Download Practical information for lecturers in the UND SMHS medical

Created January 2011
Practical Information for Medical Curriculum Lecturers
Venue and Scheduling
-lectures to first year medical students are conducted in Haugen Lecture theater
-lectures to the second year medical students are conducted in the United Hospital lecture theater
-please see the particular Block schedule for individual lecture programming
-each lecture is to begin at the top of the hour and is 50 minutes in length
-it is important that each lecture end 10 minutes prior to the top of the hour to allow the next
lecturer to load their presentation and to provide the students with a brief break
-it is the responsibility of each lecturer to prepare 50 minutes worth of material for presentation.
Please DO NOT go over the scheduled time as this impacts the next lecturer
Block Objectives
-faculty should review both the block objectives and Step I objectives Content Description and
General Information document from the Federation of State Medical Boards of the
United States and the National Board of Medical Examiners (Appendix 1) periodically
to ensure proper coverage of a lecture topic. A number of sample questions are included.
Handouts
-each lecturer is responsible for supplying paper copies of their handouts. Please make one copy
for each student along with 5 extra copies.
-handouts should be placed in the appropriate bin at the back of the lecture theatre at least 24
hours prior to the scheduled lecture
-at a minimum, handouts should list the lecture objectives (as derived from block objectives) and
reference required or recommended readings or sources of additional information
-for PowerPoint-style handouts, print no more than 4-6 slides per page. Figures that are not
legible should be included in a larger (readable) size as an appendix at the back of the
lecture notes
-handouts should be double-sided and 3-hole punched
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Created January 2011
PowerPoint
-computers in the lecture theaters use a Microsoft Windows operating system
-computers in the lecture theaters can run PowerPoint files in .ppt or .pptx format
-lecturers may load PowerPoint files onto the computers from a memory stick, CD or by retrieving
the file via email
-all programs running on the computer can be projected on the lecture theater screens allowing
display of websites, DICOM images, movies or other applications along with corresponding
audio
-lecturers that desire to use their own computers are responsible for ensuring that the dedicated,
lecture hall-based computer system is returned to a functional state for the next lecturer
Dissemination
Handouts
-in addition to the paper copies of the handouts that are placed in the lecture theatre, an
electronic copy of handouts (in Word or PDF format) should be sent to Tracy Uhlir
([email protected]) for posting on the SMHS Blackboard site (in your email to
Tracy, please include the date/time of the lecture, whether the file is related to a lecture or
lab experience and whether it was delivered to the first or second year class)
-submission of an electronic copy is expected any time prior to 24hours following the
corresponding scheduled lecture
-handouts and PowerPoints may be disseminated directly to the students using the SMHS
dropbox. Do not email handouts or PowerPoints to the class as attachments
PowerPoints
-lecture PowerPoints (in PowerPoint or PDF format) should be sent to Tracy Uhlir
([email protected]) for posting on the SMHS Blackboard site (in your email to
Tracy, please include the date/time of the lecture, whether the file is related to a lecture or
lab experience and whether it was delivered to the first or second year class)
-submission of an electronic copy is expected any time prior to 24hours following the
corresponding scheduled lecture
-if your presentation uses a format other than PowerPoint (such as Keynote or Impress) please
submit your files to Tracy Uhlir using the PDF format
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Created January 2011
Recording of lectures
-the policy regarding the recording of lectures can be found at the link below. Please review
this policy and complete the form indicating either inclusion in, or exclusion from, the
recording and distribution of your lectures.
SMHS main web page
Education
Office of Medical Education
For Faculty (from left-hand menu)
Select “Podcast Permission Form”
http://www.med.und.edu/ome/podcastPermission.cfm
Student Assessment
-for each hour of lecture, it is expected that four (4) multiple choice questions be generated and
submitted to Dr. Kurt Borg ([email protected])
-the appended guidelines Constructing Written Test Questions For the Basic and Clinical
Sciences from the National Board of Medical Examiners (Appendix 2) will assist you in
creating ideal multiple choice questions. Please review these very helpful suggestions prior
to submitting new questions or approving previously submitted questions.
-in order to gauge the type and depth of questions utilized on national exams, appended
(Appendix 1 and Appendix 3) are documents: Content Description and General
Information document from the Federation of State Medical Boards of the United States
and the National Board of Medical Examiners, and Subject Examinations: Content
Outlines and Sample Items from the National Board of Medical Examiners. This
document provides a number of questions from each discipline that may be reviewed in
order to assess the type of questions utilized and the depth of knowledge explored for each
discipline.
Outside Lecturers
-you will receive directions to the medical school, a parking permit and rules, and a payment form
(to indicate where payment should be sent)
-please try to send your PowerPoint to Janelle Studney ([email protected] ) one
week in advance of your lecture and she will arrange to have it loaded onto the lecture hall
computer.
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Created January 2011
Lecture Evaluations
-pre-tenured faculty are suggested to obtain student lecture evaluations (please contact Dr. Clint
Hosford [email protected]) from each Block in which they lecture
-pre-tenured faculty are also strongly encouraged to arrange for peer lecture evaluations and
administrative lecture evaluations for both formative and evaluative purposes
-post-tenured faculty are suggested to obtain student lecture evaluations (please contact Dr. Clint
Hosford [email protected]) from at least one Block per year
-the email below (from Block III, 2011) is typical of the notice that you will receive from Dr. Hosford
and covers this subject in greater detail:
Hello everyone,
If you've received this e-mail, you're scheduled to deliver one or more lectures to our second year medical
th
th
students during the Jan. 10 – Mar. 4 time period (i.e., Block 3). As you’re probably aware, with each
block of instruction the Office of Medical Education asks most individuals if they want/need their lectures
evaluated. The frequency of your lecture evaluations should, however, follow a general schedule.
Specifically, if you're pre-tenure, your lectures should be evaluated in every block that you lecture. If
you're post-tenure, your lectures should be evaluated at least once per year but not more than once per
semester. (Therefore, if you're post-tenure, haven’t had your lecture(s) evaluated this academic year and
don’t anticipate lecturing again this academic year, you should have your lecture(s) evaluated this block.)
If you're not on a tenure track, you should follow the same schedule as post-tenure faculty. If you're
interested, I've attached a more detailed description of the lecture evaluation process and rationale. I’ve
also attached a blank copy of the evaluation reporting form in case you’d like to review the items to which
the students will be responding.
If you do NOT want/need your lecture(s) evaluated, you don’t need to do anything. But if you DO
want/need your lecture(s) evaluated, you need to let me know. Please send me an e-mail no later than
th
next Wednesday (Jan. 12 ) to let me know. Please understand that if I don't hear from you, I'll assume
you don't want/need your lecture(s) evaluated.
Please note: An individual’s lecture evaluation covers every lecture that that person delivers during the
block. Because changes to the lecture schedule are occasionally made during the early phase of the
block, this message is being sent only to those individuals who begin lecturing during the first two weeks
of the block. Therefore, if you want/need your lectures evaluated this block, you should respond to this
request. Later I’ll send a similar message to those individuals whose start lecturing during the latter part of
the block. I’m also sending a similar message to those individuals scheduled to lecture during Block 7.
If you have any questions about this, please feel free to contact me.
Thank you!
Clint Hosford
Office of Medical Education
777-4713
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Appendix 1
A Joint Program of the Federation of State
Medical Boards of the United States, Inc.,
and the National Board of Medical Examiners®
2011
Step 1
Content Description and
General Information
Appendix 1
Copyright © 2011 by the Federation of State Medical Boards of the United States, Inc. and the National Board
of Medical Examiners® (NBME®). All rights reserved. Printed in the United States of America.
The USMLE® is a joint program of the Federation of State Medical Boards of the United States, Inc. and the
National Board of Medical Examiners.
1
Appendix 1
CONTENTS
Introduction …………………………………………………………..
3
Preparing for the Test, Applying for the Test,
Scheduling Test Dates, and Testing ………………………....
3
Examination Content ………………………………………………....
3
Step 1 Test Question Formats ………………………………………… 4
Content Outline ……………………………………………………....
6
Sample Step 1 ……………………………………………………….. 20
Normal Laboratory Values ………………………………………….. 21
Sample Items ………………………………………………………… 23
Answer Form for Step 1 Sample Questions…………………………. 55
Answer Key for Step 1 Sample Questions…………………………… 56
2
Appendix 1
Introduction
This booklet is intended to help you prepare for
Step 1 of the United States Medical Licensing
Examination® (USMLE®) if you are an applicant
with an eligibility period that has an ending date
in 2011. Eligibility periods are explained in the
2011 USMLE Bulletin of Information, with which
you must become familiar to apply for the
examination. In addition to reading the Bulletin,
you should run the sample Step 1 test materials
and tutorials provided at the USMLE Web site.
The information in this booklet, USMLE sample
test materials and software tutorials, and other
informational materials are available at the
USMLE Web site (http://www.usmle.org).
Information regarding any changes in the USMLE
program will also be posted at the USMLE Web
site. You must obtain the most recent information
to ensure an accurate understanding of current
USMLE rules.
Preparing for the Test, Applying for the Test,
Scheduling Test Dates, and Testing
In addition to the information in this booklet, you
should review the sections that appear in the
Bulletin: Preparing for the Test, Applying for the
Test and Scheduling Your Test Date, and Testing.
Although the sample test materials in this booklet
are provided in computer format at the USMLE
Web site, you must run the tutorial and sample
materials to become familiar with the test
software prior to your test date. Please monitor
the USMLE Web site (http://www.usmle.org)
announcements section to access updated
orientation and practice materials. The sample
materials available at the USMLE Web site
include an additional block of items with
associated audio or video findings and a
sequential item set. You should become familiar
with test items that have audio or video
components and sequential item sets as these
formats may be used in the actual examination.
The block of items with associated audio or video
and sequential item sets does not appear in this
booklet.
The Step 1 examination consists of questions
("test items") presented in standard multiplechoice formats, as described on pages 4 and 5 of
this booklet. The test items are divided into
"blocks" (see the Test Lengths and Formats in the
Bulletin). You may want to study the descriptions
of test item formats that follow before you run the
sample test items. A Normal Laboratory Values
Table,
including
Standard
International
conversions, is reproduced on pages 21 and 22 of
this booklet. This table will be available as an online reference when you take the examination.
Please note that values shown in the actual
examination may differ slightly from those
printed in this booklet.
Examination Content
Step 1 consists of multiple-choice questions
prepared by examination committees composed
of faculty members, teachers, investigators, and
clinicians with recognized prominence in their
respective fields. Committee members are
selected to provide broad representation from the
academic, practice, and licensing communities
across the United States and Canada. The test is
designed to measure basic science knowledge.
Some questions test the examinee’s fund of
information per se, but the majority of questions
require the examinee to interpret graphic and
tabular material, to identify gross and microscopic
pathologic and normal specimens, and to solve
problems through application of basic science
principles.
Step 1 is constructed from an integrated content
outline that organizes basic science content
according to general principles and individual
organ systems. Test questions are classified in one
of these major areas depending on whether they
focus on concepts and principles that are
important across organ systems or within
individual organ systems.
Sections focusing on individual organ systems are
subdivided according to normal and abnormal
processes,
principles
of
therapy,
and
psychosocial, cultural, and environmental
considerations. Each examination covers content
related to the traditionally defined disciplines of
3
Appendix 1
anatomy, behavioral sciences, biochemistry,
microbiology, pathology, pharmacology, and
physiology, as well as to interdisciplinary areas
including genetics, aging, immunology, nutrition,
and molecular and cell biology.
Strategies for Answering Single One Best Answer
Test Questions
While not all topics listed in the content outline
are included in every examination, overall content
coverage is comparable in the various
examination forms that will be taken by different
examinees.
Try to generate an answer and then look for it
in the option list.
A full content outline for the USMLE Step 1
examination is provided on pages 6 to 19. It
describes the scope of the examination in detail.
To facilitate review, the major categories are
indicated in bold type, with the subcategories in
regular type.
Of the remaining options, select the one that
is most correct.
The content outline is not intended as a
curriculum development or study guide. It
provides a flexible structure for test construction
that can readily accommodate new topics,
emerging content domains, and shifts in
emphasis. The categorizations and content
coverage are subject to change. Broadly based
learning that establishes a strong general
understanding of concepts and principles in the
basic sciences is the best preparation for the
examination.
Step 1 Test Question Formats
Single One Best Answer Questions
This is the traditional, most frequently used
multiple-choice format. These items consist of a
statement or question followed by three to
thirteen response options arranged in alphabetical
or logical order. A portion of the questions
involves interpretation of graphic or pictorial
materials. The response options for all questions
are lettered (eg, A, B, C, D, E). Examinees are
required to select the best answer to the question.
Other options may be partially correct, but there
is only ONE BEST answer.
Read each question carefully. It is important
to understand what is being asked.
Alternatively, read each option carefully,
eliminating those that are clearly incorrect.
If unsure about an answer, it is better to guess
since unanswered questions are automatically
counted as wrong answers.
Example Item
A 32-year-old woman with type 1 diabetes
mellitus has had progressive renal failure over the
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 the most likely
cause?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
(J)
Acute blood loss
Chronic lymphocytic leukemia
Erythrocyte enzyme deficiency
Erythropoietin deficiency
Immunohemolysis
Microangiopathic hemolysis
Polycythemia vera
Sickle cell disease
Sideroblastic anemia
β-Thalassemia trait
(Answer: D)
4
Appendix 1
Sequential Item Sets
A single patient-centered vignette may be
associated with two or three consecutive
questions about the information presented. Each
question is linked to the initial patient vignette but
is testing a different point. Questions are designed
to be answered in sequential order. You are
required to select the one best answer to each
question. Other options may be partially correct,
but there is only ONE BEST answer. You must
click “Proceed to Next Item” to view the next
item in the set; once you click on this button, you
will not be able to add or change an answer to the
displayed (previous) item.
5
Appendix 1
Step 1 Content Outline
Table of Contents
General Principles …………………………………………………………………………………...
Biochemistry and Molecular Biology
Biology of Cells
Human Development and Genetics
Biology of Tissue Response to Disease
Gender, Ethnic, and Behavioral Considerations Affecting Disease Treatment and Prevention
Multisystem Processes
Pharmacodynamic and Pharmacokinetic Processes
Microbial Biology and Infection
Quantitative Methods
7
Hematopoietic and Lymphoreticular Systems ……………………………………………………… 9
Central and Peripheral Nervous Systems …………………………………………………………… 10
Skin and Related Connective Tissue ………………………………………………………………… 11
Musculoskeletal System ………………………………………………………………………………. 12
Respiratory System …………………………………………………………………………………… 13
Cardiovascular System ……………………………………………………………………………….. 14
Gastrointestinal System ………………………………………………………………………………. 15
Renal/Urinary System ………………………………………………………………………………… 16
Reproductive System ………………………………………………………………………………….. 16
Endocrine System ……………………………………………………………………………………… 18
Immune System ………………………………………………………………………………………… 18
Examples of diseases and normal processes are listed within this content outline. The purpose of these examples is
only to clarify and illustrate the particular categories they are appended to; they are not intended to direct the
examinee toward preparing for questions on them. Examinees should not focus their studies on the examples only.
The examination encompasses the categories in the content outline, but the examination will not be limited to or
emphasize the examples or the categories for which examples are given.
6
Appendix 1
General Principles
Biochemistry and molecular biology
• gene expression: DNA structure, replication, exchange, and epigenetics
• gene expression: transcription
• gene expression: translation, post-translational processing, modifications, and disposition of proteins
(degradation), including protein/glycoprotein synthesis, intra/extracellular sorting, and processes/functions
related to Golgi complex and rough endoplasmic reticulum
• structure and function of proteins and enzymes
• energy metabolism
Biology of cells
• adaptive cell responses and cellular homeostasis
• intracellular accumulations
• mechanisms of injury and necrosis
• apoptosis
• mechanisms of dysregulation
- cell biology of cancer, including genetics of cancer
- general principles of invasion and metastasis, including cancer staging
• cell/tissue structure, regulation, and function, including cytoskeleton, organelles, glycolipids, channels, gap
junctions, extracellular matrix, and receptors
Human development and genetics
• principles of pedigree analysis
- inheritance patterns
- occurrence and recurrence risk determination
• population genetics: Hardy-Weinberg law, founder effects, mutation-selection equilibrium
• principles of gene therapy
• genetic testing and counseling
• genetic mechanisms
Biology of tissue response to disease
• acute inflammatory responses (patterns of response)
– acute inflammation and mediator systems
– vascular response to injury, including mediators
– principles of cell adherence and migration
– microbicidal mechanisms and tissue injury
– clinical manifestations
• chronic inflammatory responses
• reparative processes
– wound healing, hemostasis, and repair; thrombosis, granulation tissue, angiogenesis, fibrosis, scar/keloid
formation
– regenerative processes
Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial,
cultural, occupational, and environmental
• progression through the life cycle, including birth through senescence
– cognitive, language, motor skills, and social and interpersonal development
– sexual development
– influence of developmental stage on physician-patient interview
• psychological and social factors influencing patient behavior
– personality traits or coping style, including coping mechanisms
– psychodynamic and behavioral factors, related past experience
– family and cultural factors, including socioeconomic status, ethnicity, and gender
– adaptive behavioral responses to stress and illness
– maladaptive behavioral responses to stress and illness
– interactions between the patient and the physician or the health care system
– patient adherence (general and adolescent)
7
Appendix 1
•
•
patient interviewing, consultation, and interactions with the family
– establishing and maintaining rapport
– data gathering
– approaches to patient education
– enticing patients to make lifestyle changes
– communicating bad news
– “difficult” interviews
– multicultural ethnic characteristics
medical ethics, jurisprudence, and professional behavior
– consent and informed consent to treatment
– physician-patient relationships
– death and dying
– birth-related issues
– issues related to patient participation in research
– interactions with other health professionals, including impaired physician and patient safety
– sexuality and the profession; other “boundary” issues
– ethics of managed care
– organization and cost of health care delivery
Multisystem processes
• nutrition
– generation, expenditure, and storage of energy at the whole-body level
– assessment of nutritional status across the life span, including calories, protein, essential
nutrients, hypoalimentation
– functions of nutrients
– protein-calorie malnutrition
– vitamin deficiencies and/or toxicities (including megaloblastic anemia with other findings)
– mineral deficiencies and toxicities
• temperature regulation
• adaptation to environmental extremes, including occupational exposures
– physical and associated disorders (including temperature, radiation, burns, decreased atmospheric
pressure, high-altitude sickness, increased water pressure)
– chemical (including gases, vapors, smoke inhalation, agricultural hazards, organic solvents,
heavy metals, principles of poisoning and therapy)
• fluid, electrolyte, and acid-base balance disorders
• inherited metabolic disorders, including disorders related to amino acids, purines, porphyrins, carnitine, fatty
acids, and carbohydrates
Pharmacodynamic and pharmacokinetic processes
• general principles
– pharmacokinetics: absorption, distribution, metabolism, excretion, dosage intervals
– mechanisms of drug action, structure-activity relationships (including anticancer drugs)
– concentration- and dose-effect relationships, types of agonists and antagonists and their actions
– individual factors altering pharmacokinetics and pharmacodynamics
– mechanisms of drug adverse effects, overdosage, toxicology
– mechanisms of drug interactions
– regulatory issues
– signal transduction, including structure/function of all components of signal transduction pathway such
as receptors, ligands
– cell cycle/cell cycle regulation
Microbial biology and infection
• microbial identification and classification, including principles, microorganism identification, and nonimmunologic lab diagnosis
• bacteria
– structure
– processes, replication, and genetics
– oncogenesis
– antibacterial agents
• viruses
8
Appendix 1
•
•
•
•
– structure
– processes, replication, and genetics
– oncogenesis
– antiviral agents
fungi
– structure
– processes, replication, and genetics
– antifungal agents
parasites
– structure
– processes, replication, and genetics
– antiparasitic agents
prions
epidemiology, outbreaks, and infection control
Quantitative methods
• fundamental concepts of measurement
– scales of measurement
– distribution, central tendency, variability, probability
– disease prevalence and incidence
– disease outcomes
– associations
– health impact
– sensitivity, specificity, predictive values
• fundamental concepts of study design
– types of experimental studies
– types of observational studies
– sampling and sample size
– subject selection and exposure allocation
– outcome assessment
– internal and external validity
• fundamental concepts of hypothesis testing and statistical inference
– confidence intervals
– statistical significance and Type I error
– statistical power and Type II error
Hematopoietic and Lymphoreticular Systems
Normal processes
• embryonic development, fetal maturation, and perinatal changes
• organ structure and function
• cell/tissue structure and function
– production and function of erythrocytes, hemoglobin, O2 and CO2 transport, transport proteins
– production and function of platelets
– production and function of coagulation and fibrinolytic factors
• repair, regeneration, and changes associated with stage of life
Abnormal processes
• infectious, inflammatory, and immunologic disorders
– infections of the blood, reticuloendothelial system, and endothelial cells
– autoimmunity and autoimmune diseases
– anemia of chronic disease
– non-immunologically mediated transfusion complications, transplant rejection
• traumatic and mechanical injury
• neoplastic disorders (including lymphoma, leukemia, multiple myeloma, dysproteinemias, amyloidosis)
• metabolic and regulatory disorders, including acquired
– nutritional anemias
– cythemia
– hemorrhagic and hemostatic disorders
9
Appendix 1
•
•
•
•
•
•
– bleeding secondary to platelet disorders and disorders of primary hemostasis
vascular and endothelial disorders
systemic disorders affecting the hematopoietic and lymphoreticular system
idiopathic disorders
degenerative disorders
drug-induced adverse effects of the hematopoietic and lymphoreticular systems
congenital and genetic disorders affecting the hematopoietic and lymphoreticular systems
Principles of therapeutics
• mechanisms of action and use of drugs for treatment of disorders of the hematopoietic system
– blood and blood products
– treatment of anemia, drugs stimulating erythrocyte production
– drugs stimulating leukocyte production
– anticoagulants, thrombolytic drugs
– antiplatelet drugs
– antimicrobials and antiparasitics
– antineoplastic and immunosuppressive drugs in the clinical context of disease
• other therapeutic modalities
Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial,
cultural, occupational, and environmental
• emotional and behavioral factors
• influence on person, family, and society
• occupational and other environmental risk factors
• gender and ethnic factors
Central and Peripheral Nervous Systems
Normal processes
• embryonic development, fetal maturation, and perinatal changes, including neural tube derivatives,
cerebral ventricles, neural crest derivatives
• organ structure and function
– spinal cord, including gross anatomy, blood supply, and spinal reflexes
– brain stem
– brain, including gross anatomy and blood supply; cognition, language, memory; hypothalamic
function; limbic system and emotional behavior; circadian rhythms and sleep; control of eye
movement
– sensory systems, including proprioception, pain, vision, hearing, balance, taste, and olfaction
– motor systems, including brain and spinal cord, basal ganglia, and cerebellum
– autonomic nervous system
– peripheral nerve
• cell/tissue structure and function
– axonal transport
– excitable properties of neurons, axons, and dendrites, including channels
– synthesis, storage, release, reuptake, and degradation of neurotransmitters and neuromodulators
– pre- and postsynaptic receptor interactions, trophic and growth factors
– brain metabolism
– glia, myelin
– brain homeostasis: blood-brain barrier; cerebrospinal fluid formation and flow; choroid plexus
• repair, regeneration, and changes associated with stage of life, including definition of brain death
Abnormal processes
• infectious, inflammatory, and immunologic disorders (including demyelinating disorders, myasthenia gravis
and muscle channelopathies, and disorders of the eye and ear)
• traumatic and mechanical disorders
• neoplastic disorders, including primary and metastatic
• metabolic and regulatory disorders
• vascular disorders
• systemic disorders affecting the nervous system
• idiopathic disorders affecting the nervous system
• congenital and genetic disorders, including metabolic
10
Appendix 1
•
•
•
•
•
•
degenerative disorders
paroxysmal disorders
disorders of special senses
psychopathologic disorders, processes, and their evaluation
– early-onset disorders
– disorders related to substance use
– schizophrenia and other psychotic disorders
– mood disorders
– anxiety disorders
– somatoform disorders
– personality disorders
– physical and sexual abuse of children, adults, and elders
– other disorders
drug-induced adverse effects on the central and peripheral nervous system
neurologic pain syndromes
Principles of therapeutics
• mechanisms of action and use of drugs for treatment of disorders of the nervous
system
– anesthetics
– hypnotic sedatives
– psychopharmacologic agents
– anticonvulsants
– analgesics
– stimulants, amphetamines
– antiparkinsonian drugs and drugs for dementia, Alzheimer type; multiple sclerosis; and restless legs
syndrome
– skeletal muscle relaxants, botulinum toxin
– neuromuscular junction agonists and antagonists
– antiglaucoma drugs
– drugs used to decrease intracranial pressure
– antimigraine agents
– drugs affecting the autonomic nervous system, including all general autonomic pharmacology
– antimicrobials, antineoplastic drugs, and antiparasitics
– drugs used to treat cerebrovascular disorders
– treatment for substance abuse disorders
• other therapeutic modalities
Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial,
cultural, occupational, and environmental
• emotional and behavioral factors
• influence on person, family, and society
• occupational and other environmental risk factors
• gender and ethnic factors
Skin and Related Connective Tissue
Normal processes
• embryonic development, fetal maturation, and perinatal changes
• organ structure and function
• cell/tissue structure and function, including barrier functions, thermal regulation, eccrine function
• repair, regeneration, and changes associated with stage of life or ethnicity
• skin defense mechanisms and normal flora
Abnormal processes
• infectious, inflammatory, and immunologic disorders
– bacterial infections
– viral infections
– fungal infections, including mycoses, dermatophytosis
11
Appendix 1
•
•
•
•
•
•
•
•
•
– parasitic infections, ectoparasitic infestations, and mycobacterial infections
– immune and autoimmune disorders
traumatic and mechanical disorders
– thermal injury
– decubitus ulcers
– effects of ultraviolet light and radiation
neoplastic disorders
– keratinocytes
– melanocytes
– vascular neoplasms
– other
metabolic, regulatory, and structural disorders
vascular disorders
systemic disorders affecting the skin
idiopathic disorders
degenerative disorders
drug-induced adverse effects on the skin and related connective tissue
congenital and genetic disorders affecting the skin and related connective tissue
Principles of therapeutics
• mechanisms of action and use of drugs for treatment of disorders of the skin and
connective tissue
– anti-inflammatory agents
– emollients
– sunscreen
– retinoids
– antimicrobial and antiparasitic agents
– cytotoxic and immunologic therapy and antineoplastic drugs
• other therapeutic modalities
Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial,
cultural, occupational, and environmental
• emotional and behavioral factors
• influence on person, family, and society
• occupational and other environmental risk factors
• gender and ethnic factors
Musculoskeletal System
Normal processes
• embryonic development, fetal maturation, and perinatal changes
• organ structure and function
• cell/tissue structure and function
– biology of bones, joints, tendons, skeletal muscle
– exercise and physical conditioning
• repair, regeneration, and changes associated with stage of life
Abnormal processes
• infectious, inflammatory, and immunologic disorders
• traumatic and mechanical disorders (including fractures, sprains, strains, dislocations, joint injuries, repetitive
motion injuries, and impingement syndromes)
• neoplastic disorders
• metabolic, regulatory, and structural disorders (including osteomalacia,
osteoporosis, osteodystrophy, gout, and pseudogout)
• vascular disorders
• systemic disorders affecting the musculoskeletal system
• idiopathic disorders
• degenerative disorders
• drug-induced adverse effects on the musculoskeletal system
• congenital and genetic disorders affecting the musculoskeletal system
12
Appendix 1
Principles of therapeutics
• mechanisms of action and use of drugs for treatment of disorders of the
musculoskeletal system
– nonsteroidal anti-inflammatory drugs and analgesics
– muscle relaxants
– antigout therapy
– immunosuppressive and antineoplastic drugs
– drugs affecting bone mineralization
– antimicrobial and antiparasitic agents
• other therapeutic modalities
Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial,
cultural, occupational, and environmental
• emotional and behavioral factors
• influence on person, family, and society
• occupational and other environmental risk factors
• gender and ethnic factors
Respiratory System
Normal processes
• embryonic development, fetal maturation, and perinatal changes
• organ structure and function
– airways, including mechanics and regulation of breathing
– lung parenchyma, including ventilation, perfusion, gas exchange
– pleura
– nasopharynx and sinuses
• cell/tissue structure and function, including surfactant formation, alveolar structure
• repair, regeneration, and changes associated with stage of life
• pulmonary defense mechanisms and normal flora
Abnormal processes
• infectious, inflammatory, and immunologic disorders
– infectious diseases
– infectious diseases of the upper respiratory tract
– pyogenic infectious diseases of the lower respiratory tract and pleura, viral infections, and associated
complications
– other infectious diseases of the lower respiratory tract
– immunologic disorders
– allergic and hypersensitivity disorders
– autoimmune disorders
– inflammatory disorders
– pneumoconioses
– acute and chronic alveolar injury
– chronic obstructive pulmonary disease
– restrictive pulmonary disease
• traumatic and mechanical disorders
• neoplastic disorders (including upper airway, lower airway and lung parenchyma, pleura, and metastatic
tumors)
• metabolic, regulatory, and structural disorders
• vascular and circulatory disorders (including thromboembolic disease, pulmonary hypertension, pulmonary
edema, and pleural effusion)
• systemic disorders affecting the respiratory system
• idiopathic disorders
• degenerative disorders
• drug-induced adverse effects on the respiratory system
• congenital and genetic disorders affecting the respiratory system
13
Principles
Appendix
1
of therapeutics
mechanisms of action and use of drugs for treatment of disorders of the respiratory system
– decongestants, cough suppressants, expectorants, mucolytics
– bronchodilator drugs
– anti-inflammatory and cytotoxic drugs
– antimicrobial agents and antiparasitic agents
– antineoplastic agents
– pulmonary vasodilators
• other therapeutic modalities
•
Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial,
cultural, occupational, and environmental
• emotional and behavioral factors
• influence on person, family, and society
• occupational and other environmental risk factors
• gender and ethnic factors
Cardiovascular System
Normal processes
• embryonic development, fetal maturation, and perinatal changes
• organ structure and function
– chambers, valves
– cardiac cycle, mechanics, heart sounds, cardiac conduction
– hemodynamics, including systemic, pulmonary, coronary, and blood volume
– circulation in specific vascular beds
• cell/tissue structure and function
– heart muscle, metabolism, oxygen consumption, biochemistry, and secretory function
– endothelium and secretory function, vascular smooth muscle, microcirculation, and lymph flow
(including mechanisms of atherosclerosis)
– neural and hormonal regulation of the heart, blood vessels, and blood volume, including responses to
change in posture, exercise, and tissue metabolism
• repair, regeneration, and changes associated with stage of life
Abnormal processes
• infectious, inflammatory, and immunologic disorders
• traumatic and mechanical disorders
• neoplastic disorders
• metabolic and regulatory disorders (including dysrhythmias, systolic and diastolic dysfunction, low- and
high-output heart failure, cor pulmonale, systemic hypertension, ischemic heart disease, myocardial
infarction, systemic hypotension and shock, and dyslipidemias)
• vascular disorders
• systemic diseases affecting the cardiovascular system
• congenital and genetic disorders of the heart and central vessels
• idiopathic disorders
• drug-induced adverse effects on the cardiovascular system
• degenerative disorders
Principles of therapeutics
• mechanisms of action, use, and adverse effects of drugs for treatment of disorders of the
cardiovascular system
– coronary and peripheral vasodilators
– antiarrhythmic drugs
– antihypertensive drugs
– measures used to combat hypotension and shock
– drugs affecting cholesterol and lipid metabolism
– drugs affecting blood coagulation, thrombolytic agents, and antiplatelet agents
– inotropic agents and treatment of heart failure
– immunosuppressive, antimicrobial, antineoplastic, and antiparasitic drugs
– drugs to treat peripheral arterial disease
– other pharmacotherapy
14
Appendix 1
•
other therapeutic modalities
Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial,
cultural, occupational, and environmental
• emotional and behavioral factors
• influence on person, family, and society
• occupational and other environmental risk factors
• gender and ethnic factors
Gastrointestinal System
Normal processes
• embryonic development, fetal maturation, and perinatal changes
• organ structure and function, including alimentary canal, liver and biliary system, salivary glands
and exocrine pancreas, motility, and digestion and absorption
• cell/tissue structure and function
– endocrine and neural regulatory functions, including GI hormones
– salivary, gastrointestinal, pancreatic, hepatic secretory products, including enzymes, proteins, bile salts,
and processes
– synthetic and metabolic functions of hepatocytes
• repair, regeneration, and changes associated with stage of life
• gastrointestinal defense mechanisms and normal flora
Abnormal processes
• infectious, inflammatory, and immunologic disorders
• traumatic and mechanical disorders
– malocclusion
– hiatal hernia
– obstruction
– perforation of hollow viscus and blunt trauma
– inguinal, femoral, and abdominal wall hernias
– esophageal, intestinal, and colonic diverticula
• neoplastic disorders, including benign and malignant
• metabolic and regulatory disorders (including motility disorders, malabsorption, hepatic failure,
cholelithiasis, nutritional disorders)
• vascular disorders (including portal hypertension, esophageal varices, hemorrhoids, anal fissure, ischemia,
angiodysplasia, thromboses, vasculitis)
• systemic disorders affecting the gastrointestinal system
• idiopathic disorders
• degenerative disorders
• drug-induced adverse effects on the gastrointestinal system
• congenital and genetic disorders affecting the gastrointestinal system
Principles of therapeutics
• mechanisms of action and use of drugs for treatment of disorders of the gastrointestinal system
– treatment and prophylaxis of peptic ulcer disease and gastroesophageal reflux
– drugs to alter gastrointestinal motility
– fluid replacement
– pancreatic replacement therapy and treatment of pancreatitis
– drugs for treatment of hepatic failure and biliary disease
– anti-inflammatory, immunosuppressive, antineoplastic, antimicrobial, and antiparasitic drugs
• other therapeutic modalities
Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial,
cultural, occupational, and environmental
• emotional and behavioral factors
• influence on person, family, and society
• occupational and other environmental risk factors
• gender and ethnic factors
15
Appendix 1
Renal/Urinary System
Normal processes
• embryonic development, fetal maturation, and perinatal changes
• organ structure and function
– kidneys, ureters, bladder, urethra
– glomerular filtration and hemodynamics
– tubular reabsorption and secretion, including transport processes and proteins
– urinary concentration and dilution
– renal mechanisms in acid-base balance
– renal mechanisms in body fluid homeostasis
– micturition
• cell/tissue structure and function, including renal metabolism and oxygen consumption, hormones
produced by or acting on the kidney
• repair, regeneration, and changes associated with stage of life
Abnormal processes
• infectious, inflammatory, and immunologic disorders
– infectious disorders
– upper urinary tract
– lower urinary tract
– inflammatory and immunologic disorders
– glomerular disorders
– tubular interstitial disease
• traumatic and mechanical disorders
• neoplastic disorders, including primary and metastases
• metabolic and regulatory disorders
– renal failure, acute and chronic
– tubular and collecting duct disorders
– renal calculi
• vascular disorders
• systemic diseases affecting the renal system
• idiopathic disorders
• degenerative disorders
• drug-induced adverse effects on the renal/urinary system
• congenital and genetic disorders affecting the renal/urinary system
Principles of therapeutics
• mechanisms of action and use of drugs for treatment of disorders of the renal and urinary system
– diuretics, antidiuretic drugs
– drugs and fluids used to treat volume, electrolyte, and acid-base disorders
– drugs used to enhance renal perfusion
– anti-inflammatory, antimicrobial, immunosuppressive, antineoplastic, and antiparasitic drugs
– drugs used to treat lower urinary tract system
• other therapeutic modalities
Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial,
cultural, occupational, and environmental
• emotional and behavioral factors
• influence on person, family, and society
• occupational and other environmental risk factors
• gender and ethnic factors
Reproductive System
Normal processes
• embryonic development, fetal maturation, and perinatal changes, including gametogenesis
• organ structure and function
– female structure, including breast
– female function
– male structure
16
Appendix 1
–
–
•
•
– male function
intercourse, orgasm
pregnancy, including ovulation, fertilization, implantation, labor and delivery, the puerperium,
lactation, gestational uterus, placenta
cell/tissue structure and function, including hypothalamic-pituitary-gonadal axis, sex steroids, and
gestational hormones
reproductive system defense mechanisms and normal flora
Abnormal processes
• infectious, inflammatory, and immunologic disorders (female and male)
• traumatic and mechanical disorders (female and male)
• neoplastic disorders (including female reproductive, male reproductive, breast [including fibrocystic
changes], trophoblastic disease)
• metabolic and regulatory processes (female and male)
• prenatal and perinatal counseling and screening
• systemic disorders affecting reproductive function
• disorders relating to pregnancy, the puerperium, and the postpartum period
– obstetric problems
– complications affecting other organ systems
– disorders associated with the puerperium
– antepartum, intrapartum, postpartum disorders of the fetus
• idiopathic disorders
• drug-induced adverse effects on the reproductive system
• degenerative disorders
• congenital and genetic disorders affecting the reproductive system
Principles of therapeutics
• mechanisms of action and use of drugs for treatment of disorders of the reproductive system and management
of normal reproductive function
– female reproductive tract
– fertility drugs
– oral contraception, other methods of contraception
– estrogen, progesterone replacement, treatment of menopause
– stimulants and inhibitors of labor
– estrogen and progesterone antagonists
– stimulators and inhibitors of lactation
– male reproductive tract
– fertility drugs
– androgen replacement and antagonists
– gonadotropin-releasing hormone and gonadotropin replacement, including all gonadotropin-releasing
hormone antagonists
– abortifacients
– antimicrobial and antiparasitic agents
– antineoplastics
– restoration of potency
• other therapeutic modalities affecting the reproductive system
Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial,
cultural, occupational, and environmental
• emotional and behavioral factors
• influence on person, family, and society
• occupational and other environmental risk factors
• family planning and pregnancy
• gender identity, sexual orientation, sexuality, libido
• effects of traumatic stress syndrome, violence, rape, child abuse
17
Endocrine
System
Appendix
1
Normal processes
• embryonic development, fetal maturation, and perinatal changes
• organ structure and function
– hypothalamus, posterior and anterior pituitary gland
– thyroid gland
– parathyroid glands
– adrenal cortex, adrenal medulla
– pancreatic islets
– ovary and testis
– adipose tissue
• cell/tissue structure and function, including hormone synthesis, secretion, action, and metabolism
– peptide hormones
– steroid hormones, including vitamin D
– thyroid hormones
– catecholamine hormones
– renin-angiotensin system
• repair, regeneration, and changes associated with stage of life
Abnormal processes
• infectious, inflammatory, and immunologic disorders
• traumatic and mechanical disorders
• neoplastic disorders (including pituitary, thyroid, parathyroid, adrenal cortex, pancreatic islets, neural crest,
pheochromocytoma)
• metabolic and regulatory processes (including diabetes mellitus, pituitary, hypothalamus, thyroid,
parathyroid, pancreatic islet disorders, adrenal disorders)
• vascular disorders
• systemic disorders affecting the endocrine system
• idiopathic disorders
• degenerative disorders
• drug-induced adverse effects on the endocrine system
• congenital and genetic disorders affecting the endocrine system
Principles of therapeutics
• mechanisms of action and use of drugs for treatment of disorders of the endocrine system
– hormones and hormone analogs
– stimulators of hormone production
– inhibitors of hormone production
– hormone antagonists
– potentiators of hormone action
– antiobesity agents
– nonhormonal therapy for endocrine disorders
– other treatment for diabetes
• other therapeutic modalities
Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial,
cultural, occupational, and environmental
• emotional and behavioral factors
• influence on person, family, and society
• occupational and other environmental risk factors
• gender and ethnic factors
Immune System
Normal processes
• development of cells of the adaptive immune response, including positive and negative selection during
immune development
• structure, production, and function
– granulocytes, natural killer cells, macrophages, mast cells, dendritic cells, cell receptors
– T lymphocytes, including T-lymphocyte receptors, accessory molecules, cell activation and proliferation,
cytotoxic T lymphocytes, and memory T lymphocytes
18
Appendix 1
–
•
•
B lymphocytes and plasma cells, including B-lymphocyte receptors, immunoglobulins, cell activation
and proliferation, including development of antibodies and memory B lymphocytes
– structure and function of lymph nodes, host defense mechanisms, host barriers to infection, mucosal
immunity
– immunogenetics
– Rh and ABO antigens, including genetics
cellular basis of the immune response and immunologic mediators
– antigen processing and presentation in the context of MHC I and MHC II molecules, including
distribution of MHC I and MHC II on different cells, mechanism of MHC I and MHC II deficiencies,
and the genetics of MHC
– regulation of the adaptive immune response
– activation, function, and molecular biology of complement
– function and molecular biology of cytokines
basis of immunologic diagnosis
Abnormal processes
• disorders with alterations in immunologic function
– abnormalities in adaptive immune responses
– deficiencies of phagocytic cells and natural killer cells
– complement deficiency
– HIV infection/AIDS
– Non-HIV infections of lymphocytes
– systemic diseases of immunologic function
– systemic disorders affecting the immune system and the effect of age on the function of components of
the immune system
• immunologically mediated disorders
– type I, type II, type III hypersensitivity
– type IV hypersensitivity
– transplantation risks and rejection, including transfusion reactions
– isoimmunization, hemolytic disease of the newborn
• drug-induced adverse effects on the immune system, including Jarisch-Herxheimer
Principles of therapeutics
• mechanisms of action and use of drugs that specifically affect immune function
– vaccines (active and passive)
– antiretrovirals
– immunomodulating and antineoplastic drugs
– biologics, including monoclonal and polyclonal antibodies
• other therapeutic modalities
Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial,
cultural, occupational, and environmental
• emotional and behavioral factors
• influence on person, family, and society
• occupational and other environmental risk factors
• gender and ethnic factors
19
Appendix 1
Sample Step 1
Sample Questions
The following pages include 138 sample test questions. These questions are the same as those you install on your computer from the
USMLE Web site. For information on obtaining the test software and additional information on preparing to take the test and testing,
you must review the 2011 USMLE Bulletin of Information: see Preparing for the Test and Testing. Please note that reviewing the
sample questions as they appear on pages 23-54 is not a substitute for acquainting yourself with the test software. You should run the
Step 1 tutorial and sample test questions that are provided on the USMLE Web site well before your test date. The sample materials
available at the USMLE Web site include an additional block of items with associated audio or video findings and a sequential item
set. You should become familiar with test items that have audio or video components and sequential item sets as these formats may be
used in the actual examination. The block of items with associated audio or video and sequential item sets does not appear in this
booklet.
These sample questions are illustrative of the types of questions used in the Step 1 examination. Although the questions exemplify
content on the examination, they may not reflect the content coverage on individual examinations. In the actual examination, questions
may appear randomly; they will not be grouped according to specific content. The questions will be presented one at a time in a format
designed for easy on-screen reading, including use of exhibit buttons (separate windows) for the Normal Laboratory Values Table
(included here on pages 21-22) and some pictorials. Photographs, charts, and x-ray films referred to in this booklet are not of the same
quality as the pictorials used in the actual examination. In addition, you will have the capability to adjust the brightness and contrast of
pictorials on the computer screen.
To take the following sample test questions as they would be timed in the actual examination, you should allow a maximum of one
hour for each block, for a total of three hours. Please be aware that most examinees perceive the time pressure to be greater during an
actual examination. An answer form for recording answers is provided on page 55. In the actual examination, answers will be selected
on the screen; no answer form will be provided. An answer key is provided on page 56.
20
Appendix 1
USMLE Step 1 Laboratory Values
* Included in the Biochemical Profile (SMA-12)
REFERENCE RANGE
SI REFERENCE INTERVALS
BLOOD, PLASMA, SERUM
* Alanine aminotransferase (ALT), serum ................. 8-20 U/L ................................................... 8-20 U/L
Amylase, serum .......................................................25-125 U/L ................................................ 25-125 U/L
* Aspartate aminotransferase (AST), serum ..............8-20 U/L .................................................... 8-20 U/L
Bilirubin, serum (adult) Total // Direct ................... 0.1-1.0 mg/dL // 0.0-0.3 mg/dL ................ 2-17 μmol/L // 0-5 μmol/L
* Calcium, serum (Ca2+) ............................................8.4-10.2 mg/dL .......................................... 2.1-2.8 mmol/L
* Cholesterol, serum .................................................. Rec:<200 mg/dL ...................................... <5.2 mmol/L
Cortisol, serum ........................................................0800 h: 5-23 μg/dL // 1600 h: 3-15 μg/dL 138-635 nmol/L // 82-413 nmol/L
2000 h: < 50% of 0800 h ........................... Fraction of 0800 h: < 0.50
Creatine kinase, serum ............................................Male: 25-90 U/L ....................................... 25-90 U/L
Female: 10-70 U/L ................................... 10-70 U/L
* Creatinine, serum ....................................................0.6-1.2 mg/dL ........................................... 53-106 μmol/L
Electrolytes, serum
Sodium (Na+) ........................................................136-145 mEq/L ......................................... 136-145 mmol/L
* Potassium (K+) ......................................................3.5-5.0 mEq/L ........................................... 3.5-5.0 mmol/L
Chloride (Cl–) ........................................................95-105 mEq/L .......................................... 95-105 mmol/L
Bicarbonate (HCO3–) .............................................22-28 mEq/L ............................................ 22-28 mmol/L
Magnesium (Mg2+) ................................................1.5-2.0 mEq/L ........................................... 0.75-1.0 mmol/L
Estriol, total, serum (in pregnancy)
24-28 wks // 32-36 wks .........................................30-170 ng/mL // 60-280 ng/mL ................ 104-590 nmol/L // 208-970 nmol/L
28-32 wks // 36-40 wks .........................................40-220 ng/mL // 80-350 ng/mL ................ 140-760 nmol/L // 280-1210 nmol/L
Ferritin, serum .........................................................Male: 15-200 ng/mL ................................ 15-200 μg/L
Female: 12-150 ng/mL ............................. 12-150 μg/L
Follicle-stimulating hormone, serum/plasma .........Male: 4-25 mIU/mL ................................. 4-25 U/L
Female: premenopause 4-30 mIU/mL ...... 4-30 U/L
midcycle peak 10-90 mIU/mL ............... 10-90 U/L
postmenopause 40-250 mIU/mL ........... 40-250 U/L
Gases, arterial blood (room air)
pH .........................................................................7.35-7.45 .................................................. [H+] 36-44 nmol/L
PCO2 ......................................................................33-45 mm Hg ............................................ 4.4-5.9 kPa
PO2 ........................................................................75-105 mm Hg .......................................... 10.0-14.0 kPa
* Glucose, serum ........................................................Fasting: 70-110 mg/dL ............................. 3.8-6.1 mmol/L
2-h postprandial: < 120 mg/dL ................ < 6.6 mmol/L
Growth hormone - arginine stimulation .................. Fasting: < 5 ng/mL ................................... < 5 μg/L
provocative stimuli: > 7 ng/mL ............. > 7 μg/L
Immunoglobulins, serum
IgA .......................................................................76-390 mg/dL ............................................ 0.76-3.90 g/L
IgE ........................................................................0-380 IU/mL ............................................ 0-380 kIU/L
IgG .......................................................................650-1500 mg/dL ....................................... 6.5-15 g/L
IgM .......................................................................40-345 mg/dL ........................................... 0.4-3.45 g/L
Iron .........................................................................50-170 μg/dL ............................................ 9-30 μmol/L
Lactate dehydrogenase, serum ................................ 45-90 U/L .................................................. 45-90 U/L
Luteinizing hormone, serum/plasma ...................... Male: 6-23 mIU/mL ................................. 6-23 U/L
Female: follicular phase 5-30 mIU/mL .... 5-30 U/L
midcycle 75-150 mIU/mL ...................... 75-150 U/L
postmenopause 30-200 mIU/mL ........... 30-200 U/L
Osmolality, serum ................................................... 275-295 mOsmol/kg H2O ......................... 275-295 mOsmol/kg H2O
Parathyroid hormone, serum, N-terminal ...............230-630 pg/mL ......................................... 230-630 ng/L
* Phosphatase (alkaline), serum (p-NPP at 30 C) ....20-70 U/L ................................................. 20-70 U/L
* Phosphorus (inorganic), serum ................................ 3.0-4.5 mg/dL ........................................... 1.0-1.5 mmol/L
Prolactin, serum (hPRL) .........................................< 20 ng/mL ............................................... < 20 μg/L
* Proteins, serum
Total (recumbent) ................................................. 6.0-7.8 g/dL .............................................. 60-78 g/L
Albumin ................................................................3.5-5.5 g/dL ............................................... 35-55 g/L
Globulin ...............................................................2.3-3.5 g/dL ............................................... 23-35 g/L
Thyroid-stimulating hormone, serum or plasma .....0.5-5.0 μU/mL .......................................... 0.5-5.0 mU/L
Thyroidal iodine (123I) uptake ..................................8%-30% of administered dose/24 h .......... 0.08-0.30/24 h
Thyroxine (T4), serum .............................................5-12 μg/dL ................................................ 64-155 nmol/L
Triglycerides, serum................................................35-160 mg/dL ............................................ 0.4-1.81 mmol/L
Triiodothyronine (T3), serum (RIA) ....................... 115-190 ng/dL .......................................... 1.8-2.9 nmol/L
Triiodothyronine (T3) resin uptake .......................... 25%-35% .................................................. 0.25-0.35
* Urea nitrogen, serum ..............................................7-18 mg/dL ............................................... 1.2-3.0 mmol/L
* Uric acid, serum ......................................................3.0-8.2 mg/dL ........................................... 0.18-0.48 mmol/L
21
Appendix 1
USMLE Step 1 Laboratory Values (continued)
REFERENCE RANGE
SI REFERENCE INTERVALS
BODY MASS INDEX (BMI)
Body mass index ...................................................... Adult: 19-25 kg/m2
CEREBROSPINAL FLUID
Cell count ................................................................. 0-5/mm3 ............................................................ 0-5 x 106/L
Chloride ................................................................... 118-132 mEq/L ................................................ 118-132 mmol/L
Gamma globulin ....................................................... 3%-12% total proteins ...................................... 0.03-0.12
Glucose ................................................................... 40-70 mg/dL .................................................... 2.2-3.9 mmol/L
Pressure ................................................................... 70-180 mm H2O .............................................. 70-180 mm H2O
Proteins, total .......................................................... <40 mg/dL ...................................................... <0.40 g/L
HEMATOLOGIC
Bleeding time (template) ......................................... 2-7 minutes ....................................................... 2-7 minutes
Erythrocyte count ..................................................... Male: 4.3-5.9 million/mm3 ............................... 4.3-5.9 x 1012/L
Female: 3.5-5.5 million/mm3 ............................ 3.5-5.5 x 1012/L
Erythrocyte sedimentation rate (Westergren)........... Male: 0-15 mm/h ............................................. 0-15 mm/h
Female: 0-20 mm/h .......................................... 0-20 mm/h
Hematocrit ............................................................... Male: 41%-53% ............................................... 0.41-0.53
Female: 36%-46% ............................................ 0.36-0.46
Hemoglobin A1c ....................................................... < 6% ................................................................. < 0.06
Hemoglobin, blood................................................... Male: 13.5-17.5 g/dL ....................................... 2.09-2.71 mmol/L
Female: 12.0-16.0 g/dL .................................... 1.86-2.48 mmol/L
Hemoglobin, plasma ................................................ 1-4 mg/dL ......................................................... 0.16-0.62 mmol/L
Leukocyte count and differential
Leukocyte count ..................................................... 4500-11,000/mm3 ............................................. 4.5-11.0 x 109/L
Segmented neutrophils ......................................... 54%-62% ......................................................... 0.54-0.62
Bands.................................................................... 3%-5% ............................................................. 0.03-0.05
Eosinophils .......................................................... 1%-3% ............................................................. 0.01-0.03
Basophils .............................................................. 0%-0.75% ......................................................... 0-0.0075
Lymphocytes ....................................................... 25%-33% .......................................................... 0.25-0.33
Monocytes ........................................................... 3%-7% ............................................................. 0.03-0.07
Mean corpuscular hemoglobin ................................. 25.4-34.6 pg/cell .............................................. 0.39-0.54 fmol/cell
Mean corpuscular hemoglobin concentration ......... 31%-36% Hb/cell ............................................ 4.81-5.58 mmol Hb/L
Mean corpuscular volume ....................................... 80-100 μm3 ....................................................... 80-100 fL
Partial thromboplastin time (activated) ................... 25-40 seconds ................................................... 25-40 seconds
Platelet count ............................................................ 150,000-400,000/mm3 ...................................... 150-400 x 109/L
Prothrombin time ..................................................... 11-15 seconds ................................................... 11-15 seconds
Reticulocyte count.................................................... 0.5%-1.5% ........................................................ 0.005-0.015
Thrombin time ......................................................... <2 seconds deviation from control .................. <2 seconds deviation from control
Volume
Plasma ................................................................... Male: 25-43 mL/kg........................................... 0.025-0.043 L/kg
Female: 28-45 mL/kg ....................................... 0.028-0.045 L/kg
Red cell .................................................................. Male: 20-36 mL/kg .......................................... 0.020-0.036 L/kg
Female: 19-31 mL/kg ...................................... 0.019-0.031 L/kg
SWEAT
Chloride.................................................................... 0-35 mmol/L .................................................... 0-35 mmol/L
URINE
Calcium ................................................................... 100-300 mg/24 h .............................................. 2.5-7.5 mmol/24 h
Chloride.................................................................... Varies with intake ............................................. Varies with intake
Creatinine clearance ................................................. Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)
30 wks .................................................................... 6-18 mg/24 h .................................................... 21-62 μmol/24 h
35 wks .................................................................... 9-28 mg/24 h .................................................... 31-97 μmol/24 h
40 wks .................................................................... 13-42 mg/24 h .................................................. 45-146 μmol/24 h
17-Hydroxycorticosteroids ...................................... Male: 3.0-10.0 mg/24 h .................................... 8.2-27.6 μmol/24 h
Female: 2.0-8.0 mg/24 h................................... 5.5-22.0 μmol/24 h
17-Ketosteroids, total ............................................... Male: 8-20 mg/24 h .......................................... 28-70 μmol/24 h
Female: 6-15 mg/24 h....................................... 21-52 μmol/24 h
Osmolality ............................................................... 50-1400 mOsmol/kg H2O
Oxalate ..................................................................... 8-40 μg/mL ...................................................... 90-445 μmol/L
Potassium ................................................................ Varies with diet ................................................ Varies with diet
Proteins, total .......................................................... <150 mg/24 h .................................................. <0.15 g/24 h
Sodium .................................................................... Varies with diet ................................................ Varies with diet
Uric acid ................................................................... Varies with diet ................................................ Varies with diet
22
Appendix 1
SAMPLE ITEMS
BLOCK 1, ITEMS 1-46
1.
A 25-year-old woman has a 3-day history of
vomiting and diarrhea. She has postural
hypotension and poor tissue turgor. Her serum
sodium concentration is 130 mEq/L. Which of
the following findings is most likely?
3.
(A) Decreased serum aldosterone
concentration
(B) Increased serum atrial natriuretic
peptide concentration
(C) Increased effective circulating volume
(D) Increased serum ADH (vasopressin)
concentration
(E) Urine osmolality less than serum
osmolality
2.
A 52-year-old woman comes to the physician
because of a 2-day history of fever and left flank
pain. She has been treated for multiple episodes
of pyelonephritis during the past 3 years. Her
temperature is 37.8°C (100.1°F). Physical
examination shows left flank tenderness.
Urinalysis shows 12–18 WBC/hpf with
occasional lymphocytes and mononuclear cells
with features of macrophages. Cultures of urine
grow 80,000 colonies/mL of Proteus mirabilis.
An x-ray of the abdomen shows a 3-cm mass in
the lower pole of the left kidney. Gross
examination of the mass after it has been
resected shows that it is yellow, 3.2-cm in
diameter, and centrally but not marginally
necrotic. Histologic examination of the mass
shows a predominance of epithelioid cells with
partially clear and granular-to-foamy cytoplasm.
Nuclei are eccentric, normochromic, symmetric,
and without significant pleomorphism. Scattered
lymphocytes and plasma cells are intermixed.
Which of the following is the most likely
diagnosis?
(A) Acute pyelonephritis
(B) Malacoplakia
(C) Renal cell carcinoma, clear cell type,
intermediate grade
(D) Renal cell carcinoma, granular cell type
(E) Xanthogranulomatous pyelonephritis
A 50-year-old man with a history of alcoholism
has difficulty with short-term memory. He is
unable to recall the date and cannot remember
what he ate for breakfast this morning. He thinks
the examiner is a long-lost friend and carries on a
conversation with the examiner as if they have
known each other for years. His long-term
memory appears intact. The patient dies shortly
thereafter of a myocardial infarct. Pathologic
examination of his brain is most likely to
disclose an abnormality involving which of the
following?
(A)
(B)
(C)
(D)
(E)
4.
A 72-year-old man who is a retired construction
worker comes to the physician because he has
had a lesion on his face for 3 months. Physical
examination shows a 6-mm, red, ulcerated lesion
with heaped borders. A biopsy specimen of the
lesion shows atypical, dysplastic keratinocytes
within the epidermis and dermis. Which of the
following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
5.
Amygdala
Caudate nucleus
Hippocampus
Locus caeruleus
Mammillary bodies
Actinic keratosis
Discoid lupus erythematosus
Melanoma
Mycosis fungoides
Squamous cell carcinoma
A 1-day-old newborn is evaluated for possible
sepsis. Blood cultures grow gram-positive cocci
in pairs and chains that agglutinate with group B
antiserum. The most likely epidemiologic risk
factor for this infection involves bacterial
colonization of which of the following?
(A)
(B)
(C)
(D)
(E)
Mother's vagina
Newborn's gastrointestinal tract
Newborn's nasopharynx
Placenta
Umbilical cord remnant
23
Appendix 1
6.
A 21-year-old man is brought to the emergency department by friends because of blurred vision, headache,
abdominal pain, nausea, and vomiting for 30 minutes. His friends say that he drank 60 mL of wood alcohol 1 hour
ago after a bet at a fraternity house party. His pulse is 58/min and regular, respirations are 28/min and shallow, and
blood pressure is 130/72 mm Hg. Physical examination shows no other abnormalities. Laboratory studies show:
Serum
Na+
Cl−
K+
HCO3−
Urine
pH
Crystals
139 mEq/L
85 mEq/L
4.5 mEq/L
13 mEq/L
5
none
Arterial blood gas analysis on room air:
pH
PO2
PCO2
7.28
108 mm Hg
22 mm Hg
Which of the following is the most appropriate initial treatment for this patient?
(A)
(B)
(C)
(D)
(E)
7.
Intravenous ethanol therapy
Intravenous sodium bicarbonate therapy
Oral acetylcysteine therapy
Oral activated charcoal therapy
Hemodialysis
A 42-year-old woman, gravida 2, para 2, comes
for a routine examination. She has type
2 diabetes mellitus well controlled with
glyburide. She has a history of vulvar
condylomata acuminata successfully treated with
laser ablation 12 years ago. She does not smoke.
She drinks a six-pack of beer nightly. She is
sexually active and uses a diaphragm with
spermicide for contraception. Her mother had
breast cancer at the age of 65 years. The patient
is 157 cm (5 ft 2 in) tall and weighs 100 kg (220
lb); BMI is 40 kg/m2. Physical examination
shows
no
other
abnormalities.
Pelvic
examination shows a 2-cm ulcer on the cervix. A
biopsy specimen of the cervical lesion shows
invasive squamous cell carcinoma. Which of the
following is the most significant predisposing
factor for this patient's cervical cancer?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
Alcohol use
Diaphragm and spermicide use
Heredity
Human papillomavirus infection
Obesity
Parity
Type 2 diabetes mellitus
8.
Three weeks after traveling to California to study
desert flowers, a 32-year-old man develops a
fever, chest pain, and sore muscles. Two days
later, red tender nodules appear on the shins, and
the right ankle is painful and tender. An x-ray of
the chest shows a left pleural effusion. Which of
the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
9.
Blastomycosis
Coccidioidomycosis
Histoplasmosis
Mycobacterium marinum infection
Mycoplasma pneumoniae infection
A 55-year-old man who has alcoholic cirrhosis is
brought to the emergency department because he
has been vomiting blood for 2 hours. He has a 2month history of abdominal distention, dilated
veins over the anterior abdominal wall, and
internal hemorrhoids. Which of the following
veins is the most likely origin of the
hematemesis?
(A)
(B)
(C)
(D)
(E)
Inferior mesenteric veins
Left gastric vein
Periumbilical veins
Superior rectal vein
Superior vena cava
24
Appendix 1
10.
A patient being treated with clindamycin for
aspiration pneumonia develops diarrhea. The
stool contains a toxin that kills cultured epithelial
cells. Stool culture grows an anaerobic grampositive rod. The same organism is cultured from
his bedpan. Which of the following is most
likely to sterilize the bedpan?
13.
(A) Boiling for 45 minutes
(B) Exposure to benzalkonium chloride for
1 hour
(C) Exposure to ethyl alcohol for 1 hour
(D) Exposure to saturated steam (121°C) for
15 minutes
(E) Heating in an oven at 150°C for 30
minutes
11.
A 12-year-old boy is brought to the physician by
his father because of redness and swelling of his
left foot for 24 hours. Three days ago, the boy
scraped his foot while wading in a drainage
ditch. Examination of the left foot shows a
purulent abrasion with edema, erythema, and
tenderness on the lateral side. Infection is most
likely to next spread from the lateral side of the
foot to the regional lymph nodes in which of the
following areas?
(A)
(B)
(C)
(D)
(E)
12.
(A) Hematogenous dissemination from the
respiratory tract
(B) New infection from the grandson by the
respiratory route
(C) New infection from the skin of the
grandson
(D) Reactivation of a latent infection from
the patient's dermal dendritic cells
(E) Reactivation of a latent infection from
the patient's dorsal root ganglion
14.
Lateral surface of the thigh
Medial malleolus, posteriorly
Popliteal fossa
Sole of the foot
Superficial inguinal area
A 4-month-old boy is brought to the emergency
department
30 minutes
after
becoming
unresponsive. He has a 1-day history of poor
breast-feeding and vomiting. He is unresponsive
to stimuli. Physical examination shows mild
hepatomegaly.
Serum
studies
show
hypoglycemia and absence of ketones. The
patient becomes responsive following an
intravenous bolus of glucose. Urine studies show
no ketones and increased concentrations of C6
and C8 carbon chain dicarboxylic acids. A
deficiency of which of the following enzyme
activities is the most likely cause of the findings
in this patient?
(A) Fructose-1,6-bisphosphatase
(B) Glucose-6-phosphatase
(C) Medium-chain acyl-CoA
dehydrogenase
(D) Methylmalonyl-CoA mutase
(E) Ornithine carbamoyltransferase
A 72-year-old man comes to the physician
because of sharp pain of his right thorax for 3
days and a rash in a band-like distribution over
his right chest for 1 day. He babysits his 4-yearold grandson who recently developed
chickenpox. Physical examination shows a
vesicular rash in a T8 dermatomal distribution.
Which of the following is the most likely source
of virus in this patient's infection?
Vascular control is studied in an intact hind
extremity of an anesthetized experimental
animal. After a normal control period, the blood
flow to the extremity is completely occluded for
1 minute. When the occlusion is released, blood
flow increases abruptly and exceeds the control
value for several minutes (reactive hyperemia).
After an appropriate recovery period, the
procedure is repeated and the extremity is
actively exercised during the occlusion period.
Which of the following best describes the
reactive hyperemia after the second occlusion
compared with that after the first occlusion?
(A)
(B)
(C)
(D)
15.
Abolished
Decreased but not abolished
Increased
Unchanged
A 30-year-old woman has anxiety about episodes
of abdominal pain that have alternated with
diarrhea and constipation over the past year. She
often has these episodes when she is stressed or
tired. Physical examination and laboratory
studies are within normal limits during these
episodes. Which of the following is the most
likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
Gastroenteritis
Generalized anxiety disorder
Hypochondriasis
Irritable bowel syndrome
Major depressive disorder
Somatization disorder
25
Appendix 1
16.
An investigator is studying the effect of the number of hours watching television (Factor A) on the percent of
hemoglobin A1c in people with type 2 diabetes mellitus. Two different variables, Factor A and hemoglobin A 1c, are
compared. The results of the study indicate a correlation coefficient of +0.9. Which of the following graphs shown
best corresponds to these results?
17.
A 25-year-old woman is brought to the
emergency department 1 hour after she fainted.
She has had mild intermittent vaginal bleeding,
sometimes associated with lower abdominal
pain, during the past 3 days. She has had severe
cramping pain in the right lower abdomen 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 tenderness to palpation in the right lower
quadrant. Bimanual pelvic examination shows a
tender walnut-sized mass in the right
parametrium. Which of the following is the most
likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
Appendicitis
Cancer of the ovary
Ectopic pregnancy
Endometriosis
Ovarian cyst
Placenta previa
18.
A 32-year-old woman with schizophrenia is
brought to the physician because of rapid
heartbeats, sweating, muscle rigidity, and
confusion for 1 day. Medications include
acetaminophen for dysmenorrhea, haloperidol,
and multivitamins. Her temperature is 40.2°C
(104.4°F), pulse is 100/min, respirations are
26/min, and blood pressure is 160/80 mm Hg.
The skin is warm and moist, and the neck is
supple. Funduscopic examination is normal.
Deep tendon reflexes are 2+ without clonus, and
plantar reflexes are normal; there is generalized
muscle
rigidity.
Her
thyroid-stimulating
hormone concentration is 2.8 μU/mL. Which of
the following is the most likely cause of this
patient's condition?
(A)
(B)
(C)
(D)
(E)
Cerebral infarction
Neuroleptic malignant syndrome
Sepsis
Serum triiodothyronine (T 3) toxicosis
Substernal toxic multinodular goiter
26
Appendix 1
19.
A 5-month-old girl has bilateral retinoblastoma. Neither parent has a history of having had retinoblastoma.
Chromosomal analysis of the patient's stimulated peripheral blood lymphocytes is done; the photograph is of a
representative karyotype. Which of the following critical events has most likely resulted from an aberration
involving chromosome 13?
(A)
(B)
(C)
(D)
(E)
20.
Proto-oncogene activation
Proto-oncogene amplification
Proto-oncogene loss
Tumor-suppressor gene activation
Tumor-suppressor gene loss
A 37-year-old man comes to the physician
because of a 6-month history of chest pain that
occurs when he swallows food; he has had a 9kg (20-lb) weight loss during this period. He has
not had heartburn or increased sensitivity in his
hands to cold temperatures. He is 178 cm (5 ft 10
in) tall and now weighs 59 kg (130 lb); BMI is
19 kg/m2. Physical examination shows no
abnormalities. A barium swallow shows
esophageal dilation. Manometry shows a high
resting pressure at the lower esophageal
sphincter; there is little or no decrease in
pressure associated with swallowing. Which of
the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
Achalasia
Esophagitis
Gastric ulcer
Gastroesophageal reflux disease
Hiatal hernia
Systemic sclerosis (scleroderma)
21.
A 4-year-old boy has delayed motor
development and choreoathetosis. He had normal
development at birth. He chews his fingers and
lips, which has resulted in tissue loss. He has
arthritis. Serum and urine uric acid
concentrations are increased. Which of the
following abnormalities is the most likely cause
of these findings?
(A) Adenine phosphoribosyltransferase
deficiency
(B) Hypoxanthine-guanine
phosphoribosyltransferase
deficiency
(C) Increased cellular turnover of nucleic
acids
(D) Increased conversion of hypoxanthine
to inosine monophosphate
(E) Phosphoribosylpyrophosphate
synthetase deficiency
27
Appendix 1
22.
A 2-year-old boy is brought to the emergency department because of shortness of breath and left-sided abdominal
pain for 3 hours. He appears pale. Physical examination shows hypotension and tachycardia. There is splenomegaly
with the spleen tip palpated 8 cm below the left costal margin. Laboratory studies show:
Hemoglobin
Hematocrit
Leukocyte count
Platelet count
5.1 g/dL (N=12.1–14.9)
16% (N=37%–44.4%)
4500/mm3 (N=4000–11,500)
87,000/mm3 (N=150,000–400,000)
A photomicrograph of a Wright-stained peripheral blood smear is shown. Which of the following is the most likely
cause of this patient's current condition?
(A)
(B)
(C)
(D)
(E)
23.
Aplastic crisis
Autoimmune hemolysis
Congestive heart failure
Salmonellal sepsis
Splenic sequestration
A 17-year-old boy comes to the emergency
department because of severe thirst and
weakness and a 4-kg (1.8-lb) weight loss over
the past 36 hours. He began having voluminous
painless watery diarrhea on the airplane while
returning from a trip to Thailand 36 hours ago.
He has not vomited. While supine, pulse is
110/min and blood pressure is 110/60 mm Hg.
While standing, pulse is 170/min and blood
pressure is 70/40 mm Hg. His abdomen is
nontender and bowel sounds are increased.
Which of the following treatments is most
appropriate at this time?
(A)
(B)
(C)
(D)
(E)
(F)
Ciprofloxacin
Doxycycline
Exploratory laparotomy
Potassium chloride
Rehydration
Trimethoprim-sulfamethoxazole
24.
A 58-year-old woman comes to the physician
because of intermittent vaginal bleeding during
the past 3 months. She has been treated with
tamoxifen since having a partial mastectomy and
radiation therapy for a stage II carcinoma of the
left breast 4 years ago. Her last menstrual period
was at the age of 48 years. She has never had an
abnormal Pap smear. Speculum examination
shows no abnormalities. Bimanual examination
shows no abnormal masses. Which of the
following structures is the most likely source of
the bleeding?
(A)
(B)
(C)
(D)
(E)
Cervical canal
Fallopian tube
Ovary
Uterine endometrium
Vagina
28
Appendix 1
25.
A 26-year-old man with HIV infection comes to the physician for a follow-up examination. Six months ago, he had
an acute infection characterized by jaundice. Current medications include zidovudine (AZT), delavirdine, and
ritonavir. Laboratory studies 6 months ago and today show:
Serum
Total bilirubin
ALT
Hepatitis B surface antigen (HBsAg)
Hepatitis B e antigen (HBeAg)
IgM anti-hepatitis B core antigen (anti-HBcAg)
Anti-HBsAg
Anti-HBeAg
Anti-HBcAg
6 Months Ago
Today
2.5 mg/dL
68 U/L
positive
positive
positive
negative
negative
positive
3.5 mg/dL
45 U/L
positive
negative
negative
negative
positive
positive
This patient's infection is most likely to resolve when he develops antibodies to which of the following?
(A)
(B)
(C)
(D)
(E)
26.
A 40-year-old man with a 20-year history of
alcohol abuse is brought to the hospital by his
friends because he was difficult to rouse. He ate
a large meal several hours ago. He is emaciated
and lethargic. Examination shows severely
restricted horizontal eye movements and ataxia
of both upper extremities. The most likely cause
of these findings is a deficiency of which of the
following nutrients?
(A)
(B)
(C)
(D)
(E)
27.
Cytotoxic T lymphocytes
HBcAg
HBeAg
HBsAg
Natural killer cells
Folic acid
Vitamin A
Vitamin B1 (thiamine)
Vitamin B6 (pyridoxine)
Vitamin B12 (cobalamin)
A 20-year-old woman comes to the physician
because of a 5-year history of increasingly
severe, unilateral, throbbing headaches. The
headaches, which are associated with nausea and
occasional vomiting, are exacerbated by loud
noises and last approximately 4 hours. Physical
and neurologic examinations show no
abnormalities. Treatment with which of the
following at the onset of a headache is most
likely to provide pain relief in this patient?
(A)
(B)
(C)
(D)
(E)
28.
A 32-year-old man with non-Hodgkin lymphoma
comes to the physician 6 days after finishing the
initial chemotherapy regimen. His leukocyte
count is 1600/mm3, indicating greater bone
marrow suppression than expected. When
questioned, the patient says that he has been
taking Madagascar periwinkle as an herbal
remedy for his condition. He obtains this
substance from an herbalist. Which of the
following is the most appropriate response by the
physician?
(A) Ask the patient to stop using the herbal
supplement because supplements are
generally ineffective
(B) Continue the patient's chemotherapy
(C) Explain the adverse effects this herbal
supplement has on the patient's
treatment
(D) Report the herbalist to the Food and
Drug Administration
(E) Suggest that the patient take daily
multivitamin and protein
supplements in addition to the
herbal supplement
Amitriptyline
Divalproex
Oxygen
Phenytoin
Sumatriptan
29
Appendix 1
29.
A 10-month-old girl is brought to the physician because of a 2-day history of diarrhea. She can sit unassisted and has
started to crawl. Her mother is concerned because she babbles most of the time she is awake, and she becomes very
upset if her mother leaves the room, "even for just a second." Which of the following best describes the girl's
development?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
30.
Cognitive
Delayed
Delayed
Delayed
Delayed
Normal
Normal
Normal
Normal
Social
delayed
delayed
normal
normal
delayed
delayed
normal
normal
Warfarin is administered to a 56-year-old man
following placement of a prosthetic cardiac
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. In addition
to monitoring prothrombin time, which of the
following actions should the physician take to
maintain adequate anticoagulation?
(A) Begin therapy with vitamin K
(B) Increase the dosage of warfarin
(C) Make no alterations in the dosage of
warfarin
(D) Decrease the dosage of warfarin
(E) Stop the warfarin and change to lowdose aspirin
31.
A 30-year-old woman whose mother and
grandmother have died of carcinoma of the
breast refuses to have mammography. She says
that she knows she is at risk but states, "I hate
having my breasts squashed–it's uncomfortable."
Her physician would like her to have annual
mammograms. Which of the following is most
likely to influence her to agree to
mammography?
Motor
delayed
normal
delayed
normal
delayed
normal
delayed
normal
32.
An otherwise healthy 26-year-old woman has
had petechiae on her legs during the last 24
hours. Laboratory studies show:
Hemoglobin
Hematocrit
Leukocyte count
Neutrophils
Lymphocytes
Monocytes
Mean corpuscular volume
Platelet count
13.1 g/dL
39.7%
8500/mm3
65%
30%
5%
82.2 μm3
20,000/mm3
A peripheral blood smear shows normal red cell
morphology; a bone marrow smear shows
mature megakaryocytic hyperplasia. Which of
the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
Acute megakaryocytic leukemia
Acute myelogenous leukemia
Aplastic anemia
Immune thrombocytopenic purpura
Epstein-Barr viral infection
Papovavirus infection
Thrombotic thrombocytopenic purpura
(A) Exaggerate her risk for breast cancer
(B) Insist that she obtain counseling
regarding unresolved grief
(C) Offer analgesia prior to mammography
(D) Show her photographs of the results of
untreated cancer
(E) Tell her that the therapeutic relationship
will be terminated unless she has
annual mammograms
30
Appendix 1
33.
A 45-year-old woman has a 6-month history of progressive shortness of breath on exertion. She does not smoke.
Pulmonary function findings are shown (values are given as % of predicted normal):
Vital capacity
Forced expiratory volume in 1 second (FEV1)
Diffusing capacity for carbon monoxide
Maximum voluntary ventilation
60
70
50
60
Which of the following most likely explains her limited ability to increase ventilation?
(A)
(B)
(C)
(D)
(E)
34.
A 50-year-old man has had gradually progressive
weakness of the hands during the past year.
Physical examination shows atrophy of the
forearm muscles, fasciculations of the muscles of
the chest and upper extremities, and
hyperreflexia of the lower extremities. A
Babinski sign is present bilaterally. Sensation is
intact. Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)
35.
Airway obstruction
Decreased activation of pulmonary juxtacapillary (J) receptors
Decreased lung compliance
Depression of central chemoreceptors
Depression of peripheral chemoreceptors
Amyotrophic lateral sclerosis
Dementia, Alzheimer type
Guillain-Barré syndrome
Multiple cerebral infarcts
Multiple sclerosis
A 3-month-old male infant is brought to the
physician because of recurrent viral infections
and rashes over his trunk. Lymph nodes are
difficult to detect on physical examination;
imaging studies indicate the lack of a thymus.
Urine deoxyadenosine concentration is 100 times
greater than normal. A peripheral blood smear
shows a marked decrease in both mature B and T
lymphocytes. A deficiency of which of the
following enzymes is most likely in this patient?
(A)
(B)
(C)
(D)
(E)
36.
Adenine phosphoribosyltransferase
Adenosine deaminase
Adenosine kinase
Adenylosuccinate synthetase
Hypoxanthine-guanine
phosphoribosyltransferase
(F) Ribonucleotide reductase
A 35-year-old man who works at a facility
processing highly radioactive substances
accidentally receives a high, whole-body dose of
ionizing
radiation
estimated
to
be
1500 rads (15 gray). He dies 1 week later. At
autopsy, histologic examination of the skin
shows scattered, individual epidermal cells with
shrunken, markedly eosinophilic cytoplasm and
pyknotic, fragmented nuclei. These morphologic
changes most likely indicate which of the
following processes?
(A)
(B)
(C)
(D)
(E)
37.
Apoptosis
Coagulation necrosis
Liquefaction necrosis
Mutagenesis
Tumor initiation
A 73-year-old woman comes to the physician
because of a 2-month history of diffuse weakness
and tingling of her arms and legs. Neurologic
examination shows weakness of the extensor and
flexor muscles of the lower extremities. Knee
and ankle deep tendon reflexes are exaggerated.
Sensation to vibration and position is decreased
in all extremities, but the decrease is more
prominent in the lower extremities than in the
upper extremities. This patient most likely has a
deficiency of which of the following vitamins?
(A)
(B)
(C)
(D)
(E)
Niacin
Vitamin B1 (thiamine)
Vitamin B2 (riboflavin)
Vitamin B6 (pyridoxine)
Vitamin B12 (cyanocobalamin)
31
Appendix 1
38.
A comatose 35-year-old man is admitted to the hospital after being involved in a motorcycle collision. He is
intubated and mechanically ventilated. He dies 8 weeks later. A photomicrograph of tracheal tissue obtained at
autopsy is shown. Which of the following processes best describes these findings?
(A)
(B)
(C)
(D)
(E)
(F)
39.
Atrophy
Dysplasia
Hyperplasia
Hypertrophy
Metaplasia
Neoplasia
A 76-year-old man with a history of prostatic
hypertrophy has the recent onset of increased
difficulty urinating. Symptoms began shortly
after he started taking a nasal decongestant orally
for cold symptoms. Which of the following types
of receptors is most likely to be involved in these
adverse effects?
α1-Adrenergic
β2-Adrenergic
Ganglionic nicotinic
Nicotinic receptor at the neuromuscular
junction
(E) Serotoninergic
(A)
(B)
(C)
(D)
40.
A 26-year-old woman is brought to the
emergency department 3 hours after ingesting
approximately 50 tablets of aspirin in a suicide
attempt. She is nauseated, confused, and sleepy.
Her pulse is 130/min, respirations are 30/min,
and blood pressure is 100/60 mm Hg. Which of
the following sets of laboratory values is most
likely on evaluation of blood obtained before
treatment?
(A)
(B)
(C)
(D)
(E)
Serum
HCO3−
↑
↓
↑
↓
↑
Arterial Blood
pH
PCO2
↓
↑
↓
↓
↑
↓
↓
↑
↑
↑
32
Appendix 1
41.
A 43-year-old woman comes to the physician because she has not had a menstrual period for 3 months. Vital signs
are normal. Examination of the breasts shows expressible galactorrhea bilaterally; there is no tenderness.
Examination of external genitalia shows no abnormalities. The vaginal mucosa is pink and moist. There is a small
cervical os with no lesions, drainage, or tenderness; cervical mucus is consistent with the proliferative phase. The
uterus is small, nontender, and slightly posterior. Examination of the adnexa shows no masses or tenderness. Serum
studies show:
2.1 μU/mL
1.1 μg/dL
20 pg/mL (N=30–400)
1 mIU/mL
1 mIU/mL
60 ng/mL
Thyroid-stimulating hormone
Thyroxine (T4)
Estradiol
Follicle-stimulating hormone
Luteinizing hormone
Prolactin
Which of the following is the most likely cause of the amenorrhea in this patient?
(A)
(B)
(C)
(D)
(E)
42.
A full-term female newborn is examined shortly
after birth. She appears to be small for
gestational age, and she has excess skin on the
nape of the neck and lymphedema of the hands
and feet. Chromosomal analysis shows some
cells with a normal 46,XY karyotype and some
cells with a 45,X karyotype. Which of the
following mechanisms best explains this
cytogenetic abnormality?
(A)
(B)
(C)
(D)
(E)
43.
Adrenal 17α-hydroxylase deficiency
Decreased prolactin release from the pituitary gland
Lesion of the infundibular stalk
Menopause
Pregnancy
C3b deposition
Cytomegalovirus infection
Graft-versus-host disease
Tolerance induction
Type I (immediate) hypersensitivity
A 5-year-old girl is brought to the emergency
department because of fever and severe
abdominal pain. Acute appendicitis is diagnosed.
In the examination room, she keeps her right hip
flexed and resists active extension of the hip. The
inflamed structure associated with these
symptoms is most likely in contact with which of
the following structures?
(A) Abdominal wall and the external
oblique muscle
(B) Obturator internus muscle
(C) Psoas major muscle
(D) Quadratus lumborum muscle
(E) Transversus abdominis muscle
Nondisjunction in mitosis
Reciprocal translocation
Robertsonian translocation
Skewed X-inactivation
Uniparental disomy
A 46-year-old woman receives a non−Tlymphocyte-depleted, allogeneic bone marrow
transplant from a matched, unrelated donor.
Immunosuppressive therapy with cyclosporine is
started. One month later, she has fever. Cytolytic
destruction of the skin, gastrointestinal tract, and
liver is seen, with associated dermatitis, enteritis,
and hepatitis. Which of the following best
explains these findings?
(A)
(B)
(C)
(D)
(E)
44.
45.
A 24-year-old primigravid woman at 28 weeks'
gestation has had nagging headaches, a puffylooking face, and swollen legs for the past week.
Her blood pressure is 180/95 mm Hg; it was
within normal limits earlier in the pregnancy.
Urinalysis shows a protein concentration of 0.6
g/dL. Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)
Acute glomerulonephritis
Congestive heart failure
Eclampsia
Nephrotic syndrome
Preeclampsia
33
Appendix 1
46.
Hospital discharge of a 75-year-old man is delayed due to unavailability of a bed in a nursing home. He is bedridden
and unable to attend to his personal needs. During a 3-day period, his pulse increases from 82/min to 125/min, and
blood pressure decreases from 124/72 mm Hg to 100/55 mm Hg. Laboratory values include:
Hemoglobin
Serum
Urea nitrogen
Glucose
Na+
Creatinine
Day 1
16.4 g/dL
Day 3
18.4 g/dL
18 mg/dL
100 mg/dL
135 mEq/L
1.1 mg/dL
56 mg/dL
89 mg/dL
151 mEq/L
1.2 mg/dL
Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Acute renal failure
Dehydration
Diabetic ketoacidosis
Gastrointestinal hemorrhage
Syndrome of inappropriate ADH (vasopressin)
34
Appendix 1
SAMPLE ITEMS
BLOCK 2, ITEMS 47-92
47.
A 74-year-old man comes to the physician for a
follow-up examination. He has a 3-month history
of severe pain and swelling of the
metacarpophalangeal joints, wrists, elbows, and
knees. Previous treatment with aspirin,
methotrexate, and naproxen has not relieved his
symptoms. He has one kidney. Physical
examination shows no other abnormalities. His
serum rheumatoid factor is increased, and serum
creatinine concentration is 3.8 mg/dL. Which of
the following is the most appropriate
pharmacotherapy?
(A)
(B)
(C)
(D)
(E)
48.
Serum
Glucose
C peptide
Insulin
Cortisol
Urine sulfonylurea
35 mg/dL
0.5 ng/mL (N=0.5–2.5)
20 μU/mL (N=5–20)
10 μg/dL
negative
Which of the following is the most likely site of
a tumor in this patient?
Adrenal cortex
Adrenal medulla
Pancreas
Parathyroid gland
Pituitary gland
Thyroid gland
An 18-year-old female athlete reports easy
fatigability and weakness. Physical examination
shows no abnormalities. Laboratory studies
show:
Serum
Na+
Cl−
K+
HCO3−
Urine
Na+
K+
Acetaminophen
Colchicine
Etanercept
Gold salts
Indomethacin
A previously healthy 32-year-old woman who
works as a nurse comes to the emergency
department because of a 3-week history of
episodes of dizziness, nausea, and profuse
sweating that resolve with eating. She does not
smoke. She drinks four glasses of wine weekly.
Vital signs are within normal limits. Physical
examination shows no abnormalities. While in
the emergency department, she becomes dizzy
and diaphoretic; and her serum glucose
concentration is 45 mg/dL. Laboratory studies
obtained during the episode show:
(A)
(B)
(C)
(D)
(E)
(F)
49.
141 mEq/L
85 mEq/L
2.1 mEq/L
35 mEq/L
80 mEq/24 h
170 mEq/24 h
Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)
50.
Aldosterone deficiency
Anxiety reaction with hyperventilation
Diabetic ketoacidosis
Ingestion of anabolic steroids
Surreptitious use of diuretics
A 15-year-old girl is brought to the physician by
her mother because of an 8-month history of
fatigue; she has had a 6.8-kg (15-lb) weight gain
during this period. The mother states that her
daughter has been depressed for the past
2 months and recently failed a subject in school
because she did not have the energy to complete
a book report. The patient's dog died 3 months
ago. Her mother has major depressive disorder
treated with paroxetine. The patient is 152 cm (5
ft) tall and weighs 68 kg (150 lb); BMI is
29 kg/m2. Her pulse is 50/min, and blood
pressure is 100/50 mm Hg. Physical examination
shows thinning hair and dry skin. Mental status
examination shows a goal-oriented thought
process and a depressed mood. Which of the
following is the most likely cause of these
findings?
(A)
(B)
(C)
(D)
(E)
Adjustment disorder
Bulimia nervosa
Chronic fatigue syndrome
Hypothyroidism
Major depressive disorder
35
Appendix 1
51.
A 68-year-old woman has the sudden onset of weakness in her right arm and leg. She can speak, but her words are
not enunciated clearly. Neurologic examination 6 weeks later shows an extensor plantar reflex on the right. When
she is asked to protrude her tongue, it deviates to the left, and the muscle in the left side of the tongue shows
considerable atrophy. Which of the following labeled areas in the transverse sections of the brain stem is most likely
damaged?
52.
A 6-year-old boy is brought to the physician by
his parents because of a 3-day history of fever,
headache, and cough productive of a green, foulsmelling discharge that also exits from his nose.
He has had repeated episodes of similar
symptoms during the past 4 years. He appears
pale and lethargic. His height and weight are
both below the 10th percentile. Coarse rhonchi
are heard bilaterally. An x-ray of the chest shows
scattered peripheral opacities, dilated and
thickened airways consistent with bronchiectasis,
and a cardiac apex that is directed toward the
right. The most likely cause of his recurrent
infections is a dysfunction of which of the
following cell types?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
(J)
Alveolar capillary endothelial cell
Alveolar macrophage
Chondrocyte
Ciliated columnar epithelial cell
Clara cell
Goblet cell
Kulchitsky cell
Squamous epithelial cell
Type I pneumocyte
Type II pneumocyte
53.
A 76-year-old man comes to the emergency
department because of a 12-hour history of fever
and left lower quadrant abdominal pain. He has
not passed a stool for the past 36 hours. His
temperature is 38.3°C (100.9°F). A tender mass
is palpable in the left lower quadrant of the
abdomen. Stool is negative for occult blood.
Laboratory studies show:
Hemoglobin
Leukocyte count
Platelet count
Serum amylase
Urinalysis
13 g/dL
17,000/mm3
(84% neutrophils)
200,000/mm3
115 U/L
0 to 1 WBC/hpf
An x-ray of the abdomen shows no
abnormalities. The most likely diagnosis is an
acute episode of which of the following
disorders?
(A)
(B)
(C)
(D)
(E)
Cystitis
Diverticulitis
Infectious colitis
Ischemic colitis
Pyelonephritis
36
Appendix 1
54.
A 2-week-old female newborn delivered at term
is brought to the physician by her mother
because of an increasingly severe diaper rash
since birth. No congenital anomalies were noted
after delivery. Physical examination shows a red
and swollen umbilical remnant that has not
separated. There are ulcerations of the skin but
no purulent exudate in the area of the diaper. A
culture of one of the ulcers grows
Staphylococcus aureus. Despite antibiotic
therapy, 1 month later she develops a perirectal
fissure, culture of which grows Escherichia coli
but a smear of which shows scarce segmented
neutrophils. Laboratory studies now show:
Hemoglobin
Hematocrit
Mean corpuscular volume
Leukocyte count
Segmented neutrophils
Bands
Lymphocytes
Monocytes
Platelet count
Serum
IgA
IgG
IgM
12.7 g/dL
38%
98 μm3
89,790/mm3
89%
6%
3%
2%
249,000/mm3
56.
(A)
(B)
(C)
(D)
(E)
57.
92 mg/dL
766 mg/dL
101 mg/dL
55.
Acute myelogenous leukemia
AIDS
Chédiak-Higashi syndrome
Common variable immunodeficiency
Leukocyte adhesion deficiency
A 70-year-old man is brought to the emergency
department by his wife because of fever and
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 is heard.
The diagnosis of bacterial endocarditis is made.
Gentamicin therapy is initiated. This patient is at
increased risk for developing which of the
following as a result of this therapy?
(A)
(B)
(C)
(D)
(E)
Cardiac ischemia
Hearing loss
Hyperglycemia
Lung infection
Torsades de pointes
58.
pH
7.30
7.30
7.40
7.50
7.50
PCO2
(mm Hg)
28
55
40
30
47
HCO3−
(mEq/L)
15
27
24
22
35
A 37-year-old man with pancreatic cancer is
brought to the emergency department because of
fever and muscle aches for 4 days. His
temperature is 39.7°C (103.5°F), and blood
pressure is 70/40 mm Hg. Physical examination
shows no other abnormalities. Blood cultures
grow lactose-positive, motile, gram-negative
rods. Which of the following is the most likely
cause of this patient's hypotension?
(A)
(B)
(C)
(D)
(E)
A peripheral blood smear shows normochromic,
normocytic erythrocytes and leukocytes with
normal morphology. This patient most likely has
which of the following conditions?
(A)
(B)
(C)
(D)
(E)
An 18-year-old woman has gastroenteritis with
nausea and vomiting and is able to ingest only
small amounts of water. After 3 days, she
develops light-headedness, especially when
sitting or standing. Arterial blood gas analysis is
most likely to show which of the following sets
of values?
Endothelial cell cytotoxin
Endotoxin
Hemolysin
Protease
Superantigen
A 23-year-old man who is a graduate student
comes to the physician because of a 3-month
history of anxiety. He says that he has difficulty
completing experiments in the laboratory and
that he often worries about germs. He spends
more than 2 hours daily cleaning his workbench
with 50% hypochlorite solution to reduce his
anxiety. He has persistent intrusive concerns that
he will become infected while working with
Serratia marcescens isolates. He becomes angry
when others use his equipment or workbench.
Physical examination shows no abnormalities.
Which of the following is the most appropriate
pharmacotherapy for this patient?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
Amoxapine
Amoxicillin
Amphetamine
Carbamazepine
Chlorpromazine
Desipramine
Fluoxetine
37
Appendix 1
59.
A 26-year-old man is brought to the emergency department 45 minutes after sustaining multiple injuries in a motor
vehicle collision. His respirations are 16/min. Examination of the right side of the chest shows crepitations,
tenderness to palpation of the ribs, and decreased breath sounds. Chest x-rays confirm several rib fractures, a
pulmonary contusion, and a right pneumothorax. A chest tube is inserted to reinflate the right lung. A contrastenhanced CT scan of the chest is shown. Which of the following labeled structures best identifies the superior vena
cava?
60.
An 8-year-old boy needs to be coaxed to go to
school and, while there, often complains of
severe headaches or stomach pain. His mother
frequently has to take him home because of his
symptoms. At night, he tries to sleep with his
parents. When they insist that he sleep in his own
room, he says that there are monsters in his
closet. Which of the following best explains this
behavior?
62.
(A) Childhood schizophrenia
(B) Normal concerns of latency-age
children
(C) Separation anxiety disorder
(D) Socialized conduct disorder
(E) Symbiotic psychosis
61.
A healthy 19-year-old man receives a tetanus
immunization booster prior to induction into the
US Marines. Six hours later, he has pain and
massive swelling at the site of injection. The
following day, the skin breaks down, forming an
ulcer at the site. Which of the following events
plays a critical role in this reaction?
(A) Accumulation of mononuclear cells at
the site of antigen injection
(B) Antigen capture by Langerhans cells in
the epidermis
(C) Local fixation of complement by
preformed circulating antibodies
(D) Local release of histamine
(E) Predominant synthesis of IgM
antibodies
A 45-year-old man has a left ventricular ejection
fraction of 25% (N>55%) with diffuse
hypokinesis. He has a sedentary lifestyle. He eats
red meat up to 6 times weekly and drinks 4
alcoholic beverages daily. He is 185 cm (6 ft 1
in) tall and weighs 86 kg (190 lb); BMI is 25
kg/m2. His blood pressure is 90/60 mm Hg.
Coronary arteriography shows no evidence of
atherosclerosis. To prevent further heart damage,
which of the following is the most appropriate
recommendation?
(A) Aerobic exercise program
(B) Avoidance of alcohol
(C) Ingestion of more vegetables and
decrease in red meat intake
(D) Isometric/weight-training exercise
program
(E) Weight loss
63.
A full-term 2-week-old male newborn has
cyanosis. Pregnancy and delivery were
uncomplicated. His lungs are clear, and a
midsystolic murmur is heard that is loudest in the
left third intercostal space and associated with a
thrill. Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)
Atrial septal defect
Bicuspid aortic valve
Coarctation of the aorta
Patent ductus arteriosus
Tetralogy of Fallot
38
Appendix 1
66.
A 28-year-old man who had rheumatic fever as a
child comes to the physician's office because of
fatigue and dyspnea for the past 4 months. An
early diastolic sound followed by a low-pitched
rumbling decrescendo diastolic murmur is
present 4 cm left of the sternal border in the
fourth intercostal space and is heard best with the
patient in the left lateral decubitus position.
Which of the following valve defects is most
likely in this patient?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
67.
64.
During an experiment, an investigator finds a
point mutation (CGG→TGG) in the gene
encoding the protein kinase regulatory subunit.
The genetic code is shown in the figure. This
mutation is most likely to alter the amino acid
sequence with which of the following changes?
(A)
(B)
(C)
(D)
(E)
65.
Arg→Trp
Gly→Arg
Gly→Trp
Thr→Gly
Trp→Arg
A 30-year-old man is brought to the emergency
department 30 minutes after being stung by
several wasps. He is confused and has difficulty
breathing. His temperature is 38°C (100.4°F),
pulse is 122/min, respirations are 34/min, and
blood pressure is 80/40 mm Hg. Physical
examination shows dry skin and decreased
capillary refill. There are multiple erythematous,
inflamed marks on the back and 1+ pitting
edema of the ankles. In addition to the
administration of 0.9% saline, the most
appropriate next step in management is
administration of which of the following?
(A)
(B)
(C)
(D)
(E)
(F)
Atropine
Captopril
Epinephrine
Losartan
Methacholine
Whole blood
A 25-year-old man is brought to the emergency
department because of a 1-week history of fever
and cough productive of purulent sputum. His
temperature is 38.9°C (102°F), pulse is 110/min,
respirations are 24/min, and blood pressure is
110/70 mm Hg. Crackles, decreased breath
sounds, and decreased fremitus are present in the
right lower lobe. A chest x-ray shows a pleural
effusion over the lower third of the thorax on the
right in the midscapular line. A thoracocentesis
is scheduled. Which of the following locations in
the midscapular line in this patient would be
most appropriate for insertion of the needle
during this procedure?
(A)
(B)
(C)
(D)
(E)
(F)
68.
Aortic regurgitation
Aortic stenosis
Mitral regurgitation
Mitral stenosis
Pulmonic regurgitation
Pulmonic stenosis
Tricuspid regurgitation
Tricuspid stenosis
Above the 2nd rib
Below the 2nd rib
Above the 5th rib
Below the 5th rib
Above the 9th rib
Below the 9th rib
A 50-year-old woman with a history of ovarian
cancer comes to the physician's office because of
swelling in her right leg for the past month.
Examination shows edema in the right lower
extremity. Which of the following is the most
likely cause of the edema?
(A) Decreased capillary hydrostatic pressure
(B) Decreased interstitial hydrostatic
pressure
(C) Increased capillary oncotic pressure
(D) Increased capillary permeability
(E) Obstruction of lymph vessels
39
Appendix 1
71.
69.
A 47-year-old man comes to the physician
because of a 4-day history of pain in his left foot
that began when he tripped over a curb. He has a
25-year history of type 2 diabetes mellitus.
Examination of the left foot shows tenderness to
palpation of the medial aspect of the left great
toe and a decreased dorsal pedal pulse. The x-ray
shown was taken to detect any fractures. No
fracture is seen, but the arrow indicates
calcification of which of the following
structures?
(A)
(B)
(C)
(D)
(E)
70.
Extensor digitorum longus tendon
First dorsal metatarsal artery
Long plantar ligament
Skin
Sural nerve
A 24-year-old woman who breast-feeds her
infant develops a warm, painful mass and
erythema of the overlying skin in the upper outer
quadrant of the right breast. The pain and redness
resolve with antibiotic therapy. Several months
later, the same area is firm and the overlying skin
is dimpled. Which of the following is the most
likely cause of these findings?
(A)
(B)
(C)
(D)
(E)
Breast abscess with scarring
Fibroadenoma
Fibrocystic change
Infiltrating mammary carcinoma
Traumatic fat necrosis
A previously healthy 36-year-old man comes to
the emergency department 12 hours after the
sudden onset of increasingly severe abdominal
pain. He recently returned from a 3-week sailing
trip around Central America and several
Caribbean islands. His temperature is 38.3°C
(100.9°F), pulse is 96/min, respirations are
18/min, and blood pressure is 130/72 mm Hg.
Abdominal examination shows right lower
quadrant tenderness. His leukocyte count is
12,200/mm3 (70% segmented neutrophils, 6%
bands, 1% eosinophils, 20% lymphocytes, and
3% monocytes). Exploratory laparotomy and an
appendectomy are done. Examination of the
appendix shows multiple mucosal ulcers.
Unicellular microorganisms are seen within the
exudates at the base of the ulcers. Some of the
microorganisms contain erythrocytes. Which of
the following is the most likely source of this
patient's infection?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
72.
Being bitten by a sand fly
Infection from a sexual partner
Mosquito bite
Undercooked freshwater fish
Undercooked saltwater fish
Water contaminated by human feces
Water contaminated by infected snails
A 60-year-old man has a 5-day history of
productive cough and shortness of breath with
exertion. In addition to a normal left lung base,
examination of the chest in the area of the right
lung base shows:
Breath sounds
Percussion note
Tactile fremitus
Adventitious sounds
bronchial
dull
increased
crackles
Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
Asthmatic bronchitis
Bullous emphysema
Chronic bronchitis
Congestive heart failure
Lobar pneumonia
Pleural effusion
Pleuritis
Pneumothorax
Pulmonary embolism
40
Appendix 1
73.
A 10-year-old boy is brought to the emergency department because of vomiting for 6 hours. He has had excessive
thirst and excretion of large amounts of urine for 3 weeks. His pulse is 120/min, and respirations are 32/min.
Physical examination shows sunken eyes and diminished skin turgor. Serum studies show hyperglycemia, ketosis,
and metabolic acidosis. Urine studies show glucose and ketones. Which of the following sets of hepatic findings is
most likely in this patient?
(A)
(B)
(C)
(D)
(E)
(F)
74.
Protein Kinase A
↑
↑
↑
↓
↓
↓
Phosphoprotein
Phosphatase
↑
↓
↓
↑
↓
↓
A 46-year-old man comes to the physician
because of a 2-week history of intermittent
dizziness and difficulty standing up. His
symptoms began after he started treatment with
sildenafil for erectile dysfunction. Physical
examination shows no abnormalities. Which of
the following is the most likely mechanism of
action of sildenafil causing these adverse effects?
76.
(A) Decreased basal vascular smooth
muscle tone
(B) Decreased parasympathetic nerve
activity
(C) Decreased sympathetic nerve activity
(D) Increased basal vascular smooth muscle
tone
(E) Increased parasympathetic nerve
activity
(F) Increased sympathetic nerve activity
75.
A 15-year-old girl is brought to the physician
because of a 3-week history of excessive thirst
and voiding excessive amounts of urine. She
shows no signs of kidney damage, and she is not
taking any medications. Physical examination
shows no abnormalities. She undergoes an 8hour water deprivation test. She is also given
5 units of ADH (vasopressin), subcutaneously.
Under both conditions, she continues to produce
large volumes of dilute urine. Her symptoms are
most likely due to a relative lack of which of the
following proteins from the apical membranes of
collecting duct epithelial cells?
(A)
(B)
(C)
(D)
(E)
Aquaporin
Epithelial Na+ channel
Na+–K+-ATPase
Na+–K+–2Cl− cotransporter
Urea transporter
cAMP
↓
↑
↓
↑
↑
↓
A 37-year-old woman comes to the physician
because of a 2-month history of pain with
movement of her hands and feet. Physical
examination shows warmth and swelling of the
metacarpophalangeal and metatarsophalangeal
joints. Laboratory studies show increased titers
of antibodies to Fc component of IgG and a
negative antinuclear antibody test result. A drug
is prescribed that binds to tumor necrosis factorα (TNF-α) and blocks its interaction with cellsurface TNF receptors. Her symptoms improve
within 1 month. She is most likely receiving
treatment with which of the following drugs?
(A)
(B)
(C)
(D)
(E)
77.
Adalimumab
Anakinra
Gold
Methotrexate
Prednisone
A 6-year-old boy with glioblastoma has a
recurrence of the tumor despite aggressive
treatment. The physician discusses the patient's
prognosis with his parents and recommends
palliative care. The parents ask how they should
talk with their son about his prognosis and
possible death. The physician advises that the
parents should be honest and follow the patient's
lead during the conversation. This patient most
likely has which of the following concepts of
death?
(A)
(B)
(C)
(D)
Being asleep
Being final
Being a long journey
Being a temporary separation from his
parents
(E) No understanding of death
41
Appendix 1
78.
A 25-year-old woman comes to the physician because of a 10-year history of frequent occurrences of fever blisters.
Physical examination shows perioral vesicles. Microscopic examination of culture of scrapings from three vesicles
shows herpes simplex virus 1. Which of the following patterns in the figure shown was most likely observed when
the viral DNA from the cultures was examined by restriction enzyme analysis on polyacrylamide gels?
79.
A 26-year-old man who is HIV positive has a
CD4+ T-lymphocyte count of 250/mm3 (N≥500).
After 5 weeks of therapy with two nucleoside
reverse transcriptase inhibitors and a protease
inhibitor, he feels weak and is easily fatigued.
His hemoglobin concentration has decreased
from 12.8 g/dL to 8.2 g/dL. Which of the
following is the most likely cause of the anemia
in this patient?
(A) Decreased formation of erythrocytes
(B) Folic acid deficiency
(C) Increased formation of erythrocyte
antibodies
(D) Increased fragility of erythrocytes
(E) Iron deficiency
80.
A 9-month-old girl has had two seizures in the
past month. She was born at home and received
no state-mandated newborn screening. She has
developmental delays. Her skin is fair and her
hair is a lighter color than that of other family
members. Her diapers have a musty odor. Which
of the following is most likely to have an
increased concentration in this infant's urine?
(A)
(B)
(C)
(D)
(E)
Homocysteine
Homogentisic acid
Isoleucine
Isovaleric acid
Phenylacetic acid
81.
An 84-year-old woman who resides in an
assisted living facility is brought to the
emergency department because of fever and
cough for 1 week. The cough has been
productive of foul-smelling, yellow-green
sputum for 24 hours. She has a 2-year history of
dementia, Alzheimer type. Her temperature is
38.5°C (101.3°F), pulse is 80/min, respirations
are
20/min,
and
blood
pressure
is
116/66 mm Hg. Coarse inspiratory crackles are
heard over the right lung field. Laboratory
studies show a leukocyte count of 13,500/mm3
(72% segmented neutrophils, 8% bands, 1%
eosinophils, 16% lymphocytes, and 3%
monocytes). A CT scan shows a cavitary lesion
in the superior segment of the right lower lobe.
The lesion has a thick wall and an irregular
peripheral margin; there is no displacement of
the adjacent bronchovascular bundle. Which of
the following is the most likely cause of the lung
lesion in this patient?
(A) Antecedent viral pneumonia
(B) Aspiration of gastric contents
(C) Bronchial obstruction by metastatic
carcinoma
(D) Lung infarction secondary to arterial
thrombosis
(E) Primary carcinoma of the lung
(F) Secondary infection of a congenital
lung cyst
(G) Septic embolism from an
extrapulmonary site
42
Appendix 1
82.
A 6-year-old girl has the sudden onset of
swelling of her face, hands, legs, and feet 1 week
after a viral upper respiratory tract infection. She
is afebrile and normotensive. Laboratory studies
show:
Serum
Albumin
Urea nitrogen
Creatinine
Cholesterol
Urine protein
85.
2.0 g/dL
6.0 mg/dL
0.6 mg/dL
280 mg/dL
4+; 6.0 g/24 h
Which of the following is the most likely
diagnosis?
A 75-year-old man has had increasing shortness
of breath with exertion during the past 2 weeks.
He has a 25-year history of hypertension well
controlled with diuretics. Two months ago,
serum
urea
nitrogen
and
creatinine
concentrations were within the reference ranges.
His pulse is 98/min, respirations are 19/min, and
blood pressure is 180/100 mm Hg. The lungs are
dull to percussion at the bases, and crackles are
heard one third of the way up bilaterally. Cardiac
examination shows increased jugular venous
pressure, an S3 gallop, and no murmur. There is
3+ pitting edema of the lower extremities. Serum
studies show:
Na+
K+
Cl−
HCO3−
Urea nitrogen
Creatinine
(A) Focal glomerulosclerosis
(B) Membranous glomerulonephritis
(C) Membranoproliferative
glomerulonephritis
(D) Minimal change disease
(E) Rapidly progressive glomerulonephritis
126 mEq/L
5.4 mEq/L
108 mEq/L
16 mEq/L
75 mg/dL
3 mg/dL
This patient most likely has which of the
following types of acid-base disturbance?
83.
An 80-year-old man is admitted to the hospital
for treatment of a burn that covers 20% of his
total body surface area. Two days after
admission, his behavior has changed. He accuses
the staff of torturing him. He cannot recall why
he was admitted to the hospital and is not
oriented to date and place. His wife says he was
"fine" before the burn. Which of the following is
the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
84.
Adjustment disorder
Delirium
Paranoid personality disorder
Schizophrenia, paranoid type
Senile onset of dementia, Alzheimer
type
A 30-year-old man with peptic ulcer disease
suddenly develops pain, redness, and swelling of
his right first metatarsophalangeal joint. There is
no history of injury. Serum uric acid
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 this patient?
(A)
(B)
(C)
(D)
(E)
Allopurinol
Colchicine
Morphine
Probenecid
Sulfinpyrazone
(A)
(B)
(C)
(D)
86.
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
A 12-year-old girl is brought to the emergency
department by her parents because of a 3-day
history of fever and a 12-hour history of
lethargy. Her parents say that she has been
sleeping 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 Gram stain shows gram-negative
diplococci. Which of the following is the most
likely causal organism?
(A)
(B)
(C)
(D)
(E)
Haemophilus influenzae
Mycoplasma pneumoniae
Neisseria meningitidis
Salmonella typhi
Streptococcus pneumoniae
43
Appendix 1
87.
A 40-year-old woman receives an intravenous infusion of drug X that selectively constricts the efferent arterioles in
her kidneys. Following the infusion, total cardiac output and renal afferent arteriolar tone are unchanged, but renal
efferent arteriolar tone and total renal vascular resistance have both increased. Which of the following sets of
changes most likely occurred following the infusion of drug X?
Glomerular Filtration Rate
↓
↓
↓
↑
↑
(A)
(B)
(C)
(D)
(E)
88.
Filtration Fraction
↓
↑
↑
↓
↑
One day after a 10-km race, a previously healthy
42-year-old man has dark urine. Urinalysis
shows:
Specific gravity
Dipstick
Glucose
Blood
Nitrates
Microscopic examination
WBC
RBC
1.010
negative
positive
negative
89.
91.
Acute glomerulonephritis
Hypovolemia
Renal infarct
Renal vein thrombosis
Rhabdomyolysis
A 50-year-old woman has had a painless mass in
the parotid gland for the past 8 months. A 2-cm,
discrete, solid mass is found in the parotid gland
on parotidectomy. Histologic examination shows
a neoplastic lesion with uniform epithelial and
myoepithelial cells; these cells form acini,
tubules, and ducts supported by myxoid and
chondroid stroma. Which of the following is the
most likely complication of this type of parotid
lesion?
(A) Contralateral immune-mediated
parotitis
(B) Hematogenous metastases to lungs and
bone
(C) Ipsilateral submaxillary salivary gland
neoplasm
(D) Local recurrence
(E) Regional lymph node metastases
A 52-year-old woman is admitted to the hospital
because of breast cancer metastatic to the liver.
Her prognosis is poor. She begs her husband to
stay with her at the hospital because she is afraid
to be left alone. Which of the following defense
mechanisms best explains her behavior?
(A)
(B)
(C)
(D)
(E)
negative
negative
Which of the following is the most likely cause
of these findings?
(A)
(B)
(C)
(D)
(E)
90.
Renal Blood Flow
↑
↓
↔
↔
↓
A healthy 28-year-old woman comes to the
physician for advice on losing weight. She is 150
cm (4 ft 11 in) tall and weighs 56 kg (124 lb);
BMI is 25 kg/m2. Physical examination shows no
other abnormalities. The physician recommends
a diet that will restrict her daily intake by
500 kilocalories. Which of the following
processes is most likely to increase in this patient
as a result of following this diet?
(A)
(B)
(C)
(D)
(E)
92.
Denial
Displacement
Regression
Repression
Sublimation
Adipocyte glucose uptake
Cerebral ketone utilization
Hepatic lipid oxidation
Muscle glucose uptake
Resting energy expenditure
An 18-year-old woman comes to the physician
for a health maintenance examination. She has
not had major medical illnesses. She takes no
medications. She does not smoke cigarettes,
drink alcohol, or use illicit drugs. Physical
examination shows diffuse brownish yellow
discoloration of all teeth. Which of the following
most likely occurred during childhood to cause
this finding?
(A)
(B)
(C)
(D)
(E)
(F)
Amelogenesis imperfecta
Dentinogenesis imperfecta
Rh incompatibility
Syphilis
Tetracycline use
Vitamin D deficiency
44
Appendix 1
SAMPLE ITEMS
BLOCK 3, ITEMS 93-138
93.
A 29-year-old man is brought to the physician
for removal of a cast from his left leg. He
sustained a fracture of the left lower extremity
6 weeks ago and was immobilized in a cast that
extended from just below the knee to the foot. At
the time of injury, there was severe pain but
normal strength in the extremity. When the cast
is removed today, physical examination shows a
pronounced left footdrop with paresthesia and
sensory loss over the dorsum of the left foot and
lateral leg. Injury to which of the following
nerves is the most likely cause of this patient's
condition?
(A)
(B)
(C)
(D)
(E)
95.
(A) Autoimmune disorder
(B) Defective ion transport at epithelial
surfaces
(C) Disaccharidase deficiency
(D) Inability to synthesize apolipoprotein B
(E) Villous atrophy of the jejunum
Common fibular (peroneal)
Femoral
Obturator
Sciatic
Tibial
96.
94.
A 15-year-old girl who is a ballet dancer has not
had a menstrual period for the past 3 months.
Menses were previously regular at 29-day
intervals. She has lost weight over the past year;
her weight is 70% of that expected for her
height. She is afebrile and has purpuric lesions
on her extremities and trunk. Platelet, absolute
neutrophil, and lymphocyte counts are below the
reference range. She has macrocytic anemia. The
most likely cause of these symptoms is a
deficiency of which of the following nutrients?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
(J)
(K)
(L)
(M)
Folic acid
Iron
Linoleic acid
Magnesium
Niacin
Protein
Vitamin A
Vitamin B6 (pyridoxine)
Vitamin C
Vitamin D
Vitamin E
Vitamin K
Zinc
A 7-month-old infant is brought to the
physician's office because of poor weight gain
despite large food intake. He has had two
episodes of pneumonia and has frequent bulky
stools. He coughs frequently. X-rays of the lungs
show increased markings and hyperinflation.
Trypsin is absent in a fresh stool sample, and the
fat content is increased. Which of the following
is the most likely cause of this infant's disorder?
A 45-year-old man has abnormal circadian
variation in body temperature, disruption of the
sleep-wake cycle, and an impaired nocturnal
surge of secretion of melatonin. An MRI of the
brain is most likely to show a lesion involving
which of the following nuclei?
(A)
(B)
(C)
(D)
(E)
97.
Accessory optic
Lateral preoptic
Pretectal
Suprachiasmatic
Supraoptic
A 33-year-old woman contracts malaria while on
a 3-month business trip to a Central American
country. She is treated with a full course of
chloroquine and recovers uneventfully. Four
months after returning to the USA, she has
another febrile illness that resembles malaria. A
peripheral blood smear shows ring forms in her
erythrocytes. Which of the following species of
Plasmodium is most likely to have caused the
second febrile illness?
(A)
(B)
(C)
(D)
P. falciparum
P. knowlesii
P. malariae
P. vivax
45
Appendix 1
100.
A 75-year-old woman has increasing shortness
of breath on exertion. Findings on physical
examination are unremarkable. X-rays of the
chest show no abnormalities of the heart or
lungs. Pertinent laboratory findings include:
Hematocrit
Hemoglobin
Mean corpuscular volume
28%
9 g/dL
70 μm3
Which of the following is the most likely basis
for these findings?
(A)
(B)
(C)
(D)
(E)
101.
98.
99.
(A)
(B)
(C)
(D)
(E)
B lymphocytes
Eosinophils
Macrophages
Neutrophils
T lymphocytes
NaCl (mmol)
30
90
180
200
Assuming that 1 L of 0.9% saline contains 150
mmol of NaCl and weighs 1 kg, how much will
this patient weigh (in kg) at the end of day 4?
(A)
(B)
(C)
(D)
(E)
Appendicitis
Intussusception
Meckel diverticulum
Necrotizing enterocolitis
Strangulated hernia
A 3-year-old boy has a history of repeated
pyogenic infections. He had normal antibody
responses following childhood immunizations
and normal recovery from chickenpox and
measles. Decreased numbers or functional
defects in which of the following cells best
explains the cause of his infections?
A 70-kg (154-lb) man on a fixed NaCl intake
(200 mmol/day) is given daily injections of a
potent mineralocorticoid hormone for 4 days. He
has free access to water and consumes his usual
caloric intake. Excretion of NaCl is as follows:
Day
1
2
3
4
A 4-year-old girl has the sudden onset of
abdominal pain and vomiting. She has a mass in
the right lower quadrant and hyperactive bowel
sounds. A segment of resected bowel is shown in
the photograph. Which of the following is the
most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Acquired hemolytic anemia
Chronic blood loss
Folic acid deficiency
β-Thalassemia minor
Pernicious anemia
102.
66
68
70
72
74
A 20-year-old man comes to the physician's
office for a scheduled health maintenance
examination. His father died of a myocardial
infarction at age 55 years. Physical examination
shows a tendon xanthoma on the elbow. His
serum total cholesterol concentration is 360
mg/dL. A mutation is most likely to be found in
which of the following genes?
(A)
(B)
(C)
(D)
(E)
apoA2
apoC2
apoE-ε4
LDL receptor
VLDL receptor
46
Appendix 1
105.
A 30-year-old woman comes to the emergency
department because she thinks she has had a
heart attack. One hour ago, she had the sudden
onset of chest pain faintness, pounding heart,
flushed skin, and nausea that lasted 20 minutes.
She now feels better. She has limited her activity
because she has had two similar episodes over
the past 2 weeks. Medical evaluation is normal.
Which of the following is the most appropriate
nonpharmacologic therapy?
(A)
(B)
(C)
(D)
(E)
106.
103.
A 64-year-old man comes to the physician
because of swelling in his feet for the past
2 years. He says that his skin is dry and itchy and
his feet "feel heavy." One of his legs is shown.
Which of the following is the most likely cause
of his condition?
(A) Arteriolar constriction and arteriolar
hypertension
(B) Arteriolar dilation and venous
hypertension
(C) Venous constriction and arteriolar
constriction
(D) Venous hypertension and incompetent
valves
(E) Venous hypertension and venous
constriction
104.
An otherwise healthy 3-week-old boy is brought
to the physician's office because of jaundice and
dark urine for the past 2 weeks. He has
hepatomegaly, and his stools are loose, claycolored, and acholic. Serum conjugated bilirubin
concentration is increased. Which of the
following is the most likely cause of the
hyperbilirubinemia?
(A)
(B)
(C)
(D)
(E)
Assertiveness training
Cognitive behavioral therapy
Dynamic psychotherapy
Psychoanalysis
Psychodrama
A 52-year-old man with recently diagnosed type
2 diabetes mellitus comes to the physician for a
follow-up examination. Physical examination
shows no abnormalities. Laboratory studies show
an increased hemoglobin A1c despite patient
compliance
with
diet
and
exercise
recommendations. Treatment with a sulfonylurea
is started. Which of the following is most likely
to occur in this patient?
(A) Decreased entry of glucose into the
muscle cells
(B) Decreased production of glucose from
the liver
(C) Decreased secretion of insulin from the
pancreas
(D) Decreased speed of carbohydrate
absorption from the intestines
(E) Increased entry of glucose into the
muscle cells
(F) Increased production of glucose from
the liver
(G) Increased secretion of insulin from the
pancreas
(H) Increased speed of carbohydrate
absorption from the intestines
Defect in cholesterol synthesis
Deficiency of glucuronosyltransferase
Hemolysis
Inflammation of the terminal ileum
Obstruction of the biliary system
47
Appendix 1
107.
Investigators are studying the use of a new laboratory test to identify patients with a particular disease. The table
below summarizes the results of initial research involving 200 subjects.
Test Result
Positive
Negative
Present
60
20
80
Disease
Absent
40
80
120
100
100
200
Which of the following is the approximate sensitivity of a positive test result?
(A)
(B)
(C)
(D)
(E)
108.
0.30
0.33
0.60
0.67
0.75
A 48-year-old man has hepatic cancer that is
unresponsive to standard therapy. He enrolls in a
clinical study of a novel chemotherapeutic agent
that, as a side effect, blocks kinesin, a component
of the cellular microtubular transport system.
One week later, he develops skeletal muscle
weakness. An alteration in which of the
following components of the neuromuscular
junction is the most likely cause of the muscle
weakness?
(A) A decrease in the number of
postsynaptic neurotransmitter
receptors
(B) A decrease in the number of presynaptic
neurotransmitter vesicles
(C) A decrease in the presynaptic neuron
calcium permeability
(D) Impaired α-motoneuron action potential
conduction
(E) Impaired skeletal muscle action
potential conduction
109.
After infection with measles virus, a 6-year-old
boy produces antibodies to all eight viral
proteins. The next year he is again exposed to
measles virus. Antibodies to which of the
following viral proteins are most likely to be
protective?
(A)
(B)
(C)
(D)
(E)
Hemagglutinin
Matrix
Nonstructural
Nucleocapsid
Polymerase
110.
A 68-year-old man has had low back pain over
the past 2 months. Laboratory studies show a
normochromic,
normocytic
anemia
and
azotemia.
Serum
and
urine
calcium
concentrations are abnormally increased, and
urinalysis shows excessive protein (4+) and
proteinaceous casts. Bone marrow examination
is most likely to show uncontrolled proliferation
of which of the following cells?
(A)
(B)
(C)
(D)
(E)
111.
Basophils
Lymphocytes
Macrophages
Plasma cells
Reticulocytes
A 32-year-old man is brought to the emergency
department because of multiple nonlethal stab
wounds. He is incarcerated and serving a life
sentence for murder and armed robbery. After
his condition is stabilized, he insists that it is his
"right" to remain in the hospital until he is fully
"cured." He threatens to harm the attending
physician if she endorses his return to prison.
Which of the following is the most likely
diagnosis?
(A) Adjustment disorder with mixed
features
(B) Antisocial personality disorder
(C) Bipolar disorder, manic
(D) Borderline personality disorder
(E) Narcissistic personality disorder
(F) Paranoid personality disorder
(G) Post-traumatic stress disorder
(H) Schizophrenia, paranoid type
48
Appendix 1
112.
A previously healthy 8-month-old boy is brought to the physician because his eyes have been crossed for 6 days. His
mother recalls that her maternal grandfather wore an eye patch. Ophthalmologic examination under general
anesthesia shows a solitary retinal tumor of the right eye approximately 2 optic disc diameters with calcifications
and vitreous seedings. Physical examination shows strabismus and white pupillary reflex in the right eye. Molecular
analysis of the tumor shows two faulty copies of a gene for a protein that serves as an important inhibitor of cellcycle progression. This regulatory protein normally exerts its effect in preventing this uncontrolled growth at which
of the following labeled points in the diagram shown?
113.
A 16-year-old boy is brought to the physician for
a routine examination. He has a lifelong history
of developmental delays and unusual movements
such as hand flapping. He has a meager
vocabulary. Two maternal uncles have mental
retardation. Physical examination shows coarse
facial features and macro-orchidism. DNA
testing shows an expansion of a trinucleotide
repeat. The patient comes from a family of
four daughters. If the parents appear healthy, on
average how many of their daughters are most
likely carriers of this gene mutation?
(A)
(B)
(C)
(D)
(E)
114.
0
1
2
3
4
A 23-year-old woman has a progressive increase
in her serum β-human chorionic gonadotropin
(β-hCG) concentrations during an 8-week
period. A hydatidiform mole is removed, but the
β-hCG concentration continues to increase.
Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)
115.
A 66-year-old man has become increasingly
short-tempered with his wife. He has diarrhea,
weight loss, and weakness in the proximal
muscles. He has atrial fibrillation and
tachycardia. Which of the following is the most
likely diagnosis?
(A)
(B)
(C)
(D)
(E)
116.
Congestive heart failure
Cushing syndrome
Hyperthyroidism
Mitral valve prolapse
Pheochromocytoma
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?
(A)
(B)
(C)
(D)
(E)
Androstenedione
Dihydrotestosterone
Estradiol
Estrone
Testosterone
Adrenal adenoma
Choriocarcinoma
Ectopic pregnancy
Pituitary insufficiency
A second noninvasive mole
49
Appendix 1
117.
A 40-year-old woman comes to the physician because of sluggishness and cold intolerance for 3 months. Five years
ago, she had diffuse thyroid gland enlargement with histology as shown in the photomicrograph. One year later, the
size of the gland had decreased. She has gained 10 kg (22 lb) during the past 5 years. Physical examination now
shows no palpable thyroid gland. Serum studies show:
Thyroid-stimulating hormone
Thyroxine (T4)
Thyroid-peroxidase antibody
On Initial Visit
1 μU/mL
5.5 μg/dL
8 IU/mL (N=0–2)
5 Years Later
10 μU/mL
3.2 μg/dL
9 IU/mL
Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
118.
Chronic autoimmune (Hashimoto) thyroiditis
Diffuse nontoxic goiter
Diffuse toxic goiter (Graves disease)
Follicular carcinoma
Papillary carcinoma
Riedel thyroiditis
Subacute granulomatous thyroiditis
A 55-year-old man is brought to the emergency
department because of a 4-hour history of
temperatures to 39.4°C (103°F). He has
completed four courses of chemotherapy for lung
cancer. Physical examination shows no other
abnormalities.
Combination
intravenous
antibiotic therapy is started, but the patient does
not significantly improve. A chest x-ray shows a
new pulmonary infiltrate. Bronchoalveolar
lavage and a lung biopsy specimen confirm a
diagnosis of aspergillosis. A regimen of
amphotericin B is started. This patient is most
likely to develop which of the following adverse
effects?
(A)
(B)
(C)
(D)
(E)
Dermal necrosis
Liver toxicity
Renal impairment
Retinal damage
Vestibular toxicity
119.
A 63-year-old woman is brought to the physician
because of blurred vision in the right eye for
1 day. She also has had a right-sided headache
for the past week and fever with fatigue for the
past 2 weeks. Physical examination shows a
vessel along the right temple that is nodular and
tender. Histologic examination of the vessel
shows multinucleated histiocytes infiltrating the
wall of a medium-sized artery. Which of the
following is the most appropriate next step in
management?
(A) Administration of a β-adrenergic
blocking agent
(B) Administration of a corticosteroid
(C) Administration of sulfone
(D) Cranial angiography
(E) Surgical removal of the involved vessel
50
Appendix 1
120.
A 63-year-old man with a 5-year history of congestive heart failure comes to the emergency department because of a
1-month history of fatigue and labored breathing. Evaluation shows pulmonary edema. Furosemide is administered.
Which of the following sets of physiologic changes is most likely following administration of the drug?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
121.
A previously healthy 3-month-old boy is brought
to the physician because of a runny nose 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 causal
virus was most likely transmitted by which of the
following routes?
(A)
(B)
(C)
(D)
(E)
122.
Na+–K+–Cl− Transport in the
Thick Ascending Loop of Henle
↑
↑
↑
↑
↓
↓
↓
↓
123.
Blood transfusion
Ingestion of contaminated formula
Inoculation onto mucous membranes
Insect bite
Transplacental transfer
A 40-year-old woman comes to the physician
because of pain in the region of her left jaw, leftsided earache, and headache for 3 days. The
patient has not had any trauma to her face or jaw
but says she often grinds her teeth. She is
concerned because she is a singer, and it is
painful when she opens her mouth wide to sing.
There is also a clicking sound when she opens
her mouth. Physical examination shows the left
side of the jaw deviating slightly to the left on
elevation. The area around the left mandibular
condyle is painful on palpation. Mandibular
depression is difficult to perform because of
pain. This movement also elicits an audible
clicking sound. There is tightness indicative of a
muscle spasm along the left mandibular ramus.
Palpation shows no other area of tightness.
Spasms of which of the following muscles are
most likely associated with this condition?
(A)
(B)
(C)
(D)
(E)
Osmolarity of the
Medullary Interstitium
↑
↑
↓
↓
↑
↑
↓
↓
A 30-year-old woman with a 1-week history of
severe diarrhea feels dizzy when she stands up.
Blood pressure (while supine) is 112/76 mm Hg
with a pulse of 88/min; blood pressure (while
standing) is 80/60 mm Hg with a pulse of
120/min. In addition to controlling her diarrhea,
the most appropriate initial therapy is
intravenous administration of which of the
following?
(A)
(B)
(C)
(D)
(E)
(F)
124.
Water Absorption in the
Descending Loop of Henle
↑
↓
↑
↓
↑
↓
↑
↓
Desmopressin
5% Dextrose in water
Fresh frozen plasma
0.9% Saline
Methoxamine
Verapamil
A 30-year-old man comes to the clinic because
of a painful ulcer on his penis for the past week.
He has had multiple sexual partners, including
commercial sex workers. Physical examination
shows lymphadenopathy in the inguinal region
and a 1-cm tender ulcer with no induration
located on the frenulum. A culture of the ulcer
grows colonies on supplemented chocolate agar.
A Gram stain of the colonies shows gramnegative coccobacilli. Which of the following is
the most likely causal organism?
(A)
(B)
(C)
(D)
(E)
Haemophilus ducreyi
Herpes simplex virus
Neisseria gonorrhoeae
Treponema pallidum
Trichomonas vaginalis
Buccinator
Masseter
Mylohyoid
Posterior belly of the digastric
Superior pharyngeal constrictor
51
Appendix 1
125.
A 25-year-old man is started on clozapine for
schizophrenia, paranoid type. He had been
unsuccessfully treated for the past 2 months with
haloperidol. The patient should be monitored for
which of the following adverse effects?
(A)
(B)
(C)
(D)
(E)
126.
128.
Decreased erythrocyte count
Decreased leukocyte count
Decreased platelet count
Increased eosinophil count
Increased hemolysis
(A) Cardiac tamponade
(B) Embolus to the right middle cerebral
artery
(C) Necrosis of the myocardium
(D) Rupture of the papillary muscle
(E) Ventricular fibrillation
A 74-year-old man has had confusion for 2
weeks. He has smoked two packs of cigarettes
daily for 50 years. An x-ray of the chest shows a
5-cm mass in the lung. Laboratory studies of
serum show:
129.
Na+
Cl−
K+
HCO3−
Glucose
Creatinine
110 mEq/L
72 mEq/L
4.5 mEq/L
30 mEq/L
200 mg/dL
1.4 mg/dL
Which of the following is the most likely cause
of these findings?
(A) Adenocarcinoma of the lung
(B) Craniopharyngioma
(C) Medullary carcinoma of the thyroid
gland
(D) Renal cell carcinoma
(E) Small cell carcinoma of the lung
127.
A 6-week-old male infant is brought to the
emergency department because of a swollen
abdomen. He is refusing to eat and has not had a
bowel movement for 3 days. His mother says
that he had constipation since birth and was kept
in the hospital an extra day after birth because of
delayed passage of stool. Physical examination
shows abdominal distention. An x-ray of the
abdomen shows distended loops of proximal
bowel with an abrupt narrowing to a small
caliber of the distal 15-cm segment of colon.
Which of the following pathologic findings is
most likely in a biopsy specimen of the distal
rectum in this patient?
(A)
(B)
(C)
(D)
(E)
Absent myenteric ganglion cells
Abundant inspissated mucus
Hypertrophy of the muscle wall
Nodular lymphoid hyperplasia
Transmural coagulative necrosis
A 72-year-old man collapses while playing golf.
He has a 5-year history of angina and type 2
diabetes mellitus. Paramedics arrive in 10
minutes. Examination shows no respirations or
blood pressure; an ECG shows asystole.
Cardiopulmonary resuscitation is attempted for
10 minutes without success. Which of the
following is the most likely cause of death in this
patient?
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 hours after the
overdose but felt better the following day. At this
time, he has jaundice and pain in the right upper
quadrant. Which of the following drugs is most
likely to have caused the pain, vomiting, and
jaundice?
(A)
(B)
(C)
(D)
(E)
130.
Acetaminophen
Aspirin
Cimetidine
Diphenhydramine
Triazolam
A previously healthy 48-year-old man comes to
the physician because of fever and cough for 2
days. He attended a convention 10 days ago, and
two of his friends who stayed in the same hotel
have similar symptoms. His temperature is
38.3°C (101°F), pulse is 76/min, respirations are
20/min, and blood pressure is 130/70 mm Hg.
Crackles are heard over the right lung base. A
chest x-ray shows a patchy infiltrate in the right
lower lobe. A Gram stain of sputum shows
segmented neutrophils and small gram-negative
rods that stain poorly. A sputum culture grows
opal-like colonies on yeast extract. Which of the
following is the most likely causal organism?
(A)
(B)
(C)
(D)
(E)
Campylobacter jejuni
Eikenella corrodens
Legionella pneumophila
Proteus mirabilis
Pseudomonas aeruginosa
52
Appendix 1
131.
A 12-year-old girl is admitted to the hospital
because of marked shortness of breath, an
erythematous rash, and painful, swollen hip and
knee joints. She is agitated. A chest x-ray shows
an enlarged heart and changes consistent with
pulmonary edema. Intractable congestive heart
failure develops, and she dies on the second
hospital day. This child most likely had a recent
history of which of the following?
(A)
(B)
(C)
(D)
(E)
132.
133.
(A)
(B)
(C)
(D)
(E)
135.
AIDS-associated gastroenteritis
Amebiasis
Crohn disease
Clostridium difficile-associated colitis
Escherichia coli-associated colitis
Ischemic colitis
Salmonella gastroenteritis
Ulcerative colitis
A 29-year-old woman comes to the physician for
a consultation 1 month after her 7-year-old
daughter was killed in a motor vehicle collision.
The patient is upset and restless and wrings her
hands frequently. She cannot sleep at night, has
lost her appetite, and cries easily and frequently.
She is preoccupied with thoughts of her daughter
and sometimes thinks she momentarily sees her
daughter sitting in the living room. She says she
wishes that she had been hit by the car, too. She
denies any thoughts of killing herself. Which of
the following is the best explanation for these
findings?
Dysthymic disorder
Major depressive disorder
Normal grief reaction
Obsessive-compulsive disorder
Schizoaffective disorder
A 2-year-old girl is brought to the emergency
department because of pain in her right forearm
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?
(A)
(B)
(C)
(D)
(E)
Cyanosis with chest pain
Jaundice
Meningitis
Pharyngitis
Skin infection
A 21-year-old man has weight loss and severe
intermittent bloody diarrhea. A barium enema
and colonoscopy show multiple ulcers and
inflammatory changes extending from the rectum
to the mid-transverse colon. Biopsy specimens
taken from multiple sites show acute and chronic
inflammation restricted to the mucosa. Which of
the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
134.
A 25-year-old man comes to the physician
because of progressive weakness and an
increasingly protuberant abdomen during the
past 3 years. Physical examination shows
splenomegaly. His hematocrit is 28%, and
platelet count is 20,000/mm3. A biopsy specimen
of bone marrow shows accumulation of lipidladen macrophages. Glucocerebroside has
accumulated in the patient's reticuloendothelial
cells (macrophage system). Inheritance of mutant
alleles most likely caused impairment of which
of the following enzyme activities in this
patient?
(A)
(B)
(C)
(D)
(E)
(F)
136.
Calcitonin
Collagen, type I
1α-Hydroxylase
Parathyroid hormone
Vitamin D receptor
Ceramidase
α-Galactosidase
β-Glucosidase
Hexosaminidase
α-L-Iduronidase
Sphingomyelinase
A 95-year-old woman in a nursing home has had
advanced vascular dementia, severe dysphagia,
and a 9-kg (20-lb) weight loss over the past 2
months. Her four children are divided regarding
the decision to provide artificial feeding through
a gastrostomy tube. There is no living will. The
oldest son approaches the physician after a
family meeting and says, "You should simply
decide what is best for her and tell the others
that's what we should do." Assuming the
physician proceeds in this manner, which of the
following best describes the physician's action?
(A)
(B)
(C)
(D)
(E)
Paternalism
Preserving fairness in use of resources
Protecting patient autonomy
Rationing care
Truth-telling
53
Appendix 1
137.
A 16-year-old girl is brought to the emergency
department after attempting suicide by cutting
her wrist. The deepest part of the wound is
between the tendons of the flexor carpi radialis
and the flexor digitorum superficialis. This
patient is most likely to have a deficit of which
of the following?
(A)
(B)
(C)
(D)
Adduction and abduction of the fingers
Extension of the index finger
Flexion of the ring and small fingers
Sensation over the base of the small
finger
(E) Opposition of the thumb and other
fingers
138.
A 12-year-old girl with sickle cell disease has
pain in her right arm. An x-ray of the right upper
extremity shows bony lesions consistent with
osteomyelitis. Which of the following is the most
likely causal organism?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
Clostridium septicum
Enterococcus faecalis
Listeria monocytogenes
Proteus mirabilis
Pseudomonas aeruginosa
Salmonella enteritidis
Serratia marcescens
54
Appendix 1
Answer Form for Step 1 Sample Questions
Block 1 (Questions 1-46)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
___
___
___
___
___
___
___
___
___
___
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
___
___
___
___
___
___
___
___
___
___
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
___
___
___
___
___
___
___
___
___
___
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
___
___
___
___
___
___
___
___
___
___
41.
42.
43.
44.
45.
46.
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
87.
88.
89.
90.
91.
92.
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
133.
134.
135.
136.
137.
138.
___
___
___
___
___
___
Block 2 (Questions 47-92)
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
___
___
___
___
___
___
___
___
___
___
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
___
___
___
___
___
___
___
___
___
___
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
___
___
___
___
___
___
___
___
___
___
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
Block 3 (Questions 93-138)
93.
94.
95.
96.
97.
98.
99.
100.
101.
102.
___
___
___
___
___
___
___
___
___
___
103.
104.
105.
106.
107.
108.
109.
110.
111.
112.
___
___
___
___
___
___
___
___
___
___
113.
114.
115.
116.
117.
118.
119.
120.
121.
122.
___
___
___
___
___
___
___
___
___
___
123.
124.
125.
126.
127.
128.
129.
130.
131.
132.
55
Appendix 1
Answer Key for Step 1 Sample Questions
Block 1 (Questions 1-46)
1. D
2. E
3. E
4. E
5. A
6. A
7. D
8. B
9. B
10. D
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
C
C
E
C
D
A
C
B
E
A
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
B
E
E
D
D
C
E
C
H
D
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
C
D
C
A
B
A
E
E
A
B
41.
42.
43.
44.
45.
46.
C
A
C
C
E
B
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
B
A
A
E
B
D
B
B
A
C
87.
88.
89.
90.
91.
92.
E
E
D
C
C
E
123. D
124. A
125. B
126. E
127. A
128. E
129. A
130. C
131. D
132. H
133.
134.
135.
136.
137.
138.
C
B
C
A
E
F
Block 2 (Questions 47-92)
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
C
C
E
D
B
D
B
E
B
E
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
B
G
E
C
C
B
E
A
C
D
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
E
E
B
A
F
E
B
A
A
A
Block 3 (Questions 93-138)
93. A
94. A
95. B
96. D
97. D
98. B
99. D
100. B
101. D
102. D
103. D
104. E
105. B
106. G
107. E
108. B
109. A
110. D
111. B
112. D
113. C
114. B
115. C
116. B
117. A
118. C
119. B
120. H
121. C
122. B
56
Appendix 2
Constructing Written Test Questions
For the Basic and Clinical Sciences
Third Edition
(Revised)
National Board of Medical Examiners
3750 Market Street
Philadelphia, PA 19104
Appendix 2
The Basic Rules for One-Best-Answer Items
•
Each item should focus on an important concept, typically a common or potentially catastrophic clinical problem.
Don’t waste testing time with questions assessing knowledge of trivial facts. Focus on problems that would be
encountered in real life. Avoid trivial, “tricky,” or overly complex questions.
•
Each item should assess application of knowledge, not recall of an isolated fact. The item stems may be relatively long; the options should be short. Clinical vignettes provide a good basis for a question. For the clinical sciences,
each should begin with the presenting problem of a patient, followed by the history (including duration of signs and
symptoms), physical findings, results of diagnostic studies, initial treatment, subsequent findings, etc. Vignettes may
include only a subset of this information, but the information should be provided in this specified order. For the basic
sciences, patient vignettes may be very brief; “laboratory vignettes” are also appropriate.
•
The stem of the item must pose a clear question, and it should be possible to arrive at an answer with the options
covered. To determine if the question is focused, cover up the options and see if the question is clear and if the examinees can pose an answer based only on the stem. Rewrite the stem and/or options if they could not.
•
All distractors (ie, incorrect options) should be homogeneous. They should fall into the same category as the correct answer (eg, all diagnoses, tests, treatments, prognoses, disposition alternatives). Rewrite any dissimilar distractors. Avoid using “double options” (eg, do W and X; do Y because of Z) unless the correct answer and all distractors are double options. Rewrite double options to focus on a single point. All distractors should be plausible,
grammatically consistent, logically compatible, and of the same (relative) length as the correct answer. Order the
options in logical order (eg, numeric), or in alphabetical order.
•
Avoid technical item flaws that provide special benefit to testwise examinees or that pose irrelevant difficulty.
Do NOT write any questions of the form “Which of the following statements is correct?” or “Each of the following statements is correct EXCEPT.” These questions are unfocused and have heterogeneous options.
Subject each question to the five “tests” implied by the above rules. If a question passes all five, it is probably well-phrased
and focused on an appropriate topic.
33
Appendix 2
Chapter 4
Item Content:
Testing Application of Basic Science Knowledge
™
Item Content for the Basic Sciences
Traditionally, items are classified by the cognitive processes required to answer the question (eg, recall, interpretation, or problem solving; memory, comprehension, or reasoning). Recall items are thought to test examinees’ knowledge of isolated facts.
Interpretation items require examinees to review some information (often in tabular or graphical form) and reach some conclusion (eg, a diagnosis). Problem-solving items present a situation and require examinees to take some action (eg, the next
step in patient management). Interpretation and problem-solving items are thought to involve “higher order” skills, rather than
just rote memory of factual information.
Unfortunately, the cognitive processes required to answer an item are often difficult to determine, because they are as dependent on the background of the examinee as they are on the item content. For example, an item concerning blood flow in a
patient with ventricular septal defect might require simply recall with little or no conscious thought from a pediatric cardiologist or cardiovascular physiologist, but a typical Step 1 examinee might have to reason out the answer from basic principles of hemodynamics. The cognitive processes involved in responding to a question vary by examinee, making this taxonomic approach difficult to use.
A simpler, more objective approach bases item classification on the task of the examinee. If an item requires an examinee
to reach a conclusion, make a prediction, or select a course of action, it should be classified as an application of knowledge
item. If an item tests only rote memory for isolated facts (without requiring their application), it should be classified as a
recall item. All items should require application of knowledge, allowing assessment of both an examinee’s information base
plus ability to use that information.
Chapter 4. Item Content: Testing Application of Basic Science Knowledge
35
Appendix 2
The following pair of item stems illustrate the difference between a question assessing recall of an isolated fact and a question assessing application of knowledge.
Basic Science Recall Item Stem:
What area is supplied with blood by the posterior inferior cerebellar artery?
Basic Science Application of Knowledge Item Stem:
A 62-year-old man develops left-sided limb ataxia, Horner’s syndrome, nystagmus, and loss of appreciation of facial
pain and temperature sensations. What artery is most likely to be occluded?
It is common to use clinical vignettes as item stems to assess application of basic science knowledge to interpret clinical situations. For example, instead of asking examinees to identify the muscles innervated by a cranial nerve, provide a set of
physical findings and ask examinees to identify the most likely site of the lesion. Instead of asking for a description of respiratory acidosis or alkalosis, provide values for arterial blood gases (and other patient findings as needed) and ask examinees to identify the most likely pathophysiologic explanation. Make sure that examinees can answer the question based on
an understanding of basic science; experience in patient care should not be necessary.
“Lab vignettes” can also be useful in preparing items that test application of knowledge. These items present lab experiments and require examinees to use their understanding of basic science principles to predict or explain the results. The
vignettes may describe classic experiments in a basic science area, or they may involve less well-known or hypothetical situations. Such items effectively shift the focus of assessment from knowledge of isolated facts to use of basic science principles to solve problems.
Use of patient and lab vignettes to assess application of knowledge has several benefits. First, the “face validity” of the exam is
greatly enhanced by using “problem-solving” items. Second, items are more likely to focus on important information, rather than
trivia. Third, it helps to identify those examinees who have memorized a substantial body of factual information, but are unable
to use that information effectively.
36
Appendix 2
Guidelines for Basic Science Item Content
• Test application of knowledge using experimental and clinical vignettes
• Focus items on key concepts and principles that are essential information (without access to references) for all
examinees to understand
• Test material that is relevant to learning in clinical clerkships, postgraduate medical education, and beyond
• Avoid items that only require recall of isolated facts
• Avoid esoteric or interesting topics that are not essential
These two items were written to assess the same topic. We recommend that questions be written like the second item, not the
first one.
Acute intermittent porphyria is the result of a defect in
the biosynthetic pathway for
A. collagen
B. corticosteroid
C. fatty acid
D. glucose
*E. heme
F. thyroxine (T4)
An otherwise healthy 33-year-old man has mild weakness and occasional episodes of steady, severe abdominal pain with some cramping but no diarrhea. One
aunt and a cousin have had similar episodes. During
an episode, his abdomen is distended, and bowel
sounds are decreased. Neurologic examination shows
mild weakness in the upper arms. These findings suggest a defect in the biosynthetic pathway for
A. collagen
B. corticosteroid
C. fatty acid
D. glucose
*E. heme
F. thyroxine (T4)
Chapter 4. Item Content: Testing Application of Basic Science Knowledge
37
Appendix 2
Item Templates
The overall structure of an item can be depicted by an item template. You can typically generate many items using the same
template. For example, the following template could be used to generate a series of questions related to gross anatomy:
A (patient description) is unable to (functional disability). Which of the following is most
likely to have been injured?
This is a question that could be written using this template:
A 65-year-old man has difficulty rising from a seated position and straightening his trunk, but he has no difficulty
flexing his leg. Which of the following muscles is most likely to have been injured?
*A. Gluteus maximus
B. Gluteus minimus
C. Hamstrings
D. Iliopsoas
E. Obturator internus
Many basic science questions can be presented within the context of a patient vignette. The patient vignettes may include
some or all of the following components:
Age, Gender (eg, A 45-year-old man)
Site of Care (eg, comes to the emergency department)
Presenting Complaint (eg, because of a headache)
Duration (eg, that has continued for 2 days).
Patient History (with Family History ?)
Physical Findings
+/- Results of Diagnostic Studies
+/- Initial Treatment, Subsequent Findings, etc.
38
Appendix 2
Additional Templates
A (patient description) has a (type of injury and location). Which of the following structures is most likely to be affected?
A (patient description) has (history findings) and is taking (medications). Which of the following medications is the most likely cause of his (one history, PE or lab finding)?
A (patient description) has (abnormal findings). Which [additional] finding would suggest/suggests a diagnosis of (disease
1) rather than (disease 2)?
A (patient description) has (symptoms and signs). These observations suggest that the disease is a result of the (absence or
presence) of which of the following (enzymes, mechanisms)?
A (patient description) follows a (specific dietary regime). Which of the following conditions is most likely to occur?
A (patient description) has (symptoms, signs, or specific disease) and is being treated with (drug or drug class). The drug acts
by inhibiting which of the following (functions, processes)?
A (patient description) has (abnormal findings). Which of the following (positive laboratory results) would be expected?
(time period) after a (event such as trip or meal with certain foods), a (patient or group description) became ill with (symptoms
and signs). Which of the following (organisms, agents) is most likely to be found on analysis of (food )?
Following (procedure), a (patient description) develops (symptoms and signs). Laboratory findings show (findings). Which
of the following is the most likely cause?
A (patient description) dies of (disease). Which of the following is the most likely finding on autopsy?
A patient has (symptoms and signs). Which of the following is the most likely explanation for the (findings)?
A (patient description) has (symptoms and signs). Exposure to which of the (toxic agents) is the most likely cause?
Which of the following is the most likely mechanism of the therapeutic effect of this (drug class) in patients with (disease)?
A patient has (abnormal findings), but (normal findings). Which of the following is the most likely diagnosis?
See Appendix B for additional examples.
Chapter 4. Item Content: Testing Application of Basic Science Knowledge
39
Appendix 2
Types of Questions
Guess my drug
Guess my toxic exposure
Guess my diet
Guess my mood
Predict physical findings
Predict lab findings
Predict sequelae
Identify underlying cause/diagnosis
Identify cause of drug responses
Identify drug to administer
Sample Lead-ins and Option Lists
Which of the following is (abnormal)?
Options sets could include sites of lesions; list of nerves; list of muscles; list of enzymes; list of hormones; types of cells;
list of neurotransmitters; list of toxins, molecules, vessels, spinal segments.
Which of the following findings is most likely?
Options sets could include list of laboratory results; list of additional physical signs; autopsy results; results of microscopic examination of fluids, muscle or joint tissue; DNA analysis results; serum levels.
Which of the following is the most likely cause?
Options sets could include list of underlying mechanisms of the disease; medications that might cause side effects; drugs
or drug classes; toxic agents; hemodynamic mechanisms, viruses, metabolic defects.
Which of the following should be administered?
Options sets could include drugs, vitamins, amino acids, enzymes, hormones.
Which of the following is defective/deficient/nonfunctioning?
Options sets could include list of enzymes, feedback mechanisms, endocrine structures, dietary elements, vitamins.
Given the pedigree, what is the likelihood that the next child (specify gender) will have the disease?
40
Appendix 2
Writing the Options: Altering Item Difficulty
The incorrect options in each question are called distractors.
Each distractor should be selected by some examinees; therefore, each distractor should be plausible and none should
stand out as being obviously incorrect. Common misconceptions and faulty reasoning provide a good source of plausible distractors. Distractors directly affect the difficulty of a
question. Consider the question to the right.
Who was the primary author of the Declaration of
Independence?
A. Abraham Lincoln
B. Thomas Jefferson
C. Franklin Roosevelt
D. King George II
E. Catherine the Great
In the example above, the options are quite divergent and Thomas Jefferson is easily identified as the correct answer. Someone who knows relatively little about American history could answer this correctly.
Now consider the same question with a different set of options.
In this example, the question becomes more difficult; the
options are all plausible answers to someone who has limited
knowledge. For some content areas, options like those in the
first example might be appropriate; for others, those in the second example are more appropriate.
Who was the primary author of the Declaration of
Independence?
A. George Washington
B. Thomas Jefferson
C. Alexander Hamilton
D. Benjamin Franklin
E. James Madison
When writing your options, make sure that they are:
• Homogeneous in content (eg, all are diagnoses; all are next steps in patient care)
• Incorrect or inferior to the correct answer
• Plausible and attractive to the uninformed
• Similar to the correct answer in construction and length
• Grammatically consistent and logically compatible with the stem
Chapter 4. Item Content: Testing Application of Basic Science Knowledge
41
Appendix 2
Item Shape
An appropriately shaped item includes as much of the item as possible in the stem; the stem should be relatively long and
the options should be relatively short. The stem should include all relevant facts; no additional data should be provided in
the options.
Appropriately Shaped Item:
Long Stem
A.
B.
C. Short Options
D.
E.
Poorly Shaped Item:
Short Stem
A.
B.
C. Long Options
D.
E.
42
Appendix 3
National Board of
Medical Examiners
Of the United States of America
___________________________________________________________________________________________
SUBJECT EXAMINATIONS
Content Outlines and Sample Items
Basic Sciences – Paper and Web Versions
Comprehensive Basic Science – Paper and Web Versions
Clinical Science – Paper Version only
Comprehensive Clinical Science – Paper Version only
Introduction to Clinical Diagnosis – Paper and Web Versions
___________________________________________________________________________________________
March 2010
Appendix 3
TABLE OF CONTENTS
Basic Science Subject Examinations*
Behavioral Sciences
1
Biochemistry
8
Gross Anatomy and Embryology
14
Histology and Cell Biology
20
Microbiology
26
Neuroscience
32
Pathology
38
Pharmacology
44
Physiology
50
Clinical Science Subject Examinations
Clinical Neurology
56
Family Medicine
63
Medicine
70
Obstetrics & Gynecology
77
Pediatrics
83
Psychiatry
90
Surgery
97
Introduction to Clinical Diagnosis Subject Examinations*
103
Comprehensive Subject Examinations
Comprehensive Basic Science Examination*
109
Comprehensive Clinical Science Examination
*Exams available in the web format
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
115
Appendix 3
BEHAVIORAL SCIENCES
Progression through life cycle
Psychological and social factors influencing patient behavior
Patient interviewing, consultation, and interactions with the family
Medical ethics, jurisprudence, and professional behavior
Nutrition including vitamin deficiencies and eating disorders
1%B5%
5%B10%
10%B15%
5%B10%
1%B5%
Central & peripheral nervous systems
Normal processes (brain stem, brain, motor systems,
autonomic nervous systems)
Psychopathologic disorders
Principles of therapy and pharmacodynamic
general principles
50%B55%
5%B10%
30%B40%
5%B10%
Gender, ethnic, and behavioral considerations affecting
disease treatment and prevention (including psychosocial,
cultural, occupational, and environmental)
1.
A 50-year-old man develops difficulty walking while receiving
drug therapy for paranoid behavior. Physical examination
shows masked facies and diffuse muscle rigidity. He is slow in
initiating movement and walks with a shuffling narrow-based
gait. Which of the following drugs is the most likely cause of
these findings?
(A)
(B)
(C)
(D)
(E)
2.
Barbiturate
Benzodiazepine
Monoamine oxidase inhibitor
Phenothiazine
Tricyclic compound
A 24-year-old man is brought to the emergency department by
his mother after barricading himself in his apartment. For 8
months, he has believed that aliens follow him and control his
mind. He was fired from his part-time job 6 months ago
because of unusual behavior. There are no other apparent
psychosocial stressors. His paternal grandmother has major
depressive disorder. He does not use drugs, but his mother
states that he frequently drinks beer. There is no disturbance of
mood, sleep, or appetite. Examination shows an extremely
agitated and suspicious patient. There is a 1 x 1-cm abrasion in
the right frontal area. His blood alcohol concentration is
0.5 mg/dL, and serum γ-glutamyltransferase (GGT) activity is
40 U/L (N=5–50). Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)
3.
Alcohol-induced mood disorder
Bipolar disorder, manic
Brief psychotic disorder
Schizoaffective disorder
Schizophrenia, paranoid type
5%B10%
A 43-year-old woman is brought to the emergency
department 1 hour after a stranger stole her purse. She is
agitated and extremely upset. She is 163 cm (5 ft 4 in) tall
and weighs 91 kg (200 lb); BMI is 34 kg/m2. Physical
examination shows no other abnormalities. Her blood glucose
concentration is increased. Which of the following is the most
likely explanation for this finding?
(A)
(B)
(C)
(D)
(E)
4.
β-Cell hypersecretion
Cushing disease
Glucagon-secreting adenoma
Pancreatitis
Normal stress hormone response
A 4-year-old girl is brought to the physician by her mother
because of a fever for 1 day. The physician is more than 1
hour behind schedule because of two patient emergencies
earlier that day. When he enters the room, the mother yells,
"Do you know how long we've had to wait? This is totally
unacceptable!" It is most appropriate for the physician to
initially state which of the following?
(A) "I am frustrated, too, with being so far behind
schedule."
(B) "I hope my staff explained about the difficult
patients who caused the delay."
(C) "It must have been very difficult to be here for
so long with a sick child."
(D) "My office staff scheduled too many patients for
today."
(E) "Unfortunately, some patients demand more time
than we scheduled for them."
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-1-
Appendix 3
5.
A 45-year-old man is admitted to the hospital because of chest
pain for 1 hour. He has a sedentary lifestyle, and his diet is
high in fat and sodium. The diagnosis of acute angina is made,
and the appropriate treatment is administered. After the
patient's condition is stabilized, the physician recommends an
exercise regimen and a low-fat, low-sodium diet. Two weeks
later, the patient returns for a follow-up examination. He
indicates that he has not yet returned to work and spends most
of the day lying on the couch. He has not had any chest pain,
shortness of breath, dyspnea with exertion, or peripheral
edema. Which of the following initial statements by the
physician is most appropriate?
8.
(A) Normal grief reaction, and she requires no
medical attention
(B) Normal grief reaction, and she would benefit
from diazepam therapy
(C) Pathologic grief reaction, and she should be
treated with an antidepressant
(D) Pathologic grief reaction, and she should be
treated with psychotherapy
(E) Pathologic grief reaction, and she should be
encouraged to move in with one of her
children
(A) "Are you afraid you might have a heart attack if
you exercise?"
(B) "Are you doing any types of exercise other than
channel surfing?"
(C) "Have you also not been following the diet I
recommended?"
(D) "What do you think is interfering with your
ability to resume activity?"
(E) "When would you like to start working on
improving your health?"
6.
A firstborn 1-year-old girl is hospitalized for evaluation of
arrested growth. Pregnancy and delivery were uncomplicated,
and development was normal initially. The infant is listless and
has a diaper rash. She is below the 5th percentile for length and
weight. No other abnormalities are noted. After 1 week of
routine hospital care, the infant has gained 1 kg (2.2 lb) and
has become more responsive. Which of the following is the
most likely explanation for the arrested growth?
(A)
(B)
(C)
(D)
(E)
7.
Hypothyroidism
Infantile psoriasis
Milk allergy
Parental neglect
Pyloric stenosis
A 15-year-old boy with generalized tonic-clonic seizures is
brought to the physician by his mother for a follow-up
examination. She says he has not been taking his medication
regularly. In his presence, she explains to the physician that
she is baffled by her son's behavior and Acan't get him to take
his pills, let alone take out the trash.@ Even after his mother
leaves, the patient stares out the window and refuses to talk.
Which of the following behaviors during the interview is most
appropriate to assess the patient's compliance with this
regimen?
(A)
(B)
(C)
(D)
(E)
The children of a 67-year-old woman ask their family
physician for advice about their mother's behavior 4 weeks
after the death of her husband of 40 years. They are
concerned because she weeps whenever she comes upon an
object in her home that she associates with him. Her appetite
has decreased, and she has had a 2-kg (4.4-lb) weight loss.
She awakens 1 hour before the alarm goes off each morning.
She is able to care for herself. Although she does not leave
her home for any social activities, she does enjoy visits from
her family. Which of the following is the most likely
explanation and appropriate management?
9.
A 4-year-old girl is brought to the physician because she
consistently uses her left hand. Her mother, who is also lefthanded, tells the physician that she wants her daughter to be
right-handed because she resents all the obstacles she faced as
a left-handed child. She makes her daughter practice with a
crayon held only in her right hand. Which of the following
responses by the physician is most appropriate?
(A) "I know you want the best for your daughter,
but pressing her to change is unlikely to
work and might cause its own problems."
(B) "I understand your concerns, and since she is
only 4, your efforts will likely result in her
being right-handed by age 7 years."
(C) "Times have changed. There is much less
discrimination against left-handed people
now."
(D) "You may be causing irreversible psychological
trauma to your child, which could be worse
than being left-handed."
(E) "You shouldn't interfere with nature."
Confront the patient about his poor behavior
Explain the patient's resistance to him
Laugh and joke with the patient
Project a firm, businesslike manner
Project a respectful, tolerant attitude and
encourage free discussion
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-2-
Appendix 3
10. A 65-year-old man comes to the physician for a follow-up
examination after the results of a bronchoscopy showed
squamous cell carcinoma. When the physician tells the patient
the diagnosis, the patient becomes tearful and responds, "No,
you're wrong! This must be a mistake. This can't happen to me.
Let's do more tests." This patient is most likely at which of the
following stages of grief?
(A)
(B)
(C)
(D)
Anger
Bargaining
Denial
Depression
11. A 10-month-old boy is brought to the emergency department
by his babysitter 1 hour after he was difficult to arouse
following a head injury. The babysitter says he hit his head
after falling off a bed and that she could not wake him at first
when she found him lying on the floor. The patient is
conscious and not in distress. Physical examination shows a 2cm hematoma over the left parietal region of the head. There
are ecchymoses in various stages of healing on different body
surfaces, including the buttocks and low back. Neurologic
examination shows no abnormalities. When questioned about
the bruises, the babysitter replies, "He just seems to bruise
easily. Maybe he has some sort of bleeding problem." After
notifying the parents, the physician should do which of the
following next?
(A) Ask the hospital social worker to obtain a criminal
background check on the babysitter
(B) Have a court appoint a guardian for the child
(C) Notify child protective services of suspected
abuse
(D) Refer the patient to a pediatric hematologist
(E) Register a formal complaint against the babysitter
with the local police department
12. A 10-year-old girl is brought to the physician by her parents
for a well-child examination. When alone with the physician,
the parents state that they are concerned because some of her
friends seem overly preoccupied with food when they are
visiting. Their daughter also has begun to show an interest in
fashion magazines and stylish clothing. Although their
daughter has had consistent and appropriate weight gain
throughout her life, the parents are aware of the risks for eating
disorders and are eager to do anything they can to avoid such a
problem. It is most appropriate for the physician to recommend
which of the following to the parents regarding their daughter?
(A)
(B)
(C)
(D)
(E)
Encourage more family meals
Forbid access to fashion magazines
Have her eat more at every meal
Suggest she prepare her own meals
Weigh her weekly
13. A 46-year-old man comes to the physician for a follow-up
examination. He underwent coronary artery bypass grafting 3
weeks ago. He works long hours daily as the head chef and
owner of a restaurant. He has had a 14-kg (30-lb) weight gain
since opening his restaurant 3 years ago. He attributes this
weight gain to "working around food all day, every day." He
does not smoke cigarettes. His father had a myocardial
infarction at the age of 60 years. The patient is 175 cm (5 ft
9 in) tall and now weighs 102 kg (225 lb); BMI is 33 kg/m2.
Physical examination shows no other abnormalities. He tells
the physician that he is afraid to cut down on his work hours
because his business might suffer as a result, but he says, "I
don't want to have a heart attack like my dad did." Which of
the following responses by the physician is most appropriate?
(A) "The fact that you do not smoke cigarettes
balances out your other risk factors, such as
your weight and family history."
(B) "Given your family history, modifying other risk
factors won't have much impact."
(C) "I suggest you have someone else run your
business for the time being, so you can
spend your days in a more healthy
environment."
(D) "Let's discuss some lifestyle changes, including
weight loss, exercise, and decreased
stress."
(E) "Since the only risk factor for a myocardial
infarction you can change is your weight, I
suggest you initiate a weight-loss program
fairly soon."
14. A 40-year-old woman with hypertension comes to the
physician for a follow-up examination. Her blood pressure is
160/96 mm Hg. She tells the physician that she has been
having difficulty being compliant with her medication
regimen and low-sodium diet. Which of the following
responses by the physician is most appropriate?
(A) "I will go over the regimen and diet again to
make sure you understand them."
(B) "I'd like you to read these pamphlets on the risks
of hypertension. You will then realize the
seriousness of your condition."
(C) "If you don't follow my recommendations, you
could end up having a heart attack or stroke.
You could also become blind."
(D) "Tell me the difficulties you've been having.
Perhaps we can make your regimen and
diet easier for you to follow."
(E) "Unfortunately, if you do not follow your
medication regimen and diet, I will find it
difficult to act as your physician."
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-3-
Appendix 3
15. A 27-year-old woman comes to the physician because of an
itchy rash on her hands for 2 weeks. She states that she began
training as a hairstylist 3 weeks ago and works 6 hours daily,
cutting, coloring, and highlighting hair and giving perms.
Examination of the hands shows edema with weepy vesicular
lesions in a glove pattern bilaterally. Which of the following
initial actions by the physician is most appropriate?
(A) Advise the patient to stop her training and look for
another type of job
(B) Immediately irrigate the affected area with
copious amounts of water and prescribe an
anti-inflammatory ointment
(C) Inform the patient that her lesions are consistent
with poison ivy dermatitis and determine
when and where she was exposed
(D) Prescribe oral corticosteroid treatment and tell the
patient to avoid giving perms since harsh
chemicals are involved
(E) Prescribe topical corticosteroid treatment and
advise the patient to wear non-latex gloves
at work
16. A 42-year-old man with mild mental retardation comes to his
primary care physician for a follow-up examination. The
patient has received care from this physician for many years.
He recently received the diagnosis of inoperable
retroperitoneal sarcoma. His prognosis is poor. He serves as
his own guardian and lives independently. His oncologist
recommends chemotherapy that is highly toxic and has less
than a 5% response rate for this type of tumor. The primary
care physician believes that the burden of suffering clearly
outweighs the limited potential benefit of this treatment. The
patient says that he is unsure whether he wishes to undergo the
chemotherapy. Which of the following is the most appropriate
next step by the primary care physician?
(A) Ask the patient what he understands about the
treatment and its likely effects
(B) Contact the oncologist and request that he
reconsider this treatment plan
(C) Emphasize the toxic adverse effects of the
treatment and how uncomfortable the patient
would be
(D) Encourage the patient to allow the primary care
physician to decide what is best for him
(E) Stress the extremely low chance that treatment
will provide any benefit to the patient
17. A 5-year-old boy with Down syndrome is admitted to the
hospital because of a 1-month history of fatigue, intermittent
fever, and weakness. Results from a peripheral blood smear
taken during his evaluation are indicative of possible acute
lymphoblastic leukemia. The physician recommends a bone
marrow aspiration to confirm the diagnosis and subsequent
cytogenetic studies as needed. The patient's parents refuse to
consent to the procedure because they think such an invasive
test will cause their son too much unnecessary pain. Without
confirmation of the diagnosis and results from cytogenetic
testing, the patient's treatment may be adversely affected.
Which of the following is the most appropriate next step for
the physician?
(A) Accede to the parents' wishes to spare their son
further pain
(B) Consult child protective services
(C) Discuss options to manage the potential pain
during the procedure
(D) Do the necessary procedure despite the parents'
objections
(E) Explain that the child will die if the procedure is
refused
18. A 70-year-old man with terminal pancreatic cancer is
admitted to the hospital because of severe shortness of breath.
He has no documented advance care plans. His three children
tell the physician that they want everything possible to be
done for their father, including cardiopulmonary resuscitation
(CPR) and intubation, if necessary. The patient is cachectic
and unaware of his surroundings. Which of the following
initial responses by the physician is most appropriate?
(A) "I hear you, and I understand how difficult it
must be for you to see your father ill.
Let's talk more about the options."
(B) "I know that you are distressed about your
father's illness, but you must accept that he
will die soon."
(C) "I want you to reconsider your decision about
CPR and intubation. Your father's prognosis
is very poor."
(D) "Relatives in this type of situation feel distressed,
and they want to prolong the life of their
loved one unnecessarily."
(E) "You are just prolonging the inevitable. Your
father is going to die."
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-4-
Appendix 3
19. A 32-year-old woman comes to the emergency department
after taking 40 1-mg tablets of alprazolam. She says that her
boyfriend threatened to leave her, and she feels "empty." She
drinks several six-packs of beer weekly and uses cocaine daily.
She has outbursts of rage whether or not she is intoxicated.
Which of the following is the most likely personality disorder?
(A)
(B)
(C)
(D)
Antisocial
Borderline
Dependent
Narcissistic
20. A 34-year-old woman with major depressive disorder comes
to the physician for a follow-up examination. She says that
her depressive symptoms are worsening. Multiple medication
regimens have been ineffective. The patient says that she
spoke recently with a former college roommate who also has
depression. Her friend is currently enrolled in a clinical trial
for a new antidepressant at a local center. The patient says,
"My friend seems to be doing really well with this new
medication, and I think I'd like to try it out to see if it would
work for me, too. Can you write me a referral to the center
where my friend is enrolled?" Which of the following is the
most appropriate initial response by the physician to this
patient's request?
(A) Decline to refer the patient because she has
treatment-refractory depression that
typically is not accepted into clinical trials
(B) Discuss the conduct of clinical trials so that the
patient has a clear understanding of how
they operate
(C) Inform the patient that she cannot receive future
care from the physician if she enrolls in the
clinical trial
(D) Inform the patient that she will not get the best
care possible if she enrolls in an
experimental trial
(E) Refer the patient to the center because so many
other treatment options have failed
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-5-
Appendix 3
Answer Form for Behavioral Science Sample Questions
(Questions 1-20)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-6-
Appendix 3
Answer Key for Behavioral Science Sample Questions
(Questions 1-20)
1. D
2. E
3. E
4. C
5. D
6. D
7. E
8. A
9. A
10. C
11. C
12. A
13. D
14. D
15. E
16. A
17. C
18. A
19. B
20. B
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-7-
Appendix 3
BIOCHEMISTRY
Gene expression: DNA structure, replication, and exchange
Gene expression: transcription (including defects)
Gene expression: translation (including defects)
Structure and function of proteins
Energy metabolism
Metabolic pathways of small molecules
Biology of cells
Human development and genetics
Biology of tissue response to disease
Nutrition
Pharmacodynamic and pharmacokinetic processes
Normal processes
Hematopoietic & lymphoreticular system
Central & peripheral nervous system
Endocrine system
1.
In order to determine the rate of DNA synthesis in various
mammalian tissues, the administration of which of the
following labeled substances would be most specific in
labeling DNA?
(A)
(B)
(C)
(D)
(E)
2.
CAC
CTU
CUC
GAC
GCC
Which of the following post-translational modifications is
most likely to be found on a cyclin B protein that is targeted
for degradation?
(A)
(B)
(C)
(D)
(E)
Adenosine
Cytosine
Guanosine
Thymidine
Uridine
A 2-year-old boy who recently emigrated from Somalia is
brought to the physician because of a 1-day history of pain of
his arms and legs. Physical examination shows pale mucous
membranes and hepatosplenomegaly. Laboratory studies show
a hemoglobin concentration of 8 g/dL. A peripheral blood
smear shows sickle cells. Genetic analyses show a point
mutation in the β-globin gene leading to a change of a GAG
codon (glutamate) to a GUG codon (valine). Which of the
following anticodons is most likely in the tRNA for valine?
(A)
(B)
(C)
(D)
(E)
3.
5%B10%
5%B10%
5%B10%
5%B10%
15%B20%
15%B20%
5%B10%
1%B5%
1%B5%
5%B10%
1%B5%
10%B15%
1%B5%
1%B5%
5%B10%
4.
Acetylated lysine residues
Phosphorylated serine residues
Phosphorylated threonine residues
Phosphorylated tyrosine residues
Ubiquitinated lysine residues
A previously healthy 16-year-old girl is brought to the
physician because of abdominal cramps, bloating, and loose
stools for 6 months. These symptoms began after she ingested
skim milk in an attempt to lose weight. She is at the 50th
percentile for height and 75th percentile for weight. Physical
examination shows no abnormalities. Stool studies show a 3+
Clinitest reagent response and pH of 5. After the patient
ingests milk, there is an increased hydrogen concentration in
expired air. A deficiency of which of the following enzyme
activities is the most likely cause of the gastrointestinal
symptoms in this patient?
(A)
(B)
(C)
(D)
(E)
(F)
Amylase
Carboxypeptidase
Fructose-1,6-bisphosphate aldolase
Galactokinase
Lactase
Sucrase
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-8-
Appendix 3
5.
A married couple is screened to assess the risk for Gaucher
disease in their children. The activities of glucocerebrosidase
in the sera of the mother and father are 45% and 55%,
respectively, of the reference value. The couple has one child.
Which of the following is the probability of the child
possessing one or more alleles of the Gaucher mutation?
(A)
(B)
(C)
(D)
(E)
6.
The release of epinephrine from the chromaffin granules of the
adrenal medulla into the bloodstream in response to neural
stimulation is mediated by which of the following?
(A)
(B)
(C)
(D)
(E)
7.
Acetylcholine
γ-Aminobutyric acid (GABA)
Cortisol
Dopamine
Serotonin
During normal screening for phenylketonuria, a male newborn
has a serum phenylalanine concentration of 35 mg/dL (greater
than 20 mg/dL is considered a positive test). Signs of tyrosine
deficiency also are apparent. Enzymatic analysis using
cultured fibroblasts, obtained after circumcision, shows normal
activity of phenylalanine hydroxylase. A possible explanation
for these findings is a deficiency in function of which of the
following coenzymes?
(A)
(B)
(C)
(D)
(E)
8.
0
0.25
0.5
0.75
1.0
Adenosylcobalamin
Biopterin
Dihydroquinone
Pyridoxal phosphate
Tetrahydrofolic acid
A 2-year-old boy with mental retardation has chewed the tips
of his fingers on both hands and a portion of his lower lip. His
serum uric acid concentration is increased, and he has a history
of uric acid renal calculi. His 5-year-old brother has similar
findings. Which of the following abnormal enzyme activities is
the most likely cause of these findings?
(A) Decreased adenine phosphoribosyltransferase
(B) Decreased adenosine deaminase
(C) Decreased hypoxanthine-guanine
phosphoribosyltransferase
(D) Increased phosphoribosylpyrophosphate synthetase
(E) Increased xanthine oxidase
9.
A 14-year-old girl is brought to the physician because of a
recent growth spurt of 15 cm (6 in) during the past year. She
also has had increasing fatigue and palpitations during this
period. Her paternal aunt has a history of palpitations and
severe myopia. She is at the 95th percentile for height and
50th percentile for weight. Physical examination shows a
long, thin face. Ophthalmologic examination shows
dislocated lenses. Cardiac examination shows a
hyperdynamic precordium with early click and systolic
murmur. Echocardiography shows an enlarged aortic root and
mitral valve prolapse. Abnormal synthesis of which of the
following proteins is the most likely cause of this patient's
disorder?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
Collagen, type I
Elastin
Fibrillin-1
Fibroblast growth factor R3
Laminin
Neurofibromin
PAX 6
10. Native collagen is composed almost entirely of which of the
following types of structures?
(A)
(B)
(C)
(D)
(E)
α-Helix
β-Pleated sheet
Random coils
Triple helix
Two peptides connected by a disulfide bond
11. An otherwise healthy 20-year-old woman of Mediterranean
descent is given sulfamethoxazole to treat a bladder infection.
Three days after beginning the antibiotic regimen, the patient
has moderately severe jaundice and dark urine. Pain with
urination and a low-grade fever have resolved. Her
hematocrit is 20%. Substantial numbers of erythrocytes
contain Heinz bodies. Her condition worsens until day 6 of
antibiotic therapy, when it begins to resolve. Symptoms are
completely gone by day 9 of continued antibiotic therapy.
Which of the following conditions is the most likely
explanation for these findings?
(A)
(B)
(C)
(D)
(E)
Aplastic anemia
Generalized cytochrome-b5 reductase deficiency
Glucose-6-phosphate dehydrogenase deficiency
Pyruvate kinase deficiency
Systemic infection cured by antibiotic therapy
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
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Appendix 3
12. A 45-year-old woman has the sudden onset of severe
headaches. During one of these episodes, her blood pressure is
190/115 mm Hg. Her usual blood pressure is 130/90 mm Hg.
Her sister had similar episodes several years ago. Urinalysis
shows increased concentrations of metanephrine and
vanillylmandelic acid. The patient is most likely to have a
neoplasm that secretes which of the following?
(A)
(B)
(C)
(D)
(E)
ACTH
Aldosterone
Cortisol
Epinephrine
Renin
13. An inherited disorder of carbohydrate metabolism is
characterized by an abnormally increased concentration of
hepatic glycogen with normal structure and no detectable
increase in serum glucose concentration after oral
administration of fructose. These two observations suggest that
the disease is a result of the absence of which of the following
enzymes?
(A)
(B)
(C)
(D)
(E)
Fructokinase
Glucokinase
Glucose-6-phosphatase
Phosphoglucomutase
UDP glucose
14. A 15-year-old girl limits her diet to carrots, tomatoes, green
vegetables, bread, pasta, rice, and skim milk. She has an
increased risk for vitamin A deficiency because its absorption
requires the presence of which of the following?
(A)
(B)
(C)
(D)
(E)
Heme
Intrinsic factor
Phosphatidylcholine
Protein
Triglyceride
15. An increased concentration of fructose 2,6-bisphosphate in
hepatocytes will have a positive regulatory effect on which of
the following?
(A) Gluconeogenesis and glucose-6-phosphatase
(B) Gluconeogenesis and phosphoenolpyruvate
carboxykinase
(C) Glycolysis and glucokinase
(D) Glycolysis and phosphofructokinase 1
16. During the processing of particular N-linked glycoproteins,
residues of mannose 6-phosphate are generated. Which of the
following proteins is most likely to undergo this step in
processing?
(A) Apo B receptor
(B) The citrate transport protein of the inner
mitochondrial membrane
(C) IgG
(D) Lysosomal α-fucosidase
(E) Mitochondrial isocitrate dehydrogenase
17. A 65-year-old man with coronary artery disease comes to the
physician for a follow-up examination. He is 183 cm (6 ft)
tall and weighs 84 kg (185 lb); BMI is 25 kg/m2. His blood
pressure is 130/80 mm Hg. The lungs are clear to
auscultation. Cardiac examination shows no point of maximal
impulse. Serum studies show a glucose concentration of
95 mg/dL and homocysteine concentration of 19.3 μmol/L
(N=5–15). Serum lipid concentrations are within the
reference range. Which of the following amino acids is most
likely to be decreased in this patient?
(A)
(B)
(C)
(D)
(E)
Arginine
Leucine
Lysine
Methionine
Ornithine
18. Which of the following is required to transport fatty acids
across the inner mitochondrial membrane?
(A)
(B)
(C)
(D)
(E)
(F)
Acyl carrier protein
Albumin
Carnitine
Chylomicrons
Creatinine
Lecithin-cholesterol acyltransferase
19. Failure to bind LDL to its receptor results in uncontrolled
synthesis of cholesterol. This occurs because synthesis of
which of the following enzymes is not repressed?
(A) Acyl CoA cholesterol acyltransferase
(B) 3-Hydroxy-3-methylglutaryl (HMG)-CoA
reductase
(C) Lecithin-cholesterol acyltransferase
(D) Lipoprotein lipase
(E) Lysosomal protease
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-10-
Appendix 3
20. A 67-year-old man has a restricted diet that includes no fresh citrus fruits or leafy green vegetables. His teeth are loose and his gums
bleed easily. This patient's disorder most likely results from a defect in collagen synthesis that involves which of the following amino
acids?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
Arginine
Cysteine
Histidine
Hydroxyproline
Leucine
Methionine
Serine
Tryptophan
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-11-
Appendix 3
Answer Form for Biochemistry Sample Questions
(Questions 1-20)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-12-
Appendix 3
Answer Key for Biochemistry Sample Questions
(Questions 1-20)
1. D
2. A
3. E
4. E
5. D
6. A
7. B
8. C
9. C
10. D
11. C
12. D
13. C
14. E
15. D
16. D
17. D
18. C
19. B
20. D
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-13-
Appendix 3
GROSS ANATOMY AND EMBRYOLOGY
1.
1%B5%
95%B99%
1%B5%
15%B20%
1%B5%
15%B20%
5%B10%
5%B10%
5%B10%
5%B10%
5%B10%
5%B10%
Process
Normal
Abnormal
75%B80%
20%B25%
A 45-year-old woman has a uterine leiomyoma that is 5 cm in
diameter and is pressing on the urinary bladder, causing
urinary frequency. Which of the following is the most likely
location of the leiomyoma?
(A)
(B)
(C)
(D)
(E)
2.
System
General Principles: Human Development and Genetics
Individual Organ Systems
Hematopoietic & lymphoreticular
Central & peripheral nervous
Skin & related connective tissue
Musculoskeletal
Respiratory
Cardiovascular
Gastrointestinal
Renal/urinary
Reproductive
Endocrine
Cervical canal
Lateral margin of the uterine cavity
Subendometrially in the uterine cavity
Subperitoneally on the anterior surface of the
uterine corpus
Subperitoneally on the posterior surface of the
uterine fundus
A 5-year-old girl is brought to the emergency department
because of fever and severe abdominal pain. Acute
appendicitis is diagnosed. In the examination room, she keeps
her right hip flexed and resists active extension of the hip. The
inflamed structure associated with these symptoms is most
likely in contact with which of the following structures?
(A)
(B)
(C)
(D)
(E)
3.
Abdominal wall and the external oblique muscle
Obturator internus muscle
Psoas major muscle
Quadratus lumborum muscle
Transversus abdominis muscle
A 61-year-old man comes to the physician because of a 3month history of episodes of headache, heart palpitations, and
excessive sweating. He has had a 10-kg (22-lb) weight loss
during this period. While being examined, during an episode
his blood pressure is 210/110 mm Hg. Physical examination
shows no other abnormalities. Urine studies show increased
catecholamine concentrations. A CT scan of the abdomen is
most likely to show a mass in which of the following
locations?
(A)
(B)
(C)
(D)
(E)
4.
Adrenal glands
Appendix
Kidneys
Pancreas
Stomach
A 6-year-old boy has a large intra-abdominal mass in the
midline just above the symphysis pubis. During an operation,
a cystic mass is found attached to the umbilicus and the apex
of the bladder. Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)
Hydrocele
Meckel cyst
Meckel diverticulum
Omphalocele
Urachal cyst
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-14-
Appendix 3
5.
A 55-year-old man who has alcoholic cirrhosis is brought to
the emergency department because he has been vomiting blood
for 2 hours. He has a 2-month history of abdominal distention,
dilated veins over the anterior abdominal wall, and internal
hemorrhoids. Which of the following veins is the most likely
origin of the hematemesis?
(A)
(B)
(C)
(D)
(E)
6.
A 3-year-old girl with mild craniofacial dysmorphosis has
profound hearing deficits. Further evaluation indicates
profound sensory auditory deficits and vestibular problems.
Altered development of which of the following is most likely
to account for these observations?
(A)
(B)
(C)
(D)
(E)
(F)
7.
Ectodermal placode
Intermediate mesoderm
Lateral plate mesoderm
Neural crest cell
Paraxial mesoderm
Prochordal mesoderm
A 19-year-old woman comes to the physician because of a 5day history of increasingly severe right lower abdominal pain
and bloody vaginal discharge. Her last menstrual period was 8
weeks ago. Abdominal examination shows exquisite
tenderness of the right lower quadrant. A serum pregnancy test
result is positive. Ultrasonography shows no gestational sac in
the uterus. Which of the following is the most likely location
of this patient's fertilized egg?
(A)
(B)
(C)
(D)
(E)
8.
Inferior mesenteric veins
Left gastric vein
Periumbilical veins
Superior rectal vein
Superior vena cava
Cervix
Peritoneum of the right lower abdominal wall
Rectouterine pouch (of Douglas)
Right fallopian tube
Right ovary
A 22-year-old man is brought to the emergency department
because of a suprahyoid stab wound that extends from one side
of the neck to the other. His tongue deviates to the right when
protruded; there is no loss of sensory modality on the tongue.
The injury most likely involves which of the following nerves?
(A)
(B)
(C)
(D)
(E)
Left hypoglossal
Left vagus
Right hypoglossal
Right glossopharyngeal
Right lingual
9.
A 45-year-old woman is found to have adenocarcinoma of the
left breast. Resection of the tumor is scheduled, and the
physician also plans to obtain samples of the draining nodes.
To find these nodes, a radiotracer is injected adjacent to the
tumor and images are obtained. The first draining sentinel
node in this patient is most likely found at which of the
following locations?
(A)
(B)
(C)
(D)
(E)
Contralateral neck
Ipsilateral axilla
Ipsilateral mediastinum
Ipsilateral supraclavicle
Medial contralateral breast
10. A 3629-g (8-lb) male newborn is delivered at term. During
the initial examination, urine is found to be leaking from the
umbilicus. This patient most likely has an abnormality of
which of the following fetal structures?
(A)
(B)
(C)
(D)
(E)
Umbilical arteries
Umbilical vein
Urachus
Urogenital sinus
Urorectal septum
11. A 70-year-old man has a 90% blockage at the origin of the
inferior mesenteric artery. He does not have intestinal angina.
Which of the following arteries is the most likely additional
source of blood to the descending colon?
(A)
(B)
(C)
(D)
(E)
Left gastroepiploic
Middle colic
Sigmoid
Splenic
Superior rectal
12. A 30-year-old man comes to the emergency department 1
hour after injuring his left knee in a volleyball game. He says
he twisted his left leg when he fell to the floor after he and a
teammate accidentally collided. He cannot bear weight on his
left leg. Physical examination shows tenderness and swelling
of the left knee. When the patient sits on the edge of the
examination table, the left knee can be displaced anteriorly at
an abnormal degree. Which of the following is most likely
injured in this patient?
(A)
(B)
(C)
(D)
(E)
Anterior cruciate ligament
Fibular collateral ligament
Meniscofemoral ligament
Oblique popliteal ligament
Transverse ligament of the knee
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-15-
Appendix 3
13. A 70-year-old man is brought to the emergency department
because of a 1-week history of increasingly severe left-sided
lower abdominal pain and passing gas in his urine. His
temperature is 38.9°C (102°F). A CT scan of the abdomen
shows gas in the bladder and edema of the fat surrounding the
sigmoid colon. There is no obvious lymph node enlargement.
Which of the following is the most likely cause of this patient's
condition?
(A)
(B)
(C)
(D)
(E)
Appendicitis with fistula
Bladder infection
Diverticulitis with fistula
Prostate cancer with fistula
Urinary tract infection
14. A 60-year-old man has tenderness in the region distally
between the tendons of the extensor pollicis longus and
extensor pollicis brevis (anatomical snuff-box) after falling on
the palm of his right hand. A fracture of which of the following
carpal bones is most likely in this patient?
(A)
(B)
(C)
(D)
(E)
Hamate
Lunate
Scaphoid
Trapezium
Triquetrum
15. A 20-year-old man is brought to the emergency department 1
hour after he was involved in a motorcycle collision. He was
not wearing a helmet. Physical examination shows clear fluid
dripping from the nose. X-rays show a fracture of the
cribriform plate of the ethmoid bone. This patient is at greatest
risk for impairment of which of the following senses?
(A)
(B)
(C)
(D)
(E)
(F)
Balance
Hearing
Olfaction
Taste from the anterior two thirds of the tongue
Taste from the posterior one third of the tongue
Vision
16. A 7-year-old boy tires easily while running. On auscultation, a
harsh continuous murmur is heard at the left of the sternum
between the first two ribs. Arterial blood oxygen content is
slightly higher in the right hand than in the left hand. X-rays of
the chest show no abnormalities. Which of the following is the
most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Anomalous return of pulmonary blood to the
right atrium
Patent ductus arteriosus
Patent foramen ovale
Stenosis of the aortic valve
Tricuspid atresia
17. A 50-year-old woman is brought to the emergency
department because of severe upper abdominal pain for
24 hours. She has a 2-day history of intermittent fever and
pale stools. Her temperature is 38.9°C (102°F), pulse is
120/min, respirations are 20/min, and blood pressure is 90/50
mm Hg. Physical examination shows jaundice and tenderness
of the right upper quadrant of the abdomen. Serum studies
show a bilirubin concentration of 5 mg/dL, alkaline
phosphatase activity of 450 U/L, and lipase activity of 400
U/L (N=14B280). Which of the following is the most likely
cause of this patient's symptoms?
(A)
(B)
(C)
(D)
(E)
Impaction of a gallstone in the
hepatopancreatic ampulla
Intestinal obstruction secondary to diverticulitis
Pancreatic mucinous cystadenoma
Penetration and perforation of a peptic ulcer
Ulcerative colitis
18. A 6-year-old boy is brought to the physician by his parents
for a follow-up examination because of a heart murmur that
has been present since birth. His only symptom is fatigue. His
pulse is 110/min, and blood pressure is 80/40 mm Hg.
Physical examination shows no cyanosis or clubbing of the
fingers. Cardiac examination shows a normal S1 and a split
S2. A grade 3/6 pansystolic murmur is heard maximally at the
lower left to mid left sternal border. He undergoes cardiac
catheterization and is found to have a higher than expected
oxygen level in the right ventricle. Which of the following is
the most likely cause of these findings?
(A)
(B)
(C)
(D)
(E)
Coarctation of the aorta
Congenital bicuspid aortic valve
Pulmonary artery stenosis
Tricuspid stenosis
Ventricular septal defect
19. A 32-year-old woman, gravida 2, para 2, develops fever and
left lower abdominal pain 3 days after delivery of a full-term
male newborn. Abdominal examination shows a tender,
palpable mass. Ultrasonography of the mass shows an ovarian
vein thrombosis. The thrombus is most likely to extend into
which of the following veins?
(A)
(B)
(C)
(D)
(E)
Hemiazygos vein
Inferior vena cava
Left internal iliac vein
Left internal pudendal vein
Left renal vein
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-16-
Appendix 3
20. During a study of bladder function, a healthy 20-year-old male subject drinks 1 L of water and delays urination for 30 minutes after
feeling the urge to urinate. Which of the following muscles permits his voluntary control of micturition?
(A)
(B)
(C)
(D)
(E)
Coccygeus
Detrusor
External urethral sphincter
Internal urethral sphincter
Obturator internus
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-17-
Appendix 3
Answer Form for Gross Anatomy and Embryology Sample Questions
(Questions 1-20)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-18-
Appendix 3
Answer Key for Gross Anatomy and Embryology Sample Questions
(Questions 1-20)
1. D
2. C
3. A
4. E
5. B
6. D
7. D
8. C
9. B
10. C
11. B
12. A
13. C
14. C
15. C
16. B
17. A
18. E
19. E
20. C
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-19-
Appendix 3
HISTOLOGY AND CELL BIOLOGY
1.
30%B35%
1%B5%
25%B30%
1%B5%
5%B10%
1%B5%
1%B5%
1%B5%
5%B10%
5%B10%
1%B5%
1%B5%
1%B5%
1%B5%
Organ Systems
Hematopoietic & lymphoreticular
Central & peripheral nervous
Skin & related connective tissue
Musculoskeletal
Respiratory
Cardiovascular
Gastrointestinal
Renal/urinary
Reproductive
Endocrine
65%B70%
1%B5%
10%B15%
5%B10%
5%B10%
5%B10%
5%B10%
5%B10%
5%B10%
5%B10%
5%B10%
An oophorectomized monkey is treated with high doses of
estrogen. Which of the following changes is most likely to
occur in the endometrium after 1 year of treatment?
(A)
(B)
(C)
(D)
(E)
2.
General Principles
Biochemistry and molecular biology
Cell biology
Signal transduction
Cell components
Nucleus
Cytoskeleton
Secretion and exocytosis, endocytosis, transcytosis
Cell cycle, mitosis, meiosis
Epithelial cells
Muscle cells
Human development and genetics
Biology of tissue response
Immune responses
Atrophy
Hyperplasia
Hypertrophy
Hypoplasia
Metaplasia
Actin
Myosin
T tubule
Tropomyosin
Troponin
Z disk
A new drug is developed that prevents the demyelinization
occurring in the progress of multiple sclerosis. The drug
protects the cells responsible for the synthesis and
maintenance of myelin in the central nervous system. These
cells are most likely which of the following?
(A)
(B)
(C)
(D)
(E)
Which of the following muscle cell components helps spread
the depolarization of the muscle cell membranes throughout
the interior of muscle cells?
(A)
(B)
(C)
(D)
(E)
(F)
3.
4.
Astrocyte
Ependymal cell
Microglial cell
Oligodendrocyte
Schwann cell
A 10-year-old boy undergoes an appendectomy. Granulation
tissue develops normally at the incision site. Tissue
remodeling begins at this site with degradation of collagen in
the extracellular matrix by which of the following proteins?
(A)
(B)
(C)
(D)
(E)
Cytokines
Lipoxygenases
Metalloproteinase
Nitric oxide
Plasminogen activator
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-20-
Appendix 3
5.
In which of the following nuclear structures is DNA actively
transcribed to rRNA?
(A)
(B)
(C)
(D)
(E)
6.
Envelope
Lamina
Matrix
Nucleolus
Pore
A 22-year-old man is brought to the emergency department in
respiratory distress 15 minutes after he was stung on the arm
by a wasp. His pulse is 100/min, respirations are 30/min, and
blood pressure is 100/60 mm Hg. Physical examination shows
grunting respirations and subcostal retractions. Expiratory
wheezes are heard over both lung fields. There is generalized
urticaria. Secretion of the molecule causing this patient’s
symptoms is most likely mediated by which of the following?
(A)
(B)
(C)
(D)
(E)
(F)
Activation of complement
Activation of mast cell
Activation of T lymphocytes
Production of IgA
Production of IgG
Production of IgM
10. An experiment is conducted in which the mitochondrial
content of various tissues is studied. It is found that the
mitochondrial content is directly proportional to the amount of
energy one cell is required to generate and expend. The
mitochondrial content is most likely greatest in which of the
following types of cells?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
11. A 45-year-old man without a history of bleeding or excessive
bruising dies suddenly due to rupture of an aortic dissection.
Genetic analysis at autopsy shows a defect in the gene for
fibrillin. Which of the following events most likely occurs
with defective fibrillin?
(A)
(B)
(C)
7.
A 66-year-old man with Zollinger-Ellison syndrome
undergoes a gastrectomy. He is informed that he will require
treatment with intramuscular vitamin B12 (cyanocobalamin)
for the rest of his life. This therapy is necessary because this
patient lacks which of the following types of cells?
(A)
(B)
(C)
(D)
(E)
8.
Beginning with protein synthesis in membrane-bound
ribosomes, hepatocytes secrete proteins into the circulation via
which of the following mechanisms?
(A)
(B)
(C)
(D)
(E)
9.
Chief
G (gastrin)
Goblet
Mucous neck
Parietal
Active transport through the cell membrane
Diffusion through the cell membrane
Transport by microtubules and exocytosis
Transport in vesicles and exocytosis
Transport through pores in the cell membrane
Cardiac muscle cells
Chondrocytes
Endothelial cells
Epidermal cells
Hepatocytes
Osteocytes
White adipocytes
(D)
(E)
Elastic fibers in the extracellular matrix are
not correctly formed
Hyaluronic acid in proteoglycans is not sulfated
on the proper hydroxyl residues
Intermediate filaments are not assembled in the
endothelial cells
Shorter side chains of chondroitin sulfate are
present on proteoglycans
Tubulin is not polymerized correctly due to the
lack of GTP in endothelial cells
12. A 42-year-old woman comes to the physician for a follow-up
examination after two separate Pap smears have shown
dysplastic epithelial cells. Results of a molecular diagnostic
test show DNA that encodes high-risk versions of the human
papillomavirus E6 and E7 proteins. The viral E6 protein binds
to the cellular p53 tumor suppressor gene, causing it to be
degraded. Which of the following best describes the
mechanism by which the E6 protein causes cervical cancer?
(A)
(B)
(C)
(D)
(E)
Arrests the cell cycle
Enhances tissue invasion and metastasis
Inhibits telomerase expression
Prevents apoptosis
Sustains angiogenesis
Which of the following is required to transport fatty acids
across the inner mitochondrial membrane?
(A)
(B)
(C)
(D)
(E)
(F)
Acyl carrier protein
Albumin
Carnitine
Chylomicrons
Creatinine
Lecithin-cholesterol acyltransferase
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-21-
Appendix 3
13. Which of the following is the correct sequence of events in the initiation of contraction of a skeletal muscle fiber?
(A)
(B)
(C)
(D)
(E)
Depolarization
of Sarcolemma
1
2
3
4
5
Conformational
Change in
Troponin-Tropomyosin
Complex
2
5
5
2
3
14. A 90-year-old woman is brought to the emergency department
30 minutes after she fell while climbing the steps into her
house. Physical examination shows tenderness over the right
shin area. An x-ray of the right lower extremity shows a
fracture of the tibia. A DEXA scan shows decreased bone
density. Increased activity of which of the following cell types
is the most likely cause of the decrease in bone mass in this
patient?
(A)
(B)
(C)
(D)
(E)
Chondrocytes
Osteoblasts
Osteoclasts
Osteocytes
Osteoprogenitor cells
15. A 50-year-old man comes to the physician because of a cough
productive of large quantities of mucus for 6 months. He has
smoked 1 pack of cigarettes daily for 25 years. Which of the
following cell types is the most likely cause of the increase in
this patient's secretion of mucus?
(A)
(B)
(C)
(D)
(E)
Columnar ciliated epithelial cells
Goblet cells
Interstitial cells
Macrophages
Pneumocyte epithelial cells
Release of Ca2+ from
Sarcoplasmic
Reticulum
3
4
2
5
4
(A)
(B)
(C)
(D)
(E)
Cell membrane damage
Endoplasmic reticulum dilation
Mitochondrial swelling
Polysome dissociation
Sodium pump dysfunction
Acetylcholine
Binding to
Receptors
5
1
1
1
2
17. During an experimental study, an investigator finds that the
regulation of cell cycle and programmed cell death may be
initiated by the mitochondrion. The interaction of the
mitochondrion with the activation of the caspase family of
proteases and subsequent apoptosis is most likely mediated by
which of the following?
(A)
(B)
(C)
(D)
(E)
Calcium release
cAMP production
Cytochrome c release
GTP binding
Nitric oxide release
18. A 48-year-old man has hepatic cancer that is unresponsive to
standard therapy. He enrolls in a clinical study of a novel
chemotherapeutic agent that, as a side effect, blocks kinesin, a
component of the cellular microtubular transport system. One
week later, he develops skeletal muscle weakness. An
alteration in which of the following components of the
neuromuscular junction is the most likely cause of the muscle
weakness?
(A)
(B)
(C)
16. A 65-year-old man with severe atherosclerotic coronary artery
disease comes to the emergency department because of a 12hour history of chest pain. Plasma activity of the MB isozyme
of creatine kinase (MB-CK) is markedly increased. Which of
the following processes is the most likely explanation for the
increased plasma MB-CK?
Propagation into
Transverse Tubules
4
3
4
3
1
(D)
(E)
A decrease in the number of postsynaptic
neurotransmitter receptors
A decrease in the number of presynaptic
neurotransmitter vesicles
A decrease in the presynaptic neuron calcium
permeability
Impaired α-motoneuron action potential
conduction
Impaired skeletal muscle action potential
conduction
19. A polysome is actively involved in translation. The ribosomes
are attached to which of the following?
(A)
(B)
(C)
(D)
(E)
Single-stranded DNA
Double-stranded DNA
mRNA
rRNA
tRNA
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-22-
Appendix 3
20. A pathologist uses monoclonal antibodies against several intermediate filament proteins and finds that a tumor section stains positive
for cytokeratin only. The tumor most likely originated from which of the following tissues?
(A)
(B)
(C)
(D)
(E)
Connective
Epithelial
Glial
Muscle
Neural
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-23-
Appendix 3
Answer Form for Histology & Cell Biology Examination Sample Questions
(Questions 1-20)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-24-
Appendix 3
Answer Key for Histology & Cell Biology Examination Sample Questions
(Questions 1-20)
1. B
2. C
3. D
4. C
5. D
6. B
7. E
8. D
9. C
10. A
11. A
12. D
13. B
14. C
15. B
16. A
17. C
18. B
19. C
20. B
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-25-
Appendix 3
MICROBIOLOGY
1.
Microbiology Module (125 items)
General Principles
Biochemistry, Molecular Biology, Genetics
Tissue Response to Disease
Pharmacodynamic/Pharmacokinetic Processes
Microbial Biology and Infection
Microbial classification and its basis
Bacteria and bacterial diseases
Viruses and viral diseases
Fungi and fungal infections
Parasites and parasitic diseases
Principles of sterilization and pure culture technique
Immune Responses
65%B70%
5%B10%
1%B5%
1%B5%
50%B55%
1%B5%
25%B30%
20%B25%
1%B5%
1%B5%
1%B5%
1%B5%
Organ Systems
Hematopoietic & lymphoreticular
Central & peripheral nervous
Skin & related connective tissue
Musculoskeletal
Respiratory
Cardiovascular
Gastrointestinal
Renal/urinary
Reproductive
10%B15%
1%B4%
1%B4%
1%B4%
1%B4%
1%B4%
1%B4%
1%B4%
1%B4%
1%B4%
Immunology Module (25 items)
Immunologic Processes
Immunologic Diseases
12%B15%
8%B10%
A 45-year-old woman comes to the physician because of
progressive facial swelling and pain during the past week. She
has a 10-year history of poorly controlled type 1 diabetes
mellitus. Physical examination shows ecchymoses over the left
orbital and periorbital regions with proptosis. There is a
necrotic lesion with a black eschar in the left naris. Findings on
microscopic examination of material from the lesion include
broad, irregularly shaped, nonseptate hyphae with branches at
right angles. Which of the following is the most likely cause of
the nasal lesion?
(A)
(B)
(C)
(D)
(E)
Histoplasma capsulatum
Rhizopus oryzae
Sporothrix schenckii
Torulopsis glabrata
Trichophyton rubrum
2.
A 21-year-old woman who is a college student is brought to
the emergency department 2 hours after the onset of fever,
chills, severe headache, and confusion. Her temperature is
39°C (102.2°F), respirations are 16/min, and blood pressure is
100/60 mm Hg. Physical examination shows numerous
petechial lesions over the upper and lower extremities. There
is resistance to neck flexion. Analysis of cerebrospinal fluid
shows numerous leukocytes and gram-negative diplococci.
Administration of which of the following vaccines is most
likely to have prevented this patient's condition?
(A)
(B)
(C)
(D)
(E)
Haemophilus influenzae type b vaccine
Meningococcal conjugate vaccine, 4-valent
Pneumococcal conjugate vaccine, 7-valent
Pneumococcal polysaccharide vaccine,
23-valent
Varicella vaccine
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-26-
Appendix 3
3.
A sexually active 37-year-old woman comes to the physician
because of a 2-day history of pain in the area of her genitals.
Pelvic examination shows shallow, small, extremely tender
ulcers with red bases in the vulvar and vaginal regions. A
Tzanck smear shows the presence of multinucleated giant
cells. Which of the following infectious agents is the most
likely cause of these findings?
(A)
(B)
(C)
(D)
(E)
4.
5.
(A)
(B)
(C)
(D)
(E)
6.
Aggregation
Chemotaxis
Ingestion
Intracellular killing
Pseudopod formation
A 33-year-old woman contracts malaria while on a 3-month
business trip to a Central American country. She is treated with
a full course of chloroquine and recovers uneventfully. Four
months after returning to the USA, she has another febrile
illness that resembles malaria. A peripheral blood smear shows
ring forms in her erythrocytes. Which of the following species
of Plasmodium is most likely to have caused the second febrile
illness?
(A)
(B)
(C)
(D)
8.
Binding to reverse transcriptase
Binding to RNase H
Blockade of integration
Incorporation into viral DNA
Phosphorylation of nucleoside trisphosphates
A 35-year-old woman delivers a newborn who develops
meningitis. The mother has a streptococcus isolated from her
vagina. The organism agglutinates with antiserum directed
against type B surface carbohydrate. The virulence of this
organism is related to a bacterial constituent that interferes
with which of the following host phagocyte functions?
P. falciparum
P. knowlesii
P. malariae
P. vivax
Three weeks after traveling to California to study desert
flowers, a 33-year-old man develops fever, chest pain, and
muscle soreness. Two days later, red, tender nodules appear
on the shins, and the right ankle is tender and painful. An xray of the chest shows a left pleural effusion. Which of the
following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Candida albicans
Chlamydia trachomatis
Herpes simplex virus
Treponema pallidum
Trichomonas vaginalis
During an experimental study, an investigator develops a new
member of the class of non-nucleoside reverse transcriptase
inhibitors. This new drug most likely inhibits HIV infection
through which of the following mechanisms?
(A)
(B)
(C)
(D)
(E)
7.
At a banquet, the menu includes fried chicken, home-fried
potatoes, peas, chocolate eclairs, and coffee. Within 2 hours,
most of the diners become violently ill, with nausea,
vomiting, abdominal pain, and diarrhea. Analysis of the
contaminated food is most likely to yield large numbers of
which of the following organisms?
(A)
(B)
(C)
(D)
(E)
9.
Blastomycosis
Coccidioidomycosis
Histoplasmosis
Mycobacterium marinum infection
Mycoplasma pneumoniae infection
Enterococcus faecalis
Escherichia coli
Proteus mirabilis
Salmonella typhimurium
Staphylococcus aureus
A 35-year-old woman is admitted to the hospital because of
fever and dry cough for 3 days. An x-ray of the chest shows
abnormal findings. Laboratory tests show cold agglutinating
antibodies in serum. Results of routine cultures of blood and
sputum are negative. Which of the following is the most
likely pathogen?
(A)
(B)
(C)
(D)
(E)
Influenza virus
Mycobacterium tuberculosis
Mycoplasma pneumoniae
Staphylococcus aureus
Streptococcus pneumoniae
10. A mutation that causes the loss of the 3 , 5 exonuclease
activity of DNA-dependent DNA polymerase is most likely
to also cause Escherichia coli to have problems with which
cellular process?
(A)
(B)
(C)
(D)
(E)
Replacing misincorporated bases
Segregating sister chromosomes
Supercoiling of DNA
Synthesizing an RNA primer
Transferring DNA strands during conjugation
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-27-
Appendix 3
11. A 69-year-old woman comes to the emergency department
because of a 2-day history of increasingly severe fever and
back pain; she also has a burning sensation with urination, and
there is an aromatic smell to the urine. She has had three
urinary tract infections treated with ciprofloxacin during the
past year. Her temperature is 39.1°C (102.3°F). Physical
examination shows right flank tenderness. Laboratory studies
show:
Leukocyte count
Urine
pH
Protein
WBC
Bacteria
15,500/mm3
9
trace
numerous
>100,000 colonies/mL
A urine culture grows a urease-positive organism that displays
swarming motility on nonselective agar. Which of the
following is the most likely causal organism?
(A)
(B)
(C)
(D)
(E)
Enterococcus faecalis
Escherichia coli
Klebsiella pneumoniae
Proteus mirabilis
Staphylococcus saprophyticus
12. During an experiment, an investigator gently abrades the skin
from the flank of a mouse, creating a 1 x 2-cm skin window. A
glass coverslip is then placed over the area so that cells
attracted to the site attach to the coverslip for assessment. Two
hours later, an extravasation of cells from the vasculature is
noted on the coverslip. Which of the following complement
components is the direct cause of the enhanced vascular
permeability and chemoattraction in the abraded skin area in
this experiment?
(A)
(B)
(C)
(D)
(E)
C1q
C4b
C5a
C7
C9
13. A 35-year-old man comes to the physician for a follow-up
examination. He has had persistent left upper quadrant
abdominal pain for 3 weeks despite therapy with omeprazole.
Upper esophagogastroduodenoscopy shows an active duodenal
ulcer. Tests of gastric and duodenal biopsy specimens for
urease are positive. Which of the following is the most likely
causal organism?
(A)
(B)
(C)
(D)
(E)
Campylobacter jejuni
Clostridium difficile
Helicobacter pylori
Proteus vulgaris
Salmonella typhi
14. A 2-year-old boy is diagnosed with staphylococcal scalded
skin syndrome. In vitro studies show the causal organism to
be resistant to penicillin. Which of the following mechanisms
of action is most likely involved in this resistance?
(A)
(B)
(C)
(D)
(E)
Active efflux of the antibiotic from the
bacteria
Decreased uptake of the antibiotic into the
bacteria
Mutation of the 30S ribosomal subunit
Mutation of the 50S ribosomal subunit
Production of β-lactamase by the bacteria
15. A 3-year-old girl is brought to the emergency department by
her father because of a persistent cough for 2 weeks. She
sometimes vomits following a paroxysm of coughing. While
she is not coughing, she appears well. She has not yet
received any routine childhood vaccinations. Her temperature
is 37°C (98.6°F). Physical examination shows petechiae over
the sclera and face. Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)
Diphtheria
Influenza
Pertussis
Plague
Tularemia
16. An investigator injects an experimental animal with a newly
discovered bacterial strain to evaluate T-lymphocyte
activation. It is found that bacterial engulfment by
macrophages results in the presentation of bacterial-derived
peptide ligands to CD4+ T lymphocytes. Which of the
following cell-surface molecules on the macrophage is most
directly involved in the presentation of the processed
peptides?
(A)
(B)
(C)
(D)
(E)
CD28
Class II MHC
Fcε receptor
Interleukin-2 (IL-2) receptor
Membrane immunoglobulin
17. An investigator conducts an experiment on Clostridium
perfringens and then sterilizes the culture dishes by
autoclaving. This method of sterilization is most appropriate
because it ensures that which of the following bacterial
structures are inactivated?
(A)
(B)
(C)
(D)
(E)
Adhesion factors
Endotoxins
Fimbriae
Pili
Spores
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-28-
Appendix 3
18. A 52-year-old woman living in Maryland comes to the
physician because of a 1-week history of low-grade fever,
fatigue, and a red rash over the skin behind her left knee. She
is an avid hiker. Her temperature is 38°C (100.4°F). Physical
examination shows an 8-cm, warm, nontender, erythematous
lesion with partial central clearing over the skin of the left
popliteal area. Which of the following is the most likely causal
organism?
(A)
(B)
(C)
(D)
(E)
Borrelia burgdorferi
Ehrlichia chaffeensis
Francisella tularensis
Rickettsia rickettsii
Streptobacillus moniliformis
20. A 45-year-old man comes to the physician because of fever
and night sweats for 8 days. He has Crohn disease treated
with infliximab. His temperature is 39°C (102.2°F). Physical
examination shows diffuse cervical lymphadenopathy. A
biopsy specimen of the nodes shows caseating granulomas.
No organisms are identified on Gram stain. Which of the
following is the most likely causal organism?
(A)
(B)
(C)
(D)
(E)
Aspergillus niger
Brucella abortus
Francisella tularensis
Mycobacterium tuberculosis
Treponema pallidum
19. An 8-month-old girl is brought to the emergency department
because of a 1-day history of rapid breathing. Her temperature
is 38.4°C (101.1°F), pulse is 160/min, respirations are 60/min,
and blood pressure is 100/68 mm Hg. Bilateral expiratory
wheezing and crackles are heard on auscultation. A chest x-ray
shows areas of atelectasis and hyperinflation. Which of the
following is the most likely causal virus?
(A)
(B)
(C)
(D)
(E)
Measles virus
Respiratory syncytial virus
Rhinovirus
Rotavirus
Varicella-zoster virus
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-29-
Appendix 3
Answer Form for Microbiology Sample Questions
(Questions 1-20)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-30-
Appendix 3
Answer Key for Microbiology Sample Questions
(Questions 1-20)
1. B
2. B
3. C
4. A
5. C
6. D
7. B
8. E
9. C
10. A
11. D
12. C
13. C
14. E
15. C
16. B
17. E
18. A
19. B
20. D
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-31-
Appendix 3
NEUROSCIENCE
Neuroscience (125 items)
Biology of cells (signal transduction, muscle cells)
Central and peripheral nervous system
Normal processes
Embryonic development
Organ structure and function
Spinal cord
Brain stem
Brain
Sensory systems
Motor systems
Autonomic nervous systems
Peripheral nerve
Cell/tissue structure and function
Repair, regeneration, and changes associated with stage of life
Abnormal processes
Infectious, inflammatory, immunologic disorders
Traumatic and mechanical disorders
Neoplastic disorders
Metabolic/regulatory disorders
Vascular disorders
Systemic disorders
Idiopathic disorders
Congenital/metabolic disorders
Degenerative disorders
Paroxysmal disorders
Disorders of the special senses
Principles of therapeutics
Psychopathology/Psychopharmacology
(25 items optional)
Neuropathology
(25 items optional)
Nutrition
Central and peripheral nervous system
Infectious, inflammatory,
immunologic disorders
Traumatic/mechanical disorders
Neoplastic disorders
Vascular disorders
Congenital/metabolic disorders
Degenerative disorders
1%B5%
95%B99%
65%B70%
1%B5%
50%B55%
5%B10%
5%B10%
5%B10%
5%B10%
5%B10%
1%B5%
1%B5%
5%B10%
1%B5%
25%B30%
1%B5%
1%B5%
1%B5%
1%B5%
1%B5%
1%B5%
1%B5%
1%B5%
1%B5%
1%B5%
1%B5%
1%B5%
1%B5%
95%B99%
20%B25%
1%B5%
20%B25%
15%B20%
5%B10%
20%B25%
Personality traits or coping style
Central/peripheral nervous system
Psychopathologic disorders
Early-onset disorders
Substance abuse disorders
Schizophrenia
Mood disorders
Anxiety disorders
Somatoform disorders
Physical and sexual abuse
Other disorders
Psychopharmacologic agents
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-32-
1%B5%
95%B99%
70%B75%
1%B5%
10%B15%
10%B15%
15%B20%
10%B15%
1%B5%
5%B10%
1%B5%
20%B25%
Appendix 3
1.
A 43-year-old man sustains a wound to the lateral neck. This
results in weakness of elevation and retraction of the shoulder
on the ipsilateral side and difficulty turning the head up and
toward the contralateral side. No sensory changes are present.
Which of the following nerves most likely has been injured?
(A)
(B)
(C)
(D)
(E)
2.
5.
Axillary
Lateral cord of the brachial plexus
Phrenic
Spinal accessory
Suprascapular
An investigator is studying normal sleep patterns in healthy
volunteers. Saccadic motions of the eyes are seen
approximately 90 minutes after the subjects fall asleep. Which
of the following is most likely to be observed in the subjects
during this period of saccadic eye movements?
(A)
(B)
(C)
(D)
(E)
6.
(A) Difficulty awakening
(B) An EEG pattern resembling that of the waking
state
(C) Hyperactive muscle tone
(D) Increased movements
(E) Irregular respiratory rhythm
3.
Drug X applied to a nerve axon decreases the duration of the
action potential without affecting the resting potential or peak
amplitude of the action potential. Which of the following is the
most likely mechanism of action of Drug X?
7.
Block of voltage-dependent Na+ permeability
Decrease in the rate of Na+ inactivation
Decrease in voltage-dependent Na+ permeability
Increase in the rate of voltage-dependent
changes in K+ permeability
(E) Inhibition of the Na+–K+ pump
A 65-year-old man has loss of pain and temperature sensation
on the right side of the face and from the neck down on the
left. Examination shows partial paralysis of the soft palate,
larynx, and pharynx, and ataxia, all on the right. The most
likely cause of these findings is thrombosis to which of the
following arteries?
(A)
(B)
(C)
(D)
(E)
Basilar
Right posterior inferior cerebellar
Left posterior inferior cerebellar
Right superior cerebellar
Left superior cerebellar
Choroid plexus
Dura mater
Pia mater
Roof of the third ventricle
A 68-year-old woman is brought to the physician by her
husband because of strange behavior. The previous
evening, she had gotten up suddenly from the dinner table
and started to undress in front of guests. Further
questioning discloses a 1-year history of a progressive
change in behavior. She writes everything down on a
notepad; otherwise, she forgets. She cannot remember the
names of her four grandchildren or the date of her wedding
anniversary. These symptoms are most likely associated
with a deficit in which of the following?
(A)
(B)
(C)
(D)
(E)
8.
Acute occlusion of the retinal artery
Demyelination of the optic nerve
Increased intracranial pressure
Inflammation of the anterior chamber
Inflammation of the optic nerve
A 4-month-old boy is brought to the physician by his
mother for a well-child examination. He is at the
98th percentile for head circumference. Physical
examination shows dilation of the scalp veins and spasticity
of the lower extremities. The physician suspects excessive
cerebrospinal fluid accumulation in the ventricular system
of the brain. The source of this fluid is most likely which of
the following?
(A)
(B)
(C)
(D)
(A)
(B)
(C)
(D)
4.
A 45-year-old man has a progressively severe headache.
Funduscopic examination discloses blurred margins and
bulging of the optic discs. The retinal veins are engorged
and show no pulsatile flow. Which of the following is the
mechanism most likely to explain these findings?
Acetylcholine
Dopamine
Glucose 6-phosphate dehydrogenase
Insulin
Serotonin
A 50-year-old man has had gradually progressive hand
weakness. He has atrophy of the forearm muscles,
fasciculations of the muscles of the chest and arms,
hyperreflexia of the lower extremities, and extensor plantar
reflexes. Sensation is not impaired. Which of the following
is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Amyotrophic lateral sclerosis
Dementia, Alzheimer type
Guillain-Barré syndrome
Multiple cerebral infarcts
Multiple sclerosis
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-33-
Appendix 3
9.
An 8-year-old boy is brought to the physician by his mother
because he is not paying attention in class. His mother says
that his teacher has described his in-school behavior as
"frequently stopping what he is doing and then blinking and
making chewing movements." His mother has noticed that he
sometimes "stares off into space" and seems to be
daydreaming. Physical examination shows no abnormalities.
An EEG during one of the episodes shows generalized spikeand-wave bursts at 3 Hz per second. This patient most likely
has which of the following types of seizures?
(A)
(B)
(C)
(D)
(E)
Absence
Akinetic
Complex partial
Generalized tonic-clonic
Myoclonic
10. A previously healthy 18-year-old man is brought to the
emergency department because of fever, a poorly localized
headache, and a stiff neck for 12 hours. The symptoms were
preceded by nasal congestion, muscle aches, and chills 3 days
ago. His temperature is 38.7°C (101.6°F). Physical
examination shows nuchal rigidity and photophobia. There is
no papilledema. Neurologic examination shows no focal
findings. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
Acute meningitis
Classic migraine
Cluster headache
Idiopathic intracranial hypertension
Subarachnoid hemorrhage
Temporal arteritis
Tension-type headache
11. A 36-year-old woman comes to the physician because of a 10month history of difficulty falling asleep due to a crawling
sensation in her legs. She has to get up several times during the
night to relieve the feeling. The symptoms started shortly after
she delivered her son 1 year ago. She says her husband
complains because she has become a "jumpy" sleeper, and her
movements sometimes wake him up. Physical examination
shows no abnormalities. Which of the following is the most
likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Amyotrophic lateral sclerosis
Multiple sclerosis
REM sleep behavior disorder
Restless legs syndrome
Sleep myoclonus
12. A 53-year-old woman dies 4 days after an automobile
collision. She sustained multiple injuries including a
femoral fracture. Widespread petechiae are found in the
cerebral white matter at autopsy. Which of the following is
the most likely cause of these findings?
(A)
(B)
(C)
(D)
(E)
Acute respiratory distress syndrome
Contrecoup injury
Fat embolization
Septicemia
Subdural hematoma
13. A 23-year-old woman with chronic hepatic disease is
brought to the physician because of a 6-month history of
progressive behavioral and personality changes, difficulty
walking, clumsiness of her arms and legs, and slurred
speech. Physical examination shows facial dystonia and
dysarthria. There is intention tremor, rigidity, and ataxia of
all extremities. Slit-lamp examination shows a brownish
ring around the cornea of both eyes. Which of the following
abnormalities in plasma is most likely in this patient?
(A)
(B)
(C)
(D)
(E)
(F)
Decreased calcium concentration
Decreased ceruloplasmin concentration
Decreased transferrin concentration
Increased ammonium concentration
Increased ketones
Increased lactate concentration
14. A new drug is developed that prevents the demyelinization
occurring in the progress of multiple sclerosis. The drug
protects the cells responsible for the synthesis and
maintenance of myelin in the central nervous system. These
cells are most likely which of the following?
(A)
(B)
(C)
(D)
(E)
Astrocyte
Ependymal cell
Microglial cell
Oligodendrocyte
Schwann cell
15. A 47-year-old man with Down syndrome is brought to the
physician by his sister because of an 8-month history of
regression in his abilities. The sister describes a gradual
decline in his language skills and progressive fearfulness.
The patient no longer remembers songs that he has known
for years, and he does not wish to participate in family
activities anymore. Pathologic examination of the brain
would most likely show which of the following in this
patient?
(A)
(B)
(C)
(D)
(E)
Deposits of long-chain fatty acids
Intracellular arylsulfatase A
Lewy bodies and nigral atrophy
Neuronal plaques and tangles
Perivenular inflammatory cells
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-34-
Appendix 3
16. A 29-year-old man who emigrated from Scotland 3 years ago
is brought to the emergency department because of severe
shortness of breath for 2 hours. He has a debilitating condition
that began 2 years ago with an odd sticky feeling of his skin,
but physical examination at that time showed no abnormalities.
His condition has progressed to include severe major
depressive disorder, dementia, unsteady gait, difficulty
walking, and impaired coordination. He now is confined to a
wheelchair and has severe dementia and the inability to speak.
There is no family history of a similar condition. On arrival,
his respirations are 24/min, and he dies shortly thereafter. At
autopsy, examination of the brain shows a spongiform
encephalopathy. Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)
Dementia, Alzheimer type
Frontotemporal dementia
Parkinson disease
Pick disease
Variant Creutzfeldt-Jakob disease
17. A 52-year-old woman comes to the physician because of
gradual loss of feeling in her feet during the past 6 months. She
is a portrait painter. She has a 23-year history of hypertension
and a 20-year history of type 2 diabetes mellitus. Menopause
occurred 1 year ago. She has smoked 2 packs of cigarettes
daily for 30 years. She took an oral contraceptive for 20 years.
Current medications include hormone replacement therapy,
diuretics, and an oral hypoglycemic agent. Her blood pressure
is 135/85 mm Hg. Sensation to pinprick is decreased over both
feet. Which of the following is the strongest predisposing risk
factor of this new finding?
(A)
(B)
(C)
(D)
(E)
Hypertension
Long-term exposure to paint fumes
Long-term use of exogenous hormones
Long-term use of tobacco
Type 2 diabetes mellitus
19. A 23-year-old woman is brought to the physician by her
roommate because of a 7-month history of progressive
changes in behavior. The roommate states that the patient
isolates herself in her room most of the time and has little
to do with others. The patient has accused the roommate of
trying to poison her food and has heard voices telling her
that she will be killed. She appears disheveled. On
examination, she is extremely guarded and says little.
When she does speak, her statements are illogical and
difficult to comprehend. She denies any disturbance of
mood. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
Brief psychotic disorder
Chronic hallucinogen abuse
Delusional disorder
Major depressive disorder with psychotic
features
(E) Schizophrenia, paranoid type
20. A 21-year-old woman comes to the physician 2 weeks
after being involved in a motor vehicle collision that
occurred when she fell asleep while driving. She says
that during the past 2 years she has had several incidents
of falling asleep at inappropriate times, including while
walking. She also reports intermittent loss of muscle tone
while awake and occasional sleep paralysis. She does not
snore. Physical examination shows no abnormalities.
Polysomnography shows a sleep latency of less than 5
minutes and four sleep-onset REM periods. Which of the
following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Chronic insomnia
Narcolepsy
Restless legs syndrome
Sleep apnea
Sleep bruxism
18. A 49-year-old woman comes to the physician because of a 3month history of waking at night because of pain and
numbness of her right hand. She reports that shaking her hand
decreases the severity of the pain. She has been cutting hair at
a beauty salon 6 days weekly for 35 years. Examination of the
right hand shows tenderness with palpation and distal tingling
on percussion of the volar wrist. Prolonged forcible palmar
flexion of the right wrist produces tingling. Which of the
following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Carpal tunnel syndrome
Early rheumatoid arthritis
Osteoarthritis
Stress fracture
Tendinitis
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-35-
Appendix 3
Answer Form for Neuroscience Sample Questions
(Questions 1-20)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-36-
Appendix 3
Answer Key for Neuroscience Sample Questions
(Questions 1-20)
1. D
2. B
3. D
4. B
5. C
6. A
7. A
8. A
9. A
10. A
11. D
12. C
13. B
14. D
15. D
16. E
17. E
18. A
19. E
20. B
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-37-
Appendix 3
PATHOLOGY
1.
35%B40%
1%B5%
1%B5%
10%B15%
5%B10%
1%B5%
5%B10%
Organ Systems
Hematopoietic & lymphoreticular
Central & peripheral nervous
Skin & related connective tissue
Musculoskeletal
Respiratory
Cardiovascular
Gastrointestinal
Renal/urinary
Reproductive
Endocrine
60%B65%
5%B10%
5%B10%
5%B10%
1%B5%
1%B5%
5%B10%
5%B10%
5%B10%
5%B10%
1%B5%
A 16-year-old boy is undergoing evaluation for jaundice.
Laboratory studies show normal hepatic enzyme activities, a
negative direct antiglobulin (Coombs) test, increased mean
corpuscular hemoglobin concentration, and increased osmotic
fragility of erythrocytes. Which of the following types of
erythrocyte is most likely to be seen on a peripheral blood
smear?
(A)
(B)
(C)
(D)
(E)
2.
General Principles
Cell Biology
Human Development and Genetics
Biology of Tissue Response
Multisystem Processes
Microbial Biology and Infection
Immune Responses
Ovalocyte
Schistocyte
Spherocyte
Target cell
Teardrop cell
A 34-year-old woman is brought to the emergency department
by her husband because of confusion for 2 hours. She is
unconscious on arrival. Her husband says that she has a 1-year
history of episodes of nervousness, light-headedness, and
dizziness that resolve after she eats a meal. Physical
examination shows no other abnormalities. Her serum glucose
concentration is 25 mg/dL. After an intravenous infusion of
0.9% saline and glucose, she regains consciousness. Which of
the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
3.
A 60-year-old man comes to the physician because of a
cough for 2 months. He says that he has noticed changes in
his face during the past 3 months. He has smoked 2 packs of
cigarettes daily for 30 years. His temperature is 37°C
(98.6°F), pulse is 72/min, respirations are 19/min, and blood
pressure is 160/95 mm Hg. Physical examination shows a
round face, central obesity, excess fat over the posterior neck
and back, and abdominal striae. His serum calcium
concentration is 9 mg/dL. Urine dipstick of a clean-catch
midstream specimen shows 3+ glucose. A chest x-ray shows
a 3-cm mass in the left upper lobe with enlargement of hilar
nodes. A biopsy specimen of the mass shows small cell
carcinoma. Further serum studies are most likely to show an
increased concentration of which of the following proteins?
(A)
(B)
(C)
(D)
(E)
Adrenocorticotropic hormone
Epidermal growth factor
IgM
Parathyroid hormone-related protein
Serotonin
Cushing syndrome
Insulinoma
Multiple endocrine neoplasia syndrome
Pancreatic gastrinoma
Pheochromocytoma
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-38-
Appendix 3
4.
A 45-year-old man with chronic pancreatitis has a 9-kg (20-lb)
weight loss and diarrhea. Analysis of a 24-hour stool sample
shows 28 g of fat. A deficiency of which of the following
enzymes is the most likely cause?
(A)
(B)
(C)
(D)
(E)
5.
6.
Emphysema
Lung abscess
Mesothelioma
Small cell carcinoma of the lung
Viral pneumonia
A previously healthy 28-year-old man dies in a motor vehicle
collision. At autopsy, the kidneys are enlarged bilaterally, and
each weighs 3 kg. The external surface of the kidneys appears
to be a mass of cysts. Microscopic examination of the kidneys
shows intact nephrons interspersed between the cysts. The
most likely cause of these changes in the kidneys involves
which of the following modes of inheritance?
(A)
(B)
(C)
(D)
(E)
7.
Amylase
Carboxypeptidase
Lactase
Lipase
Lipoprotein lipase
A 70-year-old man comes to the physician because of a 2-year
history of shortness of breath and progressive chest pain. He
worked as a carpenter installing insulation from the ages of 21
to 31 years. Physical examination shows absent breath sounds
and dullness to percussion over the right lung base. A chest xray shows thickened pleura on the right side and a mediumsized pleural effusion. Pleural fluid studies show a protein
concentration greater than 3 g/dL (N=1–2). A pleural biopsy
specimen shows spindle cells. Which of the following is the
most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Autosomal dominant
Autosomal recessive
Chromosome 22q11.2 deletion
Mitochondrial
X-linked
An autopsy of a 24-year-old woman shows pleuritis,
membranous thickening of glomerular capillary walls,
concentric rings of collagen around splenic arterioles, and
excrescences on the underside of the mitral valve. Analysis of
blood is most likely to show which of the following?
(A)
(B)
(C)
(D)
(E)
8.
Antinuclear antibody
Increased C3 concentration
Lymphocytosis
Monoclonal gammopathy
Positive bacterial culture
At autopsy, the heart of a 30-year-old man weighs 550 g. The
left ventricle is dilated and hypertrophied. The aortic root is
markedly dilated, and the aortic valve cusps are intact. The
external iliac arteries contain irregular, focal cystic areas
within the media with pools of mucopolysaccharide and
fraying fragmentation of the elastica. Which of the following
is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
9.
Ankylosing spondylitis
Cardiovascular syphilis
Marfan syndrome
Osteogenesis imperfecta, type II (recessive)
Systemic lupus erythematosus
A 10-year-old boy is brought to the emergency department 15
minutes after he sustained abdominal injuries in a motor
vehicle collision. Physical examination shows massive
ecchymoses over the trunk and abdomen. A CT scan shows
internal bleeding. The patient undergoes operative removal of
a portion of the lower left lobe of the lung, the left lobe of the
liver, half of the left kidney, half of the spleen, and a 2-foot
section of the small intestine. Assuming survival of the acute
trauma, which of the following organs is likely to have the
most complete regeneration in this patient?
(A)
(B)
(C)
(D)
(E)
Kidney
Liver
Lung
Small intestine
Spleen
10. A previously healthy 2-year-old boy is brought to the
emergency department because of bloody stools for 2 days.
His vital signs are within normal limits. Abdominal
examination shows no abnormalities. Laboratory studies
show:
Hemoglobin
Hematocrit
Leukocyte count
Platelet count
11 g/dL
37%
9500/mm3
250,000/mm3
Test of the stool for occult blood is positive. During an
emergency laparotomy, a 3 x 2-cm protrusion is found on the
antimesenteric border of the small intestine approximately 50
cm proximal to the ileocecal valve. Which of the following is
the most likely cause of this patient's condition?
(A)
(B)
(C)
(D)
(E)
Carcinoid tumor
Ectopic adrenal gland
Meckel diverticulum
Retrocecal appendix
Umbilical hernia
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-39-
Appendix 3
11. A 50-year-old man comes to the physician because of
progressive fatigue and darkening of his skin during the past 2
years. He has not spent much time in the sun during this
period. Physical examination shows slate-gray skin and
hepatomegaly. Serum studies show:
Ferritin
Transferrin saturation
AST
ALT
500 ng/mL
70% (N=20%–60%)
41 U/L
45 U/L
A liver biopsy specimen stained with Prussian blue is positive.
Which of the following best describes the altered function of
mutated HFE gene product in this patient?
(A)
(B)
(C)
(D)
(E)
Decreased lysozyme synthesis
Decreased NADPH production
Decreased oxidase activity
Increased fatty acid absorption
Increased iron absorption
12. A 69-year-old woman is brought to the emergency department
because of progressive difficulty with her vision during the
past day. She also has a 3-month history of headache and scalp
tenderness. She says, "This morning I had a blind spot in my
left eye, and it just grew bigger as the day went on." Her vital
signs are within normal limits. Ophthalmologic examination
shows visual acuity of 20/100 in the left eye and 20/40 in the
right eye. Physical examination shows no other abnormalities.
Laboratory studies show an erythrocyte sedimentation rate of
129 mm/h. Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)
Acute occipital infarction
Glaucoma
Left carotid dissection
Systemic lupus erythematosus
Temporal arteritis
13. A 30-year-old woman comes to the physician because of a 2month history of unsteady gait and numbness of both legs.
Eight years ago, she underwent resection of the terminal ileum
because of severe Crohn disease. Physical examination shows
mild spastic weakness. Sensation to pinprick, vibration, and
fine touch is decreased in the upper and lower extremities. A
deficiency of which of the following is the most likely
underlying cause of these findings?
(A)
(B)
(C)
(D)
(E)
14. A 10-month-old girl is brought to the physician by her father
because she does not seem to be gaining weight despite an
increased appetite. He says that she passes 8 to 10 stools
daily. She has no history of major medical illness, but during
the past winter she had several infections of the ear and
respiratory tract that were treated with antibiotics. She
appears malnourished but is in no apparent distress. She is at
the 5th percentile for length and weight. Diffuse crackles are
heard over the lower lung fields on auscultation. Her sweat
chloride concentration is 69 mmol/L. Which of the following
is the most likely underlying cause of these findings?
(A)
(B)
(C)
(D)
(E)
Abnormal cystic fibrosis transmembrane
conductance regulator gene function
Acid phosphatase deficiency
Atypical conjugation of arylsulfatase A, B, and
C
α-L-Fucosidase deficiency
Impaired production of phosphatidylcholine
(lecithins)
15. The chairman of a large pathology department is planning for
the personnel that he will need in the future. He is trying to
decide whether his department will have more need for a
dermatopathologist or a cytopathologist. He decides against
the cytopathologist because he expects the number of Pap
smears to fall off dramatically in the future. The development
of which of the following is the most likely reason for this
expected decrease in the number of Pap smears?
(A)
(B)
(C)
(D)
(E)
Highly effective oral drugs that prevent
dysplasia of the uterine cervix
Operative guidelines requiring the amputation
of the cervix for mild squamous
dysplasia
Three-dimensional conformal radiation
treatment
A vaccine against high-risk human
papillomaviruses
Vaginal suppositories that markedly reduce the
number of bacteria in the vagina
Folic acid
Iron
Protein
Vitamin B1 (thiamine)
Vitamin B12 (cobalamin)
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-40-
Appendix 3
16. A 22-year-old woman comes to the physician because of a 1day history of fever and right flank pain. Her temperature is
39°C (102.2°F). Physical examination shows right flank
tenderness. Urinalysis shows bacteria, numerous WBC/hpf,
and WBC casts. Complete blood count shows leukocytosis.
Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Cervicitis
Cystitis
Pyelonephritis
Urethritis
Vaginitis
17. A previously healthy 30-year-old woman comes to the
physician for a follow-up visit after a chest x-ray shows
bilateral hilar adenopathy and a calcified 1-cm nodule in the
periphery of the right lower lobe. Physical examination shows
no abnormalities. Her serum calcium concentration is 11
mg/dL. Pulmonary function test results are within normal
limits. Bronchoscopy with bronchoalveolar lavage yields 40%
lymphocytes and 60% macrophages, with a CD4:CD8 Tlymphocyte ratio of 10:1. A bronchial biopsy specimen shows
a nonnecrotizing granuloma. Specially stained sections of a
bronchial biopsy specimen show no acid-fast bacilli or fungi.
Cultures of lung tissue grow no organisms. Which of the
following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
Coccidioidomycosis
Hypersensitivity pneumonitis
Sarcoidosis
Silicosis
Tuberculosis
Wegener granulomatosis
19. A 50-year-old man with type 2 diabetes mellitus has a 1-week
history of swelling and a feeling "like electric shocks" in his
right wrist and hand. He is a computer programmer, and the
shock-like feeling is worse with activity and at the end of the
day. There is atrophy of the right thenar eminence. With the
hand hyperextended, pain radiates into the fingers when the
examiner taps the flexor surface of the distal wrist. Which of
the following nerves is most likely compressed in this
patient?
(A)
(B)
(C)
(D)
(E)
Deep radial
Median
Musculocutaneous
Radial ulnar
Superficial radial
20. A 3-year-old boy is brought to the physician because of a 2day history of fever and an itchy rash. The rash began on his
face and then spread to his trunk, arms, and legs. Several
children at his day-care center have had similar symptoms.
His temperature is 38.9°C (102°F), pulse is 100/min,
respirations are 20/min, and blood pressure is 110/60 mm Hg.
Physical examination shows multiple red papules and vesicles
over the face, trunk, and upper and lower extremities. Some
vesicles contain clear fluid, whereas others are crusted.
Which of the following is the most likely causal virus?
(A)
(B)
(C)
(D)
(E)
Cytomegalovirus
Epstein-Barr virus
Herpes simplex virus 2
Human papillomavirus
Varicella-zoster virus
18. A 3-year-old girl is brought to the emergency department 30
minutes after she tripped and fell. Physical examination shows
blue sclera and edema and tenderness over the right proximal
lower extremity. X-rays show a fracture of the right femur, as
well as several fractures of varying ages of the left clavicle,
right humerus, and right fibula. Which of the following is the
most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Achondroplasia
Ehlers-Danlos syndrome
Hurler syndrome
Marfan syndrome
Osteogenesis imperfecta
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-41-
Appendix 3
Answer Form for Pathology Subject Test Examination Sample Questions
(Questions 1-20)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-42-
Appendix 3
Answer Key for Pathology Subject Test Examination Sample Questions
(Questions 1-20)
1. C
2. B
3. A
4. D
5. C
6. A
7. A
8. C
9. B
10. C
11. E
12. E
13. E
14. A
15. D
16. C
17. C
18. E
19. B
20. E
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-43-
Appendix 3
PHARMACOLOGY
General Principles
Pharmacokinetics, Pharmacodynamics
Antimicrobial Drugs
Carcinogens, Environmental Insults,
Antineoplastic/Immunosuppressant Drugs
40%B45%
5%B10%
10%B15%
Organ Systems (including mechanism of action, therapy, adverse effect)
Hematopoietic & lymphoreticular
Central & peripheral nervous
Anesthetics
Hypnotics
Psychopharmacologic agents
Anticonvulsants
Stimulants, amphetamines
Antiparkinsonian drugs
Botulinum toxin
Neuromuscular junction blocking agents
Antiglaucoma drugs
Drugs used to decrease intracranial pressure
Antimigraine agents
Drugs affecting autonomic nervous system
55%B60%
5%B10%
35%B40%
1%B5%
1%B5%
1%B5%
1%B5%
1%B5%
1%B5%
1%B5%
1%B5%
1%B5%
1%B5%
1%B5%
5%B10%
5%B10%
Skin & related connective tissue
Musculoskeletal
Respiratory
Cardiovascular
Gastrointestinal
Renal/urinary
Reproductive
Endocrine
1.
Ten months after starting procainamide therapy for cardiac
arrhythmias, a 56-year-old man develops arthritis and other
symptoms consistent with drug-induced systemic lupus
erythematosus. Results of a blood test are positive for
antinuclear antibodies. This finding is consistent with which of
the following genetic polymorphisms in drug metabolism?
(A)
(B)
(C)
(D)
(E)
Debrisoquine 4-hydroxylase deficiency
Erythrocyte catechol-O-methyltransferase
deficiency
Glucose 6-phosphate dehydrogenase deficiency
Phenytoin hydroxylase deficiency
Slow acetylator phenotype
1%B5%
1%B5%
1%B5%
15%B20%
1%B5%
5%B10%
1%B5%
1%B5%
2. An 83-year-old man has a 2-month history of akinesia,
rigidity, and tremor. He has been taking a drug for the past 7
years to control severe behavioral and psychiatric symptoms
associated with dementia, Alzheimer type. This adverse
effect is most likely mediated through which of the
following?
(A)
(B)
(C)
(D)
(E)
(F)
Anticholinergic effects
Antidopaminergic effects
Downregulation of γ-aminobutyric acid
(GABA)
Inhibition of norepinephrine reuptake
Inhibition of serotonin reuptake
Upregulation of GABA
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-44-
Appendix 3
3.
A 23-year-old man who is HIV positive has Pneumocystis
jiroveci (formerly P. carinii) pneumonia. Therapy is started
with trimethoprim-sulfamethoxazole, and his pneumonia
resolves. The pharmacotherapy was effective because of
inhibition of which of the following?
(A)
(B)
(C)
(D)
(E)
4.
5.
Calcium
Carotene
Creatinine
Iron
Orotic acid
Phosphate
Uric acid
DNA
DNA polymerase
Growth factor receptors
Reverse transcriptase
Ribosomes
An 18-year-old woman comes to the physician because of
nausea, vomiting, and abdominal pain 1 hour after ingesting a
glass of wine with dinner. Three days ago, she began antibiotic
treatment for vaginitis after a wet mount preparation of vaginal
discharge showed a motile protozoan. This patient most likely
has been taking which of the following drugs?
(A)
(B)
(C)
(D)
Ceftriaxone
Chloroquine
Clindamycin
Metronidazole
A 20-year-old woman comes to the emergency department
after ingesting at least 30 tablets of an unknown drug. Initial
physical examination shows no abnormalities. Thirty-six
hours later, serum AST activity is 1500 U/L, and serum ALT
activity is 2000 U/L. The drug this patient ingested is most
likely which of the following?
(A)
(B)
(C)
(D)
(E)
8.
Acetaminophen
Aspirin
Chlorpheniramine
Ibuprofen
Prednisone
A 42-year-old woman who is a chemist is brought to the
emergency department because of a 1-hour history of severe
abdominal cramps, nausea and vomiting, hypotension,
bradycardia, sweating, and difficulty breathing due to
bronchospasm and congestion. Exposure to which of the
following is most likely?
(A)
(B)
(C)
(D)
(E)
9.
A 62-year-old man is being treated with cisplatin for small cell
carcinoma of the lungs. The efficacy of cisplatin depends on
interaction with which of the following?
(A)
(B)
(C)
(D)
(E)
6.
Cell wall synthesis
Dihydrofolate reductase
Incorporation of p-aminobenzoic acid
Incorporation of sterol into membranes
Topoisomerase II
A 62-year-old man comes to the physician because of burning
pain and tenderness of his right great toe 1 day after heavy
ethanol consumption. Physical examination shows erythema,
swelling, warmth, and tenderness of the right great toe. After a
2-week course of nonsteroidal anti-inflammatory drug
treatment, his symptoms decrease in severity but do not
completely resolve. The serum concentration of which of the
following is most likely increased in this patient?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
7.
Acrylamide
Cyanogen bromide
Isoflurophate (DFP)
Phentolamine
Propranolol
A 35-year-old woman receives the diagnosis of
gastroesophageal reflux disease. Omeprazole is administered.
Which of the following is the most likely mechanism of
action of this drug?
(A)
(B)
(C)
(D)
(E)
Blockade of gastrin receptors
Blockade of H1 receptors
Blockade of M3 receptors
Inhibition of H+–K+ ATPase activity
Inhibition of synthesis of gastrin
10. In a 40-year-old man with hypertension, which of the
following agents has the greatest potential to activate
presynaptic autoreceptors, inhibit norepinephrine release, and
decrease sympathetic outflow?
(A)
(B)
(C)
(D)
(E)
α1-Adrenergic agonist
α2-Adrenergic agonist
β1/β2 -Adrenergic antagonist
Angiotensin-converting enzyme inhibitor
Calcium antagonist
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-45-
Appendix 3
11. A 35-year-old woman is brought to the emergency department
because of an 18-hour history of severe pain, nausea, vomiting,
diarrhea, and anxiety. She was discharged with a pain
medication from the hospital 2 weeks ago after treatment of
multiple injuries sustained in a motor vehicle collision. She
took her last dose 36 hours ago. Her temperature is 36.6°C
(97.8°F), pulse is 105/min, respirations are 24/min, and blood
pressure is 160/85 mm Hg. Physical examination shows
rhinorrhea and piloerection. Bowel sounds are normal. She
rates the pain as an 8 on a 10-point scale. Which of the
following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
Acute appendicitis
Caffeine withdrawal
Ethanol withdrawal
Gastric ulcers
Gastroenteritis
Oxycodone withdrawal
12. A 21-year-old woman comes to the physician for counseling
prior to conception. She delivered a female newborn with
anencephaly 1 year ago. The newborn died at the age of 4
days. She asks the physician if she can take any vitamins to
decrease her risk for conceiving a fetus with anencephaly. It is
most appropriate for the physician to recommend which of the
following vitamins?
(A)
(B)
(C)
(D)
(E)
(F)
Biotin
Folic acid
Vitamin B1 (thiamine)
Vitamin B2 (riboflavin)
Vitamin B6 (pyridoxine)
Vitamin B12 (cyanocobalamin)
13. A 38-year-old man comes to the physician because of a 6month history of occasional episodes of chest tightness,
wheezing, and cough. The symptoms are often mild and
resolve spontaneously. He has been otherwise healthy. His
respirations are 13/min. The lungs are clear to auscultation.
Cardiac examination and chest x-ray show no abnormalities.
Which of the following agents is most appropriate to treat
acute episodes in this patient?
(A)
(B)
(C)
(D)
(E)
Albuterol
Beclomethasone
Cromolyn
Ipratropium
Theophylline
14. A new drug, Drug X, relieves pain by interacting with a
specific receptor in the body. Drug X binds irreversibly to
this receptor, resulting in a long duration of action. Which of
the following types of bonds is most likely formed between
Drug X and its receptor?
(A)
(B)
(C)
(D)
(E)
Covalent
Hydrogen
Hydrophobic
Ionic
van der Waals
15. A 49-year-old man with hypertension comes to the physician
for a follow-up examination. At his last visit 2 months ago,
his serum total cholesterol concentration was 320 mg/dL. He
then began a low-cholesterol diet. His blood pressure is
145/95 mm Hg. Physical examination shows no other
abnormalities. Serum studies show a total cholesterol
concentration of 310 mg/dL. Kidney and liver function test
results are within normal limits. The most appropriate
pharmacotherapy for this patient is a drug that has which of
the following mechanisms of action?
(A)
(B)
(C)
(D)
(E)
Activates peroxisome proliferator-activated
receptors
Decreases hepatic production of VLDL
cholesterol
Forms insoluble complexes with bile acids in
the gut
Impairs absorption of cholesterol in the small
intestine brush border
Inhibits 3-HMG-CoA reductase
16. A 17-year-old girl is brought to the physician by her parents
30 minutes after having a generalized tonic-clonic seizure
while playing in a soccer game. She currently takes no
medications. Physical examination shows no abnormalities.
After further testing including 24-hour continuous EEG
monitoring, carbamazepine is prescribed. This patient's use of
additional medications should be monitored because of which
of the following changes in drug disposition after starting
pharmacotherapy?
(A)
(B)
(C)
(D)
(E)
Decreased absorption in the intestine
Decreased distribution to the brain
Increased excretion by the kidneys
Increased metabolism by the liver
Increased recirculation in the bile
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-46-
Appendix 3
17. A 14-year-old boy is brought to the physician for examination
prior to participating on his school's soccer team. Physical
examination shows jaundice. Serum studies show a total
bilirubin concentration of 2.5 mg/dL, ALT activity of 70 U/L,
and ceruloplasmin concentration of 5 mg/dL (N=20–40). A
slit-lamp examination shows the presence of brownish rings in
the cornea, surrounding the iris. The most appropriate
treatment at this time is a drug with which of the following
mechanisms of action?
(A)
(B)
(C)
(D)
(E)
(F)
Decreases serum ALT activity
Decreases serum bilirubin concentration
Decreases urine selenium excretion
Increases serum chloride concentration
Increases urine copper excretion
Increases urine lead excretion
18. A 60-year-old woman comes to the physician because she
recently was diagnosed with non-small cell lung carcinoma
and she wants to discuss possible treatment options. She tells
the physician that she is concerned about the possible adverse
effects of chemotherapy. The physician says that serious
toxicity caused by antineoplastic drugs is seen in the bone
marrow. Which of the following best explains this finding?
(A)
(B)
(C)
(D)
(E)
(F)
Cells in the marrow divide rapidly
Cells in the marrow have specific surface
targets for most of these drugs
Cells in the marrow lack the enzymes to protect
against the drugs
Chemotherapy drugs act preferentially against
cells with no nucleus
Chemotherapy drugs penetrate well into the
marrow because it is very vascular
Chemotherapy drugs tend to be lipid-soluble
and concentrate in the marrow
19. A 38-year-old woman with an 18-year history of type 1
diabetes mellitus and progressive renal failure is being
considered for dialysis. Laboratory studies show normocytic,
normochromic anemia. Which of the following medications is
most appropriate to treat the anemia in this patient?
(A)
(B)
(C)
(D)
(E)
Erythropoietin
Folic acid
Folinic acid
Vitamin B1 (thiamine)
Vitamin B12 (cyanocobalamin)
20. A 47-year-old woman is admitted to the hospital for treatment
of pneumococcal pneumonia. Treatment with gentamicin and
penicillin is initiated. Within 10 minutes of the administration
of antimicrobial therapy, her respirations increase to 30/min,
and blood pressure decreases to 80/40 mm Hg. Epinephrine,
antihistamine, and corticosteroid therapy is started. Her
condition improves slowly during the next 2 hours. Her
antimicrobial therapy is changed to gentamicin only, and her
condition continues to improve. Administration of which of
the following types of drugs is most likely to cause a similar
adverse reaction in this patient?
(A)
(B)
(C)
(D)
Cephalosporins
Macrolides
Quinolones
Tetracyclines
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-47-
Appendix 3
Answer Form for Pharmacology Sample Questions
(Questions 1-20)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-48-
Appendix 3
Answer Key for Pharmacology Sample Questions
(Questions 1-20)
1. E
2. B
3. B
4. G
5. A
6. D
7. A
8. C
9. D
10. B
11. F
12. B
13. A
14. A
15. E
16. D
17. E
18. A
19. A
20. A
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-49-
Appendix 3
PHYSIOLOGY
Physiology (125 items)
Cell Biology
Multisystem Processes (Nutrition, Acid-Base, Temperature/Environment)
Organ Systems
Skin & related connective tissue
Musculoskeletal
Respiratory
Cardiovascular
Gastrointestinal
Renal/urinary
Reproductive
Endocrine
Neurophysiology (25 items optional)
Nerve Organ Structure and Function (brain, sensory systems, motor systems,
autonomic nervous system)
Nerve Cell/Tissue Structure and Function (neurons, neurotransmitters, brain
metabolism, glia/myelin, brain homeostasis)
1.
A hormone is known to activate phospholipase C with
subsequent release of calcium from internal stores. The release
of calcium most likely occurs as a result of an increase in the
concentration of which of the following intracellular second
messengers?
(A)
(B)
(C)
(D)
(E)
2.
Calcium
cAMP
cGMP
Diacylglycerol
Inositol 1,4,5-trisphosphate
A 28-year-old man with a history of intravenous drug use
comes to the physician because of a 6-week history of fever,
nonproductive cough, chills, and progressive shortness of
breath. His temperature is 39°C (102.2°F), pulse is 110/min,
respirations are 32/min and regular, and blood pressure is
120/80 mm Hg. Physical examination shows a white, patchy,
loosely adherent exudate on the buccal mucosa bilaterally. A
chest x-ray shows bilateral interstitial infiltrates. After
receiving treatment for pneumonia, he agrees to participate in a
clinical study of the effects of interleukin-2 (IL-2). After
administration of IL-2, which of the following hematologic
changes is most likely in this patient?
(A)
(B)
(C)
(D)
(E)
(F)
3.
Decreased CD4+ T lymphocytes
Decreased erythrocytes
Decreased platelet count
Increased CD4+ T lymphocytes
Increased erythrocytes
Increased platelet count
1%B5%
1%B5%
5%B10%
15%B20%
10%B15%
15%B20%
5%B10%
5%B10%
45%B50%
50%B55%
A 5-year-old girl falls through the ice while skating on an
outdoor pond. She is removed from the water within 1
minute, but dry clothing is not available, and she is still cold
and wet 20 minutes later. Which of the following mechanisms
helps maintain the patient’s core temperature during the
period following her rescue?
(A)
(B)
(C)
(D)
(E)
4.
10%B15%
10%B15%
Cutaneous vasodilation
Diving response
Increased thermoregulatory set point
Release of endogenous pyrogen
Shivering
A 39-year-old woman comes to the physician for a follow-up
examination because she recently was diagnosed with
hypertension. Her blood pressure is 156/100 mm Hg.
Physical examination shows no other abnormalities. Serum
studies show normal findings. A 24-hour urine collection
shows three times the normal excretion of epinephrine and
metanephrine. The excessive epinephrine production in this
patient is most likely caused by which of the following cell
types?
(A)
(B)
(C)
(D)
(E)
Chromaffin
Juxtaglomerular
Zona fasciculata
Zona glomerulosa
Zona reticularis
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-50-
Appendix 3
5.
A 48-year-old man has hepatic cancer that is unresponsive to
standard therapy. He enrolls in a clinical study of a novel
chemotherapeutic agent that, as a side effect, blocks kinesin, a
component of the cellular microtubular transport system. One
week later, he develops skeletal muscle weakness. An
alteration in which of the following components of the
neuromuscular junction is the most likely cause of the muscle
weakness?
8.
A demonstration is performed during a lecture on muscle
physiology in which a student is asked to fully extend his
right arm with the palm up. Two large textbooks are placed
on his palm, one at a time. Which of the following facilitates
the maximum amount of tension that allows the student to
keep his arm extended in place under the increasing weight of
the books?
(A)
(A)
(B)
(C)
(D)
(E)
6.
After an overnight fast, a 52-year-old man undergoes infusion
of acid through a catheter into the upper duodenum. This most
likely will increase pancreatic secretion mainly through the
action of which of the following substances?
(A)
(B)
(C)
(D)
(E)
7.
A decrease in the number of postsynaptic
neurotransmitter receptors
A decrease in the number of presynaptic
neurotransmitter vesicles
A decrease in the presynaptic neuron calcium
permeability
Impaired α-motoneuron action potential
conduction
Impaired skeletal muscle action potential
conduction
Cholecystokinin
Gastrin
Glucagon
Secretin
Vasoactive intestinal polypeptide
A 20-year-old woman is brought to the emergency department
20 minutes after being stung by a wasp. She says that she feels
a lump in her throat and chest tightness. She has a history of
allergy to wasp venom. Her pulse is 120/min, and blood
pressure is 80/40 mm Hg. Physical examination shows
eruptions that coalesce into giant urticaria. There is audible
wheezing. Which of the following best describes the cause of
this patient's reaction?
(A)
(B)
(C)
(D)
(E)
Activation of macrophages by soluble immune
complexes
Binding of antigen to preexisting cell-fixed IgE
antibodies
Formation of IgG antibodies against extracellular
matrix antigen
Formation of IgM antibodies against cell surface\
receptor antigens
Induction of a cytotoxic reaction by CD8+ T
lymphocytes
(B)
(C)
(D)
(E)
9.
Amount of Ca2+ released from the sarcoplasmic
reticulum
Amount of muscle phosphocreatine
Amplitude of the action potential
Number of motor units recruited
Rate of cross-bridge recycling
During an experiment on the cough reflex in humans, a
subject inhales air containing different amounts of particles
that will impact and adhere to mucus primarily in the trachea.
Blockade of which of the following receptors would most
likely prevent this subject's reflex to initiate a cough?
(A)
(B)
(C)
(D)
(E)
Chemoreceptors
Irritant receptors
J receptors
Proprioceptors
Stretch receptors
10. A 35-year-old man has an adenoma of the parathyroid gland,
with increased serum concentrations of parathyroid hormone
(PTH) and calcium. In this patient, PTH induces which of the
following processes to cause hypercalcemia?
(A)
(B)
(C)
(D)
Production of 25-hydroxycholecalciferol
Shift of Ca2+ from the intracellular to the
extracellular fluid compartment
Stimulation of osteoclast activity
Suppression of renal production of 1,25
dihydroxycholecalciferol
11. A female newborn delivered at 32 weeks' gestation develops
severe respiratory distress within hours of birth. Despite
resuscitative efforts, the patient dies. Examination of the
lungs at autopsy shows lung alveoli with radii of less than
50 μm (N=100). Which of the following is most likely
decreased in the lungs of this newborn?
(A)
(B)
(C)
(D)
(E)
Airway resistance
Compliance
Elastic recoil
Surface tension
Vascular resistance
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-51-
Appendix 3
12. A 55-year-old woman who is obese has a greater risk for
endometrial carcinoma than a 55-year-old woman with the
same health history and status who is not obese. Which of the
following best explains this increased risk?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
Accelerated catabolism of antioxidants
Association of obesity with smoking
Carcinogenic effects of dietary fats
Greater average number of pregnancies
Impairment of immune surveillance by T
lymphocytes
Increased production of estrogen by adipose tissue
Later age of menopause
More frequent episodes of vaginitis
13. A 4-hour-old female newborn delivered at 30 weeks' gestation
has respiratory distress. Her temperature is 36.5°C (97.7°F),
pulse is 160/min, respirations are 85/min, and blood pressure is
68/40 mm Hg. Arterial blood gas analysis on room air shows:
pH
PCO2
PO2
7.18
78 mm Hg
55 mm Hg
Endotracheal intubation and mechanical ventilation are
required. The primary cause of this patient's condition is a
dysfunction of which of the following cell types?
(A)
(B)
(C)
(D)
(E)
Alveolar macrophages
Pneumocytes
Pulmonary chondrocytes
Pulmonary vascular endothelial cells
Smooth muscle cells
14. A 22-year-old man is brought to the emergency department
because of a 6-hour history of severe, sharp, upper back pain.
He has had progressive fatigue during the past 3 weeks. He is
183 cm (6 ft) tall and weighs 79 kg (175 lb); BMI is 24 kg/m2.
His temperature is 36.9°C (98.5°F), pulse is 90/min, and blood
pressure is 160/55 mm Hg. Physical examination shows long,
thin upper and lower extremities. Fingertip to fingertip with
arms outstretched is 189 cm (74 in) wide. A high-pitched
midsystolic click is heard predominantly over the apex. Which
of the following best describes the primary genetic cause of
this patient's condition?
(A)
(B)
(C)
(D)
(E)
15. A 25-year-old woman comes to the physician because of a 2day history of muscle cramps and profuse, watery stools. She
returned from a trip to Pakistan 3 days ago. Her temperature
is 37°C (98.6°F), pulse is 120/min, and blood pressure is
80/50 mm Hg. Stool culture shows numerous curved, gramnegative bacteria; there are no erythrocytes or leukocytes.
Oral rehydration is initiated. The blood pressure increases,
and the pulse decreases. The oral hydration formula most
likely promotes sodium absorption via the gut by allowing
cotransport with which of the following?
(A)
(B)
(C)
(D)
(E)
Albumin
Fatty acid
Glucose
Magnesium
Potassium
16. A 26-year old woman is brought to the emergency
department because of a 4-day history of flu-like symptoms
accompanied by vomiting following each attempt to eat or
drink. Her temperature is 38.5°C (101.3°F), pulse is 93/min,
respirations are 24/min, and blood pressure is 105/70 mm Hg.
Physical examination shows no other abnormalities. Which of
the following additional findings is most likely in this
patient?
(A)
(B)
(C)
(D)
(E)
Decreased serum ADH (vasopressin)
concentration
Increased serum aldosterone concentration
Increased serum atrial natriuretic peptide
Increased urine sodium and chloride
concentrations
Increased urine volume
17. A 77-year-old man comes to the physician because of
swelling of his legs and feet for 6 months. He has a 40-year
history of alcoholism and a 5-year history of hepatic disease.
Physical examination shows ascites and a 2+ edema of the
lower extremities. A decrease in which of the following most
likely promotes edema formation in this patient?
(A)
(B)
(C)
(D)
(E)
Capillary hydrostatic pressure
Filtration coefficient
Interstitial colloid osmotic pressure
Interstitial fluid hydrostatic pressure
Plasma colloid oncotic pressure
Expression of genomic duplication within the
fibrin gene
Mutation in keratin-14 gene
Nonsense mutation in fibrillin-1 gene
Overexpression of collagen X gene
Overexpression of fibronectin gene
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-52-
Appendix 3
18. During a study of gastric parietal cells, an investigator attempts to elicit maximum hydrochloric acid secretion from the stomach of an
experimental animal. Which of the following combinations of substances is most likely to lead to this desired effect?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
Acetylcholine
Increased
Increased
Increased
Decreased
Decreased
Decreased
Decreased
Gastrin
increased
increased
decreased
increased
decreased
decreased
decreased
19. A 30-year-old woman comes to the physician for a routine
health maintenance examination. She takes no medications.
Physical examination shows no abnormalities. Serum studies
show a calcium concentration of 12 mg/dL. An increase in
which of the following substances is the most likely cause of
the serum finding in this patient?
(A)
(B)
(C)
(D)
(E)
Bone morphogenic protein
Calcitonin
Integrins
Parathyroid hormone
Vitamin A
Histamine
increased
increased
decreased
increased
increased
decreased
decreased
Secretin
increased
decreased
decreased
increased
increased
increased
decreased
20. A 28-year-old woman comes to the physician because of a
3-month history of shortness of breath with exertion. She
takes an oral contraceptive. There are no occupational
exposures to birds or grain dusts. Her respirations are 20/min.
The lungs are clear to auscultation. Cardiac examination
shows a regular rate and rhythm; S2 is slightly louder than S1.
Cardiac catheterization shows a pulmonary artery pressure of
78/31 mm Hg (N=15–30/3–12) with a normal left ventricular
end-diastolic pressure. Which of the following is most likely
changed in this patient?
(A)
(B)
(C)
(D)
(E)
Decreased alveolar ventilation
Decreased left ventricular afterload
Increased muscle tone
Increased pulmonary compliance
Increased pulmonary vascular resistance
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-53-
Appendix 3
Answer Form for Physiology Examination Sample Questions
(Questions 1-20)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-54-
Appendix 3
Answer Key for Physiology Examination Sample Questions
(Questions 1-20)
1. E
2. D
3. E
4. A
5. B
6. D
7. B
8. D
9. B
10. C
11. B
12. F
13. B
14. C
15. C
16. B
17. E
18. B
19. D
20. E
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-55-
Appendix 3
CLINICAL NEUROLOGY
General Principles
Organ Systems
Mental Disorders
Diseases of the Nervous System and Special Senses
Disorders of the special senses
Structural disorders (trauma, cerebrovascular disease, infections)
Toxic, metabolic, and degenerative disorders
Paroxysmal and sleep disorders
Neuromuscular disorders
Other Organ Systems
Physician Task
Promoting Health and Health Maintenance
Understanding Mechanisms of Disease
Establishing a Diagnosis
Applying Principles of Management
1.
A 39-year-old man is admitted to the hospital by his brother
for evaluation of increasing forgetfulness and confusion
during the past month. His brother reports that the patient has
been drinking heavily and eating very little, and has been
slightly nauseated and tremulous. He wanders at night
because he cannot sleep. On admission to the hospital,
intravenous administration of 5% dextrose in water is
initiated. Two hours later, the patient has ophthalmoplegia
and is completely confused. Which of the following is the
most appropriate next step in management?
(A)
(B)
(C)
(D)
(E)
3.
Administration of an anticoagulant
Administration of diazepam
Administration of large doses of vitamin B1
(thiamine), intravenously
Administration of large doses of vitamin C,
intravenously
Continued administration of intravenous fluids
with magnesium
A 47-year-old man comes to the physician because of a 2-year
history of fatigue. He has had progressive difficulty with
daytime sleepiness and has intermittently fallen asleep at
work. He has no difficulty falling asleep or staying asleep at
night but awakens in the morning not feeling well rested. His
vital signs are within normal limits. Examination of the throat
shows no abnormalities except for hypertrophied tonsils. His
hemoglobin concentration is 17.9 g/dL, leukocyte count is
8700/mm3, and platelet count is 170,000/mm3. Which of the
following is the most likely cause of this patient's symptoms?
(A)
(B)
(C)
(D)
(E)
5%B10%
5%B10%
15%B20%
50%B65%
15%B20%
A 45-year-old man has had a 1-week history of increasing
neck pain when he turns his head to the right. He also has had
a pins-and-needles sensation starting in the neck and radiating
down the right arm into the thumb. His symptoms began 3
months ago when he developed severe pain in the neck and
right shoulder. Neurologic examination shows limitation of
motion on turning the neck to the right. There is 4+/5
weakness of the right biceps and decreased pinprick over the
right thumb. Deep tendon reflexes are 1+ in the right biceps
and brachioradialis; all others are 2+. Which of the following
is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
4.
2.
1%B5%
95%B99%
5%B10%
70%B90%
Carpal tunnel syndrome
Cervical root compression
Multiple sclerosis
Thoracic outlet syndrome
Ulnar nerve compression
A 29-year-old man is brought to the emergency department
because he has a severe bilateral headache and irritability. His
pulse is 120/min, respirations are 30/min, and blood pressure
is 200/120 mm Hg. Ophthalmoscopic examination shows
blurring of the optic discs. Deep tendon reflexes are 3+ and
symmetric. Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)
Alcohol intoxication
Heavy metal poisoning
Hypertensive encephalopathy
Hyperthyroidism
Panic disorder
Chronic Epstein-Barr virus infection
Chronic fatigue syndrome
Erythroleukemia
Polycythemia vera
Sleep apnea
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-56-
Appendix 3
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
(J)
(K)
(L)
(M)
(N)
(O)
(P)
(Q)
Alcohol-induced amnestic episode (blackout)
Alcohol withdrawal
Apathetic hyperthyroidism
Bipolar disorder, depressed
Delirium because of medical condition
Dementia, alcohol-related
Dementia, Alzheimer type
Generalized anxiety disorder
Masked depression
Medication toxicity
Multi-infarct (vascular) dementia
Normal age-associated memory decline
Normal-pressure hydrocephalus
Parkinson disease
Pick disease
Pseudodementia
Residual schizophrenia
For each patient with a memory problem, select the most likely diagnosis.
5.
A 29-year-old woman with an 11-year history of bipolar disorder comes to the physician because she is concerned about memory loss
during the past 2 weeks. She has had difficulty remembering appointments that she has made, and on one occasion, she got lost going
to the health club where she has been a member for years. She has taken lithium carbonate for 8 years, and she has been taking a
friend=s diuretic for perimenstrual weight gain during the past 3 months. Physical examination shows a resting tremor of both hands
and mild ataxia. On mental status examination, she is oriented to person, place, and time, but she recalls only one of three objects after
5 minutes.
6.
A 63-year-old man is brought to the physician by his daughter because she is concerned about his memory loss during the past year.
Yesterday he could not remember his 18-month-old granddaughter=s name. Although he denies that there is any problem, she says he
has been forgetful and becomes easily confused. There is no history of alcohol abuse. His temperature is 37°C (98.6°F), pulse is
77/min, respirations are 12/min, and blood pressure is 118/84 mm Hg. On mental status examination, his mood is normal. He is
oriented to person and place but initially gives the wrong month, which he is able to correct. He recalls memories from his youth in
great detail but only recalls one of three words after 5 minutes. He has difficulty recalling the names of common objects and does not
remember the name of the current US president. Physical examination, laboratory studies, and thyroid function tests show no
abnormalities.
7.
A 65-year-old man has had increasingly severe headaches and
diffuse muscle aches during the past 3 months. He also has a
1-month history of jaw pain when chewing food and
decreasing visual acuity in his left eye. His temperature is
38°C (100.4°F). Visual acuity in his left eye is 20/100, and
the left optic disc is slightly atrophic. His muscle strength is
normal. Which of the following tests should be obtained
next?
(A)
(B)
(C)
(D)
(E)
Measurement of erythrocyte sedimentation
rate
Antinuclear antibody assay
Examination of cerebrospinal fluid
CT scan of the head
Electroencephalography
8.
A 19-year-old woman comes to the physician because of a 3month history of intermittent drooping of her left eyelid each
evening and occasional difficulty chewing and swallowing.
She also has had two episodes of double vision that occurred
in the evening and resolved by the following morning.
Examination shows no abnormalities except for slight ptosis
on the right. Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)
Acute intermittent porphyria
Brain stem glioma
Complex partial seizures
Guillain-Barré syndrome
Myasthenia gravis
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-57-
Appendix 3
9.
A 72-year-old man is brought to the physician by his daughter because of a 2-day history of confusion, disorientation, and lethargy. He
has had no weakness. He had a cerebral infarction 1 year ago and has been treated with daily aspirin since then. He is awake but
lethargic. His temperature is 38.9°C (102°F), pulse is 82/min, respirations are 16/min, and blood pressure is 144/88 mm Hg. Physical
examination shows no abnormalities. He is disoriented to place and time but recognizes his daughter. Laboratory studies show:
Hemoglobin
Leukocyte count
Segmented neutrophils
Eosinophils
Lymphocytes
Monocytes
Serum
Na+
Cl−
K+
HCO3−
Urea nitrogen
Creatinine
Urine
pH
Specific gravity
WBC
RBC
Bacteria
Nitrates
11.1 g/dL
12,200/mm3
60%
2%
30%
8%
130 mEq/L
92 mEq/L
4.1 mEq/L
21 mEq/L
29 mg/dL
1 mg/dL
7
1.020
10/hpf
6/hpf
positive
positive
Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Delirium
Dementia, Alzheimer type
Major depressive disorder
Multi-infarct (vascular) dementia
Parkinson disease
10. A 21-year-old college student comes to student health services
requesting medication to help her sleep. Four days ago, she
returned from a 1-year trip to India where she studied
comparative religions. Since her return, she has been unable to
fall asleep until 4 or 5 AM and has difficulty awakening before
noon. She constantly feels tired, has difficulty concentrating,
and does not feel ready to begin classes. Her appetite has not
decreased, but she has an aversion to eating meat since
following a vegetarian diet in India. She has no history of
medical or psychiatric illness. She takes no medications and
does not drink alcohol. She appears sleepy. She is 173 cm
(5 ft 8 in) tall and weighs 54 kg (120 lb); BMI is 18 kg/m2.
Her pulse is 60/min, and blood pressure is 115/70 mm Hg. She
is alert and oriented to person, place, and time. When asked to
subtract serial sevens from 100, she begins accurately but then
repeatedly loses track of the sequence. Which of the following
is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
Adjustment disorder with depressed mood
Bipolar disorder
Circadian rhythm sleep disorder
Major depressive disorder
Malingering
Primary insomnia
11. A 67-year-old woman comes to the physician for a follow-up
examination. She had a pulmonary embolism and required
treatment in the hospital for 3 weeks. She had a
retroperitoneal hemorrhage; anticoagulant therapy was
temporarily discontinued, and she underwent placement of an
inferior vena cava (IVC) filter. She had a hematoma that was
resolving on discharge from the hospital 2 weeks ago. Today,
she says she has had a persistent sensation of tingling and
numbness of her left thigh that she did not report in the
hospital because she thought it would go away; the sensation
has improved somewhat during the past week. Her only
medication is warfarin. Vital signs are within normal limits.
Examination of the skin shows no abnormalities. Muscle
strength is normal. Sensation to light touch is decreased over a
5 x 5-cm area on the lateral aspect of the left anterior thigh.
Which of the following is the most likely cause of this
patient's decreased sensation?
(A)
(B)
(C)
(D)
(E)
(F)
Cerebral infarction during the hospitalization
Complication of the IVC filter placement
Compression of the lateral femoral cutaneous
nerve
Hematoma of the left thigh
Spinal cord infarct
Vitamin B12 (cobalamin) deficiency
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-58-
Appendix 3
12. A 77-year-old woman is admitted to the hospital because of difficulty walking. She has had progressive pain and paresthesia of both
feet over the past 3 weeks. She has a history of mild hypertension treated with hydrochlorothiazide and hypothyroidism treated with
thyroid replacement therapy. Her pulse is 80/min, respirations are 16/min, and blood pressure is 150/80 mm Hg. Neurologic
examination shows decreased ankle jerk reflexes bilaterally and decreased vibratory sense and proprioception in the lower extremities.
Laboratory studies show:
Hemoglobin
Leukocyte count
Mean corpuscular volume
Serum
K+
Urea nitrogen
Creatinine
Glucose
10 g/dL
11,000/mm3 with a normal differential
106 μm3
4.1 mEq/L
8 mg/dL
1.1 mg/dL
110 mg/dL
Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Diabetic neuropathy
Hypothyroidism
Pulmonary osteoarthropathy
Spinal stenosis
Vitamin B12 (cobalamin) deficiency
13. An 82-year-old man is admitted to the hospital because
nursing staff in his skilled nursing care facility report that he
has appeared sad and depressed during the past 2 months. It is
reported that he has a history of psychiatric illness, but details
are not provided. He has been taking olanzapine, paroxetine,
and haloperidol for 2 years. He does not appear to be in acute
distress. He is 160 cm (5 ft 3 in) tall and weighs 48 kg (105
lb); BMI is 19 kg/m2. Physical examination shows 2+
cogwheel rigidity of the upper extremities. Neurologic
examination shows psychomotor retardation. On mental status
examination, he is alert and generally pleasant and
cooperative. His affect has little intensity or range. He says he
does not feel depressed or anxious. Laboratory findings are
within the reference range. Which of the following is the most
likely cause of this patient's current symptoms?
(A)
(B)
(C)
(D)
(E)
Adjustment disorder
Akathisia
Dementia, Alzheimer type
Drug-induced parkinsonism
Major depressive disorder
15. A 27-year-old woman comes to the physician because of a 3week history of fatigue and blurred vision. She occasionally
has had double vision during this period. For the past year, she
has had 3- to 4-day episodes of numbness and tingling of her
arms and legs. She has no personal or family history of serious
illness. Her only medication is an oral contraceptive. She has
smoked one pack of cigarettes daily for 5 years. Vital signs
are within normal limits. Funduscopic examination shows no
abnormalities. Visual acuity is decreased in the left eye.
Sensation to light touch is decreased over the hands and feet;
sensation to pinprick is increased over the fingers and toes
bilaterally. An MRI of the brain shows several hyperintense
oval plaques in the periventricular region on T2-weighted
images. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Glioma
Guillain-Barré syndrome
Multiple sclerosis
Systemic lupus erythematosus
Toxoplasmosis
14. A 25-year-old butcher has had severe episodic pain in his right
thumb and right second and third digits for 2 months. The pain
frequently awakens him from sleep. He has decreased
sensation over the palmar surface of the thumb and index and
long fingers of the right hand and atrophy of the thenar muscle
mass. Compression of which of the following nerves is the
most likely cause?
(A)
(B)
(C)
(D)
(E)
Median
Musculocutaneous
Posterior interosseous
Radial
Ulnar
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-59-
Appendix 3
16. A 57-year-old woman comes to the physician because of a 2year history of difficulty sleeping. After she gets into bed at
night, her legs feel cold and crampy, and she cannot settle into
a comfortable position. Walking around temporarily relieves
her symptoms. She also has difficulty sitting for a prolonged
period of time. She has a mild anxiety disorder but takes no
medications. Vital signs are within normal limits. Examination
shows no abnormalities. Which of the following is the most
likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
Benign fasciculations
Major depressive disorder
Parkinson disease
REM sleep behavior disorder
Restless legs syndrome
Stiff-person syndrome
17. A 77-year-old man comes to the emergency department 1
hour after a 15-minute episode of right arm weakness and an
inability to speak in sentences; the symptoms have now
resolved. He has a 30-year history of hypertension treated
with hydrochlorothiazide. He does not have diabetes mellitus
or coronary artery disease. During the past 8 weeks, he has
walked 3 miles daily without symptoms. His pulse is 80/min,
respirations are 14/min, and blood pressure is 144/88 mm Hg.
Examination, including cardiopulmonary and neurologic
examinations, shows no abnormalities. A carotid bruit is heard
on the left. An ECG shows a normal sinus rhythm with a
ventricular rate of 76/min. Echocardiography shows no
abnormalities. Carotid duplex ultrasonography and follow-up
MR angiography show an 80% left internal carotid stenosis.
Which of the following is the most appropriate next step to
prevent cerebral infarction in this patient?
(A)
(B)
(C)
(D)
(E)
(F)
Prophylactic atorvastatin
Prophylactic naproxen
Prophylactic warfarin
Carotid endarterectomy
Extracranial-intracranial bypass surgery
Percutaneous coronary intervention
18. A 62-year-old man with alcoholism is admitted to the hospital
because of somnolence and hepatic failure. On admission, his
serum sodium concentration is 109 mEq/L. Hypertonic saline
is administered, and the next day his serum sodium
concentration is 138 mEq/L. Three days after admission, he
has severe weakness; neurologic examination shows flaccid
paresis of both the upper and lower extremities. Which of the
following is the most likely cause of this patient's acute
neurologic symptoms?
(A)
(B)
(C)
(D)
(E)
19. A 32-year-old woman comes to the emergency department 3
hours after the sudden onset of a severe headache. The pain is
associated with nausea and vomiting. Medical history is
noncontributory. She is drowsy but easy to arouse. Her
temperature is 37.1°C (98.8°F), pulse is 92/min, respirations
are 10/min, and blood pressure is 130/70 mm Hg.
Examination of the head shows no abnormalities. Flexion of
the neck produces pain. The optic fundi are normal. Motor and
sensory examinations show no abnormalities. Cranial nerves
are intact. Deep tendon reflexes are symmetric. Babinski sign
is present bilaterally. Which of the following is most likely to
confirm the diagnosis?
(A)
(B)
(C)
(D)
(E)
X-rays of the sinuses
Carotid duplex ultrasonography
EEG
CT scan of the head
Biopsy of the temporal artery
20. A previously healthy 4-year-old boy is brought to the
emergency department 8 hours after the onset of fever and a
diffuse, constant headache. He had been well until 2 days ago
when he developed malaise. Yesterday, he slept more than
usual and had temperatures to 39.2°C (102.5°F).
Immunizations are up-to-date. He is lethargic and irritable
when aroused. He holds his head extended and cries when his
neck is flexed. Muscle strength is normal, and deep tendon
reflexes are symmetrically increased. A lumbar puncture
yields turbid cerebrospinal fluid. Laboratory studies show:
Serum glucose
Cerebrospinal fluid
Opening pressure
Glucose
Protein
Leukocyte count
Segmented neutrophils
Lymphocytes
Erythrocyte count
120 mg/dL
250 mm H2O
10 mg/dL
85 mg/dL
750/mm3
95%
5%
0/mm3
A Gram stain of cerebrospinal fluid shows gram-negative
diplococci. A CT scan of the head shows no abnormalities.
Which of the following is the most likely causal organism?
(A)
(B)
(C)
(D)
(E)
Cytomegalovirus
Haemophilus influenzae
Neisseria meningitidis
Streptococcus agalactiae (group B)
Varicella-zoster virus
Alcohol withdrawal
Central pontine myelinolysis
Hepatic encephalopathy
Hepatorenal syndrome
Vitamin B1 (thiamine) deficiency
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-60-
Appendix 3
Answer Form for Clinical Neurology Sample Questions
(Questions 1-20)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-61-
Appendix 3
Answer Key for Clinical Neurology Sample Questions
(Questions 1-20)
1. C
2. E
3. B
4. C
5. J
6. G
7. A
8. E
9. A
10. C
11. C
12. E
13. D
14. A
15. C
16. E
17. D
18. B
19. D
20. C
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-62-
Appendix 3
FAMILY MEDICINE
The Family Medicine examination predominantly comprises patient encounters in an ambulatory setting.
1.
General Principles
Organ Systems
Immunologic Disorders
Diseases of the Blood and Blood-forming Organs
Mental Disorders
Diseases of the Nervous System and Special Senses
Cardiovascular Disorders
Diseases of the Respiratory System
Nutritional and Digestive Disorders
Gynecologic Disorders
Renal, Urinary, and Male Reproductive System
Disorders of Pregnancy, Childbirth, and the Puerperium
Disorders of the Skin and Subcutaneous Tissues
Diseases of the Musculoskeletal System and Connective Tissue
Endocrine and Metabolic Disorders
1%B5%
95%B99%
5%B10%
5%B10%
5%B10%
5%B10%
10%B15%
10%B15%
10%B15%
5%B10%
5%B10%
1%B5%
1%B5%
5%B10%
5%B10%
Physician Task
Promoting Health and Health Maintenance
Understanding Mechanisms of Disease
Establishing a Diagnosis
Applying Principles of Management
15%B20%
20%B25%
35%B40%
20%B25%
Distribution Across Age Groups
Childhood
Adolescence
Adulthood
Geriatric
5%B15%
5%B10%
65%B75%
5%B15%
An 18-year-old college student is brought to the emergency
department by her friend because she has been crying for 3
hours. The friend reports that earlier in the day the patient
gave away her books, furniture, and other personal items as
gifts to friends and spent the rest of the day writing letters
and crying. The patient states that she is displeased with her
academic performance and upset about a recent failed
relationship. She has not been sleeping well. Which of the
following is the most appropriate next step in management?
(A)
(B)
(C)
(D)
(E)
Recommend a study skills course
Arrange a family conference
Prescribe a benzodiazepine
Prescribe a tricyclic antidepressant
Immediate psychiatric evaluation
2.
A 23-year-old man comes to the physician because of a 1week history of painful urination and a clear urethral
discharge. One month ago, he had similar symptoms and
completed a course of doxycycline therapy for a chlamydial
infection. He has no previous history of sexually
transmitted diseases. He has been sexually active with one
female partner for 2 years, and she takes an oral
contraceptive. Examination shows no abnormalities. A
urine polymerase chain reaction test is positive for
Chlamydia trachomatis. In addition to resuming
doxycycline therapy, which of the following is the most
appropriate next step?
(A)
(B)
(C)
(D)
(E)
Recommend testing for his partner
Obtain a urethral culture
Order a pelvic ultrasonography
Order a voiding cystourethrography
Begin acyclovir therapy
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-63-
Appendix 3
3.
A 37-year-old woman comes to the physician because of a
3-year history of intermittent, mild, diffuse abdominal
cramps and bloating. Her symptoms occur after meals and
are relieved with bowel movements. She also has
constipation four to six times monthly. She says the
constipation resolves spontaneously, but she sometimes has
diarrhea for 1 to 2 days afterwards. She has not had any
other symptoms. She has no history of serious illness and
takes no medications. Examination shows no abnormalities.
Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
4.
5.
(A)
(B)
(C)
(D)
(E)
7.
Reassure the mother that such difficulties are
common at this age
Encourage the father to take a more prominent
role in the patient's care
Advise the mother of the risk for long-term
complications without better compliance
Assess the patient's understanding of his
illness and willingness to manage his own
disease
Change the injection schedule to once daily
Chronic aspiration
Congestive heart failure
Hyperventilation syndrome
Intrinsic asthma
Periarteritis nodosa
A 50-year-old man has had progressive weakness and
shortness of breath with exertion for 3 months. He appears
malnourished; conjunctivae are pale, and there are scattered
petechiae. Laboratory studies show:
Hemoglobin
6 g/dL
Mean corpuscular volume 115 μm3
Leukocyte count
2500/mm3 with
hypersegmented neutrophils
Reticulocyte count
0.5%
Platelet count
60,000/mm3
Avoiding oral sex
Avoiding symptomatic partners
Consistent condom use
Limiting his number of sexual partners
Antibiotic prophylaxis
A 14-year-old boy with a 9-year history of type 1 diabetes
mellitus has become increasingly noncompliant with his
medication regimen. He occasionally refuses the mixture
of short-acting and intermediate-acting insulin, which is
administered subcutaneously by his mother twice daily.
His mother reports that his behavior and eating patterns are
increasingly erratic. Which of the following is the most
appropriate next step?
A 38-year-old woman has had eight to ten episodes of
shortness of breath during the past 2 years. The episodes
begin with a sensation of tightness in the chest that
gradually increases over 24 hours and lasts up to 2 days.
Audible wheezing and a slight cough occur during severe
episodes. She feels well between episodes. Physical
examination shows no abnormalities except mild
prolongation of expiration. Which of the following is the
most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Collagenous colitis
Colon cancer
Diverticulosis
Inflammatory bowel disease
Irritable bowel syndrome
A 17-year-old boy comes to the physician for a precollege
examination. He has no history of serious illness. He does
not smoke cigarettes or drink alcohol. He is not currently
sexually active. Examination shows no abnormalities.
During a discussion of sexual activity, the patient
acknowledges that abstinence is the most effective method
of avoiding infection with transmitted diseases but says he
is thinking about becoming sexually active. He asks for
advice about safe sex. Which of the following is the most
important recommendation for this patient?
(A)
(B)
(C)
(D)
(E)
6.
The most likely cause of his condition is a deficiency of
which of the following?
(A)
(B)
(C)
(D)
(E)
8.
Folic acid
Iron
Vitamin B1 (thiamine)
Vitamin B6
Vitamin C
A 19-year-old football player is brought to the emergency
department after collapsing during practice. His father died
suddenly at the age of 25 years during military basic
training. The patient's pulse is 120/min, regular, and weak;
respirations are 25/min and shallow; and blood pressure is
90/40 mm Hg. A loud holosystolic murmur is heard at the
apex and right upper sternal border with no clicks or thrills.
Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Aortic stenosis
Hypertrophic obstructive cardiomyopathy
Primary pulmonary hypertension
Pulmonary valve stenosis
Rheumatic mitral stenosis
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-64-
Appendix 3
9.
A 27-year-old nulligravid woman comes to the physician because of irregular menses for 10 months. During this time, she has
been unable to conceive and has had frequent constipation, cold intolerance, and fatigue. She has not had headache or visual
changes. Menses previously occurred at regular 30-day intervals and lasted 5 days. She is 163 cm (5 ft 4 in) tall and weighs 58 kg
(128 lb); BMI is 22 kg/m2. Her temperature is 37°C (98.6°F), pulse is 84/min, respirations are 18/min, and blood pressure is
120/70 mm Hg. Physical examination, including pelvic examination, shows no abnormalities. Serum studies show:
Thyroid-stimulating hormone
Estradiol
β-hCG
Prolactin
40 μU/mL
40 pg/mL (N=30–400)
<2 mIU/mL
10 ng/mL
Which of the following is the most appropriate pharmacotherapy?
(A)
(B)
(C)
(D)
(E)
Cabergoline
Clomiphene
Ethinyl estradiol
Ibuprofen
Levothyroxine
10. A 25-year-old woman comes to the physician because of a
1-month history of constant fatigue and decreased
motivation. She is a graduate student and is concerned
because her academic performance is declining. She is not
sad but has had progressive feelings of worthlessness and
describes herself as feeling numb. She no longer takes
pleasure in activities that she used to enjoy. She has
difficulty concentrating and falling asleep and frequently
awakens during the night. She also has had a 2.3-kg (5-lb)
weight loss that she attributes to a decreased appetite. She
has to force herself to eat. She has no history of serious
illness and takes no medications. She has increased her
alcohol intake during the past week to three glasses of red
wine daily. Physical examination shows no abnormalities.
Mental status examination shows moderate psychomotor
retardation and a blunted affect. When asked about suicidal
ideation, she says she thinks about death and sometimes
wonders what the point of living is but does not have
suicidal thoughts. Which of the following is the most
appropriate pharmacotherapy?
(A)
(B)
(C)
(D)
(E)
(F)
Chlorpromazine
Haloperidol
Lorazepam
Paroxetine
Phenelzine
Topiramate
11. A 6-month-old girl has had a flat, bluish discoloration over
her sacrum since birth. The rash measures 7 x 9 cm and has
irregular but defined borders. Which of the following is the
most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
Actinic keratosis
Hairy nevus
Juvenile melanoma
Malignant melanoma
Mongolian spot
Nevus flammeus
Strawberry hemangioma
12. A 25-year-old man comes to the physician because of a 2day history of fever. He uses intravenous illicit drugs. His
temperature is 39.4°C (103°F). A grade 3/6 systolic
murmur is heard at the lower left sternal border. The right
knee is swollen, warm, and tender; extension is limited by
pain. His hematocrit is 35%, and erythrocyte sedimentation
rate is 70 mm/h. A serum rheumatoid factor titer is positive
at 1:640. Which of the following is the most likely cause of
this patient's knee findings?
(A)
(B)
(C)
(D)
(E)
Gouty arthritis
Rheumatoid arthritis
Septic arthritis
Synovitis
Systemic lupus erythematosus
13. A 72-year-old woman comes to the physician in October
for a routine health maintenance examination. She feels
well and asks about which immunizations she should be
receiving. During her previous routine examination last
year, she received influenza and pneumococcal vaccines.
Two years ago, she received a tetanus vaccine after she cut
herself with the lid of a tin can. She has hypertension
treated with a diuretic. She is active and lives
independently with her husband. She is 157 cm (5 ft 2 in)
tall and weighs 72 kg (160 lb); BMI is 29 kg/m2. Her
temperature is 37°C (98.6°F), pulse is 80/min, respirations
are 20/min, and blood pressure is 130/70 mm Hg. Physical
examination shows no other abnormalities. Which of the
following vaccines is most appropriate to administer at this
time?
(A)
(B)
(C)
(D)
Diphtheria-tetanus toxoid
Influenza virus
Measles-mumps-rubella
Pneumococcal
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-65-
Appendix 3
14. A 16-year-old boy is brought to the physician by his
parents because of fatigue, oversleeping, and deteriorating
school performance over the past 4 months. His parents
state that he occasionally appears exuberant and has
bloodshot eyes; he recently exhibited strange behavior at a
family reunion. He has a history of binge eating and a 6.8kg (15-lb) weight gain over the past 6 months. Which of the
following is the most likely explanation for this condition?
(A)
(B)
(C)
(D)
(E)
Alcohol abuse
Amphetamine abuse
Bulimia nervosa
Cannabis abuse
Inhalant intoxication
15. An 18-year-old college student comes to student health
services 12 hours after her partner's condom broke during
sexual intercourse. Her last menstrual period was
approximately 3 weeks ago, but she states that since
starting her freshman year, menses have occurred at
irregular 28- to 40-day intervals. Examination shows no
abnormalities. She is concerned about her risk for
pregnancy. Which of the following is the most appropriate
advice for this patient?
(A)
(B)
(C)
(D)
(E)
(F)
Reassurance that the patient is 1 week past the
time of ovulation
Advise the patient that too much time has
passed to prevent pregnancy
Spermicidal douche
Oral contraceptives once daily for 1 month
One levonorgestrel tablet now and again in
12 hours
Dilatation and curettage within 24 hours
16. A 7-year-old boy is brought to the physician because of
poor school performance during the past 6 months. He had
been achieving all developmental milestones and had done
well last year in first grade, but his teacher this year reports
that he seems unable to understand the concepts of letters
and numbers. He also has had behavioral problems and at
times exhibits aggressive behavior toward other children.
His parents feel he has had trouble adjusting to disruption
in his life caused by a family move to an older home in the
inner city. Examination shows no abnormalities. Which of
the following is the most appropriate next step in
diagnosis?
(A)
(B)
(C)
(D)
(E)
Karyotype analysis
Measurement of blood lead concentration
EEG
MRI of the brain
Cerebrospinal fluid analysis
17. A 42-year-old woman comes to the emergency department
because of a 3-hour history of blood in her urine. During
the past 2 days, she has had painful and frequent urination.
She has no history of medical or gynecologic illness or
abnormal Pap smears. She takes no medications and has no
known drug allergies. She is sexually active with her
husband, and they use foam and condoms for
contraception. Vital signs are within normal limits.
Examination shows moderate suprapubic tenderness. The
remainder of the examination shows no abnormalities.
Which of the following is the most likely causal organism?
(A)
(B)
(C)
(D)
(E)
Escherichia coli
Haemophilus ducreyi
Neisseria gonorrhoeae
Peptostreptococcus anaerobius
Pseudomonas aeruginosa
18. An asymptomatic 47-year-old woman comes to the
physician for a follow-up examination. Six blood pressure
readings during the past 3 months have ranged between
140/80 mm Hg and 150/90 mm Hg. She has a 5-year
history of type 2 diabetes mellitus and hyperlipidemia.
Current medications include an oral hypoglycemic agent
and an HMG-CoA reductase inhibitor. Her mother has
hypertension, coronary artery disease, and type 2 diabetes
mellitus. The patient's blood pressure today is
160/90 mm Hg. Examination shows no other abnormalities.
Serum studies show a glucose concentration of 178 mg/dL
and creatinine concentration of 1.5 mg/dL. Urinalysis
shows 1+ protein. Which of the following is the most
appropriate medication to add to this patient's regimen?
(A)
(B)
(C)
(D)
(E)
ACE inhibitor
β-Adrenergic blocking agent
Calcium-channel blocking agent
Loop diuretic
No additional pharmacotherapy is indicated at
this time
19. A previously healthy 13-month-old girl is brought to the
physician in January by her mother because she has had
watery, nonbloody diarrhea five times during the past 24
hours. She has had a low-grade fever and two episodes of
vomiting during this period. She attends day care, and other
children have had similar symptoms. She weighs 10 kg
(22 lb), unchanged from 2 weeks ago. Her temperature is
37.7°C (100°F), pulse is 140/min, respirations are 24/min,
and blood pressure is 90/58 mm Hg. Examination shows
moist mucous membranes; the patient cries with tears. The
extremities are warm with normal capillary refill time. The
remainder of the examination shows no abnormalities.
Which of the following is the most likely causal organism?
(A)
(B)
(C)
(D)
(E)
Campylobacter jejuni
Cryptosporidium parvum
Giardia lamblia
Rotavirus
Salmonella enteritidis
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-66-
Appendix 3
20. A 47-year-old man comes to the physician because of a 4month history of generalized fatigue. During this period, he
has had a decreased appetite resulting in a 7.3-kg (16-lb)
weight loss. He has no history of serious illness. He
occasionally takes an over-the-counter cough suppressant
as needed. He has smoked two packs of cigarettes daily for
30 years. He drinks one to two beers daily. He is employed
as an automobile mechanic. His paternal grandfather had
bladder cancer, and a maternal aunt had uterine cancer. He
is 183 cm (6 ft) tall and weighs 68 kg (150 lb); BMI is 20
kg/m2. His temperature is 37.2°C (99°F), pulse is 90/min,
respirations are 20/min, and blood pressure is 122/64 mm
Hg. Examination shows temporal wasting. Wheezing and
rhonchi are heard throughout all lung fields. An x-ray of
the chest shows multiple nodules bilaterally. A biopsy
specimen of a nodule shows small cell carcinoma. Which
of the following is the strongest predisposing factor for this
patient's condition?
(A)
(B)
(C)
(D)
(E)
(F)
Age
Exposure to asbestos
Family history of multiple cancers
Gender
History of alcohol use
History of smoking
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-67-
Appendix 3
Answer Form for Family Medicine Subject Test Sample Questions
(Questions 1-20)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-68-
Appendix 3
Answer Key for Family Medicine Subject Test Sample Questions
(Questions 1-20)
1. E
2. A
3. E
4. C
5. D
6. D
7. A
8. B
9. E
10. D
11. E
12. C
13. B
14. D
15. E
16. B
17. A
18. A
19. D
20. F
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-69-
Appendix 3
MEDICINE
1.
General Principles
Organ Systems
Immunologic Disorders
Diseases of the Blood and Blood-forming Organs
Diseases of the Nervous System and Special Senses
Cardiovascular Disorders
Diseases of the Respiratory System
Nutritional and Digestive Disorders
Gynecologic Disorders
Renal, Urinary, and Male Reproductive System
Disorders of the Skin and Subcutaneous Tissues
Diseases of the Musculoskeletal System and Connective Tissue
Endocrine and Metabolic Disorders
1%B5%
95%B99%
5%B10%
5%B10%
5%B10%
15%B20%
15%B20%
10%B15%
1%B5%
10%B15%
5%B10%
5%B10%
5%B10%
Physician Tasks
Promoting Health and Health Maintenance
Understanding Mechanisms of Disease
Establishing a Diagnosis
Applying Principles of Management
10%B15%
20%B25%
40%B45%
20%B25%
A 22-year-old woman with a 10-year history of asthma comes
to the physician because she has had to increase her use of her
albuterol inhaler during the past 6 weeks. Her asthma was
previously well controlled with inhaled glucocorticoids. She
has a 2-year history of generalized anxiety disorder controlled
with fluoxetine and a 5-year history of migraines. The
migraines were well controlled with sumatriptan until 4
months ago when she began to have headaches twice weekly;
propranolol was added to her regimen at that time. She has
been taking an oral contraceptive for the past year. She says
she has been under increased stress at graduate school and in
her personal life during the past 3 months; during this period,
she has been drinking an average of four cups of coffee daily
(compared with her usual one cup daily). She does not drink
alcohol or use illicit drugs. She appears mildly anxious but is
not in respiratory distress. Scattered end-expiratory wheezes
are heard. The remainder of the examination shows no
abnormalities. Which of the following is the most likely cause
of the exacerbation of this patient's asthma?
(A)
(B)
(C)
(D)
(E)
Fluoxetine therapy
Increased caffeine intake
Oral contraceptive therapy
Propranolol therapy
Sumatriptan therapy
2.
A 28-year-old woman has palpitations that occur
approximately once a week, last 1B5 minutes, and consist of
rapid, regular heart pounding. The episodes start and stop
suddenly and have not been associated with chest discomfort
or dyspnea. There is no history of heart problems. She drinks
two to three cups of coffee daily. She rarely drinks alcohol
and does not smoke. Her pulse is 96/min and regular, and
blood pressure is 120/88 mm Hg. A stare and lid lag are
noted. The thyroid gland is firm and 1.5 times larger than
normal. There is a midsystolic click at the apex and a grade
2/6, early systolic murmur at the upper left sternal border. An
ECG is normal except for evidence of sinus tachycardia.
Which of the following is the most appropriate next step in
diagnosis?
(A)
(B)
(C)
(D)
(E)
Ambulatory ECG monitoring
Measurement of serum thyroid-stimulating
hormone concentration
Measurement of urine catecholamine
concentration
MUGA scan
Echocardiography
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-70-
Appendix 3
3.
A study is conducted to assess the benefits of a new drug to
reduce the recurrence of colonic polyps. The results show a
number needed to treat (NNT) of 16. Which of the following
is the most accurate interpretation of this result?
(A)
(B)
(C)
(D)
(E)
4.
Basal cell carcinoma
Fibrocystic changes of the breast
Malignant melanoma
Mastitis
Pigmented nevus
Port-wine stain
Squamous cell carcinoma
Superficial breast carcinoma
Two days after receiving 3 units of packed red blood cells for
postpartum hemorrhage, a 24-year-old woman has fatigue and
slight jaundice. Laboratory studies show:
Hemoglobin
8.8 g/dL
Hematocrit
28%
Serum total bilirubin 5 mg/dL
For every 16 patients treated, 1 would benefit
from the new drug
For every 100 patients treated, 16 would benefit
from the new drug
The new drug is 1.6 times more beneficial than a
placebo
93% of patients taking the new drug would benefit
from it
84% of patients taking the new drug would not
have any benefit from it
A previously healthy 57-year-old woman comes to the
physician 1 week after noticing a lump under her right arm.
She is concerned that it is breast cancer because both her
mother and maternal aunt died of breast cancer. She does not
smoke, drink alcohol, or use illicit drugs. She has avoided the
sun for the past 10 years. She notes that her skin has never
tanned but always burned and freckled when exposed to the
sun. She exercises daily on a stationary bicycle and eats a
well-balanced diet. Her temperature is 37°C (98.6°F), pulse is
82/min and regular, respirations are 14/min, and blood
pressure is 130/74 mm Hg. There are numerous freckles over
the entire body. Examination of the right breast shows a
0.6-cm, flat, brown lesion; the lesion is mottled with deep
purple and black areas and has an irregular border. There are
no breast masses, dimpling, peau d'orange, or nipple
discharge. The patient says that the lesion has been present for
1 year, but she has never had it examined. There is a firm,
nontender mass in the right axilla. Examination shows no
other abnormalities. Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
5.
Liver tests are otherwise within normal limits. Which of the
following is the most appropriate next step in diagnosis?
(A)
(B)
(C)
(D)
(E)
6.
A 30-year-old man has had nausea, vomiting, and severe
colicky right flank pain radiating into the thigh for 4 hours. He
is afebrile. There is right costovertebral angle tenderness.
Urinalysis shows RBCs too numerous to count and no
bacteria. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
7.
Cytomegalovirus antibody titer
Direct and indirect antiglobulin (Coombs)
tests
Monospot test
Serology for hepatitis B markers
Ultrasonography of the gallbladder
Acute glomerulonephritis
Bacterial cystitis
Benign prostatic hyperplasia
Bladder carcinoma
Renal cell carcinoma
Urinary tract tuberculosis
Urolithiasis
A 66-year-old woman comes to the emergency department 1
hour after the sudden onset of retrosternal chest discomfort
accompanied by nausea and diaphoresis. She has hypotension,
jugular venous distention, and a murmur of tricuspid
regurgitation. An ECG shows ST-segment elevation in the
right precordial leads. Which of the following is the most
likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Constrictive pericarditis
Dissecting aortic aneurysm
Pericardial tamponade
Pulmonary emboli
Right ventricular infarction
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-71-
Appendix 3
8.
A 20-year-old African American woman comes to the physician because of a 6-month history of diffuse joint pain, especially in her
hips and knees. During this period, she occasionally has had a rash on her nose and cheeks. She has no history of serious illness and
takes no medications. Her temperature is 38.1°C (100.5°F). Examination shows warmth and swelling of the knees. Laboratory studies
show:
Hemoglobin
Erythrocyte sedimentation rate
Serum
Urea nitrogen
Creatinine
10.5 g/dL
40 mm/h
30 mg/dL
1.8 mg/dL
Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
9.
Ankylosing spondylitis
Gouty arthritis
Psoriatic arthritis
Reactive arthritis
Rheumatoid arthritis
Septic arthritis
Systemic lupus erythematosus
A 37-year-old man with type 1 diabetes mellitus comes to the
physician for a routine examination. His only medication is
insulin. His pulse is 72/min, respirations are 12/min, and
blood pressure is 138/88 mm Hg. Funduscopic examination
shows microaneurysms and hemorrhages. Sensation to
vibration and light touch is decreased over the lower
extremities. His serum creatinine concentration is 1.6 mg/dL.
A 24-hour urine collection shows 550 mg of protein.
Treatment with which of the following is most likely to slow
progression of this patient's renal disease?
(A)
(B)
(C)
(D)
(E)
Atenolol
Clonidine
Hydralazine
Hydrochlorothiazide
Lisinopril
10. A 50-year-old man is admitted to the hospital within 2 hours
of the onset of nausea, vomiting, and acute crushing pain in
the left anterior chest. He has a family history of early
coronary artery disease. The pain does not subside with the
administration of nitroglycerin, sublingually. An ECG shows
ST-segment elevation in leads aVL and V2 through V4.
Which of the following is the most appropriate management to
decrease myocardial damage and mortality?
(A)
(B)
(C)
(D)
(E)
Administration of digitalis
Administration of lidocaine
Administration of quinidine
Coronary artery bypass grafting within 1 week
Thrombolytic therapy
11. A previously healthy 67-year-old woman comes to the
physician with her husband because of a 4-month history of a
resting tremor of her right arm. Her husband reports that her
movements have been slower and that she appears less stable
while walking. Examination shows increased muscle tone in
the upper extremities that is greater on the right than on the
left. There is decreased right arm swing. Her gait is slow and
shuffling. Which of the following is the most likely
explanation for this patient's symptoms?
(A)
(B)
(C)
(D)
(E)
Bilateral frontal lobe degeneration
Decreased dopaminergic input to the striatum
Decreased serotonergic activity in the brain stem
Excessive output of oxytocin
Excessive thalamic output of norepinephrine
12. A 47-year-old man comes to the physician because of a 4week history of increased thirst and urination. He has had a
23-kg (50-lb) weight gain during the past 2 years. He has no
history of serious illness and takes no medications. His mother
and maternal grandfather have type 2 diabetes mellitus. The
patient does not smoke and drinks one beer every night. He is
175 cm (5 ft 9 in) tall and now weighs 104 kg (230 lb); BMI is
34 kg/m2. His pulse is 90/min, and blood pressure is 150/88
mm Hg. The remainder of the examination shows no
abnormalities. His serum glucose concentration is 330 mg/dL.
Which of the following is the most likely underlying cause of
this patient's increased serum glucose concentration?
(A)
(B)
(C)
(D)
(E)
Autoimmune destruction of islet cells
Chronic pancreatitis
Exogenous production of corticosteroids
Insulin resistance
Pancreatic cancer
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-72-
Appendix 3
13. A previously healthy 39-year-old woman is brought to the
physician because of a tingling sensation in her fingers and
toes for 2 days and rapidly progressive weakness of her legs.
She had an upper respiratory tract infection 2 weeks ago. She
was unable to get up from bed this morning. Examination
shows weakness of all four extremities, distal greater than
proximal. Deep tendon reflexes are absent. Sensation is mildly
decreased over the feet. Which of the following is the most
likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Guillain-Barré syndrome
Multiple sclerosis
Myasthenia gravis
Poliomyelitis
Tick paralysis
14. A previously healthy 77-year-old woman who resides in a
skilled nursing care facility is brought to the emergency
department 6 hours after the onset of acute midback pain that
began while lifting a box. The pain does not radiate, and she
has no other symptoms. She continues to carry out her daily
activities. She appears to be in mild distress. She is 157 cm
(5 ft 2 in) tall and weighs 47 kg (104 lb); BMI is 19 kg/m2.
Examination shows mild tenderness over T11. There is no
tremor. Serum studies show a calcium concentration of 9.1
mg/dL, a urea nitrogen concentration of 12 mg/dL, and a
creatinine concentration of 0.5 mg/dL. An x-ray of the dorsal
and lumbar spine shows an anterior wedge fracture of T11. In
addition to treating the pain, supplementation with which of
the following is most likely to improve this patient's
underlying condition?
(A)
(B)
(C)
(D)
(E)
25-Hydroxycholecalciferol
Levothyroxine
Selenium
Vitamin C
Vitamin E
15. A 52-year-old woman comes to the physician because of a
3-month history of diarrhea and intermittent abdominal pain
that radiates to her back. The pain is exacerbated by eating.
She describes her stools as greasy, foul-smelling, and difficult
to flush. She has had a 4.5-kg (10-lb) weight loss during the
past 4 months. She has a history of chronic alcohol abuse.
Examination shows mild epigastric tenderness. An x-ray of
the abdomen shows calcifications in the epigastrium. Which
of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Bacterial overgrowth
Celiac disease
Lactose intolerance
Malabsorption of bile salts
Pancreatic insufficiency
16. A 67-year-old woman comes to the physician because of an
8-month history of progressive shortness of breath. The
shortness of breath initially occurred only with walking long
distances but now occurs after walking ¼ mile to her mailbox.
She also has a daily morning cough productive of whitish tan
sputum. She has had no chest pain, palpitations, orthopnea, or
paroxysmal nocturnal dyspnea. She has smoked one pack of
cigarettes daily for 52 years. Her pulse is 88/min, respirations
are 20/min, and blood pressure is 144/90 mm Hg.
Examination shows a barrel-shaped chest. Breath sounds are
decreased, and faint expiratory wheezes are heard in all lung
fields. There is no peripheral edema. An x-ray of the chest
shows no abnormalities except for hyperinflation. Which of
the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
Angina pectoris
Asthma
Chronic obstructive pulmonary disease
Chronic pulmonary embolism
Congestive heart failure
Panic disorder
17. A 22-year-old woman comes to the physician because of a
10-day history of pain in multiple joints. She first had pain in
her right elbow, and then her right shoulder, and now has pain,
redness, and swelling in her left knee that began 2 days ago.
She currently has no pain in the right shoulder and elbow.
There is no history of trauma. She is sexually active, and she
and her partner use condoms for contraception inconsistently.
Examination of the left knee shows warmth, erythema,
tenderness, and soft-tissue swelling. Range of motion of the
knee is limited to 10 degrees of flexion. The remainder of the
examination, including pelvic examination, shows no
abnormalities. Arthrocentesis of the knee joint yields 10 mL
of cloudy fluid with a leukocyte count of 18,300/mm3
(97% segmented neutrophils). Microscopic examination of the
leukocytes within the joint fluid is most likely to show which
of the following?
(A)
(B)
(C)
(D)
(E)
Acid-fast bacteria
Cuboidal positively birefringent crystals
Gram-negative diplococci
Gram-positive cocci in clusters
Needle-shaped negatively birefringent crystals
18. A 47-year-old woman comes to the physician for a routine
health maintenance examination. She feels well and has no
history of serious illness. Her mother, brother, and sister have
hypertension. The patient's pulse is 84/min, and blood
pressure is 138/85 mm Hg. Examination shows no
abnormalities. The most appropriate recommendation is
decreased intake of which of the following?
(A)
(B)
(C)
(D)
(E)
Calcium
Carbohydrates
Potassium
Protein
Sodium
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-73-
Appendix 3
19. A 32-year-old man comes to the physician because of a 12day history of abdominal cramps and bloating, diarrhea, and
flatulence. He says that he started a new exercise program 2
weeks ago and has been consuming a high quantity of yogurt
bars, peanut butter, and protein- and calorie-enriched milk
shakes to "bulk up." He has no history of serious illness and
takes no medications. His temperature is 37°C (98.6°F). The
abdomen is distended, nontender, and tympanitic to
percussion. Bowel sounds are increased. The remainder of the
examination shows no abnormalities. Which of the following
is the most likely cause of this patient's symptoms?
(A)
(B)
(C)
(D)
(E)
Allergy to peanuts
Fungal overgrowth in the small bowel
Incarcerated hernia
Irritable bowel syndrome
Lactase deficiency
20. A 22-year-old college student comes to student health services
because of a 7-day history of low-grade fever, sore throat,
fatigue, and general malaise. One month ago, she had a
painless vulvar ulcer that resolved spontaneously; she has
been otherwise healthy. Her last menstrual period was 3
weeks ago; she uses tampons regularly. She is sexually active
and has had three partners since the age of 15 years; she uses
an oral contraceptive. Her temperature is 38°C (100.4°F),
pulse is 100/min, and blood pressure is 110/60 mm Hg.
Examination shows a rash over the palms and soles and mild
cervical lymphadenopathy. Pelvic examination shows no
abnormalities. Which of the following is the most appropriate
pharmacotherapy?
(A)
(B)
(C)
(D)
(E)
Acyclovir
Dexamethasone
Interferon
Penicillin
Zidovudine (AZT)
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-74-
Appendix 3
Answer Form for Medicine Subject Test Sample Questions
(Questions 1-20)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-75-
Appendix 3
Answer Key for Medicine Subject Test Sample Questions
(Questions 1-20)
1. D
2. B
3. A
4. C
5. B
6. G
7. E
8. G
9. E
10. E
11. B
12. D
13. A
14. A
15. E
16. C
17. C
18. E
19. E
20. D
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-76-
Appendix 3
OBSTETRICS AND GYNECOLOGY
1%B5%
45%B49%
5%B10%
15%B20%
15%B20%
5%B10%
45%B49%
5%B10%
10%B15%
15%B20%
10%B15%
General Principles
Gynecology
Promoting Health and Health Maintenance
Understanding Mechanisms of Disease
Establishing a Diagnosis
Applying Principles of Management
Obstetrics
Promoting Health and Health Maintenance
Understanding Mechanisms of Disease
Establishing a Diagnosis
Applying Principles of Management
1.
A 57-year-old woman comes to the physician 1 week after
noticing a mass in her left breast during breast selfexamination. Menopause occurred 4 years ago. She was
receiving estrogen replacement therapy but discontinued it 1
year ago; she has had no menopausal symptoms. There is no
family history of breast cancer. Examination shows a 2-cm,
palpable, nontender, mobile mass in the upper outer quadrant
of the left breast; no nipple discharge can be expressed.
Examination of the right breast shows no abnormalities.
Which of the following is the most appropriate next step in
management?
(A)
(B)
(C)
(D)
(E)
2.
Reexamination in 3 months
Mammography
CT scan of the chest
Ductal lavage
Mastectomy
A 27-year-old nulligravid woman has had severe pain with
menses that has caused her to miss at least 2 days of work
during each menstrual cycle for the past year. She has
occasional pain during sexual intercourse. She weighs 50 kg
(110 lb) and is 160 cm (5 ft 3 in) tall; BMI is 20 kg/m2. Pelvic
examination shows a normal-appearing vulva and vagina. The
cervix is pink with minimal endocervical gland eversion. The
uterus is normal in size. The left ovary is 2 x 3 cm; the right is
4 x 6 cm. Which of the following is the most likely cause of
her condition?
(A)
(B)
(C)
(D)
(E)
3.
Chronic appendicitis
Endometriosis
Pelvic congestion syndrome
Polycystic ovarian syndrome
Premenstrual syndrome
A 22-year-old woman comes to the physician because of a 2day history of pain with urination, intense vaginal itching, and
a thick discharge. She has no history of serious illness. She is
sexually active and uses an oral contraceptive. Her
temperature is 37°C (98.6°F). Abdominal examination shows
no abnormalities. Genitourinary examination shows erythema
of the vulva and vagina with an odorless curd-like discharge.
The cervix appears normal. Bimanual examination shows no
abnormalities. The pH of the vaginal discharge is 4. Wet
mount preparations of the discharge with saline and with KOH
are obtained. The saline slide shows mature squamous
epithelial cells, and the KOH slide shows multiple budding
yeasts with pseudohyphae. Which of the following is the most
likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
4.
Bacterial vaginosis
Candidiasis
Chlamydia trachomatis infection
Lichen sclerosus
Scabies
Trichomoniasis
A 27-year-old nulligravid woman and her husband have been
unable to conceive for 12 months. She has never used
contraception. Menses occur at 28-day intervals, and her last
menstrual period was 2 weeks ago. She had a single episode
of pelvic inflammatory disease 4 years ago and was treated
with oral antibiotics. Vaginal examination shows no
abnormalities. Cervical cultures are normal. Which of the
following is the most appropriate next step in diagnosis?
(A)
(B)
(C)
(D)
(E)
Reevaluation in 6 months
Ultrasonography of the abdomen
Sperm penetration assay
Hysterosalpingography
Endometrial biopsy
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-77-
Appendix 3
5.
A 30-year-old woman, gravida 2, para 1, comes for her first
prenatal visit at 26 weeks' gestation. Uterine size is greater
than expected for dates. Ultrasonography shows fetal
hydrops. Which of the following is the most appropriate next
step in diagnosis?
(A)
(B)
(C)
(D)
(E)
6.
A 42-year-old woman, gravida 2, para 2, comes to the
physician because of increasingly frequent loss of urine during
the past year. She has loss of urine when she coughs, sneezes,
exercises, or plays with her children. Her incontinence is
never preceded by a sudden urge to void, and she does not
have loss of urine at night. Her children were born after
uncomplicated vaginal deliveries. She has no history of other
hospital admissions or serious illness. She takes no
medications. Abdominal examination shows no abnormalities.
The external genitalia, vagina, and cervix appear normal. The
uterus and adnexa are normal to palpation. There is loss of a
small amount of urine with Valsalva maneuver. Her postvoid
residual volume is 50 mL. Urinalysis shows no abnormalities.
Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
7.
Overactive bladder with incontinence
Overflow incontinence
Stress incontinence
Urinary tract infection
Vesicovaginal fistula
During a routine examination, a 25-year-old woman expresses
concern about her risk for ovarian cancer because her mother
died of the disease. Which of the following is the most
appropriate course of action?
(A)
(B)
(C)
(D)
(E)
8.
Maternal HIV antibody test
Maternal Rh status with antibody screening
Cervical and urine cultures for group B
streptococcus
MRI of the fetus
Amniocentesis for measurement of α-fetoprotein
concentration
Reassure her that ovarian cancer is not hereditary
Obtain a more detailed family history of cancer
Recommend a diet high in beta-carotene
Annual CT scans of the abdomen
Prophylactic oophorectomy
At her 6-week postpartum visit, an 18 year-old woman,
gravida 1, para 1, tells her physician that she has a pinkish
vaginal discharge that has persisted since her delivery,
although it is decreasing in amount. On physical examination,
the uterus is fully involuted and there are no adnexal masses.
Which of the following is the most appropriate next step in
management?
(A)
(B)
(C)
(D)
(E)
9.
A 32-year-old nulligravid woman comes to the physician
because of a 6-week history of persistent foul-smelling
vaginal discharge and vaginal itching. Her symptoms have not
improved despite 2 weeks of treatment with over-the-counter
antifungal medications and fluconazole. She has been sexually
active and monogamous with her boyfriend during the past
year, and they use condoms consistently. Examination shows
excoriated labia and erythematous vaginal mucosa. There is a
frothy, watery-gray discharge in the posterior vaginal vault. A
wet mount preparation of the discharge shows numerous
multi-flagellated organisms the size of erythrocytes. Which of
the following is the most likely causal organism?
(A)
(B)
(C)
(D)
(E)
Haemophilus ducreyi
Neisseria gonorrhoeae
Pseudomonas aeruginosa
Treponema pallidum
Trichomonas vaginalis
10. An asymptomatic 24-year-old primigravid woman at 36
weeks= gestation comes for a routine prenatal visit. A grade
2/6, systolic ejection murmur is heard at the left upper sternal
border. The S2 varies with inspiration, and the pulmonic
component is soft; diastole is clear. Which of the following is
the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Anomalous pulmonary venous return
Atrial septal defect
Flow murmur
Patent ductus arteriosus
Pulmonary valve stenosis
11. A 42-year-old woman, gravida 3, para 3, comes to the
physician because she has not had a menstrual period for 2
months. She reports that she had an episode of spotting 3
weeks ago. She has had no other symptoms. She has no
history of abnormal Pap smears; her last Pap smear was 10
months ago. She is sexually active with her husband and uses
condoms. She is 163 cm (5 ft 4 in) tall and weighs 72 kg
(160 lb); BMI is 28 kg/m2. On physical examination, the
abdomen is nontender to palpation. Pelvic examination shows
a slightly enlarged uterus; there are no palpable adnexal
masses. Which of the following is the most appropriate next
step in management?
(A)
(B)
(C)
(D)
(E)
Measurement of serum β-hCG concentration
Measurement of serum thyroid-stimulating
hormone concentration
CT scan of the pelvis
Oral contraceptive therapy
Endometrial biopsy
Reassurance that this is normal
Measurement of serum prolactin concentration
Quantitative β-hCG test
Administration of amplicillin
Dilatation and curettage
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-78-
Appendix 3
12. A 57-year-old woman comes to the physician for a routine
health maintenance examination. She takes a multivitamin
supplement and calcium (500 mg/d). She has followed a
vegan diet for 30 years. She exercises daily for 30 minutes.
She does not smoke cigarettes or drink alcohol. There is a
family history of osteoporosis. She is 168 cm (5 ft 6 in) tall
and weighs 60 kg (132 lb); BMI is 21 kg/m2. Examination
shows no abnormalities. Bone densitometry shows evidence
of low bone density. She prefers not to be treated with
medications. The physician recommends that the patient
increase her daily dose of the calcium supplement. The most
appropriate next step in management is supplementation with
which of the following?
(A)
(B)
(C)
(D)
(E)
Fish oil
Magnesium
Vitamin C
Vitamin D
Zinc
13. A 2778-g (6-lb 2-oz) male newborn is born at 37 weeks'
gestation to a 27-year-old woman, gravida 3, para 2, after an
uncomplicated labor and delivery. The mother has no medical
insurance and did not receive prenatal care. She says she did
not have any health problems during pregnancy, but she
continued to consume two bottles of beer weekly during her
pregnancy. She does not take any medications, vitamins, or
herbal supplements. Her diet consists mostly of rice and
beans. Examination of the newborn shows spina bifida. Which
of the following measures during the mother's pregnancy is
most likely to have prevented this child's deformity?
(A)
(B)
(C)
(D)
(E)
(F)
Abstinence from alcohol
Increase dietary intake of omega-3 fatty acids
Glucose tolerance test
Screening for group B streptococcal infection
TORCH titer screening
Folic acid supplementation
14. Two hours after vaginal delivery at term of a 3062-g (6-lb
12-oz) newborn, a 32-year-old woman, gravida 3, para 3, has
the onset of heavy vaginal bleeding. Labor was augmented
with oxytocin because of a prolonged first stage and required
forceps delivery over a midline second-degree episiotomy.
The abdomen is soft and nontender. Examination shows a
boggy uterus palpated 4 cm above the umbilicus. The
perineum is intact. Which of the following is the most likely
cause of this patient's hemorrhage?
(A)
(B)
(C)
(D)
(E)
Disseminated intravascular coagulation
Episiotomy site bleeding
Uterine atony
Uterine infection
Uterine rupture
15. A 19-year-old primigravid woman at 8 weeks' gestation is
brought to the emergency department because of light vaginal
bleeding and mild lower abdominal cramps during the past 8
hours. Her temperature is 37°C (98.6°F), pulse is 84/min,
respirations are 18/min, and blood pressure is 110/70 mm Hg.
Abdominal examination shows no tenderness or masses;
bowel sounds are normal. On pelvic examination, there is old
blood in the vaginal vault and at the closed cervical os. The
uterus is consistent in size with a 6- to 8-week gestation.
Transvaginal ultrasonography shows an intrauterine
pregnancy. A fetal heartbeat is seen. Which of the following is
the most appropriate next step in management?
(A)
(B)
(C)
(D)
(E)
Discharge home for observation
Oral administration of misoprostol
Intramuscular administration of methotrexate
Operative laparoscopy
Dilatation and curettage
16. A 16-year-old girl is brought to the emergency department 6
hours after the onset of moderate lower abdominal cramps and
intermittent nausea. She has not vomited during this time. She
says that her last menstrual period was 2 months ago, but she
has had intermittent bleeding since then, including spotting for
the past 2 days. Menarche was at the age of 15 years. Menses
occur at irregular 25- to 45-day intervals. She is sexually
active and uses condoms inconsistently. Her temperature is
38.1°C (100.6°F), pulse is 94/min, respirations are 22/min,
and blood pressure is 120/80 mm Hg. Examination shows a
soft abdomen with lower quadrant tenderness, especially on
the right. Bowel sounds are normal. Pelvic examination shows
scant vaginal bleeding and a palpable, tender right adnexal
mass. The cervix appears normal. There is no cervical motion
tenderness. Which of the following is the most appropriate
next step in management?
(A)
(B)
(C)
(D)
(E)
Complete blood count
Measurement of serum β-hCG concentration
Abdominal x-ray
Ceftriaxone and azithromycin therapy
Exploratory laparoscopy
17. A 13-year-old girl is brought to the physician because of a 1year history of intermittent irregular vaginal bleeding; the
bleeding ranges from spotting to heavier than a normal
menstrual period, occurs every 2 to 8 weeks, and lasts 10 to 30
days. Examination shows a pink, well-rugated vagina with no
discharge; the cervix appears normal. The uterus is 6 cm in
length, regular in contour, and nontender. There are palpable,
normal-sized, nontender ovaries. Which of the following is the
most appropriate pharmacotherapy to alleviate this patient's
symptoms?
(A)
(B)
(C)
(D)
(E)
Continuous low-dose estrogen
Gonadotropin-releasing hormone agonist
Oral contraceptives
Tetracycline
Thyroid hormone
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-79-
Appendix 3
18. A previously healthy 25-year-old woman, gravida 2, para 2,
comes to the emergency department because of a 3-day
history of painful swelling of her vaginal area. Her last
menstrual period was 2 months ago. She is sexually active
with one male partner and uses depot medroxyprogesterone
for contraception. Her temperature is 38.4°C (101.2°F), pulse
is 96/min, respirations are 16/min, and blood pressure is
125/82 mm Hg. Examination shows a 4-cm, exquisitely tender
mass in the inferior aspect of the left labium minus. The
swelling and tenderness prevent insertion of either a speculum
or fingers into the vagina. Which of the following is the most
likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
Bartholin gland abscess
Chancroid
Condylomata acuminata
Herpes simplex
Lymphogranuloma venereum
Primary syphilis
19. A 22-year-old primigravid woman at 34 weeks' gestation is
brought to the emergency department by ambulance after
being found unconscious by her husband. Paramedics report
that she was having tonic-clonic movements that have now
stopped. Her last visit to the physician was 2 weeks ago.
Pregnancy had been uncomplicated. On arrival, she is awake,
lethargic, and mildly confused. She says that she had a
headache and did not feel well earlier in the day. She has no
history of serious illness. Her only medication is a prenatal
vitamin. Her temperature is 37°C (98.6°F), pulse is 80/min,
respirations are 18/min, and blood pressure is
170/110 mm Hg. Examination shows a nontender, soft uterus
consistent in size with a 34-week gestation. Cranial nerves are
intact. Motor function is normal. Deep tendon reflexes are 3+.
Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
20. A 15-year-old girl is brought to the physician by her mother
because she believes that her daughter has become sexually
active and wants her to use contraception. During an interview
with the patient alone, she reports that she has become
sexually active with one male partner over the past 3 months.
She and her partner use condoms consistently, and she is not
interested in any other form of contraception at this time.
Menarche was at the age of 12 years, and menses occur at
regular 28-day intervals. She has had no symptoms of sexually
transmitted diseases. Examination shows no abnormalities. In
addition to counseling the patient about all contraceptive
methods, which of the following is the most appropriate next
step?
(A)
(B)
(C)
(D)
(E)
Do not inform the mother that her daughter and
her partner use condoms, but encourage the
daughter to communicate the information
Inform the mother that her daughter and her
partner use condoms
Inform the mother that her daughter is protecting
herself appropriately against pregnancy, but
do not mention what form of contraception
Inform the mother that you have administered
depot medroxyprogesterone to the patient
Inform the mother that you have given the patient
a prescription for an oral contraceptive
Absence seizures
Cerebral infarction
Eclampsia
Migraine
Pheochromocytoma
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-80-
Appendix 3
Answer Form for Obstetrics and Gynecology Sample Questions
(Questions 1-20)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-81-
Appendix 3
Answer Key for Obstetrics and Gynecology Sample Questions
(Questions 1-20)
1. B
2. B
3. B
4. D
5. B
6. C
7. B
8. A
9. E
10. C
11. A
12. D
13. F
14. C
15. A
16. B
17. C
18. A
19. C
20. A
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-82-
Appendix 3
PEDIATRICS
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
(J)
Normal Development
Organ Systems
Immunologic Disorders
Diseases of the Blood and Blood-forming Organs
Mental Disorders
Diseases of the Nervous System and Special Senses
Cardiovascular Disorders
Diseases of the Respiratory System
Nutritional and Digestive Disorders
Gynecologic Disorders
Renal, Urinary, and Male Reproductive System
Disorders of Pregnancy, Childbirth, and the Puerperium
Disorders of the Skin and Subcutaneous Tissues
Diseases of the Musculoskeletal System and Connective Tissue
Endocrine and Metabolic Disorders
5%B10%
90%B95%
5%B10%
5%B10%
1%B5%
5%B10%
10%B15%
10%B15%
10%B15%
1%B5%
10%B15%
1%B5%
1%B5%
5%B10%
5%B10%
Physician Tasks
Promoting Health and Health Maintenance
Understanding Mechanisms of Disease
Establishing a Diagnosis
Applying Principles of Management
5%B10%
25%B30%
40%B45%
10%B15%
Ankyloglossia (tongue-tie)
Attention-deficit/hyperactivity disorder
Autistic disorder
Hearing loss
Neurodegenerative disorder
Normal language development
Mental retardation
Parental neglect
Selective mutism
Serous otitis media
For each child brought for a well-child examination, select the most likely diagnosis.
1.
A 4-year-old boy squeals and cries but uses no words. His gross and fine motor skills are well developed. He is preoccupied
with objects and does not play with other children. The child responds normally to sounds but appears disinterested and
detached.
2.
A 16-month-old infant babbled at 6 months, began to mimic sounds at 10 months, and began to use a few recognizable words
between 12 and 14 months. At 16 months, the child is continuing to use single words but is not using simple two-word phrases.
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-83-
Appendix 3
3.
A 2-month-old infant has a 5-cm strawberry hemangioma
on the cheek that is increasing in size. No other lesions are
noted. Which of the following is the most appropriate next
step in management?
(A)
(B)
(C)
(D)
(E)
4.
5.
(B)
(C)
(D)
"The decision about your child's gender is
entirely yours."
"You have a beautiful new daughter."
"Your baby is a boy, but his genitals are not yet
fully developed."
"Your baby looks healthy, but we will not
know the gender until we run additional
tests."
One week after a Abreathing treatment@ in the emergency
department for an initial episode of coughing and
wheezing, a 10-year-old girl is brought to the physician for
a follow-up examination. She has a 3-year history of nasal
allergies; both her parents have allergic rhinitis. She is
afebrile. The lungs are clear to auscultation. An x-ray of the
chest shows normal findings. Which of the following
medications is most appropriate on an as-needed basis?
(A)
(B)
(C)
(D)
(E)
Inhaled β-adrenergic agonist
Inhaled corticosteroids
Inhaled cromolyn sodium
Oral β-adrenergic agonist
Oral theophylline
A 4-year-old boy is brought to the physician by his parents
because of a 2-month history of difficulty sleeping. His
parents report that he typically awakens 1 hour after going
to sleep and cries loudly. When his parents come to his
room, he appears frightened and is unaware of their
attempts to comfort him. In the morning, he has no memory
of these episodes. Physical examination shows no
abnormalities. Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)
8.
Acute otitis media
Furunculosis
Mastoiditis
Otitis externa
Tympanic membrane perforation
A 3175-g (7-lb) newborn is delivered at term to a
21-year-old woman, gravida 1, para 1. Pregnancy, labor,
and delivery were uncomplicated. Examination shows
ambiguous genitalia. Which of the following is the most
appropriate physician response to the parents regarding
their newborn's gender?
(A)
6.
Observation of the lesion
Solid carbon dioxide application to the lesion
Intralesional corticosteroid treatment
Laser therapy to the lesion
Surgical removal of the lesion
A previously healthy 15-year-old girl comes to the
physician because of increasing left ear pain during the past
3 days. Vital signs are within normal limits. Examination of
the left ear shows edema and erythema of the auditory
canal with a greenish discharge. Manipulation of the left
pinna elicits pain. The tympanic membrane can only
partially be visualized, and examination of what can be
seen appears normal with normal mobility. Examination of
the right ear shows no abnormalities. Which of the
following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
7.
A male newborn is born to a 32-year-old woman by
cesarean delivery at 38 weeks' gestation and weighs 4309 g
(9 lb 8 oz). The pregnancy was complicated by gestational
diabetes that was difficult to manage. Apgar scores are 6
and 8 at 1 and 5 minutes, respectively. This newborn is at
increased risk for developing which of the following within
the next 24 hours?
(A)
(B)
(C)
(D)
(E)
(F)
9.
Factitious disorder
Oppositional defiant disorder
Seizure disorder
Separation anxiety disorder
Sleep terror disorder
Hypercalcemia
Hyperglycemia
Hyperkalemia
Hypoglycemia
Hypokalemia
Hypothermia
A 14-year-old girl is brought to the physician for a wellchild examination. She reports that she occasionally feels
sad because "everyone else is confident except me." She
notes that she likes a new boy in her class, but she is afraid
that "he doesn't know that I exist." She sometimes worries
that she will attract his attention, but this is not a constant
worry. She adds, "I know he likes this really pretty singer
on TV, and I could never measure up to her. I am not sure
that anyone can really relate to my situation." She generally
gets along well with friends and family. She is in the eighth
grade and maintains a B average. She plays on the school
soccer team and is an active member of the Girl Scouts.
She does not drink alcohol or use illicit drugs. She is not
sexually active. She is at the 60th percentile for height and
50th percentile for weight. She is casually dressed. Physical
examination shows no abnormalities. On mental status
examination, she is cooperative with a mildly anxious
mood and a full range of affect. She says she is not
depressed. Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)
Generalized anxiety disorder
Histrionic personality disorder
Major depressive disorder
Narcissistic personality disorder
Normal development
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-84-
Appendix 3
10. A previously healthy 6-year-old boy is brought to the
physician because of a 1-week history of right knee pain
and swelling. He also has had occasional chills and muscle
pain for 1 week. He went camping with his father in eastern
Pennsylvania approximately 2 months ago. Two weeks
after the trip, he had a solid red rash that slowly spread over
most of his right thigh and resolved spontaneously 2 weeks
later. Examination of the right knee shows swelling, an
effusion, and mild tenderness to palpation. Which of the
following is most likely to confirm the diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
Complete blood count
Determination of erythrocyte sedimentation rate
Serum antinuclear antibody assay
Serum Lyme (Borrelia burgdorferi) antibody
assay
Serum rheumatoid factor assay
X-ray of the right knee
11. An 8-year-old boy is brought to the physician by his mother
for a well-child examination. His mother reports that she is
exhausted because he is constantly "on the go," is
increasingly difficult to manage, and needs constant
supervision. Last week, he climbed out on the roof of their
house "just to see how high up it was." He has had trouble
maintaining friendships because he is "bossy" and easily
frustrated if he does not win at games. His mother says that
he wakes up cheerful and full of energy each morning and
that he says he will "really try to be good." His teacher
usually calls by noon to report about his difficult behavior.
He is disruptive in class and often "plays the class clown."
When asked to sit still and do his work, he becomes
frustrated and shouts, "I can't sit still." He is unable to work
quietly for more than 15 minutes. The school has
threatened to suspend him if his behavior does not improve.
His grades are poor. He is at the 70th percentile for height
and 45th percentile for weight. Vital signs are within
normal limits. Physical examination shows no
abnormalities. During the examination, he is cheerful and
verbally impulsive. After the examination, his mother
becomes tearful and says she does not know what to do.
Which of the following is the most appropriate initial
response?
(A)
(B)
(C)
(D)
(E)
"Clearly he needs medication right away."
"I think that the school is being unfair to your
child."
"It certainly sounds as though things have
been difficult for you."
"You should look into other schools to give him
a fresh start."
"You should see a therapist to talk about your
feelings."
12. A previously healthy 10-year-old boy is brought to the
emergency department by his parents immediately after the
sudden onset of difficulty breathing that began when he
was stung on the arm by a bee. On arrival, he is in severe
respiratory distress. His temperature is 38°C (100.4°F),
pulse is 115/min, respirations are 60/min, and blood
pressure is 80/40 mm Hg. Examination shows
supraclavicular and intercostal retractions. There is diffuse
urticaria over the trunk and upper and lower extremities.
Expiratory wheezes are heard bilaterally. Which of the
following is the most appropriate initial pharmacotherapy?
(A)
(B)
(C)
(D)
(E)
Oral diphenhydramine
Inhaled fluticasone
Subcutaneous epinephrine
Intravenous methylprednisolone
Intravenous ranitidine
13. A 16-year-old girl is brought to the physician because of
severe acne over her face and upper back for 6 months. She
has had no itching or scaling of the acne. Treatment with
topical and oral antibiotics has not resolved her symptoms.
Examination shows numerous papules and pustules with
widespread erythema over the face and upper back. There
is no hyperpigmentation. The patient requests information
about beginning isotretinoin, because she says it improved
her boyfriend's acne. Which of the following is the most
appropriate initial step prior to treatment with isotretinoin?
(A)
(B)
(C)
(D)
(E)
(F)
Complete blood count with differential
Determination of prothrombin and partial
thromboplastin times
24-Hour urine collection for measurement of
creatinine clearance
Measurement of serum thyroid-stimulating
hormone concentration
Measurement of urine β-hCG concentration
PPD skin test
14. A 3-year-old girl is brought to the emergency department 2
days after the onset of fever, profuse watery diarrhea, and
progressive lethargy. On arrival, she appears ill and is
poorly responsive. Her temperature is 39.4°C (103°F),
pulse is 180/min, respirations are 40/min, and blood
pressure is 80/45 mm Hg. Examination shows poor skin
turgor and cool extremities. Mucous membranes are dry.
Capillary refill time is delayed. Which of the following is
the most appropriate next step to decrease the risk of acute
renal failure in this patient?
(A)
(B)
(C)
(D)
(E)
Monitoring urine output
Ceftriaxone therapy
Diuretic therapy
Fluid resuscitation
Vasopressor therapy
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-85-
Appendix 3
15. A 3-year-old girl with Down syndrome is brought to the physician because of a 1-week history of frequent nosebleeds, decreased
appetite, and lethargy. She takes no medications. Her temperature is 38°C (100.4°F), pulse is 100/min, respirations are 20/min,
and blood pressure is 80/45 mm Hg. Examination shows no abnormalities except for pallor. Laboratory studies show:
Hemoglobin
Hematocrit
Leukocyte count
Segmented neutrophils
Atypical lymphocytes
Platelet count
6.5 g/dL
19%
100,000/mm3
15%
85%
45,000/mm3
Which of the following is the most likely mechanism of these laboratory findings?
(A)
(B)
(C)
(D)
(E)
(F)
Bone marrow hypoplasia
Infiltration of bone marrow by leukemic blasts
Iron deficiency
Lymphocyte inhibitors of erythropoiesis
Reticuloendothelial phagocytosis of platelets
Serum immunoglobulin A deficiency
16. A 16-year-old girl is brought to the physician for a school
physical examination. She has no history of serious illness
and takes no medications. Menarche has not yet occurred.
She is 155 cm (5 ft 1 in) tall and weighs 66 kg (145 lb);
BMI is 27 kg/m2. Her blood pressure is 140/80 mm Hg in
the left arm and 105/70 mm Hg in the left leg. Vital signs
are otherwise within normal limits. A grade 2/6 systolic
murmur is heard best over the upper back to the left of the
midline. The extremities are well perfused with strong
peripheral pulses. Breast development is Tanner stage 2,
and pubic hair development is Tanner stage 1. This patient
most likely has an abnormality of which of the following
vessels?
(A)
(B)
(C)
(D)
(E)
Aorta
Coronary artery
Pulmonary artery
Renal artery
Renal vein
17. An 11-year-old girl with cystic fibrosis is admitted to the
hospital 18 hours after the onset of shortness of breath.
During the past 11 years, she has had more than 20
episodes of respiratory exacerbations of her cystic fibrosis
that have required hospitalization. Current medications
include an inhaled bronchodilator, inhaled corticosteroid,
oral pancreatic enzyme, and oral multivitamin. Her
temperature is 38°C (100.4°F), pulse is 96/min, respirations
are 28/min, and blood pressure is 92/68 mm Hg. Diffuse
wheezes and crackles are heard bilaterally. A sputum
culture grows Burkholderia cepacia. Which of the
following is the most likely cause of this patient's recurrent
respiratory tract infections?
(A)
(B)
(C)
(D)
(E)
Immune suppression
Impaired clearing of airway secretions
Increased exposure to infectious organisms
Interstitial fibrosis
Restrictive changes of the small airways
18. A 3-week-old infant is brought to the physician by his
mother because of a 1-week history of increasingly
frequent vomiting. She says that at first he vomited
occasionally, but now he vomits after every feeding. The
vomitus is nonbilious and consists of breast milk. He has
had fewer wet diapers during the past 2 days. He was born
at term following an uncomplicated pregnancy and initially
fed well. He appears lethargic and dehydrated. A 1 x 2-cm,
firm, mobile, olive-shaped mass is palpated immediately to
the left of the epigastrium. Which of the following is the
most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Congenital megacolon (Hirschsprung disease)
Duodenal atresia
Intussusception
Midgut volvulus
Pyloric stenosis
19. A 15-year-old girl is brought to the physician by her mother
because of a 1-year history of monthly cramps that begin 2
days before menses and last 3 days. The cramps have
increased in severity during the past 6 months. She is
unable to practice with her volleyball team because of the
pain and typically misses 2 days of school monthly.
Menarche was at the age of 12 years. Menses occur at
regular 30-day intervals and last 4 days with normal flow.
She has no history of serious illness and takes no
medications. She has never been sexually active. Physical
examination shows no abnormalities. Which of the
following is the most likely cause of this patient's pain?
(A)
(B)
(C)
(D)
(E)
Bladder wall permeability
Degenerating myoma
Endometrial prostaglandin production
Escherichia coli infection
Intestinal hypermobility
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-86-
Appendix 3
20. A 5-year-old girl is brought to the physician by her parents for evaluation of recurrent injuries. Her parents say that she started
walking at the age of 14 months and since then has always seemed clumsier and had more injuries than other children. She has
had increasingly frequent pain with exertion since starting a soccer program 3 months ago. She usually has pain or swelling of
her knees or ankles after practice. She has been taken to the emergency department three times during the past 3 weeks because
of concern about possible fractures; x-rays showed no abnormalities. Today, the patient walks with a limp. Examination shows
numerous paper-like scars over the torso and upper and lower extremities. A midsystolic click is heard at the apex. The left ankle
is swollen and tender; range of motion is limited by pain. The hips and the joints of the upper and lower extremities are
hypermobile, including 25 degrees of genu recurvatum, thumbs that may be extended to touch the forearms, and flexibility at the
waist, with palms easily touching the floor with straight knees. Which of the following is the most likely explanation for this
patient's physical findings?
(A)
(B)
(C)
(D)
(E)
(F)
Cerebellar degeneration
Collagen abnormality
Complement deficiency
Defect in the migration of segmented neutrophils
Immune complex deposition
Vitamin D deficiency
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-87-
Appendix 3
Answer Form for Pediatrics Subject Test Sample Questions
(Questions 1-20)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-88-
Appendix 3
Answer Key for Pediatrics Subject Test Sample Questions
(Questions 1-20)
1. C
2. F
3. A
4. D
5. D
6. A
7. E
8. D
9. E
10. D
11. C
12. C
13. E
14. D
15. B
16. A
17. B
18. E
19. C
20. B
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-89-
Appendix 3
PSYCHIATRY
General Principles
Organ Systems
Mental Disorders
Mental disorders usually first diagnosed in infancy, childhood, or adolescence
Substance-related disorders
Schizophrenia and other psychotic disorders
Mood disorders
Anxiety disorders
Somatoform disorders
Other disorders/conditions
Diseases of the Nervous System and Special Senses
Physician Tasks
Promoting Health and Health Maintenance
Understanding Mechanisms of Disease
Establishing a Diagnosis
Applying Principles of Management
1.
A 3-year-old girl is brought to the physician by her parents
because they are concerned about her behavior. They describe
their daughter as stubborn and always on the go. She can
rarely sit still for more than 10 minutes. She often refuses to
comply with their requests and sometimes throws 3- to 5minute temper tantrums. They report that she dawdles at
bedtime and requires frequent direction and assistance in
preparing for bed. Her preschool teacher notes that she is
active and talkative without being disruptive and is beginning
to demonstrate more interactive play with her peers. She
generally sleeps through the night and occasionally wets the
bed. Her appetite is good. Her first word was at the age of 11
months, and she began walking without assistance at the age
of 14 months. Physical examination shows no abnormalities.
On mental status examination, she initially hides behind her
mother but warms to the interviewer after a few minutes and
begins playing with toys in the office. Her speech is 90%
intelligible, and her vocabulary is large for her age. Which of
the following is the most appropriate next step in
management?
(A)
(B)
(C)
(D)
(E)
(F)
Reassurance
Play therapy
Speech therapy
Enuresis alarm
Trial of fluoxetine
Trial of methylphenidate
5%B10%
90%B95%
75%B85%
10%B20%
1%B5%
10%B15%
55%B65%
15%B20%
2.
A 45-year-old man is brought to the physician by his spouse.
He has been drinking heavily since he was passed over for a
job promotion 3 days ago. He stayed in bed over the
weekend. He has no personal history of psychiatric disorders
and no personal or family history of alcohol abuse. He is
crying and states, AI can't believe it,@ when addressed. When
asked what he will do, he states, AI don't know, but if I don't
go back to work tomorrow, I'll lose my job.@ Which of the
following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
3.
Adjustment disorder with depressed mood
Bipolar disorder
Dysthymic disorder
Major depressive disorder
Substance abuse
A previously healthy 18-year-old woman is brought to the
physician for evaluation because of loss of appetite,
sleeplessness, and extreme irritability for 3 weeks. After
missing many practices, she quit the college softball team that
she previously enjoyed. She often feels tired and has
difficulty sitting still and concentrating on schoolwork. Her
menses occur at regular intervals. She weighs 50 kg (110 lb)
and is 168 cm (5 ft 6 in) tall; her BMI is 18 kg/m2. Her pulse
is 74/min, respirations are 16/min, and blood pressure is
110/70 mm Hg. Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)
Adjustment disorder with mixed disturbance of
emotions and conduct
Anorexia nervosa
Attention-deficit/hyperactivity disorder
Dysthymic disorder
Major depressive disorder
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-90-
Appendix 3
4.
A 57-year-old man comes to the physician accompanied by
his wife because of a 2-year history of fatigue. He reports
waking up tired nearly every morning, often with a headache.
He naps almost every afternoon. He thinks that the fatigue is
affecting his concentration and performance at work. His wife
says that he snores frequently during the night and sometimes
wakes up gasping for air. She describes him as a restless
sleeper. His tonsils and adenoids were removed when he was a
child. He has no history of serious illness and takes no
medications. He is 178 cm (5 ft 10 in) tall and weighs 115 kg
(253 lb); BMI is 36 kg/m2. His pulse is 86/min, and blood
pressure is 164/88 mm Hg. The nasal septum is at the midline.
Examination shows no other abnormalities. Which of the
following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
5.
Allow her to express herself
Prescribe an antianxiety drug
Prescribe an antidepressant drug
Refer her for psychological testing
Obtain a psychiatric consultation
A 47-year-old man is brought to the emergency department by
police after he was found eating garbage from a dumpster
behind a restaurant. He says that he just came to this town and
that he is homeless, so he has no money for food. He admits to
several psychiatric hospitalizations in the past but says that he
no longer needs medication. He appears dirty and is
malodorous. Vital signs are within normal limits. Physical
examination shows no abnormalities. On mental status
examination, his speech is clear, but his thought process is
disorganized with many loose associations. At several times
during the interview, he appears to be preoccupied with
internal stimuli. He says that he hears voices having an
ongoing conversation in his head. Which of the following is
the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
A 32-year-old woman is brought to the emergency department
because of fever, hallucinations, agitation, and confusion for 8
hours.
She has a history of alcohol, cocaine, and
benzodiazepine abuse. Her temperature is 37.8°C (100°F),
pulse is 110/min, respirations are 16/min, and blood pressure
is 150/90 mm Hg. Examination shows tremors and
telangiectasia. The lungs are clear to auscultation. There is a
holosystolic murmur; the abdomen is tender, and the liver
edge is palpable 3 cm below the right costal margin. Rectal
examination shows no abnormalities. Her serum alkaline
phosphatase activity is 200 U/L, serum ALT activity is 60
U/L, and serum AST activity is 90 U/L. Which of the
following is the most likely cause of this condition?
(A)
(B)
(C)
(D)
(E)
8.
A 52-year-old woman whose husband died 2 months ago
consults a physician because of headaches and feelings of
uncertainty. She describes the headaches as a band around her
head; they occur unpredictably and are not accompanied by
any other symptoms. She has no history of psychiatric illness.
While talking with the physician, the patient begins to cry and
talk about her deceased husband; she feels her life is empty
now and worries about her future. Which of the following is
most appropriate at this point?
(A)
(B)
(C)
(D)
(E)
6.
Chronic fatigue syndrome
Narcolepsy
REM sleep behavior disorder
Restless legs syndrome
Sleep apnea
7.
A 10-year-old boy is brought to the physician because of
increasing behavior problems in school since starting 5th
grade 3 months ago. His teacher states that he is unable to sit
quietly through a classroom period and frequently disrupts the
class and interrupts other children while they are talking. His
parents report that he has always been an active child and are
concerned because he is inattentive when he runs or walks.
During examination, he fidgets with his hands and feet and is
easily distracted from completing a task. Which of the
following is the most appropriate pharmacotherapy?
(A)
(B)
(C)
(D)
(E)
9.
Acute cocaine toxicity
Alcohol withdrawal
Benzodiazepine withdrawal
Panic disorder
Schizophreniform disorder
Amitriptyline
Fluoxetine
Haloperidol
Imipramine
Methylphenidate
A 27-year-old woman is brought to the emergency department
1 hour after a friend found her barely arousable in her
disorderly apartment with a nearly starving cat. The patient
appears extremely thin. Her pulse is 90/min, respirations are
6/min, and blood pressure is 90/60 mm Hg. Physical
examination shows small pupils, cracked lips, and bruises and
scratches over the upper extremities. Mental status
examination shows mild obtundation, blunted affect, and
slow, incoherent speech. Which of the following is the most
appropriate next step in management?
(A)
(B)
(C)
(D)
(E)
Observation in a quiet darkened room
Oral administration of chlorpromazine
Intramuscular administration of naloxone
Intravenous administration of haloperidol
Intravenous administration of lorazepam
Bipolar disorder
Brief psychotic disorder
Delusional disorder
Major depressive disorder with psychotic features
Psychotic disorder due to a general medical
condition
Schizophrenia
Schizotypal personality disorder
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-91-
Appendix 3
10. A healthy 9-year-old boy is brought to the physician by his
parents because they are concerned that he dislikes attending
school. Every morning he cries and begs to stay home. He
misses school at least 1 day weekly because his mother is
exhausted from fighting with him to attend. His teachers
report that he is quiet in class and rarely participates. He has
difficulty reading at the level of his peers and lacks
confidence. At home, he tends to stay in the same room as his
mother and will sometimes follow her around the house.
When his parents plan an evening out, he often becomes
tearful and asks many questions about when they will return.
He likes to have friends over to his house and appears to enjoy
being with them. Physical examination shows no
abnormalities. During the examination, he sits on his mother's
lap and is quiet but cooperative. He makes brief eye contact
and speaks in a low volume, becoming tearful when
questioned about being away from his mother. Which of the
following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
Dysthymic disorder
Mild mental retardation
Oppositional defiant disorder
Reading disorder
Separation anxiety disorder
Social phobia
11. A 47-year-old woman is brought to the physician by her
husband because of bizarre behavior for 1 week. Her husband
says that she makes no sense when she speaks and seems to be
seeing things. She also has had difficulty sleeping for 2
months and has gained approximately 9 kg (20 lb) during the
past 5 months. During this time, she has been moody and
easily fatigued. He also notes that the shape of her face has
become increasingly round and out of proportion with the rest
of her body despite her weight gain. She has no history of
psychiatric or medical illness. She is 160 cm (5 ft 3 in) tall
and weighs 70 kg (155 lb); BMI is 28 kg/m2. Her pulse is
98/min, respirations are 8/min, and blood pressure is 148/92
mm Hg. Physical examination shows truncal obesity and
ecchymoses over the upper and lower extremities. Neurologic
examination shows no focal findings. Mental status
examination shows pressured speech and a disorganized
thought process. There is evidence of visual and auditory
hallucinations. Urine toxicology screening is negative. Which
of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
12. One day after admission to the hospital for agitation and
hallucinations, a 19-year-old man has the onset of severe
muscle stiffness that prevents him from rising out of bed. At
the time of admission, treatment with haloperidol was begun.
Today, he appears lethargic and diaphoretic. His temperature
is 39.7°C (103.5°F), pulse is 120/min, and blood pressure is
160/110 mm Hg. Physical examination shows generalized
severe rigidity of the upper extremities bilaterally. On mental
status examination, he is not oriented to person, place, and
time. Which of the following is the most appropriate next step
in management?
(A)
(B)
(C)
(D)
(E)
Observation only
Add fluoxetine
Add lithium carbonate
Discontinue haloperidol
Increase the dosage of haloperidol
13. A 32-year-old woman comes to the physician because of a 3week history of depressed mood. She works as a local news
anchor. She says that she has always had a busy schedule, but
lately she has not had her usual amount of energy and has had
difficulty getting up and going to work. She describes herself
as normally a "hyper" person with energy to perform multiple
tasks. During the past 10 years, she has had similar episodes
in which she has had depressed mood associated with a
decreased energy level that makes her feel "slowed down."
The episodes never last more than a few weeks. She
sometimes goes through periods when she feels a surge in
energy, sleeps very little, feels at the top of her mental
powers, and is able to generate new ideas for the news station;
these episodes never last more than 5 days. She says that she
loves feeling this way and wishes the episodes would last
longer. She takes no medications. She does not drink alcohol
or use illicit drugs. Her temperature is 37°C (98.6°F), pulse is
70/min, and blood pressure is 125/80 mm Hg. Physical
examination shows no abnormalities. Mental status
examination shows a depressed mood and flat affect. Which
of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Attention-deficit/hyperactivity disorder
Cyclothymic disorder
Dysthymic disorder
Major depressive disorder
Mood disorder due to a general medical condition
Brief psychotic disorder
Major depressive disorder with psychotic features
Psychotic disorder due to a general medical
condition
Schizophrenia
Schizotypal personality disorder
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-92-
Appendix 3
14. A 77-year-old woman is brought to the emergency department
by her husband because of agitation and confusion for 3
hours. He states that she has been intermittently crying out
and does not appear to recognize him. A routine health
maintenance examination 3 days ago showed no abnormalities
except for mild memory deficits. Her current temperature is
37.8°C (100°F), pulse is 100/min, respirations are 14/min, and
blood pressure is 130/60 mm Hg. Physical examination shows
no abnormalities except for mild tenderness to palpation of the
lower abdomen. Mental status examination shows confusion;
she is oriented to person but not to time or place. Which of the
following is the most appropriate next step in diagnosis?
(A)
(B)
(C)
(D)
(E)
Determination of erythrocyte sedimentation rate
Measurement of serum alkaline phosphatase
activity
Measurement of serum folate concentration
Urinalysis
Western blot assay
15. A 14-year-old boy is brought to the physician by his mother
after she found an unsmoked marijuana cigarette in his
bedroom. The mother reports that her son has never done
anything like this before. His academic performance is
excellent. When interviewed alone, the patient reports that his
friends heard about smoking marijuana and acquired some
from their peers to find out what it was like. He adds that he
has never smoked marijuana before. He requests that his
teachers not be informed because they would be very
disappointed if they found out. Physical examination shows
no abnormalities. On mental status examination, he is pleasant
and cooperative and appears remorseful. Which of the
following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Conduct disorder
Marijuana abuse
Marijuana dependence
Parent-child relational problem
Normal adolescence
16. An otherwise healthy 27-year-old man is referred to a
cardiologist because of three episodes of severe palpitations,
dull chest discomfort, and a choking sensation. The episodes
occur suddenly and are associated with nausea, faintness,
trembling, sweating, and tingling in the extremities; he feels
as if he is dying. Within a few hours of each episode, physical
examination and laboratory tests show no abnormalities. He
does not abuse drugs or alcohol and has no history of
interpersonal problems. Which of the following is the most
likely diagnosis?
(A)
(B)
(C)
(D)
(E)
17. A 42-year-old woman is brought to the physician by her
husband because of persistent sadness, apathy, and tearfulness
for the past 2 months. She has a 10-year history of systemic
lupus erythematosus poorly controlled with corticosteroid
therapy. Physical examination shows 1-cm erythematous
lesions over the upper extremities and neck and a malar
butterfly rash. On mental status examination, she appears
depressed. She says that she would be better off dead. Which
of the following is the most appropriate next step in
management?
(A)
(B)
(C)
(D)
(E)
Ask the patient about her suicidal thoughts
Reassure the patient that she will get well
Recommend psychiatric hospitalization
Begin paroxetine therapy
Increase the dose of corticosteroid
18. A 27-year-old man is brought to the emergency department by
police 2 hours after threatening his next door neighbor. The
neighbor called the police after receiving a note demanding
that she stop videotaping all of the activities in the patient's
home or he would call the police. During the examination, the
patient is cooperative. He explains that he has lived in the
neighborhood for 8 months. Three months ago, he noticed that
his neighbor installed a new satellite dish and says that since
that time, she has been watching every move he makes. He
reports no personal or family history of psychiatric illness. He
has not had changes in sleep pattern and performs well in his
job as a car salesman. He appears neatly dressed. Physical
examination shows no abnormalities. On mental status
examination, his thought process is organized and logical.
There is no evidence of suicidal or homicidal ideation or
hallucinations. He says that he is not suspicious of anyone
other than his neighbor. Which of the following is the most
likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Bipolar disorder
Brief psychotic disorder
Delusional disorder
Major depressive disorder with psychotic features
Schizophrenia
Delusional disorder
Generalized anxiety disorder
Hypochondriasis
Panic disorder
Somatization disorder
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-93-
Appendix 3
19. A 9-year-old girl is brought to the physician by her adoptive
parents because they are concerned about her increasing
difficulty at school since she began third grade 7 weeks ago.
Her teachers report that she is easily frustrated and has had
difficulty reading and paying attention. She also has had
increased impulsivity and more difficulty than usual making
and keeping friends. Her biologic mother abused multiple
substances before and during pregnancy, and the patient was
adopted shortly after birth. She is at the 20th percentile for
height and 40th percentile for weight. Examination shows a
flattened nasal bridge and a long philtrum. During the
examination, she is cheerful. Psychoeducational testing shows
an IQ of 82. The most likely explanation for these findings is
in utero exposure to which of the following?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
Alcohol
Cocaine
Ecstasy (3,4-methylenedioxymethamphetamine)
Heroin
Marijuana
PCP (phencyclidine)
Toluene
20. A 77-year-old man comes to the physician with his daughter
for a follow-up examination to learn the results of
neuropsychological testing performed 1 week ago for
evaluation of a recent memory loss. Results of the testing
indicated cognitive changes consistent with early stages of
dementia. Three weeks ago, he received the diagnosis of
prostate cancer and has shown signs of a depressed mood
since then. Twenty years ago, he required treatment in a
hospital for major depressive disorder. His symptoms resolved
with antidepressant therapy, and he has not taken any
psychotropic medication for the past 15 years. The patient's
daughter comes into the examination room before her father
and asks that the physician not tell her father any information
that might be upsetting, given his vulnerability to depression.
She says she is concerned about what the results might be and
how her father will handle them. The patient enters the room
soon after his daughter makes her request. Which of the
following is the most appropriate initial physician statement to
this patient?
(A)
(B)
(C)
(D)
(E)
"Because of your history of depression, I would
like you to start on an antidepressant medication
before we talk any further about your
neuropsychological testing."
"Before going over your test results, I'd like to
hear how you have been doing. You have been
through a difficult time."
"I would like to talk with your daughter a bit about
your test results, and then I will go over things
with you."
"Your daughter is concerned about you. I think
you need to see a psychiatrist before we go any
further here."
"Your tests were inconclusive, and I would like to
have you start on a medication to help with your
memory as a precaution."
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-94-
Appendix 3
Answer Form for Psychiatry Sample Questions
(Questions 1-20)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-95-
Appendix 3
Answer Key for Psychiatry Sample Questions
(Questions 1-20)
1. A
2. A
3. E
4. E
5. A
6. F
7. B
8. E
9. C
10. E
11. C
12. D
13. B
14. D
15. E
16. D
17. A
18. C
19. A
20. B
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-96-
Appendix 3
SURGERY
1.
1%B5%
95%B99%
1%B5%
5%B10%
5%B10%
10%B15%
10%B15%
25%B30%
5%B10%
5%B10%
1%B5%
1%B5%
5%B10%
5%B10%
Physician Tasks
Promoting Health and Health Maintenance
Understanding Mechanisms of Disease
Establishing a Diagnosis
Applying Principles of Management
1%B5%
20%B25%
45%B50%
25%B30%
A 52-year-old woman with glioblastoma multiforme in the
frontal lobe tells her physician that she does not want
operative treatment. She is mentally competent and
understands that an operation is the only effective treatment
of her tumor, and that without an operation she will die. She
is afraid of the adverse effects of an operation and says she
has lived a long and happy life. Two weeks later, she lapses
into a coma, and her husband requests that the operation be
carried out. Which of the following is the most appropriate
consideration for her physician in deciding whether to
operate?
(A)
(B)
(C)
(D)
(E)
2.
General Principles
Organ Systems
Immunologic Disorders
Diseases of the Blood and Blood-forming Organs
Diseases of the Nervous System and Special Senses
Cardiovascular Disorders
Diseases of the Respiratory System
Nutritional and Digestive Disorders
Gynecologic Disorders
Renal, Urinary, and Male Reproductive System
Disorders of Pregnancy, Childbirth, and the Puerperium
Disorders of the Skin and Subcutaneous Tissues
Diseases of the Musculoskeletal System and Connective Tissue
Endocrine and Metabolic Disorders
Her age
Her husband's request
Her previously expressed wishes
Her quality of life
Medical indications for treatment
Ten years ago, a 60-year-old woman underwent an aortic
valve replacement with a porcine heterograft. She now has
shortness of breath with exertion. Examination and x-ray of
the chest show evidence of congestive heart failure. Which
of the following is the most likely explanation for these
findings?
(A)
(B)
(C)
(D)
(E)
3.
A 42-year-old woman comes to the emergency department
because of a 2-day history of intermittent lower abdominal
pain and nausea and vomiting. She has not passed flatus or
stool during this time. She describes the pain as waxing and
waning. Initially, the vomitus was food that she had recently
eaten, but it is now bilious; there has been no blood in the
vomit. She underwent a hysterectomy 2 years ago for
leiomyomata uteri. Vital signs are within normal limits.
Examination shows a distended tympanitic abdomen with
diffuse tenderness and no rebound. Bowel sounds are
initially quiet but then become loud with the onset of pain.
Abdominal x-rays show distended loops of bowel with airfluid levels. Which of the following is the most likely
mechanism of this patient's symptoms?
(A)
(B)
(C)
(D)
(E)
Chronic postoperative infection
Immunologic damage to the bowel wall due to
exposure to occult antigens during the
operation
Inflammatory reaction to suture material left
inside the abdomen
Mechanical obstruction from implantation of
leiomyomata uteri
Proliferation of fibroblasts forming scar tissue
in the area of the operation
Degeneration of the valve
Development of an ascending aortic aneurysm
Development of mitral stenosis
Development of a ventricular septal defect
Embolus to the coronary circulation
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-97-
Appendix 3
4.
A 4-year-old boy is brought to the physician by his parents
because of a 4-month history of difficulty running and
frequent falls. His parents report that his calves have been
gradually increasing in size during this period. Examination
shows diffusely enlarged muscles of the calves and lumbar
lordosis. Sensation is intact. He has difficulty arising from a
supine position. Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)
5.
6.
Bronchial disruption
Hemothorax
Myocardial infarction
Pericardial tamponade
Tension pneumothorax
A 70-year-old man is admitted to the hospital for elective
coronary artery bypass grafting. On the day of his
operation, an asymptomatic carotid bruit is found. Which of
the following is the most appropriate immediate next step in
diagnosis?
(A)
(B)
(C)
(D)
(E)
7.
Duchenne muscular dystrophy
Juvenile rheumatoid arthritis
Lumbosacral radiculopathy
Rhabdomyosarcoma
Spina bifida
An 18-year-old man is brought to the emergency
department 10 minutes after he sustained a stab wound to
his chest. On arrival, he is unresponsive to painful stimuli.
His pulse is 130/min, respirations are 8/min and shallow,
and palpable systolic blood pressure is 60 mm Hg. He is
intubated and mechanically ventilated, and infusion of 0.9%
saline is begun. After 5 minutes, his pulse is 130/min, and
blood pressure is 70/40 mm Hg. Examination shows a 2-cm
wound at the left sixth intercostal space at the midclavicular
line. There is jugular venous distention. Breath sounds are
normal. The trachea is at the midline. Heart sounds are not
audible. Which of the following is the most likely cause of
these findings?
(A)
(B)
(C)
(D)
(E)
Duplex scan of the neck
CT scan of the head
PET scan of the brain
MRI of the brain
Cerebral angiography
Ten days after admission to the hospital because of acute
pancreatitis, a 56-year-old man with alcoholism develops
chills and temperatures to 39.4°C (103°F). Examination
shows a tender abdomen with hypoactive bowel sounds.
Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
8.
Pancreatic abscess
Pancreatic insufficiency
Perforated duodenal ulcer
Retroperitoneal hemorrhage
Splenic vein thrombosis
A 24-year-old nulligravid woman is brought to the
emergency department after a syncopal episode at work.
She has had progressively severe cramps in the lower
abdomen over the past 6 hours. She has had spotty vaginal
bleeding for 2 days; her last menstrual period began 7
weeks ago. She is diaphoretic and anxious. Her temperature
is 37°C (98.6°F), pulse is 130/min, respirations are 26/min,
and blood pressure is 80/60 mm Hg. Examination shows
blood in the vaginal vault and diffuse abdominal tenderness;
there is pain with cervical motion. Which of the following is
the most appropriate next step in management?
(A)
(B)
(C)
(D)
(E)
9.
Intravenous administration of fluids
Intravenous administration of broad-spectrum
antibiotics
Transfusion of O-negative blood
Transfusion of type-specific blood
Culdocentesis
A 52-year-old man comes to the physician because of a 5month history of pain in his left knee that is exacerbated by
walking long distances. There is no history of trauma. He
has hypertension well controlled with enalapril. His job
does not require carrying heavy loads. He is 180 cm (5 ft
11 in) tall and weighs 95 kg (210 lb); BMI is 29 kg/m2. His
pulse is 82/min and regular, respirations are 16/min, and
blood pressure is 130/82 mm Hg. Examination of the left
knee shows mild crepitus with flexion and extension; there
is no effusion or warmth. X-rays of the knees show
narrowing of the joint space in the left knee compared with
the right knee. Which of the following is most likely to
improve this patient's symptoms?
(A)
(B)
(C)
(D)
(E)
High-impact aerobics program
Weight loss program
Daily colchicine prophylaxis
Daily shark cartilage supplementation
Daily vitamin D supplementation
10. A previously healthy 32-year-old man comes to the
emergency department because of a 3-day history of pain
and swelling of his right knee. Two weeks ago, he injured
his right knee during a touch football game and has had
swelling and bruising for 5 days. One week ago, he
underwent extraction of a molar for severe dental caries. He
is sexually active with one male partner and uses condoms
consistently. HIV antibody testing was negative 3 months
ago. His temperature is 38.6°C (101.5°F), pulse is 100/min,
and blood pressure is 120/60 mm Hg. Examination of the
right knee shows warmth, erythema, and a joint effusion.
Flexion and extension of the right knee are severely limited.
An x-ray of the knee confirms the joint effusion. Which of
the following is the most appropriate next step in diagnosis?
(A)
(B)
(C)
(D)
(E)
Venous Doppler ultrasonography
Bone scan
MRI of the knee
Arthroscopic exploration of the knee
Arthrocentesis
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-98-
Appendix 3
11. A 57-year-old woman with inoperable small cell carcinoma of the lung has had lethargy, loss of appetite, and nausea for 1 week.
She received radiation therapy 2½ years ago. She has stable angina pectoris controlled with nitrates. Her pulse is 68/min,
respirations are 16/min, and blood pressure is 118/72 mm Hg. There is no jugular venous distention, and skin turgor is normal. She
is oriented to person and place but not to time. Laboratory studies show:
Serum
Na+
Cl−
K+
HCO3−
Urea nitrogen
Glucose
Creatinine
Osmolality
Urine
Na+
Osmolality
128 mEq/L
100 mEq/L
4.2 mEq/L
24 mEq/L
11 mg/dL
92 mg/dL
0.8 mg/dL
270 mOsmol/kg H2O
78 mEq/L
310 mOsmol/kg H2O
An x-ray of the chest shows a mass in the right upper lobe of the lung that is unchanged from an x-ray taken 3 months ago. Which
of the following is the most likely explanation for these findings?
(A)
(B)
(C)
(D)
(E)
Compulsive water drinking
Congestive heart failure
Hypothyroidism
Surreptitious use of diuretics
Syndrome of inappropriate secretion of ADH (vasopressin)
12. A 3799-g (8-lb 6-oz) female newborn is born by cesarean
delivery because of a breech presentation. Apgar scores are
7 and 9 at 1 and 5 minutes, respectively. Initial examination
shows a palpable clunk when the left hip is abducted,
flexed, and lifted forward. Posterior pressure on the flexed
hip elicits a similar clunk. The remainder of the examination
shows no abnormalities. Which of the following is the most
likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Congenital hip dysplasia
Legg-Calvé-Perthes disease
Osgood-Schlatter disease
Osteogenesis imperfecta
Slipped capital femoral epiphysis
13. A previously healthy 72-year-old man comes to the
physician because of decreased urinary output during the
past 2 days; he has had no urinary output for 8 hours.
Examination shows suprapubic fullness and an enlarged
prostate. His serum urea nitrogen concentration is 88
mg/dL, and serum creatinine concentration is 3.5 mg/dL.
Which of the following is the most appropriate next step in
management?
(A)
(B)
(C)
(D)
(E)
Ultrasonography of the prostate
Ultrasonography of the kidneys
CT scan of the abdomen
Bladder catheterization
Intravenous pyelography
14. A 3-year-old boy is brought to the emergency department
because of a 2-week history of persistent cough and
wheezing. His mother states that his symptoms occur when
he laughs or runs. He has not had any other symptoms, and
no one else at home is sick. Three weeks ago, he had an
episode of choking and coughing while eating dinner. His
temperature is 37.6°C (99.7°F), pulse is 90/min, respirations
are 20/min, and blood pressure is 70/45 mm Hg. Expiratory
wheezes are heard on the right with normal airflow. The
remainder of the examination shows no abnormalities. His
symptoms do not improve after administration of nebulized
albuterol. An expiratory chest x-ray shows hyperinflation of
the right lung; there is no mediastinal or tracheal shift.
Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Asthma
Foreign body aspiration
Laryngotracheobronchitis (croup)
Psychogenic cough
Tension pneumothorax
15. Two hours after undergoing a right hepatic lobectomy, a
59-year-old woman has a distended abdomen. Her pulse is
120/min, and blood pressure is 100/60 mm Hg. Which of
the following is the most likely cause of these findings?
(A)
(B)
(C)
(D)
(E)
Deficiency of factor III
Deficiency of factor VII
Deficiency of factor XII
Deficiency of platelets
Poor mechanical hemostasis
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-99-
Appendix 3
16. Three days after undergoing elective laparoscopic cholecystectomy for cholelithiasis, a 42-year-old woman has the onset of
hematomas at all surgical sites. She was treated for deep venous thrombosis 3 years ago but was not taking any medications at the
time of this admission. Results of preoperative laboratory studies were within the reference range. Prior to the operation, she
received heparin and underwent application of compression stockings. Her initial postoperative course was uncomplicated. Her
only medication is ibuprofen. She is 163 cm (5 ft 4 in) tall and weighs 87 kg (192 lb); BMI is 33 kg/m2. Her temperature is 37.3°C
(99.2°F), pulse is 94/min, respirations are 16/min, and blood pressure is 112/74 mm Hg. Examination shows mild hematomas at all
surgical sites. The abdomen is soft and nontender. There is no organomegaly. Bowel sounds are normal. Laboratory studies show:
Hemoglobin
Hematocrit
Leukocyte count
Platelet count
10.3 g/dL
30%
12,000/mm3
45,000/mm3
Which of the following is the most likely cause of this patient's current findings?
(A)
(B)
(C)
(D)
(E)
Acute intermittent porphyria
Heparin-induced thrombocytopenia
Hypersplenism
Inhibition of cyclooxygenase
von Willebrand disease
17. Two days after undergoing surgical repair of a ruptured
abdominal aortic aneurysm, a 67-year-old man requires
increasing ventilatory support. He remains intubated and is
being mechanically ventilated at an FIO2 of 0.6 and a
positive end-expiratory pressure of 7.5 cm H2O. He has
chronic obstructive pulmonary disease. He had a myocardial
infarction 2 years ago. His only medication is a sedative. He
has smoked two packs of cigarettes daily for 40 years. He
appears diaphoretic. His temperature is 38.1°C (100.6°F),
pulse is 120/min, and blood pressure is 90/60 mm Hg; the
ventilatory rate is 25/min. Examination shows jugular
venous distention. Breath sounds are absent on the left. The
trachea is shifted to the right. Pulse oximetry shows an
oxygen saturation of 82%. Which of the following is the
most appropriate next step in diagnosis?
19. A 57-year-old woman comes to the physician for a routine
follow-up examination. She has a 5-year history of
hypertension treated with captopril. She has had a 6.8-kg
(15-lb) weight gain since her last visit 1 year ago; she is 165
cm (5 ft 5 in) tall and currently weighs 72 kg (160 lb); BMI
is 27 kg/m2. Her temperature is 37°C (98.6°F), pulse is
88/min, respirations are 14/min, and blood pressure is
160/86 mm Hg. The lungs are clear to auscultation. Cardiac
examination shows no abnormalities. The abdomen is soft
and nontender with no palpable masses. Pedal pulses and
sensation to pinprick are diminished bilaterally. Fasting
serum studies show a total cholesterol concentration of 240
mg/dL and glucose concentration of 182 mg/dL. Which of
the following is the most likely cause of these findings?
(A)
(A)
(B)
(C)
(D)
ECG
Transthoracic echocardiography
CT scan of the chest
Needle aspiration of the left side of the chest
18. A previously healthy 62-year-old man comes to the
physician because of a 2-month history of cough. He has
smoked two packs of cigarettes daily for 40 years.
Examination shows no abnormalities. An x-ray of the chest
shows a 2.5-cm noncalcified pulmonary nodule in the right
upper lobe. A CT scan of the chest confirms the x-ray
findings. An x-ray of the chest obtained 1 year ago showed
no abnormalities. Which of the following is the most
appropriate next step in diagnosis?
(A)
(B)
(C)
(D)
(E)
Measurement of serum calcium concentration
Second x-ray of the chest in 6 weeks
Ventilation-perfusion lung scans
Bronchoscopy with transbronchial biopsy
Median sternotomy
(B)
(C)
(D)
(E)
Abnormal insulin secretion with insulin
resistance
Autoimmune β-cell destruction
Excess glycogen breakdown
Excess release of glucagon and catecholamines
Insulin allergy
20. A 3-year-old girl is brought to the emergency department
because of left leg pain after falling at preschool 2 hours
ago. She has a history of fractures after minor trauma. She
has consistently been at the 10th percentile for height and
weight since birth. Examination shows blue sclerae. There
is an obvious deformity of the left thigh. An x-ray shows a
new fracture of the left femur and evidence of previous
fracturing. Which of the following is the most likely cause
of these findings?
(A)
(B)
(C)
(D)
(E)
(F)
Child abuse
Defective type I collagen
Deficient sulfate ion transport
Hypocalcemia
Hypophosphatemia
Vitamin D deficiency
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-100-
Appendix 3
Answer Form for Surgery Examination Sample Questions
(Questions 1-20)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-101-
Appendix 3
Answer Key for Surgery Examination Sample Questions
(Questions 1-20)
1. C
2. A
3. E
4. A
5. D
6. A
7. A
8. A
9. B
10. E
11. E
12. A
13. D
14. B
15. E
16. B
17. D
18. D
19. A
20. B
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-102-
Appendix 3
INTRODUCTION TO CLINICAL DIAGNOSIS
15%B20%
1%B5%
General Principles
Human development and genetics
Gender, ethnic, and behavioral considerations
affecting disease treatment and prevention
Progression through life cycle
Psychologic and social factors influencing patient behavior
Patient interviewing, consultation, and interactions
with the family
Medical ethics, jurisprudence, and professional behavior
Nutrition
10%B15%
1%B5%
1%B5%
5%B10%
1%B5%
1%B5%
80%B85%
1%B5%
15%B20%
1%B5%
5%B10%
10%B15%
15%B20%
10%B15%
1%B5%
5%B10%
1%B5%
Organ Systems
Hematopoietic & lymphoreticular
Central & peripheral nervous
Skin & related connective tissue
Musculoskeletal
Respiratory
Cardiovascular
Gastrointestinal
Renal/urinary
Reproductive
Endocrine
1.
A 6-month-old boy is brought to the physician because of left
knee swelling for 24 hours. Three months ago, he had three
large hematomas on his forehead that resolved without
treatment. His two sisters and his mother have no history of
similar symptoms. His mother's maternal uncle and her brother
died before the age of 30 years of massive cerebral
hemorrhages. Physical examination shows deep ecchymoses
over the buttocks and severe swelling of the left knee. The
most likely explanation for these findings is a deficiency of
which of the following?
(A)
(B)
(C)
(D)
(E)
2.
Actinic keratosis
Basal cell carcinoma
Melanoma
Seborrheic keratosis
Squamous cell carcinoma
A 23-year-old woman comes to the physician because of a
5-month history of intermittent discharge from both breasts.
Her last menstrual period was 6 months ago. She takes no
medications and is otherwise healthy. She has never been
sexually active. Physical examination shows scant white fluid
expressible from the breasts bilaterally. Serum studies are
most likely to show an increase in which of the following
hormone concentrations?
(A)
(B)
(C)
(D)
(E)
(F)
Factor I (fibrinogen)
Factor V (proaccelerin)
Factor VIII (antihemophilic factor)
Factor XIII (transglutaminase)
von Willebrand factor
A 56-year-old man has had a small, slowly growing nodule on
his chin during the past 3 years. The lesion is 1.3 cm in
diameter, the center is ulcerated, and the border is waxy.
Examination of tissue obtained on excision of the lesion is
most likely to show which of the following?
(A)
(B)
(C)
(D)
(E)
3.
4.
Estradiol
Follicle-stimulating hormone
Luteinizing hormone
Progesterone
Prolactin
Testosterone
A 39-year-old man has the acute onset of pain, corneal
clouding, and diffuse redness in the left eye. There is no
discharge. Vision is 20/20 in the right eye and 20/100 in the
left eye. The left pupil is dilated. Which of the following is
the most likely cause of these findings?
(A)
(B)
(C)
(D)
(E)
Acute glaucoma
Acute hordeolum
Bacterial conjunctivitis
Corneal abrasion
Subconjunctival hemorrhage
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-103-
Appendix 3
5.
A 27-year-old man with a sleep disorder enrolls in a research study. During sleep evaluation, he is noted to snore loudly and stop
breathing for prolonged periods of 30 to 40 seconds. Toward the end of one of these apneic periods, arterial blood gas analysis is done.
Which of the following sets of findings is most likely in this patient?
(A)
(B)
(C)
(D)
(E)
6.
Haemophilus influenzae
Listeria monocytogenes
Neisseria meningitidis
Pseudomonas aeruginosa
Streptococcus pneumoniae
A 55-year-old man who is a farmer is brought to the
emergency department 30 minutes after his wife found him
unresponsive in their barn. She reports that he was foaming at
the mouth and had evidence of tearing of the eyes, vomiting,
and diarrhea. He is unresponsive to painful stimuli. His pulse is
45/min, and blood pressure is 90/60 mm Hg. Bilateral diffuse
wheezes are heard on auscultation of the chest. This patient has
most likely sustained poisoning by which of the following?
(A)
(B)
(C)
(D)
(E)
8.
PCO2
decreased
increased
decreased
increased
decreased
A 65-year-old woman comes to the physician because of a
2-day history of a high temperature, chills, and headache. She
was diagnosed with multiple myeloma 6 months ago. Her
temperature is 39°C (102.2°F), pulse is 90/min, and blood
pressure is 150/80 mm Hg. Examination shows lethargy and
severe neck rigidity; no other abnormalities are noted. Which
of the following organisms is most likely to be found on Gram
stain of cerebrospinal fluid?
(A)
(B)
(C)
(D)
(E)
7.
pH
Increased
Normal
Normal
Decreased
Decreased
Carbon monoxide
Ethanol
Ethylene glycol
Methanol
Organophosphate
A 28-year-old female executive has irresistible urges to sleep
during the day. She often has episodes of dropping her head,
slurred speech, and suddenly dropping things from her hands,
all lasting for seconds to minutes. In addition, she frequently
has vivid, colorful dreams just before falling asleep.
Occasionally, when in certain emotionally charged situations,
she feels like her whole body goes limp; however, she
remembers everything. Which of the following is the most
likely diagnosis?
(A)
(B)
(C)
(D)
(E)
PO2
normal
increased
increased
decreased
normal
9.
A 15-year-old girl is brought to the physician by her mother
for a follow-up examination. She has a 3-year history of
seizure disorder treated with topiramate. Her mother says, "I
am worried because she's refused to take her medication since
she started dating this new guy. She won't even tell me why."
Physical examination shows no abnormalities. After the
mother is asked to leave the room, which of the following is
the most appropriate statement by the physician to begin a
discussion of this patient's lack of adherence to her
medication regimen?
(A)
(B)
(C)
(D)
(E)
"Can you tell me why you don't want to take
your medication anymore?"
"I would like to discuss the serious consequences
that could result from your not taking
your medication."
"I'm worried that your boyfriend isn't a good
influence on you."
"Perhaps I can talk to your boyfriend about your
condition so that you can take your
medication again."
"Since you are still a minor, you must respect
your mother's decision and take your
medication."
10. A 78-year-old woman is brought to the physician because of
a headache and visual problems for 4 days. The headache is
more severe on the left side, in the area above and in front of
her ear. She has had intermittent fevers, difficulty chewing,
and a 4.5-kg (10-lb) weight loss during the past 6 weeks. Her
temperature is 37.4°C (99.4°F). Visual fields are decreased.
There is tenderness to palpation on the left side of the scalp.
Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
Acute meningitis
Cluster headache
Idiopathic intracranial hypertension
Migraine
Subarachnoid hemorrhage
Temporal arteritis
Tension-type headache
Absence seizures
Delayed sleep phase syndrome
Insomnia
Narcolepsy
Night terrors
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-104-
Appendix 3
11. A 65-year-old man comes to the physician because of a 6week history of fatigue and difficulty swallowing; he also has
had a 6.8-kg (15-lb) weight loss during this period. Ten years
ago, he underwent operative resection of squamous cell
carcinoma of the floor of the mouth. He takes no medications.
He has smoked 2 packs of cigarettes daily for 40 years and
drinks 60 oz of alcohol weekly. Physical examination shows a
nontender abdomen with bowel sounds present. The physician
suspects a second primary cancer. This cancer is most likely
located at which of the following sites?
(A)
(B)
(C)
(D)
(E)
Brain
Esophagus
Liver
Lymph nodes
Stomach
12. A previously healthy 34-year-old woman had a single rigor 3
days ago. Since then she has had temperatures to 38.9 C
(102 F), shortness of breath with minimal exertion, and cough
productive of rust-colored sputum. An x-ray of the chest shows
consolidation in the right lower lobe of the lung. Which of the
following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Mycoplasmal pneumonia
Pneumococcal pneumonia
Pseudomonal pneumonia
Toxoplasmosis
Tuberculosis
13. A 35-year-old woman comes to the physician because of
abdominal pain for 6 months. She has not had fever, nausea, or
vomiting. She has no history of major medical illness. She
takes no medications. She does not smoke cigarettes or drink
alcohol. Physical examination shows ecchymoses in various
stages of healing over the upper and lower extremities. There
are acute hematomas around the wrists. Test of the stool for
occult blood is negative. A pregnancy test result is negative. It
is most appropriate for the physician to ask which of the
following questions to begin a discussion with this patient
about the possibility of physical abuse?
(A)
(B)
(C)
(D)
(E)
"Can you tell me how you received these
bruises?"
"What do you think about making an appointment
with a social worker?"
"Why do you stay with someone who physically
abuses you?"
"Why don't you tell me why you really came to
see me?"
"Would you like me to report whoever did this to
you to the authorities?"
14. A 22-year-old football player is brought to the emergency
department 1 hour after he sustained a left leg injury during a
tackle. Physical examination shows mild tenderness and
anterior instability of the tibia with the knee in 90 degrees of
flexion (positive drawer sign). Active range of motion of the
left knee is limited by pain. Which of the following best
explains these findings?
(A)
(B)
(C)
(D)
(E)
Hemarthrosis
Patellar fracture
Tear of the anterior cruciate ligament
Tear of the medial ligament
Tear of the medial meniscus
15. A postmenopausal 60-year-old woman comes to the
physician because of a 2-year history of vaginal dryness,
intermittent vaginal pain, and decreased pleasure with sexual
intercourse. Vital signs are within normal limits. Abdominal
examination shows no abnormalities. Pelvic examination
shows pale, dry vaginal mucosa. No masses are palpated.
Which of the following is the most appropriate next step in
management?
(A)
(B)
(C)
(D)
(E)
Advise the patient that since these problems are
expected for a woman her age, the risks
associated with pharmacotherapy
outweigh any benefits
Explain to the patient that it will be important to
assess the impact of her condition on her
husband as further treatment is initiated
Inform the patient that she should accept her
symptoms as part of the normal aging
process
Inform the patient that these problems are often
psychological and that she would benefit
from psychotherapy
Reassure the patient that her symptoms are
common among women her age and
that there are treatments available
16. A 73-year-old woman is brought to the emergency
department because of severe back pain for 1 day. She has
had no recent falls or trauma to the area. Menopause occurred
at the age of 52 years. Her temperature is 37°C (98.6°F),
pulse is 92/min, and blood pressure is 140/92 mm Hg.
Physical examination shows spinal tenderness at T8. A spinal
x-ray shows fractures at T8 and T10. Which of the following
is the most likely underlying cause of this patient's condition?
(A)
(B)
(C)
(D)
(E)
Osteitis deformans (Paget disease)
Osteomalacia
Osteoporosis
Pott disease
Spinal metastasis
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-105-
Appendix 3
17. An 18-year-old man comes to the physician because of nausea,
headache, blood in his urine, and malaise for 2 days. Three
weeks ago, he had severe pharyngitis that resolved
spontaneously after several days without antibiotic therapy.
His blood pressure is 165/88 mm Hg. Physical examination
shows mild peripheral edema. His serum creatinine
concentration is 2.1 mg/dL, and serum CH50 concentration is
markedly decreased. Urinalysis shows:
Protein
RBC
WBC
RBC casts
2+
25–50/hpf
10–20/hpf
present
Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Goodpasture syndrome
IgA nephropathy
Malignant hypertension
Post-streptococcal glomerulonephritis
Wegener granulomatosis
18. A 60-year-old woman comes to the physician because of a
3-month history of abdominal fullness and increasing
abdominal girth with vague lower quadrant pain. Abdominal
examination shows distention. Pelvic examination shows a 10cm, hard, irregular, nontender, right adnexal mass. Which of
the following is the most appropriate statement by the
physician at this time?
(A)
(B)
(C)
(D)
(E)
"Do you have any friends or family members with
you today who could join us before I tell you
the diagnosis?"
"I'm concerned about something I found
during the examination today. Let's talk
about what needs to be done to figure out
what it is."
"I'm not sure whether there is something abnormal
in your pelvis. You'll need to undergo a
pelvic ultrasonography for further study."
"It looks like you have ovarian cancer, but we'll
need to do further tests to be sure."
"Unfortunately, I need to refer you to a cancer
specialist because you have some abnormal
examination findings."
19. A 26-year-old woman comes to the emergency department
because of a 12-hour history of lower abdominal pain and
vaginal bleeding. There is no history of medical illness, and
she takes no medications. Her temperature is 37°C (98.6°F),
pulse is 125/min, respirations are 40/min, and blood pressure
is 96/64 mm Hg. Abdominal examination shows distention
and tenderness. Decreased bowel sounds are heard. Pelvic
examination shows an adnexal mass on the right.
Measurement of which of the following is the most
appropriate next step in management of this patient?
(A)
(B)
(C)
(D)
(E)
Leukocyte count
Platelet count
Prothrombin time
Serum α-fetoprotein concentration
Serum β-human chorionic gonadotropin
concentration
20. A 25-year-old woman with stable cystic fibrosis meets
inclusion criteria for a placebo-controlled industry-sponsored
research study on a new treatment. The primary care
physician is not part of the research team, but he is familiar
with the research and considers it to be scientifically sound.
The research protocol provides medication and medical care
limited to assessing medication effects and adverse effects for
6 months. The patient knows of the study and asks the
physician if she should enroll. Which of the following is the
most appropriate initial response by the primary care
physician?
(A)
(B)
(C)
(D)
Advise against participation because the research
is funded by a pharmaceutical company
Provide the patient with basic information
about the study, and ask if she would like
to learn more from the research team
Strongly recommend to the patient that she
participate in the study because it will
benefit future generations
Tell the patient that if she enrolls in the study, he
will not be able to provide any medical care
for her during this study
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-106-
Appendix 3
Answer Form for Introduction to Clinical Diagnosis Sample Questions
(Questions 1-20)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-107-
Appendix 3
Answer Key for Introduction to Clinical Diagnosis Sample Questions
(Questions 1-20)
1. C
2. B
3. E
4. A
5. D
6. E
7. E
8. D
9. A
10. F
11. A
12. B
13. A
14. C
15. E
16. C
17. D
18. B
19. E
20. B
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-108-
Appendix 3
COMPREHENSIVE BASIC SCIENCE EXAMINATION
The Comprehensive Basic Science Examination is a general, integrated achievement test covering material typically learned
during basic science education, with somewhat more emphasis on second-year courses. The exam reflects content coverage on
USMLE Step 1 and uses the same item formats.
System
General Principles
Individual Organ Systems
Hematopoietic & lymphoreticular
Central & peripheral nervous
Skin & related connective tissue
Musculoskeletal
Respiratory
Cardiovascular
Gastrointestinal
Renal/urinary
Reproductive
Endocrine
40%B50%
50%B60%
Process
Normal
Abnormal
Principles of therapeutics
Psychosocial, cultural, occupational, and environmental considerations
1.
In a steady state, the difference in CO2 content between the
venous blood leaving a tissue and the arterial blood entering
the tissue is determined by which of the following ratios?
(A)
(B)
(C)
(D)
(E)
2.
Alveolar ventilation to tissue blood flow
Alveolar ventilation to tissue O2 consumption
Tissue CO2 production to tissue blood flow
Tissue CO2 production to tissue O2 consumption
Tissue CO2 production to venous P CO2
A 16-month-old boy is brought to the physician by his mother
for a well-child examination. His mother expresses concern
that he did not walk until the age of 14 months, whereas his
older sister walked at the age of 10 months. Physical
examination shows no abnormalities. Which of the following
best explains this patient's condition?
(A)
(B)
(C)
(D)
(E)
3.
Autistic disorder
Child abuse
Oppositional defiant disorder
Sensory integration disorder
Normal development
A 77-year-old woman is visited by the home care nurse who
notes that the patient is more lethargic than usual. Her skin
and mucous membranes are dry. An increase in the serum
concentration or activity of which of the following provides
the strongest indication that the patient is dehydrated?
(A)
(B)
(C)
(D)
(E)
4.
30%B50%
30%B50%
15%B25%
10%B20%
Albumin
Alkaline phosphatase
Bilirubin
Calcium
Uric acid
A male newborn delivered at 26 weeks' gestation develops
respiratory distress immediately after a spontaneous vaginal
delivery. His respirations are 40/min. Physical examination
shows cyanosis and lower rib retractions with respiration.
Heart sounds are normal. Bilateral breath sounds are heard on
auscultation. A chest x-ray shows bilateral lung opacities. The
most likely cause of this patient's breathing difficulties is
insufficient production of which of the following substances?
(A)
(B)
(C)
(D)
(E)
Collagen, type III
α-Fetoprotein
Meconium
Retinoic acid
Surfactant
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
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Appendix 3
5.
A 28-year-old woman, gravida 1, para 1, comes to the
physician because of progressive fatigue since delivering a
male newborn 6 months ago. She is sleeping 8 to 10 hours
nightly, but she is still tired during the day. She also has not
had a menstrual period since her pregnancy. Pregnancy was
complicated during the third trimester by severe bleeding from
placenta previa. She required multiple blood transfusions
during the cesarean delivery, but she did well after the
delivery. She was unable to breast-feed her newborn because
of poor milk production. Which of the following is the most
likely diagnosis?
(A)
(B)
(C)
(D)
(E)
8.
(A)
(B)
(C)
(D)
(E)
Anemia
Cardiomyopathy
Major depressive disorder
Postpartum pituitary infarction
Thyroiditis
9.
6.
A 12-year-old African American boy is brought to the
physician by his mother because of a swollen right earlobe for
3 weeks. He had the ear pierced at a local mall 6 weeks ago.
The swelling has persisted despite removal of the earring 3
weeks ago. The mother developed a thick rubbery scar on her
abdomen after a cesarean delivery 12 years ago. His
temperature is 37°C (98.6°F). Physical examination shows a
nontender, flesh-colored swelling of the right earlobe. The skin
is intact over the swelling, and it is soft and nontender. There is
no cervical lymphadenopathy. Which of the following is the
most likely cause of the swelling in this patient?
(A)
(B)
(C)
(D)
(E)
7.
Bacterial infection
Contact dermatitis
Foreign body
Keloid
Lipoma
A 5-year-old boy is brought to the physician by his parents
because of an 8-month history of difficulty walking. His
parents say that he limps when he walks and has a waddling
gait; he also has difficulty standing. When getting up from a
sitting position, he uses his hands to walk up his thighs and
push his body into a standing position. His parents have not
noticed any weakness of his arms. His mother is an only child,
but she has an uncle who became bedridden as a child and died
of respiratory arrest. Physical examination shows prominent
calf muscles. Muscle strength is 4/5 at both hips but normal
elsewhere. This patient most likely has a mutation in the gene
coding for which of the following proteins?
(A)
(B)
(C)
(D)
(E)
Actin
Dystrophin
Frataxin
Myelin
Myosin
A 27-year-old man comes to the physician because of pain
with urination for 3 days. He has had no fever or chills. He is
sexually active with three partners and does not use condoms
consistently. He began having sexual relations with his most
recent partner 1 week ago. His temperature is 37°C (98.6°F).
Physical examination shows no abnormalities except for a
clear, watery urethral discharge. Urinalysis shows 10–20
WBC/hpf but no bacteria. Which of the following is the most
likely causal organism?
Chlamydia trachomatis
Entamoeba histolytica
Escherichia coli
Helicobacter pylori
Shigella flexneri
A 20-year-old college student develops fever, severe
pharyngitis, hepatosplenomegaly, and lymphadenopathy. The
pathogenesis of this syndrome most likely involves a doublestranded DNA virus infection of which of the following cells?
(A)
(B)
(C)
(D)
(E)
B lymphocytes
Kupffer cells
Macrophages
Neutrophils
T lymphocytes
10. A 2-year-old boy with Down syndrome is brought to the
physician by his mother for a follow-up examination. His
blood pressure is increased in the upper extremities and
decreased in the lower extremities. Physical examination
shows cyanosis of the lower extremities. An AP x-ray of the
chest shows notching of the inferior surfaces of the 3rd
through 8th ribs. The diagnosis of left ventricular hypertrophy
is suspected. Which of the following is the most likely
underlying abnormality in this patient?
(A)
(B)
(C)
(D)
(E)
Atrial septal defect
Coarctation of the aorta
Persistent truncus arteriosus
Tetralogy of Fallot
Transposition of the great arteries
11. A 1-day-old neonate has hemolytic disease of the newborn.
The parents are both Rh-positive, but IgG isohemagglutinins
are found in the mother's blood. Which of the following
parental blood types is most likely to cause this condition?
(A)
(B)
(C)
(D)
(E)
Mother
A
AB
B
B
O
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
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Father
O
O
A
O
AB
Appendix 3
12. A previously healthy 42-year-old woman comes to the
emergency department because of progressive shortness of
breath and intermittent cough productive of blood-tinged
sputum for 10 days. She has no history of major medical illness
and takes no medications. Her respirations are 24/min. Diffuse
rhonchi are heard in both lung fields on auscultation. A chest
x-ray shows patchy opacities bilaterally. Laboratory studies
show:
Serum creatinine
Urine
Protein
RBC
RBC casts
(E)
3+
3+
numerous
Goodpasture syndrome
Hemolytic uremic syndrome
Löffler syndrome
Mucocutaneous lymph node syndrome
(Kawasaki disease)
Wegener granulomatosis
13. A 10-year-old boy is found to have mild iron deficiency
anemia. His mother informs the physician that the family
members belong to a religious denomination that does not
consume meat. Her son refuses to eat dark green vegetables or
to take vitamin pills, stating that they make him feel nauseated.
It is most appropriate for the physician to ask the mother which
of the following questions next?
(A)
(B)
(C)
(D)
(E)
(A)
(B)
(C)
(D)
(E)
Binds to H2 receptors
Creates a cytoprotective layer in the stomach
Inhibits H+–K+ ATPase
Prevents absorption of dietary acids
Stimulates serotonin receptors
2.5 mg/dL
A serum anti-glomerular basement membrane autoantibody
assay is positive. Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
14. A 45-year-old man is diagnosed with gastroesophageal reflux
disease. Omeprazole treatment is initiated. Which of the
following is the mechanism of action of this drug?
"Are you concerned that if you let him get away
with not eating right when he's 10, he'll be
more likely to give you trouble when he's
a teenager?"
"Can you tell me exactly why your religion
prohibits meat?"
"Would you like information on other iron
rich foods consistent with a vegetarian
diet?"
"Would you like me to write a note to your
religious leader requesting a medical
exemption from your dietary
requirements?"
"Wouldn't your son rather eat spinach than get an
iron shot every week?"
15. A 64-year-old man comes to the physician because of a 3-day
history of painful rash over his right flank. Three days before
the rash appeared, he had pain in the same area. His
temperature is 37.4°C (99.3°F), pulse is 78/min, respirations
are 17/min, and blood pressure is 130/70 mm Hg. Physical
examination shows clustered lesions in a band-like area over
the right flank. The lesions have an erythematous base and are
crusted. Which of the following is the most likely causal
virus?
(A)
(B)
(C)
(D)
(E)
Cytomegalovirus
Epstein-Barr virus
Human papillomavirus
Kaposi sarcoma virus
Varicella-zoster virus
16. A 27-year-old man with AIDS is brought to the hospital 30
minutes after having a seizure. He currently takes no
medications. A CT scan of the head shows multiple ringenhancing lesions. Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
Amoebiasis
Cysticercosis
Echinococcosis
Schistosomiasis
Toxoplasmosis
Trichinosis
17. An investigator has conducted an experiment to determine
whether certain environmental exposure morbidity is
eliminated if a person carries a specific allele of three
different genes on three separate chromosomes. The
frequencies of an individual having the allele for these
respective genes are 0.6, 0.2, and 0.1. All three alleles are
necessary to confer protection. The probability that a
randomly selected individual will have all three alleles is
closest to which of the following?
(A)
(B)
(C)
(D)
(E)
0.900
0.600
0.200
0.100
0.012
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
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Appendix 3
18. A health inspector confiscates chickens smuggled into Taiwan
from mainland China after she discovers them in the hold of a
ship. Testing shows that, although the chickens appear healthy,
they are infected with the H5N1 subtype of the influenza A
virus. Which of the following is the primary concern for human
health from these virus-infected chickens?
(A)
(B)
(C)
(D)
(E)
(F)
Mutation of the virus to a form that causes fatal
encephalitis
Mutation of the virus to a form that causes fatal
renal disease
Mutation of the virus to a form that is highly
infectious among humans
Secretion of a product that will cause
immunosuppression in those that eat the
meat
Secretion of a product that will cause mutations
of the virus in the fetuses of mothers that eat
the meat
Secretion of a product that will make the meat of
the chicken poisonous to eat
20. A 42-year-old woman comes to the physician for a routine
health maintenance examination. She says that she feels fine.
She is 170 cm (5 ft 7 in) tall and weighs 86 kg (190 lb); BMI
is 30 kg/m2. Her blood pressure is 131/82 mm Hg. Physical
examination shows no other abnormalities. Fasting serum
studies show:
Glucose
Cholesterol, total
Triglycerides
C-reactive protein
105 mg/dL
210 mg/dL
185 mg/dL
0.35 mg/L (N=0.08–3.1
This patient is at increased risk for developing which of the
following conditions?
(A)
(B)
(C)
(D)
(E)
Atherosclerosis
Chronic lymphocytic (Hashimoto) thyroiditis
Systemic lupus erythematosus
Systemic sclerosis (scleroderma)
Type 1 diabetes mellitus
19. A 35-year-old woman has hypertension and truncal obesity.
Serum studies show:
Cortisol (AM)
Cortisol (PM)
ACTH (AM)
Cortisol 8 h after
1 mg dexamethasone
Cortisol 8 h after
8 mg dexamethasone
100 μg/dL (N=5B20)
100 μg/dL (N=2.5B10)
130 pg/mL (N=20B100)
95 μg/dL
30 μg/dL
Which of the following is the most likely cause of this
woman's increased serum cortisol concentration?
(A)
(B)
(C)
(D)
(E)
Adrenocortical adenoma
Ectopic corticotropin-releasing hormone
producing neoplasm
Ectopic corticotropin-secreting neoplasm
Pituitary microadenoma
Self-administration of synthetic glucocorticoids
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
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Appendix 3
Answer Form for Comprehensive Basic Science Examination Sample Questions
(Questions 1-20)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-113-
Appendix 3
Answer Key for Comprehensive Basic Science Examination Sample Questions
(Questions 1-20)
1. C
2. E
3. A
4. E
5. D
6. D
7. B
8. A
9. A
10. B
11. E
12. A
13. C
14. C
15. E
16. E
17. E
18. C
19. D
20. A
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
-114-
Appendix 3
COMPREHENSIVE CLINICAL SCIENCE EXAMINATION
The Comprehensive Clinical Science Examination is a general, integrated achievement test covering material typically learned
during core clinical clerkships. The exam reflects content coverage on USMLE Step 2 and uses the same item formats.
Normal Growth and Development and General Principles of Care
Organ Systems
Immunologic Disorders
Diseases of the Blood and Blood-forming Organs
Mental Disorders
Diseases of the Nervous System and Special Senses
Cardiovascular Disorders
Diseases of the Respiratory System
Nutritional and Digestive Disorders
Gynecologic Disorders
Renal, Urinary, and Male Reproductive System
Disorders of Pregnancy, Childbirth, and the Puerperium
Disorders of the Skin and Subcutaneous Tissues
Diseases of the Musculoskeletal System and Connective Tissue
Endocrine and Metabolic Disorders
Physician Tasks
Promoting Health and Health Maintenance
Understanding Mechanisms of Disease
Establishing a Diagnosis
Applying Principles of Management
1.
A clinical trial of a potentially valuable medical treatment is
planned. It is unlikely that it will directly benefit the study
subjects but very likely that it will benefit future patients.
There is a risk for short-term minor gastric discomfort but
essentially no risk for long-term adverse effects. The
investigator concludes that disclosure of the risks may
discourage participation in the trial. Which of the following is
the most appropriate next step?
(A)
(B)
(C)
(D)
(E)
Proceed with the trial only with disclosure,
because informed consent is an absolute
requirement
Proceed with the trial only with disclosure,
because the trial will not directly benefit the
subjects
Proceed with the trial using only subjects who
agree to participate without disclosure
Proceed with the trial without disclosure, because
the probability of long-term harm to subjects
is remote
Proceed with the trial without disclosure, because
the risks to subjects are outweighed by the
possible benefits to many patients
10%B20%
80%B90%
15%B20%
20%B35%
25%B40%
15%B25%
2.
A 25-year-old man comes to the emergency department
because of a 1-month history of fever, chills, nonproductive
cough, and progressive shortness of breath; he now becomes
short of breath after walking 20 feet. He has had a 4.5-kg
(10-lb) weight loss during this period. He has not seen a
physician for 10 years, and he takes no medications. He has a
10-year history of intravenous heroin use and shares needles.
He is in mild respiratory distress while sitting. His
temperature is 38.6°C (101.4°F), pulse is 92/min, respirations
are 24/min, and blood pressure is 110/70 mm Hg. Pulse
oximetry on room air shows an oxygen saturation of 90%.
There is no jugular venous distention. Diffuse crackles are
heard bilaterally. There is no peripheral edema. An x-ray of
the chest shows diffuse interstitial infiltrates bilaterally. This
patient is most likely to have which of the following
immunologic abnormalities?
(A)
(B)
(C)
(D)
(E)
(F)
Decreased B-lymphocyte count
Decreased CD4+ T-lymphocyte count
Decreased serum complement concentrations
Decreased serum IgA concentration
Decreased splenic opsonization
IgG autoantibodies
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
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Appendix 3
3.
A 27-year-old man is brought to the emergency department 20 minutes after his roommate found him unconscious on their bathroom
floor. The patient has a history of intravenous heroin use. He has no history of serious illness and takes no medications. On arrival, he
appears cyanotic. He is unresponsive to verbal and painful stimuli. His temperature is 37.1°C (98.8°F), pulse is 80/min, respirations are
4/min, and blood pressure is 110/60 mm Hg. Examination shows new and old needle tracks over the upper and lower extremities.
Cardiopulmonary examination shows no abnormalities. Arterial blood gas analysis on room air shows:
pH
PCO2
PO2
HCO3−
7.20
80 mm Hg
50 mm Hg
29 mEq/L
Which of the following is the best explanation for this patient's hypoxemia?
(A)
(B)
(C)
(D)
(E)
4.
Decreased inspired oxygen tension
Hypoventilation
Impaired diffusion capacity of the lung for carbon monoxide
Right-to-left shunt
Ventilation-perfusion mismatch
A 15-year-old boy has had pain in the knee since sustaining an
injury in a high school football game 6 weeks ago. The high
school trainer has been treating him with heat and ultrasound,
without significant improvement. Physical examination
shows tenderness of the medial femur approximately 7.5 cm
above the joint. There is no ligamentous instability, joint
swelling, or effusion. Which of the following is the most
appropriate next step in diagnosis?
(A)
(B)
(C)
(D)
(E)
6.
(A)
(B)
(C)
(D)
(E)
Anteroposterior and lateral x-rays
Arthrography
Arthroscopy
Measurement of serum calcium concentration
Ultrasonography
7.
5.
A 2-week-old boy is brought to the physician because of a
3-day history of persistent discharge from his eyes. He was
born at term following an uncomplicated pregnancy and
delivery. Examination of the eyes shows tarsal inflammation
and a thin mucopurulent discharge. Testing of scrapings from
the tarsal conjunctivae is positive for Chlamydia trachomatis.
The remainder of the examination shows no abnormalities.
Which of the following is the most likely mode of
transmission of this patient's infection?
(A)
(B)
(C)
(D)
(E)
Aerosol exposure
Contact with maternal cervical secretions
Exposure to household pets
Poor hand washing by caregivers
Transplacental transmission
A 62-year-old man comes to the physician because of blood in
his urine for 24 hours. Vital signs are within normal limits.
Examination shows no abnormalities. Tissue obtained on
bladder biopsy shows transitional cell carcinoma. Abstinence
from which of the following is most likely to have prevented
this condition?
Alcohol
Coffee
Diet soda
Tea
Tobacco
A 21-year-old nulligravid woman who is not using
contraception has had irregular menstrual periods since
menarche at age 13 years. She has noted increased hair
growth on her face and lower abdomen. On pelvic
examination, there is copious cervical mucus and slightly
enlarged irregular ovaries. Which of the following is the most
likely cause of these findings?
(A)
(B)
(C)
(D)
(E)
Adrenal adenoma
Idiopathic hirsutism
Ovarian tumor
Pituitary adenoma
Polycystic ovarian syndrome
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
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Appendix 3
8.
A 50-year-old man has a 1-hour history of unremitting chest
pressure and Agassiness.@ He has no history of cardiac
problems but does have a history of peptic ulcer disease.
Physical examination shows no abnormalities except for a
blood pressure of 140/80 mm Hg. Which of the following is
the most appropriate initial step in diagnosis?
(A)
(B)
(C)
(D)
(E)
9.
Test of the stool for occult blood
ECG
X-ray series of the upper gastrointestinal tract
Echocardiography
Endoscopy of the upper gastrointestinal tract
A 32-year-old nulligravid woman comes to the physician
because of a 20-minute episode of shortness of breath when
she awoke this morning. Her only medication is an oral
contraceptive. She has smoked one pack of cigarettes daily for
10 years. She is sexually active with multiple partners.
Physical examination shows erythema, swelling, warmth, and
tenderness behind the right knee; a cord-like mass can be
palpated. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Corticosteroid-induced arthritis
Gonococcal arthritis
Pulmonary embolism
Steroid-induced asthma
Systemic lupus erythematosus
10. A 4030-g (8-lb 14-oz) newborn has internal rotation of the left
upper extremity at the shoulder, extension at the elbow,
pronation of the forearm, and flexion of the fingers following
a low forceps delivery. He was born at term following an
uncomplicated pregnancy. Passive range of motion of the left
upper extremity is full; the newborn does not cry or grimace
when the left arm, shoulder, or clavicle is palpated.
Examination shows no other abnormalities. Which of the
following is the most likely underlying mechanism of this
condition?
(A)
(B)
(C)
(D)
(E)
Anterior dislocation of the left shoulder
An inherited skeletal dysostosis
Intracerebral hemorrhage
Posterior dislocation of the cervical vertebrae
Traction on the brachial plexus during delivery
11. A 72-year-old man comes for a routine health maintenance
examination. He has a 5-year history of progressive difficulty
falling asleep at night and waking up early in the morning. He
has not had snoring, nightmares, or changes in appetite or
weight. He has felt energized since starting a new business
venture 8 months ago. He has hypertension treated with
hydrochlorothiazide. He does not smoke cigarettes, drink
alcohol, or use illicit drugs. His blood pressure is
145/88 mm Hg. The lungs are clear to auscultation. Cardiac
examination shows an S4 gallop. Laboratory studies are within
normal limits. Which of the following is the most likely cause
of this patient's insomnia?
(A)
(B)
(C)
(D)
(E)
(F)
Hypertension
Hyperthyroidism
Major depressive disorder
Malignancy
Sleep apnea
Normal aging
12. A 15-year-old boy who recently received the diagnosis of
acute lymphocytic leukemia is scheduled to undergo
chemotherapy. Initially, he is eager to begin treatment, but
after discussing possible adverse effects of chemotherapy with
his parents and physician, he refuses to undergo treatment.
Which of the following is the most appropriate next step in
management?
(A)
(B)
(C)
(D)
(E)
(F)
Ask the patient why he refuses to undergo
treatment
Tell the patient that he is refusing treatment
because he is denying the seriousness of his
illness
Recommend projective psychological testing
Begin behavior therapy for oppositional behavior
Proceed with chemotherapy
Begin clonazepam therapy
13. A 22-year-old woman comes to the physician because of a
1-year history of intermittent lower abdominal cramps
associated with bloating and mild nausea. The cramps are
occasionally associated with constipation and bowel
movements relieve the pain. She has not had any other
symptoms. She has no history of serious illness and takes no
medications. Her last menstrual period was 2 weeks ago. She
appears well. Abdominal examination shows mild diffuse
tenderness to palpation. Which of the following is the most
likely diagnosis?
(A)
(B)
(C)
(D)
(E)
Crohn disease
Irritable bowel syndrome
Meckel diverticulum
Peptic ulcer disease
Ulcerative colitis
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
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Appendix 3
14. A 10-year retrospective study is conducted to determine
factors that could predispose women to have children with
complex congenital heart disease. A total of 1000 women
were asked whether they had flu-like symptoms during their
first trimester. The investigators found that women who had
children with complex congenital heart disease were five
times more likely than women with healthy newborns to
report flu-like symptoms in their first trimester. Which of the
following features of this study is most likely to affect the
validity of this conclusion?
(A)
(B)
(C)
(D)
(E)
Assessment bias
Case mix bias
Random error
Recall bias
Selection bias
(A)
(B)
(C)
(D)
(E)
15. An asymptomatic 32-year-old woman comes to the physician
for a follow-up examination. She has a 10-month history of
hypertension that has been difficult to control with
medication. Current medications include metoprolol,
lisinopril, hydrochlorothiazide, and nifedipine. Her blood
pressure today is 170/110 mm Hg. Abdominal examination
shows a bruit in the left upper quadrant. Which of the
following is the most likely cause of this patient's
hypertension?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
Coarctation of the aorta
Essential hypertension
Hyperaldosteronism
Hypercortisolism
Hyperthyroidism
Pheochromocytoma
Pituitary adenoma
Renal artery stenosis
16. Five days after falling and hitting her chest, a 55-year-old
woman has acute midsternal chest pain that radiates to the
back and is exacerbated by deep inspiration. Immediately
following the accident, she had acute sternal pain that resolved
in 1 day. Her temperature today is 37.7°C (99.9°F). A
three-component scratchy sound is heard across the
precordium. An x-ray of the chest shows a normal cardiac
silhouette. An ECG shows diffuse ST-segment elevation and
T-wave inversion. Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)
17. A 19-year-old primigravid woman comes to the physician for
her first prenatal visit. Her last menstrual period was 18 weeks
ago. Her pregnancy has been complicated by cocaine use. She
has no history of serious illness and takes no medications. Her
temperature is 36.7°C (98°F), pulse is 90/min, respirations are
16/min, and blood pressure is 110/50 mm Hg. Examination
shows scleral icterus and poor dentition. The fundal height is
20 cm. The remainder of the examination shows no
abnormalities. This patient is at greatest risk for which of the
following conditions?
Acute myocardial infarction
Pleurodynia
Purulent pericarditis
Traumatic pericarditis
Viral pericarditis
Abruptio placentae
Gestational diabetes
Macrosomia
Pituitary infarction
Postdates pregnancy
18. A 37-year-old woman comes to the emergency department 40
minutes after the onset of shortness of breath, dizziness, and
an itchy rash. She says she feels a lump in her throat. Her
symptoms began while she was eating at a restaurant buffet.
She has an allergy to peanuts. She is alert but anxious and in
respiratory distress. Her temperature is 37°C (98.6°F), pulse is
120/min, respirations are 30/min, and blood pressure is
75/50 mm Hg. Examination shows an urticarial rash on the
trunk and extremities. There is swelling of the lips but no
swelling of the tongue or pharynx. Diffuse wheezing is heard
bilaterally. In addition to intravenous 0.9% saline and an
antihistamine, which of the following drugs should be
administered immediately?
(A)
(B)
(C)
(D)
(E)
Diazepam
Dobutamine
Epinephrine
Phentolamine
No additional pharmacotherapy is indicated
19. Two days after beginning primaquine for malaria prophylaxis,
a 17-year-old African American boy is brought to the
physician because of dark urine and yellowing of his eyes. His
pulse is 88/min, respirations are 12/min, and blood pressure is
124/68 mm Hg. Examination shows scleral icterus and pale
mucous membranes. His hemoglobin concentration is 10 g/dL.
A blood smear shows erythrocyte fragments and Heinz
bodies. Which of the following is the most likely explanation
for these findings?
(A)
(B)
(C)
(D)
(E)
Decreased porphobilinogen deaminase activity
Decreased production of β-globin chains
Deficiency of glucose 6-phosphate
dehydrogenase
Deficiency of glycosylphosphatidylinositol
Fragmentation of erythrocytes by fibrin strands
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
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Appendix 3
20. A 17-year-old boy comes to the physician because he believes that his penis is too large. He has been uncomfortable with the size of
his genitals since he underwent puberty 4 years ago. He is concerned that people will see the bulge of his genitals under his clothing.
Although he has never had sexual intercourse, he is afraid that his size will make it difficult or painful for most women. He plays
intramural basketball but no longer undresses in front of teammates or uses public showers. He has not had changes in sleep or
appetite. He has no history of serious illness and takes no medications. He occasionally drinks one or two beers on weekends but uses
no illicit drugs. He continues to receive mostly B and C grades in school. He is 183 cm (6 ft) tall and weighs 68 kg (150 lb); BMI is
20 kg/m2. Genital development is Tanner stage 4. Physical examination shows no abnormalities. On mental status examination, he
appears embarrassed, and he describes his mood as "okay." Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
Body dysmorphic disorder
Delusional disorder
Hypoactive sexual desire disorder
Narcissistic personality disorder
Schizoid personality disorder
Sexual aversion disorder
Social phobia
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
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Appendix 3
Answer Form for Comprehensive Clinical Science Examination Sample Questions
(Questions 1-20)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
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Appendix 3
Answer Key for Comprehensive Clinical Science Examination Sample Questions
(Questions 1-20)
1. A
2. B
3. B
4. A
5. B
6. E
7. E
8. B
9. C
10. E
11. F
12. A
13. B
14. D
15. H
16. D
17. A
18. C
19. C
20. A
Copyright © 2003, 2008 by the National Board of Medical Examiners® (NBME®)
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