1.

Closure of the pulmonic valve occurs when the pressure in the pulmonary artery
exceeds that in the
A) coronary sinus
B) left atrium
C) pulmonary veins
D) right atrium
E) right ventricle
E
2. What is the principal site of therapeutic action of aspirin in the diagram of a blood
vessel?
G
3. A 23-year-old woman has prolonged episodes of wheezing, dyspnea, and anxiety that
are relieved by -adrenergic agonists. The major mediator of her condition is
A) bradykinin
B) eosinophil chemotactic factors
C) leukotrienes
D) prostaglandin E
E) thromboxane
C
4. Cerebrospinal fluid leaving the ventricular system through the median aperture (of
Magendie) collects in which labeled space in the sagittal MRI of the head?
G
5. A 53-year-old obese woman who has hypertension is brought to the emergency
department after collapsing. Prior to admission, she had severe excruciating stabbing-
like chest pain radiating to her left shoulder. She is anxious and in severe pain. Pulse is
110/min, and blood pressure is 160/80 mm Hg. On auscultation, heart sounds are
distant; pulsus paradoxus is present. ECG shows low voltage and ST-T wave
changes. An x-ray film of the chest shows widening of the mediastinum. The most
likely diagnosis is
A) aortic dissection with cardiac tamponade
B) hypertensive crisis
C) massive pulmonary thromboembolism
D) myocardial infarct with congestive failure
E) rupture of the papillary muscle
A
6. A 6-year-old boy says his left ear hurts. His mother says that he has been tugging the
ear. The external canal and tympanic membrane appear normal, but the tympanic
membrane does not move when the pressure in the nasopharynx is increased. Which
of the following is the most likely cause of these findings?
A) Auditory tube obstruction
B) Cholesteatoma
 C) Otitis externa
D) Purulent otitis media
E) Serous otitis media
A
7. A 7-month-old female infant is brought to the physician's office after having a tonic-
clonic seizure. Findings include ataxia, hypotonia, hearing loss, hair loss, and a rash.
Laboratory studies show normal plasma amino acid concentrations but abnormal
urinary organic acid concentrations consistent with multiple carboxylase deficiency.
The administration of which of the following is the most appropriate treatment of this
patient?
A) Biotin
B) Vitamin B2 (riboflavin)
C) Vitamin B6 (pyridoxine)
D) Vitamin B12 (cyanocobalamin)
E) Vitamin C
A Biotin involved in carboxylation rxns
8. A 54-year-old woman with type 2 diabetes mellitus well controlled with oral
hypoglycemic agents comes to the physician because of a 2-week history of swelling
in her left knee. She tells the physician that her knee is very stiff when she awakens in
the morning and at bedtime. The pain and stiffness worsen with exertion. Low-dose
ibuprofen results in incomplete relief. Which of the following best explains why a
larger dose of ibuprofen is more appropriate?
A) The anti-inflammatory dose is nearly twice the analgesic dose
B) The drug is excreted at a fast rate because of renal complications of diabetes
mellitus
C) Increasing the dose extends the half-life of the drug
D) Menopausal women metabolize the drug at a faster rate than premenopausal
women
E) Oral hypoglycemic agents interfere with protein binding of ibuprofen
A
9. A 42-year-old woman has a 3-month history of an intermittent reddish-brown
discharge from the nipple of her right breast. No masses are palpable in either breast.
There is no pain or tenderness. Which of the following is the most likely diagnosis?
A) Fibroadenoma
B) Fibrocystic disease
C) Intraductal papilloma
D) Lobular carcinoma
E) Mastitis
F) Traumatic fat necrosis
C
10. A 50-year-old woman has myalgias, nervousness, a pounding heart, difficulty falling
 asleep, and decreased appetite. She had a thyroidectomy 6 months ago and is taking
levothyroxine. Pulse is 120/min, and blood pressure is 140/70 mm Hg. Serum
thyroid-stimulating hormone concentration is 0.1 U/mL. Which of the following is
the most appropriate therapy?
A) Add diazepam to her regimen
B) Add fluoxetine to her regimen
C) Add imipramine to her regimen
D) Add verapamil to her regimen
E) Decrease the dose of levothyroxine
F) Increase the dose of levothyroxine
E
11. After several courses of treatment for non-Hodgkin's lymphoma, a 33-year-old man
develops gross hematuria. Which of the following drugs is most likely to be
responsible for this adverse effect?
A) Carmustine (BCNU)
B) Cyclophosphamide
C) Daunorubicin
D) Methotrexate
E) Vincristine
B
12. The prevalence of a disease is half as great in town A than it is in town B, but the
incidence of the disease is no different in town A than it is in town B. Which of the
following best explains these findings?
A) The case fatality rate is twice as high in town A
B) The duration of the disease is twice as long in town B
C) The number of new cases in town A is twice as many as those in town B
D) People in town A use medical care facilities half as often as those in town B
E) The proportion of asymptomatic cases is twice as much in town B than in town A
B
13. In patients with bronchial asthma, which of the following eosinophil products is most
likely to be responsible for damage to the epithelium?
A) Heparin
B) Leukotriene C4
C) Major basic protein
D) NADPH oxidase
E) Platelet activating factor
C
14. Which of the following best describes how Clostridium perfringens evades
destruction by neutrophils in patients with clostridial myonecrosis?
A) Damaging neutrophil membranes by means of a membrane-damaging toxin
 B) Preventing contact with neutrophils by means of a polysaccharide capsule
C) Preventing phagocytosis by disruption of neutrophil actin polymerization
D) Survival in the cytoplasm of a neutrophil
E) Survival in the phagosome of a macrophage
A
15. The initial vaccines against Haemophilus influenzae type B prepared with capsular
polysaccharides were not very effective in children less than 2 years old. Subsequent
vaccines have been greatly improved by the conjugation of the capsular
polysaccharides to one of several proteins. Why does this conjugation improve
immunogenicity?
A) CD4+ T lymphocytes are activated
B) Cytotoxic T lymphocyte responses are increased
C) Direct activation of B lymphocytes by the vaccine is increased
D) Nonimmune clearance of the vaccine is decreased
E) Phagocytosis of the vaccine is increased
A
16. An examiner strokes a wisp of cotton across a patient's left cornea. There is no
response. The examiner then strokes the cotton across the patient's right eye; both
eyes blink. The most likely explanation of these findings is damage to which of the
following cranial nerves on the left?
A) Optic
B) Oculomotor
C) Trigeminal
D) Abducens
E) Facial
C
17. During the second and third trimesters of pregnancy, women have increased levels of
circulating glucocorticoids but have few of the catabolic responses associated with
excess glucocorticoids. The most likely explanation of this finding is increased
A) autoantibodies to steroids
B) metabolic clearance of steroids
C) steroid-binding proteins
D) steroid receptors
E) steroid uptake mechanisms
C
18. A 37-year-old man develops a spiking fever in the intensive care unit after an
operation to control an abdominal hemorrhage. Evaluation does not show a focal
infection. Therapy with a broad-spectrum cephalosporin is initiated. After 3 days of
antibiotic therapy, the patient has abdominal pain and profuse watery diarrhea.
Examination of stool for ova and parasites is negative. Stool tests positive for
Clostridium difficile antigen. The most appropriate therapy is
 A) amphotericin
B) erythromycin
C) metronidazole
D) penicillin
E) trimethoprim-sulfamethoxazole
C
19. A 45-year-old man has a myocardial infarction. A coronary stent restores blood flow,
but reperfusion causes a paradoxical increase in damage. Which of the following is
the most likely mechanism of the new myocardial damage?
A) Direct poisoning of mitochondrial enzymes
B) Increase in lipid peroxidation of membranes
C) Inhibition of ATPase-dependent transport
D) Loss of intracellular amino acids
E) Prevention of cross-linking of labile amino acids
B
20. A previously healthy 2-year-old boy has a 1x2-cm mass at the midline of the neck
immediately above the larynx. The mass is not tender and moves when he
swallows. The mass is most likely to be
A) a branchial cleft cyst
B) lymphadenopathy
C) a submental abscess
D) a thyroglossal duct cyst
E) the thyroid gland
D
21. Tumor necrosis factor is the primary mediator of host responses initiated by
lipopolysaccharide (LPS) and leading to septic shock. LPS-mediated activation of
transcription most likely depends on which of the following transcription factors?
A) c-
ras
B) Nuclear factor-kappa B
C) p53
D) Rb protein
E) VP-16 (etoposide)
B
22. A mother reports that her 1-year-old male infant is less active. Weakness is
progressive. The mother says that even though her son is weak, his muscles appear
larger than before. The most likely diagnosis is
A) central core disease
B) Duchenne's muscular dystrophy
C) limb-girdle dystrophy
 D) myotonic dystrophy
E) nemaline myopathy
B
23. The graph shows an isovolumetric pressure-flow curve obtained at 25% of total lung
capacity. An increase in which of the following is most likely to increase the plateau
value of the expiratory flow rate?
A) Airway resistance
B) Amount of surfactant in the alveolar space
C) Ciliary beating frequency
D) Expiratory effort
E) Lung volume
F) Parasympathetic activity of fibers innervating the airways
E???
24. A 15-year-old girl has had a sore throat and temperatures to 37.7 C (100 F) for 3
days. Physical examination shows erythematous pharyngeal mucosa and cervical
lymphadenopathy. Leukocyte count is 12,000/mm3 with 60% lymphocytes. A slide
agglutination test is positive for antibodies against Epstein-Barr virus. This virus is
most likely to replicate initially in which of the following cells?
A) Peripheral blood B lymphocytes
B) Peripheral blood monocytes
C) Peripheral blood T lymphocytes
D) Pharyngeal B lymphocytes
E) Pharyngeal monocytes
F) Pharyngeal T lymphocytes
D
25. A 45-year-old man has frequent headaches, diffuse arthralgias and generalized
weakness, pain in both hands, pain in the temporomandibular joint that is worse on
chewing, and increasing shoe size. He has difficulty picking up small objects. Which
of the following is the most likely diagnosis?
A) Acromegaly
B) Cushing's disease
C) Hypothyroidism
D) Prolactinoma
E) Seminiferous tubule dysgenesis (Klinefelter's syndrome)
A
26. An 82-year-old woman has become increasingly disoriented over the past year. She
is pleasant and attempts to be cooperative. She performs poorly on a Mini-Mental
State Examination. Pulse is 80/min, and blood pressure is 160/90 mm Hg. MRI of the
head shows small lacunar lesions predominantly in the lenticulostriate arteries of the
internal capsules and in other widely disparate regions of both cerebral cortices.
Which of the following is the most likely explanation for these findings?
 A) Dementia, Alzheimer's type
B) Huntington's disease
C) Multi-infarct dementia
D) Multiple sclerosis
E) Parkinsonism
C
27. A 41-year-old woman remains hospitalized and in bed for 10 days because of
complications following a hysterectomy for uterine leiomyomas. On the tenth day,
she suddenly develops severe respiratory distress and collapses. She is resuscitated,
but dies 2 days later. A lung as seen at autopsy is shown. Which of the following is
the most likely diagnosis?
A) Bronchopneumonia
B) Interstitial pneumonia
C) Lung abscess
D) Pulmonary infarct
E) Pulmonary metastases
D
28. The diagram shows a liver lobule. Long-term destruction of the hepatocytes, collapse
of the histologic architecture, and production of fibrous material in the areas
indicated by the arrow is most likely to result in which of the following?
A) Decreased intestinal motility
B) Gallstones
C) Increased central venous pressure
D) Increased hepatic venous pressure
E) Increased portal pressure
E
29. The recombinant vaccine used to immunize against hepatitis B infections elicits
antibodies against which of the following viral proteins?
A) HBcAg
B) HBeAg
C) HBsAg
D) Polymerase
C
30. A 55-year-old man with diabetes mellitus has burning dysesthesias over the lateral
aspect of his left lower leg. Capsaicin-containing cream is effective in alleviating the
symptoms. The substance most likely to have caused the dysesthesias is
A) ADH (vasopressin)
B) angiotensin II
C) dopamine
 D) inositol
E) neuropeptide Y
F) nitric oxide
G) norepinephrine
H) substance P
H
31. A 2-day-old male neonate is transferred to the neonatal intensive care unit because of
tachypnea and intense cyanosis. There is a prominent lift and a soft, systolic murmur
is heard along the left sternal border. S1 is loud at the lower left sternum. X-ray film
of the chest shows a normal heart size and pulmonary vascular pattern.
Echocardiography shows the aorta lying anterior and to the right of the pulmonary
artery. Which of the following is the most likely diagnosis?
A) Aortic coarctation
B) Kartagener's syndrome
C) Patent ductus arteriosus
D) Transposition of the great vessels
E) Ventricular septal defect
D
32. A 42-year-old man begins drug therapy for hypertension. Three months later, he has
a chronic nonproductive cough. Findings on x-ray films of the chest are normal. He
is most likely taking which of the following antihypertensive drugs?
A) Enalapril
B) Hydrochlorothiazide
C) Prazosin
D) Propranolol
E) Verapamil
A
33. A 72-year-old woman comes to the physician because of an episode of acute
substernal chest pain that occurred while she was rushing to catch a bus. She has
basilar crackles at both lung bases. S1 is normal and S2 is decreased. A grade 3/6
systolic murmur is heard best at the upper right sternal border and radiates to the
neck. The following data obtained during cardiac catheterization were taken before
and during exercise:

Left ventricular volume

Aortic pressure End-diastolic End-systolic Heart rate
(mm Hg) (mL) (mL) (/min)

Control 130/70 140 50 85

Exercise 160/80 165 58 120

While exercising, the patient has shortness of breath but no chest pain. Which of the
 following is the most likely cause of the shortness of breath?
A) Decreased cardiac output during exercise
B) Decreased pulmonary blood flow
C) Increased aortic pressure
D) Increased end-diastolic pressure of the left ventricle during exercise
E) Tachycardia
D
34. In a student laboratory session, a male medical student finds erythrocytes in his
urine. This finding is confirmed by the hospital laboratory. He denies any history of
renal problems or recent illness. Vital signs are within normal limits.
Antistreptolysin O titer is less than 1:100. Microscopic examination of urine is
unremarkable except for rare red cell casts. There is no proteinuria. The most likely
diagnosis is
A) diabetic glomerulosclerosis
B) IgA nephropathy
C) lupus nephritis
D) membranous glomerulonephritis
E) poststreptococcal glomerulonephritis
B
35. A 3-year-old girl has multiple bone fractures, mild hearing loss, and blue sclerae.
Her mother also has blue sclerae and has near-total bilateral hearing loss. These
findings are most likely to be due to a defect in which of the following proteins?
A) Dystrophin
B) Elastin
C) Fibrillin
D) Myosin
E) Type I collagen
E
36. A genetic element is found to contain several genes and to catalyze its own
movement within and between chromosomes. Inverted 35-nucleotide repeats are
present at the ends of this genetic element. This genetic element in hepatocytes is
incapable of replicating independently. Based on this description, this genetic
element is best categorized as which of the following?
A) Complex transposon
B) Insertion sequence
C) Plasmid
D) Regulon
A
37. After 6 hours of excruciating pain, a 26-year-old man passes a 3-mm calculus. The
calculus is most likely to be composed primarily of
 A) bilirubin
B) calcium salts
C) cystine
D) triple phosphate
E) urate
B
38. A 12-year-old boy is brought to the emergency department because of vomiting and
rapid breathing. Over the past 2 weeks, he has been drinking fluids and urinating
excessively. He has lost weight. He is thin, afebrile, and drowsy. Respirations are
rapid and deep, and there is a fruity odor on his breath. Laboratory studies show:

Arterial blood pH 7.0

Serum
Glucose 575 mg/dL
Urea nitrogen (BUN) 74 mg/dL
Creatinine 2.0 mg/dL

Which of the following is most likely to be increased in this patient's blood?

A) Ammonia
B) Carnitine
C) -Hydroxybutyrate
D) Isovaleric acid
E) Sodium
c
39. A 25-year-old man swallows 100 mL of carbon tetrachloride in a suicide attempt.
Which of the following is the most likely outcome?
A) Central nervous system failure as a consequence of DNA damage in neurons
B) Gastric toxicity related to erosive gastritis
C) Heart failure as a result of lipid peroxidation of cardiac myocytes
D) No toxicity because the kidneys will excrete the carbon tetrachloride
E) Severe hepatotoxicity as a consequence of damage to the plasma membranes
E
40. A 20-year-old woman takes ibuprofen and misoprostol for rheumatoid arthritis. She
is planning to become pregnant. Her physician advises her to stop misoprostol to
avoid which of the following?
A) Fetal malformations
B) Intrauterine growth retardation
C) Premature closure of the fetal ductus arteriosus
D) Spontaneous abortion
D
41. A previously healthy 32-year-old woman has the onset of recurrent headaches. She
develops nausea, vomiting, weakness, abdominal pain, and easy bruisability. Her
temperature is 38.5 C (101.3 F). Laboratory studies show:

Hemoglobin 6.9 g/dL

Leukocyte count 15,000/mm3
Mean corpuscular volume 78 m3
Platelet count 30,000/mm3

She is immediately admitted to the hospital. Over the next few days, she develops
progressive lethargy and lapses into a coma. A peripheral blood smear is most likely
to show
A) macrocytes
B) schistocytes
C) sickle cells
D) spherocytes
E) target cells
B
42. A 35-year-old married man comes to the physician because of a 2-day history of
burning with urination. He tells the physician that he had an affair while on a
business trip 2 weeks ago. The next day, the patient's wife telephones the physician,
stating, "My husband saw you yesterday. Does he have a sexually transmitted
disease?" Which of the following responses by the physician is most appropriate?
A) "I recommend that you see your gynecologist as soon as possible."
B) "I suggest that you ask your husband if he has had any sexual relations outside the
marriage."
C) "I'm sorry, but I will need your husband's permission to discuss his care with you."
D) "I'm sure everything is going to be all right."
E) "Perhaps you and your husband should seek marital counseling."
C
43. A 59-year-old man comes to the physician because he has had malaise, fatigue, and
anorexia since losing his job 3 months ago. Serum -glutamyltransferase (GGT)
activity is increased. Which of the following questions is most appropriate to initiate
a discussion about his use of alcohol?
A) "Do you think you are a problem drinker?"
B) "How much do you drink in a typical week?"
C) "Is there something you have not told me so far?"
D) "So, do you like to hit the bottle sometimes?"
E) "What is your favorite drink?"
F) "You are not a drinker, are you?"
B
44. The photomicrograph is of lung tissue as seen at autopsy of a patient with an
occupational exposure to
A) asbestos
B) beryllium
C) coal dust
D) iron
E) silica
A
45. A 20-year-old woman develops severe pain and erythema over sun-exposed skin and
large bullae over her shoulders while vacationing in Florida. Skin testing results in
major positive reactions to methylparaben, which is often used as a preservative in
medicines. A sunscreen containing which of the following is CONTRAINDICATED
in this patient?
A) Avobenzone
B) Benzophenones
C) Cinnamates
D) p-Aminobenzoic acid esters
E) Salicylates
D
46. A 15-year-old girl has fever, nausea, and acute abdominal pain and tenderness.
Laboratory studies show a neutrophilic leukemoid reaction. A laparotomy and
appendectomy are done. Which of the following histologic findings will establish the
diagnosis of acute appendicitis?
A) Follicular lymphoid hyperplasia
B) Histiocytic infiltrate of the lamina propria
C) Lymphoid infiltrate of the mucosa
D) Mucosal ulceration
E) Neutrophilic infiltrate of the muscularis
E
47. The largest collection of neurons in the central nervous system that use
norepinephrine as a neurotransmitter is found in the
A) basal nucleus (of Meynert-ACH)
B) locus ceruleus-NE
C) raphe nuclei-5HT
D) substantia
nigra-DA
E) ventral tegmental area
B
48. A 58-year-old man comes to the physician because of blood in his urine. He had a
nephrectomy 10 years ago because of injuries sustained in a motor vehicle collision.
Evaluation shows renal cell carcinoma in his remaining kidney and pulmonary
 metastases. Interleukin-2 (IL-2) therapy is started. Three weeks later, CT scan
confirms regression of the tumor. Which of the following most likely caused the
regression?
A) An effect of IL-2 on tumor vascularization
B) Cytotoxic effects of IL-2 on tumor cells
C) Increased natural killer cell activity
D) Induction of antitumor antibodies by IL-2
E) Induction of B-lymphocyte proliferation
F) Spontaneous remission
C
49. A 45-year-old woman says that her feet feel hot. The skin of her feet is pink, dry, and
hot. Which of the following fibers are most likely to be disrupted?
A) Autonomic afferent
B) Postganglionic sympathetic
C) Preganglionic parasympathetic
D) Somatic cutaneous afferent
B
50. A 73-year-old woman has bronchopneumonia. Numerous neutrophils, attracted in
part by 5-hydroperoxyeicosatetraenoic acid (5-HPETE) and leukotrienes, are present
in the affected bronchioles and alveoli. Which of the following enzymes is most
directly involved in the production of these molecules?
A) C3 convertase
B) Cyclooxygenase
C) 5-Lipoxygenase
D) Phosphatase
E) Superoxide dismutase
C