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* nbme 15 questions!!!
  doctor1001 - 06/14/13 20:03
  Can someone PLEASE help me with these questions? I would really appreciate it if you can also provide with some explanations. Thanks in advance!!!!

1) A 4 day old male newborn who was born at home is brought to the ER b/c of respiratory distress and cyanosis. The mother reports that she found him in his crib not breathing. He began to breath again after she picked him up. Examination shows narrow thorax. His ears have periauricular skin tags. He also has micrognathia, glossoptosis, amandibular cleft, and a short palate. Tracheostomy relives respiratory distresss. Defect such as there are consistent with altered development of which of the following pharyngeal arches?

a) First
b) Second
c) Third
d) Fourth
e) Sixth

2) A 5 year old boy is brought to the emergency department 15 minutes after developing hives and SOB and then collapsing. He had been eating peanuts 4 minutes before the onset of symptoms. On arrival his pulse is 220/min and respiration are 10/min, and palpable bp is 40 mm Hg. After establishing patent airway next step in management is administration of which of the following?
a) Albuterol
b) Dexamethasone
c) Diphenhydramine
d) Epinephrine
e) Loratadine

3) A 4-year-old boy with asthma is brought to the emergency department because of a 4-hour history of difficulty breathing. His symptoms do not improve with the use of an inhaled 3-adrenergic agonist Physical examination shows tachypnea and intercostal and subcostal retractions Expiratory wheezing is heard bilaterally on auscultation Following the administration of intravenous methylprednisolone, there is marked clinical improvement. Which of the following molecular pathways of methylprednisolone best explains this improvement?

A) Binding to its cell surface receptor and induction of phosphorylation of JAK2 and the STAT family
B) Binding to its cytoplasmic receptor, translocation to the nucleus, and activation of transcription of target genes
C) Binding to its C protein-coupled membrane receptor and stimulation of adenylyl cyclase
D) Binding to its serine kinase receptor on the cell membrane that signals through SMAD
E) Binding to its tyrosine kinase receptor on the cell membrane that undergoes autophosphorylation and activation of multiple kinases

4) A 47-year-old man is admitted to the hospital for treatment of a myocardial infarction. On admission, pulse oximetry on 30% oxygen shows an oxygen saturation greater than or equal to 95%. Three hours later, the patient develops shortness of breath. Pulse oximetry now shows an oxygen saturation of 90%. Crackles are heard at the lung bases, and a grade 2/6 systolic murmur is heard. Arterial blood gas analysis on 30% oxygen shows:

pH 7.41
Pco2 36 mm Hg
Po2 60 mm Hg

Which of the following is the most likely cause of this patient's hypoxemia?

a) Decreased alveolar ventilation
b) Decreased erythrocyte transit time in pulmonary capillaries
c) Decreased lymphatic drainage
d) Increased permeability of pulmonary capillaries
e) Increased plasma colloid osmotic pressure
f) Increased pulmonary capillary pressure

5) A 66 year old woman with ovarian cancer comes to the emergency department because of the inability to urinate for 2 days and bilateral flank pain for 8 hours. She has not had suprapubic pain. Vital signs are normal. Physical examination shows bilateral costovertebral angle tenderness. Insertion of a foley catheter yields no urine. Renal ultrasonography shows bilateral hydronephrosis. Which of the following is most likely present in this patientís kidney?

a. Decreased glomerular oncotic pressure
b. Decreased interstitial hydrostatic pressure
c. Decreased tubular hydrostatic pressure
d. Increased glomerular oncotic pressure
e. Increased interstitial oncotic pressure
f. Increased tubular hydrostatic pressure

6) A 65 year old woman comes to the physician for a follow-up examination after a DEXA scan showed a decrease in bone density. Physical examination shows no abnormalities. Which of the following sets of findings in bone is most likely in this patient?
Osteoblast activity Osteoclast activity Receptor activator of nuclear factor kB ligand (RANKL) concentration
a. Inc Inc Inc
b. Inc Dec Inc
c. Inc Dec Dec
d. Dec Inc Inc
e. Dec Inc Dec
f. Dec Dec Dec

7) A 52-year-old man is brought to the physician 3 days after the sudden onset of blindness of the left eye. He does not have any eye pain. Funduscopy of the left eye shows a pale, opaque fundus and a bright red fovea centralis. Visual field testing shows a dense scotoma of the entire visual field of the left eye; testing of the right eye shows no abnormalities. At a follow-up examination 6 months later, the patient remains blind in the left eye. If the left eye is illuminated, which of the following reactions is mostly likely in the right pupil of this patient?

A) Constriction because the left optic tract is binocular
B) Constriction because projections to the Edinger-Westphal nucleus are bilateral
C) Dilation because the posterior commissure is intact
D) Dilation because the right superior cervical ganglion is intact
E) No constriction because the left ciliary nerve has been permanently damaged
F) No constriction because the retinal ganglion cells in the left eye have been destroyed.

8) A 25 year old woman comes to the physician because of palpitation and insomnia for 5 months, she has lost 11 lbs, pulse is 125/min. Physical examination shows exopthalomas, thyromegaly, and hand tremors. Serum studies shows TSH less than 0.1, T4 = 18, T3 = 250. The SS in this patient are most likely caused by hormone acting on which of the following receptors?

a) Cytokine linked kinase
b) G protein coupled receptor
c) Nuclear/retinoid X binding DNA
d) Serine/threonine kinase
e) Tyrosine kinase


9) A 55-year-old woman comes to the physician because of a 3-day history of persistent rightshoulder pain. She began a weight-training program 6 weeks ago. She says that the pain intensified after she increased the amount of weight that she had been lifting above her head. She rates the pain as 8 on a 10-point scale. Examination of the right shoulder shows point tenderness just lateral to the acromion, over the humeral head. Passive motion of the shoulder is full. Pain is reproduced with resisted abduction of the shoulder when the shoulder is abducted 90 degrees and the arm is giving the "thumbs down" sign. Sensation is intact over the right upper extremity. Which of the following tendons is most likely injured in this patient?

A) Deltoid
B) lnfraspinatus
C) Subscapularis
D) Supraspinatus
E) Teres major
F) Teres minor


10) A male newborn has multiple congenital anomalies resulting from failure of migration of neural crest cells during embryonic development. He dies 3 weeks after birth. At autopsy, examination of this patientís tissues and organs is most likely to show which of the following findings?

a) Abnormal calcification of the long bones of the extremities
b) Absence of adrenal medulla
c) Anencephaly
d) Decreased number of spinal motoneurons
e) Hyperpigmentation of the skin

11) A 50 year old man is brought to the physician because of progressive left sided vision loss during the past 6 months. On conformational filed testing, the patient cannot see to the left with either eye. The most likely cause of this patients vision loss is lesion in which of the following locations in the drawing of the ventral surface of the brain?
I put G and got it wrong. I am assuming its F.. but not sure why I got it wrong

12) A 50-year-old man comes to the physician because of a 2-week history of progressive shortness of breath while climbing stairs to his office every morning. He reports no other problems, but he is concerned because his father had a major myocardial infarction at the age of 52 years. His pulse is 110/min and regular, respirations are 16/min, and blood pressure is 135/95 mm Hg. The lungs are clear to auscultation. Cardiac examination shows normal heart sounds with a physiologic split of S2. Stress echocardiography shows hypokinesis of the posterior left ventricle with increasing activity levels. Which of the following is the most likely cause of the posterior left ventricular findings in this patient?

a) Disruption of the sympathetic nerves to the left ventricle
b) Extravascular compression of the coronary arteries
c) Increased left ventricular end-diastolic pressure
d) Increased myocardial oxygen consumption
e) Stenosis of the right coronary artery

13) A 75 year old woman comes to the physician because of a 3 month history of an enlarging lesion on her face. Physical examination shows a 1.5 cm brown-black, mottled, scaly, lesion with irregular borders. Microscopic examination of a biopsy specimen of the lesion shows atypical melanocytes spread along the basilar layer of the epidermis. Which of the following is the most likely cause of these findings?

A) Acanthosis nigricans
B) Actinic keratosis
C) Compound nevus
D) Lentigo maligna
E) Seborrheic keratosis

14) A newborn undergoes surgical repair of esophageal atresia. Pathologic examination of resected tissue shows that the esophagus is fibrotic and has no lumen. Which of the following embryonic germ layers is the most likely origin of the cells that fill the lumen?

B)Intermediate mesoderm
C)Neural crest
D)Paraxial mesoderm
E)Surface ectoderm
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* Re:nbme 15 questions!!!
  doctor1001 - 06/15/13 11:01
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* Re:nbme 15 questions!!!
  nanidine - 06/15/13 15:45
  1- a- sounds like first arch syndrome/treacher collins
2-d- tx anaphylaxis- severe allergies to peanuts
3-b- most steroids use cytoplasmic receptors, not cell membrane receptors/G-proteins. Thyroid hormones is steroid-like and use nuclear receptors. Cytoplasmic and nuclear receptors both act by binding to DNA or DNA response elements. In this case it may act to down regulate the transcription of phospholipase enzymes thus reducing the inflammation/ecosinods. My issue is that steroid that work via DNA effects usually take longer to cause an effect than does G-proteins on the cell membrane receptors.
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* Re:nbme 15 questions!!!
  nanidine - 06/15/13 15:59
  4-f- A systolic murmur could be aortic/pul stenosis or mitral/tricuspid regurgitation. Since he has breathing problems, the left heart is the problem. I am going with the mitral valve regurg because aortic stenosis is usually not acute- think fibrosis. Mitral regurg means blood is backing up into the LA, and into the pulmonary veins = Left Heart failure. The pulmonary veins normally bring oxygen-rich blood to the heart>>>aorta>>>>>body from the lungs; When this oxygen-rick blood backs up you get tissue hypoxemia.  
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* Re:nbme 15 questions!!!
  nanidine - 06/15/13 16:14
  5-f- The ovarian cancer is compressing the ureter and/or bladder causing obstruction. The urine is backing up into the calyx>>>pelvis>>>collecting ducts and other tubules= increase hydrostatic pressure in the tubules.  
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* Re:nbme 15 questions!!!
  nanidine - 06/15/13 16:33
  6-a- tricky. In osteoporosis bone reabsorption is greater than bone deposition. But for osteoclast/RANK to reabsorb bone, they must be activated by RANKL which is made by osteoblast. So all three is increased. Usually osteoprotegrin/OPG binds RANKL so that it cannot over-activate osteoclast. Remember OPG is a TNF like the cytokines in immunology and that osteoclast is really a PMN like macrophage. Also OPG is activated by estrogen. In this patient low estrogen>>>low OPG is the problem, not osteoclast and osteoblast directly.  
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* Re:nbme 15 questions!!!
  fyzo - 06/15/13 19:56
2. D
4. D
6. D/a not 100% sure.
7. F
8 c
9 d
10 b
11. Rt homonymous anopia
12 e
13 d
14 a
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* Re:nbme 15 questions!!!
  nanidine - 06/15/13 22:16
  7- ?
8- b) G protein coupled receptor- thyroid hormone overstimulate the Sympathetic nervous system via beta-1-adrenergic receptors which is why propranolol can releive the palpitations, increased heart rate and insomnia
10-B- adrenal medulla makes Epi. and is derived from neural creast
11- right optic tract lesion = left contralateral homonymous hemianopia. pg.442 Kaplan-Anatomy
13-d-not quite melanoma...but the irregular borders and atypical cells spells cancerous
14-a- all mucosal surfaces is endoderm derived
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