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nor B12 deficiency), they also show high creatinine and BUN (consistent with Hx
of DM) so the most probable cause of the anemia is chronic renal failure
29- (D) The history suggests minimal change nephropathy, a disease characterize
d by heavy selective proteinuria due to loss of negative charge in the glomerula
r basement membrane
3031- (F) Slow nerve conduction indicates a problem in the myelin sheath, leading
to slowing down of action potential propagation; the latter depends on voltage
gated Na channels. Neurotransmitter gated channels serve to make the initial exc
itation to the nerve, so their impairment would lead to absent impulse not slowe
d conduction.
32- (B) Tough one! Quote: The first step in population sampling is identifying t
he population which the researchers wish to learn more about. If, for example, s
omeone wants to find out how many African Americans have cats, the researchers k
now that the population under scrutiny is the African American community. Popula
tion sampling is used to select representative individuals from this vast commun
ity so that an estimate about cat ownership among other members of this communit
y can be extrapolated. On the other hand convenience sampling
is the one in which
a sample of readily accessible individuals is used, rather than a diverse sampl
e of larger population. This link explains it all http://www.wisegeek.com/what-is
-a-population-sampling.htm
33- (D) Classical example and photo of subarachnoid hemorrhage
34- (B) Tachycardia, hypertension, papillary dilatation and diaphoresis all poi
nt out to increased sympathetic discharge typical of amphetamine and cocaine int
oxication
35- (D) Hemidesmosomes anchor basal cells of the epidermis to the basement memb
rane; the case described is a case of bullous pemphigoid. Desmosomes on the othe
r hand serve to attach the cells of the epidermis to each other not to BM, and t
hey are destroyed in pemphigus vulgaris.
36- (E) The man most probably has immotile cilia syndrome which is characterize
d by sinusitis, bronchiectasis, immotile sperms, and usually situs inversus tota
lis.
37- (D) The description typically fits pheochromocytoma, when such a tumor occu
rs outside the adrenal gland, it is called paraganglioma.
38- (B) The organism described is pseudomonas aeroginosa, normally it is not en
capsulated, but in cystic fibrosis the organism produces a capsule of sodium alg
inate that forms a biofilm around the organism and makes it difficult for antibi
otics to penetrate.
39- (E) Typical description of pneumocytes type II that produce surfactant.
40- (E) History of hypovolemia and urine analysis shows: granular cast, oliguri
a, increased sodium excretion (>1%), and fixed osmolality. All points to acute t
ubular necrosis which is a reversible condition; upon restoration of normal bloo
d volume, the tubular cells regenerate.
41- (C) The pulmonary circulation originates from the right ventricle and recei
ves all of the cardiac output; the bronchial circulation on the other hand origi
nates from left ventricle and is part of the systemic circulation and so receive
s only a part of the cardiac output.
42- (C) History of amenorrhea for two months without any associated symptom or
sign puts pregnancy on top of the list; best thing to rule it out is doing serum
B-HCG.
43- (A) The only open-ended question, the others jump to assumptions and in add
ition all contain closed-ended questions.
4445- (E) Ubiquitination of the misfolded proteins (tagging them with ubiquitin p
rotein) is the signal for the proteasome to attack these misfolded proteins.
46- (F) Testosterone is the only choice of which decreased concentration would
lead to erectile dysfunction.
47- (D) A case of disuse atrophy in which there is increased protein degradatio
n in the muscle cells leading to decrease in their size, but they don t die, it is
a reversible a condition.
20- (B) Informed consent entails that the patient be fully informed about the p
urpose, methods, benefits, risks and alternatives of any procedure performed
21- (C) Nitric oxide (NO) is used as a vasodilator to treat pulmonary hypertens
ion; nitroglycerin is a famous precursor to nitric oxide. It is an oxidizing age
nt that can lead to the oxidation of iron inside the hemoglobin converting it to
methemoglobin and rendering it incapable of binding to oxygen.
22- (B) Collapse of the femoral head with preservation of the cartilage indicat
es avascular (aka aseptic) necrosis; the cartilage being an avascular structure
is protected from the effects of ischemia, while the femoral head is highly vuln
erable to ischemia due to its limited blood supply. The corticosteroids taken by
the patient is a known risk factor for aseptic necrosis of the femur.
23- (A) The rash is due to the late phase of type I hypersensitivity in which e
osinophils arrive to the scene as a result of the chemotactic factors released b
y mast cells in addition to histamine during the early phase
24- (F) Uterine relaxation (tocolysis) is the only choice that s mediated by B2 a
drenoreceptors.
25- (C) Bupivacaine, like most other local anesthetics, works by inhibiting mem
brane Na channels and so decreasing the excitability of the sensory nerves.
26- (E) The case is probably cretinism. The remnant that would be expected to f
orm a midline cyst in such a case is the thyroglossal duct.
27- (C) The photo shows the desmoplastic reaction characteristic of ductal carc
inoma; the most important prognostic factor is the degree of spread (staging) of
the tumor.
28- (A) The only choice that characterizes hypochondriasis. Somatoform patients
are usually indifferent to their disease (la belle indifference).
29- (C) The only drug of the choices that would cause steatorrhea is orlistat,
because it works by inhibiting fat digestion and absorption in the small intesti
ne by inhibiting pancreatic lipase.
30- (C) Smoking causes squamous metaplasia of the respiratory epithelium presen
t in the larynx, trachea and bronchi. The metaplastic epithelium is a risk facto
r for squamous cell carcinoma
31- (C) Out of the 200 people who ate lettuce, 40 developed diarrhea. The proba
bility of developing diarrhea is 40/200=0.2
32- (A) The thoracic portion of the esophagus takes blood supply from branches
of the aorta and the bronchial arteries.
33- (B) The clinical picture indicates impairment of function of the mitochondr
ia inside heart cells. Since the mutation affects tRNA, protein synthesis would
most likely be impaired.
34- (B) Pyelonephritis is the most probable complication in that case with a hi
story of recurrent UTI, leukocytosis and bilateral hydroureter and hydronephrosi
s.
35- (G) All the symptoms, signs and lab results are typical of hypothyroidism.
The most accurate initial test is serum TSH.
36- (B) The number one cause of death of both men and women in developed countr
ies is cardiovascular disease, followed by cerebral infarction, followed by canc
er.
37- (B) The patient most probably has celiac disease (malabsorption syndrome co
ntrolled by restricting wheat, barley and rye). The pruritic vesicular rash on t
he elbows associated with celiac disease is called dermatitis herpetiformis.
38- (C) History typical of Lesch-Nyhan (self-mutilating behavior, neurological
symptoms and x-linked inheritance). It is caused by HGPRT enzyme deficiency lead
ing to hyperuricemia.
39- (E) Observing a group of patients who have the risk factors of a disease fo
r the occurrence of that disease describes prospective cohort study.
40- (C) Glossitis, angular stomatitis and especially spoon-shaped nails are fou
nd in iron deficiency anemia, also it is the only cause among the choices for de
creased MCV.
41- (A) A crescendo-decrescendo systolic murmur that s best heard in the second r
ight intercostal space and radiates to the carotids--> aortic stenosis
42- (D) The history is typical for Duchenne s muscular dystrophy (x-linked, delay
ed milestones, positive Gower s sing), the muscle described is the adductor magnus
which takes origin partially from the inferior ramus of the ischium, and insert
s into the medial side of the femur.
43- (E) The case describes oculomotor nerve palsy (mydriasis, ptosis and outwar
d strabismus), the only muscle of the choices that s not supplied by CN III is the
superior oblique (CN IV)
44- (B) The only statement that doesn t direct the patient or judge him, nor try
to threaten and intimidate him.
45- (E) The only conscious defense mechanism that can be learned and would be b
eneficial in that case is suppressions of the memory of his father.
46- (E) The ureters are crossed by the ovarian vessels and are liable to accide
ntal ligation during oophorectomy; the flank pain is consistent with the urinary
retention that would result from ligation of the ureter.
47- (B) The two drugs that act as cough suppressants are codeine and dextrometh
orphan. Compared to codeine, dextromethorphan is a less potent opiate, it has a
much less abuse potential and doesn t cause constipation.
48- (C) The case describes Chediak-Higashi syndrome, an immunodeficiency syndro
me due to defective neutrophil function due to failure of phagolysosome formatio
n.
49- (B) Neuraminidases are enzymes that clip off the terminal sialic acid resid
ues from the newly formed virions in order for them to be released from the cell
membrane of the infected cells.
50- (A) The case describes acute intermittent porphyria, which is autosomal dom
inant. Except for congenital erythropoietic porphyria (AR), all the other well k
nown types of porphyria are AD.
Block 4
1- (E) EBV infects B-lymphocytes, but the cells that react to the infection are
T-lymphocytes because it is a viral infection. In EBV infection the reactive T
cells undergo some morphologic changes (become enlarged with abundant vacuolated
cytoplasm) and are called atypical lymphocytes.
2- (E) Erythromycin, like other macrolides, works by inhibiting translocation o
f the ribosome along the mRNA. Choice B is puromycin, C is diphtheria toxin, and
D is tetracyclines.
3- (B) Hemangioma is a benign tumor that arises from the endothelial cells that
line the blood vessels.
4- (E) Sumatriptan activates 5HT1B/1D receptors, which are serotonin receptors.
5- (C) Positive predictive value (PPV) equals (TP/TP+FP), when the prevalence i
ncreases, the rate of the false positive (FP) decreases and so the PPV increases
.
6- (B) Hyperreflexia (sign of UMN lesion) + fasciculations (sign of LMN lesion)
indicate most probably a case of amyotrophic lateral sclerosis (ALS). It is cha
racterized by difficulty swallowing due to paralysis of the somatic muscles of t
he pharynx and upper esophagus.
7- (C) Staphylococcus aureus most probably caused the acute endocarditis in muc
h the same way it causes it in IV drug abusers; by getting access from skin woun
d into the right side of the heart.
8- (J) Typical description of VSD.
9- (D) A case of ovarian torsion, which causes obstruction of the ovarian blood
vessels that pass through the suspensory ligament of the ovary leading to ovari
an ischemia.
10- (C) Most probably a case of Giardia lamblia, the diagnosis can be made by v
isualizing ova and parasites in the stool
11- (A) Bevacizumab is a humanized monoclonal antibody directed against VEGF, i
t comes from human origin using recombinant DNA technology, and thus it doesn t en
counter a strong immune response against them, unlike antibodies extracted from
other species that encounter a strong immune response leading in many cases to t
ype III hypersensitivity reactions (serum sickness)
12- (A) The patient most likely has a prolactin secreting pituitary adenoma, th
olescents and resolves on its own in the majority of them with time.
31- (A) Progressive weakness of the proximal and distal muscles, double vision,
eyelid drooping + mediastinal mass--> myasthenia gravis which is commonly assoc
iated with thymic hyperplasia/thymoma. It is caused by auto-Abs that block the A
.Ch. receptors at the motor end plate.
32- (C) The pic shows severe vertebral osteoporosis with a compression fracture
, the most plausible answer is IL-1 since it activates osteoclasts and is increa
sed in postmenopausal osteoporosis which is characterized by increased resorptio
n.
33- (E) The key sentence here is her symptoms become much more pronounced as the
day progresses which is typical of MG, none of the other choices would cause tha
t. Besides, having normal residual volume excludes the obstructive lung diseases
(alpha 1-antitrypsin and chronic bronchitis).
34- (D) Nodular infiltrates + hilar adenopathy + noncaseating granulomas--> cla
ssical sarcoidosis.
35- (C) Most probably a case of metabolic syndrome, these patients have dyslipi
demia which is characterized by increased triglycerides and FFAs, and decreased
HDL cholesterol.
36- (C) The T4-binding substance in the blood is Thyroid binding globulin (TBG)
. Since Thyroid hormone is a steroid (lipid-soluble), it traverses the cell memb
rane and acts intracellularly on a nuclear receptor.
37- (A) Patients with Gilbert syndrome are asymptomatic, they may suffer mild j
aundice in cases of stress and infection like that case, the jaundice is due to
the decreased capacity of the glucuronyl-transferase enzyme, therefore the jaund
ice would be caused by unconjugated bilirubin. Normal liver enzymes exclude choi
ces B and E, choices C and D should have been accompanied by other signs of anem
ia (C) or liver failure (D).
38- (F) One of the most dangerous infections in DM that occurs specially after
DKA is mucormycosis, the fungus gains access through the cribriform plate and ma
y spread to the orbit and the brain, it causes a necrotizing inflammation, hence
the black eschar.
39- (E) A classical case of rheumatoid arthritis, the pathology involves granul
omatous inflammation in the synovium of the joints, the reactive synovium forms
a mass called pannus that destroys the joint and ends up in fibrosis causing the v
arious deformities seen in RA.
40- (A) Type II error (beta error) is calculated by the equation (beta=1
power)
, therefore beta equals 0.2 in trial X and 0.1 in trial Y, that is, as the power
increases the likelihood of the error decreases.
41- (D) In people with DM increased glucose leads to its increased conversion t
o sorbitol by the enzyme aldose reductase which is found in the lens, the proble
m with sorbitol is that it can t cross the cell membrane, so it gets trapped insid
e the cell, and it draws water because it is osmotically active, this leads to o
pacification of the lens and cataract formation.
42- (E) A classical presentation of sickle cell anemia causing acute chest synd
rome which is a form of sickle cell crisis. The substitution of glutamic acid wi
th valine in the B-chains leads to polymerization of the Hb under hypoxic condit
ions forming insoluble polymers, due to this the RBCs become sickle shaped and s
ticky and they clog the small capillaries leading to ischemia in many organs whi
ch leads to the crisis.
43- (B) The carbonic anhydrase inhibitor (acetazolamide) is of benefit in high
altitude sickness because it causes acidosis, which counteracts the alkalosis ca
used by hyperventilation, however it is also a diuretic, and so it would cause s
ome hypovolemia in normotensive persons which can lead to orthostatic hypotensio
n. The only other choice that can cause orthostatic hypotension is impaired symp
athetic activity, but it is unrelated to acetazolamide.
44- (B) The sequence (AATAAA) which is transcribed into (AAUAAA) is the signal
required to start adenylation and formation of the poly A tail, and it is locate
d downstream (3 ) of the coding region, the function of the tail is to protect the
mRNA from cleavage, in its absence most of the mRNA would be broken down by the
endonucleases in the nucleus.