1- (D) doesnt enjoy being with people, prefers individual activities, indifferen

t
to sexual intimacy --> Schizoid
2- (F) Uterosacral Ligament is the only structure that extends posteriorly
3- (D) young female, neurological symptoms, white matter plaques --> Multiple S
clerosis
4- (D) Local IL-1 and TNF effects lead to activation of osteoclasts and bone re
sorption--> hypercalcemia
5- (E) Ischemia stimulates baroreceptors in afferent arterioles--> increased re
nin
6- (F) Cocaine works by inhibiting NE reuptake at the presynaptic terminals
7- (D) Post partum hemorrhage, placenta adherent to the uterus, no decidua--> P
lacenta accrete
8- (D) NE acts on B1 receptors in the SA node, AV node and cardiac myocytes to
increase rate and contractility
9- (C) Chronic mal-absorption leading to signs of severe vitamin deficiencies (
retinal degeneration, ataxia, motor dysfunction) + acanthocytosis + low choleste
rol--> abetalipoproteinemia due to Apo B 100 deficiency
10- (C) Exposure to paint thinner + ophthalmologic and neurologic symptoms + an
ion gap metabolic acidosis--> probably methanol exposure which is metabolized by
Formaldehyde dehydrogenase
11- (F) Parasympathetic innervation to the stomach provided by the vagal trunks
increases acid output; other choices are all sympathetic
12- (C) Inheritance passed by female to 100% of offspring--> mitochondrial; var
iation in symptoms explained by Heteroplasmy
13- (D) CRF in middle age + family history + bilateral abdominal masses--> Poly
cystic kidney disease
14- (A) Long-term heavy smoker, painless hematuria--> most probably Bladder Can
cer
15- (B) Abdominal pain, nausea, vomiting short time after eating pastries + no
fever--> Enterotoxin ingestion
16- (C) Chronic transplant rejection carried out by CD8+ T cells is due to Dire
ct cytotoxicity to graft cells
17- (B) Withdrawal symptoms of Heroin include hyper-excitability and increased
sympathetic discharge
18- (A) History of hypercoagulability and miscarriage + prolonged PTT--> Antiph
ospholipid antibody syndrome
19- (B) Interferon-y receptor deficiency leads to defective intracellular killi
ng of mycobacteria by macrophages
20- (F) All symptoms suggestive of scleroderma which leads esophageal fibrosis-> decreased peristalsis and LES tone.
2122- (H) HSV becomes protected from immune response by establishing a latent inf
ection in the sensory nerve cells, in case of genital herpes in the dorsal root
ganglia of the lumbar or sacral plexus.
23- (E) The most common cardiac tumor in adults, in addition to being a famous
source of embolism is myxoma, usually in the left atrium
24- (A) The clinical picture is suggestive of tetanus poisoning due to wound in
fection by clostridium tetani, the toxin works by inhibiting the release of the
inhibitory neurotransmitter glycine in the spinal cord leading to disinhibition
of the motor nerve cells
25- (A) The clinical picture is suggestive of Cushing disease due to increased
ACTH secretion by pituitary adenoma leading to hyperplasia of the cells in the z
ona fasciculata of the adrenal glands
26- (A) The antibody worked by blocking the tumor receptor on the surface of he
patocytes, preventing tumor cells from homing to the liver cells
27- (D) Absence of blinding in the study created an observer bias which led to
variability in outcome assessment
28- (C) The patient is clearly affected by the severity of his pain, he hasnt a

t
tempted suicide on his own so I think restraining him wouldnt be of benefit, ree
v
aluating him after controlling the precipitating factor (i.e. the pain) would be
the best option
29- (D) The patients behavior is strongly related to instances in which she bec
o
mes separated from her mother which can be considered normal behavior only betwe
en 12-18 months of age, in addition no signs of defiant or criminal behavior to
justify oppositional defiant or conduct disorders, respectively.
30- (E) Variation in phenotype between individuals carrying the same genotype d
efines variable expressivity
31- (E) Acetazolamide acts by inhibiting bicarbonate reabsorption and hydrogen
ion secretion in the proximal tubule
32- (E) The photograph shows a collection of blood vessels of abnormal shape in
the medial side of the brain, together with the history of seizures this is sug
gestive of congenital vascular malformation
33- (D) History of amenorrhea and infertility + obesity + hirsutism--> polycyst
ic ovarian syndrome
34- (A) Micafungin, like capsofungin, works by inhibiting carbohydrate synthesi
s in the fungal cell wall
35- (B) The patients diet rules out dietary deficiency as a cause, besides ther
e
is a high incidence of other autoimmune disorders in patients who have autoimmu
ne thyroiditis, among those is pernicious anemia
36- (A) Ligaments, like cartilage are avascular and therefore lack of good bloo
d supply would slow down the healing process
3738- (D) History and symptoms are suggestive of heart failure, the presence of l
owered PO2 indicates respiratory insufficiency which in case of heart failure is
commonly caused by pulmonary edema
39- (A) The presence of alveolar hyaline membranes is indicative of ARDS which
is the only acute process involving diffuse alveolar damage, the other choices a
ll indicate a chronic process
40- (D) The HSG shows a malformed unicornuate uterus which is caused by the dys
genesis of the paramesonephric ducts
41- (A) The lab findings show hyponatremia and decreased plasma osmolality and
increased urine osmolality indicative of hypersecretion of ADH
42- (C) Warfarin causes a decrease in factors II, VII, IX, and X, its toxicity
can be treated by vit. K in mild cases and fresh frozen plasma in severe cases
43- (C) The photo shows gram positive bacilli, the only one from the choices th
ats fits the description is Listeria
44- (C) Left sided numbness and paralysis that are more severe in the face and
upper limb--> middle cerebral artery infarction
45- (D) Since the neurovascular bundle runs in the lower part of the rib all th
e choices with below can be ruled out. The only left choice thats below 7th rib
is
(D). In addition thoracentesis should be done between 8th and 10th ribs to avoid
lung injury
46- (A) The presence of adhesins (pilli) aids the bacteria in adhering to the u
rinary tract epithelium and withstanding the urine flow
47- (D) LD= Vd X Css= 8 X 0.35= 2.8 mg/kg X 55 kg = 154 mg
48- (C) The most beneficial drug in hepatic encephalopathy is lactulose, works
by trapping ammonium in the intestines.
4950- (F) The case indicates nephrogenic DI, the proximal tubule is always isoton
ic. The ADH works on the distal tubule and collecting ducts, when its action is
blocked the osmolality inside these regions will be hypotonic
Block 2:
1- (D) Cephalexin like all other b-lactams works by inhibiting bacterial cell w

all synthesis
2- (A) Hypoglycemia triggers glucagon release which activates adenylyl cyclase
in the liver leading to glycogen breakdown
3- (B) Hereditary hemochromatosis is caused by increased absorption of iron fro
m the small intestine
4- (A) History indicating a case of pulmonary embolism, in which perfusion is c
ut while ventilation remains normal
5- (B) Cisplatin works by cross-linking DNA
6- (C) Tachycardia and hypotension + the other symptoms are suggestive of ongoi
ng hemorrhage, the presence of weak pulse in lower limbs makes leaking aortic an
eurysm the most probable answer
78- (B) Winging of the scapula after mastectomy--> long thoracic nerve injury
9- (C) Typical case of multiple myeloma
10- (A) Unilateral headache and tearing and rhinorrhea + symptoms occur regular
ly every day at the same time and at same period over years --> cluster headache
11- (A) The description typically fits apoptosis, the man probably was sufferin
g from acute viral hepatitis
12- (C) The womans history is suggestive of atherosclerosis which is a risk fac
t
or for ischemic colitis, in addition the splenic flexure is a watershed area bet
we
en the middle and left colic arteries and is most commonly affected in cases of
ischemic colitis
13- (C) Homologous pairing is essential for crossing over, in which homologous
chromosomes exchange segments with each other during meiosis 1, this is necessar
y for genetic variation
14- (B) Typical case of Goodpastures syndrome in which antibodies attack baseme
n
t membranes, causing crescentric glomerulonephritis with linear immunoflourescen
ce and alveolar damage
15- (D) Old age, left lower quadrant pain, fever + typical CT scan findings-->
diverticulitis
16- (E) Since the antigen was a polysaccharide it generated only a B cell respo
nse which led to only IgM production. IgG response requires isotype switching fr
om IgM which depends on T cell stimulation to B cells, T cells in that case were
not stimulated because they recognize only protein antigens not polysaccharides
.
17- (B) The reason for increased risk of gastric adenocarcinoma in the Japanese
population is the carcinogens present in the diet, the patient continued consum
ing the same diet after his arrival.
18- (C) Overdosage of neostigmine caused desensitization of the nicotinic recep
tors at the motor end plate. MG is due to autoimmune deactivation of nicotinic r
ec
eptors, so choice A and other choices involving muscarinic receptors can be rule
d out.
19- (D) Hand cleansing is generally the most important and effective measure in
preventing nosocomial infections, not sure however about choice (B), someone el
se should confirm
20- (E) Praziquantel is the only choice that works by the way described in the
question stem
21- (B) Elbow flexion is done mainly by the biceps and brachialis muscles, both
supplied by the musculocutaneous nerve.
22- (D) Imprinting in that case caused Prader-Willi syndrome because he inherit
ed the defective chromosome from his father, while his cousin has Angelman syndr
ome because she inherited that chromosome from her mother.
23- (E) As the stimulation frequency increases the amount of calcium released f
rom the sarcoplasmic reticulum increases, and so the amount of calcium sequester
ed in order to be able to release a greater amount of calcium with each successi
ve contraction.

24- (D) The results show that those who have a high selenium diet have 0.3 the
risk of those who have a diet low in selenium (i.e. a lower risk), and since the
CI doesnt contain 1 the result can be considered significant.
25- (D) Premature baby with respiratory distress + typical findings on CXR--> n
eonatal RDS due to surfactant deficiency.
26- (E) Thats the function of myeloperoxidase; converting hydrogen peroxide int
o
hyalide radicals
27- (B) Using compression sleeves is one of the recommended treatments for lymp
hedema http://en.wikipedia.org/wiki/Lymphedema#Compression
28- (C) The lab results show severe anemia with normal MCV (so its neither iron
nor B12 deficiency), they also show high creatinine and BUN (consistent with Hx
of DM) so the most probable cause of the anemia is chronic renal failure
29- (D) The history suggests minimal change nephropathy, a disease characterize
d by heavy selective proteinuria due to loss of negative charge in the glomerula
r basement membrane
3031- (F) Slow nerve conduction indicates a problem in the myelin sheath, leading
to slowing down of action potential propagation; the latter depends on voltage
gated Na channels. Neurotransmitter gated channels serve to make the initial exc
itation to the nerve, so their impairment would lead to absent impulse not slowe
d conduction.
32- (B) Tough one! Quote: The first step in population sampling is identifying
t
he population which the researchers wish to learn more about. If, for example, s
omeone wants to find out how many African Americans have cats, the researchers k
now that the population under scrutiny is the African American community. Popula
tion sampling is used to select representative individuals from this vast commun
ity so that an estimate about cat ownership among other members of this communit
y can be extrapolated. On the other hand convenience sampling is the one in whi
ch
a sample of readily accessible individuals is used, rather than a diverse sampl
e of larger population. This link explains it all http://www.wisegeek.com/what-i
s
-a-population-sampling.htm
33- (D) Classical example and photo of subarachnoid hemorrhage
34- (B) Tachycardia, hypertension, papillary dilatation and diaphoresis all poi
nt out to increased sympathetic discharge typical of amphetamine and cocaine int
oxication
35- (D) Hemidesmosomes anchor basal cells of the epidermis to the basement memb
rane; the case described is a case of bullous pemphigoid. Desmosomes on the othe
r hand serve to attach the cells of the epidermis to each other not to BM, and t
hey are destroyed in pemphigus vulgaris.
36- (E) The man most probably has immotile cilia syndrome which is characterize
d by sinusitis, bronchiectasis, immotile sperms, and usually situs inversus tota
lis.
37- (D) The description typically fits pheochromocytoma, when such a tumor occu
rs outside the adrenal gland, it is called paraganglioma.
38- (B) The organism described is pseudomonas aeroginosa, normally it is not en
capsulated, but in cystic fibrosis the organism produces a capsule of sodium alg
inate that forms a biofilm around the organism and makes it difficult for antibi
otics to penetrate.
39- (E) Typical description of pneumocytes type II that produce surfactant.
40- (E) History of hypovolemia and urine analysis shows: granular cast, oliguri
a, increased sodium excretion (>1%), and fixed osmolality. All points to acute t
ubular necrosis which is a reversible condition; upon restoration of normal bloo
d volume, the tubular cells regenerate.
41- (C) The pulmonary circulation originates from the right ventricle and recei
ves all of the cardiac output; the bronchial circulation on the other hand origi

nates from left ventricle and is part of the systemic circulation and so receive
s only a part of the cardiac output.
42- (C) History of amenorrhea for two months without any associated symptom or
sign puts pregnancy on top of the list; best thing to rule it out is doing serum
B-HCG.
43- (A) The only open-ended question, the others jump to assumptions and in add
ition all contain closed-ended questions.
4445- (E) Ubiquitination of the misfolded proteins (tagging them with ubiquitin p
rotein) is the signal for the proteasome to attack these misfolded proteins.
46- (F) Testosterone is the only choice of which decreased concentration would
lead to erectile dysfunction.
47- (D) A case of disuse atrophy in which there is increased protein degradatio
n in the muscle cells leading to decrease in their size, but they dont die, it i
s
a reversible a condition.
4849- (E) Induction of cytochrome P450 by alcohol leads to increased metabolism o
f acetaminophen by this enzyme, which leads to increased production of hepatotox
ic metabolites. This is how alcohol lowers the threshold for acetaminophen toxic
ity.
50- (B) Treatment of infertility of unapparent cause often starts with a trial
to increase the ovulation in order to increase the probability of fertilization;
the drug most commonly used to induce ovulation is clomiphine citrate.
block 3
1- (D) The question is referring to Neisseria gonorrhea, one of its most importa
nt virulence factors is the pilli (fimbria) with which it can adhere to the urin
ary tract epithelium
2- (A) Tretinoin is a form of vitamin A, as other fat soluble vitamins it works
by binding to intracellular receptor to activate nuclear gene transcription
3- (C) In patients who have aspirin induced asthma the aspirin triggers the att
ack by inhibiting the production of prostaglandins from arachidonic acid by cycl
ooxeganse, shifting all arachidonic acid to be converted to leukotrienes by the
enzyme lipooxygenase; which in turn causes bronchoconstriction
4- (E) IL-2 produced by stimulated CD4+ T cells works on the interleukin recept
or on other T lymphocytes to stimulate their proliferation
5- (D) History of dementia + gait and urinary problems + enlarged ventricles-->
most probably normal pressure hydrocephalus
6- (A) Atropine is the best initial treatment for organophosphorus poisoning
7- (A) B-chains are characterized by their ability to bind 2,3 bisphosphoglycer
ate, which in turn decreases its affinity to oxygen, this is the reason why Hb A
has lesser affinity to O2 compared to Hb F whose y-chains cant bind to that sub
s
tance
8- (F) Being HIV positive and with the acute presentation + plus the interstiti
al infiltrate and the silver stained specimen make PCP pneumonia the most probab
le answer
9- (B) Most probably the allele of P53 linked to the m allele of the locus is d
efective (i.e. the normal cells have are heterozygous; they have only one normal
allele which is the one linked with the n allele of the locus). The tumor cells
have lost this single normal allele, so in these cells both alleles are now def
ective
10- (E) Diarrhea not improved with fasting = secretory diarrhea, so this elimin
ates all the choices but cholera and VIP, hypokalemia and hyperglycemia in addit
ion to the absence of travel history makes VIP the most probable answer
11- (C) History of recurrent UTI + the description of a calculus filling the re
nal pelvis is consistent with staghorn calculus thats formed from magnesium ammo
n
ium phosphate (also called struvite)
12- (B) Ischemia in the heart leads to coagulative necrosis

13- (D) In case of congestive heart failure the atrial myocytes secrete atrial
natriuretic peptide (ANP) that inhibits Na reabsorption, increased Na delivery t
o the macula densa leads to inhibition of renin release
14- (A) HLA-B27 (a subclass of MHC class 1) shows the strongest assossiation wi
th ankylosing spondylitis
15- (D) Alcoholism selectively destroys the vermis (central) part of the cerebe
llum which is responsible for coordination of truncal movements, leading to gait
instability. The other choices are fine movements coordinated by the more later
al parts of the cerebellum
16- (D) A case of congenital hypertrophic pyloric stenosis
17- (B) Ciprofloxacin like other flouroquinolones works by inhibiting DNA gyras
e, bacteria resistant to that class of drug have an enzyme thats not affected by
it
18- (E) Mild GERD can be treated by diet and lifestyle modifications, in additi
on to antacids or a protective agent as sucralfate, no need for acid suppression
.
19- (C) The case describes infection with diphtheria, the toxin works by ADP ri
bosylation of elongation factor-2
20- (B) Informed consent entails that the patient be fully informed about the p
urpose, methods, benefits, risks and alternatives of any procedure performed
21- (C) Nitric oxide (NO) is used as a vasodilator to treat pulmonary hypertens
ion; nitroglycerin is a famous precursor to nitric oxide. It is an oxidizing age
nt that can lead to the oxidation of iron inside the hemoglobin converting it to
methemoglobin and rendering it incapable of binding to oxygen.
22- (B) Collapse of the femoral head with preservation of the cartilage indicat
es avascular (aka aseptic) necrosis; the cartilage being an avascular structure
is protected from the effects of ischemia, while the femoral head is highly vuln
erable to ischemia due to its limited blood supply. The corticosteroids taken by
the patient is a known risk factor for aseptic necrosis of the femur.
23- (A) The rash is due to the late phase of type I hypersensitivity in which e
osinophils arrive to the scene as a result of the chemotactic factors released b
y mast cells in addition to histamine during the early phase
24- (F) Uterine relaxation (tocolysis) is the only choice thats mediated by B2
a
drenoreceptors.
25- (C) Bupivacaine, like most other local anesthetics, works by inhibiting mem
brane Na channels and so decreasing the excitability of the sensory nerves.
26- (E) The case is probably cretinism. The remnant that would be expected to f
orm a midline cyst in such a case is the thyroglossal duct.
27- (C) The photo shows the desmoplastic reaction characteristic of ductal carc
inoma; the most important prognostic factor is the degree of spread (staging) of
the tumor.
28- (A) The only choice that characterizes hypochondriasis. Somatoform patients
are usually indifferent to their disease (la belle indifference).
29- (C) The only drug of the choices that would cause steatorrhea is orlistat,
because it works by inhibiting fat digestion and absorption in the small intesti
ne by inhibiting pancreatic lipase.
30- (C) Smoking causes squamous metaplasia of the respiratory epithelium presen
t in the larynx, trachea and bronchi. The metaplastic epithelium is a risk facto
r for squamous cell carcinoma
31- (C) Out of the 200 people who ate lettuce, 40 developed diarrhea. The proba
bility of developing diarrhea is 40/200=0.2
32- (A) The thoracic portion of the esophagus takes blood supply from branches
of the aorta and the bronchial arteries.
33- (B) The clinical picture indicates impairment of function of the mitochondr
ia inside heart cells. Since the mutation affects tRNA, protein synthesis would
most likely be impaired.
34- (B) Pyelonephritis is the most probable complication in that case with a hi
story of recurrent UTI, leukocytosis and bilateral hydroureter and hydronephrosi

s.
35- (G) All the symptoms, signs and lab results are typical of hypothyroidism.
The most accurate initial test is serum TSH.
36- (B) The number one cause of death of both men and women in developed countr
ies is cardiovascular disease, followed by cerebral infarction, followed by canc
er.
37- (B) The patient most probably has celiac disease (malabsorption syndrome co
ntrolled by restricting wheat, barley and rye). The pruritic vesicular rash on t
he elbows associated with celiac disease is called dermatitis herpetiformis.
38- (C) History typical of Lesch-Nyhan (self-mutilating behavior, neurological
symptoms and x-linked inheritance). It is caused by HGPRT enzyme deficiency lead
ing to hyperuricemia.
39- (E) Observing a group of patients who have the risk factors of a disease fo
r the occurrence of that disease describes prospective cohort study.
40- (C) Glossitis, angular stomatitis and especially spoon-shaped nails are fou
nd in iron deficiency anemia, also it is the only cause among the choices for de
creased MCV.
41- (A) A crescendo-decrescendo systolic murmur thats best heard in the second
r
ight intercostal space and radiates to the carotids--> aortic stenosis
42- (D) The history is typical for Duchennes muscular dystrophy (x-linked, dela
y
ed milestones, positive Gowers sing), the muscle described is the adductor magnu
s
which takes origin partially from the inferior ramus of the ischium, and insert
s into the medial side of the femur.
43- (E) The case describes oculomotor nerve palsy (mydriasis, ptosis and outwar
d strabismus), the only muscle of the choices thats not supplied by CN III is th
e
superior oblique (CN IV)
44- (B) The only statement that doesnt direct the patient or judge him, nor try
to threaten and intimidate him.
45- (E) The only conscious defense mechanism that can be learned and would be b
eneficial in that case is suppressions of the memory of his father.
46- (E) The ureters are crossed by the ovarian vessels and are liable to accide
ntal ligation during oophorectomy; the flank pain is consistent with the urinary
retention that would result from ligation of the ureter.
47- (B) The two drugs that act as cough suppressants are codeine and dextrometh
orphan. Compared to codeine, dextromethorphan is a less potent opiate, it has a
much less abuse potential and doesnt cause constipation.
48- (C) The case describes Chediak-Higashi syndrome, an immunodeficiency syndro
me due to defective neutrophil function due to failure of phagolysosome formatio
n.
49- (B) Neuraminidases are enzymes that clip off the terminal sialic acid resid
ues from the newly formed virions in order for them to be released from the cell
membrane of the infected cells.
50- (A) The case describes acute intermittent porphyria, which is autosomal dom
inant. Except for congenital erythropoietic porphyria (AR), all the other well k
nown types of porphyria are AD.
Block 4
1- (E) EBV infects B-lymphocytes, but the cells that react to the infection are
T-lymphocytes because it is a viral infection. In EBV infection the reactive T
cells undergo some morphologic changes (become enlarged with abundant vacuolated
cytoplasm) and are called atypical lymphocytes.
2- (E) Erythromycin, like other macrolides, works by inhibiting translocation o
f the ribosome along the mRNA. Choice B is puromycin, C is diphtheria toxin, and
D is tetracyclines.
3- (B) Hemangioma is a benign tumor that arises from the endothelial cells that
line the blood vessels.

4- (E) Sumatriptan activates 5HT1B/1D receptors, which are serotonin receptors.

5- (C) Positive predictive value (PPV) equals (TP/TP+FP), when the prevalence i
ncreases, the rate of the false positive (FP) decreases and so the PPV increases
.
6- (B) Hyperreflexia (sign of UMN lesion) + fasciculations (sign of LMN lesion)
indicate most probably a case of amyotrophic lateral sclerosis (ALS). It is cha
racterized by difficulty swallowing due to paralysis of the somatic muscles of t
he pharynx and upper esophagus.
7- (C) Staphylococcus aureus most probably caused the acute endocarditis in muc
h the same way it causes it in IV drug abusers; by getting access from skin woun
d into the right side of the heart.
8- (J) Typical description of VSD.
9- (D) A case of ovarian torsion, which causes obstruction of the ovarian blood
vessels that pass through the suspensory ligament of the ovary leading to ovari
an ischemia.
10- (C) Most probably a case of Giardia lamblia, the diagnosis can be made by v
isualizing ova and parasites in the stool
11- (A) Bevacizumab is a humanized monoclonal antibody directed against VEGF, i
t comes from human origin using recombinant DNA technology, and thus it doesnt e
n
counter a strong immune response against them, unlike antibodies extracted from
other species that encounter a strong immune response leading in many cases to t
ype III hypersensitivity reactions (serum sickness)
12- (A) The patient most likely has a prolactin secreting pituitary adenoma, th
e treatment is with a dopamine agonist (like bromocriptine of cabergoline) that
inhibits prolactin production and in the majority of patients leads to shrinkage
of tumor size.
13- (C) The photograph shows the neuromuscular junction, Lambert-Eaton syndrome
is an autoimmune disorder caused by production of Abs against the presynaptic c
alcium channels at the NMJ, leading to inhibition of Ach release; it usually inv
olves the proximal muscles especially of the lower limbs, and is associated with
cancer.
14- (C) HPV E6 protein is the only foreign protein shown, and thus it would pro
duce the strongest immune response, all the other proteins are self-proteins.
15- (E) These symptoms are suggestive of carcinoid syndrome caused by metastati
c carcinoid tumor; the most common primary site for this tumor is the appendix f
ollowed by the small intestine.
16- (A) The stem describes a branchial cyst, formed due to incomplete obliterat
ion of the second branchial cleft by the branchial arch during embryonic develop
ment; it is found in front of the anterior border of the sternomastoid muscle. (
N.B. The other cystic neck swelling, cystic hygroma, is found along the posterio
r border).
17- (C) The most plausible answer is inhibition of CYP450, but I cant come up w
i
th a good explanation for it.
18- (C) Having an affected child with an AR disease means that both parents are
carriers, so the probability the next child is 50% being carrier, 25% being hom
ozygous normal, and 25% being affected with the 2 recessive alleles.
19- (D) The case describes mucopolysaccharidosis (specifically Hunters syndrome
)
thats X-linked and is characterized by the deficiency of iduronate sulfatase en
z
yme that metabolizes mucopolysaccharides as heparan and dermatan sulfate.
20- (F) One of the most serious side effects of metformin is lactic acidosis, d
ue to inhibition of aerobic metabolism in muscles.
21- (D) The case describes mitochondrial myopathy in which ragged-red fibers is
a
characteristic finding. The most important mitochondrial process that becomes i
mpaired in these patients is oxidative phosphorylation, and this impairment is t

he cause of elevated lactic acid.

22- (E) The use of gentamicin (nephrotoxic drug), high urinary Na level (>20 mE
q/L) and the presence of brown granular cast all suggest a case of ATN which mos
tly affects the PCT because it is the most metabolically active and energy deman
ding part of the kidney.
23- (A) Since the patient is borderline obese, the most important recommendatio
n would be to lower his weight. A low calorie diet that takes into account all t
ypes of food taken is more efficient than targeting any single category.
24- (E) High carboxyhemoglobin indicates CO poisoning, CO impairs oxidative pho
sphorylation in the mitochondria by inhibiting the last step catalyzed by the en
zyme cytochrome oxidase (aka Cyt a+a3)
25- (A) In cases of acute inflammation such as this one (acute appendicitis) ce
rtain cytokines released from the PMNs and macrophages in the inflammation site
act on the hypothalamus to produce fever, the most important of these mediators
are TNF, IL-1, IL-6.
26- (C) The question needs you to know the function of the protease enzyme. Oth
er viral enzymes like reverse transcriptase, integrase, etc. first get formed as
a part of big polypeptide chain thats located in the core of the virus; the pro
t
ease functions to break down that polypeptide to release those enzymes, thus lea
ding to the maturation of the core.
27- (B) Struvite stones are formed in an alkaline medium, such a medium is prom
oted by a bacterium that has a urease enzyme which can break down the urea into
ammonia and thus cause alkaline pH. The only bacterium listed that has urease en
zyme is proteus.
28- (B) A patient complaining to you about his physician--> encourage the patie
nt to communicate with the physician.
29- (B) Sensory deficit in the left hand--> a problem in the right somatosensor
y cortex located in the right postcentral gyrus.
30- (C) Typical adolescent gynecomastia that occurs in a large proportion of ad
olescents and resolves on its own in the majority of them with time.
31- (A) Progressive weakness of the proximal and distal muscles, double vision,
eyelid drooping + mediastinal mass--> myasthenia gravis which is commonly assoc
iated with thymic hyperplasia/thymoma. It is caused by auto-Abs that block the A
.Ch. receptors at the motor end plate.
32- (C) The pic shows severe vertebral osteoporosis with a compression fracture
, the most plausible answer is IL-1 since it activates osteoclasts and is increa
sed in postmenopausal osteoporosis which is characterized by increased resorptio
n.
33- (E) The key sentence here is her symptoms become much more pronounced as th
e
day progresses which is typical of MG, none of the other choices would cause th
a
t. Besides, having normal residual volume excludes the obstructive lung diseases
(alpha 1-antitrypsin and chronic bronchitis).
34- (D) Nodular infiltrates + hilar adenopathy + noncaseating granulomas--> cla
ssical sarcoidosis.
35- (C) Most probably a case of metabolic syndrome, these patients have dyslipi
demia which is characterized by increased triglycerides and FFAs, and decreased
HDL cholesterol.
36- (C) The T4-binding substance in the blood is Thyroid binding globulin (TBG)
. Since Thyroid hormone is a steroid (lipid-soluble), it traverses the cell memb
rane and acts intracellularly on a nuclear receptor.
37- (A) Patients with Gilbert syndrome are asymptomatic, they may suffer mild j
aundice in cases of stress and infection like that case, the jaundice is due to
the decreased capacity of the glucuronyl-transferase enzyme, therefore the jaund
ice would be caused by unconjugated bilirubin. Normal liver enzymes exclude choi
ces B and E, choices C and D should have been accompanied by other signs of anem
ia (C) or liver failure (D).
38- (F) One of the most dangerous infections in DM that occurs specially after

DKA is mucormycosis, the fungus gains access through the cribriform plate and ma
y spread to the orbit and the brain, it causes a necrotizing inflammation, hence
the black eschar.
39- (E) A classical case of rheumatoid arthritis, the pathology involves granul
omatous inflammation in the synovium of the joints, the reactive synovium forms
a mass called pannus that destroys the joint and ends up in fibrosis causing the
v
arious deformities seen in RA.
40- (A) Type II error (beta error) is calculated by the equation (beta=1 power
)
, therefore beta equals 0.2 in trial X and 0.1 in trial Y, that is, as the power
increases the likelihood of the error decreases.
41- (D) In people with DM increased glucose leads to its increased conversion t
o sorbitol by the enzyme aldose reductase which is found in the lens, the proble
m with sorbitol is that it cant cross the cell membrane, so it gets trapped insi
d
e the cell, and it draws water because it is osmotically active, this leads to o
pacification of the lens and cataract formation.
42- (E) A classical presentation of sickle cell anemia causing acute chest synd
rome which is a form of sickle cell crisis. The substitution of glutamic acid wi
th valine in the B-chains leads to polymerization of the Hb under hypoxic condit
ions forming insoluble polymers, due to this the RBCs become sickle shaped and s
ticky and they clog the small capillaries leading to ischemia in many organs whi
ch leads to the crisis.
43- (B) The carbonic anhydrase inhibitor (acetazolamide) is of benefit in high
altitude sickness because it causes acidosis, which counteracts the alkalosis ca
used by hyperventilation, however it is also a diuretic, and so it would cause s
ome hypovolemia in normotensive persons which can lead to orthostatic hypotensio
n. The only other choice that can cause orthostatic hypotension is impaired symp
athetic activity, but it is unrelated to acetazolamide.
44- (B) The sequence (AATAAA) which is transcribed into (AAUAAA) is the signal
required to start adenylation and formation of the poly A tail, and it is locate
d downstream (3) of the coding region, the function of the tail is to protect th
e
mRNA from cleavage, in its absence most of the mRNA would be broken down by the
endonucleases in the nucleus.
45- (E) Classical presentation of gestational trophoblastic disease (GTD) chara
cterized by hyperemesis gravidarum, a uterus thats large for the gestational age
,
and markedly increased levels of HCG. It is due to abnormal proliferation of th
e trophoblastic tissue.
46- (B) From the blistering diseases the one that most commonly involves the mo
ut
h is pemphigus vulgaris; it is caused by auto-Abs to the desmosomes between the
keratinocytes in the stratum spinosum layer of the epidermis.
47- (B) He has multiple risk factors; being male, above 45 y/o, living alone, a
nd having major illness.
48- (C) The IIB/IIIA receptor on platelets is the receptor that binds fibrinoge
n and it is essential for the process of platelet adhesion and aggregation and t
o strengthen the blood clot.
49- (B) Except for the glucagon receptor, all the other choices are common to b
oth glucagon and epinephrine because both act to initiate the G-protein sequence
that ends up in activating glycogen phosphorylase and breaking down glycogen.
50- (C) Tyrosine kinases is a family of enzymes that act as downstream effector
s of various growth factors, they function through phosphorylating tyrosine resi
dues on different proteins, since it is a missense mutation (i.e. it didnt lead
t
o a premature termination of translation, so didnt affect the amount of the enzy
m
e formed) it probably led to the formation of a non-functional enzyme that cant

p
hosphorylate.