ข้อสอบ MD  NL  ชุดที่ 23 
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ชื่อ - สกุล *
เลขประจำตัวนิสิต *
1.  Heme synthesis occurs in the bone marrow and liver. Defi ciency of δ-aminolevulinic acidhydrase would lead to the accumulation of which of the following? *
1 point
2. A 50-year-old man develops nonbloody watery diarrhea while working as an aid worker ina refugee camp in Bangladesh. He arrived in the area 2 days ago. A stool smear shows noWBCs. He subsequently develops dehydration and electrolyte abnormalities leading tocardiac and renal failure. Which of the following organisms is the most likely cause of thisman’s enterocolitis? *
1 point
3.  A 40-year-old man comes to the emergency department because of diplopia anddysphagia that developed after he consumed homemade strawberry jam. While in theemergency department, he develops general muscle weakness and requires intubation dueto sudden respiratory muscle paralysis. Which of the following pathogens is most likelyresponsible for this patient’s condition? *
1 point
4.  A 33-year-old woman with a history of Graves’ disease is brought to the emergencydepartment unresponsive following a bout of confusion and agitation. On physicalexamination her temperature is 39.2° C (102.5° F), her blood pressure is 100/70 mm Hg, andher pulse is 165/min. A systolic ejection murmur is heard at the apex, and the patient has 3+pitting edema at the ankles. Following primary stabilization, which of the following wouldconstitute appropriate pharmacotherapy for this patient’s underlying condition? *
1 point
5. A physician decides to place a patient on a calcium channel blocker for treatment of herangina. Calcium channel blockers can relax the smooth muscle of blood vessels and canalso have various effects on cardiac contractility, conduction, and heart rate. Which of thefollowing calcium channel blockers would be most effective in reducing heart rate andcontractility? *
1 point
6.  A 55-year-old woman presents to her doctor with feelings of fatigue, increased appetite,increased sweating, and palpitations. Physical examination is unremarkable except forexophthalmos. She receives pharmacologic treatment for her condition, but soon developsa fever and multiple infections in her throat and gastrointestinal tract. Her doctor quicklydiscontinues the medication Which medication was she most likely prescribed? *
1 point
7. Which of the following types of hepatocellular injury is commonly seen afteracetaminophen overdose? *
1 point
8. A 22-year-old woman who is a professional tennis player presents to the physician withpain on the lateral aspect of her elbow radiating down her forearm. Repetitive use of whichof the following muscles most likely lead to this patient’s condition? *
1 point
9. A 40-year-old man was admitted to the neurology service for evaluation of persistentnumbness over his left jaw and lower face. MRI reveals a schwannoma, which is compressinga cranial nerve as the nerve exits the skull. The cranial nerve involved in this case exits theskull through which of the following foramina? *
1 point
10. A 44-year-old schizophrenic patient on a psychiatric ward is interviewed daily as part ofher treatment. She has been persistently reporting that she is married to Paul McCartney.This psychotic symptom is a disorder of which of the following? *
1 point
11. Patients with renal artery stenosis may present with very high blood pressures due toincreased renin secretion. Which of the following structures in the kidney is responsible forsensing inadequate perfusion and secreting renin? *
1 point
12. A 28-year-old woman who is 6 months pregnant presents to the emergency departmentwith a temperature of 38.2° C (100.8° F) and complains of shaking chills and pain on her rightside, which she locates by pointing to the area above her right iliac crest. During theexamination she is tender to percussion at the junction of the lower ribs and the thoracicvertebrae. Urinalysis reveals WBC casts. Which of the following is the most likely diagnosis? *
1 point
13. Diuretics are medications that increase the amount of urine flow by inhibiting transportproteins or enzymes in the nephron. Different classes of diuretics affect different parts of thenephron. Which of the following diuretics will also decrease the amount of calcium excretedfrom the kidney? *
1 point
14. A 53-year-old woman experiences hot flashes associated with menopause. She calls herprimary care physician to ask for advice about the risks and benefits of hormonereplacement therapy (HRT). Which of the following is a potential benefit of HRT? *
1 point
15. A young couple is having trouble conceiving and decides to undergo in vitro fertilization.The woman begins treatment to stimulate ovulation prior to ova collection and fertilization.Which of the following hormones is most directly responsible for ovulation? *
1 point
16. Following a normal pregnancy and labor, a baby is born to a young couple. The babycries immediately and has Apgar scores of 9 at both 1 and 5 minutes. While examining thebaby, the pediatrician at delivery notes that the baby has some labial scrotal fusion and aphalluslike organ. The baby is also hypotensive and hypovolemic. Genotyping reveals akaryotype of 46,XX. Which of the following is the most likely cause of the patient’s physicalfindings and symptoms? *
1 point
17. A 46,XY infant is born with a nonsense mutation in the SRY gene. Which of the followingwill be the symptomatic manifestation of this mutation? *
1 point
18 Abnormal opening of the urethra on the ventral penis is caused by the failure of acertain urogenital structure to complete normal development in the fetus. This structure ispresent in both male and female infants, but has a different fate in each. What structure inthe female infant is derived from the fetal structure described here? *
1 point
19.  A 71-year-old man is brought to the emergency department by ambulance after he wasfound by his neighbor walking around his garden confused and unable to answer questions.He is confused and oriented only to person. His temperature is 37.6° C (99.7° F), heart rate is110/min, respiratory rate is 20/min, and blood pressure is 130/92 mm Hg. While in theemergency department the patient has a seizure. Laboratory tests show a serum sodiumlevel of 115 mEq/L, potassium of 3.8 mEq/L, glucose of 100 mg/dL, and osmolality of 250mOsm/ kg. Urine electrolyte testing show a urine osmolality of 500 mOsm/kg. X-ray of thechest shows a mass in the lung. Which of the following is the most likely etiology of themass? *
1 point
20. A full-term neonate presents to the pediatrician with failure to pass meconium. Digitalexamination of the rectum results in a gush of retained fecal material. Which of thefollowing is the most likely diagnosis in this infant? *
1 point
21. Over the course of embryologic development, the predominant location of hematopoiesischanges several times. Where does this process take place during the 11th week of fetal life? *
1 point
22. A 37-year-old man comes to the physician with recurrent viral infections. Blood studiesshow normal levels of circulating lymphocytes and neutrophils. A defi ciency in which of thefollowing cytokines would most likely lead to this man’s condition? *
1 point
23. A baby is observed at birth to be noncyanotic. The mother is known to have beeninfected with rubella during the pregnancy. On physical examination the patient is found tohave a continuous murmur that is present in both systole and diastole. A nonsteroidal antiinfl ammatory drug is prescribed, and on follow-up the murmur has disappeared. Which ofthe following is the most likely congenital lesion? *
1 point
24. A 34-year-old man with moderately severe ulcerative colitis has been taking oralprednisone for 4 months. Which of the following symptoms is the most likely adverse effectof this drug? *
1 point
25. A 35-year-old woman that is pregnant with her fourth child comes to the physicianbecause of painful gastrointestinal bleeding for the past month. The pain and bleeding areworse when she defecates. Which of the following is themost likely diagnosis? *
1 point
26. A 45-year-old woman presents to her physician with a 2-day history of right upperquadrant pain, nausea, gas, and vomiting. She reports that her symptoms are worse after sheeats a fatty meal. Which of the following substances inhibits the hormone causing her rightupper quadrant pain? *
1 point
27. A 22-year-old man is diagnosed with medullary thyroid carcinoma, and his blood testsare significant for hypercalcemia and increased plasma catecholamine levels. He reports thathis mother also had medullary thyroid carcinoma in her twenties and that she recently hadsurgery to remove her parathyroid glands. These findings suggest a possible mutation inwhich of the following genes? *
1 point
28. A woman is concerned about her risks for developing cervical cancer. Which of thefollowing factors poses the largest risk for developing cervical cancer? *
1 point
29. A 47-year-old man with chronic asthma who has been treated with high-dose steroids formany years develops a productive cough, weight loss, and night sweats. Imaging studiesreveal the presence of abscesses in the lungs and brain. Cultures show gram-positive filaments that are weakly acid-fast. Which of the following organisms is responsible for thispatient’s condition? *
1 point
30. A term infant is born after an uncomplicated pregnancy to a 35-year-old woman. Oncutting the umbilical cord, the pysician notes an abnormality that leads him to consult apediatric cardiologist. Which of the following abnormalities did this physician most likelyobserve? *
1 point
31. A 45-year- old man presents with chronic back pain. Theradiography reveals fracture ofthoracic vertebral bodies. Bonebiopsy shows aggregation of epithelioid cells, plasmacells andlymphocytes with central caseous necrosis.What is the most likely causativeorganism? *
1 point
32. A 55-year- old man is diagnosed with liver cirrhosis and hepatic encephalopathy. Whichintermediate in tricarboxylic acid cycle is deficient in this patient? *
1 point
33. A 60-year- old strict vegetarian woman presents with fatigue, loss of appetite and shortnessof breath. Physical examination shows moderately pale. Which of the following nutrient isdeficient and responsible for these clinical features? *
1 point
34. A newborn girl presents to the neonatologist with an inability to swallow, coughing,choking, and vomiting when fed. Work-up reveals a tracheoesophageal fi stula. Which of thefollowing may have been present during the mother’s pregnancy with this child? *
1 point
35. Which of the following polymorphonuclear cells/squamous epithelial cells ratio is likelyto show the adequate sputum? *
1 point
36. A 1-month- old infant presents with constipation without meconium passing. PE:abdominal distention, explosive stool after rectal examination. Rectal biopsy showslack of ganglion cell. Which of the following cells fails to migrate into the affected organ inthis case? *
1 point
37. A 15-year-old girl presents to the physician with underdeveloped breasts and hirsutism.Her medical history includes early appearance of axillary and pubic hair and amenorrhea. Onexamination her blood pressure is 90/55 mmHg. The enzyme deficient in this patient isneeded for the production of which of the following hormones? *
1 point
38. A 3-month-old infant presents with failure to thrive, poor feeding, and lethargy. Aphysical examination reveals an enlarged liver and jaundice. Laboratory analysis reveals anelevated blood galactitol level and increased urinary reducing substance. Which of thefollowing could correctly describe the levels of intermediates of galactose metabolism inthis patient? *
1 point
39. When a particular ligand binds to its receptor, there is an increase in the cleavage ofphosphatidylinositol biphosphate into inositol triphosphate and diacylglycerol. Both of thesesubstances have actions within the cell. Which of the following would be an example of areceptor that functions in this manner? *
1 point
40. 45 year-old alcoholic man presents with fever, severe epigastric pain, nausea, andvomiting.Laboratory test : increased serum amylase. Which of the following type of necrosisis most likelyto occur in the affected organ? *
1 point
41. A girl has microcytic hypochromic anemia & basophilic stripping. Radiological findingreveals dense lines in epiphyseal of long bone. She live near factory. What substance cancause this finding? *
1 point
42. . A 60-year-old man suffering from depressive disorder for a year gets better withfluoxetine treatment. Which of the following neurotransmitters is affected by thismedication? *
1 point
43. A 1-year-old boy develops severe pneumonia and respiratory failure. The bronchialsecretion shows large, multinucleated clumps of cell. Which of the following is the mostlikely causative agent? *
1 point
44. A 57-year-old woman is scheduled for elective hysterectomy. Severing which of thefollowing structures during surgery would disrupt the most blood flow to the ipsilateralovary? *
1 point
45. A 25-year-old man comes to the emergency department with bloody sputum. A fewweeks later he progresses to renal failure with significant hematuria and hypertension. Arenal biopsy shows linear immunofluorescence. Which of the following types ofhypersensitivity reaction is this patient experiencing? *
1 point
46. Mannitol, an osmotic diuretic, is sometimes used to lower intracranial pressure. Wherealong the nephron is the primary site of action of mannitol? *
1 point
47. A biopsy of one of several red, tender, subcutaneous nodules from the anterior lowerlegs of a 27-year-old man is obtained by a dermatologist. On histopathology, she sees apanniculitis (inflammation of subcutaneous fat) with widening of tissue septa from edema,increased neutrophils, and fibrin exudation. Which of the following diseases is often presentin someone with these nodules? *
1 point
48. A 20-year-old man presents to the physician with a nontender indurated mass over hismandible. He has had this mass for 4 months and decided to come to the physicianbecause the mass started to ooze a thick yellow exudate. Yellow granules are seen onmicroscopic examination of the discharge. Which of the following organisms is most likelyresponsible for this man’s lesion? *
1 point
49. 60 years old male, blurred vision while taking amitriptyline due to blockade of whichfollowing receptor? *
1 point
50. A pap smear from 25-year-old woman cells with high N/C ratio, condensation of chromatin,irregular nuclear membrane and perinuclear halo. What is organism the patient infected? *
1 point
51. สภาวะที่มีการอดอาหารเป็นเวลานานจะมีการเปลี่ยนแปลงของกระบวนการทำงานชีวเคมีอย่างไร *
1 point
52. ชายย 40 ปี ไข้หวัดมา 3 วัน ซื้อยำมารับประทานเอง มีอาการอ่อนเพลีย ซีด ปัสสาวะดำ ตรวจร่างกาย พบว่าซีดปานกลาง ตาเหลืองเล็กน้อย คลำม้ามไม่พบ ชายผู้นี้มีความบกพร่อง enzyme ใน pathway ใด *
1 point
53. เด็กที่ถูกลักพาตัวหลังจากนั้นพ่อแม่ที่มาแสดงตน จะสามารถพิสูจน์ได้ด้วยวิธใด *
1 point
54. .ชาย 50 ปี ติดสุราเรื้อรัง ตรวจร่างกายพบ flapping tremor, fetor hepaticus ภาวะดังกล่าวเกิดจากสาเหตุใด *
1 point
55. Albinism เป็นโรคที่ขาดเอนไซม์ใด *
1 point
56. เด็กอายุ 6 ปี ปวดท้องเรื้อรัง 2 เดือน ซีดเล็กน้อย blood smear พบ Basophilic strippling สาเหตุที่พบเกิดจากอะไร *
1 point
57. Preterm 28 wk. 10 วัน มี anemia เป็นความผิดปกติของการสร้างเม็ดเลือดแดงที่อวัยวะใด *
1 point
58. The blood smear show eccentrocyte. What is next investigation that should be done? *
1 point
59. ภาวะใดทำให้ Hb ใน HbO2 ปล่อย O2 ให้แก่ tissue ได้ง่ายขึ้น *
1 point
60 .แม่ตั้งครรภ์ ที่ได้รับ folate ไม่เพียงพอ อาจส่งผลต่อทารกอย่างไร *
1 point
61. Dilated lateral and third ventricle. Where is the most obstruction? *
1 point
62. Which component of hair is used for DNA investigation? *
1 point
63. .Vibrio cholera มีกลไกการออกฤทธิ์ผ่าน 2nd messenger ตัวใด *
1 point
64. What is the most complicated of ARPKD in children *
1 point
65. ชายอายุ 65 ปี เป็น erectile dysfunction แพทย์สั่งการรักษาด้วย sildenafil ข้อใดเป็นกลไกการออกฤทธิ์ของยาดังกล่าว *
1 point
66. . A 40-year-old woman has had chronic congestive heart failure for the past 3 years. In thepast 2 months, she developed a cough productive of rust-colored sputum. A sputumcytology specimen now shows numerous hemosiderin-laden macrophages. Which of thefollowing subcellular structures in these macrophage is most important for the accumulationof this pigment? *
1 point
67. An experiment analyzes factors involved in the cell cycle during growth factor-inducedcellular regeneration in a tissue culture. Cyclin B synthesis is induced; the cyclin B binds andactivates cyclin-dependent kinase 1 (CKD1). The active kinase produce by this process ismost likely to control progression in which of the following phase of the cell cycle? *
1 point
68. A 53-year-old woman with no prior illness has a routine checkup by her physician. Onexamination she has a BP of 150/95 mmHg. If her hypertension remains untreated for years,which of the following cellular alterations would most likely be seen in her myocardium? *
1 point
69. A 19-year-old woman develops a sore throat and fever during the past day. Physicalexamination shows pharyngeal erythema and swelling. Laboratory findings includeleukocytosis. She is given naproxen. Which of the following features of the acuteinflammatory response is most affected by this drug? *
1 point
70. An 11-year-old girl becomes infected with hepatitis A and experiences mild nausea for 1week. On physical examination, she has minimal right upper quadrant tenderness and scleralicterus. Laboratory findings include serum AST of 68 U/L , ALT of 75 U/L , and total bilirubinof 5.1 mg/dL. Her laboratory findings most likely result from which of the following changesin her hepatocyte? *
1 point
71. On day 28 of her menstrual cycle, a 23-year-old woman experiences onset of menstrualbleeding that lasts for 6 days. She has had regular cycle since menarche. Which of thefollowing processes most likely occurs in her endometrial cells to initiate the onset ofmenstrual bleeding? *
1 point
72.. A 77-year-old woman experiences a sudden loss of consciousness, with loss ofmovement on the right side of the body. Cerebral angiography shows an occlusion of theleft middle cerebral artery. Elaboration of which of the following mediators will be mostbeneficial in preventing further ischemic injury to her cerebral cortex? *
1 point
73. A 92-year-old woman is diagnosed with Staphylococcus aureus pneumonia andreceives a course of antibiotic therapy. Two weeks later, she no longer has a productivecough, but she still has a temperature of 38.1° C. A chest radiograph shows the findings inthe figure. Which of the following terms best describes the outcome of the patient'spneumonia? *
1 point
74. A 22-year-old primigravida notes absent fetal movement for 2 days. The fetus isdelivered stillborn at 19 weeks' gestation. The macerated fetus shows marked hydropsfetalis and a large posterior cystic hygroma of the neck. At autopsy, internal anomaliesinclude aortic coarctation and a horseshoe kidney. Which of the following karyotypes is mostlikely to be present in cells obtained from this fetus? *
1 point
75. A 14-year-old boy presents with fever, sore throat, and cervical lymphadenopathy. Hethen develops hepatomegaly and splenomegaly lasting for 2 months. His peripheral bloodsmear shows leukocytosis with "atypical" lymphocytes. Which of the following cell types ismost likely to eliminate the virally infected cells? *
1 point
76. 29 A 32-year-old man is involved in a vehicular accident and sustains fractures of theright femur and tibia and the left humerus. The fractures are stabilized surgically. He is instable condition for 2 days, but then suddenly becomes severely dyspnea. Which of thefollowing complications from his injuries is the most likely cause of his sudden respiratorydifficulty? *
1 point
77. In a study that examines granuloma formation in the lung in response to infection withMycobacterium tuberculosis, it is observed that some cells within the granuloma expressMHC class II antigens. These class II antigen-bearing cells are most likely derived from whichof the following peripheral blood leukocytes? *
1 point
78. A 70-year-old woman has had episodes of dyspnea with wheezing and coughing,accompanied by urticaria for the past 3 years. She has had bouts of rhinitis. She has a 10-year history of osteoarthritis. On physical examination she has nasal polyps. Use of which ofthe following medications is the most likely risk factor for her respiratory disease? *
1 point
79. A study of transfusion reactions reveals that some patients experienced an increase inbody temperature that was greater than 1°C, accompanied by chills and hypotension. Bloodcultures are positive for bacterial organisms. These patients respond to antibiotic therapy.Which of the following types of blood products did they most likely receive? *
1 point
80. A 50-year-old man with a history of infective endocarditis has increasing fatigue. Hereceives a bileaflet tilting disk mechanical mitral valve prosthesis. After surgery, he is stable,and an echocardiogram shows no abnormal valvular or ventricular function. Which of thefollowing pharmacologic agents should he receive regularly after this surgical procedure? *
1 point
81. A neonate developing normally has a newborn checkup. On physical examination, thereis a systolic murmur. Echocardiography reveals a muscular defect of the intraventricularseptum. A checkup 30 years later fails to reveal either a murmur or a flow defect betweenthe ventricles. Which of the following cells most likely proliferated and led to disappearanceof the defect? *
1 point
82. A 3-year-old child has erosion of a roughened corneal surface caused by xerophthalmia.Keratomalacia results in corneal scarring with eventual blindness after 4 years. This oculardamage is now less common because of a United Nations initiative to treat a dietarydeficiency of which of the following nutrients? *
1 point
83. A 26-year-old woman with a 6-month history of depression accompanied by activesuicidal ideation ingests 35 g of acetaminophen. She quickly experiences nausea andvomiting. Within 1 day, she becomes progressively obtunded. On physical examination, hertemperature is 36.9° C, pulse is 75/min, respirations are 15/min, and blood pressure is100/65 mm Hg. She is treated with N-acetylcysteine. Depletion of which of the following ismost likely to accentuate her organ damage? *
1 point
84. A 22-year-old star football player suddenly collapses during practice and has a cardiacarrest and cannot be resuscitated. The medical examiner investigating this sudden deathfinds marked coronary atherosclerosis and histologic evidence of hypertension in the renalblood vessels at autopsy. Use of which of the following substances by this man most likelyled to these findings? *
1 point
85.An epidemiologic study of a community shows an increased incidence for basal cell andsquamous cell carcinomas in adults. These lesions are distributed predominantly on palmsand soles. Analysis of groundwater pumped from wells for drinking shows increased levels ofa heavy metal used in pressure-treated lumber (with a greenish hue), insecticides, andherbicides. Which of the following metals is most likely implicated by this study? *
1 point
86. A 15-year-old boy has developed a small eschar on his left forearm around the site of atick bite he received 6 days ago. A hemorrhagic rash involving the trunk, extremities, palms,and soles then develops over the next 3 days. Over the past day, small, 0.2-cm to 0.4-cmfoci of skin necrosis have developed on his fingers and toes. His temperature is 39° C. He istreated with doxycycline and improves over the next 2 weeks. Which of the followingorganisms is most likely to produce these findings? *
1 point
87. A study of sexually transmitted infections identifies an organism most commonly foundin tropical and subtropical regions. This organism is associated with painful ulcerating genitalpapules in HIV-infected persons. Microscopic examination of lesional exudate with silverstain shows coccobacilli. Which of the following organisms is most likely to produce thesefindings? *
1 point
88. A 31-year-old woman has had vulvar pruritus along with a thick, whitish, odorless,globular vaginal discharge for the past week. On pelvic examination, the cervix appearserythematous, but there are no erosions or masses. A Pap smear shows budding cells andpseudohyphae. No dysplastic cells are present. Which of the following infectious agents ismost likely to produce these findings? *
1 point
89. A 13-year-old girl began menstruation 1 year ago. She now has abnormal uterinebleeding, with menstrual periods that are 2 to 7 days long and 2 to 6 weeks apart. Theamount of bleeding varies from minimal spotting to a very heavy flow. On physicalexamination, there are no remarkable findings. A pelvic ultrasound scan shows noabnormalities. Which of the following is most likely to produce these findings? *
1 point
90. A 62-year-old obese, nulliparous woman has an episode of vaginal bleeding, whichproduces only 5 mL of blood. On pelvic examination, there is no enlargement of the uterus,and the cervix appears normal. A Pap smear shows cells consistent with adenocarcinoma.Which of the following preexisting conditions is most likely to have contributed to thedevelopment of this malignancy? *
1 point
91. A 28-year-old woman has had fever, pelvic pain, and a feeling of pelvic heaviness for thepast week. Pelvic examination shows a palpable painful left adnexal mass. Laparoscopyshows an indistinct left fallopian tube that is part of a 5-cm circumscribed, red-tan massinvolving the left adnexal region. Which of the following infectious agents is most likely toproduce these findings? *
1 point
92. A 26-year-old woman delivered a normal neonate a month ago following anuncomplicated pregnancy. She now has vaginal bleeding. Hysteroscopy shows a nodule inthe uterine fundus. Laboratory studies show hCG level of 200 mIU/mL. She is givenchemotherapy but the lesion does not regress. Hysterectomy is performed. Microscopicexamination of the nodule shows intermediate trophoblast cells. Immunostaining for whichof the following proteins is most likely to yield positive results in this nodule? *
1 point
93. A 39-year-old woman has had no menstrual periods for the past year, along withmalaise, cold intolerance, and loss of body hair. She has had headaches for the past 5months. On physical examination her lateral visual fields are reduced. She is most likely tohave a neoplasm composed of which of the following cell types? *
1 point
94. A 42-year-old woman has a sudden onset of fever with headache, nausea, diaphoresis,and palpitations. On physical examination her temperature is 39.2° C; pulse, 115/min;irregular respiratory rate, 30/min; and blood pressure, 150/85 mm Hg. Deep tendon reflexesare 4+ bilaterally. Her outstretched hands exhibit a high frequency tremor. Which of thefollowing drugs should she receive emergently? *
1 point
95. A 51-year-old man from Kolkata has an area of depression in his mouth that hasenlarged over the past 7 months. On oral examination, there is a 1.5 x 0.7 cm velvety,erythematous area with focal surface erosion on his left buccal mucosa. The lesion isexcised and on microscopic examination there is dysplastic squamous epithelium. Which ofthe following is the most likely risk factor for developing this lesion? *
1 point
96. A 16-year-old boy who is receiving chemotherapy for acute lymphoblastic leukemia hashad pain for 1 week when he swallows food. Physical examination shows no abnormalfindings. Upper gastrointestinal endoscopy shows 0.5- to 0.8-cm mucosal ulcers in the regionof the mid to lower esophagus. The shallow ulcers are round and sharply demarcated, andhave an erythematous base. Which of the following is most likely to produce these findings? *
1 point
97. A 72-year-old man takes large quantities of nonsteroidal anti-inflammatory drugs (NSAIDs)because of chronic degenerative arthritis of the hips and knees. Over the past 2 weeks, hehas had epigastric pain with nausea and vomiting and an episode of hematemesis. Onphysical examination, there are no remarkable findings. A gastric biopsy specimen is mostlikely to show which of the following lesions? *
1 point
98. A 54-year-old, previously healthy man sustained an extensive thermal burn injury involving70% of the total body surface area of his skin. He was hospitalized in stable condition. Threeweeks after the initial burn injury, he developed melanotic stools. His blood pressure droppedto 80/40 mm Hg, and his hematocrit declined to 18%. Where are gastrointestinal ulcerations most likely to be found in this man? *
1 point
99. A 47-year-old woman with a lengthy history of heartburn and dyspepsia experiencessudden onset of abdominal pain. On physical examination, she has severe mid epigastricpain with guarding. Bowel sounds are reduced. An abdominal plain film radiograph showsfree air under the left leaf of the diaphragm. She is immediately taken to surgery, and aperforated duodenal ulcer is repaired. Which of the following organisms is most likely tohave produced these findings? *
1 point
100. Over a holiday weekend, more than 100 adults at a resort hotel develop a diarrhealillness marked by voluminous, watery stools more than 10 times per day. They also reportheadache, abdominal cramping pain, and myalgias. On physical examination they havemanifestations of dehydration and mild fever. Laboratory studies of stool samples show noincrease in leukocytes or fat, and no RBCs. Their illness lasts just 1 to 3 days and resolveswith no sequelae. Which of the following infectious agents is the most likely cause for theirillness? *
1 point
101. A 20-year-old woman in her ninth month of pregnancy has increasing pain on defecationand notices bright red blood on the toilet paper. She has had no previous gastrointestinalproblems. After she gives birth, the rectal pain subsides, and there is no more bleeding. Whichof the following is the most likely cause of these findings? *
1 point
102 A 53-year-old woman has increasing abdominal girth for the past 2 years. On physicalexamination she has abdominal distension. An abdominal CT scan shows multiple noduleson peritoneal surfaces along with low attenuation mucinous ascites. Paracentesis isperformed and cytologic examination of the fluid obtained shows well-differentiatedcolumnar cells with minimal nuclear atypia. Where did this proliferative process most likelyarise in this woman? *
1 point
103. หญิงอายุ45 ปี ตรวจพบ pericarditis with pericardial effusionแพทย์ทำ pericardiocentesis หัตถการดังกล่าวต้องเจาะบริเวณ intercostal space ด้านซ้ายชิดกับsternum ช่องใดต่อไปนี้ *
1 point
104. ทารกแรกเกิด ตรวจร่างกายพบ normal general appearance,nodysmorphic feature,apical beat at right 4th intercostal space ลักษณะดังกล่าวเข้าได้กับโรคหรือภาวะใดต่อไปนี้มากที่สุด *
1 point
105. ชายอายุ 15ปี เป็น rheumatic heart disease ตรวจเพิ่มเติมพบ mitralvalve involvementพยาธิสภาพดังกล่าวเกิดขึ้นที่โครงสร้างใดต่อไปนี้ *
1 point
106. ทารกอายุ1 ปีเหนื่อยง่าย ริมฝีปากเขียวคล าโดยเฉพาะขณะดูดนมหรือร้องไห้ ตรวจร่างกายพบ BP ที่แขนขาใกล้เคียงกันลักษณะดังกล่าวเข้าได้กับโรคหรือภาวะใดต่อไปนี้มากที่สุด *
1 point
107.  ทารกอายุ3 วัน คลอดก่อนก าหนด หนัก 2,300 กรัม หายใจเร็วไม่เขียว ตรวจร่างกายพบ murmur ที่left infraclavicular areaเมื่อให้indomethacin พบว่า murmur ดังกล่าวหายไปลักษณะดังกล่าวเข้าได้กับโรคใด *
1 point
108. ทารกอายุ10 เดือน หายใจหอบเหนื่อย ตรวจร่างกายพบ systolic murmur at 4thintercostalspace ชิดขอบซ้ายของsternumลักษณะดังกล่าวเกิดจากความผิดปกติของโครงสร้างใด *
1 point
109. ชายอายุ20 ปีเป็น Marfan syndrome เจ็บหน้าอกซ้ายอย่างรุนแรงร้าวไปกลางหลัง ผลตรวจเพิ่มเติมเข้าได้กับdissecting aorticaneurysmโรคที่พบในผู้ป่วยรายนี้ น่าจะเกิดจากความผิดปกติที่structure ใดมากที่สุด *
1 point
110. หญิงอายุ65 ปี เจ็บกลางหน้าอกอย่างรุนแรง ร้าวไปกลางหลังเป็น HT มา 20 ปี รักษาไม่ต่อเนื่อง ภาพรังสีทรวงอกพบwidening of mediastinumลักษณะดังกล่าวเกิดจากพยาธิสภาพในข้อใดต่อไปนี้ *
1 point
111. หญิงอายุ15 ปี มีไข้มา 1 สัปดาห์ ปวดบวมที่ข้อเท้าซ้ายแล้วย้ายมาปวดที่เข่าขวา มีก้อนใต้ผิวหนังที่ข้อศอก ช่วง 2 วันที่ผ่านมาเหนื่อยมากขึ้นเรื่อยๆ นอนราบไม่ได้ ตรวจรางกายพบ pitting edema atboth legs, crepitation at both lungs ใหประวัตเพิ่มเติมว่าเมื่อ3 สัปดาห์ก่อนมีไข้และเจ็บคอพยาธิสภาพที่myocardium ของผู้ป่วยรายนี้เข้าได้กับรูปแบบใด *
1 point
112. A 53-year-old man comes to the physician because of a 6-month history of intermittentblood in his stool. He has had no pain with defecation. Physical examination shows a 1-cm,visible anal mass located below the dentate line. A biopsy of the mass is scheduled. If themass if found to be malignant, it is most appropriate to evaluate which of the followinglymph nodes for possible metastasis? *
1 point
113. An 8-year-old girl has developed a mild febrile illness with a sore throat over the past 2days. On physical examina- tion, her temperature is 38.4° C, and she has a mild pharyngitis.The girl's symptoms subside in 1 week without therapy. Over the next 2 months, she hasincreasing right-sided facial drooping with inability to close the right eye. Which of thefollowing infectious organisms is most likely to produce these findings? *
1 point
114. A 75-year-old woman has a postoperative wound infection responding poorly toantibiotic therapy. Over the next 3 days she develops confusion, nausea, vomiting, diarrhea,chills, and myalgias. On examination, she is febrile; the wound site is erythematous withnecrotic, purulent exudate. Laboratory studies show neutrophilia with left shift. Gram stainof the wound exudate shows gram-positive cocci in clusters. Which of the followingsubstances is most likely being elaborated by the infectious organisms? *
1 point
115. A 25-year-old woman is brought to the emergency department 1 hour after shefainted.She has had mild intermittent vaginal bleeding, sometimes associated with lowerabdominal pain, during the past 3 days. She has had severe cramping pain in the right lowerabdomen for 12 hours. She has not had a menstrual period for 3 months; previously,menses occurred at regular 28-day intervals. Abdominal examination shows mild tendernessto palpation in the right lower quadrant. Bimanual pelvic examination shows a tenderwalnut-sized mass in the right parametrium. Which of the following is the most likelydiagnosis? *
1 point
116. A 32-year-old woman with type 1 diabetes mellitus has had progressive renal failure overthe past 2 years. She has not yet started dialysis. Examination shows no abnormalities. Her hemoglobin concentration is 9 g/dL, hematocrit is 28%, and mean corpuscular volume is 94 μm3. A blood smear shows normochromic, normocytic cells. Which of the following is themost likely cause? *
1 point
117. A 62-year-old woman comes to the physician because of low back pain for 1 week.Menopause occurred 10 years ago. Physical examination shows localized tenderness overthe lumbar spine after movement. X-rays of the spine show a compression fracture of L1-2.A DEXA scan shows decreased bone mineral density. Serumcalcium and phosphorus concentrations and serum alkaline phosphatase activity are withinthe reference ranges. A bisphosphonate drug is prescribed. The expected beneficial effect ofthis drug is most likely due to which of the following actions? *
1 point
118. A 12-year-old girl is brought to the emergency department by her parents because of a3-day history of fever and a 12-hour history of lethargy. Her parents say that she has beensleeping most of the day and has been unresponsive when awake. Her temperature is 39.2°C(102.6°F). Physical examination shows numerous petechial hemorrhages and nuchal rigidity.A lumbar puncture yields cloudy cerebrospinal fluid (CSF) that clots in the collection tube.Microscopic examination of the CSF shows numerous segmented neutrophils, and a Gramstain shows gram-negative diplococci. Which of the following is the most likely causalorganism? *
1 point
119. A 17-year-old girl has never had a menstrual period. Physical examination shows anormal female body habitus, normal breast development, and normal appearing externalgenitalia. She has no axillary or pubic hair. The patient refuses to have a pelvic or rectalexamination. Which of the following is the most likely explanation for the clinicalpresentation? *
1 point
120. A 50-year-old man has headache, vertigo, and generalized pruritus. He has the recentonset of angina pectoris. His hematocrit is 65%, leukocyte count is 12,000/mm3, anderythrocyte mass is increased. Erythropoietin concentration is decreased. Which of thefollowing is the most likely diagnosis? *
1 point
121. A 52-year-old man comes to the emergency department because he has had vomiting,nausea, and abdominal pain for the past 12 hours. He says he attempted suicide 3 days ago by"taking everything in the medicine cabinet." He was stuporous for approximately 12 hoursafter the overdose but felt better the following day. At this time, he has jaundice and pain inthe right upper quadrant. Which of the following drugs is most likely to have caused thepain, vomiting, and jaundice? *
1 point
122. A full-term female newborn is examined shortly after birth. She appears to be small forgestational age, and she has excess skin on the nape of the neck and lymphedema of thehands and feet. Chromosomal analysis shows some cells with a normal 46,XY karyotype andsome cells with a 45,X karyotype. Which of the following mechanisms best explains thiscytogenetic abnormality? *
1 point
123. A 70-year-old man is brought to the emergency department by his wife because of feverand shortness of breath for 2 days. He underwent an oral surgical procedure 6 weeks ago.His respirations are 22/min, and blood pressure is 140/60 mm Hg. A soft diastolic murmur isheard. The diagnosis of bacterial endocarditis is made. Gentamicin therapy is initiated. Thispatient is at increased risk for developing which of the following as a result of this therapy? *
1 point
124. A previously healthy 19-year-old woman comes to the physician because of a 3-dayhistory of fever, fatigue, and sore throat. She lives with a roommate who has a cat. Hertemperature is37.8°C (100°F). Physical examination shows mildly tender cervical and submentaladenopathy and pharyngitis. There is mild splenomegaly. Laboratory studies show:Hemoglobin 13.3 g/dLHematocrit 43%Leukocyte count 12,500/mm3Platelet count 250,000/mm3Heterophile antibody titer positiveThe most likely cause of this patient's condition is infection with which of the following? *
1 point
125. Six healthy subjects participate in a study of muscle metabolism during whichhyperglycemia and hyperinsulinemia is induced. Muscle biopsy specimens obtained from the subjects during the resting state show significantly increased concentrations of malonyl-CoA. The increased malonyl-CoA concentration most likely directly inhibits which of the followingprocesses in these subjects? *
1 point
126. A 23-year-old woman has a progressive increase in her serum β-human chorionicgonadotropin (β-hCG) concentrations during an 8-week period. A hydatidiform mole isremoved, but the β-hCG concentration continues to increase. Which of the following is themost likely diagnosis? *
1 point
127. A 45-year-old man has abnormal circadian variation in body temperature, disruption ofthe sleep-wake cycle, and an impaired nocturnal surge of secretion of melatonin. An MRI ofthe brain is most likely to show a lesion involving which of the following nuclei? *
1 point
128 .A 12-year-old girl is admitted to the hospital because of marked shortness of breath, anerythematous rash, and painful, swollen hip and knee joints. She is agitated. A chest x-rayshows an enlarged heart and changes consistent with pulmonary edema. Intractable congestiveheart failure develops, and she dies on the second hospital day. This child most likely had arecent history of which of the following? *
1 point
129. A 55-year-old man comes to the physician because of a 2-week history of recurrent,widespread blister formation. Physical examination shows lesions that are most numerous inthe flexural areas including theaxillae and groin. The blisters do not break easily, and thereare no oral lesions. These blisters are most likely the result of adhesion failure involvingwhich of the following? *
1 point
130. A 74-year-old man with urinary frequency and urgency has benign prostatic hyperplasia.He refuses operative intervention but agrees to a trial of finasteride therapy. During the trial,synthesis of which of the following substances is most likely to be inhibited? *
1 point
131. A 30-year-old man with peptic ulcer disease suddenly develops pain, redness, andswelling of his right first metatarsophalangeal joint. There is no history of injury. Serum uricacid concentration is 8 mg/dL. Examination of joint aspirate shows birefringent crystals.Which of the following drugs is most appropriate to treat the acute symptoms in thispatient? *
1 point
132. A 17-year-old boy comes to the emergency department because of severe thirst andweakness and a 4-kg (8.8-lb) weight loss over the past 36 hours. He began havingvoluminous painless watery diarrhea on the airplane while returning from a trip to Thailand36 hours ago. He has not vomited. While supine, pulse is 110/min and blood pressure is110/60 mm Hg. While standing, pulse is 170/min and blood pressure is 70/40 mm Hg. Hisabdomen is nontender and bowel sounds are increased. Which of the following treatmentsis most appropriate at this time? *
1 point
133. A 66-year-old man has become increasingly short-tempered with his wife. He hasdiarrhea, weight loss, and weakness in the proximal muscles. He has atrial fibrillation andtachycardia. Which of the following is the most likely diagnosis? *
1 point
134. A 6-day-old breast-fed boy is brought to the emergency department by his motherbecause of poor weight gain and irritability since delivery, and a 2-hour history of vomiting.Physical examination shows jaundice and hepatomegaly. A reducing substance test result ofthe urine is positive, and a glucose oxidase test result is negative. The concentration ofwhich of the following metabolites in liver is most likely increased in this patient? *
1 point
135. เด็กชายอายุ 1 ปี ชักเกร็งกระตุกทั้งตัว เคยมีอาการชัก 2 ครั้ง พัฒนาการช้าตั้งแต่แรกเกิด ศีรษะเล็ก ปัสสาวะมีกลิ่นเหม็นหืน สีของเส้นผมและผิวหนังจางมาก ลักษณะดังกล่าวเกิดจากการขาดเอนไซม์ใดต่อไปนี้เป็นหลัก *
1 point
136. An investigator is attempting to create new treatments for patients in shock. Her premiseis that increasing oxygen delivery and availability in tissue should reduce some of the tissuedamage seen in most forms of shock. From a basic physiologic standpoint, which of thefollowing steps would increase peripheral oxygen availability? *
1 point
137 .หญิงอายุ 45 ปี เป็น type 2 DM ได้รับการเจาะเลือดหลังอดอาหาร 8 ชั่วโมง เมื่อตั้งเลือดทิ้งไว้พบครีมขาวขุ่นลอยอยู่ด้านบน ตรวจเลือดพบ triglyceride 400 mg/dLลักษณะดังกล่าวน่าจะเกิดจากความผิดปกติของเอนไซม์ใด *
1 point
138. พ่อแม่เด็กชายอายุ 2 ปี มาพบแพทย์เนื่องจากมีความกังวลเนื่องจากลูกชายชอบแสดงอารมณ์โกรธและแผลงฤทธิ์ ในที่สาธารณะ (temper tantrums) ท่านจะแนะนำอย่างไร (ข้อนี้มี 4 ตัวเลือก) *
1 point
139. หญิงอายุ 15 ปี บ้านอยู่ใกล้เหมืองตะกั่ว ซีดมาก ตรวจพบสารตะกั่วในน้ าที่ใช้บริโภคและในเลือดของผู้ป่วย ภาวะซีดที่พบในผู้ป่วยรายนี้เกิดจากตะกั่วไปยับยั้งเอนไซม์ใดในกระบวนการสังเคราะห์ heme *
1 point
140. A 55-year-old woman with small cell carcinoma of the lung is admitted to the hospital toundergo chemotherapy. Six days after treatment is started, she develops a temperature of38°C (100.4°F). Physical examination shows no other abnormalities. Laboratory studies showa leukocyte count of 100/mm3 (5% segmented neutrophils and 95% lymphocytes). Which ofthe following is the most appropriate pharmacotherapy to increase this patient's leukocytecount? *
1 point
141. A 23-year-old woman with bone marrow failure is treated with a large dose of rabbitantithymocyte globulin. Ten days later, she develops fever, lymphadenopathy, arthralgias,and erythema on her hands and feet. Which of the following is the most likely cause ofthese symptoms? *
1 point
142. A 14-year-old girl has had nausea, intermittent diarrhea, and a 2.2-kg (5-lb) weight lossover the past 4 weeks. Examination shows a migrating serpiginous pruritic perianal rash. Herleukocyte count is 8000/mm3 with 20% eosinophils. Which of the following tests is mostlikely to yield an accurate diagnosis? *
1 point
143. A 76-year-old man with a history of prostatic hypertrophy has the recent onset ofincreased difficulty urinating. Symptoms began shortly after he started taking a nasaldecongestant orally for cold symptoms. Which of the following types of receptors is mostlikely to be involved in these adverse effects? *
1 point
144. A 38-year-old man who recently immigrated to the USA comes to the physician becauseof a 1- month history of cough and a 4.5-kg (10-lb) weight loss. Physical examination showsno abnormalities. A chest x-ray shows a right upper lobe infiltrate. One of three sputumsamples is positive for acid-fast bacilli. Treatment with isoniazid, rifampin, ethambutol, and pyrazinamide is started. Which of the following should be added to the medication regimen to prevent neurologic toxicity in this patient? *
1 point
145. Warfarin is administered to a 56-year-old man following placement of a prostheticcardiac valve. The warfarin dosage is adjusted to maintain an INR of 2.5. Subsequently,trimethoprim-sulfamethoxazole therapy is begun for a recurring urinary tract infection. Inaddition to monitoring prothrombin time, which of the following actions should thephysician take to maintain adequate anticoagulation? *
1 point
146. A 50-year-old man has headache, vertigo, and generalized pruritus. He has the recentonset of angina pectoris. His hematocrit is 65%, leukocyte count is 12,000/mm3, anderythrocyte mass is increased. Erythropoietin concentration is decreased. Which of thefollowing is the most likely diagnosis? *
1 point
147. A 2-year-old girl is brought to the emergency department because of pain in her rightforearm after a fall 1 hour ago. She has a history of fractures of the left femur and right tibia. Physical examination shows blue sclerae. There is tenderness to palpation over the distal right radius.A mutation in which of the following genes is the most likely cause of the recurrent fractures in this patient? *
1 point
148. A 70-year-old man is brought to the emergency department by his wife because of feverand shortness of breath for 2 days. He underwent an oral surgical procedure 6 weeks ago.His respirations are 22/min, and blood pressure is 140/60 mm Hg. A soft diastolic murmur isheard. The diagnosis of bacterial endocarditis is made. Gentamicin therapy is initiated. Thispatient is at increased risk for developing which of the following as a result of this therapy? *
1 point
149. A previously healthy 3-month-old boy is brought to the physician because of a runnynose and a dry cough for 2 days. Physical examination shows tachypnea, a nasal discharge,and wheezing. An x-ray of the chest shows hyperexpansion but no infiltrates. The causalvirus was most likely transmitted by which of the following routes? *
1 point
150. A 52-year-old man with recently diagnosed type 2 diabetes mellitus comes to thephysician for a follow-up examination. Physical examination shows no abnormalities. Laboratory studies show an increased hemoglobin A1c despite patient compliance with diet and exerciserecommendations. Treatment with a sulfonylurea is started. Which of the following is mostlikely to occur in this patient? *
1 point
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