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Question 1

14 month old girl, 2 month history of diarrhea. Well varied diet.

• No history of travel or contact with similar symptoms
• Duodenum shows villous atrophy and crypt hyperplasia

Answer 1

• Celiac disease, we should modified grain diet

- Screen for anti-tissue transglutaminase antibodies

Question 2

54 year old with cough & shortness of breath
- History of coronary artery disease
- Graph shows left ventricular pressure increase as well as volume to the left
Parameter is likely increased?

Answer 2

Stroke volume, the pressure volume loop shifts up and to the left = increase in cardiac contractility

Question 3

29 yo woman sexually active
- Thin walled vesicles on an erythematous base , shallow ulcers on the labia
- Tender inguinal lymphadenopathy is present
- Tzanck smear of the genital lesions shows multinucleate giant cells
Drug that will prevent future episodes works by?

Answer 3

Incorporation into newly replicating viral DNA , ACYCLOVIR, is a nucleoside analog

Question 4

Agent that inhibits bacterial glycosyltransferase enzyme is developed.
- Resistance to the drug is determined by measuring the zone of complete growth inhibition.
Which bacteria would be resistant?

Answer 4

Mycoplasma hominis (lack wall) 
Peptidoglycan is main component of bacterial wall and glycosyltransferase is crucial component

Question 5

25 yo brought after vomiting at a party, showing blood-tinged vomitus on shirt.
- Mental examination patient is alert, he insists in going home
Course of action?

Answer 5

Explain potential risks of leaving the hospital without further evaluation

Question 6

32 yo woman 4 weeks of cough, shortness of breath and low grade fevers
- Methenamine silver staining of bronchoalveolar lavage shows image in blue
Appropriate pharmacotherapy?

Answer 6

Trimethoprim-sulfamethoxazole

Question 7

56 yo woman, progressive weight gain
- Difficulty lifting heavy objects
- Persistent bronchial asthma she uses corticosteroids
- BP is 160/90, there is symmetric proximal muscle weakness of upper and lower extremities
- Glucose level is 135 and 24h urinary cortisol is increased
- High dose dexamethasone suppresses serum cortisol levels, serum ACTH levels are high normal
Cause of symptoms?

Answer 7

Pituitary adenoma ‘‘cushing disease’’ most common cause of endogenous cushing syndrome

• Ectopic source of ACTH will not be suppressed by high-dose dexamethasone
• Administration of exogenous glucocorticoids will suppressed ACTH

Question 8

32 yo migraines
- Anisocoria
- In Bright light Right pupil is dilated and left is not
- In dim light both pupils are dilated
Defect is in which pathway?

Answer 8

• Parasympathetic innervation of the right eye.
• Lesions preceding optic chiasm ‘’ retina- optic nerve’’ cause monocular vision loss
• With sympathetic defects pupil anisocoria will increase in dim light, in bright light both pupils will constrict

Question 9

6 month old boy
- Developmental milestone and hypotonia are delayed
- 2 years later presence of involuntary movements
- Aggressively bite his own lips and fingers
- Elevated uric acid
Enzyme most likely increased?

Answer 9

Phosphoribosyl pyrophosphate amidotransferase increased

- Patient has Lesch-nyhan syndrome, activity of HGPRT is decreased

Question 10

Target protein involved in signal transduction

• Protein contain multiple alpha-helical regions , each 20 amino acid residues of valine, alanine and isoleucine
• This region will perform what function?

Answer 10

Anchoring to cell membrane ‘’ G-protein coupled receptor’’
- Transmembrane domain is made up of non polar hydrophobic amino acids

• Binding to extracellular ligand can result in activation of cAMP and tyrosine kinase, opening of ion channels ‘’ composed of hydrophilic amino acids’’

Question 11

1st study on RR of MI among woman who are taking HRT 1.3 (p=0.07)
2nd study on RR of MI among woman who are taking HRT 1.32 (p=0.03)
Problem in first study?

Answer 11

Sample size, because the alpha was too high, above 0.05

Question 12

15 month old boy, large foul smelling stools
- Bacterial pneumonia 6 months ago
- 20th percentile for length and 3rd for weight
Non-distended abdomen
- Likely present in patient?

Answer 12

Decreased focal elastase

- Patient has cystic fibrosis with pancreatic insufficiency, steatorrhea and failure to thrive

Question 13

34 yo evaluation of abdominal pain 10/10
- He has been hospitalized in the past year for similar symptoms twice
- He decline when trying to obtain past medical history
- Everything seems normal, patient ask for a note to excuse him from work
Additional features present?

Answer 13

Refusal of invasive medical procedures

Question 14

23 yo fever, headache, confusion
- cerebrospinal fluid analysis reveals lymphocytic pleocytosis and a PCR is + for herpesvirus
- Treated with high dose acyclovir on third day of treatment creatinine increases to 3.4
This could have been prevented by?

Answer 14

Aggressive intravenous hydration because of acyclovir nephrotoxicity

Question 15

23 yo lives at sea level, attempting to trek to mount everest

• He reaches base camp after 7 days
• What changes has occurred in the patient?

Answer 15

Increased erythrocyte 2,3-biphosphoglycerate ( shift of O2 Hemoglobin dissociation curve to the right)

Question 16

Newborn with elevated TSH and low thyroxine on routine screening

• Ectopic thyroid gland just below tongue
• Cause of this patient’s otherwise normal physical examination despite thyroid findings?

Answer 16

Transplacental transfer of thyroxine

‘’ Congenital hypothyroidism’’ caused by abnormal gland development or location.

Question 17

45 yo woman polyuria and nocturne
- Urine output and osmolality remain unchanged with water deprivation for several hours
- After administration of desmopressin, urine output decreases and urine osmolality increases
Clearance of what substance would decrease the most after the injection?

Answer 17

Urea transporters in the medullary collecting duct, increasing urea reabsorption and decreasing renal urea clearance = enhance medullary osmotic gradient

Question 18

34 yo woman with dysuria
- Gram negative bacteria form pink colonies on lactose containing MacConkey agar
- Days later colonies appear white on same medium
This is caused by a single nucleotide deletion within the lac operon DNA sequence
- Change is most consistent with?

Answer 18

Frameshift mutation ‘’ deletion or insertion ‘’ of nucleotides not multiples of 3

Question 19

6 yo boy persistent nasal bleeding
- Boy picking the nasal aloe for over 30 minutes
- Negative history of bleeding disorders
- Silver nitrate cautery is performed and bleeding stops
Cautery applied to which location?

Answer 19

Nasal septum known as Kiesselbach plexus

Question 20

32 yo with paroxysmal supraventricular tachycardia

• Focal atrial tachycardia that originates in the Arita terminalis of the right atrium
• Nerve is close proximity to the treatment site and at risk for injury during ablation?

Answer 20

Phrenic nerve

Question 21

36 yo woman with mitral valve prolapse

• Continuous heparin and warfarin are initiated
• INR >2.5 is achieved on day 5 and heparin is discontinued
• What caused the delay in achieving therapeutic INR?

Answer 21

Clotting factors generated before warfarin initiation

Question 22

28 yo primigravid

• Administration of anti-Rh immunoglobulin
• Antibodies belong to which immunoglobulin classes?

Answer 22

IgG

Question 23

83 yo woman from nursing home
- Past 24hs combative and agitated 
- History of anxiety and depression
- Cannot state days of the week backwards
- She strikes out at a nurse's aide
How to treat behavioural symptoms?

Answer 23

Haloperidol

- She is suffering from delirium ‘‘agitation and psychosis’’

Question 24

26 yo woman, fever, joint pain
- week ago pain in small joints of her right hand
- Temperature is elevated, extremity joints are not erythematous or swollen
- Several small nontender pustules are seen on the extremities
- Culture grows on chocolate agar medium
What could have prevented the patient condition?

Answer 24

Using condoms consistently

Patient has Gonorrhoeae

Question 25

``` 65 yo man with right lower abdominal pain that radiated to his groin - Climbing stairs is difficult - Patient takes warfarin - Right patellar reflex is decreased - No signs of urinary stone problem? ```

Answer 25

Retroperitoneal hematoma '' common in patient receiving anticoagulant therapy'' causing FEMORAL NERVE MONONEUROPATHY ( Loss of sensation on the anterior aspect of the right thigh) - Nerve descends through the posts major muscle

Question 26

5 yo boy draining liver abscess undergoes hepatectomy - Cultures grow staph aureus - Inactivating mutation affecting neutrophil oxidase enzyme - Increased risk of infection for?

Answer 26

Burkholderia cepacia - chronic granulomatous disease

Question 27

3 day old boy poor feeding and emesis - Normotensive and tachycardic, dehydrated - Patient vomits and looks with green bile - Fibrous bands are seen extending from cecum and right colon to the retroperitoneum causing compression of duodenum - Embryologic process that failed?

Answer 27

Midgut rotation around the superior mesenteric artery

Question 28

67 yo man several nodules in his axilla - History of malignant melanoma on upper back - Pembrolizumab is initiated which leads to reduction in size Which best correlate to treatment-response?

Answer 28

CD8 lymphocyte infiltration | - Programmed death ligand 1 (PD-L1)

Question 29

34 yo russian immigrant, dyspnea and swelling. - Gained 4.5 kg Jugular venous pressure tracing is shown, waveform indicated by first peak correspond to?

Answer 29

Atrial contraction | - Second peak occurs because of isovolumentric ventricular contraction

Question 30

Patient with increased right atrial pressure, CT scan shows white line around heart, + lower extremity edema and weight gain Diagnosis?

Answer 30

Constrictive pericarditis

Question 31

6 yo boy with 3 days of fever and headaches - Vaccinations up to date - mild pharyngeal erythema in addition to neck stiffness - CSF highly lymphocytes Agent causing this?

Answer 31

Enterovirus '' coxsackievirus, echovirus'' cause of aseptic meningitis

Question 32

Prevalence of chronic disease in a population that sees young individuals emigrate. What effect will have on the disease prevalence over the next few years?

Answer 32

Prevalence would increase

Question 33

``` 17 yo girl had a seizure - She has a history of depression - Pupils are dilated, bowel sound decreased - Sinus tachycardia Cause ? ```

Answer 33

TCA overdose

Question 34

17 yo girl autopsy shows ovaries composed of connective tissue with no follicles - Additional abnormalities is likely to be found on postmortem examination?

Answer 34

Bicuspid aortic valve - Turner syndrome 45 XO - Premature ovarian failure characterized by high LH and FSH levels

Question 35

New glycopeptide antibiotic - Administration to adults and neonatal patients shows higher plasma concentration in adults. What causes the difference in drug effectiveness between adults and neonates?

Answer 35

Neonates have higher body water content, larger volume of distribution

Question 36

New amino glycoside antibiotic is developed against Pseudomonas - Vd is 4.5L New drug is most likely to have which properties?

Answer 36

It is highly charged or has high molecular weight, high plasma protein binding and hydrophilicity -Lipophilic drugs readily cross cell membranes therefore have a higher volume of distribution

Question 37

46 yo man hospitalized with diabetic ketoacidosis - On call physician hands off the patient to day shift physician who arrives an hour late due to nightshift job - Day shift physician forgets to check patient's anion gap. Cause?

Answer 37

Physician fatigue

Question 38

65 yo man weakness and lethargy, he has lost 5kg over past month - Smokes 1-2 packs for 40 years - Serum calcium is 14 - 8cm right lung mass with enlarged mediastinal lymph nodes Serum levels of what substance is elevated?

Answer 38

PTH- related protein

Question 39

21 yo postcoital bleeding - Patient and partner do not use condoms - Have never been diagnosed with a sexually transmitted infection - Cervix has an area of erythema surrounding external os and scant clear discharge - Papanicolaou smear shows?

Answer 39

Koilocytes ''HPV''

Question 40

``` 29 yo woman left hip pain - History of hyperthyroidism - Large, hyperpigmented macule with irregular borders located on left shoulder -Menarche at 7 yo X-ray shows osteolytic lesions Diagnosis? ```

Answer 40

McCune- Albright syndrome ( precocious puberty, fibrous dysplasia, café au lait) - Mutation in GNAS gene, continuous activation in G-Protein/CAMP/ adenylate cyclase pathway

Question 41

62 yo abdominal swelling - Alcohol induced pancreatitis - Icteric sclera, spider angiomas - Serum sodium is 130 What would be seen in serum ADH, urine sodium and total body volume?

Answer 41

Increase body volume, increase ADH, decrease urine sodium

Question 42

``` 32 yo hearing and seeing things that do not exist. - Painful throat spasms - Returned from camping trip 4 weeks ago - Mydriasis and neck rigidity Which is receptor of this condition? ```

Answer 42

Muscle acetylcholine receptors | - Patient has rabies

Question 43

15 yo girl, amenorrhea - 5th height and 20th weight - High arched palate and tanner stage i breast, widely spaced nipples Evaluation will show?

Answer 43

- Atrophic ovaries, patient has turner syndrome

Question 44

Image of sarcomere - Monoclonal antibodies directed against the binding of actin to structural support elements Region antibodies attack?

Answer 44

Line in black in the left periphery

Question 45

Study 300 patients - 100 have UTI - 70% sensitive 90% specific How many false positives?

Answer 45

20

Question 46

Study demonstrate association between alcohol consumption and transitional bladder carcinoma - RR of 1.81 and p-value of 0.03 - Divide in 2 groups smokers and non smokers Presence of discrepancy explained by?

Answer 46

Confounding, same as show she and intelligence in a school

Question 47

52 yo woman with pain and redness in her leg. - Severe leg cellulitis, given IV cefazolin - Minutes later she develops itching, dizziness and drop in BP, bilateral wheezing What is elevated because of her medication?

Answer 47

Tryptase ''anaphylactic reaction'' | - Mast cell and basophil degranulation release histamine and tryptase

Question 48

Anaphylactic reaction determined by antigen-specific IgE antibodies attached to high affinity receptors on the surface of mast cells and basophils What mechanism will trigger vasoactive substance release by these cells

Answer 48

Receptor aggregation

Question 49

Reduced number of ribosomes attached to ER. This change is likely to impair what function?

Answer 49

Synthesis of cell membrane proteins

Question 50

15 yo boy unexplained erythrocytosis - Single base substitution at amino acid position 82, replace lysine with methionine. - Impairs interaction of B subunit and 2,3 biphosphoglycerate Hemoglobin will be similar to?

Answer 50

Hemoglobin F

Question 51

52 yo man severe low back pain - Pain worse with back flexion and raising of the legs - Pinprick in perianal area does not cause rapid contraction of the anal sphincter. Nerve root involved?

Answer 51

S4

Question 52

Respiratory distress after eating at a buffet. - BP is low, pulse is high, respirations are 32/min - Diffuse wheezing and erythematous skin rash are present Changes seen in CVP, Pulmonary capillary wedge pressure, systemic vascular resistance?

Answer 52

Everything will decrease in anaphylactic shock

Question 53

``` 27 yo herniated disc, - Pain and asks for dose increase and refill - Came twice already for pain medication - Examination is unremarkable What should the physician say? ```

Answer 53

You're still experiencing a lot of pain, and it has not been easy managing it, let's discuss how you have been taking the medication

Question 54

50 yo woman had myopia for decades, she rarely has to wear glasses now. Which condition has same etiology as the changes in the patient?

Answer 54

Skin wrinkles

Question 55

29 yo wo at 28 weeks gestation - 2/6 blowing systolic murmur best heard at the left sternal border. - Murmur intensifies with inspiration - 1+ pitting edema Which is responsible for patient's murmur?

Answer 55

High blood flow across the pulmonic valve | '' Increase cardiac output during pregnancy''

Question 56

58 yo wo history of hypothyroidism - Large amount of interferon gamma is detected in her blood Which cell types is responsible for this finding?/

Answer 56

T lymphocytes | Latent tuberculosis infection

Question 57

40 yo wo with left leg weakness - Symptoms began 3 days after her father ha a heart attack - Physical examination reveals nothing Diagnosis?

Answer 57

Conversion disorder

Question 58

53 yo man pins and needle sensation in right hand - Loss of sensation over right 5th digit Weakness of which go the following movements?

Answer 58

Wrist adduction , damage to ulnar nerve - It enters forearm passing posterior to the medial epicondyle of the humerus - It innervated flexor carpi ulnaris and medial portion of flexor digitorum

Question 59

65 yo disoriented, brought in by friend - Sister lives in the area - Needs to make a decision about treatment in the next 2-3 hours What to do?

Answer 59

Attempt to contact the patient's sister for consent to intubate

Question 60

54 yo wo non healing gastric ulcer - Shiny tongue and pale palmar crease - Gait is unstable, vibration sense is markedly decreased over lower extremities, With loss of strength Spinal cord lesions?

Answer 60

Subactute combined degeneration ( B12 deficiency) | Damage to dorsal columns and lateral corticospinal tracts