Biomedical sciences Flashcards

Question 1

Q

A farmer who frequently clears the bush in Dominica with his cutlass presents to the Ross Clinic with a fungal skin infection. Which of the following are most characteristic properties of the agent causing the infection? A) Double-stranded DNA chromosome in a nucleoid B) Smooth cytoplasmic endoplasmic reticulum studded with ribosomes C) Enveloped nucleocapsid encasing a double-stranded DNA chromosome D) Cell wall containing peptidoglycan and a circular DNA chromosome E) Ergosterol in the cell membrane of septate hyphae F) Protein able to induce change in conformation of another protein

Question 2

Q

Normal microbiota are first acquired during A). during birth B) after one year of age C). by age five D). during the first month E). at age eighteen

Question 3

Q

Which of the following concerning Koch’s postulates is incorrect? A) The infectious agent must be found in the majority of individuals with a particular disease B) Koch’s postulates cannot be applied to find the agent of all diseases C) A suspected agent must be able to be demonstrated in the laboratory D) All of Koch’s postulates must be satisfied before a pathogen can be proven to cause a particular disease

Question 4

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All of the following are properties of viruses with of the exception that: A) they are not cellular B) they cannot be detected with a light microscope C) they are composed only of genetic material D) they are cellular parasites E) they are smaller than prokaryotes

Question 5

Q

Candida albicans is an example of which of the following? A) nematodes B) fungi C) viruses D) protozoa E) prokaryotes

Question 6

Q

Gastrointestinal tract infections occur primarily through a specific route. Which of the following modes of transmissions and respective countermeasures apply to gastrointestinal tract infections? A) fecal-orally; proper hand hygiene using soap and water B) postnatally; omittance of breastfeeding C) respiratory; covering up when sneezing D) sexually; proper use of condoms

Question 7

Q

A 35-year-old female hiker presents to her physician complaining of diarrhea. She recently had been drinking water from mountain streams, likely contracting an intestinal parasite. Which step of the infectious cycle is associated with excreting contaminated feces containing the parasite through diarrhea? A) Transmission B) Adhesion C) Colonization D) Invasion E) Contamination

Question 8

Q

A 43-year old diabetic woman complains about genital pruritus and a white-creamy discharge from her vagina indicative of a yeast infection after completing antimicrobial therapy. What agent is most likely responsible for her symptoms? A) Candida albicans B) Clostridium perfringens C) Staphylococcus aureus D) Pseudomonas aeruginosa E) Bacillus anthracis

Question 9

Q

An experimental protocol requires injecting a new mutant pathogen into mice. The researcher following the protocol notices the next day that all experimentally inoculated animals are dead. Which of the following measurements is associated with the all of the injected mice dying? A) ID100 B) LD100 C) ID50 D) LD50

Question 10

Q

A researcher is testing the importance of various virulence factors in a bacterial pathogen using site- directed mutagenesis. He converts a codon near the 5’ end of a gene to a stop codon, and notes that the resulting mutants are less able to adhere to mammalian cells in culture. What is the most likely product of the gene he mutated? A) 16S ribosomal RNA B) Transpeptidase C) Flagellin D) Pilin E) Type III secretion system component

Question 11

Q

A 3-year-old girl presents with a severe cough which produces a loud sound when he gasps for air. Bordetella pertussis is most likely causing the disease. Part of the virulence is autophosphorylation of a sensor and transfer of phosphate to a response regulator. Which of the following best describes this system? A) Two-component system B) Biofilm formation C) Adhesion D) Formation of the RNA polymerase holoenzyme E) SOS response E) SOS response F) Pathogenicity island

Question 12

Q

Which of the following nutrients is sequestered by the mammalian system as a protective mechanism and is often the rate-limiting nutrient for bacterial growth? A. Selenium B. Glucose C. Fatty acids D. Molybdenum E. Iron

Question 13

Q

Sporulation in Bacillus subtilis requires promoter recognition. Which of the following affects promotor recognition of the RNA polymerase? A) Sigma factor B) 30S ribosomal subunit C) 50S ribosomal subunit D) Sigma replication E) DNA polymerase I

Question 14

Q

DNA ligase A) breaks hydrogen bonds between complementary nucleotides. B) synthesizes short DNA molecules important for the function of DNA polymerase. C) seals gaps between DNA fragments. D) proofreads DNA molecules. E) assists in recognition of promoters during transcription.

Question 15

Q

In addition to coding for the amino acid methionine, what function does the codon AUG have? A. termination signal B. Start signal C. causes “wobble” D. marker for introns E. recognition site for RNA polymerase

Question 16

Q

The binding of sigma factors improves the specificity of a multiprotein complex that carries out which process? A. Conjugation B. Type III secretion C. DNA replication D. Transcription E. Translation

Question 17

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Which of the following protein secretion pathways is most commonly used by Gram-positive bacteria? A. Type II secretion B. Type I secretion C. General secretion D. Type IV secretion E. Main terminal branch

Question 18

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All of the following are characteristics of Okazaki fragments EXCEPT: A) they are checked for accuracy by DNA polymerase III. B) they make up the lagging strand of replicated DNA. C) they begin with an RNA primer. D) they are joined together by DNA ligase. E) they make up the leading strand of replicated DNA.

Question 19

Q

Which of the components of the lac operon is necessary for RNA polymerase binding? A) Promoter B) Repressor C) Permease gene lacZ D) β-galactosidase gene lacZ E) Transacetylase gene lacA

Question 20

Q

How does short interference RNA (siRNA) work? A) It binds to and inactivates a target nucleic acid sequence. B) It binds RNApol and inactivates it. C) It binds to a regulatory protein, which in turn inactivates a gene. D) It creates frameshift mutations that produce nonfunctional versions of proteins. E) It converts heterochromatin to euchromatin.

Question 21

Q

Transcription terminates after a stem-loop structure is formed in the messenger RNA. Which of the following best describes the process? A) Sigma factor-dependent termination B) Rho-independent termination C) Elongation factor closing D) DNAse-dependent termination E) Rho-dependent termination

Question 22

Q

Iron is so important for bacterial growth that bacterial pathogens have highly evolved systems to compete for free iron. What is the key protein to this system? A. ferredoxin B. lactoferrin C. lactoflavin D. siderophore E. transferrin

Question 23

Q

A 5-year-old boy has pus-filled vesicles and dry, crusted lesions on his face. A Gram stain of the pustular exudates shows gram-positive cocci in grape-like clusters. What is a unique component of the cell wall of the causative agent? A. C polysaccharide B. lipid A C. lipopolysaccharide D. lipoteichoic acid E. M protein

Question 24

Q

Which of the following characterizes a Gram-negative bacterium? A. a thick periplasm, 1 plasma membrane, LPS and teichoic acid B. a thick periplasm, 2 plasma membranes and LPS C. a thin periplasm, 2 plasma membranes, no LPS, teichoic acid and lipoteichoic acid D. the presence of teichoic acid in the cell wall

Question 25

Q

If microbial infection is BEST CLASSIFIED by the degree of host damage incurred over time, what are the two primary determinants of infectious disease? A. antibiotic resistance of the bacterial pathogen and the doubling time of the bacterium B. status of the host immunity and the virulence properties of the pathogen C. status of the host immunity and time-to-treatment D. transitional between commensalism and opportunistic pathogen

Question 26

Q

A mother brings her 20-year-old daughter to the primary care clinic. During the medical examination, the patient becomes agitated and begins to yell. In private, the patient’s mother discloses that, the previous day, the patient violently assaulted a classmate at school. The patient’s mother also discloses that she has heard her daughter talking loudly to herself and that her daughter believes “people are out to get her”. The physician determines that the patient is in imminent danger of causing harm to others. Which of the following is the most appropriate verbal intervention for the physician to make at this time? A. “I would like to help you by giving you some medication.” B. “Can you tell me if you suffer from delusions?” C. “If you do not behave, I will have to call security.” D. “If you can’t control yourself, you’ll have to see another physician.”

Answer

A

Correct answer is A. Because of the patient’s recent history of violence and current agitated state it would be best align with the patient and help them gain control. Remember, the physician wants to 1) Identify the problem, 2) Recognize the dynamics involved, and 3) Determine which technique(s) may be best applied for a good resolution. This scenario combines a patient who may be suffering from psychosis and aggressive behavior. In general, patients suffering with psychosis/delusions have poor insight into their illness (Answer choice B). It is important to NOT place the patient under pressure (Answer choice C and D). For patients demonstrating the potential for aggression, it is best to align with the patient – I/we will need to help you to regain control (answer Choice A)

Question 27

Q

A 46-year-old woman presents to a primary care clinic, complaining of a stomach ache. During the medical interview, the patient is very talkative and states that the physician is “very handsome” and asks him, “Do you work out?”. The patient’s past medical record indicates a pattern of similar flirtatious behaviors during previous office visits. Which approach would allow for exploration of the patient’s history without encouraging her flirtatious behavior? A. Frequent use of open-ended questions B. Repeated reflection of affect/emotion statements C. Exploration of sexual fantasies D. Frequent use of close-ended questions E. Repeated reflection of content statements

Answer

A

The correct answer is D. Some patients may present with flirtatious and attention seeking behavior. For these patients, physicians should remain calm, non-flirtatious, as well as, maintain professional boundaries. Thoughtful use of closed ended questions help clinician establish professional boundaries/limits. In contrast, frequent use of open-ended questions (Answer choice A) or further exploration of a patient’s sexual fantasies (Answer choice C) may/will encourage the patient to violate professional relationship boundaries. The purpose of reflective statements (Answer choices B and E) are to encourage further self-disclosure by the patients. In these scenarios, it is better for the physician to not respond to flirtatious statements/behavior (Answer choice D.)

Question 28

Q

A 68-year-old woman, recently diagnosed with diabetes, is being seen in the primary care clinic. During the medical interview, the patient discloses that she drinks 4 to 5 drinks of rum each night. She states that she likes to drink and is enjoying her recent retirement. According to the Transtheorectical model of behavior change, the physician should guide the patient to which of the following stage of change? A. Pre-contemplation B. Contemplation C. Preparation D. Action E. Maintenance

Answer

A

Correct answer is B. Because of the patient’s recent diagnosis of diabetes, it is important for the physician to address her nutrition and/or lifestyle behaviors (i.e., modifiable health behaviors). The patient reports that she drinking 4 to 5 drinks of rum each night, that she “likes to drink”, and is “enjoying her retirement”. These statements indicate that the patient has no intention of changing her behavior (the pre-contemplation stage or Answer choice A). However, the clinician will want to help this patient understand the risks of her continued use of rum/alcohol (substances that contains high sugar content) versus the positive benefits of treating her diabetes. By employing this patient education strategy, the physician will guide the patient to the contemplation stage (Answer choice B).

Question 29

Q

A 24-year-old man is being seen in the campus health clinic. During the medical interview, the patient discloses that he is only sleeping 3 hours each night. The patients states that he “should be getting more rest” but that “it is important to get good grades”. According to the Transtheorectical model of behavior change, the physician should use which of the following strategies to guide the patient to their next stage of change? A. Educate on risks versus benefits and positive outcomes related to change B. Develop realistic goals and timeline for Change C. Identify barriers and misconceptions D. Provide positive reinforcement

Answer

A

Correct answer is C. The patient reports that he is “only sleeping 3 hours each night” and that he “should be getting more rest”. These statements indicate that the patient is ambivalent about changing (or is in the Contemplation Stage). In other words, he wants “more rest”, but he also wants to “good grades”. During this Contemplation Stage, a person weighs the benefits of change versus costs or barriers (e.g., time, expense, bother, fear) of change. In order to guide the patient to next stage or the Preparation Stage, the clinician will want to employ strategies (statements) that help the patient identify barriers and misconceptions (Answer choice C). Inherent in this patient’s thinking is “if I take more time to sleep, I will not get good grades. Answer choice A is for patients in the Pre-Contemplation stage, while answer choice B is employed for patients in the Preparation stage. Answer choice D help patients remain in and/or move to the Maintenance stage of change.

Question 30

Q

A 68-year-old woman, recently diagnosed with diabetes, is being seen in the primary care clinic. During the medical interview, the patient discloses that she drinks 4 to 5 drinks of rum each night. She states that she likes to drink and is enjoying her recent retirement. The physician responds by stating, “So drinking helps you to relax and feel comfortable”. Which of the following best describes the physician’s statements? A. Reflection of content B. Reflection of affect/emotion C. Reflection of meaning D. Developing discrepancy E. Rolling with resistance

Answer

A

Correct answer is B. The patient reports that that she “likes to drink”, and is “enjoying her retirement”. These statements indicate that the patient is in the pre-contemplation stage of change. In order to express the “Spirit” of Motivational Interviewing (i.e., Collaboration - not confrontation; Evocation - not imposition; and Autonomy - not dependence). This clinician employs a reflection of affect/emotion by simply stating “So drinking helps you to relax and feel comfortable”. A reflection of content (answer choice A) would be a paraphrasing statement (e.g., so just a few drinks each day; you like retirement). A refection of meaning (answer choice C) would be a statement that the physician has a deeper understanding of the patient’s values, vision, goals. For example, “It’s important for you to have a good quality of life”.

Question 31

Q

A 24-year-old man is being seen in the campus health clinic. During the medical interview, the patient discloses that he is only sleeping 3 hours each night. The patients states that he “should be getting more rest” but that “it is important to get good grades”. The physician responds by stating, “Help me understand how you will do well on exams if you are exhausted”. Which of the following best describes the physician’s statements” A. Reflection of content B. Reflection of affect/emotion C. Reflection of meaning D. Developing discrepancy E. Rolling with resistance

Answer

A

Correct answer is D. The patient reports that he is “only sleeping 3 hours each night” and that he “should be getting more rest”. These statements indicate that the patient is in the Contemplation Stage. During the Contemplation Stage, patients weigh the benefits of change (getting more rest) versus costs of change (not getting good grades). To further amply this ambivalence and guide the patient to the Preparation Stage, the clinician develops discrepancy (Answer choice D) by stating, “Help me understand how you will do well on exams if you are exhausted”. Remember, in order to develop discrepancy, the physician: 1) clarifies important goals (do well on exams), 2) ask for help in understanding, 3) be sincerely curious, 4) Use “so”, “if” reflectively, 5) lets the patient make the argument for change, 6) explores the potential consequences of patient’s behaviors and 7) creates and amplify the discrepancy between behavior and goals. In this scenario, the clinician uses both a reflection of content (well on exams) and affect (you are exhausted) in order to achieve a goal of developing discrepancy (the best answer for this vignette).

Question 32

Q

-year-old girl presents with a severe cough which produces a loud sound when he gasps for air. Bordetella pertussis is most likely causing the disease. Part of the virulence is autophosphorylation of a sensor and transfer of phosphate to a response regulator.
Which of the following best describes this system?
A) Two-component system
B) Biofilm formation
C) Adhesion
D) Formation of the RNA polymerase holoenzyme E) SOS response
F) Pathogenicity island

Question 33

Q

Which of the following nutrients is sequestered by the mammalian system as a protective mechanism and is often the rate-limiting nutrient for bacterial growth?
A. Selenium
B. Glucose
C. Fatty acids
D. Molybdenum
E. Iron

Question 34

Q

Concerning plasmids, all of the following is true EXCEPT:
A) They can replicate autonomously.
B) They can carry genes that confer resistance against antibiotics.
C) They can be found in bacteria, fungi, and protozoa.
D) They are small circular molecules of DNA.
E) They carry genes that are required for growth and repair

Question 35

Q

Sporulation in Bacillus subtilis requires promoter recognition. Which of the following affects promoter recognition of the RNA polymerase?
A) Sigma factor
B) 30S ribosomal subunit
C) 50S ribosomal subunit
D) Sigma replication
E) DNA polymerase I

Question 36

Q

DNA ligase
A) breaks hydrogen bonds between complementary nucleotides.
B) synthesizes short DNA molecules important for the function of DNA polymerase.
C) seals gaps between DNA fragments.
D) proofreads DNA molecules.
E) assists in recognition of promoters during transcription.

Question 37

Q

Concerning transcription in bacteria, all of the following statements are true EXCEPT:
A) It occurs in the nucleoid region.
B) Sigma factors are parts of RNA polymerase that recognize promoter regions.
C) There is only a unique sigma factor, which is termed Rho protein.
D) Termination is either self-induced or due to the presence of Rho protein.
E) A variety of sigma factors affect transcription.

Question 38

Q

Which of the following is involved in translation?
A) rRNA
B) tRNA
C) mRNA
D) siRNA
E) Both A and C are correct.
F) A, B, and C are correct.

Question 39

Q

RNA polymerase and DNA polymerase differ in all of the following ways with the exception
of:
A) efficiency of proofreading.
B) type of nucleotides used.
C) direction of polymerization.
D) termination.
E) dependence on sigma factors.

Question 40

Q

Which of the following describes the majority of human pathogens?
A. Anaerobic mesophiles
B. Neutrophilic mesophiles
C. Neutrophilic aerophiles
D. Osmotolerant anaerobes
E. Osmotolerant aerophiles

Question 41

Q

In addition to coding for the amino acid methionine, what function does the codon AUG have?
A. termination signal
B. Start signal
C. causes “wobble”
D. marker for introns
E. recognition site for RNA polymerase

Question 42

Q

A 45-year-old woman presented to her primary care physician with a chief complaint of episodic headaches, unusual olfactory experiences (smelling a strong unpleasant smell that is not smelled by others), and periods of confusion. She feels certain that she is experiencing a “mental breakdown” but after performing a careful history and physical (H&P) exam, the physician recognizes that her symptoms may be related to seizure activity and decides to make a referral to a neurologist. Which of the following is the most important reason for documenting a clear and thorough H&P.
A. To avoid litigation
B. To provide continuality of care
C. To summarize the physical examination
D. To have an organized “daily update” in the medical record.

Answer

A

Correct answer is B. In this situation, a clear and thorough H&P will allow the neurologist to understand the primary care physician’s clinical reasoning and give the specialist enough information to guide further assessment as part of continuity of care. Although an H&P will be considered a medical-legal document as part of the patient’s medical record, there is nothing in this vignette to imply there is a risk for litigation (answer choice A). A summary of the physical exam is only one component of the H&P (answer choice C). An H&P is different than a SOAP note which is a standardized way of creating a “daily update” in a patients chart (answer choice D).

Question 43

Q

An 89-year-old white female with a significant Past Medical History (PMH) of coronary artery disease and hyperlipidemia, presents for follow up of chronic bilateral lower extremity (LE) edema. She noted that her edema, although present for about a year, has worsened in the past month. The woman denies any episodes of chest pain, palpitations or dyspnea. Her vital signs were: B/P 154/90(RUE), 142/88 (LUE); HR 68 regular; RR 22, not labored; T 97.4. Weight: 123 lbs (increase of 3 lbs over past month). Which section of a SOAP note would be used to record her physical exam results? A. Subjective B. Objective C. Assessment D. Plan

Answer

A

Correct answer is B. The “Objective” part of a SOAP note is used to record observations and physical exam results including vital signs, weight, general impression, focused PE results, lab findings, etc. The Subjective part of the note would include information from the patient (e.g., relevant HPI, PMH, FH, SH) (answer choice A). The Assessment part of the note would include a list of the current problems and differential diagnosis (answer choice C). The Plan part of the note would include treatment plans for managing each problem and recommendations about further testing/treatment.

Question 44

Q

43-year-old man with diabetes and chronic kidney disease is seen in the ED after a bicycle accident that resulted in minor abrasions and lacerations. After taking care of the man’s wounds, the attending physician is concerned about the man’s kidney functioning and recommends that he be admitted to the hospital to evaluate him for acute renal failure. However the man is adamant
that he feels fine and just wants to go home. What is the best next step for the physician to take?
A. Document that the man is leaving “against medical advice.”
B. Warn the man that if his kidneys are in fact failing he could die.
C. Ask the man why he feels so strongly about leaving, explain the potential consequences, and
emphasize the benefits of further hospitalization.
D. Involved the man’s spouse or next of kin to convince him that further evaluation is in his best
interest.
E. Warn the man that if he attempts to leave he will need to be restrained.

Answer

A

Correct answer is C. When faced with this situation it is best not to coerce, threaten or scare patients into staying. It is important to find out what is motivating the patient’s choice, listen to grievances, attempt to restore the therapeutic alliance, and explain risks/benefits. If the patient still wishes to leave then, it would be important to follows standardized procedures for documenting what occurred and ensure that the patient is making an informed choice.

Question 45

Q

A patient has not paid their bill for the last three appointments and is now requesting their medical records be sent to another provider. What is the most appropriate way to manage the medical records in this situation? A. Send the patient another bill using certified mail and explain that their records will not be released until their balance is $0. B. Send the outstanding balance and medical records to a third-part collections agency. C. Offer to send a digital version of the medical records since there will not be an additional cost associated with copying them. D. Release the medical records to the other provider as requested.

Answer

A

Correct answer is D. Physicians cannot refuse to transfer records requested by the patient (or authorized representative) for any reason. It would not be appropriate to withhold records until payment was made (answer choice A). Although outstanding bills are sometimes sent to a collections agency, the medical records would not be sent to a third party (answer choice B). Medical records may or may not be kept as digital versions in an electronic medical record (EMR) system (answer choice C).

Question 46

Q

A 50-year-old woman with a history of unstable angina suffers an
acute myocardial infarction. Thrombolytic therapy with tissue
plasminogen activator (tPA) is administered to restore coronary
blood flow. In spite of the therapy, the degree of cardiomyocyte
injury may increase because of which of the following cellular
abnormalities?
A. Loss of cytoskeletal intermediate filaments
B. Decreased intracellular pH from anaerobic glycolysis
C. Increased free radical formation
D. Mitochondrial swelling
E. Nuclear chromatin clumping
F. Reduced protein synthesis

Answer

A

C: Increased free radical formation (restoration of blood flow, aka reperfusion, will bring
more calcium in oxygen to previously ischemic cells. An excess with oxygen, more free
radicals will be formed).

Question 47

Q

In an experiment, a disease process is found, which leads
to scattered loss of individual cells, with the microscopic
appearance of cell and nuclear fragmentation. The overall
tissue structure remains intact. This process is most
typical for which of the following diseases?
A. Viral hepatitis
B. Brown atrophy of the heart
C. Renal transplant rejection
D. Chronic alcoholic liver disease
E. Barbiturate overdose

Answer

A

A: Viral hepatitis is a classical example of viral-induced apoptosis.

Question 48

Q

Answer

A

A: Coagulative necrosis (large vegetations on the aortic valve rapidly turn into
thromboemboli with possible following instruction of the splenic artery and ischemic
necrosis that is coagulative in nature.

Question 49

Q

A 73-year-old man suffers a stroke. On physical examination he
cannot move his right arm. A cerebral angiogram demonstrates
occlusion of the left middle cerebral artery. An echocardiogram
reveals a thrombus within the dilated left atrium. Which of the
following is the most likely pathologic brain alteration that will be
observed 24 hours after the initial event?
A. Cerebral softening from liquefactive necrosis
B. Pale infarction with coagulative necrosis
C. Predominantly the loss of glial cells
D. Recovery of damaged neurons if the vascular supply is
reestablished
E. Wet gangrene with secondary bacterial infection

Answer

A

B: Pale infarct with coagulative necrosis as a result of thromboembolism of a cerebral
artery. It 2-3 days coagulative necrosis converts to liquefactive one.

Question 50

Q

A 73-year-old man suffers a stroke. On physical examination he
cannot move his right arm. A cerebral angiogram demonstrates
occlusion of the left middle cerebral artery. An echocardiogram
reveals a thrombus within a dilated left atrium. Which of the
following is the most likely pathologic brain alteration that will be
observed 7 days after the initial event?
A. Cerebral softening from liquefactive necrosis
B. Pale infarction with coagulative necrosis
C. Predominantly the loss of glial cells
D. Recovery of damaged neurons if the vascular supply is
reestablished
E. Wet gangrene with secondary bacterial infection

Answer

A

A: Cerebral softening with liquefactive necrosis

Question 51

Q

A 40-year-old woman has sudden onset of severe abdominal pain.
Physical examination reveals diffuse tenderness in all abdominal
quadrants, with marked guarding and muscular rigidity. Laboratory
findings include serum AST- 43 U/L, ALT-30 U/L, LDH 630 U/L, and
lipase 415 U/L. An abdominal CT scan reveals peritoneal fluid
collections and decreased attenuation along with an enlarged
pancreas. Which of the following cellular changes is most likely to
accompany these findings?
A. Coagulative necrosis
B. Dry gangrene
C. Fat necrosis
D. Apoptosis
E. Liquefactive necrosis

Answer

A

C: Fat necrosis due to release of pancreatic enzymes.

Question 52

Q

A 30-year-old woman is claiming in a civil lawsuit that her
husband has abused her for the past year. A workup by her
physician reveals a 2 cm left breast mass. There is no
lymphadenopathy. No skin lesions are seen, other than a bruise to
her upper arm. A needle biopsy of the breast mass is performed.
On microscopic examination, the biopsy shows fat necrosis. This
biopsy result is most consistent with which of the following
etiologies?
A. Physiologic atrophy
B. Breast trauma
C. Lactation
D. Radiation injury

Answer

A

B: Breast trauma is a common cause of traumatic fat necrosis

Question 53

Q

A 48-year-old woman has a malignant lymphoma involving lymph
nodes in the para-aortic region. She is treated with a
chemotherapeutic agent which results in the loss of individual
neoplastic cells through fragmentation of individual cell nuclei and
cytoplasm. Over the next 2 months, the lymphoma decreases in
size, as documented on abdominal CT scans. By which of the
following mechanisms has her neoplasm primarily responded to
therapy?
A. Coagulative necrosis involving protein denaturation
B. Autophagy involving lysosomal enzymes
C. Extrinsic pathway involving caspase 8
D. Granzyme pathway involving cytotoxic T cells
E. Intrinsic pathway involving caspase 9

Answer

A

E: Intrinsic pathway involving caspase 9. Majority of chemotherapeutic drugs act via
damage of DNA of cancerous cells. DNA damage activates intrinsic pathway of apoptosis

Question 54

Q

A 45-year-old man has a traumatic injury to his forearm and
incurs extensive blood loss. On physical examination in the
emergency department his blood pressure is 70/30 mm Hg.
Which of the following cellular changes is most likely to
represent irreversible cellular injury as a result of this injury?
A. Epithelial dysplasia
B. Cytoplasmic fatty metamorphosis
C. Nuclear pyknosis
D. Atrophy
E. Anaerobic glycolysis
F. Autophagocytosis

Answer

A

C: Nuclear pyknosis. Other two confirmation findings of irreversible injury are
cytomembrane rupture and formation of large dense deposits in the mitochondria.

Question 55

Q

Answer

A

D: Squamous metaplasia (transition of the
endocervical columnar epithelium into the squamous
epithelium they usually lines the ectocervix)

Question 56

Q

A routine cervical Pap smear taken during a gynecologic
examination of a 31-year-old woman shows numerous,
loosely arranged cells with high nuclear-to-cytoplasmic
ratio. A cervical biopsy is shown on the next slide. Which
of the following best describes the pathologic findings
observed in the uterine cervix of this patient?
A. Abnormal pattern of cell proliferation
B. Increased numbers of otherwise normal cells
C. Invasiveness through the basement membrane
D. Transformation of one differentiated cell type to another
E. Ulceration and necrosis of epithelial cells

Answer

A

A: Abnormal pattern of cell proliferation (the image
represents cervical dysplasia with proliferation of
immature cells and their expansion upwards)

Question 57

Q

Mr. John Doe at age 40 was diagnosed as having moderate
hypertension. He was advised to lose weight, exercise, and
prescribed a regimen of antihypertensive drugs, which he
ignored
•At age 50, Mr. Doe complained of intermittent chest pain on
exertion that subsided on rest. His physician noted an enlarged
left ventricular profile on plain chest film.
•Mr. Doe submitted to a supervised stress test and was
diagnosed with left ventricular hypertrophy subsequent to
untreated hypertension
•Which of the myocardial images shown in the next slide
corresponds to Mr. Doe condition?

Answer

A

B: Cardiomyocyte hypertrophy: increased cel; size,
increase nuclear size, nuclear hyperchromicity, and
boxcar nuclei

Question 58

Q

A 49-year-old man with a history of alcohol abuse has increasing
abdominal girth. On examination his liver edge is firm. A liver
biopsy reveals pronounced inflammatory response, and severe
hepatocyte injury; individual hepatocytes contain globular
eosinophilic inclusions. Which of the following structural elements
are these intracellular globules most likely contain?
A. Actin filaments
B. Myosin filaments
C. Cholesterol esters
D. Fibronectin molecules
E. Cytokeratin filaments
F. Microtubules

Answer

A

E: Cytokeratin filaments that form recognizable
inclusion in the hepatocytes in patients with
alcoholic hepatitis

Question 59

Q

A 38-year-old man has a health screening examination. He
has a routine chest x-ray that shows a 2 cm partially calcified
nodule in the right lower lobe. The nodule is resected and
the following microscopic examination reveals caseous
necrosis and calcification. Which of the following processes
explains the appearance of the calcium deposition?
A. Dystrophic calcification
B. Apoptosis
C. Hypercalcemia
D. Metastatic calcification
E. Excessive ingestion of calcium

Answer

A

A: Dystrophic calcification. This is a classical
description of pulmonary TB with caseous
necrosis and calcification

Question 60

Q

A 45-year-old woman with a parathyroid adenoma and
hyperparathyroidism undergoes a CT scan, which reveals
extensive calcium deposits in the lungs and kidney
parenchyma. Which of the following mechanisms best explains
these radiologic findings?
A. Dystrophic calcification due to calcium deposits in dead and
dying tissues
B. Metastatic calcification due to deranged calcium metabolism
C. Granulomatous inflammation due to elaboration of interferon-ɣ
D. Atherosclerosis due to accumulation of cholesterol-laden
macrophages in the intima
E. Fat necrosis due to elaboration of lipase and amylase enzymes

Answer

A

B: Metastatic calcification due to deranged
calcium metabolism in hyperparathyroidism

Question 61

Q

An 8-year-old boy is stung by a bee. Within 5
minutes, he develops a 2-cm, raised, red, swollen
lesion at the site of injury. Which of the following
findings will be predominant in tissue from the lesion?
A. Reaction to the foreign body
B. Hemorrhage
C. Lymphocytic infiltration
D. Neutrophilic migration
E. Vasodilation

Answer

A

E: Vasodilation is cause of erythema, and following increased
permeability facilitates swelling

Question 62

Q

A 25-year-old carpenter punctures his thumb with a
rusty nail. Within 24 hours, the wound has become a 1-
cm red sore that drains a thick, yellow fluid. Which of the
following biologic processes accounts for tissue
swelling at the site of injury in this patient?
A. Complement fixation
B. Endothelial cell separation
C. Platelet aggregation
D. Smooth muscle cell contraction
E. Vasoconstriction

Answer

A

B: Endothelial cell separation is a cause of increased permeability with
following edema

Question 63

Q

A 1-year-old girl with a history of several infections since birth,
including pneumonia and otitis media, is admitted to the hospital
and dies of respiratory failure. Postmortem examination of the lung
tissue reveals extensive sero-fibrinous exudate without leukocytes.
She is most likely deficient in which of the following substances?
A. Alpha-chain of LFA1
B. Alpha chain of Mac-1
C. Beta-1 chain of VLA-4
D. ICAM-1
E. VCAM-1
F. Sialyl-Lewis-X
G. CD31

Answer

A

F: Defects in sialyl-Lewis X protein with following deficiency in rolling. All
other answers are wrong, because such deficiency do not exist in
humans

Question 64

Q

A 55-year-old man with a history of ischemic heart disease has
worsening congestive heart failure. He noted increasing dyspnea
and orthopnea for the past 2 months. Physical examination shows
dullness to percussion at lung bases. A chest x-ray shows bilateral
pleural effusions. A left thoracentesis is performed, and 500 mL of
fluid is obtained. Which of the following characteristics of this fluid
would most likely indicate that it is a transudate?
A. Cloudy appearance
B. High protein content
C. <3 lymphocytes/microliter
D. Presence of fibrin
E. Large size of the effusion

Answer

A

C: <3 lymphocytes/ microliter. Low cell count and low protein content are
consistent with the diagnosis of transudate

Answer 30

A

C: Defects in lysosomal trafficking as a pathogenetic event in Chédiak-
Higashi syndrome that is presented in the scenario

Answer 31

A

A: Deficiency is NADHP oxidase that is confirmed by NBT test

Answer 32

A

D: Inability to produce hypochlorous acid

Answer 33

A

B: Granuloma. The image represents suture threads
and a giant cell with few mononuclear, the features
consistent with the diagnosis of foreign body
granuloma

Answer 34

A

E: IFN-ɣ. Two mediators, IFN-ɣ and IL-4, contribute the
most in granuloma development. IL-4 is not an answer
choice in this question.

Answer 35

A

B: Purulent inflammation. The diagnosis is based on
high neutrophil count.

Answer 36

A

A, C, D, E

Answer 37

A

A, B, C, D, E

Answer 38

A

A, C,E, D

Answer 39

A

A. The blueprint of the progeny virus is encoded by the genomic material of the composite virus initially entering the host cell which is rhinovirus. This means that all following replication cycles will yield rhinovirus. The composite virus can only initiate the first round of replication since no papillomavirus capsid protein, influenza virus matrix protein or Ebola virus glycoprotein are encoded by rhinoviral RNA.

Answer 40

A

D. The papillomavirus capsid used for this composite virus is surrounded by the host-derived envelope hence it is the Ebola virus glycoproteins which project as the outermost part of the composite virion that serve as the viral attachment proteins.

Answer 41

A

B. Host-cell susceptibility is determined by viral attachment proteins (VAPs), i. e. only cells that possess receptors for the VAPs of a particular virus are susceptible to this virus. Viral attachment proteins are always present on the outermost part of the virus. Since the composite virus is an enveloped particle, the VAPs are embedded in the envelope of the virus.

Answer 42

A

G. The VAP of the composite virus being a glycoprotein, it is composed of a sugar moiety and a protein moiety.

Answer 43

A

C. The nucleic acid genome being that of a (+) ssRNA virus, the polymerase required is an RNA-dependent RNA polymerase.

Answer 44

A

A. The progeny virus is determined by the incoming genomic nucleic acid, i. e. a rhinovirus (Picornaviridae), and you know that the picornaviruses have the following structure: (+) ssRNA and a capsid. Being a (+) ssRNA virus, it does not require to carry an RNA-dependent RNA polymerase upon cell entry since this necessary enzyme will be synthesized from the direct translation by ribosomes of the incoming (+) ssRNA which acts as viral mRNA.

Answer 45

A

A. The progeny virus is determined by the incoming genomic nucleic acid, i. e. a rhinovirus, and you know that the Picornaviridae have the following structure: (+) ssRNA and capsid. In this case, in contrast to the original composite virus, the progeny virus lacks an envelope and, therefore, the outermost structure of the viral particle is the capsid; consequently, the capsid serves as the VAP.

Answer 46

A

A. Host-cell susceptibility is determined by viral attachment proteins (VAPs), i. e. only cells that possess receptors for the VAPs of a particular virus are susceptible to this virus. Viral attachment proteins are always present on the outermost part of the virus. Since the progeny virus is a naked viral particle, the VAP is the capsid of the virus.

Answer 47

A

B. Fusion occurs at the entry of the cell.

Answer 48

A

1b – 2c – 3a.

Answer 49

A

D Ibuprofen is an NSAID of the propionic acid derivative class that is approved for
children younger than 2 years. All NSAIDs inhibit prostaglandin biosynthesis by blocking
cyclooxygenase both in the peripheral tissues and in the central nervous system. The
release of prostaglandins (PGE1, PGE2) in the hypothalamus seems to be the ultimate
factor that adjusts the hypothalamic thermoregulatory mechanism to maintain body
temperature at a higher than normal level. By inhibiting prostaglandin synthesis, NSAIDs
promote the return of the hypothalamic thermostat to the normal set point. Once the normal
set point is restored, the temperature-regulating mechanisms operate (by dilation of
superficial blood vessels, sweating, etc.) to reduce temperature.
A-C All of these actions can lead to an antipyretic effect, but NSAIDs do not have these
actions.
E The inhibition of cyclooxygenase in peripheral tissues can lead to an antiinflammatory
effect that can reduce fever. However, the main mechanism of the antipyretic effect of
NSAIDs is central rather than peripheral.
F Blockade of oxidative phosphorylation in skeletal muscle leads to hyperthermia, not to an
antipyretic effect.

Answer 50

A

E The patient’s symptoms, the marked hyperthermia, and the respiratory depression
suggest severe poisoning by salicylates. This is supported by the lab results indicating
mixed respiratory and metabolic acidosis (low pH, increased PaCO2, and decreased plasma
bicarbonate content). This acid-base disturbance is typical of a high salicylate content in
blood. In salicylate poisoning, the initial event (when salicylate concentration in blood is not
yet high) is respiratory alkalosis caused by salicylate-induced stimulation of the respiratory
center. Partial compensation is achieved, as usual, by increased renal excretion of
bicarbonate. Therefore, the initial phase of poisoning (or when the poisoning is mild) is
characterized by respiratory alkalosis (high pH, decreased levels of PaCO2 and
bicarbonate). In a later phase, when salicylate blood levels become quite high, the
respiratory center becomes depressed, and respiratory acidosis supervenes. This acidosis
is uncompensated because a significant amount of bicarbonate has already been
eliminated. Moreover, salicylates cause uncoupling of mitochondrial oxidative
phosphorylation (which leads to hyperthermia) and inhibits the enzymes of the Krebs cycle,
resulting in increased pyruvic and lactic acids. Lipolysis, gluconeogenesis, and glycolysis
are also stimulated, leading to hyperglycemia and production of keto acids. Therefore, the
final picture is mixed respiratory and metabolic acidosis, as in this case.

A Acute alcohol poisoning can cause combative behavior, but hypothermia and
hypoglycemia are typical signs of alcohol poisoning, and tinnitus is usually absent.
B, C Poisoning by nonsteroidal antiinflammatory drugs other than salicylates does not
usually cause profound impairment of the acid-base balance.
D, F Poisoning by these drugs does not cause the set of symptoms showed by the patient.

Answer 51

A

C The patient’s history and symptoms suggest that the culprit drug was aspirin and that
she was affected by aspirin hypersensitivity, a syndrome that can occur in 20 to 25% of
middle-aged patients with asthma, chronic urticaria, or nasal polyps, as in this case. The
reaction does not appear to be immunologic in nature, but instead seems to be a
pseudoallergic reaction. The mechanism is not known, but it is likely related to the formation
of increased amounts of leukotrienes and other products of the lipoxygenase pathway due
to inhibition of the cyclooxygenase pathway. Patients with this syndrome experience a high
degree of cross-sensitivity to other NSAIDs, which supports the conclusion that this reaction
represents an abnormal response to a common pharmacological action.
A, D Bronchospasm induced by these drugs is exceedingly rare.
B, E These drugs do no not cause bronchospasm.

Answer 52

A

B Because the patient is suffering from hemophilia, all nonsteroidal antiinflammatory
drugs (NSAIDs) are contraindicated because they can decrease platelet aggregation and
can provoke gastrointestinal bleeding. Acetaminophen is free from the above-mentioned
effects and can be used as an analgesic in this patient.
A, C-F See correct answer explanation.

Answer 53

A

D The patient’s signs and symptoms indicate he was suffering from salicylate overdose
toxicity. Although salicylates have an antipyretic action, they can cause hyperthermia when
given in too-high doses. This seems to be primarily due to the uncoupling of oxidative
phosphorylation in skeletal muscle; that is, oxidation proceeds without phosphorylation, thus
producing heat. This action is similar to that produced by dinitrophenol.
A-C, E See correct answer explanation.

Answer 54

A

E Celecoxib is a selective inhibitor of cyclooxygenase-2. Drugs of this class (sometimes
called coxibs) have analgesic, antipyretic, and antiinflammatory actions. However, they lack
action on platelet aggregation and have lower adverse effects on the gastric mucosa than
nonselective inhibitors of cyclooxygenases. These drugs are therefore preferred in patients
at risk of peptic ulcer disease, as in this case.
A-D, F See correct answer explanation.

Answer 55

A

F The results of the autopsy and the history of the patient suggest that the cause of
death was Reye syndrome. The syndrome consists of acute encephalopathy with fatty
degeneration of the viscera. It is exceedingly rare and occurs almost exclusively in children
younger than 18 years. Lethality is estimated to be about 20%. The cause of the syndrome
is unknown, but risk factors involve use of salicylates in viral infections, as in this case.
A-E These drugs do not cause Reye syndrome.

Answer 56

A

D Primary dysmenorrhea is cyclic pain associated with menses during ovulatory cycles
but without demonstrable lesions affecting the reproductive cycle. The pain is thought to
result from uterine contraction and ischemia, most likely mediated by the actions of
prostaglandins produced by the secretory endometrium. NSAIDs taken 2 days before
menses and continued for 2 or 3 days or as needed represents the first-line
pharmacotherapy. Propionic acid derivatives are very efdective in dysmenorrhea for many
patients; in a variety of clinical trials, good to complete pain relief was reported for 40 to
100% of women using ibuprofen.
A Although acetaminophen is advertised as an analgesic for dysmenorrhea, it is much less
effective than NSAIDs because it is a very poor inhibitor of cyclooxygenase in peripheral
tissues.
B Beta-2 agonists can relax the uterus, but their action is much less effective than that of
NSAIDs in dysmenorrhea, where prostaglandins play the main role.
C, E, F These drugs would increase, not decrease, uterine contractions.

Answer 57

A

D Ibuprofen has been approved for use as an antipyretic in children and is currently
available over the counter. Because most nonsteroidal antiinflammatory drugs have
antipyretic activity, the initial choice is often based on specific patient-related
contraindications.
In this patient:
A Aspirin is contraindicated because of the risk of Reye syndrome. This serious disorder
mainly affects children or young adults, and predisposing factors include viral infection and
salicylate therapy.
B Indomethacin is not indicated for general use as an analgesic or antipyretic because of its
toxicity.
C Acetaminophen is contraindicated in this patient because of his congenital deficiency of
red blood cell glutathione synthase. Acetaminophen is partially metabolized to N-acetyl-p-
benzoquinone imine, which is rapidly conjugated with glutathione. If glutathione stores are
deficient, the metabolite reacts with hepatocyte macromolecules, resulting in hepatotoxicity.
Patients with congenital deficiency of glutathione synthase are therefore at increased risk of
acetaminophen toxicity.
E, F These drugs are not used as antipyretics.

Answer 58

A

E The patient’s symptoms and the echocardiography results suggest he had a patent
ductus arteriosus, which can occur in up to 80% of premature infants with a birth weight less
than 1200 g (2.65 lb). Patency of the ductus arteriosus is maintained in utero by the low
partial pressure of oxygen and high concentration of prostaglandins, mainly PGE1 and
PGE2, which have vasodilatory actions. Because of this, nonsteroidal antiinflammatory
drugs have been found to speed up the closure of the ductus arteriosus in newborn babies.
Indomethacin given intravenously is the treatment of choice and can achieve closure in
more than 70% of neonates.
A-D See correct answer explanation.

Answer 59

A

C Ibuprofen is an NSAID of the propionic acid derivative class. By inhibiting
cyclooxygenases, these drugs impair the biosynthesis of both prostacyclin (prostaglandin I2)
and thromboxanes.
A, B, D-F All of these options have at least one endogenous compound whose biosynthesis
is not inhibited by NSAIDs.

Answer 60

A

B Erosive gastritis, bleeding, and peptic ulcer are well recognized adverse effects of
NSAIDs. The effects are the consequence of both systemic and local actions
Systemic actions are related to inhibition of prostaglandin biosynthesis, which in turn leads
to:
-Increased gastric acid secretion (prostaglandins decrease this secretion by inhibiting cyclic
adenosine monophosphate (cAMP)-mediated activation of the proton pump), and
-Decreased bicarbonate and mucus secretion by gastric mucosa (which is increased by
prostaglandins)
Local actions occur via an ion-trapping mechanism. Most NSAIDs are weak acids with an
acid dissociation constant (pKa) less than 5. Therefore, they are mainly nonionized (i.e.,
lipid-soluble) in the stomach lumen and can cross the cell membrane by lipid diffusion. In
the neutral environment of the cytoplasm, they become ionized (i.e., water-soluble) and are
trapped inside the cell, causing cell damage.
A, E Gastrin and cholecystokinin secretions are not affected by NSAIDs.
C, D See correct answer explanation.

Answer 61

A

B: Granuloma. The image represents suture threads
and a giant cell with few mononuclear, the features
consistent with the diagnosis of foreign body
granuloma

Answer 62

A

E: IFN-ɣ. Two mediators, IFN-ɣ and IL-4, contribute the
most in granuloma development. IL-4 is not an answer
choice in this question

Answer 63

A

B: Purulent inflammation. The diagnosis is based on
high neutrophil count

Answer 64

A

Correct answer is E. The Wechsler Intelligence Test for Children (WISC) is a measure of intelligence. The Beck Depression Inventory (BDI) is a self-report measure of depression symptoms. The Wechsler Adult Intelligence Scale (WAIS) is an intelligence test. The Wechsler Memory Scale (WMS) is a test of various components of verbal and non-verbal memory. And the Minnesota Multiphasic Personality Inventory (MMPI) is a widely used measure of personality.

Answer 65

A

Correct answer is B. The Rorschach Inkblot Test asks patients to respond to ambiguous stimuli by asking “What might this be?”

Answer 66

A

Correct answer is C. Reliability refers to the accuracy and consistency of a measure. Validity refers to a test’s “usefulness” or ability to measure a content domain that corresponds to the real world. Normative data refers to a defined population or reference sample. Discrimination refers to how well a test item differentiates high vs. low performers.

Answer 67

A

Correct answer is C. Normative data is used to evaluate where an individual’s score falls relative to other scores in a predefined reference sample.

Answer 68

A

A, B, C, D, E, & F

Answer 69

A

maintain cell shape, While PG fragments can do # 1, # 3, and # 5, the reason that bacteria produce PG is as a basic cellular structure. Membranes have no real structure to them, so the only part of the cell envelope that can possibly generate shape is the PG layer. How this happens is complex (and quite interesting, and not entirely understood).

Answer 70

A

Glucose-galactose-arabinose

What are capsule made out of? Which of these things fit that category? The vast majority of bacterial capsules are polysaccharides, and are therefore composed of sugars.

Answer 71

A

A 19-y-o college student who lives in the dorm and has a sore throat- symptoms usually seem like cold symptoms

Answer 72

A

a 1-year old

Younger children and adolescents are more likely to get meningococcal meningitis than mid-aged children and adults. However, at the moment Streptococcus pneumoniae is still the most common cause of bacterial meningitis in all age groups, particularly among unvaccinated (or not recently vaccinated) but otherwise healthy elderly people. This is changing though, with the children vaccinated with PCV7 and now PCV13 vaccines getting older–risk used to be higher in children, is now higher in adults, and overall rates have declined in all groups

Answer 73

A

Reduction of host The version here is “atypical”, so what process that normally happens would be altered if this molecule has a different form? This question refers to lipid A, which is a PAMP (pathogen-associated molecular pattern). PAMPs are normally recognized by pathogen recognition receptors (PRRs), which are part of the innate immune system and activate this response when they recognize the presence of these conserved structures. If the structure of a PAMP is unusual (i.e. the pattern is changed), then the PRRs which have evolved to recognize the typical structure of that PAMP will not be able to recognize it as well. Many commensal organisms and pathogens able to cause long-term disease have evolved to be less provocative to the innate immune system.innate response

Answer 74

A

Toxic Shock Syndrome toxin-1

What organism is causing the infection? What virulence factors have you learned about so far from this organism? Which of these can produce a severe complication? Staphylococcus aureus can produce both TSST-1 and protein A (you will learn about this more later), but TSST-1 is the one that will cause a problem in this patient. The other three choices are from different organisms – you should recognize ExoA and ExoU as being from Pseudomonas aeruginosa.

Answer 75

A

Recognition of LBP-bound LOS by TLR-4

Scenario is describing meningococcal meningitis, and exposure to large amounts of circulating endotoxin (lipid A) leads to overproduction of cytokines via TLR-4-mediated pathway. This can lead to DIC, which will affect platelet counts and organ function.

Answer 76

A

Gram-positive, anaerobic bacillus

refering to Clostridium tetani tetanus toxin.

Answer 77

A

Forms pores in the organelle membrane

Referring to Listeria monocytogenes, which produces listeriolysin O, a pore forming exotoxin that facilitates bacterial escape from the phagolysosome and from the vesicles formed as it exits one cell and enters an adjacent one. Phospholipases are also important in these processes.

Answer 78

A

Endotoxin

The organism being described is Neisseria meningitidis, and the disease is meningitis. The key point here is that while capsule is important in allowing the pathogen to survive and disseminate in the patient, it is not responsible for causing the symptoms. Innate immune recognition of lipid A, and the cytokines produced in response, cause the symptoms of the disease. The organism does not produce a superantigen, enterotoxin, or exotoxin.

Answer 79

A

alfa 1 and M2

Activation of M2 receptors leads to decreased heart rate. Blockage of M2 will result in tachycardia.

Blockade of α1 will result in decreased blood pressure, the baroreceptor reflex will cause tachycardia to maintain mean arterial pressure.

The predominant tone of the heart is determined by the sympathetic nervous system. Blockade of Nn receptors in the autonomic ganglia will result in decreased sympathetic output and result in tachycardia.

Answer 80

A

Postganglionic parasympathetic

Postganglionic fibers of the ANS are all unmyelinated. Those of the parasympathetic nervous system are short.
B) Postganglionic sympathetic fibers are usually long.
C, D, E, F) All these fibers are myelinated

Answer 81

A

celian ganglion

In all autonomic ganglia receptors are primarily Nn

Answer 82

A

Increased synthesis of angiotensin II

Activation of β1 receptors increases renin secretion. Renin is the enzyme that catalyzes the biosynthesis of angiotensin II.

Answer 83

A

Correct Answer: C – The physician has begun the process of negotiating with the patient by presenting his/her side of clinical reality.

Answer 84

A

Correct Answer: D – People from many cultures use folk healers and folk remedies. As long as the treatment will not harm the patient, the physician should try to work alongside such healers, not separate patients from their cultural beliefs. Because in this case the folk treatment is innocuous, the patient can continue using it along with traditional medicine.

Answer 85

A

Correct Answer: C - Muslim women often prefer to have a female physician, particularly for gynecological or obstetrical problems. In this case, the physician should try to honor the patient’s wishes. If this is not possible, the patient should be consulted for alternative acceptable strategies. For example, she may suggest having her husband or other family member (e.g., her mother) present when she is examined by the male physician. Trying to impress the patient with one’s credentials or to frighten her into compliance is not an appropriate or effective strategy

Answer 86

A

Correct Answer: C – The patient is coping with her emotional distress by reverting to a developmentally earlier mode of functioning

Answer 87

A

Correct Answer: A – This teenager is acting out her depression and anxiety over the loss of her mother in socially unacceptable behavior.

Answer 88

A

Correct Answer: C – In sublimation, the medical student reroutes his or her unconscious, unacceptable wish for committing a violent act to a socially acceptable route (cutting people during surgery).

Answer 89

A

A, B, D, E, F

Answer 90

A

A, c,f,g,h

Answer 91

A

Chlamydia

Answer 92

A

Listeria

Rickettsiae replicate within the cytosol (and some species the nucleus) of an infected host cell. Chlamydia, Legionella, Ehrlichia, and Coxiella remain in a variety of membrane-bound vacuoles, and do not replicate within the cytosol. Listeria escapes the phagosome and replicates in the cytosol, so in that way is similar to rickettsiae.

Answer 93

A

Type IV secretion system

This question is describing Legionella pneumophila. Once inside the macrophage, this organism produces a type IV secretion system which injects bacterial effectors into the host cell leading to the recruitment of vesicles derived from the host endoplasmic reticulum. The vacuole containing the bacteria, resembling host ER, does not acidify or fuse with lysosomes, allowing the organism to survive and replicate within. Pore-forming toxin could refer to listeriolysin O, produced by Listeria; nitric oxide is produced by host cells to kill bacteria; pili are useful to Legionella in entering the host cell, but not in intracellular survival, and ER, while important in the process, is not a bacterial product.

Answer 94

A

Foul odor
General Feedback:

The fermentation products and reduced molecules frequently produced during anaerobic metabolism often lead to a particularly foul odor associated with purulence or tissue damage. While these infections are often associated with inflammation and purulence (neutrophils, not lymphocytes), pain is usually localized and the pus is yellowish or perhaps greenish in colour. A blue-green pus is more characteristically associated with Pseudomonasinfection.

Answer 95

A

Porphyromonas

The periodontal pocket is an anaerobic environment, and organisms causing periodontal inflammation (periodontitis). Porphyromonas is one organism linked to periodontitis, but there are other anaerobes that could be involved. Spirochetes are present in the normal microbiota, but are less likely to be associated with disease. Staphylococcus is a facultative anaerobes, but are not linked to this type of disease. Candida is found in the oral cavity, and can cause disease when it overgrows, but is not linked to periodontitis. Nocardia is an aerobe and would not be expected in this anatomic location.

Answer 96

A

Stimulation of adenylate cyclase

Epinephrine effects on the heart are due to the activation of β1 and β2 receptors. The postreceptor mechanism common to all β receptor activation is the stimulation of adenylate cyclase which in turn increases the amount of cAMP in target tissues.

A) This postreceptor mechanism is triggered by the activation of M2 receptors.
B)This postreceptor mechanism is triggered by the activation of nicotinic receptors
C)This postreceptor mechanism is triggered by the activation α1 and M3 receptors

Answer 97

A

Increased systemic blood pressure

The history of the patient suggests that the syncope is most likely due to inadequate cerebral perfusion. α1agonists are used to treat patients with chronic postural hypotension. The therapeutic effectiveness of these drugs is due to vasoconstriction, which increases both the systolic and diastolic blood pressure, so improving cerebral blood flow.

A) Cerebral blood flow mainly depends on autoregulation, which can maintain a normal blood flow at arterial pressure of 60 -140 mm Hg. Therefore, in spite of the strong sympathetic innervation of cranial vessels, sympathetic activity plays little role in controlling cerebral blood flow. In any case an α-agonist would constrict, not dilate, cerebral vessels.
B) α1 agonists actually decrease the heart rate since the increase in systolic and diastolic blood pressure activates the baroreceptor reflex.
C) Cardiac output is usually not directly affected by α1agonists. By decreasing the heart rate they would decrease cardiac output, but they would increase it by increasing, venous return, which in turn increases preload. These opposite actions cancel each other, in most cases.
E) β1 agonists, not α-1 agonists, activate the renin-angiotensin system

Answer 98

A

1) A partial agonist at beta-1 and beta-2 receptors (E) 2) A selective beta-1 receptor antagonist (A)
3) A beta-blockers that can also blocks potassium channels (G)
4) This drugs is frequently used in case of prostatic hyperplasia (H)
5) This drug is sometimes used in cardiovascular emergencies by IV infusion because of its extremely short half life (B)

Answer 99

A

6) Answer: B Epinephrine activates alpha-1 receptors so causing vasoconstriction, and beta-2 receptors, so causing vasodilation. Alpha-1 receptor mediated vasoconstriction and the epinephrine-induced increased stroke volume cause an increase in mean blood pressure. By blocking alpha-1 receptors the beta-2 mediated vasodilating activity of epinephrine is unopposed and blood pressure falls. A) The hypertensive effect of norepinephrine is decreased, but not reversed because norepinephrine has no vasodilating activity (it does not activate beta-2 receptors). C) By blocking alpha-1 receptors, skin vessels are relaxed and blood flow through the skin is

usually increased, not decreased. D) Blockade of alpha-1 receptors causes no direct effects upon the heart. However the vasodilation may cause reflex tachycardia. Therefore heart rate is either minimally affected or increased. E) Alpha-1 receptors are located on smooth muscle of the trigone and bladder internal sphincter. By blocking these receptors relaxation, not contraction, of these muscles occurs. F) Activation of alpha-1 receptors contracts the radial muscle of iris, so causing mydriasis. By blocking alpha-1 receptors, alpha antagonist cause relaxation, not contraction.

Answer 100

A

Answer: D A chronic treatment with selective alpha-1 blockers may cause hypotension. This hypotension usually elicits compensatory effects through actions not dependent on adrenergic activation (namely Na+ retention and expansion of blood volume). A) Hypotension, not hypertension, is a likely adverse effects of alpha-1 blockers. B) By causing hypotension these drugs tend to cause reflex tachycardia, not bradycardia. C) Alpha-1 blockers cause peripheral vasodilation, so digital vasospasm is quite unlikely. E) Alpha-1 blockers relax the internal sphincter of the bladder ,so urinary retention is unlikely.

Answer 101

A

Answer: D Prazosin is a selective alpha-1 blocker and therefore will most effectively counteract the effect of a selective alpha-1 agonist like phenylephrine A) Isoproterenol induces tachycardia by activating beta-1 and (to a lesser extent) beta-2 receptors. The blockade of alpha-1 receptors cannot antagonize this effect. B) Nicotine induces sweating by activating Nn receptors in ganglia which in turn increases sympathetic firing. However the sympathetic fibers innervating sweat glands are cholinergic and therefore, the blockade of alpha-1 receptors cannot antagonize this effect. C) Dopamine increases renal blood flow by activating D1 receptors. By blocking alpha-1 receptors prazosin can also increases renal blood flow. E) Pilocarpine contracts the ciliary muscle by activating M3 receptors. The blockade of alpha-1 receptors cannot antagonize this effect.

Answer 102

A

Answer: A Since alpha-1 blockers cause vasodilation and impair the baroreceptor reflex, they are contraindicated in all disorders leading to orthostatic hypotension, including systemic mastocytosis. In fact in this disease the large number of mast cells causes an elevated plasma histamine concentration, which in turn leads to hypotension and even to cardiovascular collapse. B, C, D, E) All these disease are actually indications, not contraindications, for the therapeutic use of prazosin.

Answer 103

A

Answer: C The blood pressure depends on cardiac output and total peripheral resistance according to the formula: BP = SV x HR x TPR. In order to completely abolish the action of norepinephrine the drug must antagonize the increased stoke volume (mediated by the activation of beta receptors) and the increased total peripheral resistance (mediated by the activation of alpha-1 receptors). Therefore the drug must have both alpha and beta blocking activity, like labetalol. A, B, D, E, F) (see explanation above)

Answer 104

A

Answer: A Gluconeogenesis and glycogenolysis are beta-2 mediated effects. By blocking these effects non-selective beta-blockers can enhance hypoglycemia induced by insulin (or other hypoglycemic drugs) in diabetic patients. C) Renin release can be stimulated by the activation of beta-1 receptors in the juxtaglomerular cells of macula densa. All beta-blockers decrease, not increase, renin release. B) Beta blockers actually decrease lipolysis and usually reduce the release of free fatty acid from adipose tissue. D, E) Beta blockers actually decrease hepatic gluconeogenesis and plasma levels of HDL.

Answer 105

A

Answer: A Isoproterenol-induced hyperglycemia is mainly due to beta-2 receptor mediated gluconeogenesis and glycogenolysis, and therefore it can be effectively counteracted by propranolol, which block beta-2 receptors. All the other listed actions cannot be antagonized by propranolol because they are not mediated by activation of beta receptors. B) Nicotine-induced activation of Nn receptors in ganglia increases the firing of postganglionic sympathetic nerves, which in turn cause skin vasoconstriction by activating alpha-1 receptors C) Norepinephrine-induced reflex bradycardia is mediated by the activation of M2 cardiac receptors. D) Phenylephrine-induced mydriasis is mediated by the activation of alpha-1 receptors E) Pilocarpine-induced contraction of bronchial musculature is mediated by the activation of M3 receptors.

Answer 106

A

Answer: B Epinephrine activates alpha-1, alpha-2, beta-1 and beta-2 receptors. Labetalol is able to block all these receptors. Therefore it will be able to antagonize all the effects of epinephrine. A, C, D, E, F) All these drug pairs act on different receptors and therefore are not a receptor agonist-antagonist match.

Answer 107

A

Answer: D Selective alpha-1 blockers (like prazosin, tamsulosin etc.) are the drugs of choice for the treatment of impaired bladder emptying in prostatic hyperplasia. By blocking alpha-1 receptors these drugs relax the prostate capsule and the internal sphincter of the bladder (which have plentiful alpha-1 receptors), so allowing a better urine flow. A, B) Beta receptors are not significantly involved in the regulation of the internal sphincter of the bladder. C) Even if activation of alpha-2 receptors would cause a decrease of norepinephrine release, the action is too weak to be clinically significant. E) Activation of M3 receptors would cause a contraction of the detrusor muscle of the bladder, which would increase the urgency to void without improving voiding because of the urethral compression due to prostate hyperplasia.

Answer 108

A

Answer: D The only drugs that are approved by FDA for both the treatment of migraine and of hypertension are beta-blockers (mainly propranolol). Common adverse effects of propranolol include insomnia and nightmares. A) Beta-blockers do not cause postural hypotension since the preload and the baroreceptor reflex are not affected by these drugs. B) Beta-blockers decrease the heart rate and have antiarrhythmic properties, so palpitations are quite unlikely. Beta-blockers block the beta-receptor mediated vasodilation so flushing is quite unlikely. C) Beta-blockers have no significant effect on eye accommodation do not cause mydriasis so impairment of far vision and photophobia are quite unlikely. E) Beta-blockers commonly cause diarrhea, which is likely related to the blockade of beta-2 receptors in the gut, and they do not cause gastroesophageal reflux. Even if constipation can occur with some beta-blockers, it is uncommon and never severe.

Answer 109

A

Answer: C The patient’s history and the exam results indicate that he was most likely suffering from hypertrophic obstructive cardiomyopathy a disorder usually inherited in an autosomal dominant pattern. In this disease the asymmetric hypertrophy of the ventricular septum leads to left ventricular outflow obstruction. Syncope usually occurs after exercise because the increased contractile function worsens the obstruction and the vasodilation from increased circulating epinephrine reduces diastolic ventricular filling. Other classic symptoms of the disease are angina (a limited coronary blood flow reserve is present in hypertrophied states) and diastolic heart failure (due to reduced compliance of the hypertrophied left ventricle). Beta-blockers (and calcium channel blockers that act on the heart, like verapamil and diltiazem) are drugs of choice in this disease because they decrease cardiac contractility and increase diastolic ventricular filling. A, B, D, E) All the other listed drugs are contraindicated in hypertrophic obstructive cardiomyopathy because either they decrease venous return (prazosin, diuretics) or increase contractile function (dobutamine, epinephrine).

Answer 110

A

Answer: D Phenoxybenzamine blocks irreversibly alpha-1 and alpha-2 receptors. Activation of alpha-2 receptors in pancreas decreases insulin secretion,. By blocking alpha-2 receptors phenoxybenzamine counteracts this effect. A, B, C, E) All these actions are due to activation of beta receptors and therefore are not blocked by phenoxybenzamine

Answer 111

A

Answer: A Chronic bacterial prostatitis is usually caused by sequestered urinary pathogens (Escherichia, Klebsiella, Proteus) that antibiotics have not eradicated. When symptoms of urinary obstruction are present, alpha adrenergic blockers may be indicated. Painful erection and impaired ejaculation are typical adverse effects of adrenergic blockers, since ejaculation is under control of the sympathetic nervous system. B, C, D, E, F) These drugs are not used in case of urinary obstruction and do not cause the symptoms reported by the patient

Answer 112

A

Answer: A .Open angle glaucoma is characterized in most cases by an increased intraocular pressure, which in turn is due to an excessive amount of aqueous humor in the anterior chamber of the eye. The pharmacological therapy of the disease is aimed to decrease this amount, either by lowering aqueous humor production or by increasing aqueous humor outflow. In the eye aqueous humor is manufactured by the cells of ciliary epithelium and is under the control of both beta receptors (which increase the production) and alpha-2 receptors (which decrease the production). Therefore the production of aqueous humor can be reduced either by drugs that block beta receptors (like timolol) or by drugs that activate alpha-2 receptors (like apraclonidine).. B, C, D, E) These actions can affect the outflow, not the production, of aqueous humor

Answer 113

A

Answer: C The symptoms the patient was complaining were classic adverse effects of beta-blockers. These drugs have been approved by FDA for migraine and are currently used to prevent migraine attacks, even if their mechanism of action in this disorders remains elusive. A) Esmolol is a beta-blocker with a very short half-life ( about 10 minutes) used only by parenteral injection or IV infusion. B, D, E, F) These drug are not used for migraine.

Answer 114

A

Correct answer: 3. This is a real case – the daughter’s power of attorney could not replace her father’s wishes. PCI was not performed. The patient was transferred to an emergency unit and received intravenous alteplase, after psychiatric examination and counselling. A suicide attempt is not sufficient to displace the presumption of competence, in the absence of a court order. A decision as to the capacity, however, is possible after psych consult – since it is a medical decision

Answer 115

A

Correct answers: 1 to 3. Confidentiality is protected by common law (contract law and law of torts) as well as statutes (HIPPA

Answer 116

A

Correct answers: 1, 2 and 3

Since this is STI the minor patient can get her results and not share with parents but if it was anything else parents can be notified.

Answer 117

A

Correct answer: 1. Although Professor H did not state that he will act on the information, he should have communicated this fact to Dr. M. On the other hand, Dr M should not have assumed that Professor H took over the management of Mr D’s case

Answer 118

A

Correct answer: 3. Although the wife has an interest in her husband’s capacity of procreation, this interest does not outweigh the patient’s right to autonomy/self-determination and privacy. Only the patient is the medical decision maker in this case, and the information has to be shared only with him.

Answer 119

A

Correct answer: 5. Between 3 and 25% of requests for psychiatric consultation in hospital settings involve questions about patients’ competence to make treatment-related decisions. In many other cases, impaired decision making in hospitalized patients may go undetected, even when patients decline recommended treatment. One study of 302 medical in-patients with acute conditions estimated that as many as 48% were in- competent to consent to medical treatment, while the clinical team responsible for these patients only identified 25% of this group as being impaired. (Appelbaum PS, Assessment of Patients’ Competence to Consent to Treatment, N Engl J Med 2007;;357:1834-40;; Raymont V, Bingley W, Buchanan A, et al. Prevalence of mental incapacity in medical inpatients and associated risk factors: cross-sectional study. Lancet 2004;;364: 1421-7) Note that competence is a legal term, and that the competence is assessed by a court, not by the psychiatrists. This is why answer option 3 is incorrect.

Answer 120

A

Correct answer: 2. Bad debt is not a justification for HIPPA violations or for infringing a patient’s right to privacy. The codes can easily be “translated” in medical diagnoses – representing therefore the equivalent of the PHI.
Referring patients’ overdue bills to debt collectors must be done without any medical information, express or codified

Answer 121

A

all of them

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