s diarrhea in the past, but bacterial immunity developed. It is commonly used for urinary tract infections. Choice (D), Doxycycline, like TMP-SMX, was used for prophylaxis but is no longer. Doxycycline is generally used for many conditions including Chlamydial infections, Anthrax, Lyme disease, and as malarial prophylaxis. Erythromycin, Choice (E), is not used for prophylaxis or treatment of traveler’s diarrhea. It is used in treatment of neonatal conjunctivitis and other bacterial infections.

Front 35

A 63-year-old man has a history of chronic cough, hemopytsis and unintentional weight loss. He has a 50-pack year history of cigarette smoking. Chest X-ray shows a central mass. His current complaint is weakness, especially in the morning. Repeated stimulation of the muscle helps relieve the weakness.

Which of the following best explains the pathogenesis?
(A) Antibodies against pre-synaptic membrane
(B) Inflammation of the muscle tissue
(C) Antibodies against post-synaptic membrane
(D) Glucocorticoid induced myopathy
(E) Denervation

Back 35

Bottom line: Lambert-Eaton syndrome is characterized by antibody binding to the pre-synaptic membrane and weakness that is relieved by repeated muscle stimulation.

Front 36

A 31-year-old Asian American female presents for her annual well-woman exam. She and her husband have been using condoms for birth control, but now they are interested in having a child. She inquires about how she can determine when she is ovulating.
Two months later, the patient reports a positive over-the-counter pregnancy test. The origin of the hormone measured in this test is
(A) Syncytiotrophoblast of the placenta
(B) Cytotrophoblast of the placenta
(C) Embryonic chorion
(D) Maternal endometrium
(E) Embryonic neural tube

Back 36

The correct answer is A. Urine and serum pregnancy tests measure B-hCG, which is produced by the syncytiotrophoblast of the placenta. B-hCG maintains the corpus luteum for the first trimester and appears in the urine 8 days after successful fertilization (earlier in the serum). The cytotrophoblast (B) is the inner layer of the trophoblast, interior to the syncytiotrophoblast and attaches the embryonic chorion (C) to the maternal endometrium (D). The embryonic neural tube (E) is the precursor to the central nervous system. It does not secrete b-hCG. Elevated B-hCG can also be found in women with hydatidiform moles, choriocarcinoma, and certain germ cell tumors, so a predictable elevation is tracked to confirm a healthy pregnancy.

Front 37

A Caucasian mother brings her 10-year-old daughter to the clinic due to poor school performance, seizures and visual impairment. History reveals delays in neurological and psychological development. Physical exam reveals long thin limbs, high arched feet and arachnodactyly. Eye exam reveals lens subluxation.
Laboratory testing is most likely to reveal elevated levels of
(A) alpha fetoprotein
(B) phenylalanine
(C) fibrillin
(D) methionine
(E) cysteine

Back 37

The correct answer is D. This child is presenting with signs and symptoms consistent with homocystinuria, a rare genetic disease caused by cystathionine synthase deficiency. Homocysteine accumulates which in turn enhances the synthesis of methionine from the homocysteine methyl transferase. In this disease, both homocysteine and methionine are elevated. Alpha-fetoprotein is elevated in neural tube defects. Phenylalanine is elevated in phenylketonuria. A mutation in fibrillin is associated with Marfan syndrome which presents similarly but without neurological symptoms or mental retardation. Furthermore fibrillin is mutated, not elevated, in Marfan syndrome. Homocysteine, not cysteine, accumulates.

Front 38

A 32-year-old mother complains of lower back pain for the last 3 months. Imaging shows no fractures or other abnormalities. Osteopathic exam reveals an L1 Neutral, Rotated right, Sidebent left (L1 NRrSl). She also has an anterior L1 counterstrain tenderpoint.
Which of the following best describes the location of this tenderpoint?
(A) On the posterior superior iliac spine
(B) One centimeter lateral to the pubic symphysis.
(C) Medial to the anterior inferior iliac spine
(D) Inferior to the anterior inferior iliac spine
(E) Medial to the anterior superior iliac spine

Back 38

The correct answer is E. The anterior L1 tenderpoint is medial to the anterior superior iliac spine (ASIS). Choice (A) describes a posterior lumbar tenderpoint. Choice (B) represents an L5 tenderpoint. Choice (C) represents an L2 tenderpoint. Choice (D) represents an L4 tenderpoint.

Front 39

A 27 year old male presents to the emergency department with acute chest pain, tachycardia, and tachypnea. Social history reveals that he is an IV drug user. What is the most likely cause of his symptoms?
(A) Tension pneumothorax
(B) Bacterial microemboli
(C) Deep venous thrombosis
(D) Fat embolism syndrome
(E) Air embolism

Back 39

IV drug users have increased risk for right sided bacterial endocarditis (most commonly from staphylococcus aureus) which may break off leading to a microemboli that may travel to the pulmonary arteries.

Front 40

A 43-year-old male presents to the clinic with a history of headaches over the orbital region for the past few months. A CT of his head reveals the presence of a 2.0-cm mass in the cavernous sinus.

Impingement of what nerves may result due to the location of this mass?
(A) CN II, III, IV
(B) CN III, IV, V3
(C) CN III, IV, V1
(D) CN II, IV, VI
(E) CN V1, V2, V3

Back 40

The cranial nerves, CN III, IV, V1, V2, and VI course through the cavernous sinuses.

Front 41

A 13-year-old male comes into the ED after being involved in a motor vehicle accident. His mother says she’s concerned her son may bleed to death due to his diagnosis of Hemophilia A.
Which of the following lab results would be expected with his current diagnosis?
(A) Decreased platelet count, Normal PT, Normal PTT
(B) Decreased platelet count, Increased PT, Normal PTT
(C) Decreased platelet count, Increased PT, Increased PTT
(D) Normal platelet count, Normal PT, Increased PTT
(E) Normal platelet count, Increased PT, Normal PTT

Back 41

Hemophilia A is an X-linked recessive disorder caused by a deficiency in factor VIII of the coagulation cascade which would result in an increased PTT time.

Front 42

A 10-year-old boy is accompanied to the office by his mother. He was hiking in the woods with his friends 3-days ago. He complains of feeling tired and having some recent headaches. Physical examination reveals the rash shown in the exhibit.
The drug of choice for this disease works by which of the following mechanisms?
(A) Blocks cross-linking of the cell wall
(B) Inhibits protein synthesis by binding the 30S ribosomal subunit
(C) Inhibits protein synthesis by binding the 50S ribosomal subunit
(D) Inhibits PABA metabolism and folate synthesis
(E) Inhibits DNA-dependent RNA polymerase

Back 42

Doxycycline, a tetracycline, is the drug of choice for Lyme disease. Tetracyclines inhibit protein synthesis by binding to the 30S bacterial ribosome.

Front 43

Cystic Fibrosis is an inherited disease that causes tremendous mucus production and progressive organ scarring and failure. The gene mutation that is commonly noted as CFTR in this disease is which of the following:
(A) Cystic fibrosis tryptophan cellular raft
(B) Cystic fibrosis T-cell receptor
(C) Cystic fibrosis transmembrane conductance regulator
(D) Cystic fibrosis transmembrane chloride response
(E) Cystic fibrosis transmission chloride receptor

Back 43

The correct answer is C. The mutation in CFTR prevents proper functioning and flow of chloride ions. (A) This is fictitious. (B) There are specific T-cell receptors within this disease, but they are not directly linked to the disease cause. (D) This is not a protein. (E) This is false and is not a protein.
Bottom Line: CFTR mutations prevent chloride transmission and create a disease state called Cystic Fibrosis.

Front 44

A 25 year old man presents to the clinic with ataxia. Slit lamp examination displays brown pigmentation in a ring distribution on patient’s cornea. Which of the following will be decreased in this patient?
(A) Hepatic copper concentration
(B) Ceruplasmin
(C) Total body copper stores
(D) Urinary copper excretion
(E) Serum aminotranferases

Back 44

The correct answer is B. This patient is presenting with signs and symptoms of Wilson’s disease. Ceruplasmin which is a protein carrier for copper in the blood along with serum copper is decreased in patients with Wilson’s disease making (B) the correct answer

Front 45

A 25 year old man presents to the clinic with ataxia. Slit lamp examination displays brown pigmentation in a ring distribution on patient’s cornea. What is the most appropriate treatment for this patient?
(A) N-acetylcysteine
(B) Methylene blue
(C) Fomepizole
(D) Aminocaproic acid
(E) Penicillamine

Back 45

The correct answer is E. This patient has Wilson’s disease- an autosomal recessive disease that results in inadequate copper excretion from the body. Pencillamine , choice (E) is the most appropriate treatment for this patient. (A) is an antidote for acetaminophen over-dose, (B) is a treatment for methemoglobin, (C) is an antidote for methanol and ethylene glycol poisoning, (D) can be used when too much tPA or streptokinase is given to help reduce bleeding.

Front 46

A 16-year-old football player presents with pain in his right elbow. The pain began when he was pushed from behind at practice yesterday, falling forward onto his outstretched hand with forearm full pronation. A radiograph series rules out a fracture. A tenderpoint is noted just lateral to the right radial head.
What is the SD?
(A) Radial head anterior
(B) Radial head posterior
(C) Lateral epicondylitis
(D) Radial head superior
(E) Radial head inferior

Back 46

The correct answer is B. Falling forward on a pronated forearm is one of the most common causes of acute somatic dysfunction with the radial head posterior. This patient's tenderpoint just lateral the right radial head indicates irritation in the attachments of the primary supinators of the forearm: the biceps and the supinator. Radial head anterior (A) will often occur by means of the opposite etiology: falling backwards onto a supinated forearm. Lateral epicondylitis (C), also known as "tennis elbow," is an overuse strain of the extensor muscles of the forearm. Referring to the radial head as superior (D) or inferior (E) is incorrect; these do not describe motion patterns of the radial head.

Front 47

A 16-year-old football player presents with pain in his right elbow. The pain began when he was pushed from behind at practice yesterday, falling forward onto his outstretched hand with forearm full pronation. A radiograph series rules out a fracture. A tenderpoint is noted just lateral to the right radial head.
Structural Exam?
(A) Restricted anterior glide of the radial head
(B) Restricted posterior glide of the radial head
(C) Olecranon process restricted in medial glide
(D) Olecranon process restricted in lateral glide
(E) Carrying angle decreased

Back 47

The correct answer is A. Falling forward on a pronated forearm is one of the most common causes of acute somatic dysfunction with the radial head posterior. Somatic dysfunction is named for the motion preference, or "the way it likes to go." Thus, because this patient's radial head prefers pronation, corresponding with posterior movement of the radial head, there will be restriction to anterior glide. Restriction to posterior glide (B), conversely, would occur with an anterior radial head. Having the olecranon process restricted in medial glide (C) would occur with an adduction dysfunction of the ulna, and a restriction in lateral glide (D) would occur with an abduction dysfunction. Carrying angle is also decreased (E) with adduction dysfunction, as the olecranon deviates laterally and the distal ulna deviates medially.

Front 48

Initial Step for muscle energy for posterior radial head?
(A) Placing the patient's forearm in supination
(B) Placing the patient's forearm in pronation
(C) Placing the distal ulna in medial glide
(D) Placing the distal ulna in lateral glide
(E) Muscle energy is contraindicated

Back 48

The correct answer is A. This patient has fallen forward on a pronated forearm, locking the radial head in pronation and corresponding with a posterior radial head dysfunction. Muscle energy is a direct treatment, meaning that the operator must engage the barrier. Remembering forearm mechanics, supinating the forearm will move the radial head anteriorly against the physiologic barrier. Placing the patient's forearm in pronation (B), would be the correct setup for the mirror diagnosis - an anterior radial head dysfunction. Choices (C) and (D) refer to treatments for the ulna. Moving the distal ulna in medial glide abducts the ulna and would be used to treat an adduction dysfunction, just as adducting the ulna would be used to treat an abduction dysfunction. Finally, as there is no acute fracture, muscle energy is not contraindicated (E).

Front 49

Panocytopenia with hypocellular bone marrow

A) Lead
B) Cyanide
C) Benzene
D) Mercury
E) Carbon monoxide

Back 49

The correct answer is C. See descriptions below:

A: Lead interferes with the synthesis of heme thus intermediate metabolites, including protoporphyrin, accumulate. Lack of heme gives rise to microcytic anemia. Blood smear may show basophilic stippling, although this finding is insensitive and non-specific.

B: Cyanide blocks electron transport in the mitochondria. A classic finding is “bitter almond” breath.

C: Benzene exposure can cause aplastic anemia

D: Mercury: Acute ingestion of mercury results in acute tubular necrosis and hemorrhagic gastritis. Chronic exposure results in neurological damage

E: Carbon monoxide binds to hemoglobin and prevents oxygen delivery to tissues. Symptoms usually start with headache, palpitations and dyspnea. Continued exposure leads to coma and death.

Front 50

An 8-year-old African American female presents with severe pain in her arms, legs, fingers and toes. The pain started two days ago without any relief. Labs and imaging are ordered.

Which of the following would be most suitable in treating her disease?
(A) Fresh frozen plasma
(B) Hydroxyurea
(C) Erythropoeitin
(D) Vitamin K
(E) Clopidogrel

Back 50

The correct answer is B. Hydroxyurea is an anti-neoplastic agent that has been indicated for reducing the rate of painful occlusive attacks in patient’s with sickle cell disease. It causes an increase in the production of fetal hemoglobin (HbF). Fresh frozen plasma (A) and Vitamin K (D) therapy are indicated when there are coagulation dysfunctions that result in excess bleeding. These therapies replenish necessary clotting factors. Although erythropoeitin (C) stimulates the production of RBCs it cannot prevent the sickling that occurs or decrease the frequency of painful occlusive crises. Clopidogrel (E) is a medication that inhibits platelet aggregation by irreversibly blocking ADP receptors. This is not relevant to the mechanism of occlusion in sickle cell disease.

Front 51

Question Identifier: PATH47BJ

A 23-year-old pregnant woman comes to the emergency department in acute distress. She has a blood pressure of 90/60 mm Hg, a heart rate of 130/min and is tachypneic. Physical examination reveals petechial hemorrhages and blood oozing from mucous membranes. Laboratory findings include a low fibrinogen level.

Which of the following additional laboratory findings is most likely

Platelet count Bleeding time PT PTT
A low high normal normal
B normal high normal high
C normal normal normal high
D low high high high
E normal normal high normal

Back 51

DIC is a consumptive coagulopathy in which thrombi consume coagulation factors I, II, V, VIII and trap platelets. Since factors from both extrinsic and intrinsic pathways are involved the PT and PTT are both prolonged. Since platelets are not available bleeding time is also prolonged.

Front 52

A 43-year-old female with metastatic breast cancer is made “Do Not Resuscitate” (DNR) after being transferred to the medical ICU for respiratory distress. On the third day of admission, the patient develops sepsis and needs antibiotic therapy.
Given the patient is “DNR” status, the most appropriate next step in management is to
(A) Withhold antibiotic therapy
(B) Attempt to reverse “DNR” status so treatment can be given
(C) Proceed with antibiotic therapy
(D) Continue ordering labs but refuse interventional therapy
(E) Give medication for pain management only

Back 52

“Do Not Resuscitate” (DNR) orders simply mean that patients in cardiopulmonary arrest should not receive CPR. They should still receive all necessary modalities of therapy such as surgery, diagnostic procedures, and antibiotic/medical treatments.

Front 53

You are a medical student invited to a dinner sponsored by a pharmaceutical company to inform you of a new antihypertensive medication. There are several attending physicians present, one of whom is scheduled to give a presentation. During the dinner you are offered two tickets to an upcoming sporting event and a new stethoscope by one of the pharmaceutical representatives.
Which of the following statements is correct regarding this situation?
(A) It is unethical to attend lectures where dinner is provided by pharmaceutical companies
(B) Gifts such as tickets to sporting events are allowed but medical devices are not
(C) It is unethical to accept all gifts, regardless if they are medically-related or not
(D) It is okay to accept the stethoscope but not the tickets
(E) It is okay to accept all gifts from pharmaceutical companies, as long as they are not in the form of money

Back 53

It is okay to accept medically-related gifts from pharmaceutical companies, but it’s not okay to accept money or gifts unrelated to your medical education.

Front 54

A 28-year-old male presents to the reservation clinic with a "rash." Upon examination, a 3cm, erythematous, and well-enclosed subcutaneous abscess is identified. The abscess is incised, drained, and a sample is sent for culture and sensitivity. The patient is also started on an antibiotic. Culture returns one week later revealing penicillinase-positive Staphylococcus aureus.
This antibiotic would NOT be effective for the patient
(A) Bacitracin
(B) Oxacillin
(C) Ticarcillin
(D) Vancomycin
(E) Methicillin

Back 54

The correct answer is C. Ticarcillin is an extended-spectrum penicillin, like ampicillin, amoxicillin, carbenicillin, azlocillin, and piperacillin. These drugs are susceptible to penicillinase-producing, or B-lactamase-positive bacteria. Methicillin (E) and Oxacillin (B) are penicillinase-resistant penicillin derivatives. Others in this class include cloxacillin, dicloxacillin, and nafcillin. Vancomycin (D) and bacitracin (A) are also not affected by B-lactamase as they differ structurally from the penicillin family. Vancomycin is the drug of choice for Methicillin-resistant S. aures (MRSA).

Front 55

A 35-year-old male presents with epigastric pain for the past 4-months. The pain tends to be worse 2-3-hours after eating. There is a family history of peptic ulcer disease. Labs show elevated calcium and decreased phosphate.

Which of the following does he have the highest risk for?
(A) Chronic renal failure
(B) Tetany
(C) Cystic changes and fibrosis of bone
(D) Amyloidosis
(E) Malignancy

Back 55

The correct answer is C. This patient has peptic ulcer disease with primary hyperparathyroidism. He most likely has MEN I (characterized by the 3 P's = Pituitary, Pancreatic, and Parathyroid tumors). Increased serum PTH causes bone resorption and fibrosis leading to osteitis fibrosa cystica. Chronic renal failure is the most common cause of secondary hyperparathyroidism (which can also lead to osteitis fibrosa cystica) but is not caused by hypercalcemia (A). Tetany is caused by hypocalcemia (B). Amyloidosis may result from multiple myeloma which also presents with hypercalcemia but doesn’t account for the peptic ulcer disease (D). The primary hyperparathyroidism is most likely caused by an adenoma, which is benign (E).

Front 56

A 35-year-old woman was diagnosed with rheumatoid arthritis 3-years ago. She has been taking naproxen for pain and joint flare-ups. X-ray shows evidence of mild joint destruction. Methotrexate is added to her treatment plan.

Which of the following is true concerning her treatment plan?
(A) Liver enzymes should tested regularly
(B) She should discontinue her contraceptive pills
(C) Naproxen slows the progress of joint destruction
(D) She is at increased risk for microcytic anemia
(E) Methotrexate interferes with tumor necrosis factor

Back 56

The correct answer is A. Methotrexate can be toxic to the liver thus liver function should be tested regularly. Methotrexate is contraindicated in pregnancy thus she should continue her contraceptive pills (B). Naproxen (an NSAID) treats the symptoms of inflammation but doesn’t slow the process of joint erosions (C). Disease modifying antirheumatic drugs (DMARDs), such as methotrexate, slows this progress. Methotrexate can interfere with folic acid reduction leading to megaloblastic anemia (D). The DMARDs that interfere with tumor necrosis factor are etanercept and infliximab (E).

Front 57

A 45-year-old female presents to the clinic with lethargy, weight gain, and cold intolerance. Physical exam shows slow deep tendon reflexes. She has a history of megaloblastic anemia and gastritis.

Which of the following additional findings is most likely?
(A) no change in TSH
(B) dry mouth and dental caries
(C) antibodies that bind to the TSH receptor
(D) diarrhea
(E) Helicobacter pylori infection

Back 57

The correct answer is B. This patient is presenting with signs and symptoms of hypothyroidism. She most likely has Hashimoto’s thyroiditis which has an autoimmune etiology. Her history suggests pernicious anemia, another autoimmune disease. Autoimmune diseases tend to occur together. Choice (B) describes Sjogren syndrome which is an autoimmune attack of the saliva glands. Primary hypothyroidism causes increased TSH (A). Choice (C) describes Graves disease, which is the most common cause of hyperthyroidism. Constipation, not diarrhea, is associated with hypothyroidism (D). Choice (E) suggests peptic ulcer disease which can also cause gastritis. The gastritis in this patient is accompanied by megaloblastic anemia thus the most likely cause is pernicious anemia due to autoantibodies against parietal cells.

Front 58

A 35-year-old female presents to the emergency department with a severe headache that come on suddenly. She complains of diplopia. Physical examination shows that the left eyeball has a down and outward gaze. The left pupil is dilated.

Aneurysm in which of the following arteries accounts for these findings?
(A) Left anterior cerebral artery
(B) Right anterior cerebral artery
(C) Left anterior communicating
(D) Left posterior communicating
(E) Left posterior cerebral

Back 58

The correct answer is D. A down and outward gaze with a dilated pupil describes a lesion that affects cranial nerve III. The posterior communicating artery is closest to this nerve thus an aneurysm can compress it. Aneurysms in the anterior cerebral arteries are common but usually do not manifest with nerve compression (A and B). There is only one anterior communicating artery, not a left and right (C).The posterior cerebral artery is not as close as the posterior communicating artery to cranial nerve III, thus it is less likely to compress it (E).

Front 59

You are a pediatrician called to a full term delivery. When the baby is brought to you, you notice skeletal deformities. On exam the patient is noted to have blue sclera. You get full body X-rays and note numerous fractures of the skull, long bones, and ribs. You also note on chest X-ray what appears to be pulmonary hypoplasia.
(A) Osteogenesis imperfecta Type 1
(B) Osteogenesis imperfecta Type 2
(C) Osteogenesis imperfecta Type 3
(D) Osteogenesis imperfecta Type 4
(E) Ehlers-Danos Syndrome

Back 59

The correct answer is B. Osteogenesis Type 2 is the most severe form, is often lethal, and has patients present with blue sclera, micrognathia, in utero fractures of the skull, long bones, and vertebrae. These patients have beaded ribs and the long bones are deformed. Causes of death usually include pulmonary hypoplasia or hemorrhages of the CNS. Type 1 (A) is the least severe form and is associated with up to 60 fractures over a persons lifetime. Fracture in type 1 appear to decrease as patients get older. Type 3 (C) is nearly as severe as type 2, but is not associated with pulmonary hypoplasia or hemorrhaging. Type 4 (D) is undefined, and most clinical aspects have not been determined. Ehlers-Danlos (E) is a collagen disorder which is not associated with increased fractures.

Front 60

You are a pediatrician called to a full term delivery. When the baby is brought to you, you notice many skeletal deformities and what appears to be many fractures throughout the body. On exam the patient is noted to have blue sclera. You get full body X-rays and note numerous fractures of the skull, long bones, and ribs. You also note on chest X-ray what appears to be pulmonary hypoplasia.
Inheritance Pattern?
(A) Autosomal recessive
(B) X-linked recessive
(C) X-linked dominant
(D) Autosomal dominant
(E) Mitochondrial

Back 60

The correct answer is D. Osteogenesis Imperfecta is primarily an autosomal dominant disease, but many new cases are a new dominant mutation.

Front 61

A 28-year-old woman at 26-weeks gestation presents to her obstetrician for a routine check-up. A glucose tolerance test was positive, suggesting gestational diabetes. Her blood pressure is 120/80 mm Hg. Physical examination is unremarkable except for edema of the ankles and feet.

Which of the following is most likely true concerning her hormonal status?
(A) hCG is at its peak
(B) Human placental lactogen is elevated
(C) Estrone is the most dominant estrogen
(D) The fetal adrenal gland contributes to estradiol synthesis
(E) The corpus luteum secretes estrogen and progesterone

Back 61

The correct answer is B. Human placental lactogen (hPL) is most elevated during the 3rd trimester. It has metabolic actions similar to growth hormone. It increases maternal lipolysis and ketogenesis. It decreases the utilization of glucose which may lead to glucose intolerance or gestational diabetes. hCG peaks at 10-weeks and then declines after the placenta takes over as the main secretor of progesterone and estrogen (A). The purpose of hCG is to maintain the corpus luteum for progesterone and estrogen secretion in early pregnancy before the placenta takes over. In the 3rd trimester the corpus luteum is no longer functioning (E). Estriol is the dominant estrogen of late pregnancy (C) and it requires contributions from the fetal adrenal gland and liver for synthesis (D). Thus estriol can be used as an index for fetal well-being.

Front 62

A 45-year-old mother and her 10-year-old daughter are brought to the emergency department after a motor vehicle accident. The emergency and surgical physicians concluded that both patients need immediate life-saving surgery and a blood transfusion. The mother refuses the treatment for both her and her daughter on religious grounds.

Which of the following is the next best step?
(A) Don't treat the mother and get a court order to treat the child
(B) Refer both patients to another hospital
(C) Get a court order to treat both patients
(D) Consult the child's father for permission to treat the child
(E) Don't treat the mother but do treat the child

Back 62

Bottom line: Competent adults have the right to refuse life-saving treatment for themselves but not their children.

Front 63

A 60-year-male worked in a shipyard for 25-years. He now, 20-years later, presents with dyspnea and cough. Chest X-ray is shown in the exhibit below:

Which of the following statements is most likely true?
(A) Smoking increases his risk of malignant mesothelioma
(B) Lung biopsy will show diffuse alveolar damage
(C) Lung biopsy will stain positive with Prussian blue
(D) He has an increased risk of developing tuberculosis
(E) He likely has distant metastases

Back 63

The correct answer is C. This patient has asbestosis caused by inhaling asbestos fibers. Symptoms typically take years to develop. Lung biopsy typically shows ferruginous bodies which arise from iron and protein coating the inhaled fibers. Due to the iron coating, these bodies stain positive with Prussian blue. Smoking increases his risk of bronchogenic cancer, not malignant mesothelioma (A). Diffuse alveolar damage is associated with respiratory distress syndrome (B). Exposure to silica dust increases the risk of developing tuberculosis (D). Chest X-ray shows the pleural plaques typical of asbestosis. These are not associated with malignancy (E).

Front 64

10-year-old boy presented with anemia, bone pain and a high frequency of infections. He was diagnosed with acute lymphocytic anemia. After 2-weeks of therapy he is started on allopurinol because his uric acid levels were high.

The dosage of which of the following drugs will most likely need to be adjusted
(A) Methotrexate
(B) Cyclophosphamide
(C) Cisplatin
(D) Fluorouracil
(E) 6-mercaptopurine

Back 64

The correct answer is E. Allopurinol, a drug that prevents the breakdown of purines to uric acid, is sometimes used to control uric acid levels in chemotherapy patients. Allopurinol inhibits the enzyme xanthine oxidase which is involved in the metabolism mercaptopurines thus greatly increases their toxicity. The dosage may need to be lowered by as much as 75%! Allopurinol doesn’t interact with methotrexate (A), cisplatin (C) or fluorouracil (D). Allopurinol may interfere with the metabolism of cyclophosphamide but not nearly as much as mercaptopurines (E).

Front 65

A 55-year-old woman presents to the clinic with shortness of breath and exercise intolerance. She has a history of uncontrolled hypertension and two myocardial infarctions. Physical examination shows 2+ pitting edema in the lower extremities and distended neck veins. Lung examination reveals crackles and rales.

She is given digoxin to improve her symptoms. Which of the following is true concerning this drug?
(A) Hyperkalemia can increase its toxicity
(B) Increases signal conduction through the AV node
(C) Has drug interactions with lidocaine
(D) Hypercalcemia increases its toxicity
(E) It binds to calcium channels in the sarcoplasmic reticulum

Back 65

The correct answer is D. Digoxin increases intracellular calcium leading to increased contractility. Hypercalcemia can cause an even greater inotropic effect thus increasing its toxicity. Hypokalemia increases digoxin toxicity (A). Digoxin mimics the parasympathetics by slowing down the signal through the AV node which could lead to an AV block (B). Digoxin toxicity is increased by quinidine (not lidocaine) because quinidine decreases its renal clearance (C). Digoxin binds to the Na+/K+ pump which drives more calcium into cell through the Na+/Ca++ exchanger (E).

Front 66

A 55-year-old male presents to the hospital after losing his footing on the rung of his ladder, and lands on his feet with his back hyper-extended. The patient reports developing symptoms in his legs immediately after the fall, and a CT scan shows vertebral bony fragments compressing the anterior spinal artery.

The most likely physical examination finding for this patient would be
(A) Increased deep tendon reflexes and upgoing toes on Babinski testing bilaterally, with normal pinpoint discrimination and pain sensation
(B) Strength intact bilaterally, but impaired pain and temperature sensation
(C) Paraplegia of the legs, loss of temperature and pain sensation bilaterally, with intact pinpoint and vibratory discrimination
(D) Flaccid paralysis and impaired pinpoint sensation of the left leg, with retained motor strength and impaired pain sensation of the right leg
(E) Decreased deep tendon reflexes and upgoing toes on Babinski testing bilaterally, with impaired pinpoint discrimination

Back 66

Bottom line: Anterior cord syndrome leads to ischemia of the supplying anterior 2/3 of the cord, presenting with bilateral motor and temperature/pain sensory deficits, with intact pinpoint and vibratory sensation due to the preserved dorsal DCML pathways.

Front 67

A 3-day old premature male presents with jaundice. This was the first pregnancy for his 30-year-old Rh- mother. His eyes, neck and trunk are affected. He is in no acute distress. He is given phototherapy and returns to normal after 3-days.

Which of the following best explains the pathogenesis
(A) Low activity of glucuronyl transferase
(B) Genetic mutation resulting in absence of glucuronyl transferase
(C) Maternal antibodies cause hemolysis
(D) Biliarty atresia
(E) Defect in bilirubin excretion

Back 67

The correct answer is A. The most likely diagnosis is physiological jaundice. This is common in premature infants because their liver isn’t mature enough to provide adequate glucuronyl transferase to conjugate bilirubin. Choice (B) describes Crigler-Najjar syndrome which is fatal due to accumulation of unconjugated bilirubin in the brain (kernicterus). Choice (C) describes hemolytic disease of the newborn. Infants with this disease are in acute distress. Furthermore it usually happens after the first child because the mother’s immune system needs to be exposed to the Rh antigen before there is an immune reaction. In biliary atresia conjugated bilirubin accumulates thus light therapy is not useful (D). Defect in biliary excretion describes Dubin-Johnson and Rotor syndromes in which conjugated bilirubin accumulates, thus light therapy is not helpful (E).

Front 68

A 53-year-old man complains of a unilateral, periorbital headache that came on suddenly. Physical examination reveals a contricted right pupil and dry, flushed facial skin on the right.

In which of the following foramina can the nerve(s) responsible for his symptoms be found?
(A) Jugular foramen
(B) Superior orbital fissure
(C) Internal auditory meatus
(D) Foramen spinosum
(E) Carotid canal

Back 68

The correct answer is E. This patient is presenting with a right-sided Horner's syndrome. This syndrome is characterized by miosis (constricted pupil), anhydrosis (lack of sweating) and ptosis (eyelid drooping). It is caused by damage to the sympathetic nerves descending from the hypothalamus. These nerves travel with internal carotid artery which enters the cranium through the carotid canal. The jugular foramen is associated with cranial nerves IX, X and XI (A). Choice (B) is associated with cranial nerves III, IV, VI and the ophthalmic branch of V (V1). Choice (C) is associated with cranial nerves VII and VIII. Choice (D) is associated with the middle meningeal artery, famous for traumatic rupturing and causing an epidural hematoma.

Front 69

A 35-year-old male actor presents for HIV monitoring. He has a runny nose, but he denies any other symptoms. His CD4 count is 186/uL, and he is referred to the HIV Clinic to begin Highly Active Antiretroviral Therapy (HAART).

This medication works by inhibiting reverse transcriptase but does NOT incorporates itself into viral DNA
(A) Zidovudine
(B) Nelfinavir
(C) Saquinavir
(D) Acyclovir
(E) Efavirenz

Back 69

The correct answer is E. Efavirenz is a non-nucleoside reverse transcriptase inhibitor (NNRTI) used as part of HAART. It does not incorporate itself into viral DNA. Zidovudine (A), also known as Azidothymidine (AZT), is a nucleoside reverse transcriptase inhibitor (NRTI). It can incorporate itself into the growing DNA chain synthesized by viral reverse transcriptase thus causing chain termination. This inhibits viral replication. Nelfinavir (B) and Saquinavir (C) are protease inhibitors. Acyclovir (D) is used as an antiviral for the herpesvirus. It inhibits DNA polymerase.

Front 70

A 55-year-old male is brought to the emergency department following a shooting where he suffered multiple gun shot wounds to the abdomen. Several hours later, the state police show up requesting access to the patient’s chart.

The correct response is to
(A) Relinquish the chart to them
(B) Refuse to relinquish the chart to them since the patient has not signed a written release
(C) Go through the chart and events with them
(D) Make sure they sign a release before gaining access to the chart
(E) Have the secretary make duplicate copies of the relevant information they need from the chart

Back 70

Police and other governmental agencies are also prohibited from viewing a patient’s medical information under the Health Insurance Portability and Accountability Act (HIPAA) unless the patient signs a release or a court order is obtained.

Front 71

A 12-year-old boy with kyphoscoliosis is taken to your office by his mother because he has been falling over while walking, stumbling and has a staggering gait. The boy has nystagmus and his toes look like they have been “hammered in.” The trinucleotide repeat associated with this disease is
(A) CAG
(B) CGG
(C) CTG
(D) GAA
(E) GGA

Back 71

The correct answer is D. This boy has Friedreich ataxia. This is an autosomal recessive disorder due to the trinucleotide repeat of GAA. This encodes the frataxin gene and causes a defect in mitochondrial function. It usually presents with stumbling, staggering and falling with childhood kyphoscoliosis. Hammer toes are a characteristic finding, along with pes cavus, dysarthria and nystagmus. Huntington Disease is CAG repeat. Fragile X Syndrome is a CGG repeat. Myotonic dystrophy is a CTG repeat. GGA repeat is not associated with any known diseases.

Front 72

A 24-year-old female arrives at the emergency department complaining of nausea, vomiting, and intense right lower quadrant abdominal pain for the last three days. Her last menstrual period was six weeks ago. Transvaginal ultrasound reveals no intrauterine gestational sac. An ectopic pregnancy is suspected.

Where is the embryo most likely implanted?
(A) Isthmus of the oviduct
(B) Ampulla of the oviduct
(C) Right ovary
(D) Cervix
(E) Rectouterine pouch

Back 72

The correct answer is B. The most common location for an ectopic pregnancy is the ampulla of the oviduct (fallopian tube). This is also the most common location for fertilization. The other choices are all possible, but less likely.

Front 73

A 24-year-old female arrives at the emergency department complaining of nausea, vomiting, and intense right lower quadrant abdominal pain for the last three days. Her last menstrual period was six weeks ago. Transvaginal ultrasound reveals no intrauterine gestational sac. An ectopic pregnancy is suspected.
Methotrexate does?
(A) A folate analogue
(B) Inhibition of the metabolism of folic acid
(C) Inhibition of thymidylate synthetase
(D) Inhibition of reverse transcriptase
(E) Inhibition of prostaglandin production

Back 73

Bottom line: Methotrexate inhibits dihydrofolate reductase and is used as a first-line treatment in small nonruptured ectopic pregnancies.

Front 74

A 45-year-old female with a 20-year history of rheumatoid arthritis presents with generalized edema and hyperlipidemia. She takes naproxen for arthritis pain. A 24 hour urine analysis shows 4.5 grams of protein excreted.

A kidney biopsy will most likely show
(A) Subepithelial immune complex deposits
(B) Papillary necrosis
(C) IgA deposits in the mesangium
(D) Kimmelstiel-Wilson nodules
(E) Positive Congo red staining

Back 74

The correct answer is E. This patient, with a history of chronic inflammation, is presenting with nephrotic syndrome (edema, hyperlipdemia, hypoalbuminemia and massive proteinuria). The most likely diagnosis is renal amyloidosis. Amyloid stains positive with Congo red. Choice (A) describes membranous glomerulonephritis, the most cause of primary nephrotic syndrome in adults, which is not associated with chronic inflammation. Papillary necrosis can result from chronic analgesic use but doesn’t manifest as nephrotic syndrome (B). Choice (C) describes Berger disease which presents with recurrent hematuria and is common in children after a viral infection. Furthermore this usually presents with nephritic syndrome (hematuria, hypertension and proteinuria of less than 3.5 g/day). Choice (D) is the classic finding in diabetic nephropathy which includes nodular accumulations in the mesangium.

Front 75

A 30-year-old woman has been taking phenytoin for general tonic-clonic seizures. She complains of drowsiness, loss of balance and facial hair growth. She is switched to valproic acid.

Which of the following is true concerning her new drug
(A) It may cause hyponatremia
(B) It can also be used for bipolar disorder
(C) It induces P450 enzymes
(D) It is known to cause Steven-Johnson syndrome
(E) It can be nephrotoxic

Back 75

The correct answer is B. Valproic acid is a drug of choice for general tonic-clonic seizures. It is also useful for bipolar disorder. Hyponatremia results from the syndrome of inappropriate ADH secretion which is a possible side-effect of carbamazepine (A). Valproic acid inhibits P450 enzymes (C). Lamotrigine, an alternative drug for partial seizures can cause Steven-Johnson syndrome (D). Side-effects of valproic acid include hepatotoxicity and GI distress (E).

Front 76

After a stroke, a 50-year-old man with chronic hypertension has a speech problem. He can understand what is said to him and gets frustrated that he cannot communicate back. His speech is non-fluent and he cannot say a complete sentence. Physical examination shows weakness in the right face and right upper limb.

Which of the following arteries and associated lobe was involved in his stroke?
(A) Right anterior cerebral artery, frontal lobe
(B) Right middle cerebral artery, parietal lobe
(C) Left middle cerebral artery, temporal lobe
(D) Left middle cerebral artery, frontal lobe
(E) Right middle cerebral artery, frontal lobe

Back 76

Occlusion of the left MCA manifests as aphasia. Broca's aphasia has non-fluent speech but good understanding and involves the left frontal lobe. Wernicke’s aphasia has fluent speech but lack of understanding and involves the left temporal lobe.

Front 77

Question Identifier: L1_PEDS19J

A full term male infant is born without complication. Upon secondary exam you notice what appears to be a complete ventral defect of the urogenital sinus and the overlying inferior abdominal wall musculature (bladder exstrophy).

Which of the following best describes the associated urogenital abnormality?
(A) Abnormal ventral opening of the penile urethra
(B) Abnormal dorsal opening of the penile urethra
(C) Abnormal ventral opening of the membranous urethra
(D) Abnormal dorsal opening of the membranous urethra
(E) Incomplete development of the foreskin

Back 77

The correct answer is B. Choice (B) describes epispadias, which is associated with exstrophy of the bladder. Choice (A) describes hypospadias, which is more common than epispadias but not associated with bladder exstrophy. If hypospadias is not repaired it can lead to recurrent urinary tract infections. Defects in the membranous urethra are not common and not associated with bladder exstrophy (C and D). Choice (E) is a description of the normal variant called a chordee.

Front 78

A previously healthy 21-year-old college student presents with malaise, headache, and muscle pain for the past 5-days. His temperature is 38.2 C (100.8 F). He admits to a non-productive cough and sore throat. Chest X-ray shows extensive diffuse infiltrates. Laboratory findings show elevated white blood cells and a high recticulocyte index.
Which of the following is true about the most likely organism?
(A) It is gram-positive
(B) It is an obligate intracellular bacteria
(C) Membrane has a lipid content higher than most bacteria
(D) Antibodies against red blood cells are produced during infection
(E) Splenomegaly is common during infection

Back 78

Mycoplasma pneumoniae causes atypical community acquired pneumonia in otherwise healthy people. Auto-antibodies against red blood cells may be produced during infection. These can cause cold agglutinins and autoimmune hemolytic anemia.

Front 79

A 70-year-old female with a history of uterine fibroids reports to your office complaining of increasing abdominal pain. Her gynecologist suggests a hysterectomy. During the operation the uterine artery is ligated.
The uterine artery is located within the
(A) Uterosacral ligament
(B) Fallopian tube
(C) Suspensory ovarian ligament
(D) Round ligament
(E) Broad ligament

Back 79

The correct answer is E. Within the broad ligament lies both the uterine artery and the ovarian artery. The round ligament (D) has Sampson’s artery running under it. The suspensory ovarian ligament (C) is incorrect because it contains the ovarian arteries and veins. The fallopian tube (B) is incorrect because it is the hollow connection between the ovary and uterus that allows fertilization. The uterosacral ligament (A) is a fibrous structure that does not contain any vascular structures.

Front 80

A 27-year-old male is mountain biking when he begins to complain of headache, nausea, shortness of breath, and swollen hands. His blood pressure is 120/80 mm Hg, heart rate is 87/min, and his respiratory rate is 21/min.

The following is true of this condition
(A) It is worse in individuals who live at low altitudes
(B) It is relieved by faster ascent
(C) It can be prevented with excessive overhydration
(D) It has no life-threatening complications
(E) It is improved with alcohol consumption

Back 80

The correct answer is A. Acute mountain sickness (AMS) is the most common altitude disease, occurring in up to 50% of individuals who ascend to 14,000 feet (4250 meters), with most cases occurring in "lowland" individuals who live at <3,000 feet. Slow, not fast, ascent (B) is the best way to avoid AMS. Above 8,000 feet, it is recommended that climbers ascend no more than 1000 feet/day. While adequate hydration is also recommended, excessive overhydration (C) can lead to hyponatremia, which will only exacerbate the symptoms and the likelihood of progression to possible life-threatening consequences (D): high altitude pulmonary edema, high altitude cerebral edema, high altitude retinal hemorrhage, and chronic mountain sickness. Alcohol (E) has the opposite effect of adequate hydration; its diuretic effects tend to dehydrate, and avoidance is recommended during and preceding the first 24 hours at a higher altitude.

Front 81

A new test for the detection of prostate cancer is being studied. It is positive in 90% of the men with prostate cancer and negative in 70% of the men without prostate cancer. The prevalence of prostate cancer in the population studied is 300 out of 1000.
A patient receives a positive test. The likelihood that he has prostate cancer is
(A) 270/300
(B) 490/700
(C) 270/480
(D) 490/520
(E) cannot be determined

Back 81

The correct answer is C. The likelihood that a patient with a positive test result has the disease is the positive predictive value. This is obtained by dividing the number of true positives by the total number of positive tests. The number of true positives is 270 (90% of 300). The number of false positives is 210 (30% of 700). Thus the positive predictive value is 270/(270 +210) = 270/480. 270300 is the sensitivity which is the number of true positives divided by the total number of people who have the disease. 490/700 is the specificity which is the number of true negatives (70% of 700) divided by the total number of people without disease. 490/520 is the negative predictive value which is the number of true negatives (70% of 700) divided by the total number of negative tests (70% of 700 + 10% of 300, where 10% of 300 is the number of false negatives).

Front 82

A 55-year-old man suffered a stroke two weeks ago. He has a history of hypertension and hypercholesterolemia. He is being treated with lovastatin. Lovastatin works by
(A) decreasing the absorption of dietary cholesterol
(B) interfering with triglyceride biosynthesis
(C) inhibiting the enzyme that metabolizes mevalonate
(D) inhibiting lipoprotein lipase
(E) up-regulating LDL receptor expression

Back 82

The correct answer is E. Lovastatin inhibits HMG-Coa reductase, the rate-limiting step in intra-hepatic cholesterol synthesis. This lowers intracellular cholesterol thus stimulating LDL receptor expression to pick up more cholesterol from the periphery. This is how lovastatin helps clear cholesterol from the blood. Ezetimibe interferes with the absorption of dietary cholesterol. Lovastatin interferes with cholesterol biosynthesis, not triglycerides. Mevalonate is the product of HMG-Coa reductase thus lovastatin inhibits the enzyme that produces it. Lipoprotein lipase hydrolyzes lipids from chylomicrons and VLDLs. Inhibiting lipoprotein lipase would increase plasma triglycerides.

Front 83

A 32-year-old woman complains of cramping abdominal pain related to meals. She has noticed that her stools are large, sticky, and float. A screening test revealed antigliadin antibodies.

Which of the following additional findings is most likely?
(A) History of chronic constipation
(B) History of meconium ileus
(C) Symptoms resolve after she stops consuming dairy
(D) Chronic Pancreatitis
(E) Hashimoto thyroiditis

Back 83

The correct answer is E. The diagnosis is celiac disease. Celiac disease is an autoimmunune disease where autoantibodies to gluten (gliadin) are produced causing malabsorption and steatorrhea when the patient consumes wheat products or grains. Autoimmune diseases commonly occur together thus many patients also have Hashimoto thyroiditis (an autoimmune attack on the thyroid). Constipation is not associated with celiac sprue (A). Choice (B) is associated with cystic fibrosis which can also cause a malabsorption syndrome but is not associated with autoantibodies. Choice (C) describes lactose intolerance. Chronic pancreatitis may result in malabsorption due to the loss of pancreatic enzymes but it is not associated with autoantibodies (D).

Front 84

A patient with a tumor in close proximity to the thalamus begins noticing distortion of sounds and increasing difficulty hearing.

What region of the thalamus is most likely affected?
(A) Medial geniculate nucleus
(B) Lateral geniculate nucleus
(C) Lateral part of the ventral posterior nucleus
(D) Medial part of the ventral posterior nucleus
(E) Ventral anterior nucleus

Back 84

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Question Identifier: L1_NEUR23BJ

A patient with a tumor in close proximity to the thalamus begins noticing distortion of sounds and increasing difficulty hearing.

What region of the thalamus is most likely affected?

(A) Medial geniculate nucleus
(B) Lateral geniculate nucleus
(C) Lateral part of the ventral posterior nucleus
(D) Medial part of the ventral posterior nucleus
(E) Ventral anterior nucleus
The current percentage of users that have answered this question correctly is 71%.
Question Explanation:

The correct answer is A. The thalamus is a major relay center that functions to direct ascending sensory and some motor information to the appropriate areas of the cerebral cortex. A patient with a thalamic tumor presenting with auditory dysfunction most likely has a lesion in the medial geniculate nucleus (A). The medial geniculate nucleus receives auditory input and directs the information to the auditory cortex of the temporal lobe. The lateral geniculate nucleus (B) receives visual input and sends information to the visual cortex of the occipital lobe. The lateral part of the ventral posterior nucleus (C) is not involved in auditory sensation, but functions in body sensation such as touch, pressure, vibration, and pain that is directed from the dorsal columns of the spinal cord. Additionally, facial sensation is supplied by the trigeminal nerve and relays this information to the medial part of the ventral posterior nucleus (D). The ventral anterior nucleus (E) is involved in motor signals mostly from the basal ganglia and cerebellum and distributes them to the motor cortex of the frontal lobe.

Front 85

A 55-year-old diabetic woman presents to the clinic with complaints of headache and weight gain. Her blood pressure is 150/90 mm Hg. Urinalysis is positive for albumin. She is given losartan.

Which of the following is blocked by this drug?
(A) Vasodilation
(B) Aldosterone secretion
(C) ADH receptors
(D) Renin activity
(E) Bradykinin activity

Back 85

The correct answer is B. Losartan is an angiotensin II receptor blocker used in hypertension. Angiotensin II has two main activities: vasoconstriction and stimulation of aldosterone secretion. Thus blocking these receptors will decrease aldosterone secretion. Losartan prevents vasoconstriction (A). Losartan blocks angiotensin II receptors (C). Losartan decreases blood pressure and water and sodium retention. These effects may stimulate renin activity (D). ACE-inhibitors increase bradykinin (which is thought to be the cause of the angioedema and cough adverse effects). Angiotensin II blockers have little effect on bradykinin (E).

Front 86

A 55-year-old diabetic woman presents to the clinic with complaints of headache and weight gain. Her blood pressure is 150/90 mm Hg. Urinalysis is positive for albumin. She is given losartan.
Which of the following is a contraindication for this drug?
(A) Asthma
(B) Cough
(C) Hepatitis
(D) Glomerulonephritis
(E) Pregnancy

Back 86

The correct answer is E. Losartan is an angiotensin II receptor blocker used in hypertension. It is contraindicated in pregnancy because it can cause damage to the fetal kidney. Beta-blockers, another antihypertensive, are contraindicated in asthma because they block bronchodilation (A). ACE-inhibitors, not losartan, may cause cough but neither of these drugs are contraindicated due to cough (B). Losartan has no significant adverse effects on the liver (C). Losartan may cause renal failure in people with renal artery stenosis but glomerulonephritis is not associated with this (D).

Front 87

A 45-year-old male presents with nausea, fatigue, edema, hypertension, and hematuria. A 24-hour urine analysis shows 4.5 grams of protein secreted. Lab results show a BUN/creatinine ratio of 10. Electron microscopy of the kidney shows extension of a mesangial cell splitting the basement membrane.

Which of the following is most likely to be found?
(A) Elevated C3 levels
(B) Normal glomeruli on light microscopy
(C) IgA deposits in the mesangium
(D) Mesangial proliferation on light microscopy
(E) Red blood cell casts

Back 87

The correct answer is D. This patient presents with intrinsic renal failure (BUN/creatinine less than 20) with a mixture of nephrotic (edema and massive proteinuria) and nephritic (hypertension and hematuria) syndromes. The electron microscope description is classic for membranoproliferative glomerulonephritis (MPGN). In this disease light microscope shows cellular proliferation in the mesangium. MPGN is associated with low C3 levels (A). Choice (B) is associated with minimal change disease, the most common cause of nephrotic syndrome in children. Choice (C) describes Berger disease which commonly presents as hematuria following a viral respiratory infection. Red blood cell casts are associated with nephritic syndrome, most commonly poststreptococcal glomerulonephritis (E).

Front 88

When performing a well child check you notice that the child can perform the following tasks: the child is able to sit with some support, she has begun to jabber and make significant sounds, and she has started to feed herself appropriate finger foods.

What is an approximate age of this child?
(A) 2 months
(B) 4 months
(C) 6 months
(D) 9 months
(E) These observations are inappropriate; the child has a verbal delay

Back 88

1M – lift head, look to faces

2M – smile responsively, follow object past midline

4M – grasp objects, laugh and squeal responsively, roll over, begin to eat soft foods

6M – sit up alone, jabber, feed self

9M – sit alone and begin to pull to stand and crawl

12M – wave, have 2 words, use cup, few steps

15M – walking, scribbling, 6 words, backward walking 2 cube tower

18M – use utensils for food, stack 4 cubes, combine words

24M – remove clothing, stack 6 cubes, kick ball, jump up

3yrs - ride tricycle, understandable, copy circle, dresses self

4 yrs -- hop on 1 foot, copy X and make stick figure, button friend, imaginery friend

5 yrs --> identify colors, coins, ties shoes, copy triangle,

Front 89

A 22-year-old male is admitted to the ICU after suffering a massive head injury from a motorcycle accident. He meets criteria for brain death on all levels. There is a stamp on his driver’s license reading “organ donor.” When approached, however, the family refuses to sign a consent approving the organ donation.

The most appropriate course of action is to
(A) Proceed with harvesting organs
(B) Consult the hospital ethics committee to persuade the family
(C) Approach the family yourself to discuss the issue
(D) Do not harvest organs for donation as per the family’s request
(E) Ask the patient’s nurse to approach the family to discuss the issue

Back 89

The correct answer is D. In the United States, persons have the right to declare themselves as an organ donor when applying for a driver’s license. Despite one’s personal wishes, the family (medical power of attorney) must sign a consent presented by the organ-donor network approving the harvest of organs. In an ideal world, family members would fully honor the wishes of the patient, but this is sometimes not the case. In the event that the family does not approve of the donation, the hospital is forced to honor their wishes and not proceed with the harvest. No attempts should be made by the physician (C) or any other member of the medical team (E) to change their minds. It would also not be appropriate for the hospital ethics committee to attempt to persuade the family (B). The worst thing you could do in this situation from a medical-legal standpoint is to disregard the family’s wishes and proceed with the organ harvest (A).

Front 90

An epidemiologist performed a case-control study to determine the risk for cervical cancer associated with a history of sexual promiscuity. The results measured an odds ratio of 0.98 with a p-value of 0.06. It was later revealed that a type II (beta) error occurred. This error could have been prevented by
(A) a meta-analysis
(B) decreasing study size
(C) better matching among study groups
(D) a control group that better represents the general population
(E) a chi-square test

Back 90

The correct answer is A. A type II error occurs if the null hypothesis is not rejected even though it is false. It occurs when the study did not detect a difference when one truly existed. The ability of a study to detect a difference among study groups is called statistical power, thus a type II error occurs when there is low statistical power. A meta-analysis combines the data from many studies and greatly increases statistical power. Increasing study size increases statistical power. Better matching among study groups helps prevent confounding bias but does not increase power. A control group that better represents the general population helps prevent selection bias. A chi-square analysis is appropriate for this data (nominal, categorical) but it will not change the statistical significance, thus it cannot prevent a type II error.

Front 91

A patient presents to the clinic after involvement in a motor vehicle accident. Osteopathic examination reveals that T6 is flexed, rotated right, sidebent right (FRrSr). You decide to use HVLA to treat the dysfunction.

Which of the following best describes the location of the transverse process of T6?
(A) Same level as the spinous process of T6
(B) ½ segment inferior to the spinous process of T6
(C) ½ segment superior to the spinous process of T6
(D) 1 segment superior to the spinous process of T6
(E) Same level as the spinous process of T7

Back 91

Rule of threes: A method to locate the spinous process (SP) in relation to transverse processes (TP) in the thoracic vertebra. The rules are as follows:

• T1-T3, SP at the same level as the corresponding TP
• T4-T6, SP is one-half vertebral level below the corresponding TP
• T7-T9, SP is one full vertebral level below the corresponding TP
• T10 follows the rules of T7-T9
• T11 follows the rules of T4-T6
• T12, follows the rules of T1-T3