[SEM2] Patho Compre

Question 1

A 50-year-old alcoholic man is picked up by a barangay captain and taken to the emergency department. The captain, who had had previous encounters with this man, was concerned that he seemed particularly lethargic and confused. Stat blood chemistries demonstrate a plasma sodium of 115 mEq/L. The emergency department doctor orders the administration of hypertonic saline; within four hours, the plasma sodium rises to 135 mEq/L. Over the next few days, the patient develops quadriparesis and weakness of the lower face and tongue. These symptoms never resolve. Damage to which one of the following neural structures probably accounts for these findings?
A. Cerebellum
B. Peripheral nerves
C. Spinal cord
D. Cerebral cortex
E. Pons

Answer 1

Question 2

A 40-year-old woman detects a lump in her left breast while taking a shower. She has also had a recent 20-kg weight loss over the past three months. Physical exam finds a firm, fixed, 2 to 3-cm upper outer quadrant mass. Excision biopsy of the mass reveals infiltrating ductal-type cells. Subsequent genetic testing reveals a mutation of the BRCA2 gene. Of the following, what is the location for this mutation?
A. 17q
B. 17p
C. 13p
D. 13q
E. 18p

Answer 2

Question 3

A pathologist receives an orchiectomy specimen from a 27-year-old man. Microscopic examination shows neoplastic cells arranged in a reticular growth pattern with glomerular-like structures composed of a central blood vessel enveloped by atypical large pleomorphic cells with prominent nucleoli floating in a loose myxoid stroma. Which one of the following substances is most likely to be increased in the man’s serum as a result of being secreted from the cells of this tumor?
A. Prostate-specific antigen
B. Beta-human chorionic gonadotropin
C. Alkaline phosphatase
D. Alpha-fetoprotein
E. Acid phosphatase

Answer 3

Question 4

A 29-year-old Asian woman presents for a routine gynecologic exam. Her menstrual cycle is normal and there is no evidence of other bleeding. Her initial laboratory blood test shows hypochromic microcytic anemia with a normal RDW. Her fecal occult blood test is negative. Hemoglobin electrophoresis reveals decreased Hgb A1 with increased Hgb A2 and Hgb F. Which of the following mutations is most likely to be present in the Beta-globin gene of this woman?
A. New stop codon
B. Single base insertion, with frameshift
C. Trinucleotide repeat
D. Splice site
E. Three-base deletion

Answer 4

Question 5

At autopsy, the brain is decreased in weight. There is bilateral symmetrical cortical atrophy involving mainly the frontal, parietal, and temporal lobes. There is ex vacuo cerebral ventricular dilation. Cerebral arteries at the base of the brain show no atherosclerosis. The cerebral cortex microscopically shows numerous neuritic plaques along with neurofibrillary tangles and amyloid angiopathy. These findings are most consistent with which of the following histories?
A. A 48-year-old man with choreiform movements
B. A 30-year-old woman with sudden loss of consciousness
C. A 44-year-old man with progressive muscular weakness
D. A 40-year-old woman with trisomy 21
E. A 2-year-old boy with blindness and decreased neurologic function

Answer 5

Question 6

A 65-year-old African man presents to the clinic with complaints regarding his urine. He states that he has recently had bloody urine, but does not have any urinary pain, hesitation, dribbling, or increased frequency. He also says he has lost 4.5 kg over the past two months. Biopsy of the patient’s bladder wall reveals squamous cell carcinoma. Which of the following risk factors has the strongest association with this patient’s disease?
A. History of heavy cigarette smoking
B. History of pelvic irradiation
C. History of schistosomiasis infection
D. History of cyclophosphamide treatment
E. History of aniline dye exposure

Answer 6

Question 7

A 26-year-old woman presents to her ENT after noticing a neck mass. Physical examination reveals a large thyroid gland that is firm, multinodular, and mobile. Her serum TSH is elevated, but her serum T3 and T4 are low. Her serum antithyroglobulin titer is positive. A thyroid scan reveals non-uniform uptake. A biopsy of the thyroid mass is most likely to reveal which of the following findings?
A. Fibrosis
B. Lymphocytic infiltration
C. Granulomas
D. Neutrophilic infiltration
E. Parafollicular cell hyperplasia

Answer 7

Question 8

A study evaluates the effect of neutralizing Transforming Growth Factor-Beta with a monoclonal antibody in lab rat models treated with thioacetamide (a compound that induces hepatic fibrosis). Comparing the extent of liver fibrosis at two time points, pre- and post-monoclonal antibody dosing, profound regression of tissue injury and fibrosis upon treatment is noted. Which of the following steps in the inflammatory-repair response is most likely affected by the antibody?
A. Production of collagen
B. Migration of epithelial cells
C. Chemotaxis of lymphocytes
D. Leukocyte extravasation
E. Increased vascular permeability

Answer 8

Question 9

A 14-year-old adolescent presents to the clinic for the evaluation of an “annoying” spot on his face. Physical examination finds a hypopigmented spot on his chin that is about 2 cm in diameter. Similar spots are present on his right shoulder, chest, and back. His past medical history is noncontributory. His family history is significant for a father and an aunt with bilateral deafness. Which of the following is the most probable diagnosis in this patient?
A. Neurofibromatosis type 1
B. Neurofibromatosis type 2
C. Tuberous sclerosis
D. Sturge-Weber syndrome
E. Osler-Rendu-Weber syndrome

Answer 9

Question 10

A 65-year-old woman is brought to the emergency department by paramedics after she was involved in a motor vehicle accident. Among her many injuries is a linear tear of her scalp measuring approximately 3.5 cm in length. Small thin strands of tissue are seen crossing this wound. Which of the following is the best term that classifies this lesion?
A. Abrasion
B. Avulsion
C. Contusion
D. Incision
E. Laceration

Answer 10

Question 11

A 42-year-old smoker and alcoholic presents with an abrupt onset of spiking fever, a productive cough with blood-tinged mucoid sputum, and pleuritic chest pain. Physical exam demonstrates dullness to percussion, crepitant rales, and increased tactile fremitus in the right upper lobe. A chest x-ray reveals a lobar consolidation in the right upper lobe. The Gram stain, which was positive, would be expected to show which one of the following?
A. Gram-positive filamentous bacteria
B. Gram-positive cocci in clumps
C. Gram-positive rods with a capsule
D. Gram-negative diplococci
E. Gram-positive rods

Answer 11

Question 12

An in-vitro study uses a monoclonal antibody to investigate the role of a particular protein. Pretreating either the monocytes or the endothelial junctions with the antibody stops transmigration. The study also notes that if the endothelium is first activated by cytokines, the antibody again blocks transmigration of both monocytes and neutrophils. However, the antibody does not stop chemotaxis of either cell. Light and electron microscopy finds the leukocytes remain tightly bound to the apical surface of the endothelial cell, precisely over the intercellular junction. What is the most likely protein being evaluated in the study?
A. CD31
B. Sialyl-Lewis X
C. LFA-1
D. CD34
E. P-selectin

Answer 12

Question 13

A polyp is resected from the proximal portion of the jejunum. Histologically, it consists of glands containing both absorptive and goblet cells supported by a stalk. Within the stalk, there are smooth muscle bundles continuous with the underlying muscularis mucosae. Which one of the following additional features is most likely to be observed in this patient?
A. Innumerable adenomatous polyps of the colon
B. Soft tissue tumors
C. Perioral and perianal pigmentation
D. Osteomas of the mandible and long bones
E. Malignant brain tumors

Answer 13

Question 14

A 22-year-old woman presents with mouth sores, sore throat, vaginal discharge, fever, and myalgia. She has no other medical problems. She takes oral contraceptive pills. She is in a monogamous relationship and states that her partner occasionally uses barrier contraception. Physical examination finds a temperature of 38.3°C, cervical and inguinal lymphadenopathy, exudative pharyngitis, and multiple ulcers on the oral mucosa, the labia, and cervix. The vaginal discharge is profuse, and Gram stain indicates many neutrophils. Which of the following is the most likely diagnosis?
A. Syphilis
B. Lymphogranuloma venereum
C. Chancroid
D. Condyloma acuminatum
E. Herpes simplex virus

Answer 14

Question 15

A 42-year-old man presents with progressive dyspnea on exertion, low-grade fevers, and weight loss over six months. He also is complaining of a primarily dry cough, although occasionally he coughs up a thick mucoid sputum. His past medical history is unremarkable. He does not smoke cigarettes. Physical examination finds him dyspneic with minimal exertion. The patient’s temperature is 37.9°C. Oxygen saturation is 91% on room air at rest. Faint basilar crackles are heard. Laboratory evaluation reveals polyclonal hypergammaglobulinemia and a hematocrit of 52%. A CT scan demonstrates bilateral alveolar infiltrates that are primarily perihilar in nature with a mosaic pattern. Bronchoscopy with bronchoalveolar lavage is done. The effluent appears milky. The cytopathology of the fluid reveals amorphous debris with periodic acid-Schiff-positive macrophages. Which of the following substances is most likely involved in the pathogenesis of this man’s condition?
A. Chloride channel protein
B. GM-CSF
C. Neutrophilic myeloperoxidase
D. Glomerular basement membrane
E. DNA topoisomerase I

Answer 15

Question 16

A total stapedectomy is done for treatment of otosclerosis in a 45-year-old man. Which one of the following histologic changes is most likely to be present?
A. No changes: Pathologic changes are limited to otic capsule
B. New woven bone formation in the footplate
C. New woven bone formation in the crura
D. Extensive osteolysis of the footplate
E. Spongiosis and formation of large marrow cavities

Answer 16

Question 17

A 45-year-old woman presents to the clinic with marked swelling of her hands. Five years previously, she had developed multiple arthralgias, and early rheumatoid arthritis was suspected; however, no confirmatory immunologic studies had been done at that time. Since then, she has experienced difficulty swallowing and mild dyspnea on exertion. Physical examination finds hands that are strikingly swollen, producing a sausage-like appearance to the fingers. Other findings include erythematous patches over the knuckles, a mild malar rash, and slight violaceous discoloration to the eyelids. No joint deformity is noted, although many joints are tender. A chest X-ray film demonstrates diffuse interstitial infiltrates. In antibody studies, high titers of antibodies directed against which of the following antigens will most likely be present?
A. dsDNA
B. SCL-70
C. c-ANCA
D. RNP
E. p-ANCA

Answer 17

Question 18

A 19-year-old woman presents with a swollen lip for one year. General examination finds lobulated nodules in her left palm and thumb. Further examination notes multiple skin-colored flat papules (trichilemmomas) on her face involving the bridge of her nose, forehead region, and on the upper lip measuring around 1-5 mm in diameter. Her lower lip showed multiple non-tender papular growths (1-3 mm in diameter) clustered at certain places. Which one of the following genes is most likely mutated in this case?
A. PTEN
B. PTCH
C. TSC1
D. ATM
E. MSH2

Answer 18

Question 19

A 25-year-old woman presents with increasing fatigue and malaise. She says she recently developed a red facial rash whenever she goes outside on a sunny day. Physical exam finds her afebrile, but with slightly increased BP and slight peripheral edema. Lab tests reveal slightly elevated BUN and creatinine, while dipstick exam of her urine shows slight proteinuria with microscopic hematuria. Very rare granular and red cell casts are noted. Her result for serum antinuclear antibodies (one of which is anti-dsDNA) reads positive. Kidney biopsy is done, and microscopic examination shows increased mesangial, epithelial, endothelial, and inflammatory cells in more than 50% of glomeruli. Some of the affected glomeruli exhibit epithelial crescents. What is the morphologic classification for this case?
A. Class IV
B. Class II
C. Class I
D. Class V
E. Class III

Answer 19

Question 20

A 31-year-old woman who is at 30 weeks of gestation presents to the emergency room with vaginal bleeding and painful abdominal cramps. Her blood pressure is 120/80 mm Hg. Urinalysis reveals no protein, leukocytes, or bacteria with few RBCs. Peripheral blood examination shows a decreased number of normocytic, normochromic RBCs with many schistocytes. Which of the following is the most likely diagnosis?
A. Abruptio placentae
B. Amniotic fluid embolism
C. Hydrops fetalis
D. Placenta previa
E. Preeclampsia

Answer 20

Question 21

A 26-year-old man presents with a hard, painless, testicular mass. At operation, frozen section reveals testicular cancer. Final histopathology of the mass would most likely reveal which of the following findings?
A. Numerous lymphocytes in the fibrous stroma between groups of tumor cells with distinct cell membranes and clear cytoplasm
B. Abnormal tissue derived from all three germ levels with scattered immature neural elements
C. A mixture of malignant cytotrophoblasts and syncytiotrophoblasts
D. Sheets of undifferentiated tumor cells having focal glandular differentiation
E. Large tumor cells with abundant eosinophilic, granular cytoplasm, and rare intracytoplasmic rhomboid crystals

Answer 21

Question 22

An 83-year-old man is hospitalized for a recent history of dyspnea, cough, and dyspepsia. His medical history reveals sigmoidectomy and ileal-cecal resection for two synchronous adenocarcinomas a year ago; hormonotherapy and radiotherapy for prostate adenocarcinoma two years ago; and tumor resection for a basal cell carcinoma and squamous cell carcinoma ten years ago. For the past 25 years, he had noted multiple asymptomatic skin lesions on his face and trunk, and these had recently increased in size and number. If a biopsy was done on these lesions, what would be the most likely histopathologic finding?
A. Pseudocysts with orthokeratin
B. Dyskeratosis
C. Pautrier microabscesses
D. Invasive nests of basaloid cells
E. Atypical melanocytes

Answer 22

Question 23

An 80-year-old man has a large infarct involving most of the left ventricular free wall. He develops congestive heart failure (CHF) with reduced cardiac output. A year later, his CHF worsens. Echocardiography reveals a large, bulging akinetic area typical for a left ventricular aneurysm. Which one of the following laboratory results would best indicate poor peripheral tissue perfusion in this patient? An increase in:
A. Sedimentation rate
B. Troponin I
C. Lactate
D. Sodium
E. Hematocrit

Answer 23

Question 24

A 40-year-old stonecutter presents with progressive shortness of breath for ten years, dry cough, and generalized weakness for seven months. Past medical history reveals that he received 9-months of anti-TB drugs 5 years back without significant improvement. Chest x-ray finds bilateral mottled opacities and a large nodular mass in the right upper and mid zones. His respiratory problems are most likely to be mediated through which of the following inflammatory processes?
A. Foreign body giant cell formation
B. Neutrophilic infiltrates producing leukotrienes
C. Macrophage elaboration of cytokines
D. Mast cell histamine release
E. Plasma synthesis of immunoglobulins

Answer 24

Question 25

A lobulated tumor is removed from the third proximal phalanx of a 25-year-old patient. Histologically, it consists of mature cartilage with a lobular architecture. The tumor expands from the metaphyseal bone and produces thinning of the cortex. If the patient had numerous tumors such as this one and a soft tissue hemangioma, what would be his condition? A. Gardner syndrome B. Maffucci syndrome C. Ollier disease D. Albright syndrome E. Osteochondromatosis

Answer 25

Question 26

A 58-year-old man presents with fatigue. Physical examination is unremarkable except for the presence of splenomegaly. A CBC shows a hematocrit of 29%, platelet count of 90,000/microliter, white blood cell count of 2,700 per microliter, and an essentially normal red cell morphology (differential: 12% monocytes, 12% granulocytes, 76% lymphocytes). A bone marrow aspiration is carried out. The aspirate is noted to be "dry," and the biopsy results are pending. Which of the following is the most likely diagnosis based on the available information of this case? A. Multiple myeloma B. Myelofibrosis C. Chronic myeloid leukemia D. Chronic lymphocytic leukemia E. Hairy cell leukemia

Answer 26

Question 27

MRL-lpr/lap (Lupus) mice are susceptible to autoimmune diseases, making them useful for biomedical research. These mice are characterized by a defect in the fas gene and a marked increase in T lymphocyte accumulation when compared with wild-type animals. Based on these findings, which of the following could be the cause of increased susceptibility of these mutants to autoimmune diseases? A. Decreased responsiveness to clonal deletion signals in the thymic cortex B. Decreased cell cycle transit time in activated T lymphocytes C. Increased responsiveness of the mature T lymphocytes to antigenic stimulation D. Increased thymocyte proliferation rate in the thymic cortex E. Decreased dependence on antigen presenting cells for T lymphocyte activation

Answer 27

Question 28

A 40-year-old man presents to the emergency room because of exertional dyspnea of recent onset. The patient appears comfortable at rest but says that he becomes short of breath with minimal effort. His temperature is 37°C, blood pressure is 160/65 mmHg, pulse is 92/min with a rapid rise and fall, and respirations are 15/min. Chest examination finds a prominent and laterally displaced apical impulse. A soft diastolic decrescendo murmur is heard along the left sternal border. Bilateral crackles are present at the lung base. The liver is not palpable, and there is no sign of peripheral edema. Which of the following is the most likely diagnosis? A. Aortic insufficiency B. Aortic stenosis C. Infective endocarditis D. Mitral stenosis E. Ventricular septal defect

Answer 28

Question 29

A 32-year-old woman is brought to the emergency room due to acute shortness of breath. A helical CT scan shows no evidence of pulmonary embolism, but an incidental finding of 4.3-cm dilatation of the ascending aorta is noted. All the following are associated with this finding, except: A. Systemic lupus erythematosus B. Takayasu's arteritis C. Rheumatoid arthritis D. Syphilis E. Marfan syndrome F. Spondyloarthropathies

Answer 29

Question 30

A 10-year-old boy presents with balance and night vision difficulty. He has had foul-smelling stools and failure to thrive as an infant. Physical exam demonstrates poor muscle coordination, ataxia, and decreased proprioception and vibration sense. Laboratory evaluation shows decreased total cholesterol and Vitamin E levels. Which one of the following is most likely mutated causing the boy’s condition? A. 7-alpha hydroxylase B. Lipoprotein lipase C. Hormone-sensitive lipase D. MTP E. LCAT

Answer 30

Question 31

A 19-year-old man comes to the outpatient department complaining of frequent headaches. He plays basketball on weekends but over the last three months he has noticed decreased exercise tolerance due to shortness of breath. He describes lower extremity swelling. His BP is 210/120 mmHg and his heart rate is 85/min. Which of the following is the most likely cause of this patient's condition? A. Adrenal cortical tumor B. Renal artery stenosis C. Renal parenchymal disease D. Adrenal medullary tumor E. Congenital heart abnormality

Answer 31

Question 32

A 20-year-old man develops purpura, fever, and hematuria after penicillin treatment for a streptococcal infection. Skin and renal biopsies show vasculitis involving arterioles and venules. Multifocal microscopic hemorrhages and glomerular necrosis are also noted. Antineutrophil cytoplasmic antibodies of the perinuclear type (p-ANCA) are present. No immune deposits are identified in skin or kidney biopsies. These clinical, laboratory, and pathologic features are most consistent with which of the following conditions? A. Microscopic polyangiitis B. Polyarteritis nodosa C. Granulomatosis with polyangiitis D. Rheumatic disease E. Henoch-Schönlein purpura

Answer 32

Question 33

A 28-year-old woman presents with “trouble with her vision”. Physical exam reveals a very tall, thin woman with long, thin fingers. Examining her eyes reveals the lens of her left eye to be in the anterior chamber. Her blood levels of methionine and cystathionine are within normal levels. Which of the following is the most likely cause of this patient’s signs and symptoms? A. Abnormal copper metabolism B. Decreased levels of vitamin D C. Defective synthesis of fibrillin D. Decreased lysyl hydroxylation of collagen E. Defective synthesis of type I collagen

Answer 33

Question 34

A 49-year-old man who worked in coal mines most of his life has severe dyspnea and a productive cough with numerous dust cells present in the sputum. Refer to the schematic of the respiratory unit of the lung. Which of the following areas of the lung would exhibit evidence of this man's disease? A. Area A only B. Area B only C. Area C only D. Areas A, B, and C E. Areas B and C

Answer 34

Question 35

A 53-year-old man with a history of worsening difficulty breathing that has developed over one year finally presents these changes to his primary physician. He has a past medical history of systemic hypertension, treated with an ACE inhibitor, and type 2 diabetes mellitus, which developed three years ago, and is treated by dietary restrictions. He is an accountant and raises pigeons for a hobby. He has never smoked. His vital signs are temperature of 37.1°C, pulse of 101 bpm, respiratory rate of 20 breaths per minute, and blood pressure of 110/68 mm Hg. Physical exam finds diffuse crackles. There is no pitting edema or jugular venous distention. Pulmonary function testing reveals a decreased FVC, and an FEV1/FVC ratio that is essentially normal. Of the following, what would biopsy of the lung be most likely to reveal? A. Alveolar airspaces filled with neutrophils B. Alveolar septal fibrosis and hemosiderin-laden macrophages C. Infiltrating small neoplastic cells D. Essentially all alveolar airspaces filled with pigment-laden macrophages E. Small granulomas scattered throughout the biopsy in the alveolar septa

Answer 35

Question 36

A 37-year-old Caucasian woman presents to an OPD clinic. Over the past week, she has developed abdominal pain and noticed that the whites of her eyes and skin are yellow. She also has fatigue and malaise. Her past medical history includes Hashimoto’s thyroiditis, for which she takes hormone replacement. Her vital signs are a temperature of 37°C, pulse of 74 bpm, and blood pressure of 101/67 mm Hg. Physical exam finds mild hepatomegaly and scleral icterus. Laboratory testing reveals ALT of 430 U/L, AST of 389 U/L, total bilirubin of 6.7 mg/dL (N: 0.1-1.2 mg/dL), and direct bilirubin of 2.3 mg/dL. The physician also orders serum IgG, which is 2,130 mg/dL (N: < 200 mg/dL). She reports no alcohol use or intravenous drug use. Given this clinical scenario, of the following, what laboratory test is likely to be positive? A. Anticentromere antibodies B. Anti–cyclic citrullinated peptide antibodies C. Anti-Jo-1 antibodies D. Anti-liver, kidney microsome 1 antibodies E. Anti–topoisomerase I antibodies

Answer 36

Question 37

A 21-year-old woman presents to the emergency department with a sudden onset of abdominal pain and ascites. Her history is remarkable for multiple bacterial infections and recurrent venous thrombosis over several years. Her review of systems reveals occasional passage of dark urine. Her CBC shows anemia, reticulocytosis, leukopenia, and thrombocytopenia. Imaging studies show hepatic vein thrombosis. A mutation affecting which of the following gene products is most likely to give rise to her condition? A. Phosphatidylinositol glycan A B. Spectrin C. Beta-globin chain D. Glucose-6-phosphate dehydrogenase E. Factor V

Answer 37

Question 38

An infant girl born at term to a 29-year-old woman has dorsal feet and hand edema, short webbed neck, and a cardiac murmur. Buccal smear reveals no Barr body. The mother is concerned about the recurrence risk of such an anomaly in subsequent pregnancies. Which of the following is the best response? A. The recurrence risk is approximately 50% B. The risk increases with maternal age C. The recurrence risk is close to 25% D. The recurrence risk is close to 10% E. The recurrence risk is close to that of the general population

Answer 38

Question 39

A 53-year-old man, who has a history of chronic alcohol abuse, had bouts of abdominal pain in the past year. For the past month, he has had more frequent and worsening abdominal pain. Physical examination demonstrates right upper and left upper quadrant pain with guarding. Abdominal plain film radiograph shows no free air, but there is extensive peritoneal fluid collection along with dilated loops of small bowel. An abdominal CT scan reveals a 7-8 cm cystic mass in the pancreatic tail. Which one of the following is the most likely diagnosis? A. Pancreatic pseudocyst B. Pancreatic adenocarcinoma C. Pancreatic endocrine tumor D. Metastatic carcinoma E. Serous cystadenoma

Answer 39

Question 40

Molecular analysis of a truncal tumor widely excised from a 47-year-old patient reveals a fusion gene that involves COL1A1 and PDGFB. Microscopic findings of this tumor would most likely reveal which of the following histopathologic findings? A. Basaloid cell nests with peripheral nuclear palisading surrounded by a myxoid stroma B. Papillomatous epidermal hyperplasia with marked overlying hyperkeratosis C. Localized proliferation of dermal spindle cells associated with pseudoepitheliomatous hyperplasia D. Storiform pattern of dense spindle cells infiltrating the dermal adipose tissue E. Islands of small basaloid cells with papillary fronds within a fibrotic stroma

Answer 40

Question 41

A 12-year-old boy is brought to the clinic due to pain in his right leg for the past three weeks. The pain frequently occurs at night and is localized to the tibia, a few centimeters below the knee. The mother reports that the pain is promptly relieved by aspirin and that the child has had no fever. Examination reveals no tissue swelling or redness about the site of pain. X-ray films reveal a 1-cm radiolucent focus in the tibial cortex surrounded by marked bone sclerosis. Biopsy of this bone lesion would most likely show which of the following findings? A. Small cells in a pale matrix with a light-blue tinge B. Small round blue cells C. Anastomosing bony trabeculae with osteoblastic rimming D. Benign spindle cells and multinucleated giant cells E. Malignant cells surrounded by delicate strands of osteoid

Answer 41

Question 42

A 36-year-old man with no significant past medical history complains of six weeks of abdominal pain, watery diarrhea, and heartburn. He reports that the two-week treatment of a proton-pump inhibitor "didn't seem to work". He has no anorexia but has lost ten pounds. He is on no medications currently, does not smoke cigarettes, and does not consume alcohol. Endoscopy reveals prominent gastric folds and three duodenal ulcers. Fasting serum gastrin is elevated. Increase in serum gastrin 15 minutes after intravenous infusion of secretin is noted. This patient's condition is most likely caused by which one of the following conditions? A. Chronic gastritis with antral sparing B. Chronic antral-predominant gastritis C. Peptic ulcer disease D. Non-gastric neoplasm E. Stress-related mucosal erosions

Answer 42

Question 43

A 35-year-old woman gives birth to a baby girl. Examination of the baby notes respiratory difficulty, “floppiness” with weak cry, and talipes (club foot). Further review of the mother’s chart notes polyhydramnios on her antenatal ultrasound. Examination of the mother finds lack of facial expression and weak muscles; she denies any health problems as an infant or child. Which of the following best explains the difference in presentations in the mother and baby? A. Pleiotropy B. Anticipation C. Genetic heterogeneity D. Incomplete penetrance E. Delayed onset

Answer 43

Question 44

A 58-year-old woman presents with increasing fatigue and left upper quadrant abdominal pain. Abdominal exam detects a markedly enlarged spleen. No lymphadenopathies are noted. Her CBC shows normocytic normochromic anemia. Peripheral blood exam shows myelocytes, nucleated red blood cells, and teardrop-shaped red blood cells. Bone marrow aspiration resulted in a “dry tap”. The bone marrow biopsy shows hypocellularity and fibrosis (reticulin is markedly increased in amount). The peripheral leukocyte alkaline phosphatase score is normal. Which one of the following clinical findings is most likely present in this patient? A. Sequestration of neutrophils B. Increased total protein in the serum C. Extramedullary hematopoiesis in the spleen D. Multiple lytic lesions in the skull E. Multiple black stones in the gallbladder

Answer 44

Question 45

A 28-year-old woman has had hypertension for two years that is difficult to control. She has been on increasing amounts of medication since her time of diagnosis of hypertension two years ago. Her current medications include a beta-blocker, an angiotensin-converting enzyme inhibitor, centrally acting alpha-agonist hypotensive agent, and a calcium channel blocker. Physical examination finds no signs of distress. Her blood pressure is 170/100 mmHg, and her heart rate is 83 beats per minute. Her physical examination demonstrates normal cardiac findings, good peripheral pulses, and absence of edema. Her laboratory test shows a potassium of 2.8 mEq/L, serum bicarbonate of 32 mEq/dL, and a fasting blood glucose of 114 mg/dL. Further testing of which of the following would be most helpful in diagnosing this woman's condition? A. 24-hour urine collection for metanephrines B. Plasma aldosterone/renin ratio C. MRI of the renal arteries D. 24-hour urine collection for cortisol E. Renal vein renin levels

Answer 45

Question 46

A 30-year-old man with an abdominal gunshot wound undergoes surgery. While repairing the small intestine, the surgeon notices a 1-cm circumscribed submucosal mass in the ileum. The lesion is resected and on gross examination shows a firm, yellow-tan cut surface. Microscopic examination of the mass reveals nests of cells with uniform small round nuclei and cytoplasm with small purple granules. The cytoplasm is immunoreactive to chromogranin. Which one of the following pathologic findings is most likely to accompany this man's lesion? A. Inflammatory bowel disease B. Multiple gastric ulcerations C. Another similar lesion D. Liver metastasis E. Tropheryma whippelii infection

Answer 46

Question 47

A 65-year-old man presents to the clinic with progressive severe shortness of breath, weight loss, and left chest pain. Chest examination reveals dullness to percussion and diminished breath sounds over the left hemithorax. A chest x-ray film shows irregular nodular thickening of the visceral pleura, with partial obliteration of the pleural sac and most pleural effusion. The underlying lung parenchyma is minimally involved. Cytologic examination of the pleural effusion is positive for malignant cells. Which of the following is the most likely predisposing factor for this patient's condition? A. Cigarette smoking B. Occupational asbestos exposure C. Occupational coal exposure D. Occupational silica exposure E. Prior radiation therapy

Answer 47

Question 48

A 56-year-old man has a slow-growing mass involving the right parotid region that he has noticed for the past year. For several months he has experienced pain in this area. Surgical excision is done, and the mass is 4 cm in diameter and found to be invading surrounding structures, including the facial nerve. This neoplasm is probably a(an): A. Adenoid cystic carcinoma B. Squamous cell carcinoma C. Lymphomatous papillary cystadenoma D. Pleomorphic adenoma E. Metastatic laryngeal carcinoma

Answer 48

Question 49

A new mother calls her obstetrician to say that she is having trouble breast-feeding. She is unable to produce enough milk to sate her baby even though her breasts are aching with stored milk. What is the name of the specialized intracellular organelle where the hormone this patient is lacking is stored? A. Birbeck granules B. Ferruginous bodies C. Herring bodies D. Lewy bodies E. Negri bodies

Answer 49

Question 50

A 22-year-old woman presents to your clinic with urinary frequency, urgency, and burning. She is sexually active with her live-in partner and she states that she felt pain during intercourse occasionally over the past three days. All of her symptoms began three days ago. Her last normal menstrual period is three weeks ago. She is afebrile and hemodynamically stable. Physical exam finds mild suprapubic tenderness. No cervical discharge or cervical motion tenderness is noted. The rest of her physical findings is unremarkable. Urinalysis shows positive leukocyte esterase, positive nitrites, and 50+ white blood cells /hpf. You decided to give her Bactrim. What is the most appropriate additional laboratory test to perform prior to starting treatment of her condition? A. Urine Beta-hCG B. Complete blood count C. Serum G6PD level D. Urine culture E. Gonorrhea and chlamydia screening

Answer 50

Question 51

A 40-year-old woman presents to the clinic with three weeks of weakness, lethargy, and depressed mood. She notes increasing difficulty with climbing stairs, rising from a chair, and combing her hair. She has no difficulty buttoning her blouse or writing. The patient also notes some dyspnea on exertion and orthopnea. She denies rash, joint aches, or constitutional symptoms. She has no medications, and the past medical history is otherwise noncontributory. The family history is notable only for coronary artery disease. Physical examination finds an elevated jugular venous pressure, and S3, and some bibasal crackles. The neurologic examination shows some marked proximal muscle weakness in the deltoids and biceps and hip flexors. Distal muscle strength is normal. Sensory examination and reflexes are normal. Laboratory tests are unremarkable except for a negative antinuclear antibody screen and a creatinine kinase of 3,200 IU/L. An autoimmune myopathy is suspected. The following may occur with this patient's condition, except: A. An increased incidence of malignancy B. Interstitial lung disease C. Dilated cardiomyopathy D. Dysphagia E. Raynaud's phenomenon

Answer 51

Question 52

A 29-year-old woman comes to her primary care physician for the evaluation of infertility. She has been trying to conceive for the last two years. She complains of pain during her menses and sexual intercourse. She is in a monogamous relationship with her husband. She does not use any prescription or illicit drugs. Her family history is insignificant. Her vital signs are within normal limits. Pelvic examination finds a tender posterior fornix. The rest of the physical examination is unremarkable. Which of the following conditions is this patient at risk of having? A. Heart failure B. Intestinal obstruction C. Cervical cancer D. Breast cancer E. Premature ovarian failure

Answer 52

Question 53

A 35-year-old man presents with acute, severe abdominal pain. Physical examination demonstrates hyper-extensible skin, hypermobile joints, and prominent venous markings that are easily seen through his abnormal skin. Work-up discovers that his acute abdominal pain is due to spontaneous rupture of his colon. Molecular testing identifies a COL3A1 mutation. What is the most likely mode of inheritance in this case? A. X-linked recessive B. Mitochondrial C. Autosomal recessive D. Autosomal dominant E. X-linked dominant

Answer 53

Question 54

A 3-year-old Caucasian girl presents with rectal prolapse. She is noted to be in the less than 5th percentile for weight and height. The parents also note that she has a foul-smelling bulky stool each day that “floats”. They also report that the child has developed a repetitive cough over the last few months. The girl’s most likely genetic disorder is due to a mutation located in which chromosome? A. 7 B. 11 C. 13 D. 15 E. 22

Answer 54

Question 55

A 35-year-old man presents to the clinic with complaints that solid food "sticks in the chest". He says that he has to chew food more carefully, take more liquids with meals, and swallow small portions. He recalls having a similar episode several months ago that got better after "following a diet", but it was much less severe. He has periodic chest pain behind the sternum for the last several years. He denies any recent significant weight loss, abdominal pain, nausea, vomiting, diarrhea/constipation, black stools, and neck lumps. He smokes one pack of cigarettes daily and consumes alcohol occasionally. Which of the following is the most likely diagnosis in this patient? A. Esophageal stricture B. Barrett's esophagus C. Achalasia D. Esophageal squamous cell carcinoma E. Esophageal adenocarcinoma

Answer 55

Question 56

A 40-year-old woman presents with a right breast mass and a firm nontender right axillary node. Excision biopsy of the breast mass came back as invasive ductal carcinoma. The patient undergoes mastectomy with axillary lymph node dissection. Flow cytometric analysis of the node reveals polyclonal population of CD3+, CD19+, CD20+, and CD68+ cells with no aneuploidy or increased in S phase. Histopathologic exam of the node would most likely show which of the following findings? A. Plasmacytosis B. Acute lymphadenitis C. Necrotizing granulomas D. Sinus histiocytosis E. Metastatic invasive ductal carcinoma

Answer 56

Question 57

A 70-year-old woman presents to the gynecologic clinic with a pruritic vulvar lesion that is white, flaky, slightly roughened, and has focal areas of ecchymoses from scratching. Biopsy report of the lesion states: "There is thinning of the squamous epithelium without any evidence of squamous atypia. The underlying dermis is composed of hypocellular collagenous tissue without any adnexal structures." These findings are consistent with which of the following diagnoses? A. Lichen sclerosis B. Paget's disease of the vulva C. Vulvar intraepithelial neoplasia grade III D. Pseudoepitheliomatous hyperplasia E. Squamous cell carcinoma

Answer 57

Question 58

A 65-year-old man presents with weakness, weight loss, and bone pain. He reports having progressive difficulty seeing. Physical exam is pertinent for hepatosplenomegaly and lymphadenopathy. Serum protein electrophoresis reveals an M-protein spike, with an elevated serum IgM level. Bone marrow aspiration shows intensely eosinophilic plasma cells. Urine contains Bence-Jones proteins. Which one of the following is the most likely diagnosis? A. Plasmacytoma B. Waldenström macroglobulinemia C. Monoclonal gammopathy of undetermined significance D. Heavy chain disease E. Multiple myeloma

Answer 58

Question 59

A 7-year-old girl is being evaluated for growth retardation and soft bones. A bone biopsy reveals a relative excess of woven bone with wide osteoid seams. Increased dietary cholecalciferol has no effect on her signs and symptoms. Which of the following enzymes is most likely to be deficient in this girl? A. 1-α-hydroxylase B. 5-α-reductase C. 7-α-hydroxylase D. 11-hydroxylase E. 21-hydroxylase

Answer 59

Question 60

A 17-year-old girl with a history of seizures and mental retardation has a 3-month history of abdominal pain and a recent onset of fever and nausea. Examination finds hypomelanotic macules and ash leaf spots. Abdominal MRI reveals a right kidney mass. Histopathology of this mass would most likely reveal which of the following findings? A. Uniform cells with clear cytoplasm containing glycogen and lipid B. Large cells with prominent eosinophilic cytoplasm containing numerous mitochondria C. Groups and sheets of transitional epithelial cells D. Muscle-like tissue and adipose tissue with prominent muscular blood vessels E. Immature tubules and abortive glomerular formation

Answer 60

Question 61

A 25-year-old man presents with cervical node enlargement. Biopsy of the affected lymph node shows effacement of lymph node architecture by a nodular growth, a thin rim of compressed normal node, and a predominantly small lymphocytic population with admixed histiocytes and scattered large cells. The large cells are immunoreactive for CD45 and CD20 and negative for CD15. One cell with features of Reed-Sternberg cells is identified in two histological sections. What is most likely diagnosis for this case? A. Mixed-cellularity Hodgkin lymphoma B. Lymphocyte-predominant Hodgkin lymphoma C. Lymphocyte-rich classic Hodgkin lymphoma D. Lymphocyte-depleted Hodgkin lymphoma E. Nodular-sclerosing Hodgkin lymphoma

Answer 61

Question 62

A 32-year-old Indian expat presents to the clinic with a four-week history of fatigue, low-grade fever, and bilateral ankle arthritis. Her medical history is significant for periodic headaches, for which she takes acetaminophen. Enlarged cervical lymph nodes are noted on examination. A lymph node biopsy reveals non-caseating granulomas. Which of the following is the most likely additional finding in this patient? A. Facial palsy B. Hepatosplenomegaly C. Elevated serum calcium level D. Maculopapular rash E. Bilateral hilar adenopathy

Answer 62

Question 63

A 42-year-old woman presents to her family physician complaining of abdominal pain. She states that she has had the pain on and off for about one year. The pain usually comes on after a meal, increases in intensity for a few minutes, and then subsides after about an hour or two. Occasionally, she feels nauseated. She has been married for 20 years and has five children. Her vital signs are a temperature of 37.1°C, blood pressure of 132/82 mm Hg, and pulse of 82 bpm. Physical exam finds her obese (weight of 230 lbs). Her conjunctivae are not discolored. Her chest is clear to auscultation, and the heart has a regular rate and rhythm. Abdominal exam demonstrates vague right upper quadrant abdominal pain. Pathologic examination of her affected organ would reveal which of the following? A. Epithelium down-pouching into the muscularis B. Extensive neutrophilic infiltrate in the wall C. Invasive neoplastic glandular epithelium D. Extensive eosinophilic infiltrate in the wall E. Squamous metaplasia of the epithelium

Answer 63

Question 64

A 30-year-old woman presents with a rapidly enlarging single, stony hard, palpable 2.5-cm nodule in her thyroid gland. Thyroid scan of the nodule is reported to be "cold". Resection of the thyroid gland with subsequent pathologic examination reveals the nodule to contain follicular structures, some of which have inwardly protruding fibrovascular branching cores covered by epithelial cells. Many of the epithelial cells have clear and ground glass nuclei. Which of the following is a recognized risk factor for this lesion? A. Hashimoto thyroiditis B. Radiation to the neck C. Amiodarone treatment D. Dietary iodine supplementation E. Family history of multiple endocrine neoplasia

Answer 64

Question 65

A 16-year-old patient with acute lymphocytic leukemia receives whole-body radiation in preparation for a bone marrow transplant. Which one of the following cells and tissues is most likely to remain unchanged by the effects of radiotherapy? A. Primary ovarian follicles B. Small intestinal epithelium C. Erythropoietic bone marrow cells D. Cerebral cortex neurons E. Spermatogonia of testicular tubules

Answer 65

Question 66

A 38-year-old woman develops an erythematous papule on her right lower leg that becomes a ring-like rash and then subsides over several weeks. Five months later, she develops migratory joint and muscle pain, substernal chest pain, and irregular heart rhythm. These problems subside. However, two years after the onset of the rash, she develops chronic arthritis of her hips, knees, and shoulders. How did she get this condition? A. Tick bite B. Multiple unprotected sex C. Wading in flooded waters D. Assassin bug bite E. Mosquito bite

Answer 66

Question 67

A 21-year-old man is combative when police arrive at a house from which the neighbors heard screaming and breaking of glass for the past hour. He collapses. He is rushed to the hospital, requiring resuscitation with defibrillation en route to try and establish a normal cardiac rhythm. Physical exam shows the following vital signs: temperature 40°C, respirations 36/minute, heart rate 110/minute, and blood pressure 175/90 mm Hg. His pupils are dilated. He expires within an hour. Autopsy finds no signs of major trauma. Which of the following drugs of abuse is most likely to produce these findings? A. “Speed” B. “Crack” C. Ethanol D. “Ecstasy” E. “Pot”

Answer 67

Question 68

A 25-year-old woman with acute onset of lower abdominal pain and excessive vaginal bleeding passed a cast of tissue composed of clot material when she went to the bathroom. Histologic exam of the tissue shows blood clot decidualized tissue, but no chorionic villi or trophoblastic tissue are present. Based on these findings, the patient most likely has: A. A possible ectopic pregnancy B. A normal menstrual period with excess clot material C. A hydatidiform mole D. Endometrial hyperplasia E. Aborted an intrauterine pregnancy

Answer 68

Question 69

A 35-year-old man presents with jaundice and pruritus. His skin is diffusely yellow on physical examination. Laboratory tests reveal markedly elevated serum levels of alkaline phosphatase, but neither antinuclear nor antimitochondrial antibodies are noted. Liver biopsy shows reactive hepatocytes and fibrosis in the sinusoids. The portal tracts show marked fibrosis around the bile ducts, but no granulomas are seen. While waiting for a liver transplant, he develops cancer and expires. Which of the following cancers is most closely associated with his liver disease? A. Pancreatic carcinoma B. Gallbladder carcinoma C. Cholangiocarcinoma D. Hepatocellular carcinoma E. Gastric carcinoma

Answer 69

Question 70

A 23-year-old Caucasian expat presents to your clinic at eight weeks of gestation for routine prenatal counseling. She states that her husband has hemophilia A. Her family history is insignificant. She is worried about the possibility of her children having hemophilia A. Which of the following is the best response in this case? A. The probability of the hemophilia for the child is close to 25%. B. The risk is difficult to estimate because the inheritance is polygenic. C. The probability of hemophilia for the child is close to 50%. D. The probability of hemophilia for the child is close to that of the general population. E. The probability of having the disease is influenced by the gender of the child.

Answer 70

Question 71

A 60-year-old woman has decreasing vision because of deepening of the optic cup with excavation. The optic nerve fibers appear atrophic. The disease that led to these findings should have been detected by screening for which one of the following? A. Elevated blood pressure B. Increased intraocular pressure C. Elevated serum glucose D. Homocystinuria E. Hypercholesterolemia

Answer 71

Question 72

A 70-year-old woman with severe osteoporosis presents for evaluation of shortness of breath. She is a lifetime nonsmoker and has had no exposures. Physical examination, however, finds marked kyphoscoliosis. All of the following pulmonary abnormalities are expected, except: A. Restrictive lung disease B. Alveolar hypoventilation C. Ventilation-perfusion abnormalities with hypoxemia D. Pulmonary hypertension E. Obstructive lung disease

Answer 72

Question 73

An animal study developed mouse models to evaluate the role of a murine gene that encodes upstream stimulatory factor 2 (USF2). Massive tissue iron overload among Usf2 knock-out mice was noted. The genes responsible for the abnormal iron homeostasis were sought out and a peptide was eventually isolated. Subsequently, another study finds severe hyposidermia and anemia among transgenic mice that constitutively expressed the peptide. What is this peptide that is thought to reduce the availability of iron and account for anemia associated with chronic illness? A. C-reactive protein B. Serum amyloid A protein C. Fibrinogen D. Transferrin E. Hepcidin

Answer 73

Question 74

A 30-year-old woman presents with progressive hearing loss and pain in the right ear. MRI shows a middle ear mass, which is removed. Microscopy demonstrates that the tumor is composed of nests of cells, which are immunoreactive for synaptophysin but negative for keratin and epithelial membrane antigen. S-100 and glial fibrillary acidic protein immunohistochemistry is negative, except for a few scattered cells. What is the most likely diagnosis of this tumor? A. Metastatic squamous cell carcinoma B. Meningioma C. Paraganglioma D. Lymphoma E. Neurofibroma

Answer 74

Question 75

A 25-year-old woman consults her doctor due to lesions in her mouth that she noticed recently. Physical examination demonstrates facial asymmetry and lowered left ear. Further history reveals that she had eight surgeries on her face that involved the left facial nerve. Further examination notes light brown macules on the skin of her trunk. Oral examination finds three masses on the left side of her palate and sublingual area. The most likely gene involved in this woman’s case produces what protein product? A. Ras GTPase activating protein B. Cyclin-dependent kinase inhibitor 2A C. DNA repair protein D. E2F inhibitor E. Anti-apoptotic protein

Answer 75

Question 76

A 60-year-old man notes blood in his urine for the past week. Physical examination shows no abnormal findings. A urinalysis confirms the presence of blood, but no proteinuria or glucosuria. His urine culture is negative. A cystoscopy reveals a 3-cm exophytic lesion in the dome of the bladder. A biopsy of this lesion is done, and microscopic examination shows fibrovascular cores covered by a thick layer of transitional cells. Which of the following risk factors is most likely to have led to development of this lesion? A. Recurrent urinary tract infection B. Diabetes mellitus C. Methicillin therapy D. NSAID’s use E. Cigarette smoking

Answer 76

Question 77

A 60-year-old man presented with a rapidly growing dome-shaped, flesh-colored nodule on the cheek. The lesion disappeared after several months. Biopsy of this nodule would have probably shown which of the following features? A. Proliferation of blood vessels B. Spindly cells within the dermis C. Keratin-filled crater D. Fibrovascular core E. Cyst with keratin debris

Answer 77

Question 78

A 70-year-old man has had right hip and thigh pain for eight months. Physical exam demonstrates reduced range of motion in both hips. No tenderness or swelling is noted. X-rays of the pelvis and right leg show sclerotic, thickened cortical bone with a narrowed joint space near the acetabulum. Lab results show elevated alkaline phosphatase levels; calcium and phosphorus levels are within normal limits. Which of the following agents is suspected to play a pathogenic role in this man’s disease? A. Papovavirus B. Epstein-Barr virus C. Herpes simplex virus D. Human papillomavirus E. Paramyxovirus

Answer 78

Question 79

Following an upper respiratory tract infection, a 5-year-old boy develops raised red bumps on the buttocks and extensor surfaces of the arms and legs. The patient also has abdominal pain, vomiting, and arthralgias. Urinalysis reveals microscopic hematuria. Kidney biopsy would probably reveal which of the following findings? A. Mesangial electron-dense deposits B. Subepithelial electron-dense deposits C. Neoplasm D. Vasculitis E. Marked interstitial nephritis

Answer 79

Question 80

A 55-year-old Puerto Rican man has a 40-pack-year history of smoking cigarettes and drinks an occasional beer on weekends. He presents with ascites, dependent pitting edema, and splenomegaly. Endoscopy shows esophageal varices. A liver biopsy reveals concentric fibrosis around the portal vein. A complete blood cell count shows eosinophilia. What is the most likely diagnosis? A. Clonorchiasis B. Bilharziasis C. Alcoholic cirrhosis D. Echinococcus E. Primary sclerosing cholangitis

Answer 80

Question 81

A 20-year-old male college student presents with sore throat and extreme fatigue following even normal non-taxing tasks such as getting dressed and going down to breakfast. He reports that he has been sick for several weeks, that he has been feverish, and that his girlfriend now seems to be getting the same thing. Physical exam finds inflamed tonsils with an adherent white exudate, prominent cervical lymphadenopathy, and splenomegaly. The most likely causative agent binds to which one of the following molecules? A. CD 46 B. CCR5 C. CD 14 D. CD 21 E. CD 155

Answer 81

Question 82

Genetic testing of a child with hypertelorism, low-set ears, micrognathia, and a fish mouth finds a microdeletion in chromosome 22. The following are most likely present in this child, except: A. History of neonatal seizures B. Decreased CD3+ cells C. Cardiac anomalies D. Splenomegaly E. Absent respiratory burst to mitogens

Answer 82

Question 83

A 62-year-old man presents to the clinic with complaints of hearing loss on the left side, and persistent tinnitus. His symptoms have been getting progressively worse for the last two weeks. He has a history of lung cancer which was treated with a combination of chemotherapy and radiotherapy four months ago. He states the tumor has "considerably shrunk in size" after the treatment. A contrast-enhanced MRI scan shows a 2 x 1-cm circumscribed mass in the left cerebellopontine angle compressing the 8th cranial nerve. Which of the following is the most likely cause of this patient's symptoms? A. Metastatic carcinoma B. Meningioma C. Acoustic neuroma D. Astrocytoma E. Medulloblastoma

Answer 83

Question 84

A 9-year-old boy is diagnosed with Chediak-Higashi syndrome, an autosomal-recessive disorder in which the affected individuals have increased susceptibility to infection. This increased susceptibility is due to defective formation of a phagolysosome preventing phagocytosis of bacteria. Which of the following structures is most likely defective in this individual’s cells accounting for the failure of fusion of the phagosome and lysosome? A. Microtubules B. Microfilaments C. Intermediate filaments D. Golgi apparatus E. Proteosome

Answer 84

Question 85

A 37-year-old man presents for evaluation of anogenital lesions. He states that the lesions have been present for years but have recently grown and become pruritic and tender. Physical exam finds him circumcised, and multiple hyperkeratotic papules on his penis shaft, perineum, and anal area are noted. He also has a palpable rectal mass with guaiac positive stool and conjunctival pallor. On further history, he admits to recent unintentional weight loss, constipation, and bloating. A CD4+ cell count is ordered and is found to be 150/mm3. CT scan of the abdomen shows a 3 × 4-cm rectal mass with multiple metastatic lesions in his liver. What protein is targeted by the infectious agent causing this patient’s rectal mass? A. p53 B. BRCA-1 C. MSH1 D. APC E. NF1

Answer 85

Question 86

A six-month-old boy is brought to the emergency room by his mother because of lethargy and poor sucking. He was in a good state of health until last week, when he had constipation and was less active than usual. He had no vomiting, seizures, or fever. His prenatal course and delivery were uncomplicated. He is on formula nutrition and receives no iron or vitamin D supplementation, although the mother gives him various fruit juices and honey. All his vaccinations are up-to-date. Which of the following should this patient be tested for during physical examination? A. Neck muscle rigidity B. Ankle clonus C. Knee reflex asymmetry D. Impaired gag reflex E. Babinski's reflex on both sides

Answer 86

Question 87

A 45-year-old G3P3 woman has had postcoital spotting for six months. Pelvic exam reveals a fungating, exophytic lesion arising from her cervix that is approximately 2 cms in diameter. Biopsy of the cervical lesion reveals a squamous cell carcinoma. Extension of the cancer onto the vagina is not evident. The parametria are not indurated by bimanual exam. Enlarged lymph nodes and metastatic lesions are not seen on pelvic and abdominal CT. What is the stage of her cancer? A. IB B. IIIB C. IA D. IIA E. IVB

Answer 87

Question 88

A 9-year-old boy is brought to his pediatrician due to generalized seborrheic skin eruption and fever. His past medical history is remarkable for several episodes of otitis media in the past year. Physical exam finds mild lymphadenopathy, hepatomegaly, and splenomegaly. Histopathology of a mastoid bone lesion reveals cells with a reniform nucleus and abundant foamy cytoplasm. Electron microscopy of the lesion reveals rod-like granules within the abnormal cells. These abnormal cells would express which one of the following markers? A. CD1a B. CD10 C. CD20 D. CD30 E. TdT

Answer 88

Question 89

A 1-year-old girl is brought to the emergency room by her mother because the child's "eyes and feet are dancing". Physical examination finds a well-developed girl with signs of acute distress. Her temperature 37.0 degrees Celsius, blood pressure is 100/55 mmHg, pulse is 100/min, and respirations are 20/min. The patient has opsoclonus, myoclonus, and ptosis of the right eye. On history, the mother notes the child was born "looking like a blueberry muffin" and has had a persistent cough since the age of two months. Which of the following is the most likely diagnosis? A. Astrocytoma B. Neuroblastoma C. Glioblastoma D. Nephroblastoma E. Hyperthyroidism

Answer 89

Question 90

A lymphoma involves the lymph nodes, bone marrow, and spleen of a 45-year-old patient. Histopathology of the lymph nodes show a vaguely nodular architecture, with striking expansion of the mantle zone around small residual follicles. Neoplastic lymphocytes are small with a slightly indented nucleus. Mitotic figures are easily identified, but transformed lymphocytes are absent. Which one of the following genotypic abnormalities characterizes this type of lymphoma? A. t(8;14) B. t(11;14) C. t(14;18) D. Trisomy 12 E. Trisomy 18

Answer 90

Question 91

An apathetic male infant in an underdeveloped country is found to have peripheral edema, a “moon” face, and an enlarged, fatty liver. Which of the following is the basic defect causing this change in the liver? A. Decreased fluid intake leads to hypernatremia B. Decreased protein intake leads to decreased lipoproteins C. Decreased caloric intake leads to hypoalbuminemia D. Decreased carbohydrate intake leads to hypoglycemia E. Decreased fat absorption leads to hypovitaminosis

Answer 91

Question 92

An 83-year-old man is brought urgently to the emergency room with hematochezia and hypotension. He has no recent history of gastrointestinal symptoms. His past medical history is significant for hypertension and degenerative joint disease. His only medications include one antihypertensive drug and a nonsteroidal anti-inflammatory drug. After fluid resuscitation and stabilization, upper and lower endoscopy is most likely to demonstrate which of the following lesions? A. Sigmoid diverticula B. Internal hemorrhoids C. Gastric ulcer D. Duodenal ulcer E. Fungating colonic mass

Answer 92

Question 93

A 3-year-old apparently well boy is brought to the pediatric outpatient department by his mother. She states that he has never been able to walk, even though she has tried to help him. He has no other medical problems. Speech and other developmental milestones are unremarkable and normal for his age. He takes no medications. Physical exam finds no abnormalities. Which of the following is the most appropriate screening test for this patient? A. Chromosome analysis B. Aminoaciduria urine test C. Phenylketonuria screen D. Serum CK E. Thyroid stimulating hormone

Answer 93

Question 94

A male infant is born at term to a 23-year-old African primigravida, blood group A, Rh D-positive. The prenatal course was complicated with asymptomatic bacteriuria and mild hypertension without proteinuria in the third trimester. The newborn demonstrates yellow sclerae 12 hours after birth. He is blood group O, Rh D-positive. The total bilirubin is 7 mg/dl, with the unconjugated bilirubin predominantly elevated. Coombs test is negative. The mother states that there is a "kind of blood disease running the family." Which of the following is the most likely cause of this patient's jaundice? A. Sickle cell anemia B. HbS-HbC disorder C. Beta-thalassemia D. G-6-PD deficiency anemia E. Physiologic jaundice

Answer 94

Question 95

A 38-year-old nulliparous woman comes to the physician for an annual check-up. She reports a 10-pack-year smoking history and a family history of early mastectomy. Physical examination finds a scaly patch on her right nipple. A firm mass is palpated and a clear discharge from the nipple is noted. Which of the following would most likely be seen on a microscopic examination of this mass? A. Proliferation of normal glands and ducts B. Necrosis C. Pools of mucin D. Large cells with clear halos E. Intralobular clusters of tumor cells

Answer 95

Question 96

Immunologists try to characterize the role of several cytokines in a 5-year-old girl’s allergic reaction to eggs. Months after initial exposure to eggs, the child was brought to the emergency department with anaphylaxis symptoms that resolved following epinephrine injection and supportive management. Which one of the following best describes the role of IL-4 in the child’s response? A. Growth of cytotoxic T cells B. Neutrophil chemotaxis C. Macrophage and Th1 cell activation D. B-cell class switching E. Stimulates IgA production

Answer 96

Question 97

A pathologist is examining tissue removed from a 57-year-old deceased man. The tissue has preservation of normal architecture; however, there is loss of nuclear and cytoplasmic basophilia. Associated with these changes are abundant extravasated red blood cells in the tissue. The man had no resuscitation done. Of the following, where did this tissue most likely originate? A. A lung B. The spleen C. The heart D. A kidney E. The brain

Answer 97

Question 98

A 30-year-old man presents to his doctor with cramping abdominal pain and bloody diarrhea for the past four days. Abdominal examination finds diffuse tenderness on palpation of the abdomen. Bowel sounds are detected. Masses and organomegaly are not appreciated. Stool culture grows Shigella flexneri. The episode resolves spontaneously within one week after onset. Six weeks later, the patient comes back with increasingly severe lower back pain. Physical examination now demonstrates stiffness of the lumbar joints and tenderness affecting the sacroiliac joints. Ibuprofen is prescribed. Several months later, the back pain recurs, and now the patient complains of redness of the right eye and blurred vision. Serologic testing for which one of the following is most likely to be positive in this patient? A. HLA-DR4 B. HLA-BW47 C. HLA-DR3 D. HLA-B27 E. Rheumatoid factor

Answer 98

Question 99

A 70-year-old man suddenly lost the upper half of the visual field in the right eye. Before this event, he had had decreasing visual acuity in both eyes for the past six years. Physical exam finds his BMI to be 32. Lab findings show a fasting blood glucose of 165 mg/dL. What underlying pathologic process is most likely to account for the sudden loss of vision in the right eye? A. Retinitis pigmentosa B. Dendritic corneal ulcer C. Uveal melanoma D. Traction retinal detachment E. Macular degeneration

Answer 99

Question 100

A renal biopsy is done on a 34-year-old man for the evaluation of proteinuria in the nephrotic range. A representative silver-stained section shows a "spiked" appearance of the glomerular basement membrane. Immunofluorescence microscopy demonstrates finely granular deposits of IgG and C3 along the capillary wall. Electron microscopy shows effacement of foot processes, associated with numerous subepithelial electron-dense deposits, which are separated from each other by extensions of the basement membrane. Which of the following is the most likely diagnosis? A. Dense deposit disease B. Focal segmental glomerulosclerosis C. Membranoproliferative glomerulonephritis D. Membranous glomerulonephritis E. Minimal change glomerulopathy

Answer 100