NBME 13 section 1

9.An 16-year-old woman with mild mental retardation is brought to the physician
because of a 3-day history of decreased ability to see in reduced light. She has a
lifelong history of chronic diarrhea. Two years ago. she developed a lack of muscle
control of her arms and legs, and generalized weakness. Her 16-year-old brother has
had similar symptoms. Ophthalmologic examination shows bilateral retinitis
pigmentosa. There is ataxia and loss of deep tendon reflexes. Laboratory studies
show erythrocytes with spiny projections and a serum total cholesterol
concentration of '40mg/dL. Which of the following apolipoproteins is most likely
deficient in this patient?

Apo A-1

Apo A-11

Apo B

Apo C

Apo E
10.A previously healthy 32-year-old man is brought to the emergency department
because of a 1-day history of intermittent flashing spots and blurred vision,
vomiting, confusion, and difficulty walking. He is a painter and says that
yesterday he cleaned up a spilled bottle of paint thinner. Ophthalmologic
examination shows dilated pupils with hyperemia of the optic disc and retinal
edema. Physical examination shows tachypnea. Serum studies show an anion gap
metabolic acidosis. The most appropriate pharmacotherapy for this patient is most
likely to inhibit the activity of which of the following?

Alcohol dehydrogenase

Aldehyde dehydrogenase

Formaldehyde dehydrogenase

Lactate dehydrogenase

Pyruvate dehydrogenase
13.A 52 year old man with a family history of renal failure comest to the physician
because of abdominal pain over the last 6 months. He has been treated in the past
for renal calculi and hypertension. Physical examination shows bilateral palpable
masses in the upper abdomen. Urinalysis shows crenated erythrocytes and mild
proteinuria. A CT scan of the abdomen identifies the cause of the patient's
problem. Which of the following is the most likely diagnosis?

Adrenal adenoma

Glomerulonephritis

Henoch-Schonlein purpura

Polycystic kidney disease

Renal cell adenoma

15.A previously healthy 6-year-old girl is brought to the emergency department
because of severe abdominal pain, nausea, and vomiting that began 4 hours after
attending a friend's birthday party. Cake and other pastries were served at the
party. She appears acutely ill and mildly dehydrated. Her temperature is 37�XC
(98.6�XF), pulse is 104/min, respirations are 20/min, and blood pressure is 96/60
mm Hg. Examination shows no abnormalities of the skin. Bowel sounds are
hyperactive. Which of the following is the most likely cause of these findings?

Bacteremia

Enterotoxin ingestion

Intestinal mucosa inflammation

Lead toxicity

Villus atrophy

Viremia
17.A male newborn is delivered at 38 weeks' gestation following an uncomplicated
pregnancy. Twelve-hours later, he begins sucking frantically and crying
inconsolably. He overreacts to stimuli around him and has a marked startle
response. The symptoms slowly resolve over the next 2 to 3 weeks. The most likely
explanation for these symptoms is maternal use of which of the following substances
during pregnancy?

Alcohol

Heroin

LSD

Marijuana

Psilocybin
20.A 64-year-old woman comes to the physician because of a 6-month history of
heartburn and difficulty swallowing solid food and liquid. She has not had nausea
or vomiting. She also has a 2-year history of pain and swelling of her wrists and
hands. She has not seen a physician in 5 years. She takes no medications. She does
not smoke. Physical examination shows no wrinkles on the face and neck. Her vital
signs are within normal limits. There is synovial thickening of the wrists
bilaterally. A photograph of the left hand is shown. Abdominal examination shows no
abnormalities. Which of the following sets of findings is most likely on esophageal
manometry? Esophageal Lower Esophageal
Peristalsis Sphincter Tone A) Increased
increased B) Increased decreased C)
Normal increased D) Normal
decreased E) Decreased increased F)
Decreased decreased
22.A 36-year-old man comes to the physician for a routine examination. He has a 5-
year history of recurrent episodes of genital herpes treated with acyclovir. He
says, "I`ve been taking the medication, but I still occasionally get lesions. When
will I be cured?" The physician informs him that herpes simplex is a lifelong
infection, with no cure at the present time. Which of the following best explains
the longevity of the herpes simplex virus?

Continual replication in dendrite cells

Continual replication in epithelial cells of the skin

Continual replication in sacral root ganglia

Continual replication in T lymphocytes

Establishment of a latent infection in B lymphocytes

Establishment of a latent infection in circulating immune cells

Establishment of a latent infection in epithelial cells of the skin

Establishment of a latent infection in sensory nerve cells

24.A 48-year-old manic brought to the emergency department because of difficulty
opening his mouth and stiffness of his neck, shoulders, and back for 4 hours. He
sustained a puncture wound to his arm 1 week ago. He has received no medical care
for 30 years. Physical examination shows trismus and opisthotonos. Which of the
following best describes the process in this patient?

Blockade of inhibitory neurotransmitter release

Cell death in central nervous system neurons.

Cell death in muscles

Cell death in peripheral nervous system neurons

Demyelinization
26.A mouse melanoma, B-16. is highly metastatic. A clone of the B-16 melanoma cells
is injected intravenously into the tail vein of mice, and 3 weeks later tumor
nodules are found in the lungs, liver, and ovaries. When an antibody to a liver
cell surface antigen is injected 1 hour prior to injection of the B-16 melanoma
cells, formation of tumor nodules in the liver is prevented, but tumor nodules
develop in the ovaries and lungs. In vitro studies do not show any cytotoxic effect
of the antibody on B-16 or hepatic cells. Which of the following processes is most
likely to be affected by the antibody?

Homing

Initiation

Invasion

Motility

Progression

Promotion
27.A study is conducted to assess the effectiveness of vitamin C in preventing
common colds in children, Patients are randomly assigned to receive either vitamin
C or no intervention. Outcome events (common cold) are reported by the parents on a
monthly basis for 1 year. Results show that those taking vitamin C have fewer colds
compared with those who received no intervention (p<0.05). Which of the following
raises the most concern about the validity of the conclusion that vitamin C
supplements prevent the common cold?

Inadequate statistical power

Non-randomization

Selection bias

Variability in outcome assessment

33.A 22-year-old nulligravid woman comes to the physician because she has been
unable to conceive for 18 months. She has had irregular menses since menarche at
the age of 13 years. She is 165 cm (5 ft 5 in) tall and weighs 88 kg (195 lb): BMI
is 32 kg/m2. Her temperature is 36.8�XC (98.2�XF), pulse is 88/min, respirations
are 14/min, and blood pressure is 140190 mm Hg. Physical examination shows moderate
hirsutism and mild acne over the face and back. Pelvic examination shows no
abnormalities of the exterior genitalia; a bimanual examination is limited by the
patient's obesity. Which of the following is the most likely cause of this
patient's infertility?

Hypothyroidism

Klinefelter syndrome

Pituitary adenoma

Polycystic ovarian syndrome

Primary ovarian failure

35.A 60 year-old man comes to the physician because of weakness and light-
headedness for 3 months. His diet consists of a healthy balance of fruits,
vegetables, whole grains, and lean chicken and fish. He has a 10-year history of
chronic autoimmune (Hashimoto) thyroiditis treated with thyroxine. Physical
examination shows pallor. Serum studies show increased concentrations of
methylmalonic acid and total homocysteine. A peripheral blood smear shows
megaloblastic anemia. Which of the following is the most likely cause of the
findings in this patient?

Cystathionine B-synthase deficiency

Failure of intrinsic factor production

Folic acid deficiency

Helicobacier pylori gastritis

Methylmalonyl-CoA mutase deficiency

36.An 18-year-old man comes to the physician 6 hours after he twisted his ankle
while playing football. Physical examination shows looseness of the lateral
collateral ligament, suggestive of a tear. Lack of which of the following
components in the ligament will roost likely limit healing of this injury?

Blood vessels

Collagen fibers

Elastic fibers

Lymphatic vessels

Nerves
41.A 51-year-old man comes to the physician because of a 2-week history of cough
productive of blood. He also has had a 3-kg (6.6-1b) weight loss during the past
month. He has smoked 2 packs of cigarettes daily for 32 years. He has hypertension
treated with metoprolol. Physical examination shows clubbing of the fingernails.
Wheezes are heard over the right upper lobe anteriorly; there are no crackles.
Laboratory studies show:
SERUM
Na+ 125 mEq/L
K+ 3.9 mEq/L
CI- 55 mEq/L
HCO3- 25 mEq/L
Urea nitrogen 8 mg/dL
Creatinine 0.4 mg/dL
Osmolality 262 mOsmolikg
Urine osmolality 564 mOsmol/kg A CT scan of the chest shows a 2.4 x 1.2-cm,
spiculated noncalcified mass in the right upper lobe eroding into the right
bronchus. This patients laboratory findings are most likely caused by an excess of
which of the following hormones?

ADH (vasopressin)

Adrenocorticotropic hormone

Brain natriuretic peptide

Cortical

Thyroxine (T4)
45.An 82-year-old woman is admitted to the hospital for treatment of a small right
pleural effusion. Physical examination shows dullness to percussion at the level of
the 7th rib and below on the right. A thoracentesis is done. The patient is sitting
up, supported by leaning against a bedside table. After preparing the skin and
delivering a local anesthetic, into which of the following locations on the right
is it most appropriate to insert the catheter?

Above the 5th rib in the midscapular line

Above the 5th rib just to the right of the sternum

Above the 7th rib in the paravertebral region

Above the 9th rib in the midscapular line

Below the 5th rib in the midaxillary line

Below the 5th rib in the midclavicular line

Below the 9th rib in the midscapular line

46.A 23-year-old woman comes to the physician because of a 1-day history of chills,
nausea, and vomiting. She also has a 4-day history of flank pain, urinary frequency
and urgency, and pain with urination. Her temperature is 38.9C (102�XF), pulse is
125/min, and blood pressure is 96/60 mm Hg. Physical examination shows right
costovertebral angle tenderness. Urinalysis shows 25 WBC/hpf. A urine sample grows
pink colonies on lactose-MacConkey agar. produces a characteristic green sheen on
eosin-methylene blue agar, and is indole positive. The production of which of the
following by the bacterium aids in the virulence of the causal organism in this
patent?

Adhesins

Antihemolytic factors

Pyrogenic exotoxin

Teichoic acid in the cell wall

Thick peptidoglycan layer

50.A 22-year-old woman is admitted to the hospital because of a 10-day history of
polydipsia and polyuria. She says that the urge to urinate often awakens her at
night. She has been taking lithium carbonate for 2 years for bipolar disorder her
dosage was increased 6 months ago because of recurrent severe manic episodes. Her
vital signs are within normal limits. Physical examination shows no abnormalities.
Over the next 24hrs, urine excretion totals 6.5 L. Laboratory studies at this time
show a serum sodium concentration of 148 mEq/L, serum osmolality of 315 mOsmol/kg,
and urine osmolality of 75 mOsmol/kg. After administration of desmopressin, urine
output and osmolality do not change. Which of the following findings in the nephron
best describes the tubular osmolality, compared with serum, in this patient?
Proximal Tubule Juxtaglomerular Apparatus Medullary Collecting Duct A)
Hypertonic----------hypertonic----------hypertonic B) Hypertonic----------
hypertonic----------hypotonic C) Hypertonic----------hypotonic-----------hypotonic
D) Isotonic --------------isotonic--------------isotonic E) Isotonic
--------------hypotonic-----------hypertonic F) Isotonic
--------------hypotonic-----------hypotonic G) Hypotonic-----------
hypertonic-----------hypertonic H) Hypotonic----------hypotonic------------
hypertonic I) Hypotonic----------hypotonic------------hypotonic

____________________________________________
NBME 13 section 2
1.A 2-year old girl takes oral cephalexin for treatment of Impetigo caused by group
A beta-hemolytic Streptococcus, Which of the following is the mechanism of action
of this antibiotic in this patient?

Binding to bacterial 30S ribosomal subunits

Binding to bacterial 50S ribosomal subunits

Inhibition of bacterial dihydrofolate reductase

Interference with bacterial cell wall synthesis

Production of beta-lactamase

2.A 10 - year old boy who has had type 1 diabetes mellitus for 1 year is receiving
insulin. One hour after his morning dose of insulin, he becomes tremulous and
diaphoretic and has tachychardia. Several hours later, his symptoms resolve. His
blood glucose concentration is now increased. Which of the following is the most
likely cause of this patient's hyperglycemia?

Activation of hepatic adenylyl cyclase

Activation of muscle glycogen synthase

Activation of muscle phosphorylase

Activation of muscle protein phosphatase

Inhibition of hepatic protein kinase A

5.A 25-year old man is diagnosed with advanced testicular cancer. Combination
chemotherapy is being considered. Cisplatin is included in the regimen because of
its effect on which of the following?

Dihydrofolate reductase

DNA

Microtubules
Purine ring biosynthesis

Ribonucleotide reductase

**9.A 78-year old man comes to the physician because of a 3-month history of
increasingly severe back pain. He has had a 5.4-kg (12-lb) weight loss during this
period. The pain occurs mostly at night, is exacerbated by movement, and is no
longer relieved by aspirin. There has been no trauma to the area. He appears
chronically ill. His pulse is 100/min, and blood pressure is 160/100 mm Hg.
Physical examination shows point tenderness over L4-5 area; there are no skin
lesions. Urinalysis shows 4+ proteins. A photomicrograph of findings from bone
marrow aspiration is shown. Which of the following is the most likely diagnosis?
Hyperparathyroidism

Metastatic bone disease

Multiple myeloma

Osteitis deformans (Paget disease)

Waldenstrom macroglobulinemia
12.A 72-year old woman comes to the emergency department because if bloody diarrhea
for the past 12 hours and diffuse abdominal pain for the past 4 days. History
includes a cerebral infarction 3 years ago from which she completely recovered.
Examination shows watery stool with red blood. Colonoscopy shows patchy ulceration
at the area near the splenic flexure. Which of the following is the most likely
diagnosis?

Celiac sprue

Irritable bowel syndrome

Ischemic colitis

Pancreatic insufficiency

Regional enteritis

Ulcerative colitis
15.A 72-year old man is brought to the emergency department because of a 1-week
history of increasingly severe abdominal pain, diarrhea, and loss of appetite. He
had had a fever for 2 days. His temperature is 38.3C (101F), and pulse is 106/min.
Abdominal examination shows distention and rebound tenderness localized to the left
lower quadrant. His leukocyte count is 18,000/mm3 (80% segmented neutrophils, 10%
bands, and 10% lymphocytes). An abdominal CT scan shows a 7-mm, thickened colonic
wall, and pericolic fat inflammation; there is a collection of contrast in this
region. Which of the following is the most likely diagnosis?

Amebiasis

Collagenous colitis

Colon cancer

Diverticulitis

Ulcerative colitis
20.During an experiment, Drug X is administered to treat trematode and cestode
infestations. Results show that Drug X increases the permeability of the cell
membranes to calcium, causing paralysis, dislodgement, and death of the parasite.
Drug X most closely resembles which of the following?

Albendazole

Bithionol

Diethylcarbamazine

Niclosamide

Praziquantel

22.A 6-year old boy is found to have almond-shaped eyes, temperature instability,
mental retardation, hyperphagia, and obesity. Cytogenetic analysis shows a balanced
translocation involving chromosome 15q11-q13. His father and paternal aunt are
found to have an identical balanced translocation. His aunt's 5-year old daughter
has a history of inappropriate laughter, abnormal gait, and mental retardation.
Which of the following genetic principles best explains the findings in this
family?

Anticipation

Genetic drift

Heteroplasmy

Imprinting

Pseudodominant inheritance

**23.The tracing shows contractile responses of a skeletal muscle preparation to

electrical stimulation at five different frequencies. The amount of calcium
sequestration in sarcoplasmic reticulurn is highest during which of the fallowing
labeled responses?
A.B.C.D.E.
24.A prospective study examined the relationship between the development of gastric
cancer and exposure to a diet rich in selenium. The investigators estimated the
relative risk of gastric cancer to be 0.3 in individuals with a high-selenium diet
(95% confidence interval 0.1-0.8). Which of the following is the most appropriate
interpretation of this finding?

Selenium causes gastric cancer

Selenium exposure is unrelated to gastric cancer

Selenium is associated with a higher risk of gastric cancer

Selenium is associated with a lower risk of gastric cancer

Selenium is positively correlated with gastric cancer

26.A 23-year old woman with type 1 diabetes mellitus is brought to the physician
for a follow-up examination. She has a 2-year history of recurrent yeast
infections. Genetic analysis shows a deficiency of myeloperoxidase. Which of the
following is the most likely cause of the increased susceptibility to infections in
this patient?

Decreased oxygen consumption after phagocytosis

Defective neutrophil degranulation

Defective production of prostaglandins

Inability to produce hydrogen peroxide

Inability to produce hydroxyl-halide radicals

27.A 25-year old woman undergoes a radical mastectomy with removal of the axillary
lymph nodes on the left side. After the operation, she develops painful edema of
the left upper extremity. Which of the following therapies is most likely to
decrease the swelling in this patient?

Application of heat

Compression sleeve

Diuretic therapy

Exercise therapy

Passive movement
28.A 50-year-old man with a long-standing history of type 2 diabetes mellitus comes
to the physician because of several fainting episodes and fatigue during the past
month. He appears chronically ill. His temperature is 37�XC (98.6�XF), pulse is
95/min, respirations are 17/min, and blood pressure is 155/95mmHg. Physical
examination shows pallor. Laboratory studies show: Hemoglobin 8 g/dL Hematocrit 24%
Mean corpuscular hemoglobin 30 pg/cell Mean corpuscular hemoglobin concentration
33% Hb/cell Mean corpuscular volume 85 um3 Leukocyte count 8000/mm3 Platelet count
200,000/mm3 SERUM Urea nitrogen 60 mg/dL Creatinine 6 mg/dL Total bilirubin 0.9
mg/dL Which of the following is the most appropriate pharmacotherapy for this
patient?

Cyclosporine

Deferoxamine

Erythropoietin

Filgrastim

Folic acid

Oprelvekin

Vitamin B12 (cyanocobalamin)

31.A 33-year-old woman who is right-handed is brought to the physician because of a
3-day history of progressive weakness and numbness of her arms and legs. Neurologic
examination shows proximal and distal weakness of the upper and lower extremities.
There is areflexia. Sensation to vibration and joint position is decreased in the
fingers and toes. Nerve conduction studies show a slow conduction velocity in the
median, ulnar, peroneal, and tibial nerves. These electrophysiologic findings most
likely indicate impaired function of which of the following ion channels?

Neurotransmitter-gated Ca++ channels

Neurotransmitter-gated K+ channels

Neurotransmitter-gated Na+ channels

Voltage-gated Ca+ + channels

Voltage-gated K+ channels

Voltage-gated Na+ channels

32.A study is conducted to evaluate the onset and course of cardiovascular disease
in African American men and women in the USA. Census data from the year 2000 are
used to select the study sample. A series of factors including family income and
years of education is defined. Census data most representative of the national
census data for the factors selected are used for sampling. Which of the following
best describes this sampling technique?

Blocked randomization

Population-based

Sample of convenience

Self-selection

Sequential
34.A 15-year-old boy is brought to the physician by his father because of
behavioral changes during the past month. He has been failing his classes at school
and staying out late at night. His father reports that the family moved to a new
neighborhood 2 months ago, and that the local teenagers are mall drug addicts and
criminals." His pulse is 110/min, respirations are 24/min. and blood pressure is
140/85 mm Hg. Physical examination shows pupillary dilation and diaphoresis. On
mental status examination, his affect is agitated, and his thought process is
confused. Intoxication with which of the following substances is the most likely
cause of this patient's symptoms?

Alcohol

Amphetamine

Amyl nitrate

Cannabis

Heroin
38.A 25-year old man with cystic fibrosis comes to the physician because of a 3-day
history of fever, cough, and progressive shortness of breath. His temperature is
38C (100.4F) and respirations are 32/min. Bilateral crackles and rhonchi are heard
on auscultation of the chest. A nutrient agar plate seeded with bronchial
secretions grows an aerobic, oxidase-positive, gram-negative rod that forms slimy
colonies and produces pyocyanin. The organism does not ferment lactose. Treatment
with multiple appropriate antibiotics has not led to eradication of the causal
organism. Which of the following is the most likely explanation for the persistent
colonization of this patient by organism?

Bacteriophage superinfection

Biofilm formation the lower respiratory tract

Overgrowth of acapsular strains

Pyocyanin synthesis
Synthesis of exotoxin A
40.A 55-year-old man is brought to the emergency department 45 minutes after he
collapsed at home. His pulse is 120/min, respirations are 16/min, and blood
pressure is 80/45 mmHg. Physical examination shows no other abnormalities. His
hemoglobin concentration is 8g/dL, hematocrit is 24%, and platelet count is
240,000/mm3. Endoscopy shows a bleeding duodenal ulcer, which is surgically
repaired. He receives 4 units of packed red blood cells. Two days later, laboratory
studies show: Hemoglobin 10 g/dL Hematocrit 30% SERUM Urea nitrogen 70 mg/dL
Creatinine 3 mg/dL URINE Blood absent Sediment granular casts Volume 100 m1124 h
Total protein 100 mg/24 h Sodium 50 mEq/L Fractional excretion of sodium 2.5%
Osmolality 300 mOsmol/kg H20 Two weeks later, the urine sediment is clear and renal
function is normal. Histologic examination of a renal biopsy specimen is most
likely to show which of the following at this time?

Coagulation necrosis

Collagen scar

Granulation tissue

Lymphocytic infiltrate and fibrogenesis

Regenerating tubular epithelial cells

41.Twenty subjects participate in a study of cardiopulmonary physiology. The
pulmonary circulation of these subjects most likely has which of the following
characteristics compared with their bronchial circulation?

Greater number of branches supplying the visceral pleura

Larger number of anastomoses with the intercostal arteries

Larger percentage of cardiac output

Larger volume of nutrient blood to the conducting airways

Lower-volume, higher pressure system

49.A previously healthy 42-year old Asian woman is brought to the emergency
department because of a 24-hour history of nausea, vomiting and progressive
lethargy. She has smoked 1 pack of cigarettes daily for 25 years and drinks four
glasses of wine daily. She uses high-dose acetaminophen daily for headaches. She
does not use illicit drugs. She is 155 cm (5ft 1 in) tall and weighs 50 kg (110
lb); BMI is 21 kg/m2. She is responsive to painful stimuli. Initial laboratory
studies show increased hepatic aminotransferase. Which of the following effects of
alcohol most likely contributed to this patient's condition?

Decreased generation of N-acetyl-p-benzoquinonelmine

Increased glucuronidation

Increased hepatic glutathione stores

Increased sulfation

Induction of cytochrome P450

50.A 32-year old woman comes to the physician because she has not been able to
conceive for 5 years. Previous fertility examinations of her husband showed no
abnormalities. Menses occur at regular 28-day intervals. Her blood pressure is
110/70 mm Hg. Physical and pelvic examinations show no abnormalities.
Hysterosalpingography shows normal findings. Her serum hormone concentrations are
within the reference range. Which of the following is the most appropriate
pharmacotherapy for this patient's infertility?

Bromocriptine

Clomiphene

Diethylstilbestrol

Ethinyl estradiol

Medroxyprogesterone
__________________________________
NBME 13 section 3
3.A 22-year-old man comes to the physician because of a 2-year history of episodes
of shortness of breath and wheezing. His respirations are 12/min. Physical
examination shows no abnormalities. It is found that the symptoms occur after he
takes certain over-the-counter medications containing aspirin. Laboratory studies
show a serum IgE concentration within the reference range and no eosinophilia. This
patients symptoms are most likely caused by excessive production of which of the
following substances?

Cyclooxygenase

Hydroxyeicosatetraenoic acid

Leukotrienes

Prostacyclin (PGI,)

Prostaglandins

Thromboxane A
6.A 35-year-old man who is a farmer is brought to the hospital by his wife because
of difficulty breathing, sweating, excess salivation, and diarrhea for the past 2
hours. His wife says that the symptoms started when he was applying a new
insecticide to his crops. Temperature is 36�XC (96.8�XF), pulse is 501min,
respirations are 22/min, and blood pressure is 90/60 mm Hg. Which of the following
is the most appropriate treatment?

Atropine

Lpratropium

Mecamylamine

Neostigmine

Propantheline

**15.An autopsy is done on a 50-year-old man who died of pneumonia despite 5 days
of antibiotic therapy in the intensive care unit. He had a 15-year history of
alcoholism. A photograph of a sagital section of the brain is shown, Based on this
pathology, which of the following findings was most likely present on neurologic
examination of the patient prior to his death?

Dysdiadochokinesia

Dysmetria on finger-nose testing

Essential tremor

Gait ataxia

Present Romberg sign

21.A female newborn is delivered al 34 weeks gestation in an advanced-care setting
where special delivery systems are available. The diagnosis of persistent pulmonary
hypertension is made. Considering that the newborn can be carefully monitored for
methemoglobinemia, which of the following is the most appropriate therapy?

Desflurane

Hyperbaric oxygen

Nitric oxide

Nitrous oxide

Oxygen diluted with helium

25.A 25-year-old man receives a bupivacaine injection for median nerve block as
treatment of camel tunnel syndrome. Which of the following is the mechanism of
action of this drug on the membrane?

Activation of the Na+/K+ ATPase

Decreased permeability to Ca++,

Decreased permeability to Na+

Increased reuptake glutamate

Inhibition of the Na+/Ca++ antiporter

**29.A 25 year-old woman with obstructive sleep apnea comes to the physician
because of oily, fatty bowel movements since starting a drug 1 month ago to aid in
weight loss. She has had a 5- kg (11lb) weight loss during this period. She is 157
cm (5 ft 2 in) tall and now weighs 66 kg (145 lb); BMI is 27 kg/m2. Her blood
pressure is 130/80 mm Hg; it was 140/85 mm Hg ether last visit 1 month ago.
Physical examination shows no other abnormalities. The results of serum lipid
studies done 1 month ago and at this visit are shown. Which of the following drugs
is the most likely cause of the steatorrhea and changes in lipid serum studies in
this patient?

Atorvastatin

Bupropion

Orlistat

Phentemine

Sibutramine
30.A 59-year-old man who has smoked 2 packs of cigarettes daily for 40 years
develops an ulcerated laryngeal neoplasm. Examination of tissue obtained on biopsy
of the lesion is most likely to show which of the following?

Adenocarcinoma

Reactive nodule
Squamous cell carcinoma

Squamous papilloma

Undifferentiated carcinoma
36.An executor of an estate consults with a physician concerning the terms of a
will. The deceased woman was a philanthropist who was active in addressing
disparities in health care. She designated that a large sum of her money be used to
educate the public about the leading cause of death in women. The most appropriate
use of this money would be a program addressing which of the following diseases?

Breast cancer

Cardiovascular disease

Cerebral infarction

Cervical cancer

Ovarian cancer
**37.A 35-year-old man has a 6-year history of weight loss, chronic abdominal pain,
bloating, and frequent voluminous, greasy, malodorous stools. He had similar
symptoms scan adolescent, but they resolved spontaneously within 2 years. His
mother has a similar illness that is controlled by restricting wheat, barley, and
rye in her diet. In addition to the gastrointestinal symptoms, the patient has a
chronic pruritic rash shown in the photograph of his elbow. Which of the following
is the most likely diagnosis of this patient's skin condition?
Bullous pemphigoid

Dermatitis herpetiforrnis

Epidermolysis bullosa

Erythema nodosum

Pemphigus vulgans
43.A 63-year-old woman comes to the physician because of a 2-month history of a
drooping left eyelid, intermittent pain of her left eye, and an unusually large
pupil. Her husband has told her that the eye appears to be "looking sideways."
Ophthalmologic examination shows ptosis, lateral strabismus, and mydriasis of the
left eye. An MRI of the brain shows an aneurysm of the left posterior communicating
artery. The function of which of the following muscles is most likely to remain
intact in this patient?

Ciliary

Inferior oblique

Inferior rectus

Pupillary constrictor

Superior oblique

Superior rectus

48.A 1-year-old girl is brought to the physician because of multiple bacterial

infections since birth. She is at the 40th percentile for length and 40th
percentile for weight. She has white hair, pale skin, blue irises, and prominent
red pupils. A complete blood count shows neutropenia. A peripheral smear shows
giant granules in the neutrophils. This patient's disorder is most likely due to
which of the following pathogenetic mechanisms?

Bone marrow suppression

Defect in leukocyte adhesion

Defect in phagolysosome function

Myeloperoxidase deficiency

NADPH oxidase deficiency

50.A 30-year-old woman is brought to the emergency department 6 hours after the
onset of severe abdominal pain and confusion. Her brother, father, and paternal
grandmother had similar problems. Two weeks ago, she began a low-calorie diet. Her
pulse is 120/rnin, and blood pressure is 1601110 mm Hg. Physical examination shows
restlessness, excess sweating, and tremors. There is no abdominal tenderness. Urine
studies show an increased porphobilinogen concentration. Which of the following is
the most likely pattern of inheritance causing this patient's condition?

Autosomal dominant

Autosomal recessive

Mitochondrial DNA mutation

Mutifactorial

X-linked dominant

X-linked recessive
____________________________
NBME 13 Sec. 4
2. A 6-year-old boy is brought to the physician by his mother because of a 2-day
history of fever, sore throat and occasional vomiting. His temperature is 39'C
(102.2�XF). Physical examination shows erythema and purulent exudate over the
posterior pharyngeal wall and tonsils. The anterior cervical glands are enlarged
and tender. A throat culture grows group A Streptococcus. Because he is allergic to
penicillin, treatment with erythromycin is begun. His condition improves during the
next 2 days. The effectiveness of this antibiotic is most likely due to which of
the following actions in protein synthesis?
A. Causes misreading of mRNA information
B. Functions as an analog of aminoacyl-tRNA
C. Inactivates elongation factor-2
D. Interferes in aminoacyl-tRNA binding
E. Interferes with translocation
3. A male newborn at 34 weeks�� gestation is delivered vaginally. Physical
examination shows no abnormalities except for a 1-cm, raised, red area on the
anterior section of the neck. His mother is concerned, and the physician explains
that the lesion is a hemangioma, a benign growth. This neoplasm most likely
originated in which of the following tissues?
Discuss
A. Ectoderm
B. Endothelium
C. Neural crest cells
D. Notochord
E. Yolk sac
7.
A 55-year-old man comes to the physician because of a 3-day history of fever and
shaking chills. He has end-stage renal disease treated with hemodialysis. His
temperature is 39.2�XC (102.6?F), pulse is 110/min, and blood pressure is 156/92 mm
Hg. Physical examination shows a tunneled central venous catheter entering the
right side of the chest below the clavicle; the area surrounding the catheter is
not tender. Echocardiography shows a 3-cm vegetation on the tricuspid valve. Which
of the following is the most likely causal organism?
A.
Escherichia coli

B.
KIebsiella pneumoniae

C.
Staphylococcus aureus

D.
Streptococcus pyogenes (group A)

E.
Viridans streptococcus
14.
An investigator is studying the human immune response to tumor cell antigens in
malignancies. Which of the following sets of cancer types and tumor antigens is
most likely to produce the highest antibody titer? Cancer Type Tumor
Antigen
A)B-cell lymphoma CD19
B)Breast cancer HER2/neu
C)Cervical cancer human papillomavirus type 16 E6 protein
D)Melanoma tyrosinase
E)Prostate cancer prostatic acid phosphatase
15.
A 45-year-old woman has a 2-week history of a heart murmur and hepatomegaly. She
has a 3-month history of flushing with hypotension and crampy diarrhea. Which of
the following is the most likely site of a primary neoplasm in this patient?
Discuss
A.
Adrenal gland

B.
Bone marrow

C.
Kidney

D.
Ovary

E.
Small intestine
19.
An 18-month-old boy is brought to the physician because of progressive facial
abnormalities and slow growth during the past 6 months. He has an older brother
with similar abnormalities who also has mental retardation. The patient is below
the 3rd percentile for length and at the 10Ih percentile for weight. Physical
examination shows coarse facial features, hepatosplenomegaly, and joint stiffness.
His urine concentrations of dermatan sulfate and heparan sulfate are increased. A
deficiency of which of the following enzyme activities is the most likely cause of
the findings in this patient?
Discuss
A.
Galactosidase

B.
Glycosylase

C.
Hexosaminidase A

D.
Lduronate sulfatase

E.
Lipoxygenase
20.
A 3-year-old girl is brought to the emergency department by her mother 1 hour alter
she was found with a half-empty bottle other grandmother's diabetes medication. The
mother tells the physician that the child consumed approximately 25 metformin
tablets. Physical examination shows no abnormalities. This patient is at greatest
risk for which of the following serum abnormalities?
Discuss
A.
Decreased calcium concentration

B.
Decreased glucose concentration

C.
Decreased sodium concentration

D.
Increased AST and ALT activities

E.
Increased creatinine concentration

F.
Increased lactic acid concentration
21.
A 5-year-old boy is brought to the physician by his mother because of a 3-month
history of headache, clumsiness, and fatigue. He had a generalized tonic-clonic
seizure 1 month ago. His mother says that he often falls while running.
Ophthalmologic examination shows ptosis of the left eye and bilateral external
ophthalmoplegia. Physical examination shows weakness of the left lower extremity.
Serum studies show an increased lactate concentration. Analysis of a calf muscle
biopsy specimen obtained from the left lower extremity shows ragged red fibers.
Which of the following metabolic processes is most likely impaired in this patient?
Discuss
A.
Fatty acid oxidation

B.
Gluconeogenesis

C.
Glycolysis
D.
Oxidative phosphorylation

E.
Pentose phosphate pathway
**22.

A 25-year-old woman comes to the physician because of a 2-day history of decreasing

urine output despite ample fluid intake. She underwent operative removal of a
perforated appendix 3 weeks ago. She received intravenous gentamicin for 2 weeks.
Physical examination shows no abnormalities. Laboratory studies show: Histologic
examination of this patient's kidneys would most likely show necrotic cells in
which of the following components of the nephron?
Discuss
A.
Bowman capsule

B.
Collecting tubule

C.
Glomerular basement membrane

D.
Mesangium

E.
Proximal tubule
23.
A 43-year-old man comes to the physician for a routine health maintenance
examination. He is 170 cm (5 ft 7 in) tall and weighs 86 kg (188 lb); BMI is 30
kg/m2. Physical examination and laboratory studies show no other abnormalities. He
tells the physician, "My older brother just got diagnosed with diabetes. I don't
want that to happen to me. What should I do?�� Which of the following diets is most
likely to be effective in decreasing this patients risk for type 2 diabetes
mellitus?
Discuss
A.
Low-calorie

B.
Low-carbohydrate

C.
Low-cholesterol

D.
Low-protein

E.
Low-sodium
28.
A 43-year-old man comes to the emergency department because of a 1-year history
chow back pain. Before the examination, the patient says, "My physician is arrogant
and insensitive. He never returns my phone calls, I always have to wait forever to
be seen, the tests he orders are painful and unnecessary, and he can never tell me
what is causing my back pain or how to treat it Which of the following is the most
appropriate response by the emergency department physician about this patient's
complaints?
Discuss
A.
Reassure the patent that his physician's behavior is not unusual and that low back
pain can be difficult to assess

B.
Encourage the patient to make an appointment with his physician to communicate his
concerns

C.
Explain to the patient how he may register a complaint against his physician with
the state medical licensing board

D.
Provide the patient with a copy of the Patients' Bill of Rights

E.
Telephone the patient's physician to make him aware that the patient is very
dissatisfied with treatment

**29. A 42-year-old woman comes to the physician because of a 3-week history of

numbness of the fingers on the left hand. Neurologic examination shows loss of
touch graphesthesia and loss of two-point discrimination in be left hand, This
patient most likely has a lesion in which of the following locations of the
hemispheres shown?
A. B. C. D. E. F. G. H. I. J.

30.
A 15-year-old boy is brought to the physician because of painless swelling in his
left breast for 1 month. There is no family history of breast cancer. He is at the
55th percentile for height and 70th percentile for weight. His pulse is 65(min, and
blood pressure is 116/76 mm Hg. Physical examination shows mild facial acne,
thickening of mustache hair on the face, and the presence of axillary hair. There
is no adenopathy. The left breast appears mildly enlarged with a palpable breast
bud: the right breast is normal with no gynecomastia. His genitalia are Tanner
stage 3. Which piths following is the most appropriate initial statement by the
physician regarding this patient's breast finding?
Discuss
A.
��Have you tried Smoking marijuana recently? That has been known to cause breast
enlargement "

B.
"Some teenagers experiment with their parents' prescription drugs, even birth
control pills. Are you?��

C.
��This is a common condition for teenage boys and should resolve in time."

D.
��This may be a sign of a chromosomal problem. We need to do some genetic testing��

E.
��This may be a sign of a more serious condition. We'll have to do more tests to be
sure."
**32.

A 77-year-old woman dies in the hospital after a long illness. Her vertebral
column, obtained at autopsy, is shown in the photograph. The process shown is most
likely associated with an increase in which of the following?
A.
Calcium

B.
Estrogen

C.
Interleukin-1 (IL-1)

D.
Monoclonal immunoglobulin

E.
Vitamin D

33.
A 32-year-old woman comes to the physician because of a 1-month history of
progressive shortness of breath and anxiety. She says that her symptoms become much
more pronounced as the day progresses. She is 170 cm (5 ft 7 in) tall and weighs 70
kg (155 lb). BMI is 24 kg/m2. Breath sounds are normal on auscultation of the
chest, but the patient has difficulty taking a long, deep breath. Arterial blood
gas analysis on room air shows: pH 7.33 Pco2 70 mm Hg Po2 65
mm Hg Pulmonary function testing shows a decreased vital capacity, tidal volume,
and expiratory reserve volume. Her residual volume is within the reference range.
Which of the following is the most likely underlying cause of this patient��s
condition?
Discuss
A.
A1 Antitrypsin deficiency

B.
Central nervous system neoplasm

C.
Chronic bronchitis

D.
Chronic opiate use

E.
Myasthenia gravis

F.
Obesity
**35.

A 48-year-old man comes to the physician because he is concerned about his weight.
He is 178 cm (5 ft 10 in) tall and weighs 91 kg (200 lb); BMI is 29 kg/m2. His
waist circumference is 103 cm (41 in). His blood pressure is 140/90 mm Hg. Physical
examination shows a protuberant abdomen. Laboratory studies show fasting serum
glucose and insulin concentrations that are increased and remain increased 2 hours
after the patient receives 75 g of oral glucose. Which of the following sets of
additional laboratory findings in serum is most likely in this patient?
Discuss
A. B. C. D. E. F.
**36.

In a healthy person, the thyroid gland produces and secretes thyroxine (T4),
maintaining metabolism. Which of the following best describes the T4-binding
substance in the blood and the type of cellular receptor for T4 in the peripheral
tissues?
Discuss
A. B. C. D. E. F.
**37.

A 23-year-old man comes to the physician because of a low-grade fever, nasal

congestion, and muscle aches for 1 week. He states that his girlfriend recently
told him that his eyes appeared yellow. He has not had clay-colored stools or dark
urine. His only medication is ibuprofen. He has no recent history of foreign travel
tattoos, use of intravenous drugs, or exposure to blood products. He is 183 cm (68)
tall and weighs 77 kg (170 lb); BMI is 23 kg/m2. Physical examination shows mild
scleral icterus but no subungual icteris. The remainder of the examination shows no
abnormalities. Serum studies show: Which of the following is the most likely
diagnosis?
Discuss
A.
Gilbert syndrome

B.
Hepatitis D

C.
Hereditary spherocytosis

D.
Idiopathic cirrhosis

E.
Steatohepatitis
43.
A previously healthy 54-year-old man comes to the clinic because of light-
headedness for 6 hours. His symptom began after skiing at a resort at an altitude
of 2743 m (9000 ft). He has been taking a carbonic anhydrase inhibitor since 2 days
before arrival at the resort. His blood pressure is 110/60 mmHg while sitting and
95/50 mmHg while standing. Physical examination shows no other abnormalities. Which
of the following is the most likely cause of his orthostatic hypotension?
Discuss
A.
High-altitude sickness

B.
Hypovolemia

C.
Hypoxia

D.
Impaired sympathetic nerve activity

E.
Respiratory alkalosis
47.
A 55-year-old man recovered from a stroke 2 months ago He lives alone. He is at
increased risk for which of the following psychiatric disorders?
A.
Agoraphobia
B.
Major depressive disorder

C.
Obsessive-compulsive disorder

D.
Post-traumatic stress disorder

E.
Social phobia
50.
A 3-year-old boy with a history of unexplained fever, lack of perspiration, absence
of response to noxious stimuli, and self-mutilating behavior is diagnosed with
congenital insensitivity to pain with anhidrosis. Genetic analysis shows a missense
mutation of the tyrosine kinase domain of the TrkA gene. Assuming this is the only
signaling defect in this patient, which of the following processes has most likely
been disrupted?
Discuss
A.
Binding of nerve growth factor to its receptor

B.
Formation of TrkA homodimer in response to nerve growth factor

C.
Phosphorylation of downstream molecules in response to nerve growth factor

D.
Retrograde transport of nerve growth factor from nerve terminals

E.
Synthesis of nerve growth factor