NBME 29

BLOCK 1
1. Prolonged starvation and untreated type 1 DM - Increased availability of acetyl
CoA.
2. Afferent limb of gag reflex - Glossopharyngeal nerve.
3. Inferior wall of heart is supplied by - Right coronary artery.
4. Bile acid resins such as cholestyramine decrease serum cholesterol concentration by
- Upregulating hepatic LDL receptors.
5. Tamoxifen - Competitive inhibition of estrogen binding to its receptor. SERM.
Estrogen receptor agonist @ breast, antagonist @ bone and endometrium.
6. Score recorded before treatment and 4 weeks after study. - Controlled trial.
7. Pic showing tophi seen in gout along with needle shaped crystals - Sodium
monourate.
8. Bone age corresponding to chronological age - Constitutive growth delay.
9. Pic showing malar rash of SLE which is similar to - Drug induced serum sickness.
10. Anemia with reticulocytopenia. S/o ACD. - Increased retention of iron within the
reticuloendothelial system.
11. Inability to pass nasogastric tube + gastric volvulus. - Paraesophageal hernia.
12. From supine to standing position. - Decreased cerebral blood flow, decreased
venous retun, decreased carotic sinus baroreceptor activity.
13. 25mm induration on PPT test in a patient with past history of TB. Lesion is likely to
show predominance of - Macrophages.
14. Patient c/o migraine refusing the prescription and expected physician to evaluate
further. - “Tell me what you think may be causing the headaches”.
15. Pic showing Myeloid blasts with auer rods. - AML.
16. C/o pneumonia in right lower lobe. - Increased tactile fremitus over the right
lower lung field. Whispered pectoriloquy is when whispers are heard clearly in lungs,
seen in consolidation and pneumonia. Normally whispers would be muffled.
17. Kidney cells likely to show first signs of anoxic injury - Proximal tubule.
18. 13 Yrs old grew 3inches during summer. Increased intestinal absorption of calcium is
due to - Hormones derived from 7-dehydrocholesterol.
19. Parkinsons disease - Alpha synuclein inclusions aka lewy bodies.
20. Average between 2 groups - Student’s t test.
21. CSF showing markedly decreased Homovanillic acid concentration. - Deficiency of
Tyrosine hydroxylase seen.
22. Hyperthyroidism - Antibodies against TSH receptor.
23. Probability of survival in 4th year ~ 90.1% which is 0.901.
24. 12 yrs old boy with edema, hypoalbuminemia and proteinuria. - MCD.
25. Pic showing paralysis of phrenic nerve activity. Drug X is - Tubocurarine.
26. Neuraminidase inhibitor - Inhibits release of virus from infected epithelial cells.
27. Pic showing irregular patches on scalp with hairs of varying lengths. -
Trichotillomania.
28. Exclusively breast fed baby. Dehydrated. Acidic stools positive for reducing
substances. Following oral admn of glucose, S.Glucose levels are normal. Following
admn of fructose, stools become normal. S/o lactose breaking down into glucose and
galactose. Both are taken up by SGLT-1. Deficiency of SGLT-1 causes decreased
absorption of both glucose and galactose. Fructose is absorbed by GLUT-5 in
erythrocytes and not affected by SGLT-1 deficiency.
29. Fibrosis and calcification of aortic valve is seen in - Normal ageing.
30. 3 days h/o abdominal pain and interscapular pain with n/v + 18kg weight loss in 6
months. Tenderness in RUQ. - Cholecystitis.
31. C/o paraplegia with UTI, for prevention of decubitus ulcers, take care of - Pressure.
32. Type 2 DM with CRF. - Increased PTH, Decreased Calcium, Increased
Phosphate.
33. Chondroitin sulphate occupies larger volume in cartilage as - It has many surface
negative charges.
34. Dehydrated marathon runner + Channel activated in normal kidney to maintain
hydration homeostasis. - Urea reabsorption in medullary collecting ducts. Decreased
S.osmolarity is sensed by ADH. Its action is to insert aquaporins in the collecting duct for
sodium and water retention, other action is to insert urea transporters in the collecting
duct.
35. Alcoholic patient with macrocytic anemia - Folic acid deficiency.
36. History s/o ITP + pic showing megakaryocytic hyperplasia. - Peripheral destruction
of platelets.
37. Proximal muscle weakness + Hyperglycemia + mild HTN + hilar lung mass. -
Paraneoplastic ACTH secretion.
38. Patient with nasal polyps develop bronchospasm after drug. S/o AERD. Aspirin
induced exacerbration of resp disease. - Irreversible COX inhibitor.
39. Oxycodone overdose. - Opioid overdose. - Constricted pupils, decreased resp,
deccreased pulse, GCS 7.
40. Gram pos organism, catalase positive, tumbling motility. S/o Listeria monocytogenes.
- Could have been avoided by - Consumption of delicatessan meats.
41. Hypokalemia + hyperglycemia + diarrhoea s/o VIPoma causing WDHA syndrome -
Somatostatin analogues can control diarrhoea.
42. Indirect inguinal hernia, more common in children and are reducible. - Lateral to
inferior epigastric artery and superior to inguinal ligament.
43. Mech of action of pioglitazone. - Stimulation of PPAR-gamma.
44. Acral lentigenous melanomas are more common in dark skinned individuals. Seen on
- Palms.
45. 27yrs old male with weakness of arms and legs + numbness + h/o bad cold 2 weeks
back + symmetrical weakness that is greater in legs than in arms + absent muscle stretch
reflexes + diminished vibration and proprioception in LE. - Demyelinating
polyneuropathy.
46. Post pregnancy, pelvic examination shows vaginal dryness and atrophy. - Estrogen
deficiency.
47. Nasal CPAP in OSA reduces - Blood pressure.
48. -
49. Acetaminophen toxicity is hepatotoxic as it causes - Peroxidation of lipid in cell
membranes. Metabolized to NAPQI which is directly hepatotoxic.
50. Diminished capacity to restore low basal calcium concentration during diastole.
Impairment of - Na Ca Exchanger.

BLOCK 2
1. Microcephaly + cataract + chorioretinitis - Rubella virus.
2. 8yrs old boy + 4 months after sisters death + cries and c/o headache - Normal
emotional response.
3. Limitation to conclude that colonic polyps is associated with increased risk of
malignancy - Follow up period is too short.
4. By changing one value in data sets - Mean, median, mode will increase.
5. Deficiency of von willebrands factor - Decreased platelet adhesion.
6. Cause of hypercalcemia in Multiple myeloma - Local interleukin-1 (IL-1) and tumor
necrosis factor effects.
7. Pic showing candida albicans causing vulvovaginitis - Rx is azoles which prevent the
formation of ergosterol by - Inhibition of the cytochrome P450-dependent
demethylation reaction.
8. Pic shows bullous pemphigoid. This has antibodies against the hemidesmosome. Its
an intricate complex which - Attaches keratinocytes to the extracellular matrix.
9. IHC positive for desmin - Muscle.
10. Perforated diverticulitis can cause spontaneous bacterial peritonitis resulting in fibrin
exudate on surface of visceral organs.
11. C/o head injury + hypernatremia + increased urine output. S/o central DI. Lack of
ADH. Dilute urine plus high serum osmolarity. Collecting duct affected.
12. 72 yrs old male with anemia and microcytic RBCs - Gastrointestinal blood loss.
13. C/o septic shock developing acute tubular necrosis. Most affected segment -
Proximal tubule.
14. Pic showing staghorn calculi - Proteus Vulgaris.
15. Obese boy with hip and knee pain. Internal rotation of hip is limited by pain. -
Slipped capital femoral epiphysis.
16. Coarse facial features + generalized hypotonia + b/l hip dislocation + inguinal hernias.
Labs show increased activity of lysosomal enzymes. Urine shows no
mucopolysaccharidoses. S/o I - Cell disease. - Addition of mannose phosphate to
lysosomal residues. This results from accumulation of oligosaccharides, lipids and
GAGs within cells throught the body. Due to failure of golgi based post translational
modification of proteolytic enzymes. D/D - Hurler’s disease - Presence of
mucopolysaccharides in urine.
17. Antibodies are induced that bind and inactivate Inhibin. - Increased S.FSH
concentration.
18. Features s/o ADPCKD. Mutation in gene that encodes for - Polycystin. ARPCKD -
fibrocystin, Familial juvenile nephronophthosis - Nephrocystin, Na-K-2Cl- transporter -
Bartter syndrome, Na-Cl Transporter - Gitleman syndrome, voltage gated chloride
channels - Congenital myotonia.
19. Features s/o syphilis. Rx is pencillins. Acts by inhibiting - Cell wall synthesis.
20. Resistance to ritonavir/lopinavir - Protein processing.
21. High pitched holosystolic murmur plus palpable thrill at left sternal border - VSD.
22. MAOI inhibit the breakdown of epinephrine in brain.
23. Parents have albinism. Children do not. - Genetic heterogeneity. Seen with AR
conditions.
24. Patient says “ you are not taking good care of me, youmust not like me very much”.
Physician replies - “ I want to help you as much as i can. Ehy dont we talk about
what’s going on in your life?”.
25. 76 yrs old man with Alzheimer’s disease, BMI 14kg/m2. S.Albumin is low. S.Cortisol
is high. - Protein calorie malnutrition.
26. Hormone decreasing synthesis of PGs and Leukotrienes. - Cortisol.
27. Pic of abdominal xray showing - Malrotation.
28. C/o abduction of right eye + mild weakness of Left Extremities + increased muscle
stretch of left extremity and gait ataxia. - Brain stem glioma.
29. Male newborn with increased phenylalanine concentration. Defect in - Metabolism
of tetrahydrobiopterin.
30. Attributable risk = risk in exposed - risk in non exposed. - 2.27 - 0.07.
31. S/o osteoporosis. - Thinned trabeculae.
32. S/o Myotonic dystrophy - Expansion of trinucleotide repeats.
33. Substitute drug to aspirin which inhibits platelet function acts by - Blocking the ADP
receptors.
34. Extreme social detachment and a cold, restrictive effect. Such patients do not enjoy
social relationships and acoid interpersonal activities. They are indifferent to priase and
criticism. - Schizoid personality disorder.
35. Central hilar lung mass - Squamous cell carcinoma.
36. Absence of nerve regeneration in group of Optic nerve fibers. - Axons of optic nerve
are myelinated by oligodendrocytes.
37. Constipation, fatigue, weightloss, microcytic anemia with firm 10cm mass in rectum
s/o colon ca. Mets to Liver most common.
38. Vaccine formulation for neisseria. To increase titre of antibodies when conjugated to
polysaccharides, conjugate with - Flagellin.
39. Lateral rotation of thigh - Piriformis.
40. B/l SNHL + long QT interval. Mutation in - Voltage gated K+ Channel.
41. Features s/o portal HTN. Bleeding vessel is - Short gastric.
42. -
43. Cause of adhesion to the endothelial surface. - Selectins.
44. Fasting/starvation state> Upregulation of epinephrine and glucagon +
downregulation of insulin. Glycolysis will be down regulated > Decreased PK,
Decreased F-2,6-Bisphosphatase. Hepatic gluconeogenesis will happen > Increased
PEP Carboxykinase and Glucose-6-phosphatase.
45. Strongest predisposing factor for sarcoidosis - Ethnicity.
46. Event to occur in immobilized muscles after 3 weeks of cast - Decreased
capillarity.
47. Features s/o Neurocysticercosis. - Taenia solium.
48. For short term relief of nasal decongestion - Use phenylephrine which is an - Alpha 1
adrenergic agonist.
49. Manometry shows increased motility in stomach caused by - Motilin.
50. Cabin’s barometric pressure is 565mmHg. Inspiratory partial pressure of alveolar
oxygen is - FiO2 * (Patm - PH2O) = 0.21 * (565 - 47) = 109. The values 21% or 0.21 and
47mmHg are always fixed for Fraction of inspired oxygen and partial pressure of water
vapors, respectively.

BLOCK 3
1. -
2. M Protein 1.8gms - MGUS.
3. Administration of antihistaminic would blunt the initialpeak of extravasation. Peak A.
4. Renal calculus lodged in ureter passing over sacroiliac joint. At this point, ureter
narrows over as it passes over - External iliac vessels. 3 points of narrowing of ureter -
UPJ, UVJ and pelvic inlet where ureter crosses over external iliac vessels.
5. Sensitivity = TP, (1 - Specificity) = FP.
6. Region of expanded trinucleotide repeats is methylated. - Decreased transcription.
7. C/o DCM, Xray shows indentation and posterior displacement of esophagus. Caused
by enlargement of - Left atrium.
8. C/o URTI + Hematuria + Mild HTN + RBC casts. IHC staining shows granular
mesangium deposits of - IgA.
9. The greatest amount of ATP is obtained from largest no. Of - Hydrogen atoms.
10. Xray shows left sided pneumothorax - Decreased breath sounds on left.
11. Synovial fluid aspirate shows leukocyte count > 90,000/mm3. - Infectious arthritis.
12. Severe anemia with normal production of alpha globin chains + production of beta
globin gene mRNA is decreased 75%. - Imbalance in synthesis of alpha and beta
globin gene products.
13. Post haloperidol, patient is agitated and has diffusely increased muscle tone with
increased CK. - Neuroleptic malignant syndrome.
14. 1-month old boy with X linked SCID develops T ALL post bone marrow transplant.
Cause of leukemia is - Integration adjacent to oncogene.
15. Cause of high anion gap metabolic acidosis. - Renal failure.
16. Bitemporal hemoaniopia + galactorrhea - Pituitary adenoma / Prolactinoma.
17. Diisopropyl fluorophosphate, a potential inhibitor of acetylcholinesterase reacts with
AA - Serine at the active site of the enzyme.
18. Fluent speech with grammatical errors, word substitutions and neologisms.-
Damage to wernicke’s area.
19. Male newborns with vomitting and convulsions in 4 hours of delivery and has bulging
fontanelle. - E.Coli. Causes of neonatal meningitis - E.coli, Strept Agalacticae, listeria.
20. H/o OCPs. Labs show higher alk phos and GGT compared to ALT & AST. S/o drug
induced cholestasis. Cause - Dialated canaliculi with bile plugs. Another drug causing
Drug induced liver injury is Amoxiclav.
21. Pic shows CMV inclusions in lung. Predisposed by decreased function of - T
lymphocytes.
22. -
23. Patient knows she has missed daily dose of injections. - “Acknowledge the
patient’s reasons for missing injections.”.
24. Biopsy LN positive for CK and EBV - Nasopharyngeal carcinoma.
25. Pain and stiffness in right hand and wrist exacerbrated by hand movement and
relived by rest. - Osteoarthritis.
26. Pic shows diffuse ulceration and inflammation of bowel segment. - Ulcerative colitis.
27. C/o nephrogenic DI. - Isotonic PT, Hypotonic JGA, Hypotonic medullary
collecting duct.
28. Features of toxic shock syndrome + Gram pos cocci in chains - Strept pyogenes. -
Releases exotoxin A. - Binding to T lymphocyte receptor and Class II MHC molecule.
29. Severe dehydration shortly after birth + decreased sodium and chloride levels + high
potassium. - 21-Hydroxylase deficiency.
30. High LDL cholesterol. S/o familial hypercholesterolemia. Impairment of - Clathrin
coated pit.
31. Neisseria infections common in deficiencies of - Late component of complement.
32. 3 months of worsening acne. Tetracyclins being taken with glass of milk in morning. -
Milk calcium chelates with tetracyclins.
33. Renal USH showing b/l hydronephrosis and hydroureters. Seen with Ca - Uterine
cervix.
34. F/o Acute mesenteric ischemia seen with atrial fibrillation which is also ass with
mitral stenosis. - Embolization.
35. C/o DM - Burning sensation in sole.
36. Medication that decreases craving for cigarettes and blocks CNS stimulation caused
by smoking. S/o Varinicline. - Partial agonist to Nicotinic acetylcholine receptor.
37. Daily headaches with tearing and nasal congestion. - Cluster headache.
38. Fluid behind tympanic membrane. Ear infection - Nasopharynx > auditory tube >
middle ear.
39. Intention to treat analysis - Treat all. No exclusions. - Analyze all non adherent
participants according to the groups to which each was randomized.
40. Anastomotic supply to maintain adequate arterial supply to testis - Artery of the
ductus deferens.
41. Features of hepatic encephalopathy with c/o arm motions and drowsiness. -
Hyperammonemia.
42. Fluoxetine has initial effect on - Raphe nucleus.
43. C/o constipation and urinary retention in a patient of MDD - Anticholinergic
medication.
44. Maximum rate of shortening when skeletal muscle undergoes contraction - Rate of
cross bridge recycling.
45. Cystic dialation of 4th ventricle, hypoplastic cerebellar hemispheres, enlarged
posterior fossa with high tentorium cerebelli. S/o Dandy walker malformation. Disorder of
- Metenchephalon.
46. S/o xeroderma pigmentosa - Nucleotide excision repair.
47. Acute MI in left dominant circulation requiring stenting. Pathway - Left coronary >
circumflex > posterior interventricular (Post descending).
48. S/o lesch nyhan syndrome. Deficiency of - HGPRT.
49. Pic showing herpes labialis - Retrograde axon transport.
50. Less CV is more precision. - Method II is more precise than method I.

BLOCK 4
1. Turners in 11 metaphase and normal XX in 09 metaphases. - Post fertilization non
disjunction.
2. Q2 = 1/40000, q = 1/200. 2pq = 2 * 1 * 1/200 = 1/100.
3. Multiple erythematous non blanching 1mm lesions on UE and LE. Likely defect in -
Production of platelets.
4. -
5. Increased likelihood of ectopic pregnancy - Previous gonorrhea infection.
6. Lytic lesion in skull bone. Pic shows coffee bean nuclei and eosinophils. - LCH.
7. DVT patients divided into two groups for evaluating CV insufficiency to check
prevalence in those who wore stockings. - Cohort study.
8. Stem s/o ARDS. - Injury to alveolar epithelium and endothelium.
9. C/o involuntary ballistic movements of right arm and leg. Lesion of - Subthalamus.
10. Stem s/o ADHD. Rx amphetamines. Action - Stimulation of release of biogenic
amine neurotransmitters.
11. Alcoholic patient with hyponatremia. Given 0.9% saline. 4 days later develops
slurred speech + weakness of extremities and dysarthria. Bilateral babinski sign present.
S/o Central pontine myelinosis. - Brain stem lesion.
12. GERD - Vagal stimulation of LES relaxation.
13. Stimulation of which receptor would benefit the patient of septic shock. - alpha 1
adrenoceptors.
14. Extravascular accumulation of fluid - Gap formation between endothelial cells.
15. Physician is 30 mins late and patient looks at watch when he enters. - “I’m sorry i
got delayed. I hope i havent made you late somewhere else.”.
16. Carotid pulse with small amplitude and a delayed upstroke. Crescedo systolic
murmur loudest at upper right sternal border. - Aortic stenosis.
17. Moderate tenderness of left flank with UTI by gram positive organism. -
Enterococcus faecalis.
18. Doxorubicin toxicity - Generation of free radicals.
19. C/o CDH. Defect in development of - Left pleuroperitoneal membrane.
20. C/o Wilms tumor. Methylation of a segment on maternal chromosome 11p15. -
Imprinting.
21. RR of disability 0.67 (0.44-0.89), RR of mortality 0.77 (0.43-1.11) - Significantly
lower RR of disability, No significant difference in RR of mortality.
22. Loop diuretics - Metabolic alkalosis and volume contraction.
23. Palpation shows a lumpy mass just superior to normal sized left testis. - Varicocele.
This is dialatation of pampiniform plexus.
24. Jaundice and pale stools in patient of congenital biliary atresia. Associated with -
vitamin E deficiency.
25. High PTH, Low S.Calcium - Osteomalacia.
26. Cortisol secreted by - Basophil cells of anterior pituitary gland.
27. Collateral arterial flow to right upper lobe - Right bronchial artery.
28. Symptoms of hyperthyroidism 6 weeks after delivery. Normal FT4, markedly less
TSH, Low RAIU. S/o post partum thyroiditis. - Release of stored thyroid hormone from
a thyroid gland infiltrated by lymphocytes.
29. Pic shows rose colored spots on trunk - Pityriasis Rosea.
30. Bluish discoloration of flanks. S/o grey turner sign. - Acute pancreatitis. Also, bluish
discouloration over umbilicus - Cullen sign.
31. Pic shows - Spillage of contrast, which is normal.
32. Fatty acids are infused into the proximal small intestine, most likely change in
peptide secretion - Increased cholecystokinin.
33. Drugs of abuse potential follow the pathway - A dopaminergic from the nucleus
accumbens to the prefrontal cortex.
34. Antibody against platelet IIb/IIIa receptor prevents binding of - Fibrinogen.
35. -
36. All cells CD3 pos, Absent IgM - X-Linked hypogammaglobulinemia.
37. Erythematous papules and pustules on forehead. S/o Acne vulgaris. - Wearing a
helmet.
38. Girl with irregular menses, use of OCPs, facial hirsuitism - PCOS.
39. H/o palpitations, intermittent headache + HTN. S/o Pheochromocytoma. CT Scan
points at - Adrenal gland.
40. History s/o RAS. Left renal vein sampling shows renin activity of 5u and right vein
renin activity of 176u. Systemic HTN directly mediated from vasoconstrictor that
emerges from - Pulmonary vasculature.
41. DHP CCB - Arteriolar vasodialator.
42. C/o ARDS, upregulation of IL-10 can prevent the lung injury.
43. SOB, non productive cough, joint stiffness, diffuse tightening of skin s/o systemic
sclerosis. Associated with - Interstitial fibrosis.
44. Cytokeratin positive - Epithelial cells.
45. Reaction after dose of rituximab - B-Lymphocyte release of cytokines.
46. NK cells destroy tumors with - Decreased expression of class I MHC molecules.
47. Breast cancer patient moving to a different city. Asks a new physician for advice. - “I
understand you have been treated by other physicians. Tell me what you know
about your disease.”
48. Urine has a burnt sugar odour. S/o Maple syrup urine disease. Deficiency of -
Branched chain alpha-ketoacid dehydrogenase.
49. Inability to flex the distal phalanx, defect in - Flexor digitorum profundus tendon.
50. CD19+, CD10 +, kappa clonality - Follicular lymphoma.