A 63-year-old woman comes to the physician 1 day after the sudden onset of pain and swelling of her right knee. She has had no injury. Her medications include occasional ibuprofen for mild osteoarthritis of both knees. Her temperature is 37°C (98.6°F), pulse is 97/min, respirations are 19/min, and blood pressure is 129/79 mmHg. Examination of the right knee shows warmth, erythema, and effusion. Exquisite tenderness is produced with minimal range-of-motion testing. Examination of synovial fluid obtained via joint aspiration shows that it is clear, with positively birefringent rhomboids observed under polarized light microscopy. Deposition of which of the following substances is the most likely cause of these findings?

A. Ammonium urate

B. Calcium oxalate

C. Calcium pyrophosphate

D. Calcium urate

E. Sodium urate

A 14-year-old girl has had nausea, intermittent diarrhea, and a 2.2-kg (5-lb) weight loss over the past 4 weeks. Examination shows a migrating serpiginous pruritic perianal rash. Her leukocyte count is 8000/mm3 with 20% eosinophils. Which of the following tests is most likely to yield an accurate diagnosis?

A. Blood smear

B. Bone marrow biopsy

C. KOH preparation

D. Microscopic examination of the stool

E. Skin snip

A previously healthy 40-year-old man is brought to the emergency department because of constant substernal chest pain for 12 hours that is exacerbated by coughing and inspiration. The pain is relieved with sitting up and leaning forward. There is no family history of heart disease. His temperature is 38°C (100.4°F), pulse is 120/min, and blood pressure is 110/60 mmHg. The lungs are clear to auscultation. Cardiac examination shows distant heart sounds. An ECG shows diffuse ST-segment elevation in all leads. An x-ray of the chest shows normal findings. The most likely cause of his condition is injury to which of the following tissues?

A. Aortic intima

B. Esophageal sphincter

C. Myocardium

D. Pericardium

E. Pleura

A 25-year-old woman comes to the office because of a 6-month history of increasingly severe low back pain and heavy menses. Her temperature is 37.1°C (98.8°F), pulse is 75/min, respirations are 13/min, and blood pressure is 115/79 mmHg. Physical examination shows no abnormalities. An endometrial biopsy specimen shows regular tubular endometrial glands with abundant mitotic figures in the endometrial glands and stroma. Which of the following proteins or enzymes regulate the progression of cells into this phase of this patient's menstrual cycle?

A. AMP-dependent kinases

B. Cyclin-dependent kinases

C. Hexokinases

D. Lipid kinases

E. Urokinases

A previously healthy 24-year-old woman who is a college student comes to the office because of a 6month history of abdominal bloating, upper abdominal discomfort, and constipation. The symptoms are more severe when she is preparing for examinations but improve after bowel movements. She takes no medications. She does not smoke or use illicit drugs. She drinks alcoholic beverages occasionally. She is 160 cm (5 ft 3 in) tall and weighs 57 kg (125 lb); BMI is 22 kg/m2. Her pulse is 72/min, and blood pressure is 100/72 mmHg. Physical examination, including digital rectal examination, shows no other abnormalities. A complete blood count and serum electrolyte concentrations are within the reference ranges. A urease breath test result is negative. Upper and lower endoscopies show no abnormalities. Which of the following is the most appropriate pharmacotherapy for this patient?

A. Azathioprine

B. Infliximab

C. Lubiprostone

D. Mesalamine

E. Sulfasalazine

A 35-year-old woman comes to the office because of a 3-day history of severe right back pain. She has not had any fever, chills, or weight loss. She has no history of major medical illness. Musculoskeletal and neurologic examinations show no abnormalities. When told that her examination is normal, the patient becomes tearful and demands an MRI of her back because her mother just died from breast cancer metastatic to bone and she fears that she may also have cancer. The patient already contacted her insurance company, who told her that if she has neurologic abnormalities an MRI may be covered by her plan. The patient asks the physician to order the MRI indicating that she has neurologic findings. Which of the following is the most appropriate initial action by the physician?

A. Advise the patient to change insurance companies as soon as she is able so that she can receive more comprehensive medical care

B. Explain that the patient does not need the MRI and that it is not appropriate to misrepresent her examination findings

C. Immediately inform the patient's insurance company about what the patient has asked the physician to do

D. Order the MRI as the patient requests

E. Recommend that the patient pay for the MRI out-of-pocket in order to ease her worry

A 3-year-old male is brought to the physician due to an enlarging abdominal mass. Physical examination reveals a mass in the left abdomen that does not cross the midline. Ophthalmic examination is unremarkable. Microscopic examination of a biopsy specimen from the abdomen reveals dense immature islands of epithelial cells, ribbons of spindle fibroblastic stromal cells and poorly formed tubular structures. The most likely diagnosis:

A. embryonal rhabdomyosarcoma

B. Ewing sarcoma

C. Hodgkin disease

D. neuroblastoma

E. Wilms tumor

Which of the following terms correspond with the phrase: a woman that is pregnant?

A. Gravida

B. Parity

C. Spermatogonia

D. Zonapellucida

A 28-year-old man decides to donate a kidney to his brother, who is in chronic renal failure, after HLA typing suggests that he would be a suitable donor. He is admitted to the hospital, and his right kidney is removed and transplanted into his brother. Which of the following indices would be expected to be decreased in the donor after full recovery from the operation?

A. Creatinine clearance

B. Renal excretion of creatinine

C. Creatinine production

D. Daily excretion of sodium

E. Plasma creatinine concentration

Which of the following nerves innervates the pronator teres muscle?

A. Radial

B. Median

C. Musculocutaneous

D. Ulnar