1*A 32-year-old woman is in an automobile accident and suffers a
 fracture of the left tenth and eleventh ribs. Which of the
 following organs is most likely to have been injured by these
  fractured ribs?
 	A. 	Descending colon		
 	B. 	Jejunum		
 	C. 	Left adrenal gland		
 	D. 	Left kidney		
 	E. 	Spleen		

2 .A 46-year-old woman presents to her physician with "double vision" and is unable to adduct her right eye on attempted left lateral gaze. Convergence is intact. Both direct and consensual light reflexes are normal. Which of the following structures is most likely to be affected? A. Left oculomotor nerve B. Medial longitudinal fasciculus C. Right abducens nerve D. Right oculomotor nerve E. Right trochlear nerve Answer
3*Which of the following CNS tumors has the worst prognosis and is associated with the shortest survival? A. Anaplastic astrocytoma (WHO grade III) B. Glioblastoma multiforme C. Meningioma D. Oligodendroglioma E. Well-differentiated astrocytoma (WHO grade II) Answer
4*A 2-week-old child shows difficulty feeding, somnolence, failure to thrive, and constipation. An alert pediatrician orders blood studies that demonstrate low T4 and high TSH. If appropriate therapy is not promptly instituted, which of the following complications would most likely occur? A. Bronchiectasis B. Gigantism C. Hepatic cirrhosis D. Mental retardation E. Renal failure Answer
5*The parents of a 5-year-old girl ask their family physician for advice regarding their child. The mother had walked into the girl's bedroom without knocking and discovered the child stimulating her genitals. The parents are concerned, but seem to be receptive. The best response the physician could give is: A. "Do you think that someone's been molesting her?" B. "Don't you think you should knock before going into her room?" C. "She probably has a vaginal infection. Bring her in so I can examine her." D. "This is perfectly normal behavior for a child this age." E. "What disturbs you about this behavior?" 6*A newborn child has the most common type of tracheoesophageal fistula (type C). When and how will this developmental anomaly most likely be discovered? A. Immediately, with his first breaths B. On the first day, with his first meal C. After one week, with persistent weight loss D. Between 1 and 3 years, with exercise intolerance E. Never; it is usually asymptomatic Answer
7*Histones can bind DNA tightly because they have a high isoelectric point. This is due to an enrichment in the amino acid A. aspartate B. glycine C. lysine D. proline E. tyrosine Answer
8*An 82-year-old man complains to his physician at his yearly checkup that his legs begin to ache about half way through his daily 2-mile walk . The pain subsides within 1 or 2 minutes after he stops walking. He also complains of erectile dysfunction. Which of the following is most likely to be decreased in this man? A. Arterial oxygen content B. Arterial pulse at the ankle C. Oxygen extraction in his leg muscles D. Peripheral vascular resistance E. Serum lipid levels Answer
9*A wrestler's chest is compressed during a match, causing a posterior displacement of the clavicle at the sternoclavicular joint. Which of the following structures would be most at risk? A. Aorta B. Esophagus C. Heart D. Superior vena cava E. Trachea Answer
10*A 6-year-old boy with a sore throat, cough, and fever is noted to have a marked elevation in his serum C-reactive protein. This finding indicates which of the following? A. Developing autoimmune reaction B. Ineffective immune response C. Meningitis D. Non-specific inflammation E. Respiratory compromise Answer
11*A 48-year-old male presents for a routine evaluation 3 months after starting on an antihypertensive medication. His physical examination is unremarkable and blood pressure is 128/83. Laboratory results reveal the following lipid profile: total cholesterol 280 mg/dL, HDL 34 mg/dL, LDL 188 mg/dL, and triglycerides 191 mg/dL. His lipid profile was normal prior to beginning his antihypertensive medication. Which of following medications most likely caused the patient's dyslipidemia? A. Benazepril B. Diltiazem C. Guanfacine D. Metoprolol E. Prazosin Answer
12*A pathologist reports the presence of koilocytotic atypia in a cervical biopsy from a 25-year-old woman. On the basis of this histopathologic finding, which of the following conditions does this patient most likely have? A. Chlamydia infection B. Gonococcal infection C. Herpes simplex virus infection D. Human papillomavirus infection E. Severe squamous dysplasia F. Squamous cell carcinoma in situ G. Trichomonas infection Answer
13*Examination of a karyotype taken from a metaphase preparation reveals the presence of an extra chromosome. Which of the following is the most common mechanism of producing this phenomenon? A. Balanced translocation B. Chromosomal breakage C. Fertilization by two sperm D. Nondisjunction E. Unbalanced translocation Answer
14*A 24-year-old woman presents to her physician with an inability to close her right eye. Physical examination reveals weakness of the right orbicularis oculi. Which of the following additional symptoms would likely also be present? A. Blurred vision B. Hyperacusis C. Inability to chew D. Inability to feel the face E. Inability to shrug the shoulder Answer
15*A patient's left hypoglossal nerve (CN XII) is injured during a carotid endarterectomy. Which of the following would most likely result from this injury? A. Decreased gag reflex on the left B. Decreased salivation from the left submandibular and sublingual salivary glands C. Deviation of the tongue to the left on protrusion D. Inability to elevate the pharynx on the left during swallowing E. Inability to perceive sweet and salt taste sensation on the anterior part of the left side of the tongue Answer
16*During a physical examination, a physician asks a patient to say "Kuh, kuh, kuh," "La-la-la," and "Mi-mi-mi." The patient is unable to say "la" but says the other two sounds correctly. A lesion of which of the following cranial nerves is most strongly suggested by these findings? A. VII B. VIII C. X D. XI E. XII Answer
17*An inexperienced resident examines the x-ray of the arm of a child after a fall. There appears to be a fracture near, but not at, the distal end of the ulna. Before diagnosing a fracture, the resident should also consider the possibility that this is actually which of the following? A. Articular cartilage B. Epiphyseal plate C. Perichondrium D. Primary ossification center E. Secondary ossification center Answer
18*A 65-year-old male presents with a history of headache and difficulty walking. He felt well the previous night, but woke up with a severe headache and was unable to move his right leg. Clinical examination reveals no higher cortical function deficit. The optic discs are sharp, and the pupils are equal and reactive. The direct and consensual light reflexes are normal, and testing of the cranial nerves reveal no deficits. The right leg is hypotonic, and the man is unable to move it. Deep tendon reflexes are absent and Babinski's sign cannot be elicited. The most likely cause for this problem is loss of blood flow in the A. left anterior cerebral artery B. left middle cerebral artery C. left posterior cerebral artery D. right anterior cerebral artery E. right middle cerebral artery F. right posterior cerebral artery Answer
19*A 20-year-old healthy married Caucasian male undergoes a splenectomy following a severe motorcycle accident. He is started on a prophylactic course of antibiotics following surgery, which he discontinues 3 months later. 9 months after the splenectomy, he presents to the emergency room with shortness of breath, pleuritic chest pain, chills and fever, and is diagnosed with lobar pneumonia. Which of the following is the most likely organism? A. Chlamydia pneumoniae B. Pneumocystis carinii C. Pseudomonas aeruginosa D. Staphylococcus aureus E. Streptococcus pneumoniae Answer
20*A 32-year-old woman notices a rock-hard lump in one breast. She is diagnosed with breast cancer, and undergoes a mastectomy. During the procedure, the surgeon notes that the breast tumor has spread to involve the muscle layer immediately deep to the breast. Which muscle is involved? A. External oblique B. Pectoralis major C. Platysma D. Rectus abdominis E. Sternocleidomastoid Answer
21*A 55-year-old man presents to a physician with jaundice. Ultrasonography demonstrates a 5 cm mass in the head of the pancreas. Endoscopic retrograde cholangiopancreatography with cytologic sampling demonstrates cells with large hyperchromatic nuclei and a high nuclear/cytoplasmic ratio. A few small glands composed of these cells are also seen in the cytologic preparation. The overall prognosis for this man will be most similar to that of a patient with which of the following malignancies? A. Adenocarcinoma of the breast B. Adenocarcinoma of the colon C. Adenocarcinoma of the esophagus D. Adenocarcinoma of the prostate E. Primary gastric lymphoma Answer
22*A 1-week-old infant has a coarctation of the aorta just distal to the subclavian arteries. The blood pressure distal to the constriction is 50% lower than normal. Which of the following is increased in this infant? A. Blood flow in the lower body B. Glomerular filtration rate C. Plasma levels of angiotensin II D. Renal excretion of sodium E. Renal excretion of water Answer
23*A 25-year-old-man presents with weight loss, abdominal pain, and bloody diarrhea. Sigmoidoscopy/colonoscopy reveal mucosal erythema and ulceration extending in a continuous fashion proximally from the rectum. Which of the following pathologic findings would also be characteristic of this patient's illness? A. Bowel wall thickening B. Cobblestone appearance of mucosa C. Fistulas D. Pseudopolyps E. Transmural lesions Answer
24*Folate plays a role in single-carbon unit transfer in the synthesis of nucleotides. Which of the following nucleotides require folate for synthesis? A. Adenosine, cytosine, and uracil B. Adenosine, guanine, and thymidine C. Adenosine, guanine, and uracil D. Cytosine, thymidine, and uracil E. Guanine, thymidine, and uracil Answer
25*A normal birthweight, term baby with high APGAR scores fails to pass meconium within 36 hours of birth. The neonate also has a distended abdomen and has been vomiting and feeding poorly. Digital rectal examination temporarily relieves the obstruction, but the baby fails to pass stool thereafter. Barium enema examination demonstrates a very narrow distal segment of rectum with proximal dilation. Abnormalities of which of the following are most likely etiologically related to this baby's disorder? A. Chloride channels B. Ganglion cells C. Mucosal cells D. Smooth muscle cells E. Vagus nerve Answer
26*Following a difficult delivery, a baby is noted to have an adducted and internally rotated shoulder with an extended, pronated elbow. Loss of flexion and supination by which of the following muscles accounts for the elbow position? A. Biceps B. Brachialis C. Coracobrachialis D. Deltoid E. Pronator teres Answer
27*Which part of the brain is most often involved by septic emboli in patients with infective endocarditis? A. Brainstem B. Cerebellum C. Frontal lobe D. Occipital lobe E. Parietal lobe Answer
28*A 32-year-old male with a history of chronic drug abuse presents to his primary care physician complaining of uncontrollable shaking in his hands. He moves very slowly and walks with a stooped posture and shuffling gait. Physical exam reveals cogwheel rigidity, a pill-rolling tremor, and masked facies. His condition deteriorates, and he eventually dies. Structures similar to which of the following would be expected on autopsy? A. Hirano bodies B. Lewy bodies C. Lipofuscin granules D. Negri bodies E. Neurofibrillary tangles Answer
29*An aneurysm of the axillary artery within the axilla is most likely to compress which of the following neural structures? A. Axillary nerve B. Long thoracic nerve C. Lower trunk of the brachial plexus D. Medial cord of the brachial plexus E. Musculocutaneous nerve Answer
30*A 51-year-old supermarket cashier begins to have difficulty working, sometimes ringing up the wrong amount because her right hand feels "weak." She also notes that her right hand sometimes feels numb after working for long periods of time. Physical examination reveals loss of sensation on the palmar aspect of her thumb and first two fingers, as well as atrophy of the thenar eminence on her right hand. The nerve most likely injured in this patient also innervates which of the following muscles? A. Adductor pollicis B. Extensor digitorum C. Extensor pollicis longus D. Flexor carpi ulnaris E. Flexor digitorum superficialis Answer
31*While performing a surgical procedure in the neck, the surgeon ligates the superior laryngeal artery. If the nerve that accompanies this artery is damaged, which of the following functional losses will ensue? A. Loss of sensation in the laryngeal mucosa above the vocal folds B. Loss of sensation in the laryngeal mucosa below the vocal folds C. Loss of sensation in the pharyngeal mucosa D. Paralysis of the cricothyroid muscle E. Paralysis of the lateral cricoarytenoid muscle Answer
32*A young man is involved in a knife fight. Surgical exploration of a posterolateral neck wound demonstrates a large muscle with investing fascia on both its superficial and deep aspects. Damage to the fibers of this muscle at this location would most likely impair which of the following movements? A. Depression of the medial end of the scapula B. Elevation of the acromion C. Flexion of the neck D. Raising of the medial border of the scapula E. Turning of the face sideways Answer
33*A 40-year-old woman has had several episodes of rheumatic fever as a child. She is currently afebrile and feels well, and has come to a hospital for monitoring echocardiography. Which of the following would be most likely to be seen in this patient's mitral valve? A. Ballooning of valve leaflets B. "Fish mouth" valve C. Irregular beads of calcification in annulus D. Large bulky vegetation with adjacent leaflet perforation E. Tiny vegetations along line of closure of valve leaflet Answer
34*A patient with chronic reflux esophageal symptoms undergoes endoscopy, which demonstrates islands of red tissue above the gastroesophageal junction. Biopsy of several of these lesions demonstrates glandular epithelium with no atypical nuclei, with no invasion into the adjacent tissue. For which of the following cancers does this lesion predispose? A. Adenocarcinoma of the esophagus B. Adenocarcinoma of the stomach C. Sarcoma of the esophagus D. Sarcoma of the stomach E. Squamous cell carcinoma of the esophagus F. Squamous cell carcinoma of the stomach Answer
35*A 40-year-old woman has the following family and personal history: her mother died of breast cancer at age 64, she smokes one pack/day, she drinks five or more cups of coffee/day, she has no children, and she takes birth control pills. Which of the following is the most significant risk factor for breast cancer in this patient? A. Birth control pills B. Caffeine consumption C. Cigarette smoking D. Family history E. Nulliparity Answer
36*A 6-cm length of rectosigmoid colon containing a 2-cm diameter sessile polyp is surgically removed. On sectioning, the lesion shows finger-like papillae with cores of scant lamina propria. The surfaces of the papillae are covered by dysplastic columnar epithelium with considerable nuclear pleomorphism. No glandular structures are seen in the base of the lesion or in the adjacent muscle tissue. The margins of the specimen are free of dysplastic epithelium. What further therapy does this person require? A. Adjunct chemotherapy B. Complete colectomy C. Radiation therapy D. Resection of regional lymph nodes E. No further therapy is required Answer
37*A 34-year-old man presents with weight loss, diarrhea, and flatulence. Jejunal biopsy demonstrates marked atrophy of villi. This patient's condition may improve with removal of which of the following from the diet? A. Beef B. Eggs C. Potatoes D. Tomatoes E. Wheat Answer
38*A 61-year-old man presents with left leg pain and weight loss. On examination, unilateral erythema, swelling, and warmth are noted over the left leg. The man is scheduled for duplex venous ultrasonography, but on the day of his diagnostic procedure, the patient notes that his left leg is no longer painful, but now his right leg is swollen. The ultrasound examination reveals a deep venous thrombosis in the right leg, but no clot in the left leg. Which of the following underlying conditions is the likely cause of this man's presentation? A. Diverticulitis B. Pancreatic carcinoma C. Progressive systemic sclerosis D. Rheumatoid arthritis E. Schistosomiasis Answer
39*A 2-year-old boy is undergoing an eye examination due to an abnorma l light reflex his right eye, causing a so-called "cat eye." A whitish elevation of the retina is observed and invasion of the optic nerve by the tumor has begun. His family history is significant for osteosarcoma in his father. He has a sister who is asymptomatic. HindIII digestion of a PCR fragment of interest from a 180 kb gene located on the proximal half of the long arm of chromosome 13 demonstrates two different alleles (shown on the Southern blot below). Father Mother Daughter Son Band Size ________ ________ _________ _______ 2.1kb ________ 1.8kb ________ _________ 1.5kb Which of the following is the best conclusion that can be derived from the given information? A. The daughter inherited a 1.5 kb fragment from her mother B. The daughter will develop the tumor C. The disease is associated with the 2.1 kb fragment D. The disease shows an autosomal dominant pattern E. The mother was affected, but the tumor regressed spontaneously Answer
40*A 78-year-old woman with type 2 diabetes, diabetic nephropathy, and hyperuricemia presents to her physician for a physical examination, which is remarkable for hypertension. Which of the following drugs would be best for the initial treatment of this woman's hypertension? A. Atenolol B. Captopril C. Hydrochlorothiazide D. Indapamide E. Minoxidil Answer
41* Pulmonary artery pressure 45/25 mm Hg Pulmonary wedge pressure 30 mm Hg Left ventricular pressure 120/5 mm Hg Aortic pressure 120/80 mm Hg Cardiac catheterization was performed on a 51-year-old woman because of a 9-month history of worsening fatigue and shortness of breath. What is the most likely diagnosis based on the pressures shown above? A. Aortic regurgitation B. Aortic stenosis C. Mitral regurgitation D. Mitral stenosis Answer
42*A child develops a tumor of the brainstem, which on biopsy demonstrates bizarre, pleomorphic tumor cells accompanied by necrosis and hemorrhage. Which of the following is the most likely diagnosis? A. Astrocytoma B. Ependymoma C. Glioblastoma multiforme D. Oligodendroglioma E. Pilocytic astrocytoma Answer
43* The figure above illustrates an aortic pressure pulse contour from a normal individual and one obtained from a patient. The patient is most likely suffering from which of the following? A. Aortic regurgitation B. Aortic stenosis C. Arteriosclerosis D. Mitral regurgitation E. Patent ductus arteriosus Answer
44*Examination of a late aborted fetus reveals a small head, small eyes, prominent cleft lip and palate, 6 fingers on each hand, and dextrocardia. The developmental abnormalities noted in this fetus were probably due to A. 5p- B. 45, XO C. trisomy 13 D. trisomy 18 E. trisomy 21 Answer
45*A patient presents to the emergency room with malaise. The physician notices slight jaundice. Serum chemistries reveal marked elevation of both aspartate aminotransferase (AST) and alanine aminotransferase (ALT), with the AST/ALT ratio being 2.5. Alkaline phosphatase is near normal. Serum copper and serum iron are normal. Liver damage from which of the following diseases most likely accounts for these findings? A. Alcoholic hepatitis B. Biliary cirrhosis C. Hemochromatosis D. Hepatitis A E. Wilson's disease Answer
46*A 25-year-old man presents to the emergency room with severe abdominal pain. Guaiac test on stool demonstrates occult blood. The patient is taken to exploratory laparotomy, at which a small area of infarcted small bowel is found and surgically removed. Histologic studies on the removed section of bowel demonstrate a recent thrombus occluding a small muscular artery. The adjacent vessel wall shows fibrinoid necrosis with a mixed inflammatory infiltrate containing neutrophils, eosinophils, and mononuclear cells. Which of the following is the most likely cause of the small bowel infarction? A. Atherosclerosis B. Cystic medial necrosis C. Mönckeberg's arteriosclerosis D. Polyarteritis nodosa E. Wegener's granulomatosus Answer
47*A patient has had years of intermittent diarrhea and abdominal pain, but has never consulted a physician. Eventually, he begins to pass fecal material in his urine and he seeks medical attention. Which of the following diseases is most likely to cause this complication? A. Celiac disease B. Crohn's disease C. Diverticulitis D. Ulcerative colitis E. Whipple's disease Answer
48*A 34-year-old female is evaluated for diffuse pelvic pain. Her husband was treated one month previously for venereal disease, but she was not treated at that time. Now she is febrile and has a tender mass around her left adnexa. This condition, if untreated, could lead to A. endometriosis B. infertility C. leiomyomas D. menopause E. polycystic ovary disease Answer
49*A resident physician is performing a pelvic examination on a young woman. The fingers of one of her hands is in the patient's vagina and is palpating the cervix. The other hand is pressing on the abdomen. With the palm of this hand, the physician feels a bony structure in the lower midline. This structure is most likely the A. coccyx B. ilium C. ischium D. pubis E. sacrum Answer
50*A 22-year-old female Asian immigrant presents with complaints of malaise, fever, arm pain, loss of appetite, and visual problems. Her mother states that she fainted 1 week ago. The physician cannot palpate the patient's lower extremity pulses and notes that the dial pulses are weak. The erythrocyte sedimentation rate (ESR) is elevated. Which of the following is the most likely diagnosis? A. Buerger's disease B. Kawasaki's disease C. Takayasu's arteritis D. Thrombophlebitis E. Wegener's granulomatosus Answer


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