03-13-2008, 08:16 AM
guys, i think these questions are quite easy for y'all. so, i will find little twisted questions if i can for tomorrow...just for more easy review....here are more questions with explan.....GL
Autopsy of an elderly individual who died in a nursing home with no known genetic diseases reveals small
amounts of amyloid deposition in the heart. Amyloid deposition is not seen in other organs. There is no history of
long-standing inflammatory disease. This type of amyloid would be most likely to be composed of which of the
following proteins?
A. Amyloid-associated protein
B. Amyloid light chain protein
C. Beta-2-amyloid protein
D. Beta-2-microglobulin
E. Transthyretin
Explanation:
The correct answer is E. This patient has senile cardiac amyloidosis, which is usually a clinically insignificant
condition due to deposition of structurally normal transthyretin (formerly called prealbumin). The transthyretin is
a normal serum protein used to transport thyroxin and retinal. In addition to causing senile cardiac amyloidosis,
transthyretin, in a mutant rather than normal form, is deposited as amyloid in the familial amyloid
polyneuropathies.
Amyloid-associated protein (choice A) is a more common protein deposited as amyloid, and precipitates in
secondary amyloidosis associated with underlying chronic inflammatory conditions.
Amyloid light chain protein (choice B) is a common protein deposited as amyloid, and precipitates in amyloidosis
related to multiple myeloma and other monoclonal B cell proliferations.
Beta-2-amyloid protein (choice C) is deposited as amyloid in the brain (notably in blood vessels and cerebral
plaques) of patients with Alzheimer's disease.
Beta-2-microglobulin (choice D) is a normal serum protein that is deposited in amyloidosis complicating
long-term hemodialysis.
Routine physical examination of a patient demonstrates proteinuria by dipstick method. No glucose is detected.
Urine protein electrophoresis demonstrates a monoclonal spike. A tumor of which cell line would most likely
produce these findings?
A. Plasma cells
B. Renal tubular cells
C. Smooth muscle
D. T-lymphocytes
E. Transitional epithelium
Explanation:
The correct answer is A. The tumor is multiple myeloma, a neoplasm of plasma cells. The monoclonal spike on
urine protein electrophoresis is typically due to excess light chains (associated with urinary Bence-Jones
protein).
Monoclonal proteinuria would not be produced by tumors of the the other cell lines listed.
Renal cell carcinoma is a tumor of renal tubular cells (choice B).
Leiomyoma and leiomyosarcoma are tumors of smooth muscle (choice C).
Cutaneous T-cell lymphomas and T-cell leukemia are tumors of T-lymphocytes (choice D).
Transitional cell carcinoma is a tumor of transitional epithelium (choice E).
An 83-year-old female has a biopsy of an ulcerated nipple lesion that is interpreted as Paget's disease. A biopsy
of the underlying breast tissue will most likely show which of the following?
A. Acute mastitis
B. Ductal carcinoma in situ
C. Intraductal papilloma
D. Invasive lobular carcinoma
E. Normal breast tissue
Explanation:
The correct answer is B. Paget's disease of the breast is a form of ductal carcinoma in which neoplastic cells
involve the squamous epithelium of the skin by direct extension through the lactiferous ducts. Underlying breast
tissue shows the origin of the ductal carcinoma-usually ductal carcinoma in situ and less frequently invasive
ductal carcinoma.
Acute mastitis (choice A) is a disease of nursing women in which bacteria gain entry to the breast tissue via
cracks in the traumatized nipple. It is characterized by acute inflammation and tissue necrosis.
Intraductal papilloma (choice C), a papillary mass arising within the ducts, usually presents as a single
subareolar tumor that may produce a bloody or serous nipple discharge. Most intraductal papillomas are
benign and are cured with complete excision.
Invasive lobular carcinoma (choice D) is a tumor of the terminal ductules of the breast. It presents as a poorly
circumscribed, rubbery breast mass, unlike invasive ductal carcinoma, which tends to appear as a hard,
stellate, and fibrous tumor. Lobular carcinoma does not produce Paget's disease.
Paget's disease of the breast always reflects underlying duct cancer. This is in marked distinction from
extramammary Paget's disease, which may arise without an identifiable underlying malignancy (choice E).
A 52-year-old male presents with epigastric pain that improves with meals. Endoscopy demonstrates a 2 cm
ulcerated area located 3 cm distal to the pyloric junction. Basal acid output is within normal limits. Which of the
following is most likely to have made the strongest contribution to the development of this disease?
A. Aspirin use
B. Chronic antacid use
C. Drinking alcohol
D. Helicobacter pylori infection
E. Smoking
Explanation:
The correct answer is D. The patient has a duodenal peptic ulcer. The strongest risk factor for duodenal peptic
ulcer is Helicobacter pylori infection, which is found in almost 100% of these cases (contrast to 70% infection
rate in gastric peptic ulcer). The basal acid output is normal in many patients with duodenal ulcer.
Aspirin use (choice A) and ethanol use (choice C) are more strongly implicated in gastric ulcer disease than
duodenal ulcer disease.
Chronic antacid use (choice B) is seen as a result of peptic ulcer disease, not as a cause of it.
Smoking (choice E) may also be a lesser contributing factor to the development of peptic ulcer.
A 42-year-old woman is noted to have mildly elevated creatinine and blood urea nitrogen on routine physical
exam. She recalls that her father also had kidney trouble and died in kidney failure. Workup reveals persistent
azotemia and microscopic hematuria without evidence of urinary tract infection. An ultrasound of the kidneys
identifies bilaterally enlarged and multicystic kidneys. In addition to chronic renal failure, the clinician should also
be concerned about her risk of
A. liver failure
B. pancreatic insufficiency
C. portal hypertension
D. renal cell carcinoma
E. subarachnoid hemorrhage
Explanation:
The correct answer is E. Multicystic kidneys, slowly progressive renal failure, and a positive family history are
characteristics of autosomal dominant (adult) polycystic kidney disease (APKD). This disease typically presents
in the 40s to 60s and is characterized by marked renal enlargement due to numerous fluid-filled cysts, which
develop between the normally functioning nephrons. APKD is highly associated with hepatic cysts, and berry
aneurysms in the circle of Willis that may rupture, producing spontaneous subarachnoid hemorrhage.
Infrequently, APKD also produces cysts in the pancreas, spleen, or lungs, but these are not clinically relevant.
Hepatic cysts in adult polycystic disease do not ordinarily produce symptoms of hepatic failure (choice A).
Pancreatic cyst formation in APKD is not generally associated with pancreatic insufficiency (choice B).
Children with autosomal recessive polycystic kidney disease may develop congenital hepatic fibrosis with
hypertension and splenomegaly, but this is not part of APKD (choice C).
APKD is not considered a risk factor for renal cell carcinoma or any other type of cancer (choice D).
A 32-year-old African American female presents with pelvic pain, low back pain, and a sensation of "pulling" or
"stretching" in her groin. Bimanual examination reveals a firm mass in the right adnexa. An ultrasound
examination reveals the presence of fluid in the abdominal cavity and the right thoracic cavity. Which of the
following conditions is most strongly suggested by this patient's presentation?
A. Ectopic pregnancy
B. Endometrial implant
C. Ovarian fibroma
D. Pelvic inflammatory disease
E. Uterine leiomyoma
Explanation:
The correct answer is C. Meigs syndrome is the unusual combination of hydrothorax (often right sided), ascites,
and an ovarian tumor (often a benign fibroma). Low back pain and a stretching or pulling sensation are
characteristic of ascites in some patients (ascites can also be asymptomatic). The etiology of the fluid
accumulation in Meigs syndrome remains a mystery.
Ectopic pregnancy (choice A) would not be associated with hydrothorax. If an ectopic pregnancy ruptured,
blood could accumulate in the abdominal cavity, but the patient would likely be hypotensive or dead.
An endometrial implant (choice B) could cause pain, or impair fertility, but would not be expected to produce the
combination of ascites and isolated right-sided hydrothorax.
Pelvic inflammatory disease (choice D) would be unlikely to produce the combination of ascites and isolated
right-sided hydrothorax, although it might cause low back pain or pelvic pain.
A uterine leiomyoma (choice E) would not be expected to produce an adnexal mass, nor would it be likely to
cause ascites and hydrothorax.
A 3-year-old child develops severe generalized edema following a viral infection. On the basis of clinical
chemistry tests, a renal biopsy is performed, with normal light microscopic findings. Which of the following
abnormal laboratory values might be expected in this individual?
A. Decreased alpha globulin levels
B. Decreased fibrinogen
C. Increased serum calcium levels
D. Low serum albumin levels
E. Red blood cell casts in the urine
Explanation:
The correct answer is D. This child has minimal change disease, which is the major cause (over 90% of cases)
of nephrotic syndrome in children aged 2 to 6 years. The most prominent clinical chemistry finding in these
patients is massive proteinuria. The urinary protein in minimal change disease, in contrast to other causes of
nephrotic syndrome, is often composed predominantly of albumin. Many other clinical chemistry changes may
also be seen, including decreased serum albumin levels, hyperlipidemia, increased serum levels of alpha2- and
beta-globulins, decreased IgG, and increased fibrinogen. Minimal change disease characteristically shows
normal or near normal appearance of the glomeruli by light microscopy and extensive fusion of foot processes
of the glomerular podocytes by electron microscopy. A point not always recognized by beginners is that the
podocyte alterations may represent a reaction to, rather than a cause of, the proteinuria (e.g., an attempt to
"seal the holes" in the glomerulus), since varying degrees of foot process fusion (together with more specific
features) may sometimes be seen in other glomerular diseases associated with the nephrotic syndrome.
Alpha-globulin levels (choice A) would be increased, rather than decreased, in minimal change disease.
Fibrinogen levels are increased, rather than decreased (choice B).
Serum calcium levels (choice C) are typically decreased in the nephrotic syndrome, possibly due to renal loss
of vitamin D binding protein.
Red blood cell casts in the urine (choice E) are indicative of glomerulonephritis, rather than the nephrotic
syndrome.
A 42-year-old African-American man sustains severe injuries in an automobile accident and is admitted to the
intensive care unit. Examination of a peripheral blood smear on the 3rd day of admission reveals helmet cells,
schistocytes, and decreased platelets. Which of the following is most strongly suggested by these findings?
A. Autoimmune hemolysis
B. Disseminated intravascular coagulation (DIC)
C. Hereditary spherocytosis
D. Megaloblastic anemia
E. Sickle cell anemia
Explanation:
The correct answer is B. The findings suggest disseminated intravascular coagulation (DIC), which is a feared
complication of many other disorders, such as obstetrical catastrophes, metastatic cancer, massive trauma, and
bacterial sepsis. The basic defect in DIC is a coagulopathy characterized by bleeding from mucosal surfaces,
thrombocytopenia, prolonged PT and PTT, decreased fibrinogen level, and elevated fibrin split products.
Helmet cells and schistocytes (fragmented red blood cells) are seen on peripheral blood smear.
Autoimmune hemolysis (choice A) and hereditary spherocytosis (choice C) would be characterized by
spherocytes in the peripheral smear.
Macro-ovalocytes and hypersegmented neutrophils can be seen in megaloblastic anemia (choice D).
Sickle cells are seen in sickle cell anemia (choice E).
A 52-year-old man is found dead in his home. Autopsy reveals hemopericardium secondary to ventricular wall
rupture. Roughly how long before his death did the man probably have a myocardial infarction?
A. 2 days
B. 7 days
C. 12 days
D. 20 days
E. 60 days
Explanation:
The correct answer is B. Unsuspected (or denied) myocardial infarction is not uncommon, and death may occur
because of untreated complications. A number of serious complications can occur between 5 and 10 days
following infarction, due to marked weakening of the necrotic myocardium. These include rupture of the
ventricular wall leading to hemopericardium and cardiac tamponade (as this patient had), rupture of the
interventricular septum, and rupture of the papillary muscle.
Arrhythmias are the most common complication 2 days post-infarction (choice A).
Fibrinous pericarditis secondary to an autoimmune phenomenon (Dressler's syndrome) can be seen several
weeks after infarctions (choices C and D).
By 60 days after infarction (choice E), the contracted scar is usually complete, and residual complications
include left ventricular failure and arrhythmias.
A 25-year-old man presents to a rheumatologist with complaints of joint pain involving the large joints of the legs.
On questioning, the patient indicates that exacerbations in the joint pain are frequently accompanied by diarrhea.
Which of the following gastrointestinal diseases is most likely to be implicated as the cause of the patient's joint
problems?
A. Amebic colitis
B. Chronic appendicitis
C. Diverticulosis
D. Pseudomembranous colitis
E. Ulcerative colitis
Explanation:
The correct answer is E. Several gastrointestinal diseases are associated with rheumatologic complaints. The
most frequent of these are the chronic inflammatory bowel diseases, ulcerative colitis and Crohn's disease,
which can be associated with sacroiliitis (related to HLA-B27) or lower limb arthritis. Other GI diseases
associated with arthropathy include bypass surgery, Whipple's disease, Behcet's syndrome, and celiac disease.
Amebic colitis (choice A) is caused by ingestion of infectious cysts (typically from Entamoeba histolytica).
Symptoms include abdominal pain and diarrhea; malaise and weight loss may occur. Cecal amebiasis can
resemble acute appendicitis.
Chronic appendicitis (choice B) may be asymptomatic or cause poorly defined abdominal pain.
Diverticulosis (choice C) is usually a disease of older adults. It is often asymptomatic unless inflammation
supervenes.
Pseudomembranous colitis (choice D) is a severe form of diarrhea usually seen in the setting of prior antibiotic
use. The causative organism is almost always Clostridium difficile.
A 45-year-old woman complains of difficulty speaking, chewing, and swallowing. She experiences generalized
weakness that increases with effort and as the day goes on. Symptoms are significantly improved after taking
neostigmine. Autoantibodies responsible for causing the patient's condition are directed against
A. acetylcholine receptors
B. double-stranded DNA
C. dystrophin
D. erythrocyte surface antigens
E. myelin
Explanation:
The correct answer is A. The patient has myasthenia gravis (MG), which typically produces weakness
worsening over the course of the day. It often affects the eye muscles and can produce diplopia. Neostigmine,
an acetylcholinesterase inhibitor, would temporarily improve the patient's condition, which is associated with
antibodies against nicotinic acetylcholine receptors present on skeletal muscle.
Antibodies to double-stranded DNA (choice B) as well as anti-Smith antibodies are found specifically in systemic
lupus erythematosus. Peripheral nuclear staining is observed on immunofluorescence.
Antibodies to dystrophin (choice C) are not a recognized pathology. Abnormal or absent dystrophin, resulting
from mutations in the X chromosome, is associated with Becker's and Duchenne muscular dystrophy,
respectively. Pelvic girdle weakness and ataxia are classic symptoms.
Antibodies to erythrocyte surface antigens (choice D) can be found in warm antibody autoimmune hemolytic
anemia. Patients with this condition would have a positive direct Coomb's test.
Antibodies to myelin (choice E) may play a role in multiple sclerosis, which is presumed to be of autoimmune
etiology. This demyelinating disease is characterized by the spontaneous appearance and remission of
symptoms such as hyperreflexia, weakness, spasticity, dysarthria, tremor, ataxia, and visual disturbances.
Neostigmine would not produce any improvement.
A 40-year-old woman with polycythemia vera develops progressive severe ascites and tender hepatomegaly over
a period of several months. Liver function tests are near normal. Which of the following tests would be most likely
to establish the probable diagnosis?
A. Endoscopic retrograde cholangiopancreatography
B. Hepatic venography
C. Serum alpha fetoprotein
D. Serum ceruloplasmin studies
E. Serum iron studies
Explanation:
The correct answer is B. The clinical presentation is most consistent with Budd-Chiari syndrome (hepatic vein
obstruction), which may occur as a complication of thrombogenic and myeloproliferative disorders including
polycythemia vera. The presentation illustrated is the most common; alternative presentations include fulminant
liver failure and cases in which intractable abdominal pain is the most prominent initial finding. Hepatic
venography is the best technique of those listed to demonstrate the occlusion of the hepatic venous system.
Endoscopic retrograde cholangiopancreatography (choice A) is most useful in demonstrating lesions of the
biliary tree.
Serum alpha fetoprotein (choice C) is a marker for hepatocellular carcinoma.
Ceruloplasmin (choice D) levels are decreased in Wilson's disease.
Serum iron studies (choice E) are useful when considering hemochromatosis as a cause of cirrhosis.
A 10-year-old boy develops an itchy, vesicular rash, which is maximal on his face and trunk. Physical examination
demonstrates a mixture of lesions, with macules, papules, vesicles, and crusted lesions. The mother reports that
the lesions seem to be occurring in crops. Which of the following is the most likely diagnosis?
A. Herpes simplex I
B. Herpes simplex II
C. Measles
D. Shingles
E. Varicella
Explanation:
The correct answer is E. This is varicella (chicken pox), which is the primary form of infection by the herpes
zoster (varicella-zoster) virus. Recurrence due to virus harbored in neurons tends to be dermatomal in
distribution and is called shingles. Fever, malaise, headache, and myalgia may also be present, particularly in
the prodromal phase. Tzanck smear of the base of a vesicle may demonstrate multinucleated giant cells.
Immunocompromised patients can be treated with acyclovir to prevent dissemination. Chicken pox may be
complicated by secondary bacterial infection, pneumonia, systemic spread (immunosuppressed patients),
neurologic involvement (rare), Reye's syndrome (rare), and hemolytic anemia (rare).
Herpes simplex I (choice A) causes oral vesicles and ulcers.
Herpes simplex II (choice B) causes genital vesicles and ulcers.
Measles (choice C) causes a blotchy, nonvesicular rash.
Shingles (choice D) is the recurrent form of herpes zoster infection and usually is localized to a single
dermatome.
Which of the following complications is currently the major limitation to the long-term success of cardiac
transplantation?
A. Allograft rejection
B. Graft arteriosclerosis
C. Graft atherosclerosis
D. Opportunistic infections
E. Lymphoma
Explanation:
The correct answer is B. Currently, graft arteriosclerosis (AKA graft vascular disease) is the most important limit
to the long-term success of heart transplantation. For unknown reasons, the coronary arteries of transplanted
hearts undergo intimal thickening associated with hyperplasia of myocytes and fibroblasts and deposition of
matrix. This results in luminal stenosis and myocardial ischemia. Patients may develop myocardial infarction,
which is clinically silent because the heart is denervated. The overall survival after heart transplantation is 80%
at 1 year and 60% at 5 years. Do not confuse graft arteriosclerosis with graft atherosclerosis (choice C).
Atherosclerosis is caused by accumulation of cholesterol esters and development of atheromas.
Atherosclerosis may recur in the coronary arteries of transplanted hearts, but is not a limiting factor in long-term
success of heart transplantation.
Allograft rejection (choice A) is certainly a major postoperative problem. However, thanks to early diagnosis
based on periodic endomyocardial biopsy and the availability of immunosuppressant therapy, this complication
can be prevented or successfully treated.
Although opportunistic infections (choice D) and development of Epstein-Barr related lymphomas (choice E) are
undesired effects of profound immunosuppression, these complications do not constitute a significant limitation
to the overall outcome of cardiac transplantation.
A mother takes her 4-year-old to a pediatrician because the child is having chronic, severe headaches. Physical
examination demonstrates poor visual tracking with one eye, which had not been present 1 year previously. The
pediatrician orders a CT scan of the head, which demonstrates a cystic 4-cm mass above the pituitary gland.
Resection of the tumor reveals a cystic lesion filled with dark, oily fluid containing granular debris. Histologic
examination of the tumor would most likely demonstrate a tumor with areas resembling which of the following?
A. Autonomic ganglion
B. Brain
C. Skin
D. Thyroid
E. Tooth enamel organ
Explanation:
The correct answer is E. The tumor is a craniopharyngioma, which is also called an ameloblastoma because of
its histologic resemblance to tooth enamel organ, which contains ameloblasts. The resemblance is not merely
coincidental, because the embryologic development of the pituitary involves both downward growth from the
brain, forming the posterior lobe of the pituitary, and upward growth from the mouth (from remnants of Rathke's
pouch), forming the anterior lobe of the pituitary. Craniopharyngiomas may occupy the sella turcica or may be
found in a suprasellar location, often in the hypothalamus. The tumor may present with mass effects (as in this
child) or pituitary insufficiency.
Ganglioneuromas contain tissue resembling autonomic ganglia (choice A).
Dermoid cysts (mature teratomas) of the ovary can contain tissue resembling brain (choice B), skin (choice C),
or thyroid (choice D).
A 67-year-old male develops severe chest pain. He is admitted to the hospital, and diagnosed with a myocardial
infarction based on his electrocardiogram and serial CK-MB levels. One week later, he again complains of
precordial pain and develops a fever of 102°F (38.9°C). Physical examination is remarkable for a loud friction
rub. Which of the following is the most likely diagnosis?
A. Caseous pericarditis
B. Fibrinous pericarditis
C. Hemorrhagic pericarditis
D. Purulent pericarditis
E. Serous pericarditis
Explanation:
The correct answer is B. Different types of pericarditis can be seen in different settings. Fibrinous and
serofibrinous pericarditis may follow acute myocardial infarction (Dressler's syndrome) and can be seen in
uremia, chest radiation, rheumatic fever, systemic lupus erythematosus, and following chest trauma (including
chest surgery).
Caseous pericarditis (choice A) is generally due to tuberculosis.
Hemorrhagic pericarditis (choice C) can be seen with tuberculosis, malignant tumors, patients with bleeding
diatheses, and following chest surgery.
Purulent pericarditis (choice D) is seen when pyogenic infections involve the pericardium, e.g., after
cardiothoracic surgery.
Serous pericarditis (choice E) is seen in non-infectious inflammations (rheumatic fever, lupus, scleroderma,
tumors, uremia).
Autopsy of an elderly individual who died in a nursing home with no known genetic diseases reveals small
amounts of amyloid deposition in the heart. Amyloid deposition is not seen in other organs. There is no history of
long-standing inflammatory disease. This type of amyloid would be most likely to be composed of which of the
following proteins?
A. Amyloid-associated protein
B. Amyloid light chain protein
C. Beta-2-amyloid protein
D. Beta-2-microglobulin
E. Transthyretin
Explanation:
The correct answer is E. This patient has senile cardiac amyloidosis, which is usually a clinically insignificant
condition due to deposition of structurally normal transthyretin (formerly called prealbumin). The transthyretin is
a normal serum protein used to transport thyroxin and retinal. In addition to causing senile cardiac amyloidosis,
transthyretin, in a mutant rather than normal form, is deposited as amyloid in the familial amyloid
polyneuropathies.
Amyloid-associated protein (choice A) is a more common protein deposited as amyloid, and precipitates in
secondary amyloidosis associated with underlying chronic inflammatory conditions.
Amyloid light chain protein (choice B) is a common protein deposited as amyloid, and precipitates in amyloidosis
related to multiple myeloma and other monoclonal B cell proliferations.
Beta-2-amyloid protein (choice C) is deposited as amyloid in the brain (notably in blood vessels and cerebral
plaques) of patients with Alzheimer's disease.
Beta-2-microglobulin (choice D) is a normal serum protein that is deposited in amyloidosis complicating
long-term hemodialysis.
Routine physical examination of a patient demonstrates proteinuria by dipstick method. No glucose is detected.
Urine protein electrophoresis demonstrates a monoclonal spike. A tumor of which cell line would most likely
produce these findings?
A. Plasma cells
B. Renal tubular cells
C. Smooth muscle
D. T-lymphocytes
E. Transitional epithelium
Explanation:
The correct answer is A. The tumor is multiple myeloma, a neoplasm of plasma cells. The monoclonal spike on
urine protein electrophoresis is typically due to excess light chains (associated with urinary Bence-Jones
protein).
Monoclonal proteinuria would not be produced by tumors of the the other cell lines listed.
Renal cell carcinoma is a tumor of renal tubular cells (choice B).
Leiomyoma and leiomyosarcoma are tumors of smooth muscle (choice C).
Cutaneous T-cell lymphomas and T-cell leukemia are tumors of T-lymphocytes (choice D).
Transitional cell carcinoma is a tumor of transitional epithelium (choice E).
An 83-year-old female has a biopsy of an ulcerated nipple lesion that is interpreted as Paget's disease. A biopsy
of the underlying breast tissue will most likely show which of the following?
A. Acute mastitis
B. Ductal carcinoma in situ
C. Intraductal papilloma
D. Invasive lobular carcinoma
E. Normal breast tissue
Explanation:
The correct answer is B. Paget's disease of the breast is a form of ductal carcinoma in which neoplastic cells
involve the squamous epithelium of the skin by direct extension through the lactiferous ducts. Underlying breast
tissue shows the origin of the ductal carcinoma-usually ductal carcinoma in situ and less frequently invasive
ductal carcinoma.
Acute mastitis (choice A) is a disease of nursing women in which bacteria gain entry to the breast tissue via
cracks in the traumatized nipple. It is characterized by acute inflammation and tissue necrosis.
Intraductal papilloma (choice C), a papillary mass arising within the ducts, usually presents as a single
subareolar tumor that may produce a bloody or serous nipple discharge. Most intraductal papillomas are
benign and are cured with complete excision.
Invasive lobular carcinoma (choice D) is a tumor of the terminal ductules of the breast. It presents as a poorly
circumscribed, rubbery breast mass, unlike invasive ductal carcinoma, which tends to appear as a hard,
stellate, and fibrous tumor. Lobular carcinoma does not produce Paget's disease.
Paget's disease of the breast always reflects underlying duct cancer. This is in marked distinction from
extramammary Paget's disease, which may arise without an identifiable underlying malignancy (choice E).
A 52-year-old male presents with epigastric pain that improves with meals. Endoscopy demonstrates a 2 cm
ulcerated area located 3 cm distal to the pyloric junction. Basal acid output is within normal limits. Which of the
following is most likely to have made the strongest contribution to the development of this disease?
A. Aspirin use
B. Chronic antacid use
C. Drinking alcohol
D. Helicobacter pylori infection
E. Smoking
Explanation:
The correct answer is D. The patient has a duodenal peptic ulcer. The strongest risk factor for duodenal peptic
ulcer is Helicobacter pylori infection, which is found in almost 100% of these cases (contrast to 70% infection
rate in gastric peptic ulcer). The basal acid output is normal in many patients with duodenal ulcer.
Aspirin use (choice A) and ethanol use (choice C) are more strongly implicated in gastric ulcer disease than
duodenal ulcer disease.
Chronic antacid use (choice B) is seen as a result of peptic ulcer disease, not as a cause of it.
Smoking (choice E) may also be a lesser contributing factor to the development of peptic ulcer.
A 42-year-old woman is noted to have mildly elevated creatinine and blood urea nitrogen on routine physical
exam. She recalls that her father also had kidney trouble and died in kidney failure. Workup reveals persistent
azotemia and microscopic hematuria without evidence of urinary tract infection. An ultrasound of the kidneys
identifies bilaterally enlarged and multicystic kidneys. In addition to chronic renal failure, the clinician should also
be concerned about her risk of
A. liver failure
B. pancreatic insufficiency
C. portal hypertension
D. renal cell carcinoma
E. subarachnoid hemorrhage
Explanation:
The correct answer is E. Multicystic kidneys, slowly progressive renal failure, and a positive family history are
characteristics of autosomal dominant (adult) polycystic kidney disease (APKD). This disease typically presents
in the 40s to 60s and is characterized by marked renal enlargement due to numerous fluid-filled cysts, which
develop between the normally functioning nephrons. APKD is highly associated with hepatic cysts, and berry
aneurysms in the circle of Willis that may rupture, producing spontaneous subarachnoid hemorrhage.
Infrequently, APKD also produces cysts in the pancreas, spleen, or lungs, but these are not clinically relevant.
Hepatic cysts in adult polycystic disease do not ordinarily produce symptoms of hepatic failure (choice A).
Pancreatic cyst formation in APKD is not generally associated with pancreatic insufficiency (choice B).
Children with autosomal recessive polycystic kidney disease may develop congenital hepatic fibrosis with
hypertension and splenomegaly, but this is not part of APKD (choice C).
APKD is not considered a risk factor for renal cell carcinoma or any other type of cancer (choice D).
A 32-year-old African American female presents with pelvic pain, low back pain, and a sensation of "pulling" or
"stretching" in her groin. Bimanual examination reveals a firm mass in the right adnexa. An ultrasound
examination reveals the presence of fluid in the abdominal cavity and the right thoracic cavity. Which of the
following conditions is most strongly suggested by this patient's presentation?
A. Ectopic pregnancy
B. Endometrial implant
C. Ovarian fibroma
D. Pelvic inflammatory disease
E. Uterine leiomyoma
Explanation:
The correct answer is C. Meigs syndrome is the unusual combination of hydrothorax (often right sided), ascites,
and an ovarian tumor (often a benign fibroma). Low back pain and a stretching or pulling sensation are
characteristic of ascites in some patients (ascites can also be asymptomatic). The etiology of the fluid
accumulation in Meigs syndrome remains a mystery.
Ectopic pregnancy (choice A) would not be associated with hydrothorax. If an ectopic pregnancy ruptured,
blood could accumulate in the abdominal cavity, but the patient would likely be hypotensive or dead.
An endometrial implant (choice B) could cause pain, or impair fertility, but would not be expected to produce the
combination of ascites and isolated right-sided hydrothorax.
Pelvic inflammatory disease (choice D) would be unlikely to produce the combination of ascites and isolated
right-sided hydrothorax, although it might cause low back pain or pelvic pain.
A uterine leiomyoma (choice E) would not be expected to produce an adnexal mass, nor would it be likely to
cause ascites and hydrothorax.
A 3-year-old child develops severe generalized edema following a viral infection. On the basis of clinical
chemistry tests, a renal biopsy is performed, with normal light microscopic findings. Which of the following
abnormal laboratory values might be expected in this individual?
A. Decreased alpha globulin levels
B. Decreased fibrinogen
C. Increased serum calcium levels
D. Low serum albumin levels
E. Red blood cell casts in the urine
Explanation:
The correct answer is D. This child has minimal change disease, which is the major cause (over 90% of cases)
of nephrotic syndrome in children aged 2 to 6 years. The most prominent clinical chemistry finding in these
patients is massive proteinuria. The urinary protein in minimal change disease, in contrast to other causes of
nephrotic syndrome, is often composed predominantly of albumin. Many other clinical chemistry changes may
also be seen, including decreased serum albumin levels, hyperlipidemia, increased serum levels of alpha2- and
beta-globulins, decreased IgG, and increased fibrinogen. Minimal change disease characteristically shows
normal or near normal appearance of the glomeruli by light microscopy and extensive fusion of foot processes
of the glomerular podocytes by electron microscopy. A point not always recognized by beginners is that the
podocyte alterations may represent a reaction to, rather than a cause of, the proteinuria (e.g., an attempt to
"seal the holes" in the glomerulus), since varying degrees of foot process fusion (together with more specific
features) may sometimes be seen in other glomerular diseases associated with the nephrotic syndrome.
Alpha-globulin levels (choice A) would be increased, rather than decreased, in minimal change disease.
Fibrinogen levels are increased, rather than decreased (choice B).
Serum calcium levels (choice C) are typically decreased in the nephrotic syndrome, possibly due to renal loss
of vitamin D binding protein.
Red blood cell casts in the urine (choice E) are indicative of glomerulonephritis, rather than the nephrotic
syndrome.
A 42-year-old African-American man sustains severe injuries in an automobile accident and is admitted to the
intensive care unit. Examination of a peripheral blood smear on the 3rd day of admission reveals helmet cells,
schistocytes, and decreased platelets. Which of the following is most strongly suggested by these findings?
A. Autoimmune hemolysis
B. Disseminated intravascular coagulation (DIC)
C. Hereditary spherocytosis
D. Megaloblastic anemia
E. Sickle cell anemia
Explanation:
The correct answer is B. The findings suggest disseminated intravascular coagulation (DIC), which is a feared
complication of many other disorders, such as obstetrical catastrophes, metastatic cancer, massive trauma, and
bacterial sepsis. The basic defect in DIC is a coagulopathy characterized by bleeding from mucosal surfaces,
thrombocytopenia, prolonged PT and PTT, decreased fibrinogen level, and elevated fibrin split products.
Helmet cells and schistocytes (fragmented red blood cells) are seen on peripheral blood smear.
Autoimmune hemolysis (choice A) and hereditary spherocytosis (choice C) would be characterized by
spherocytes in the peripheral smear.
Macro-ovalocytes and hypersegmented neutrophils can be seen in megaloblastic anemia (choice D).
Sickle cells are seen in sickle cell anemia (choice E).
A 52-year-old man is found dead in his home. Autopsy reveals hemopericardium secondary to ventricular wall
rupture. Roughly how long before his death did the man probably have a myocardial infarction?
A. 2 days
B. 7 days
C. 12 days
D. 20 days
E. 60 days
Explanation:
The correct answer is B. Unsuspected (or denied) myocardial infarction is not uncommon, and death may occur
because of untreated complications. A number of serious complications can occur between 5 and 10 days
following infarction, due to marked weakening of the necrotic myocardium. These include rupture of the
ventricular wall leading to hemopericardium and cardiac tamponade (as this patient had), rupture of the
interventricular septum, and rupture of the papillary muscle.
Arrhythmias are the most common complication 2 days post-infarction (choice A).
Fibrinous pericarditis secondary to an autoimmune phenomenon (Dressler's syndrome) can be seen several
weeks after infarctions (choices C and D).
By 60 days after infarction (choice E), the contracted scar is usually complete, and residual complications
include left ventricular failure and arrhythmias.
A 25-year-old man presents to a rheumatologist with complaints of joint pain involving the large joints of the legs.
On questioning, the patient indicates that exacerbations in the joint pain are frequently accompanied by diarrhea.
Which of the following gastrointestinal diseases is most likely to be implicated as the cause of the patient's joint
problems?
A. Amebic colitis
B. Chronic appendicitis
C. Diverticulosis
D. Pseudomembranous colitis
E. Ulcerative colitis
Explanation:
The correct answer is E. Several gastrointestinal diseases are associated with rheumatologic complaints. The
most frequent of these are the chronic inflammatory bowel diseases, ulcerative colitis and Crohn's disease,
which can be associated with sacroiliitis (related to HLA-B27) or lower limb arthritis. Other GI diseases
associated with arthropathy include bypass surgery, Whipple's disease, Behcet's syndrome, and celiac disease.
Amebic colitis (choice A) is caused by ingestion of infectious cysts (typically from Entamoeba histolytica).
Symptoms include abdominal pain and diarrhea; malaise and weight loss may occur. Cecal amebiasis can
resemble acute appendicitis.
Chronic appendicitis (choice B) may be asymptomatic or cause poorly defined abdominal pain.
Diverticulosis (choice C) is usually a disease of older adults. It is often asymptomatic unless inflammation
supervenes.
Pseudomembranous colitis (choice D) is a severe form of diarrhea usually seen in the setting of prior antibiotic
use. The causative organism is almost always Clostridium difficile.
A 45-year-old woman complains of difficulty speaking, chewing, and swallowing. She experiences generalized
weakness that increases with effort and as the day goes on. Symptoms are significantly improved after taking
neostigmine. Autoantibodies responsible for causing the patient's condition are directed against
A. acetylcholine receptors
B. double-stranded DNA
C. dystrophin
D. erythrocyte surface antigens
E. myelin
Explanation:
The correct answer is A. The patient has myasthenia gravis (MG), which typically produces weakness
worsening over the course of the day. It often affects the eye muscles and can produce diplopia. Neostigmine,
an acetylcholinesterase inhibitor, would temporarily improve the patient's condition, which is associated with
antibodies against nicotinic acetylcholine receptors present on skeletal muscle.
Antibodies to double-stranded DNA (choice B) as well as anti-Smith antibodies are found specifically in systemic
lupus erythematosus. Peripheral nuclear staining is observed on immunofluorescence.
Antibodies to dystrophin (choice C) are not a recognized pathology. Abnormal or absent dystrophin, resulting
from mutations in the X chromosome, is associated with Becker's and Duchenne muscular dystrophy,
respectively. Pelvic girdle weakness and ataxia are classic symptoms.
Antibodies to erythrocyte surface antigens (choice D) can be found in warm antibody autoimmune hemolytic
anemia. Patients with this condition would have a positive direct Coomb's test.
Antibodies to myelin (choice E) may play a role in multiple sclerosis, which is presumed to be of autoimmune
etiology. This demyelinating disease is characterized by the spontaneous appearance and remission of
symptoms such as hyperreflexia, weakness, spasticity, dysarthria, tremor, ataxia, and visual disturbances.
Neostigmine would not produce any improvement.
A 40-year-old woman with polycythemia vera develops progressive severe ascites and tender hepatomegaly over
a period of several months. Liver function tests are near normal. Which of the following tests would be most likely
to establish the probable diagnosis?
A. Endoscopic retrograde cholangiopancreatography
B. Hepatic venography
C. Serum alpha fetoprotein
D. Serum ceruloplasmin studies
E. Serum iron studies
Explanation:
The correct answer is B. The clinical presentation is most consistent with Budd-Chiari syndrome (hepatic vein
obstruction), which may occur as a complication of thrombogenic and myeloproliferative disorders including
polycythemia vera. The presentation illustrated is the most common; alternative presentations include fulminant
liver failure and cases in which intractable abdominal pain is the most prominent initial finding. Hepatic
venography is the best technique of those listed to demonstrate the occlusion of the hepatic venous system.
Endoscopic retrograde cholangiopancreatography (choice A) is most useful in demonstrating lesions of the
biliary tree.
Serum alpha fetoprotein (choice C) is a marker for hepatocellular carcinoma.
Ceruloplasmin (choice D) levels are decreased in Wilson's disease.
Serum iron studies (choice E) are useful when considering hemochromatosis as a cause of cirrhosis.
A 10-year-old boy develops an itchy, vesicular rash, which is maximal on his face and trunk. Physical examination
demonstrates a mixture of lesions, with macules, papules, vesicles, and crusted lesions. The mother reports that
the lesions seem to be occurring in crops. Which of the following is the most likely diagnosis?
A. Herpes simplex I
B. Herpes simplex II
C. Measles
D. Shingles
E. Varicella
Explanation:
The correct answer is E. This is varicella (chicken pox), which is the primary form of infection by the herpes
zoster (varicella-zoster) virus. Recurrence due to virus harbored in neurons tends to be dermatomal in
distribution and is called shingles. Fever, malaise, headache, and myalgia may also be present, particularly in
the prodromal phase. Tzanck smear of the base of a vesicle may demonstrate multinucleated giant cells.
Immunocompromised patients can be treated with acyclovir to prevent dissemination. Chicken pox may be
complicated by secondary bacterial infection, pneumonia, systemic spread (immunosuppressed patients),
neurologic involvement (rare), Reye's syndrome (rare), and hemolytic anemia (rare).
Herpes simplex I (choice A) causes oral vesicles and ulcers.
Herpes simplex II (choice B) causes genital vesicles and ulcers.
Measles (choice C) causes a blotchy, nonvesicular rash.
Shingles (choice D) is the recurrent form of herpes zoster infection and usually is localized to a single
dermatome.
Which of the following complications is currently the major limitation to the long-term success of cardiac
transplantation?
A. Allograft rejection
B. Graft arteriosclerosis
C. Graft atherosclerosis
D. Opportunistic infections
E. Lymphoma
Explanation:
The correct answer is B. Currently, graft arteriosclerosis (AKA graft vascular disease) is the most important limit
to the long-term success of heart transplantation. For unknown reasons, the coronary arteries of transplanted
hearts undergo intimal thickening associated with hyperplasia of myocytes and fibroblasts and deposition of
matrix. This results in luminal stenosis and myocardial ischemia. Patients may develop myocardial infarction,
which is clinically silent because the heart is denervated. The overall survival after heart transplantation is 80%
at 1 year and 60% at 5 years. Do not confuse graft arteriosclerosis with graft atherosclerosis (choice C).
Atherosclerosis is caused by accumulation of cholesterol esters and development of atheromas.
Atherosclerosis may recur in the coronary arteries of transplanted hearts, but is not a limiting factor in long-term
success of heart transplantation.
Allograft rejection (choice A) is certainly a major postoperative problem. However, thanks to early diagnosis
based on periodic endomyocardial biopsy and the availability of immunosuppressant therapy, this complication
can be prevented or successfully treated.
Although opportunistic infections (choice D) and development of Epstein-Barr related lymphomas (choice E) are
undesired effects of profound immunosuppression, these complications do not constitute a significant limitation
to the overall outcome of cardiac transplantation.
A mother takes her 4-year-old to a pediatrician because the child is having chronic, severe headaches. Physical
examination demonstrates poor visual tracking with one eye, which had not been present 1 year previously. The
pediatrician orders a CT scan of the head, which demonstrates a cystic 4-cm mass above the pituitary gland.
Resection of the tumor reveals a cystic lesion filled with dark, oily fluid containing granular debris. Histologic
examination of the tumor would most likely demonstrate a tumor with areas resembling which of the following?
A. Autonomic ganglion
B. Brain
C. Skin
D. Thyroid
E. Tooth enamel organ
Explanation:
The correct answer is E. The tumor is a craniopharyngioma, which is also called an ameloblastoma because of
its histologic resemblance to tooth enamel organ, which contains ameloblasts. The resemblance is not merely
coincidental, because the embryologic development of the pituitary involves both downward growth from the
brain, forming the posterior lobe of the pituitary, and upward growth from the mouth (from remnants of Rathke's
pouch), forming the anterior lobe of the pituitary. Craniopharyngiomas may occupy the sella turcica or may be
found in a suprasellar location, often in the hypothalamus. The tumor may present with mass effects (as in this
child) or pituitary insufficiency.
Ganglioneuromas contain tissue resembling autonomic ganglia (choice A).
Dermoid cysts (mature teratomas) of the ovary can contain tissue resembling brain (choice B), skin (choice C),
or thyroid (choice D).
A 67-year-old male develops severe chest pain. He is admitted to the hospital, and diagnosed with a myocardial
infarction based on his electrocardiogram and serial CK-MB levels. One week later, he again complains of
precordial pain and develops a fever of 102°F (38.9°C). Physical examination is remarkable for a loud friction
rub. Which of the following is the most likely diagnosis?
A. Caseous pericarditis
B. Fibrinous pericarditis
C. Hemorrhagic pericarditis
D. Purulent pericarditis
E. Serous pericarditis
Explanation:
The correct answer is B. Different types of pericarditis can be seen in different settings. Fibrinous and
serofibrinous pericarditis may follow acute myocardial infarction (Dressler's syndrome) and can be seen in
uremia, chest radiation, rheumatic fever, systemic lupus erythematosus, and following chest trauma (including
chest surgery).
Caseous pericarditis (choice A) is generally due to tuberculosis.
Hemorrhagic pericarditis (choice C) can be seen with tuberculosis, malignant tumors, patients with bleeding
diatheses, and following chest surgery.
Purulent pericarditis (choice D) is seen when pyogenic infections involve the pericardium, e.g., after
cardiothoracic surgery.
Serous pericarditis (choice E) is seen in non-infectious inflammations (rheumatic fever, lupus, scleroderma,
tumors, uremia).
GL.