NBME-13.pdf

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Exam Section 1: Item 1 o f 50 N a tio n a l B oard o f M e d ica l E xa m in e rs T im e R e m a in in g :

■ M ark C o m p re h e n sive Basic S cience Self-Assessm ent 4 h r 19 m in 0 sec

1. A 64-year-old woman comes to the physician because of a 6-month history of heartburn and difficulty swallowing solid food and liquid. She has not had nausea or vomiting. She also has a 2-year history of pain and swelling of her wrists and hands. She has not seen a physician in 5 years. She takes no medications. She does not smoke. Physical examination shows no wrinkles on the face and neck. Her vital signs are within normal limits. There is synovial thickening of the wrists bilaterally. A photograph of the left hand is shown. Abdominal examination shows no abnormalities. Which of the following sets of findings is most likely on esophageal manometry?

Esophageal

Lower Esophageal

Peristalsis

Sphincter Tone

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Exam Section 1: Item 2 o f 50 I M ark

N a tio n a l B oard o f M e d ica l E xam iners C o m p re h e n sive Basic S cience Self-Assessm ent

T im e R e m a in in g : 4 h r 16 m in 41 sec

2. A 31-year-old woman is evaluated because of a 1-year history of infertility. Her hysterosalpingogram is shown. The most likely cause of these findings is malformation of which of the following embryonic tissues?

C) Mesonephric (wolffian) ducts

D) Paramesonephric (mullerian) ducts © E) Urogenital folds

F) Urogenital sinus

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

A) Adrenal adenoma B) Glomerulonephritis

O C) Henoch-Schonlein purpura O D) Polycystic kidney disease

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N a tion a: Board o f M ed ica l Examiners - G o o g le C h rom e [ o | 0

4. A 55-year-old man comes to the physician because of two episodes of painless, blood-tinged urine during the past week. His last episode was 2 days ago. He has smoked 1 pack of cigarettes daily for 35 years. Vital signs are within normal limits. Physical examination shows no abnormalities. Urinalysis shows normal findings except for microscopic blood. Which of the following is the most likely diagnosis?

O A) Bladder cancer B) Bladder diverticulum C) Interstitial cystitis D) Nephrolithiasis O E) Urinary tract infection

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

O A) Homing B) Initiation O C) Invasion O D) Motility O E) Progression O F) Promotion

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6. A retrospective study is conducted to assess the incidence and outcome of subarachnoid hemorrhage in a midwestern state. The annual incidence of this condition is 15 per 100,000 people, and the case fatality rate is 40%. Based on these data, which of the following represents the annual mortality rate for subarachnoid hemorrhage per 100,000 people in this state? © A) 0.4 x 15

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7. A 24-year-old woman comes to the physician because of a 1 -day history of pain in her left leg while walking. Her temperature is 37°C (98.6°F), pulse is 84/min, and blood pressure is 135/78 mm Hg. Examination of the left lower extremity shows only a markedly decreased pulse in the left lower extremity. An intermittent faint diastolic heart murmur is heard at the apex. Angiography of the left lower extremity shows complete obstruction of the distal left femoral artery by what appears to be a thrombus. The occlusion is removed using a catheter.

Microscopic examination of the removed specimen shows scattered mesenchymal cells in an abundant extracellular matrix. Echocardiography confirms a diagnosis of cardiac tumor. This patient most likely has which of the following types of cardiac tumors?

O A) Fibroelastoma O B) Fibroma

C) Hamartoma O D) Hemangioma O E) Myxoma

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8. An 18-year-old woman with mild mental retardation is brought to the physician because of a 3-day history of decreased ability to see in reduced light. She has a lifelong history of chronic diarrhea. Two years ago, she developed a lack of muscle control of her arms and legs, and generalized weakness. Her 16-year-old brother has had similar symptoms. Ophthalmologic examination shows bilateral retinitis pigmentosa. There is ataxia and loss of deep tendon reflexes. Laboratory studies show erythrocytes with spiny projections and a serum total cholesterol concentration of 40 mg/dL. Which of the following apolipoproteins is most likely deficient in this patient?

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9. A 21 -year-old African American man with sickle cell disease is brought to the emergency department 2 hours after the sudden onset of severe pain in his abdomen and knees. He has had six similar episodes within the past 4 years; he was admitted to the hospital each time for treatment of the pain. His course has been complicated by two episodes of pneumonia and a small cerebral infarction in the past 2 years. The patient asks the physician for extra pain medication to "kill me because I can't take it anymore." Which of the following initial actions by the physician regarding the patient's request is most appropriate?

A) Contact the hospital ethics committee B) Restrain the patient

C) Reevaluate the patient after his pain has been controlled D) Administer general anesthesia for sedation

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10. A 40-year-old woman comes to the physician for genetic counseling because of a family history of muscle weakness. She says that she has not sought treatment because her symptoms are not severe, but her children have profound muscle weakness and fatigue. Sequence analysis of mitochondrial DNA shows a mutation in 50% of the mother's mitochondrial DNA and in 100% of each of her children's mitochondrial DNA. A pedigree is shown. Which of the following genetic principles best explains the findings in this family?

A) Anticipation O B) Genetic drift O C) Heteroplasmy D) Imprinting E) Pseudodominant inheritance

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Exam Section 1: Item 11 o f 50 H Mark

National Board o f Medical Examiners Comprehensive Basic Science Self-Assessment

Tim e Remaining: 3 hr 37 min 44 sec

11. During an experiment, a cuff occluder is placed on the left renal artery of a normal rat and inflated to cause a 90% decrease in the cross-sectional area of the artery. A catheter is placed in the left and right renal veins to sample the effluent. The concentration of which of the following substances will most likely be higher in the effluent from the left renal vein than that from the right renal vein?

O A )A D H (vasopressin) O B) Aldosterone 0 C) Endothelin 0 D) Epinephrine o E) Renin

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Exam Section 1: Item 12 o f 50 National Board o f Medical Exam iners Tim e Remaining:

■ Mark Comprehensive Basic Science Self-Assessment 3 hr 37 min 35 sec

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

A) Alcohol dehydrogenase B) Aldehyde dehydrogenase C) Formaldehyde dehydrogenase D) Lactate dehydrogenase O E) Pyruvate dehydrogenase

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

A) Blockade of inhibitory neurotransmitter release B) Cell death in central nervous system neurons C) Cell death in muscles

D) Cell death in peripheral nervous system neurons O E) Demyelinization

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14. A 76-year-old woman is brought to the emergency department because of a 3-hour history of severe headache, slurred speech, and confusion. She has a 2-year history of atrial fibrillation. She has difficulty understanding and answering questions, but she is cooperative. Ophthalmologic examination shows hemianopia and a tendency to gaze to the right. The pupils are normal sized and reactive to light. Neurologic examination shows left-sided numbness and paralysis that are more severe in the face and upper extremity than in the lower extremity. Which of the following arteries is most likely involved in this patient's condition?

O A) Anterior cerebral O B) Anterior spinal O C) Middle cerebral O D) Posterior cerebral O E) Vertebral

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15. A 54-year-old woman comes to the physician because of a 5-day history of severe mid-back pain. Physical examination shows point tenderness over the T6 vertebra. Serum studies show a calcium concentration of 13.4 mg/dl_; urinalysis shows Bence Jones proteins. Which of the following is the most likely cause of this patient's hypercalcemia?

A) Excessive parathyroid hormone production

B) Excessive parathyroid hormone-related protein production C) Increased fractional calcium gastrointestinal absorption O D) Local interleukin-1 (IL-1) and tumor necrosis factor effects

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

O A) Alcohol 0 B) Heroin © C) LSD

D) Marijuana 0 E) Psilocybin

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17. A 27-year-old woman comes to the physician because of a 2-year history of sporadic double vision and a 1 -year history of intermittent numbness and tingling in her arms. The symptoms became more severe 5 days ago after a 4-day visit from her husband's parents. During the past year, she also has had four episodes of urinary incontinence. Physical examination shows mild dysarthria. On mental status examination, she has a mildly worried mood and a reactive affect. MRI of the brain shows a few small, scattered, nonspecific white-matter plaques.

Which of the following is the most likely diagnosis? A) Complex partial seizure disorder

O B) Conversion disorder O C) Huntington disease

o D) Multiple sclerosis

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18. A 30-year-old woman, gravida 2, para 2, develops severe vaginal bleeding immediately after vaginal delivery of a male newborn at term. The hemorrhage continues during the next hour, and the patient undergoes an emergency hysterectomy to control the bleeding. Examination of the uterus shows fragments of placenta adherent to the uterine wall. There is absence of the decidua basalis. Which of the following is the most likely diagnosis?

O A) Abruptio placentae O B) Chronic villitis C) Circumvallate placenta D) Placenta accreta O E) Succenturiate lobe

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19. A 55-year-old man with hepatic encephalopathy is brought to the physician because of confusion and increased lethargy during the past 24 hours. He has a history of cirrhosis of the liver caused by hepatitis C. He is easily arousable despite the lethargy. His temperature is 37°C (98.6°F). Physical examination shows scleral icterus, asterixis, a protuberant abdomen, and ascites. Test of the stool for occult blood is negative. Administration of which of the following drugs is most likely to improve this patient's mental status?

O A) Bisacodyl O B) Docusate © C) Lactulose 0 D) Octreotide 0; E) Omeprazole 0 F) Sucralfate 0 G) Ursodiol o o @ ©

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20. A 76-year-old man is admitted to the hospital because of a 2-week history of a persistent urinary tract infection. He is 165 cm (5 ft 5 in) and weighs 55 kg (121 lb); BMI is 20 kg/m2. The physician plans to initiate treatment. A component of the initial treatment includes an intravenous bolus dose of an antibiotic to attain an initial peak serum concentration of 8 mg/L. The volume of distribution of the antibiotic is 0.35 L/kg. Laboratory studies show a 24-hour urine creatinine clearance within the reference range. Which of the following is the most appropriate loading dose of this drug for this patient (in mg)?

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21. A healthy 22-year-old man is a subject in a study investigating the regulation of heart rate during exercise. He is sitting on a stationary bicycle and is instructed to begin pedaling in

5 minutes. One minute before he begins to pedal, his heart rate increases. An increase in which of the following transmitters acting at the indicated receptor best explains the increase in heart rate in this man?

Transmitter

Receptor

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22. A 15-year-old boy has intracranial neoplasms, mental retardation, and seizures associated with tuberous sclerosis complex, an autosomal dominant disorder. His 41-year-old mother is healthy but has angiofibromas, which are benign skin lesions characteristic of tuberous sclerosis complex. Which of the following best explains the findings in the boy and his mother? A) Alternate paternity

B) Anticipation

C) Parental germline mosaicism O D) Reduced penetrance

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23. A 40-year-old woman is brought to the emergency department 30 minutes after sustaining severe chest injuries in a motor vehicle collision. Despite appropriate treatment, she dies 1 hour later. She had a 25-year history of a well- controlled seizure disorder. A photograph of a coronal section of the brain obtained at autopsy is shown. Which of the following is the most likely cause of this patient's seizure disorder?

A) Glioblastoma multiforme B) Herpes simplex encephalitis C) Mesial temporal sclerosis D) Neonatal ischemic stroke E) Vascular malformation

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24. A 51-year-old man comes to the physician because of a 2-week history of cough productive of blood. He also has had a 3-kg (6.6-lb) weight loss during the past month. He has smoked 2 packs of cigarettes daily for 32 years. He has hypertension treated with metoprolol. Physical examination shows clubbing of the fingernails. Wheezes are heard over the right upper lobe anteriorly; there are no crackles. Laboratory studies show:

Serum Na+ 125 mEq/L K + 3.9 mEq/L c i- 85 mEq/L h c o3- 25 mEq/L Urea nitrogen 8 mg/dL Creatinine 0.4 mg/dL Osmolality 262 mOsmol/kg Urine osmolality 564 mOsmol/kg

A CT scan of the chest shows a 2.4 x 1.2-cm, spiculated noncalcified mass in the right upper lobe eroding into the right bronchus. This patient's laboratory findings are most likely caused by an excess of which of the following hormones?

O A) ADH (vasopressin)

O B) Adrenocorticotropic hormone O C) Brain natriuretic peptide © D) Cortisol

O E) Thyroxine (T4)

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25. A 60-year-old man comes to the physician because of weakness and light-headedness for 3 months. His diet consists of a healthy balance of fruits, vegetables, whole grains, and lean chicken and fish. He has a 10-year history of chronic autoimmune (Hashimoto) thyroiditis treated with thyroxine. Physical examination shows pallor. Serum studies show increased

concentrations of methylmalonic acid and total homocysteine. A peripheral blood smear shows megaloblastic anemia. Which of the following is the most likely cause of the findings in this patient?

A) Cystathionine 3-synthase deficiency O B) Failure of intrinsic factor production © C) Folic acid deficiency

D)

Helicobacter pylori

gastritis

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26. A 55-year-old woman is scheduled to undergo transvaginal hysterectomy and oophorectomy for dysfunctional uterine bleeding. During the procedure, the uterus must be separated from all surrounding pelvic structures. Identification and incision of which of the following structures that attaches to the cervical region and extends posteriorly is most appropriate in this

patient?

C A) Mesometrium B) Mesosalpinx C C) Mesovarium

D) Ovarian ligament

C E) Round ligament of the uterus F) Uterosacral ligament

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27. A 33-year-old woman comes to the physician because of a 16-kg (35-lb) weight gain during the past 6 months despite dieting. She is 168 cm (5 ft 6 in) tall and now weighs

104 kg (230 lb); BMI is 37 kg/m2. Her blood pressure is 156/96 mm Hg. Physical examination shows a round, ruddy face with hirsutism, excess weight predominantly in the shoulders and abdomen, and purple striae over the abdomen. An MRI shows a mass in the pituitary gland. A CT scan of the abdomen shows enlarged adrenal glands. Which of the following histologic changes would be expected in this patient's adrenal glands?

A) Cortical hyperplasia C B) Cortical hypertrophy C) Cortical metaplasia D) Medullary hyperplasia E) Medullary hypertrophy F) Medullary metaplasia

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28. A 22-year-old woman comes to the physician for a follow-up examination. One year ago, she was diagnosed with a pulmonary embolism. Two years ago, she delivered a female stillborn at 23 weeks' gestation. Physical examination today shows no abnormalities. Laboratory studies show a platelet count of 250,000/mm3, a prothrombin time within the reference range, and an increased partial thromboplastin time. The findings in this patient are most consistent with which of the following conditions?

A) Antiphospholipid antibody syndrome O B) Factor V Leiden mutation

C) Increased factor VIII (antihemophilic factor) concentration © D) Protein C deficiency

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29. A 54-year-old man comes to the physician because of a 2-week history of burning epigastric pain. He is recently divorced. His diet mainly consists of fast food. He smokes cigars and drinks one to two 12-ounce cans of beer on the weekends. He was treated for

Helicobacter pylori

infection 1 year ago. He uses high doses (600 mg daily) of over-the-counter ibuprofen for chronic joint pain. Abdominal examination shows tenderness to deep palpation of the epigastric area. A peptic ulcer is suspected. Which of the following is the strongest predisposing risk factor for this patient's condition?

O A) High-fat diet O B) Ibuprofen use O C) Ingestion of alcohol

D) Recent psychosocial stressor O E) Smoking cigars

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30. A 22-year-old nulligravid woman comes to the physician because she has been unable to conceive for 18 months. She has had irregular menses since menarche at the age of 13 years. She is 165 cm (5 ft 5 in) tall and weighs 88 kg (195 lb); BMI is 32 kg/m2. Her temperature is 36.8°C (98.2°F), pulse is 88/min, respirations are 14/min, and blood pressure is

140/90 mm Hg. Physical examination shows moderate hirsutism and mild acne over the face and back. Pelvic examination shows no abnormalities of the exterior genitalia; a bimanual examination is limited by the patient's obesity. Which of the following is the most likely cause of this patient's infertility?

A) Hypothyroidism B) Klinefelter syndrome C) Pituitary adenoma

D) Polycystic ovarian syndrome E) Primary ovarian failure

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31. A 9-year-old girl is brought to the emergency department by her father because of severe pain in her right shoulder after a fall 1 hour ago. Physical examination shows pain on movement of the right shoulder and a tender right clavicle. An x-ray of the shoulder shows a nondisplaced fracture of the right clavicle. Which of the following structures of the clavicle will most likely assist in producing new bone to heal this fracture?

O A) Epiphysis

B) Haversian canal © C) Lamella

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32. A 2-month-old boy dies of meningitis despite appropriate antibiotic therapy. Culture of his cerebrospinal fluid grows

Mycobacterium tuberculosis.

Two of his brothers died of atypical mycobacterial infections. Which of the following immunodeficiencies most likely explains this familial history?

C A) Complement deficiency

C B) Interferon-Y receptor deficiency C C) Leukocyte adhesion deficiency

D)X-linked agammaglobulinemia

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33. A previously healthy 25-year-old man is admitted to the hospital for treatment of viral pneumonia. He is mechanically ventilated because of respiratoryfailure due to hypoxemia. An open- lung biopsy specimen is obtained and shows a pattern of acute lung injury. The presence of which of the following in the biopsy specimen most clearly suggests diffuse alveolar damage rather than bronchiolitis obliterans-organizing pneumonia in this patient?

A) Alveolar hyaline membrane B) Foamy macrophages

C) Interstitial collagen deposition O D) Masson bodies

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34. A 39-year-old woman with end-stage renal disease caused by systemic lupus erythematosus undergoes kidney transplantation from a living, unrelated donor. Despite aggressive immunosuppressive therapy, the transplant is rejected after 6 months. Analysis of a biopsy specimen of the transplant shows numerous infiltrating CD8+ T lymphocytes. Which of the following is the most likely cause of rejection of the transplant in this patient?

O A) Antibody synthesis O B) Complement activation O C) Direct cytotoxicity

D) Histamine release O E) Nitric oxide production

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35. A 7-year-old girl is brought to the physician by her parents because of a 3-year history of temper tantrums when her parents leave her. She refuses to sleep alone and recently would not attend her friend's birthday slumber party. She calls to her mother if she is in another room of the house. Each morning, the patient's teacher has to carry her into school crying. Her mother recently returned to work full-time and says that she is quite angry that her daughter is behaving in such a defiant way. Her father recalls that he behaved the same way when he was her age. Which of the following is the most likely explanation for this patient's behavior?

O A) Conduct disorder

B) Oppositional defiant disorder C) Post-traumatic stress disorder D) Separation anxiety disorder O E) Normal behavior

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36. A 49-year-old man with pancreatic cancer undergoes a Whipple procedure to resect the distal stomach, duodenum, and head of the pancreas. During the procedure, the cut end of the remaining stomach is joined to the side of the jejunum (gastrojejunostomy). Which of the following nerve structures can be cut to decrease stomach acid output and decrease the likelihood of ulcers forming in the jejunum at the site of junction with the stomach?

O A) Celiac plexus B) Iliohypogastric nerves © C) Phrenic nerves O D) Subcostal nerves O E) Sympathetic chain O F) Vagal trunks

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37. A 35-year-old man comes to the physician for a routine examination. He has a 5-year history of recurrent episodes of genital herpes treated with acyclovir. He says, "I've been taking the medication, but I still occasionally get lesions. When will I be cured?" The physician informs him that herpes simplex is a lifelong infection, with no cure at the present time. Which of the following best explains the longevity of the herpes simplex virus?

A) Continual replication in dendritic cells

B) Continual replication in epithelial cells of the skin C) Continual replication in sacral root ganglia D) Continual replication in T lymphocytes

E) Establishment of a latent infection in B lymphocytes

F) Establishment of a latent infection in circulating immune cells G) Establishment of a latent infection in epithelial cells of the skin H) Establishment of a latent infection in sensory nerve cells

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38. A 3-year-old boy is brought to the emergency department because of multiple ecchymoses, bleeding into the joints, and bloody diarrhea 48 hours after ingesting an unknown quantity of warfarin that he took from his grandmother's purse. Prothrombin time is 80 sec (INR=20). Which of the following is the most appropriate initial therapy?

A) Factor IX (plasma thromboplastin component) concentrate O B) Fibrinogen concentrate

C) Fresh frozen plasma O D) Platelet concentrates

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

O A) Blood vessels O B) Collagen fibers O C) Elastic fibers O D) Lymphatic vessels © E) Nerves

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

O A) Bacteremia

B) Enterotoxin ingestion

C) Intestinal mucosa inflammation O D) Lead toxicity

E) Villus atrophy © F)Virem ia

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41. A 28-year-old woman comes to the physician for a health maintenance examination. During the interview, she tearfully tells the physician that she and her new husband are having problems. She says she wants to go out with friends, but he does not enjoy being with people, preferring individual activities such as hiking. She says he seems indifferent to sexual intimacy and neither shows much emotion nor understands her feelings at all. Which of the following personality styles best explains the husband's behavior?

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42. A 23-year-old woman is treated with acetazolamide to prevent acute altitude sickness 3 days before going on a mountain-climbing expedition. Acetazolamide acts predominately in which of the following areas of the kidney in this patient?

O A) Ascending loop of Henle O B) Collecting ducts

O C) Descending loop of Henle © D) Distal tubule

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

A) Inadequate statistical power O B) Nonrandomization

O C) Selection bias

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44. A healthy 21-year-old man dies suddenly of cardiac arrest after snorting cocaine. Cocaine-induced inhibition of which of the following is the most likely explanation for the cardiac arrest? A) Acetylcholinesterase O B) a2-Adrenergic receptors O C) (32-Adrenergic receptors O D) Monoamine oxidase O E) Muscarinic receptors O F) Norepinephrine reuptake

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45. A 62-year-old man is brought to the emergency department because of a 3-hour history of progressive difficulty breathing and mild left shoulder pain. His symptoms began after he ran up several flights of stairs. He has poorly controlled hypertension and mild angina pectoris. He has smoked one-half pack of cigarettes daily for 40 years. He appears uncomfortable and has labored breathing. Diffuse crackles, rhonchi, and scattered wheezing are heard on auscultation of the posterior lung fields. His arterial Po2 is 58 mm Hg. Which of the following is the most likely diagnosis? A) Cardiac tamponade O B) Pneumonitis O C) Pneumothorax O D) Pulmonary edema O E) Pulmonary embolism

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46. A 22-year-old woman is admitted to the hospital because of a 10-day history of polydipsia and polyuria. She says that the urge to urinate often awakens her at night. She has been taking lithium carbonate for 2 years for bipolar disorder; her dosage was increased 6 months ago because of recurrent severe manic episodes. Her vital signs are within normal limits. Physical examination shows no abnormalities. Over the next 24 hours, urine excretion totals 6.5 L. Laboratory studies at this time show a serum sodium concentration of 148 mEq/L, serum

osmolality of 315 mOsmol/kg, and urine osmolality of 75 mOsmol/kg. After administration of desmopressin, urine output and osmolality do not change. Which of the following findings in the nephron best describes the tubular osmolality, compared with serum, in this patient?

Proximal Tubule

Juxtaglomerular Apparatus

Medullary Collecting Duct

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47. An 82-year-old woman is admitted to the hospital for treatment of a small right pleural effusion. Physical examination shows dullness to percussion at the level of the 7th rib and below on the right. A thoracentesis is done. The patient is sitting up, supported by leaning against a bedside table. After preparing the skin and delivering a local anesthetic, into which of the

following locations on the right is it most appropriate to insert the catheter? O A) Above the 5th rib in the midscapular line

B) Above the 5th rib just to the right of the sternum C) Above the 7th rib in the paravertebral region D) Above the 9th rib in the midscapular line O E) Below the 5th rib in the midaxillary line

F) Below the 5th rib in the midclavicular line G) Below the 9th rib in the midscapular line

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48. A 72-year-old woman is admitted to the intensive care unit after undergoing immediate operative repair of a ruptured colonic diverticulum. During the next 2 weeks, she develops recurrent fevers. After a blood culture grows yeast, micafungin therapy is initiated. This drug most likely targets which of the following cellular structures?

C) Kinetoplast © D) Ribosome

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

O A)Adhesins

B) Anti hemolytic factors O C) Pyrogenic exotoxin

O D) Teichoic acid in the cell wall O E) Thick peptidoglycan layer

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Tim e Remaining:

50. A 38-year-old woman at 32 weeks' gestation is brought to the physician because of a 2-day history of fever, nausea, vomiting, and muscle aches. She appears acutely ill. Her temperature is 39°C (102.2°F), pulse is 120/min, and respirations are 20/min. A photomicrograph of a Gram stain of an organism recovered from a blood culture is shown. Which of the following is the most likely causal organism?

A)

Corynebacterium urealyticum

B)

Gardnerella vaginalis

C)

Listeria monocytogenes

O D

) Rhodococcus equi

E)

Staphylococcus aureus

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1. A 21-year-old woman who is a medical student comes to the physician for evaluation of recurrent throbbing headache associated with sensitivity to light and sound. Neurologic examination shows no abnormalities. Sumatriptan is initiated for suspected migraine. This drug is most appropriate for this patient because of its ability to activate which of the following types of

receptors? O A) Acetylcholine B) Y-Aminobutyric acid O C) Dopamine O D) Neurotensin 0 E) Serotonin

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2. A 5-year-old girl is brought to the physician because of listlessness, fatigue, and dull pain in the right upper quadrant of the abdomen. Her height and weight are below the 25th percentile. Laboratory findings indicate that the content of her (3-globin chain is 15% to 20% of normal. Sequencing of the (3-globin gene shows a point mutation in a sequence 3' to the coding region in which AATAAA is converted to AACAAA. Consequently, the amount of mRNAfor (3-globin is decreased to 10% of normal. Which of the following functions in mRNA synthesis and

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3. An investigator breeds a transgenic strain of mice that develops severe fasting hypoglycemia. Administration of glucagon does not correct the hypoglycemia, but administration of epinephrine results in an increase in the serum glucose concentration. Which of the following proteins is most likely defective in this mouse strain?

O A) Adenylyl cyclase O B) Glucagon receptor C) Glycogen phosphorylase O D) Heterotrimeric G protein E) Phosphorylase kinase © F) Protein kinase A o Previous o Next m © * *

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Exam Section 2: Item 4 o f 50 0 M ark

4. A 60-year-old man comes to the physician because of progressive weakness of his hands during the past 6 months. He works as a carpenter and has had difficulty handling his tools. He has smoked 1 pack of cigarettes daily for 45 years. He drinks two beers daily during the workweek and approximately six beers daily on weekends. Physical examination shows no

lymphadenopathy. There is decreased strength (4/5) in the upper and lower extremities and atrophy of the muscles of the hands. He has diffuse hyperreflexia. Fasciculations are noticed on the muscles of the hands and upper extremities. Sensory examination is normal. Over the course of this disease, which of the following findings is most likely?

O A) Dementia

o B) Difficulty swallowing O C) Loss of facial sensation

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5. A 60-year-old man has had episodes of fluctuating weakness for the past 2 years. The weakness was first noticed when he had difficulty lifting books. At times, he has had drooping of the eyelids and double vision. Recently, he has had difficulty climbing stairs and regurgitation of liquids into his nose. On physical examination, the weakness increases with repeated exercise. An x-ray of the chest shows a mass in the mediastinum. Which of the following laboratory assays is most likely to be positive?

O A) Acetylcholine receptor antibody B) Botulinum toxin

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

A) Decreased calcium concentration B) Decreased glucose concentration C) Decreased sodium concentration O D) Increased AST and ALT activities

E) Increased creatinine concentration F) Increased lactic acid concentration

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7. A 65-year-old woman with diabetic ketoacidosis has had a fever and proptosis of the left eye over the past 3 days. She is unable to move the left eye. A black eschar is present on the nasal mucosa. Which of the following is the most likely diagnosis?

A) Aspergillosis B) Candidiasis O C) Coccidioidomycosis O D) Cryptococcosis E) Histoplasmosis O F) Mucormycosis o Previous o Next m © ^

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8. A 42-year-old man comes to the physician because of a 4-week history of muscle cramping and pain. Two months ago, he began treatment with simvastatin (80 mg daily) for

hypercholesterolemia. After 1 month, marked improvement was noted in his serum LDL-cholesterol concentration, but serum triglyceride concentration remained increased. At that time, gemfibrozil was added to his regimen to decrease his triglyceride concentration. Physical examination today shows no abnormalities. This patient's myalgia is most likely related to which of the following effects of gemfibrozil on simvastatin?

A) Decreased bioavailability B) Increased absorption

O C) Inhibition of cytochrome P450 metabolism D) Inhibition of hepatic glycosylation

E) Inhibition of hepatic sulfation

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Exam Section 2: Item 9 o f 50 National Board o f Medical Examiners Tim e Remaining:

| Comprehensive Basic Science Self-Assessment 4 hr 12 min 32 sec

9. A 25-year-old woman comes to the physician because of a 2-day history of decreasing urine output despite ample fluid intake. She underwent operative removal of a perforated appendix 3 weeks ago. She received intravenous gentamicin for 2 weeks. Physical examination shows no abnormalities. Laboratory studies show:

Serum Urea nitrogen 35 mg/dL Creatinine 2.9 mg/dL Urine Specific gravity 1.010 Protein 2+ Na+ 25 mEq/L

Casts brown granular

Histologic examination of this patient's kidneys would most likely show necrotic cells in which of the following components of the nephron? C A) Bowman capsule

0 B) Collecting tubule

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

Triglycerides

HDL-cholesterol

Free Fatty Acids

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Exam Section 2: Item 11 o f 50 National Board o f Medical Examiners

| l^ ark Comprehensive Basic Science Self-Assessment

11. A 47-year-old man is brought to the emergency department 3 hours after the sudden onset of sharp left flank pain and fever. He has had similar episodes during the past 5 years. His temperature is 38.3°C (100.9°F). Abdominal examination shows exquisite tenderness in the left costovertebral region. Laboratory studies show:

Hemoglobin 16 g/dL Hematocrit 48% Leukocyte count 18,000/mm3 Segmented neutrophils 85% Bands 5% Lymphocytes 8% Monocytes

2%

Urine leukocytes 2500/mm3

Imaging studies show hydronephrosis of the left kidney and a staghorn calculus. A nephrectomy is done; the calculus is composed of magnesium ammonium phosphate (struvite). Culture of a urine sample is most likely to grow which of the following organisms?

C A)

Escherichia coli

B)

Proteus mirabilis

C)

Pseudomonas aeruginosa

D)

Serratia marcescens

E)

Staphylococcus aureus

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

0 A) Low-calorie 0 B) Low-carbohydrate 0 C) Low-cholesterol 0 D) Low-protein 0 E) Low-sodium

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13. An 18-year-old primigravid woman at approximately 16 weeks' gestation comes to the physician because of a 3-month history of nausea and vomiting. She has not had any prenatal care. Physical examination shows a uterus consistent in size with a 20-week gestation. Her serum (3-human chorionic gonadotropin concentration is markedly increased. Urinalysis shows 4+ protein. Ultrasonography of the abdomen shows echogenic material within the endometrial cavity but no fetus. The most likely cause of her condition is proliferation of which of the following? O A) Allantois O B) Blastocysts C) Decidua basalis D) Decidua capsularis O E) Trophoblastic tissue o Previous o Next m ©

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