TOPNOTCH DIAGNOSTIC EXAM ANSWER KEY SEPTEMBER 2018

Item
#
KEY
ANSWER EXPLANATION
Amino acids that form hydrophobic interaction are usually found in
the interior of the protein to minimize interaction with the surrounding
water. Methionine is the only amino acid in the choices which forms
1 A hydrophobic interactions

Histidine is used to diagnose folic acid deficiency. This can be seen

2 D in the Topnotch handout
A. The statement describes domains, not motifs
B. Primary structure is retained in denaturation
D. Hemoglobin not myoglobin
3 C
The boards uses a lot of double and triple negatives in the questions.

Collagen is rich is glycine, proline, hydroxyproline and hydroxylysine.

4 B
The case describes a patient with Alport syndrome which is a genetic
5 D disorder affecting the structure of type IV collagen

6 C It should be maximum number of hydrogen bonds.

B - Enzymes are not consumed nor are they permanently altered.
C- They are also specific for the type of reaction it catalyzes
D- The statement describes Covalent catalysis, not acid-base
catalysis
7 A
Harper 30th Edition pg 61-63

8 D The rest all describe competitive inhibition

9 C
Aspirin and 2,4 dinitrophenol are examples of uncouplers
10 D Oligomycin works by directly inhibiting ATP synthase (complex V)
Glucose and galactose are Epimers since they differ in only the
position of -OH in C4
Enantiomers are pair of structures that are mirror images of each
11 A other such as L-glucose and D-glucose
The functional group of glucose and galactose is an aldehyde not a
ketose
 Although lingual lipase comes from the back of the tongue, no
digestion of lipids happen in the oral cavity.
12 A Rather lingual lipase and gastric lipase digest TAGs containing short
and medium-chain fatty acids in stomach
This is a case of lead poisoning. Lead inactivates many enzymes in
heme synthesis including ALA dehyrdatase and ferrochelatase
Homogentisate oxidase - seen in Alkaptonuria - urine turning black
with debilitating arthralgia
Ornithine transcarbomylase deficiency - seen in hereditary
13 D hyperammonemia with patient presenting with elevated blood
glutamine, decreased BUN and respiratory alkalosis
Phenylalanine hydroxylase - seen in phenylketonuria with patients
presenting with severe mental retardation, fair skin and eczema and
musty body odor

Although PPP is a source of NADPH, this is mainly used for

lipogenesis.
14 D PPP is also the main source of pentose phosphate such as ribose-5-
phosphate which is used in producing purine and pyrimidines
B1 is the coenzyme of transketolase
15 B
This case describes a patient with Menkes syndrome. This is an x-
linked recessive disorder characterized by a deficiency of an ATP-
16 C dependent membrane transporter for copper

17 D Topnotch handout
This is due to a defect in the loading of apo B with lipid. There is
18 D absence of chylomicrons or VLDL leading to the accumulation of
triacylglycerol in the liver and intestines
19 B Due to exposure to UV light,
Rifampicin: Binds to DNA-dependent RNA polymerase
Streptomycin and Aminoglycosides: binds to the 30s subunit and
interferes with initiation
20 C Dactinomycin: Binds the DNA template and interferes with the
movement of RNA polymerase during transcription

There was one question that came out in our boards that asked
about the different type of joints.
Synarthrosis:
21 A Syndesmosis - slightly movable fibrous joint between two bones.
Example: distal tibiofibular joint
Gomphosis - binds the teeth to bony teeth sockets

Recall question. See topnotch handout

22 D
 A similar question was asked in the boards. This is a case of Erb-
23 B duchenne palsy

The medial epicondyle fracture involves the ulnar nerve. All the
24 A other statements are correct
The patient has a steppage gait due to inability to dorsiflex her foot.
Foot drop may be caused by an injury to the common peroneal or
25 D deep peroneal nerve. However, there was also noted pain in the
lateral leg and dorsum of the foot, thus common peroneal nerve is
the answer
A similar question was asked in the board exam. The auricular
26 D branch of the vagus nerve is also called Arnold's nerve.
Again, there are several double/triple negatives in the board exams
A - it should be inferior deep cervical lymph node
B- palatoglossus, which is supplied by the vagus nerve
27 C D - the intrinsic muscles of the tongue are supplied by the
hypoglossal nerve

28 C It should be anterior ethmoidal

The structures that may be affected are CN III, IV, VI, Ophthalmic
29 B and Maxillary divisions of CN V and Internal Carotid Artery
There is no such thing as great auricular artery. It should be great
30 B auricular nerve. This nerve originates from the cervical plexus
composed of spinal nerves C2 and C3
The ischial spine is used to measure the midpelvis and is not part of
31 A the pelvic inlet. There were several anatomy questions in the boards
that were related to OB
A similar question was asked in the boards

True conjugate - superior margin of the pubic symphysis

32 B Obstetric conjugate - sacral promontory to the most bulging point on
the back of the pubis symphysis, about 1cm below its upper border

A similar question was asked in the boards for both anatomy and
biochemistry
Oxytocin - increases IP3 + DAG
33 A Insulin - tyrosine kinase
EPO - tyrosine associated kinase -> Src and JAK/STAT proteins

The ureteric bud is the embryologic origin of the ureter, renal pelvis,
renal calyces and collecting tubule
34 A The metanephric tubule form the nephron (renal corpuscle, PCT,
loop of henle, DCT)
A - the upper seven pair of ribs are true ribs
B- the first rib is important clinically
C- it is kept patent by U-shaped bars of cartilage
35 D
Snell 9th edition pg 35-37
 The needle should be introduced to the left of the xiphoid process in
36 B an upward and backward direction at an angle of 45 degrees to the
skin
37 B
The splenic cords of Billroth are reticular tissue rich in macrophages
38 C and lymphocytes
A similar question came out in the boards
39 C Hassal corpuscles are large aggregates of thymic epithelial cells
Ampulla - longest and expanded region where fertilization occurs
40 A Isthmus- narrow portion nearer the uterus
Intramural - passes through the wall of the uterus

The signs and symptoms of the patient especially, her recent travel
41 A to a place endemic with Malaria and paroxysmal fever, most likely
points to a diagnosis of malaria.,
Banana-shaped gametocytes is seen in P. falciparum. This is
42 A usually present with coarse granulations or maurer dots
Quinine is the DOC for malaria in pregnant patients
43 B
Trophozoites in tetrads, forming a maltese cross, is associated with
44 D Babesia. Sign and symptoms are very similar to that of malaria
Babesia is transmitted via a bite of an ixodes tick
45 D
This is a case of Actinomyces and the DOC is Penicillin. Remember
46 C the mnemonic SNAP - sulfonamide nocardia actinomyces penicillin
C. Sordelli in particular, is associated with septic abortion
47 A
Recall question. See topnotch handout
48 E

Legionella is an ubiquitous organism. Predisposing factors include

old age, smoking and high alcohol intake. It is the causative
49 C organism of atypical pneumonia, which usually present with
confusion, non-bloody diarrhea and hyponatremia
The DOC for atypical pneumonia are macrolides such as
50 C Azithromycin
This is a case of Bubonic plague whose causative agent is Yersinia
pestis. This is transmitted by flea bites and its reservoir includes wild
51 C rodents.
 A similar case came out in the boards. This describes a case of
52 B relapsing fever which is caused by Borrelia recurrentis and
transmitted via body lice
see above
53 D
Recurrentis is disseminated hematogenously following inoculation
and multiply to enormous levels, precipitating fever and other
symptoms. Development of successful humoral immunity is largely
able clear the infection using antibodies to B. recurrentis surface
54 A antigens, heralding a waning of the fever. However, B. recurrentis
displays antigenic variation, meaning that in every population some
organisms switch their antigenic surface structure and in doing so
become resistant to the host's antibodies.

Primary - chancre; Secondary - condyloma latum, reddish pink non

55 B itchy rash on trunk and extremities including palms and soles; tertiary
- gummas, neurosyphilis, aortitis
Primary syphilis is best diagnosed by darkfield microscopy. VDRL is
used as a screening test for syphilis while FTA-ABS is the
56 A confirmatory test. Syphilis is too thin to be seen on gram stain and it
cannot be cultured in vitro.
Right angles - rhizopus
57 B V-shapes acute angles - Aspergillus
Review the table in the topnotch microbiology handout
58 E
The virus being described is Parvovirus B-19 and it is a naked
icosahedral single stranded linear DNA.
59 B It is the smallest DNA virus and the only DNA virus that is single
stranded
This is a case of schistosomiasis and the drug of choice is
60 C Praziquantel

Macula densa - monitors sodium concentration

61 A Mesangial cells - smooth muscles capable of phagocytosis

62 D
GFR=2[(53−15)−(23−0)]
=2 (38−23)
= 2 (15)
63 D = 30
 FF = GFR / RPF
FF = 30/150
64 C FF = 0.2
= 20%
Loop diuretics mainly cause hypokalemia. Remember loop diuretics
65 C act on the Na/K/2Cl receptors located in the thick ascending loop of
Henle
G cells: Gastrin
66 B I cells: cholecystokinin
M cells: motilin
Remember secretin does NOT increase pancreatic enzyme secretion
67 C
Simple and facilitated diffusion is non-energy requiring
68 D Simple diffusion and Endocytosis is non carrier-mediated
Dopamine - secreted in the substantia nigra
69 D Serotonin - found in the median raphe of the brain stem
Ach - found in several areas in the brain
Ganong pg 97-98
Microglia are scavenger cells. Astrocytes, which is a type of
70 B macroglia, is the one responsible for producing substances that are
tropic to neurons
DHPR - voltage gated Ca channels in the t tubule membrane which
activates the Ryanodine receptor
Ryanodine receptor - Ca- release channel in the SR
71 A Troponin C - part of the actin filament which binds to calcium

H band - inside the A band and is made purely of myosin

72 A Bare zone - no myosin heads
I band - purely actin

73 D
Capillaries - largest cross-sectional area
74 C Veins - capacitance vessels

Remember the mnemonic CABET, do the RIGHT thing, let go

75 D HbF more tightly binds to oxygen than HbA so as to provide a steady

supply of oxygen to the growing fetus

V1 receptors - IP3/DAG causes vasoconstriction of arterioles

76 C V2 receptors - cAMP causes insertion of aquaportin-2 in the late
distal tubule and collecting ducts
The rest of the choices all have the same alpha unit and unique beta
77 E unit
 A similar question came out in the boards

Alternative pathway is also called properdin pathway and is triggered

78 A by contact with viruses, fungi, bacteria and tumor cells
Mannose-binding lectin pathway - triggered by lectin binding with
mannose groups in bacteria

Remember prolactin secretion does not depend on any hypothalamic

hormone. We might even expect an increase in the levels of prolactin
since there will no more negative feedback from dopamine
79 E
80 B

Procedural/Remedial law - concerned with mechanical rules that

govern the means by which substantive rights and duties are
enforced
81 B Natural law - guidance of human conduct
Public law - rules that regulate the relationship between state and
subject

This is an example of an inherent right. All the others are incidental

82 C right
Under the doctrine of ostensible agent, the pathologist, radiologist
83 D and anesthesiologist are employees and at the same time
independent contractors
Golden rule method - the judge determines how much the damage
84 C he wishes to receive if he is the plaintiff in the law suit
Trespasses - enter without being granted
85 A Licensee - has no contractual relation
Invitee - essential to the operation of the hospital
Persons who can give consent if the patient is a minor
• Parents
• Paternal grandparents
86 D • Maternal grandparents
• Eldest brother or sister (if she is of age)
etc

Simple contractual - the contract stipulates the nature of procedure

Retainer - measured by space of time
87 C Dichotomous - sharing a fee
Straight fee - dependent on what will be the remaining balance
Autograft - from the same person
88 B Isograft - between genetically identical person
Xenograft - between different species
 Virgo intacta

Moral -state of not knowing the nature of sexual life

Demi - permits any form of sexual liberties as long as they abstain
from rupturing the hymen
89 C True - hymen intact; the opening barely admits the tip of the smallest
finger
False - hymen unruptured but orifice is wide and elastic to admit 2 or
more fingers

Even if the child is less than 3 days old; if the killer is the mother or
90 C father or legitimate ascendant, the penalty is that of parricide
91 B
92 A
Magnus - ligature applied around base of finger
93 C Diaphanous - finger webs are viewed through a strong light
Benzidine - chemical exam used for blood stains
Similar question came out
94 D
Similar question came out

Burking - the murderer kneels or sits on the chest, and with his
95 A hands, closes the nostrils and mouth of the victim
Lynching- homicidal hanging practiced by Americans against
negroes

Legitimate - born in lawful wedlock within 300 days following

96 A dissolution of marriage or after 180 days following the celebration of
marriage
It should be 500 grams of marijuana
97 B
Similar question came out in the boards

Carbon monoxide - bright pink

Asphyxia - dark
98 D Phosphorus - dark brown
Hydrocyanic acid - bright red
Potassium chlorate - coffee brown

20 - physical feeling of well being; 50 - increased self confidence with

decreased inhibtions; 150-300 - disorientation, mental confusion,
99 C dizzines, slurred speech; 300 - impaired consciousness, sleep or
stupor
stomach bowel test/ breslau second life test/ floatation test - dip the
organs in water and if the organs float, breathing has taken place;
100 A hydrostatic test/fodere test/ static test - one of the tests to determine
wheter respiration took place on a newborn child before death
 This is a case of anaphylaxis. A similar question came out in the
boards

101 B Th1 - IFN-gamma - bacteria, viruses, autoimmune

Th2 - IL-4, 5,13 - helminthic, allergic
Th17 - IL-17 - bacteria, viruses, autoimmune

Similar question was asked in the boards.

Make sure to memorize the table regarding hypersensitivity disease

102 C and master SLE. Several questions were asked regarding both
topics, not only in pathology, but in other subjects as well

ANA - best screening test

103 D Anti-smith and anti-dsdna - specific for SLE; anti-dsDNA correlates
with disease activity
Similar question came out in the boards. Remember that "wire-loope
104 C appearance' is the diffuse type of lupu nephritis
A - minimal mesangial
B - membranous
105 C C - focal and diffuse
D - mesangial proliferative
A similar question came out in the boards

106 B This is a case of acute rheumatic fever and is therefore type 2.

Memorize hypersensitivity reactions
A similar question came out in the boards

107 B This is insulin-resistant diabetes and this again is an example of type

2 hypersensitivity reaction.

Review the table on the microscopic findings on kidney transplant

108 D patients
Review the table on the microscopic findings on kidney transplant
109 B patients
Review the table on the microscopic findings on kidney transplant
110 C patients
Make sure to review TB as it is asked not only in pathology but in
111 A other subjects as well

112 C
113 C
 Although signs and symptoms are non-specific, biopsy showing
114 B nectrotizing inflamation with temporal heterogeneity clinches the
diagnosis
The history of asthma, allergic rhinitis as well as (+) p-anca are clues
that will tell you that this is a case of Churg -strauss. Remember
115 A eosinophils + p-anca. Only churg strauss and microscopic polyangitis
are p-ancea positive among the vasculitides.
Remember:
6-12 hours: ischemic coagulative necrosis - wavy fibers and
myocytolysis
1-3 days neutrophils
116 B 3-7 days macrophages
1-2 weeks granulation tissue

A - libman-sacks endocarditis associated with SLE

B - marantic endocarditis or nonbacterial thrombotic endocarditis
117 D C - RHD
D - Infective endocarditis

118 B
119 A
120 C

Cefradoxil is a 1st generation cephalosporin

121 A Cefprozil and Loracarbef are 2nd generation cephalosporins
Remember BBBAN ME - Bleomycin, Busulfan, Bromocriptine,
122 D Amiodarone, Nitrofurantoin, Methotrexate
The rescue agent of Cisplatin is Amifostine

Pemetrexed is an anti-folate analog which is used to treat

123 D mesothelioma and non-small cell lung cancer

The other drugs have the ability to inhibit peripheral conversion and
is usually given in patients with thyroid storm.
124 B Methimazole works by inhibits thyroid peroxidase and organification
reaction

Procainamide is a Class 1A antiarrhythmic which acts on phase 0 of

the action potential and prolongs the AP duration
125 D Tocainide, Lidocaine and phenytoin are all under class1b, which
reduces the AP duration
 There was a similar question like this that came out in the boards.
There were a lot of questions regarding anti-diabetic agents.

Miglitol is an alpha-glucosidase inhibitor. Side effects are usually

126 C gastrointestinal disturbances
Exenatide is a GLP-1 agonist
Sitagliptin is a DPP-4 inhibitor

A similar question also came out in the boards. Metformin works by

inhibiting gluconeogenesis. Glipizide is an insulin secretagogue.
Exenatide is GLP-1 agonist. From physiology, GLP-1 is a GI
hormone that causes insulin release.
127 A Sitagliptin is a DPP-4 inhibitor. DPP-4 degrades GLP-1. By inhibiting
DPP-4, GLP-1 levels increases and thus insulin release is also
increased

Aminoglycosides exhibits concentration-dependent killing action

wherein as the plasma level is increased above the MIC, an
increasing proportion of bacteria are killed.

128 D Vs

Time-dependent killing action wherein efficacy is directly related to

the time above MIC

Ketoconazole inhibits P450-dependent enzymes blocking ergosterol

synthesis
Flucytosine is converted to cystosine deaminase to 5-FU which
129 C inhibits thymidylate synthase
Griseofulvin interferes with microtubule function

Remember the mnemonic WHAT PET for drugs displaying Zero

130 A order elimination kinetics
Remember that all inhaled anesthetic causes bronchodilation except
desflurane

Halothane may cause malignant hyperthermia if used with

131 D succinylcholine
Enflurane is contraindicated in patients with epilepsy
Isoflurane - causes the highest cardiac toxicity

Similar question came out in the boards

132 C
This drug is also converted to Laudanosine which can cause
133 B seizures
Isoniazid - inhibits mycolic acid synthesis
Ethambutol - inhibits arabinosyl transferase
134 C Make sure to study TB drugs. Several questions were asked in the
boards, not only in pharma but in other subjects as well
135 C
Zidovudine - Bone marrow suppression
Didanosine - pancreatitis
136 D Efavirenz - Teratogenicity

137 B
Isoniazid, Rifampicin and Streptomycin - bactericidal
Ethambutol - bacteriostatic
138 C Similar question also came out
Remember the mnemonic: OH DANG
Ototoxicity
Hypokalemia
Dehydration
139 A Allergy to sulfa
Nephritis
Gout

Prazosin - alpha 1 selective antagonist. May cause reflex tachycardia

and first dose orthostatic hypotension
Phenoxybenzamine - irreversible alpha adrenergic receptor
140 A antagonist and may also cause reflex tachycardia and orthostatic
hypotension
Isoproterenol - non selective beta receptor agonist

Review the chart in page 3 of the surgery supplemental handout

141 B
Lipolysis occurs mainly in response to catecholamine stimulus of the
142 D hormone sensitive triglyceride lipase
Zinc - most common; manifests as diffuse eczematoid rash at
intertriginous areas
Chromium - glucose intolerance
143 D Copper - microcytic anemia
Vitamin K - hemorrhagic

Class III- contaminated - penetrating abdominal trauma, large tissue

144 C injury, enterotomy, bowel obstruction
145 C

Last resort and best performed in the OR. Usually done in cases of
146 D laryngeal fracture

This is classified as a Grade II open fracture based on the Gustilo

and Anderson system.
147 C For grade II fractures, it is appropriate to start the patient on 1st
generation cephalosporin plus aminoglycoside

Nystatin - antifungal, may interfere with activity of mafenide

Silver nitrate - hyponatremia, methemoglobinemia

148 A Silver sulfadiazine - leukopenia

Daikin solution - skin redness, irritation and swelling

149 A
The presence of amyloid confirms that this is a case of medullary
thyroid carcinoma. Since there is the possibility of it to be syndromic
(MEN 2A, MEN 2B), it is important to screen for pheochromocytoma
as this must be treated first. After which, patient should undergo total
150 C thyroidectomy with routine bilateral central neck dissection.

A question on breast ca staging was also asked in the boards

Any size with direct extension to the chest or skin makes this
151 C automatically T4
T4 with less than 3 lymph nodes involved is stage IIIB

Review the table for trauma patients. Even if the patient is

152 A hemodynamically stable, he complains of dysphagia and therefore
should be immediately sent to the OR
Type I - sliding hernia - upward dislocation of cardia
153 D Type II - rolling or paraesophageal hernia
 Achalasia - failure of LES relaxation
Nutcracker esophagus - peristaltic esophageal contraction with peak
amplitudes greater than 2SDs above normal values
154 B Hypertensive LES - elevated basal pressure of LES but with normal
relaxation and normal propulsion of esophageal body

Although vital signs are stable, presence of the following alarm

symptoms would indicate the need for upper endoscopy: weight loss,
155 B recurrent vomiting, dysphagia, bleeding, anemia

Similar question came out

156 A
SMOKING IS NOT CONSIDERED A RISK FACTOR FOR BREAST
157 B CANCER
Indirect hernia - superior or lateral to inferior epigastric vessels
Littre hernia - meckel diverticulum
158 E Grynfelt - passes through the superior lumbar triangle
Petit - passes through the inferior lumbar triangle
What is being described is a transsphincteric fistual

An extrasphincteric fistula originates in the rectal wall and tracks

159 D around both sphincters to exit laterally, usually in the ischiorectal
fossa

Type 1 and 2: Excision with roux-en-y hepaticojejunostomy

Type 3: Sphincterotomy
Type 4: Segmental liver resection
160 B Type 5: Liver transplantation

Similar questions were asked in the boards

161 B IM platinum board correlates

Similar questions were asked in the boards

162 A IM platinum board correlates
Similar questions were asked in the boards
163 C IM platinum board correlates
 Anagen effluvium - occurs after any insult to hair follicle that impairs
its mitotic/metabolic activity such as radiation therapy to the head
and chemotherapy
Telogen effluvium - transient increased shedding of telogen hairs
from resting scalp follicles usually due to a variety of physical of
164 C mental stressor
Alopecia totalis -total loss of terminal scalp hair
Fitzpatricks color atlas 6th ed 973

Alopecia areata is associated with other autoimmune disease and

165 C immunophenotyping of lymphocytic infiltrate around hair bulbs
suggests an anti-hair bulb autoimmune process

A similar question was asked in the boards

Acne is linked to a gram-positive anaerobic rod, Propionibacterium

166 D acnes. It can be exacerbated by iodine which is rich in seafood.
It is NOT caused by chocolate or fatty food

Similar question was also asked in the boards.

Comedonal acne is best treated with retinoids such as adapalene

167 B Fitzpatricks color atlas 6th ed pg 3

The first heart sound coincides with the closure of the mitral and
tricuspid valves, best heard at the apex
168 D Similar question in the boards
The patient falls under category II and should be treated with 2
169 E HRZES/ 1 HRZE/ 5 HRE
In general, infection accounts for about 20-25% of cases of FUO in
Western countries; next in frequency are neoplasms and
noninfectious inflammatory disease. In geographic areas, outside the
west, infections are much more common cause.
170 A Similar question was asked in the boards

Harrisons 19th edition pg 135

Remember that serum uric levels can be normal or low at the time of
an acute attack. It is important to do arhtrocentesis since you note
already erythema and swelling of the joint. You need to identify the
171 C joint aspirate characteristics. If it is inflammatory, the joint should be
considered infected until proven otherwise.

Similar question also came out in the boards. Remember that the first
172 C line for acute gouty attack are NSAIDS (topnotch handout)
 Remember the mnemonic HYPERGLUC - hyper-glycemia, lipidemia,
173 D uricemia, calcemia
Ivabradine - inhibits the funny channels slowing the heart rate
Nicorandil - dilates peripheral and coronary resistance vessels
174 C Ranolazine - inhibits late inward sodium current leading to a shift in
myocardial substrate uptake from fatty acid to glucose

An ischemic stroke > 3 months ago is considered a relative

175 C contraindication
Type IA - arterial spurting
Type 1B - arterial oozing
Type IIA - nonbleeding visible vessel
176 C Type IIB - adherent clot
Type IIC- pigmented flat spot
Type III - no stigmata of recent bleed

Normocytic normochromic anemia is observed in CKD patients as

177 D early stage III and is universal in stage IV patients

178 B
Pleural effusion is a minor critera
Major criteria include: PND or orthoponea, neck vein distention,
179 B rales, cardiomegaly, acute pulmonary edema, s3 gallop, increased
venous pressure > 15cm H20, hepatojugular reflux
BMI is 25.1. if we use the Asian classification, the patient would fall
under Obese type I
180 C A question on BMI was asked in the boards

Compare the lung volumes in pg. 3, topnotch handout

181 A
Hegar's sign - softening of the uterine isthmus
182 B Chadwick sign - violet discoloration of vagina

183 C
Remember Naegel's rule. +7 days - 3 months + 1 year
184 A
Phase 1: quiescence
Phase 2: activation
185 B Phase 3: stimulation
Phase 4: involution
Anterior asynclitism - anterior parietal bone
186 B Posterior asynclitism - posterior parietal bone
1st - vaginal mucosa
2nd - perineal body
187 B 3rd - anal sphincter
4th - rectal mucosa
 Pinard - press popliteal fossa and deliver leg
188 C Loveset- deliver arms

189 D
Similar question came out in the boards.

This is a case of missed abortion and therefore the plan is to ripen

190 D the cervix first and then do D&C

191 A
Plasma levels increase rapidly, doubling every 2 days, with maximal
levels being attained at 8 to 10 weeks
At 10 to 12 weeks, plasma levels begin to decline, and a
192 A nadir is reached by about 16 weeks

Review the table for cervical intraepithelial neoplasia in the topnotch

193 C handout. Several questions were asked regarding this topic
Lymphatic and vascular metastasis- explains the rare and remote
194 C sites of endometriosis, such as the spinal column and nose
Remember that the embryogenic origin of the genital system is
195 E related to the development of the urinary system. 1/3 of Patients with
uterovaginal agenesis also present with renal abnormalities
Day 18 - vacuoles move to the apical portion
196 D Day 19 - cells begin to secrete glycoprotein and
mucopolysaccharides into the lumen

197 C
198 D
199 D
200 B

Acrocyanotic - 1; HR>100 - 2; grimacing - 1; irregular respiration - 1;

201 A active movement - 2
Pustular melanosis - dark macular base containing neutrophils
202 C Neonatal acne - open and closed comedones or inflammatory
pustules and papules
 RDS - ground glass; finely granular
Bronchopulmonary dysplasia - cystic lucencies
Meconium aspiration - coarse streaking granular pattern
203 B Persistent pulmonary hypertension - may be normal but depends on
the case

A similar question came out in the board exams

204 C ABG can be done to check for oxygen saturation gradient between
preductal and postductal
A similar question also came out.

205 D In ABO incompatibility, mother is type O and the baby is either A or B

206 C
Duodenal atresia - double bubble sign
207 A Intussusception - target sign on utz
Volvulus - omega sign of coffee bean sign on chest xray
The history of URTI and normal C3 levels points to IgA nephropathy
208 D
Granular IgG, C3 - APSGN
209 A Linear IgG, C3 - Good pasture
No immune deposits - RPGN
This is a case of hemolytic uremic syndrome and
210 B management is still to continue supportive therapy

Since the patient is < 1 year old, this is stage 4s and the appropriate
211 E course of action is to simply observe
A similar question came out in the boards

Major risk factors for recurrence of febrile seizure:

212 D Age < 1 yr
Duration of fever < 24hr
Fever 38-39C

Antibiotic prophylaxis to prevent n. meningitidis:

Rifampin, Ceftriaxone and Ciprofloxacin
213 A Ciprofloxacin is not given in patients less than 1 month

This is a case of rubella caused by Togavirus

214 B
This is a case of varicella.
215 C
This is a case of measles. The enanthem is termed as Koplik spots
216 C and are found adjacent to the 2nd-3rd lower molar
 Bruton is an x-linked recessive, primary humoral immunodeficiency
characterized by decreased immunoglobulins. It is caused by a
defect in Bruton tyrosine kinase leading to defective maturation of B-
217 D cells.
Usually patients presents after 6 months old (due to decrease in
maternal IgG)

A similar question came out in the boards. Review tanner staging

218 B
Tetralogy of fallot - boot shaped heart
219 B TAPVR- snowman, figure of eigth
CoA - rib notching, inverted E, 3 sign
Intermittent : <4 days per week of <4 consecutive weeks
Persistent otherwise

Moderate-severe - sleep disturbance, impairment of daily activities,

school or work
220 D Make sure to study allergic rhinitis, classification and treatment.
Several questions (around 5-6) came out in the boards

Similar question came out

221 C
222 D
223 B
please review levels of prevention as there were a number of
questions asked. Primordial - addresses broad health determinants;
Primary - specific disease protection and prevents the onset of
224 C disease; Secondary - early diagnosis including screening programs,
tertiary - maximizing optimal level of functioning

a/ (a+c)
225 A = 150/ 200
= 75%
d/ ( d+b)
226 D = 280/ 300
= 93%
a/ (a+ b)
227 C = 150/ 170
= 88%
 d/ (c+d)
228 B = 280/330
= 85%

229 B
230 B
Negatively skewed
231 A Outlying values are small

232 C
Major therapeutic efforts - most challenging and rewarding stage for
233 A the physician

234 E
Infectivity - ability to invade and multiply
Pathogenicity - capacity to induce disease which is clinically apparent
Immunogenicity - ability to induce immunity
235 D Antigenicity - ability to combing specifically with effectors of immune
system

Similar question came out

236 C
All the rest are part of a complete standard water treatment
237 B
Aedes - dengue
Ticks - spotted fever
238 C Tse tse flies - sleeping sickness
Mites - scabies

239 D
240 B