PATHO20 05/2018

DISCLAIMER!
This compilation is solely based on recalling the items that appeared on the exam, not based on feedback.

1) An experiment analyzes factors involved in the cell cycle week later she is afebrile. Which of the following is the most
during growth factor–induced cellular regeneration in a tissue likely outcome of her pulmonary disease?
culture. Cyclin B synthesis is induced; the cyclin B binds and A Chronic inflammation
activates cyclin-dependent kinase 1 (CDK1). The active kinase B Fibrous scarring
produced by this process is most likely to control progression in C Neoplasia
which of the following phases of the cell cycle? D Resolution
A G0 to G1 E Ulceration
B G1 to S
C S to G2 6) A 15-year-old girl incurs a cut to the sole of her foot
D G2 to M after stepping on a piece of broken glass. On examination, a
E M to G1 superficial 0.5-cm laceration ceases to bleed within 5 minutes
after application of local pressure. Which of the following
2) A 53-year-old woman with no prior illnesses has a substances is released by endothelium and is most likely to
routine checkup by her physician. On examination she has a counteract platelet aggregation near this site of injury?
blood pressure of 150/95 mm Hg. If her hypertension remains A Glycoprotein IIb/IIIa
untreated for years, which of the following cellular alterations B Platelet-activating factor
would most likely be seen in her myocardium? C Prostacyclin
A Apoptosis D Tissue-type plasminogen activator
B Dysplasia E Thrombomodulin
C Fatty change F Thromboxane
D Hemosiderosis
E Hyperplasia 7) A 59-year-old woman with a history of diabetes mellitus
F Hypertrophy had a myocardial infarction 3 months ago. Her BMI is 35. She
G Metaplasia is now taking a low dose of aspirin to reduce the risk for recurrent
arterial thrombosis. On which of the following steps in
3) A 71-year-old man has had difficulty with urination, including hemostasis does aspirin have its greatest effect?
hesitancy and increased frequency, for the past 5 years. A Adhesion of platelets to collagen
A digital rectal examination reveals that his prostate gland is B Aggregation of platelets
palpably enlarged to twice normal size. A transurethral resection C Production of tissue factor
of the prostate is performed, and the microscopic appearance of D Synthesis of von Willebrand factor
the prostate “chips” obtained is that of nodules of glands with E Synthesis of antithrombin III
intervening stroma. Which of the following pathologic processes
has most likely occurred in his prostate? 8) A 58-year-old man has had episodes of prolonged epistaxis
A Apoptosis in the past 6 months. On examination he has occult
B Dysplasia blood detected in his stool. Coagulation studies show that his
C Fatty change prothrombin time is elevated, but his partial thromboplastin
D Hyperplasia time (PTT), platelet count, and platelet function are all normal.
E Hypertrophy When his plasma is mixed with an equal amount of normal
F Metaplasia plasma, the prothrombin time corrects to normal. Which of the
following underlying diseases is most likely to be associated
4) A 68-year-old man has had worsening shortness of with these findings?
breath for the past week. On physical examination, his temperature A Antiphospholipid syndrome
is 38.3° C. On percussion, there is dullness over the B Factor V Leiden mutation
left lung fields. Thoracentesis performed on the left pleural C Hemophilia A
cavity yields 800 mL of cloudy yellow fluid that has a WBC D Scurvy
count of 2500/mm3 with 98% neutrophils and 2% lymphocytes. E Sepsis with Escherichia coli
A Gram stain of the fluid shows gram-positive cocci in F Vitamin K deficiency
clusters. Which of the following terms best describes the process
occurring in his left pleural cavity? 9) A 70-year-old man was hospitalized 3 weeks ago for a
A Abscess cerebral infarction. He is now is ambulating for the first time.
B Chronic inflammation Within minutes of returning to his hospital room, he has sudden
C Edema onset of dyspnea with diaphoresis. He cannot be resuscitated.
D Fibrinous inflammation The gross appearance of the hilum of the left lung at
E Purulent exudate autopsy is shown in the figure. Which of the following risk
F Serous effusion factors most likely contributed to this finding?
A Antiphospholipid antibody
5) An 87-year-old woman has had a cough productive of B Bronchopneumonia
yellowish sputum for the past 2 days. On examination her C Factor V mutation
temperature is 37° C. A chest radiograph shows bilateral D Leg vein thrombosis
patchy infiltrates. Her peripheral blood shows leukocytosis. A E Pulmonary arterial atherosclerosis

10) An 11-year-old child has exhibited poor wound healing,
even with minor trauma, since infancy. On examination she
has hyperextensible joints and fragile, extremely stretchable
skin. A diaphragmatic hernia was repaired soon after birth.
One parent and one of three siblings are also affected. A mutation
in a gene encoding for which of the following type of
proteins is most likely causing this child’s disease?
A Enzyme
B Growth regulation
C Ion channel
D Receptor
E Structural support
11) A 28-year-old man has had hemoptysis and hematuria
for the past 2 days. On physical examination, his temperature
is 36.8° C, pulse is 87/min, respirations are 19/min, and blood
pressure is 150/90 mm Hg. Laboratory studies show creatinine
of 3.8 mg/dL and urea nitrogen of 35 mg/dL. Urinalysis shows
4+ hematuria, 2+ proteinuria, and no glucose. A renal biopsy
specimen examined microscopically shows glomerular damage
and linear immunofluorescence with labeled complement
C3 and anti-IgG antibody. Which of the following autoantibodies
has the greatest specificity for this patient’s condition?
A Anti–basement membrane
B Anticardiolipin
C Anti–double-stranded DNA
D Antihistone
E Anti–SS-A
F Anti–U1-ribonucleoprotein
12) A 40-year-old laboratory technician accidentally injects
a chemical into his skin. The next day, he notes that an area
of erythematous, indurated skin is forming around the site of
injection. Two days later, the induration measures 10 mm in
diameter. A microscopic section from this area, with immunostaining
using antibody to CD4, shows many positive lymphocytes.
Which of the following immunologic reactions is most
consistent with this appearance?
A Arthus reaction
B Graft-versus-host disease
C Delayed-type hypersensitivity
D Localized anaphylaxis
E Serum sickness
13) A 22-year-old woman has had increasing malaise and
swelling of her feet for the past week. On physical examination,
she has 2+ pitting edema to the knees and puffiness
around the eyes. Laboratory studies show serum creatinine
of 4.6 mg/dL and urea nitrogen of 42 mg/dL. A renal biopsy
specimen shows positive immunofluorescent staining for
immunoglobulin
and complement C3 within the glomeruli. The
electron microscopic appearance of a glomerulus is shown in
the figure. Which of the following immunologic mechanisms
has most likely produced the renal damage seen in this patient?
A Antibody-dependent cell-mediated cytotoxicity
B Granulomatous inflammation
C Immune complex–mediated hypersensitivity
D Localized anaphylaxis
E T cell–mediated cytotoxicity
A 37-year-old man who is HIV-positive has noticed an increasing
number and size of skin lesions on his face, trunk, and
USE DISCREETLY
extremities, as shown in the figure, over the past 18 months.
Some of the larger lesions appear to be nodular. Molecular
analysis of the spindle cells found in these skin lesions is likely
to reveal the genome of which of the following viruses?
A Adenovirus
B Cytomegalovirus
C Epstein-Barr virus
D HIV-1
E Human herpesvirus-8
(a question about HIV and another virus related to it appeared)
14) A 32-year-old woman has experienced dull pelvic pain
for the past 2 months. Physical examination shows a right adnexal
mass. An abdominal ultrasound scan shows a 7.5-cm
cystic ovarian mass. The mass is surgically excised. The surface
of the mass is smooth, and it is not adherent to surrounding
pelvic structures. On gross examination, the cystic mass
is filled with hair. Microscopically, squamous epithelium, tall
columnar glandular epithelium, cartilage, and fibrous connective
tissue are present and resemble normal tissue counterparts.
Which of the following is the most likely diagnosis?
A Adenocarcinoma
B Fibroadenoma
C Glioma
D Hamartoma
E Mesothelioma
F Rhabdomyosarcoma
G Teratoma
15) A 44-year-old woman feels painless lumps in her armpit,
which were not present a month ago. On examination, right
axillary lymphadenopathy is present. The nodes are painless
but firm. Which of the following is the most likely lesion in her
right breast?
A Acute mastitis with abscess
B Fibroadenoma
C Infiltrating lobular carcinoma
D Intraductal carcinoma
E Leiomyosarcoma
16) The mother of a 5-year-old boy notices that his abdomen
has enlarged in the past 6 months. On physical examination
there is an ill-defined abdominal mass. An abdominal CT scan
shows a 9-cm mass in the region of the right adrenal gland.
The mass is removed and microscopically shows primitive
hyperchromatic
cells. Cytogenetic analysis of tumor cells shows
many double minutes and homogeneously staining regions.
Which of the following genes is most likely to have undergone
alterations to produce these findings?
A BCL1 (cyclin gene)
B BCL2 (anti-apoptosis gene)
C IL2 (growth factor gene)
D K-RAS (GTP-binding protein gene)
E Lyn (tyrosine kinase gene)
F N-MYC (transcription factor gene)
17) A 3-year-old child has exhibited difficulty with vision in
her right eye. On physical examination, there is leukocoria of the
right eye, consistent with a mass in the posterior chamber. MR
imaging shows a mass that nearly fills the globe. The child undergoes
enucleation of the right eye. Molecular analysis of the
neoplastic cells indicates absence of both copies of a gene that
contributes to control of the cell cycle. Which of the following
genes has most likely undergone mutation in this neoplasm?
A BCR-ABL
B BCL2
C hMSH2
D K-RAS
E NF1
F p53
G RB
18) A 63-year-old man has a cough with hemoptysis for
10 days. He has a 65 pack-year history of smoking. A chest
CT scan shows a 5-cm right hilar mass. Bronchoscopy is performed,
and lung biopsy specimens show small cell anaplastic
lung carcinoma. His family history shows three first-degree
maternal relatives who developed leukemia, sarcoma, and
carcinoma before age 40 years. Which of the following gene
products is most likely to have been altered by mutation to
produce these findings?
A APC (tumor suppressor)
B BCL2 (anti-apoptosis)
C K-RAS (GTP binding)
D NF1 (GTPase activation)
E p53 (DNA damage response)
19) A 91-year-old woman is hospitalized with sepsis. On
examination she has fever and hypotension. Laboratory
studies show positive blood cultures. She has disseminated
intravascular coagulopathy and pulmonary diffuse alveolar
damage with respiratory distress. Analysis of the microbiology
laboratory findings shows that the organisms cultured
are gram-negative bacilli. Which of the following substances
elaborated by these organisms is most likely to cause this
complex of clinical findings?
A Endotoxin
B Exotoxin
C Mycolic acid
D RNA polymerase
E Superantigen
F Tumor necrosis factor
20) A 6-year-old girl has a blotchy, reddish-brown rash
on her face, trunk, and proximal extremities that developed
over the course of 3 days. On physical examination, she has
0.2-cm to 0.5-cm ulcerated lesions on the oral cavity mucosa
and generalized tender lymphadenopathy. A cough with
minimal sputum production becomes progressively worse
over the next 3 days. Which of the following viruses is most
likely to produce these findings?
A Epstein-Barr
B Mumps
C Rubella
D Rubeola
E Varicella zoster
A 31-year-old HIV-positive man has had increasing
respiratory difficulty for the past 2 days. On physical examination,
crackles are auscultated over all lung fields. A chest
radiograph shows bilateral interstitial infiltrates. Laboratory
studies show 26,800 copies of HIV-1 RNA/mL. A transbronchial
biopsy is performed; the microscopic appearance of the
specimen is shown in the figure. Which of the following is the
most likely causative organism of his pulmonary disease?
A Adenovirus
USE DISCREETLY
B Cytomegalovirus
C Epstein-Barr virus
D Herpes zoster virus
E Respiratory syncytial virus
21)16 A 36-year-old woman has been using low-dose estrogen–
containing oral contraceptives for the past 20 years. She
has smoked one pack of cigarettes per day for the past 18
years. She is G2, P2, and both pregnancies ended with term
live-born infants of low birth weight, but no anomalies. On
physical examination, no abnormal findings are noted. Her
BMI is 24. She is at increased risk for developing which of the
following conditions?
A Breast carcinoma
B Cholecystitis
C Dementia with Lewy bodies
D Endometrial carcinoma
E Myocardial infarction
F Ovarian carcinoma
22) A 75-year-old woman lives alone and eats sparingly because
of her low fixed retirement income. For the past 2 weeks,
she has noticed pain in her right leg. On physical examination,
there is marked tenderness to palpation over the lateral aspect
of the right shin, a poorly healed cut on the right hand, and a
diffuse hyperkeratotic skin rash. A radiograph shows a right
tibial diaphyseal subperiosteal hematoma. Laboratory studies
show a hemoglobin level of 11.3 g/dL. A deficiency of which of
the following nutrients is most likely to explain these findings?
A Ascorbic acid
B Folate
C Niacin
D Riboflavin
E Vitamin A
F Vitamin K
23) A healthy, 44-year-old woman, G2, P1, has a screening
ultrasound at 18 weeks’ gestation that shows no fetal
anomalies. There is decreased fetal movement at 32 weeks’
gestation, and ultrasound shows fetal growth restriction
with relative sparing of the fetal head. The placenta appears
normally positioned in the lateral fundus, but appears small,
and the amniotic fluid index is reduced. Maternal blood
pressure is normal. Which of the following conditions is
most likely to be present?
A Uteroplacental insufficiency
B Congenital Treponema pallidum infection
C Galactosemia
D Preeclampsia
E Rh incompatibility
F Trisomy 21
24) A 17-year-old primigravida gives birth at 37 weeks’
gestation. Her Hgb A1C is 6%. The birth weight is 2350 g. On
physical examination, the infant has multiple congenital
abnormalities
including single umbilical artery, cleft lip, and
spina bifida occulta. Which of the following is the most likely
risk factor for these findings?
A Infection
B Gestational diabetes
C Single gene defect
D Teratogen
E Unknown

25) A 25-year-old woman, G3, P2, is in her 39th week of pregnancy.
She has felt no fetal movement for 1 day. The infant is stillborn
on vaginal delivery the next day. On physical examination,
there are no external anomalies. Microscopic examination of the
placenta shows acute chorioamnionitis. Which of the following
infectious agents is most likely responsible for these events?
A Cytomegalovirus
B Herpes simplex virus type 2
C Streptococcus agalactiae (group B)
D Toxoplasma gondii
E Treponema pallidum
26) An 84-year-old man with a lengthy history of smoking
survived a small myocardial infarction 2 years ago. He now
reports chest and leg pain during exercise. On physical examination,
his vital signs are temperature, 37.1° C; pulse, 81/min;
respirations, 15/min; and blood pressure, 165/100 mm Hg.
Peripheral pulses are poor in the lower extremities. There is
a 7-cm pulsating mass in the midline of the lower abdomen.
Laboratory studies include two fasting serum glucose measurements
of 170 mg/dL and 200 mg/dL. Which of the following
vascular lesions is most likely to be present in this patient?
A Aortic dissection
B Arteriovenous fistula
C Atherosclerotic aneurysm
D Polyarteritis nodosa
E Takayasu arteritis
F Thromboangiitis obliterans
27) A 43-year-old man has experienced malaise, fever, and
a 4-kg weight loss over the past month. On physical examination,
his blood pressure is 145/90 mm Hg, and he has mild diffuse
abdominal pain, but no masses or hepatosplenomegaly.
Laboratory studies include a serum urea nitrogen concentration
of 58 mg/dL and a serum creatinine level of 6.7 mg/dL.
Renal angiography shows right renal arterial thrombosis, and
the left renal artery and branches show segmental luminal narrowing
with focal aneurysmal dilation. During hemodialysis
1 week later, he experiences abdominal pain and diarrhea and
is found to have melena. Which of the following serologic
laboratory test findings is most likely to be positive in this
patient?
A ANA
B C-ANCA
C HIV
D HBsAg
E Scl-70
F RPR
28) A 50-year-old man has had a chronic cough for the past
18 months. Physical examination shows nasopharyngeal ulcers,
and the lungs have diffuse crackles bilaterally on auscultation.
Laboratory studies include a serum urea nitrogen level
of 75 mg/dL and a creatinine concentration of 6.7 mg/dL. Urinalysis
shows 50 RBCs per high-power field and RBC casts.
His serologic titer for C-ANCA (proteinase 3) is elevated.
A chest radiograph shows multiple, small, bilateral pulmonary
nodules. A transbronchial lung biopsy specimen shows a necrotizing
inflammatory process involving the small peripheral
pulmonary arteries and arterioles. Which of the following is
the most likely diagnosis?
A Granulomatosis with polyangiitis
B Fibromuscular dysplasia
USE DISCREETLY
C Granuloma pyogenicum
D Kaposi sarcoma
E Polyarteritis nodosa
F Takayasu arteritis
29) An 8-year-old child has had abdominal pain and dark
urine for 10 days. Physical examination shows blotchy purple
skin lesions on the trunk and extremities. Urinalysis shows hematuria
and proteinuria. Serologic test results are negative for
MPO-ANCA (P-ANCA) and PR3-ANCA (C-ANCA). A skin
biopsy specimen shows necrotizing vasculitis of small dermal
vessels. A renal biopsy specimen shows immune complex deposition
in glomeruli, with some IgA-rich immune complexes.
Which of the following is the most likely diagnosis?
A Giant cell arteritis
B Henoch-Schonlein purpura
C Polyarteritis nodosa
D Takayasu arteritis
E Telangiectasias
30) A 50-year-old man has had increasing abdominal discomfort
and swelling of his legs for the past 2 years. He has
smoked cigarettes for 35 years. On physical examination, he
has jugular venous distention, even when sitting up. The liver
is enlarged and tender and can be palpated 10 cm below the
right costal margin. Pitting edema is observed on the lower
extremities. A chest radiograph shows bilateral diaphragmatic
flattening, pleural effusions, and increased lucency of lung
fields. Thoracentesis on the right side yields 500 mL of clear
fluid with few cells. Which of the following is most likely to be
the underlying disease in this patient?
A Acute myocardial infarction
B Chronic bronchitis
C Primary pulmonary hypertension
D Pulmonary valve stenosis
E Tricuspid valve stenosis
31) Following an uncomplicated pregnancy, a term infant
appears normal at birth, but at 1 day of life the infant develops
respiratory distress. On physical examination the infant has
tachypnea, tachycardia, and cyanosis. There is an S1 ejection
click and a split S2 with prominent P sound. A radiograph
shows normal heart size but prominent hilar vascular markings.
Echocardiography shows a small left atrium, large right
atrium, normally sized ventricles, widely patent foramen ovale,
and normally positioned aorta and pulmonary trunk. What
type of congenital heart disease does this infant most likely
have?
A Atrial septal defect
B Coarctation of the aorta, preductal type
C Patent ductus arteriosus
D Tetralogy of Fallot
E Total anomalous pulmonary venous connection
32) A 3-year-old child is developing normally. Physical
examination reveals a low-pitched cardiac murmur. An
echocardiogram
shows the presence of an ostium secundum, with
a 1-cm defect. Which of the following abnormalities is most
likely to be found in this child?
A Cyanosis at rest
B Left-to-right shunt
C Mural thrombosis
D Pericardial effusion
E Pulmonary hypertension
33) A 14-year-old boy has a high fever of 10 days’ duration.
Physical examination shows a temperature of 38.3° C; pulse,
100/min; respiratory rate, 28/min; and blood pressure, 80/40
mm Hg. He has scattered petechial hemorrhages on the trunk
and extremities. There is no enlargement of liver, spleen, or
lymph nodes. The CBC shows hemoglobin, 13.2 g/dL; hematocrit,
38.9%; MCV, 93 μm3; platelet count, 175,000/mm3; and
WBC count, 1850/mm3 with 1% segmented neutrophils, 98%
lymphocytes, and 1% monocytes. Which of the following is
the most likely diagnosis?
A Acute lymphoblastic leukemia
B Acute myelogenous leukemia
C Aplastic anemia
D Idiopathic thrombocytopenic purpura
E Systemic inflammatory response syndrome
34) A 28-year-old man is brought to the emergency department
with shock that developed over the past 12 hours. On
physical examination, his temperature is 38.6° C, pulse is 101/
min, respirations are 26/min, and blood pressure is 80/40
mm Hg. Needle tracks are noted in the left antecubital fossa.
Crackles are heard over the lower lung fields. CBC shows hemoglobin,
14.1 g/dL; hematocrit, 42.6%; MCV, 93 μm3; platelet
count, 127,500/mm3; and WBC count, 12,150/mm3 with 71%
segmented neutrophils, 8% bands, 14% lymphocytes, and 7%
monocytes. The neutrophils show cytoplasmic toxic granulations
and Döhle bodies. Which of the following is the most
likely diagnosis?
A Acute myelogenous leukemia
B Chronic myelogenous leukemia
C Infectious mononucleosis
D Pneumocystis jiroveci pneumonia
E Pseudomonas aeruginosa septicemia
F Pulmonary Mycobacterium tuberculosis
35) A 70-year-old man has experienced increasing fatigue
for the past 6 months. On physical examination, he has nontender
axillary and cervical lymphadenopathy, but there is no
hepatosplenomegaly. The CBC shows hemoglobin, 9.5 g/dL;
hematocrit, 28%; MCV, 90 μm3; platelet count, 120,000/mm3;
and WBC count, 42,000/mm3. His peripheral blood smear
shows a monotonous population of small, round, maturelooking
lymphocytes. Flow cytometry shows these cells to
be CD19+, CD5+, and deoxynucleotidyl
transferase negative
(TdT−). Cytogenetic and molecular analysis of the abnormal
cells in his blood are most likely to reveal which of the following
alterations?
A Clonal rearrangement of immunoglobulin genes
B Clonal rearrangement of T-cell receptor genes
C t(8;14) leading to c-MYC overexpression
D t(9;22) leading to BCR-ABL rearrangement
E t(14;18) leading to BCL2 overexpression
35) A 12-year-old boy has had increasing abdominal distention
and pain for the past 3 days. Physical examination of his
abdomen shows lower abdominal tenderness with tympany
and reduced bowel sounds. An abdominal CT scan shows a
7-cm mass involving the region of the ileocecal valve. Surgery
is performed and the resected mass microscopically shows
sheets of intermediate-sized lymphoid cells, with nuclei having
coarse chromatin, several nucleoli, and many mitotic figures.
USE DISCREETLY
A bone marrow biopsy sample is negative for this cell population.
Cytogenetic analysis of the cells from the mass shows
a t(8;14) karyotype. Flow cytometric analysis reveals 40% of
the cells are in S phase. The tumor shrinks dramatically after
a course of chemotherapy. Which of the following is the most
likely diagnosis?
A Acute lymphoblastic leukemia/lymphoma
B Burkitt lymphoma
C Diffuse large B-cell lymphoma
D Follicular lymphoma
E Plasmacytoma
Maybe one more question is missing
36) A 28-year-old woman has had a constant feeling of lethargy
since childhood. On physical examination, she is afebrile
and has a pulse of 80/min, respirations of 15/min, and blood
pressure of 110/70 mm Hg. The spleen tip is palpable, but
there is no abdominal pain or tenderness. Laboratory studies
show hemoglobin of 11.7 g/dL, platelet count of 159,000/
mm3, and WBC count of 5390/mm3. The peripheral blood
smear shows small round erythrocytes that lack a zone of central
pallor. An inherited abnormality in which of the following
RBC components best accounts for these findings?
A α-Globin chain
B β-Globin chain
C Carbonic anhydrase
D Glucose-6-phosphate dehydrogenase
E Heme with porphyrin ring
F Spectrin cytoskeletal protein
37) A 73-year-old man takes no medications and has had no
prior major illnesses or surgeries. For the past year, he has become
increasingly tired and listless. Physical examination shows
that he appears pale but has no hepatosplenomegaly and no
deformities.
CBC shows hemoglobin, 9.7 g/dL; hematocrit, 29.9%;
MCV, 69.7 mm3; RBC count, 4.28 million/mm3; platelet count,
331,000/mm3; and WBC count, 5500/mm3. His peripheral blood
smear is shown in the figure. Which of the following is the most
likely underlying condition causing this patient’s findings?
A Autoimmune hemolytic anemia
B Chronic alcohol abuse
C β-Thalassemia major
D Hemophilia A
E Occult malignancy
F Vitamin B12 deficiency
38) A 62-year-old man is taken to the emergency department
in a state of inebriation. He is well known there because this scenario
has been repeated many times over 15 years. On physical
examination, he is afebrile. The spleen tip is palpable, and the liver
edge is firm. Laboratory studies show hemoglobin of 8.2 g/dL,
hematocrit of 25.1%, MCV of 107 μm3, platelet count of 135,000/
mm3, and WBC count of 3920/mm3. The peripheral blood smear
shows prominent anisocytosis and macrocytosis. Polychromatophilic
RBCs are difficult to find. A few of the neutrophils show
six to seven nuclear lobes. Which of the following is the most
likely explanation of these findings in his peripheral blood cells?
A Diminished nuclear maturation from impaired
DNA synthesis
B Extravascular hemolysis of antibody-coated cells
C Imbalance in synthesis of α-globin and β-globin chains
D Increased susceptibility to lysis by complement
E Reduced deformability of RBC membranes
39) A 52-year-old woman, an electrical engineer and nonsmoker,
has a 3-month history of increasing dyspnea. On examination
she is afebrile and normotensive. CT imaging of her
chest shows lower lobe reticular opacities. A transbronchial
biopsy is performed and microscopically shows patchy interstitial
inflammation with lymphocytes and plasma cells. No
organisms are identified. Her condition slowly worsens over
the next 10 years. Which of the following is the most likely
diagnosis?
A Desquamative interstitial pneumonitis
B Hypersensitivity pneumonitis
C Idiopathic interstitial fibrosis
D Nonatopic bronchial asthma
E Nonspecific interstitial pneumonia
40) A 68-year-old woman had a cerebral infarction and
was hospitalized for 3 weeks. Her condition improved, and
she was able to get up and move about with assistance. A few
minutes after walking to the bathroom, she experienced sudden
onset of severe dyspnea with chest pain and diaphoresis.
Despite resuscitative measures, she died 30 minutes later. The
major autopsy finding is shown in the figure. Which of the following
is the most likely mechanism for sudden death in this
patient?
A Bronchoconstriction
B Compression atelectasis
C Hemorrhagic infarction
D Interstitial edema
E Acute cor pulmonale
41) A 75-year-old woman has had worsening lower leg
edema and dyspnea for the past 5 years. On physical examination,
her temperature is 36.9° C, pulse is 74/min, respirations
are 19/min, and blood pressure is 110/75 mm Hg. There is
dullness to percussion at the lung bases. A low rumbling heart
murmur is present. A chest radiograph shows bilateral pleural
effusions. An echocardiogram shows a large (4-cm) atrial septal
defect. Which of the following conditions is most likely to
be present in this woman?
A Pulmonary hypertension
B Granulomatous inflammation
C Hemorrhagic infarction
D Interstitial fibrosis
E Necrotizing vasculitis
42) A 50-year-old man has developed truncal obesity, back
pain, and skin that bruises easily over the past 5 months. On
physical examination, he is afebrile, and his blood pressure
is 160/95 mm Hg. A chest radiograph shows an ill-defined,
4-cm mass involving the left hilum of the lung. Cytologic examination
of bronchial washings from bronchoscopy shows
round epithelial cells that have the appearance of lymphocytes
but are larger. The patient is told that, although his disease is
apparently localized to one side of the chest cavity, surgical
treatment is unlikely to be curative. He also is advised to stop
smoking. Which of the following neoplasms is most likely to
be present in this patient?
A Adenocarcinoma
B Bronchial carcinoid
C Bronchioloalveolar carcinoma
D Large cell carcinoma
E Non-Hodgkin lymphoma
USE DISCREETLY
F Small cell anaplastic carcinoma
G Squamous cell carcinoma
43) A 72-year-old woman has had difficulty with vision in
her right eye for 3 months. She also has pain in the right upper
chest. The findings on physical examination include unilateral
enophthalmos, miosis, anhidrosis, and ptosis on the right side
of her face. A chest radiograph shows right upper lobe opacification
and bony destruction of the right first rib. Which of the
following conditions is most likely to be present in her?
A Bronchopneumonia
B Bronchiectasis
C Bronchogenic carcinoma
D Sarcoidosis
E Tuberculosis
44) A 47-year-old woman, a non-smoker, has a 4-month history
of mild but persistent right-sided chest pain. On physical
examination, there are no remarkable findings. A chest radiograph
shows a pleural mass on the right side. No pleural effusions
are seen. Chest CT scan shows a localized, circumscribed
3 × 7 cm mass attached to the visceral pleura; the lungs and
chest wall appear normal. At thoracotomy, the mass is excised.
On microscopic examination, the mass is composed of spindle
cells resembling fibroblasts with abundant collagenous
stroma. With immunohistochemical staining, the spindle cells
mark for CD34, but are cytokeratin-negative. There has been
no recurrence of the lesion. Which of the following is the most
likely diagnosis?
A Bronchioloalveolar carcinoma
B Hamartoma
C Hodgkin lymphoma, nodular sclerosis type
D Malignant mesothelioma
E Metastatic breast carcinoma
F Solitary fibrous tumor
45 A 19-year-old woman has noted swelling in the back of
her mouth for 2 months. On dental examination, she has an
area of swelling in the location of the left third molar. Dental
radiographs show a radiolucent unilocular, well-circumscribed
cyst surrounding the crown of the unerupted third mandibular
molar. The lesion is excised, and on microscopic examination,
the cyst is lined by stratified squamous epithelium and surrounded
by a chronic inflammatory infiltrate. What is the most
likely diagnosis?
A Ameloblastoma
B Dentigerous cyst
C Odontogenic keratocyst
D Odontoma
E Periapical cyst/granuloma
46) A 58-year-old man bothered by increasing hoarseness
for almost 6 months now has an episode of hemoptysis. On
physical examination, no lesions are noted in the nasal or
oral cavity. There is a firm, nontender anterior cervical lymph
node. The lesion shown in the figure is identified by endoscopy.
The patient undergoes biopsy, followed by laryngectomy
and neck dissection. Which of the following etiologic factors
most likely played the greatest role in the development of this
lesion?
A Epstein-Barr virus infection
B Human papillomavirus infection
C Repeated bouts of aspiration
D Smoking tobacco
E Type I hypersensitivity
47) A 22-year-old woman has had multiple episodes of aspiration
of food associated with difficulty swallowing during the
past year. On auscultation of her chest, crackles are heard at the
base of the right lung. A barium swallow shows marked esophageal
dilation above the level of the lower esophageal sphincter.
A biopsy specimen from the lower esophagus shows an absence
of the myenteric ganglia. What is the most likely diagnosis?
A Achalasia
B Barrett esophagus
C Plummer-Vinson syndrome
D Sliding hiatal hernia
E Systemic sclerosis
48) A 57-year-old woman has had burning epigastric
pain after meals for more than 1 year. Physical examination
shows no abnormal findings. Upper gastrointestinal endoscopy
shows an erythematous patch in the lower esophageal
mucosa. A biopsy specimen shows basal zone squamous epithelial
hyperplasia, elongation of lamina propria papillae, and
scattered intraepithelial neutrophils with some eosinophils.
Which of the following is the most likely diagnosis?
A Barrett esophagus
B Esophageal varices
C Iron deficiency
D Reflux esophagitis
E Systemic sclerosis
49) A 51-year-old man has sudden onset of massive emesis
of bright red blood. On physical examination, his temperature
is 36.9° C, pulse is 103/min, respirations are 23/min, and
blood pressure is 85/50 mm Hg. His spleen tip is palpable.
Laboratory studies show a hematocrit of 21%. The serologic
test result for HBsAg is positive. He has had no prior episodes
of hematemesis. The hematemesis
is most likely to be a consequence
of which of the following?
A Barrett esophagus
B Candida albicans infection
C Esophageal varices
D Reflux esophagitis
E Squamous cell carcinoma
F Zenker diverticulum
50) A 72-year-old man takes large quantities of nonsteroidal
anti-inflammatory drugs (NSAIDs) because of chronic degenerative
arthritis of the hips and knees. Over the past 2 weeks,
he has had epigastric pain with nausea and vomiting and an
episode of hematemesis. On physical examination, there are
no remarkable findings. A gastric biopsy specimen is most
likely to show which of the following lesions?
A Acute gastritis
B Adenocarcinoma
C Epithelial dysplasia
D Helicobacter pylori infection
E Hyperplastic polyp
51) A 59-year-old man has had nausea and vomiting for
5 months. He has experienced no hematemesis. On physical
examination, there is no abdominal tenderness, and bowel
sounds are present. Upper gastrointestinal endoscopy shows
erythematous areas of mucosa with thickening of the rugal
folds in the gastric antrum. The microscopic appearance of a
gastric biopsy specimen with a Steiner silver stain is shown
in the figure. Which of the following factors is most likely
responsible for this gastric mucosal pathology?
USE DISCREETLY
A Cysteine proteinase
B Cytotoxin-associated gene A
C Heat-stable enterotoxin
D Shiga toxin
E Verocytotoxin
52) A 49-year-old woman has a history of peptic ulcer disease
for which she has been treated with proton pump inhibitors. She
has had nausea with vomiting for the past 2 months. Upper GI
endoscopy reveals three circumscribed, round, smooth lesions
in the gastric body from 1 to 2 cm in diameter. Biopsies are taken
and microscopically show the lesions to consist of irregular
glands that are cystically dilated and lined by flattened parietal
and chief cells. No inflammation, Helicobacter pylori, metaplasia,
or dysplasia is present. What is the most likely diagnosis?
A Fundic gland polyps
B Gastric adenomas
C Hyperplastic polyps
D Hypertrophic gastropathy
53) A 53-year-old woman has had nausea, vomiting, and
midepigastric pain for 5 months. On physical examination, there
are no significant findings. An abdominal CT scan shows gastric
outlet obstruction. Upper gastrointestinal endoscopy shows an
ulcerated 2 × 4 cm bulky mass in the antrum at the pylorus. A
urease test is positive. Which of the following neoplasms is most
likely to be seen in a biopsy specimen of this mass?
A Adenocarcinoma
B Leiomyosarcoma
C Neuroendocrine carcinoma
D Non-Hodgkin lymphoma
E Squamous cell carcinoma
54) Hirschsprung
55) A 54-year-old woman has a long history of chronic hepatitis
B infection and has had increasing malaise for the past
year. She was hospitalized 1 year ago because of upper
gastrointestinal
hemorrhage. Physical examination now shows a
firm nodular liver. Laboratory findings show a serum albumin
level of 2.5 g/dL and prothrombin time of 28 seconds. Which
of the following additional physical examination findings is
most likely to be present in this woman?
A Caput medusae
B Diminished deep tendon reflexes
C Distended jugular veins
D Papilledema
E Splinter hemorrhage
56) A 59-year-old man has had increasing dyspnea on exertion
for the past year. His dyspnea is worse in the upright
position and diminishes when he is recumbent. On physical
examination he has clubbing of the fingers. Exercise induces
a decrease in his Po2 that improves when he stops and lies
down. Which of the following liver abnormalities is he most
likely to have?
A Biliary obstruction
B Chronic inflammation
C Cirrhosis
D Metastases
E Steatosis
57) A 42-year-old man experiences malaise and increasing
icterus for 2 weeks. Physical examination shows jaundice, but
there are no other significant findings. Serologic test results are
positive for IgM anti-HAV and negative for anti-HCV, HBsAg,
and IgM anti-HBc. Which of the following outcomes is most
likely to occur in this man?
A Chronic active hepatitis
B Complete recovery
C Fulminant hepatitis
D Hepatocellular carcinoma
E Negative serologic test results
58) A 41-year-old woman who works as a tattoo artist has
had increasing malaise and nausea for the past 2 weeks. On
physical examination, she has icterus and mild right upper
quadrant tenderness. Laboratory studies show serum AST of
79 U/L, ALT of 85 U/L, total bilirubin of 3.3 mg/dL, and direct
bilirubin of 2.5 mg/dL. She continues to have malaise for the
next year. A liver biopsy is done, and microscopic examination
shows minimal hepatocyte necrosis, mild steatosis, and
minimal portal bridging fibrosis. An infection with which of
the following viruses is most likely to produce these findings?
A HAV
B HBV
C HCV
D HDV
E HEV
59) A second year medical student develops malaise, fatigue, and loss
of appetite, 3 weeks after a meal at a local carenderia. He noted
passing dark urine and has mild scleral icterus, and right upper
quadrant tenderness. Serum AST of 62, ALT of 58, total bilirubin
concentration of 3.9, and a direct bilirubin concentration of 2.8. Which
of the following serologic tests is most likely to be positive in this
patient?
a. Anti-HAV
b. Anti-HBc
c. Anti-HBs
d. Anti-HCV
59) A 65-year-old woman has had upper abdominal pain for
the past month. On examination, the pain is localized to the
epigastric region on palpation. Abdominal CT scan shows a
well-circumscribed, 8-cm mass in the tail of the pancreas that
has many small fluid-filled areas. At laparotomy, the mass is
removed and on microscopic examination shows glycogenrich,
low cuboidal cells surrounding spaces filled with clear
fluid. There is no recurrence of the lesion. What is the most
likely diagnosis?
A Adenocarcinoma
B Autosomal dominant polycystic kidney disease
C Chronic pancreatitis
D Cystic fibrosis
E Pseudocyst
F Serous cystadenoma
60) A 36-year-old woman has had increased malaise for 3
weeks and urine output <500 mL/day for the past 4 days. On
examination, she has blood pressure 170/112 mm Hg and peripheral
edema. Urinalysis shows protein 1+ and blood 3+, but
no glucose or ketones. Urine microscopic analysis shows RBCs
and RBC casts. Her serum urea nitrogen is 39 mg/dL, and creatinine
is 4.3 mg/dL. Her serum complement C1q, C3, and C4
are decreased. A renal biopsy is performed, and immunofluorescence
microscopy shows a granular pattern of staining with
antibody to C3. Which of the following types of hypersensitivity
USE DISCREETLY
reactions is most likely causing her renal disease?
A I (IgE-mediated systemic anaphylaxis)
B II (Antibody-dependent cell-mediated cytotoxicity)
C III (Immune complex formation)
D IV (Delayed-type hypersensitivity)
61) A 17-year-old girl living in the Congo has had a chronic
febrile illness for 2 years. In the past 2 days she notes her urine
is smoky brown. On physical examination her blood pressure
is 145/95 mm Hg. Laboratory studies show her serum creatinine
is 3.7 mg/dL, and urea nitrogen is 35 mg/dL. Urinalysis
shows 4+ blood with 1+ protein, but no glucose, ketones, or
leukocytes. The serum haptoglobin is decreased and Coombs
test is negative. Her Hgb is 8.5 g/dL. A peripheral blood
smear shows rare ring stage trophozoites. Immunofluorescence
microscopy performed on renal biopsy shows granular
deposition of IgG and C3 in glomerular capillary basement
membranes. Electron microscopy shows electron-dense subepithelial
“humps.” Which of the following renal diseases is
she most likely to have?
A Focal segmental glomerulosclerosis
B Hereditary nephritis
C IgA nephropathy
D Lupus nephritis
E Membranous nephropathy
F Acute proliferative glomerulonephritis
62) A 46-year-old woman has had worsening malaise for
the past 36 hours. Her urine output is markedly diminished,
and it has a cloudy brown appearance. On examination she
has periorbital edema. Laboratory findings include serum creatinine
of 2.8 mg/dL and urea nitrogen of 30 mg/dL. A renal
biopsy is performed and on microscopic examination shows
focal necrosis in glomeruli with glomerular basement membrane
breaks and crescent formation. No immune deposits are
identified with immunofluorescence. Which of the following
autoantibodies is most likely detectable in her serum?
A Anti–DNA topoisomerase antibody
B Anti–glomerular basement membrane antibody
C Anti–neutrophil cytoplasmic autoantibody
D Antinuclear antibody
E Anti-HBs Ag
63) A 48-year-old man has had increased swelling in the
extremities for 2 months. Physical examination showed generalized
edema. A 24-hour urine collection yielded 4.1 g of
protein (albumin and globulins). He did not respond to a
course of corticosteroid therapy. A renal biopsy was done,
and microscopic examination showed diffuse thickening of
the basement membrane. Immunofluorescence staining with
antibody to the C3 component of complement was positive
in a granular pattern in the glomerular capillary loops.
Two years later, he experiences increasing malaise. Laboratory
studies now show serum creatinine level of 4.5 mg/dL
and urea nitrogen level of 44 mg/dL. Which of the following
immunologic mechanisms was most likely responsible for the
glomerular changes observed in the biopsy specimen?
A Antibodies that react with basement membrane
collagen
B Antibodies against streptococci that cross-react with
the basement membrane
C Cytotoxic T cells directed against renal antigens
D Deposition of immune complexes on the basement
membrane
E Release of cytokines by inflammatory cells
64) A 7-year-old boy has become less active over the past
10 days. On physical examination, the boy has facial puffiness.
Urinalysis shows no blood, glucose, or ketones, and
microscopic examination shows no casts or crystals. The serum
creatinine level is normal. A 24-hour urine collection yields
3.8 g of protein. He improves after corticosteroid therapy. He
has two more episodes of proteinuria over the next 4 years,
both of which respond to corticosteroid therapy. What is the
most likely mechanism causing his disease?
A Cytokine-mediated visceral epithelial cell injury
B Cytotoxic T cell–mediated tubular epithelial cell
injury
C IgA-mediated mesangial cell injury
D Immune complex–mediated glomerular injury
E Verocytotoxin-induced endothelial cell injury
65) A 6-year-old girl has become increasingly lethargic over
the past 2 weeks. On examination she has puffiness around the
eyes. Her temperature is 36.9° C, and blood pressure is 100/60
mm Hg. Laboratory findings show serum creatinine, 0.7 mg/
dL; urea nitrogen, 12 mg/dL; and cholesterol, 217 mg/dL. Urinalysis
shows pH, 6.5; specific gravity, 1.011; 4+ proteinuria;
lipiduria; and no blood or glucose. The 24-hour urine protein
level is 3.8 g. The child’s condition improves after glucocorticoid
therapy. Which of the following findings by electron microscopy
is most likely to characterize this disease process?
A Areas of thickened and thinned basement
membrane
B Effacement of podocyte foot processes
C Increased mesangial matrix
D Reduplication of glomerular basement membrane
E Subepithelial electron-dense humps
66) A 12-year-old girl has experienced increasing malaise
for the past 2 weeks. On physical examination, she has periorbital
edema. The child is afebrile. Laboratory findings show
proteinuria on dipstick urinalysis, but no hematuria or glucosuria.
Microscopic examination of the urine shows numerous
oval fat bodies. The serum creatinine level is 2.3 mg/dL.
She receives a course of corticosteroid therapy, but does not
improve. A renal biopsy is performed and microscopic examination
shows that approximately 50% of the glomeruli in the
specimen are affected by the lesion shown in the figure. What
is the most likely diagnosis?
A Dense deposit disease
B Focal segmental glomerulosclerosis
C Minimal change disease
D Nodular glomerulosclerosis
E Postinfectious glomerulonephritis
F Rapidly progressive glomerulonephritis
67) A 38-year-old woman has been feeling lethargic for
4 months. On physical examination, she is afebrile, and her
blood pressure is 140/90 mm Hg. Laboratory findings show
the serum creatinine level is 5.8 mg/dL. C3 nephritic factor
is present in serum, resulting in hypocomplementemia, and
the ANA test result is negative. Urinalysis shows 2+ blood
and 1+ protein. A renal biopsy is done; microscopic examination
shows hypercellular glomeruli and prominent ribbonlike
deposits along the lamina densa of the glomerular basement
membrane. Which of the following forms of glomerulonephritis
is most likely to be present in this patient?
A Chronic glomerulonephritis
USE DISCREETLY
B Dense deposit disease
C Membranous nephropathy
D Postinfectious glomerulonephritis
E Rapidly progressive glomerulonephritis
68) A 25-year-old man has a 5-year history of celiac sprue.
Four days after a mild upper respiratory infection, he begins
passing dark red-brown urine. The dark urine persists for
the next 3 days and then becomes clear and yellow, only to
become red-brown again 1 month later. There are no remarkable
findings on physical examination. Urinalysis shows a pH
of 6.5; specific gravity, 1.018; 3+ hematuria; 1+ proteinuria;
and no glucose or ketones. Microscopic examination of the
urine shows RBCs, but no WBCs, casts, or crystals. A 24-hour
urine protein level is 200 mg. A renal biopsy specimen from
the glomeruli of this patient is most likely to show which of
the following alterations?
A Diffuse cellular proliferation and basement membrane
thickening
B Granular staining of the basement membrane by
anti-IgG antibodies
C Mesangial IgA staining by immunofluorescence
D Subepithelial electron-dense deposits
E Thrombosis within the glomerular capillaries
69) A 15-year-old boy has been passing dark-colored urine
for the past month. On physical examination, he has bilateral
sensorineural hearing loss and corneal erosions. Urinalysis
shows a pH of 6.5; specific gravity, 1.015; 1+ hematuria;
1+ proteinuria; and no ketones, glucose, or leukocytes. The
serum creatinine level is 2.5 mg/dL, and the urea nitrogen
level is 24 mg/dL. A renal biopsy specimen shows tubular epithelial
foam cells by light microscopy. By electron microscopy,
the glomerular basement membrane shows areas of attenuation,
with splitting and lamination of lamina densa in other
thickened areas. What is the most likely diagnosis?
A Mutation in a gene encoding type IV collagen
B Increased synthesis of abnormal IgA
C Autoimmune destruction of pancreatic beta cells
D Acquired deficiency of ADAMTS13 metalloprotease
E Toxic injury to slit diaphragm proteins
A 56-year-old woman is found on health screening to
have a blood pressure of 168/109 mm Hg. No other physical
examination findings are noted. Urinalysis shows a pH of 7.0;
specific gravity, 1.020; 1+ proteinuria; and no blood, glucose,
or ketones. The ANA and ANCA test results are negative. The
serum urea nitrogen level is 51 mg/dL, and the creatinine level
is 4.7 mg/dL. The hemoglobin A1c concentration is within
the reference range. An abdominal ultrasound scan shows
bilaterally and symmetrically small kidneys with no masses.
What is her most likely diagnosis?
A Amyloidosis
B Autosomal dominant polycystic kidney disease
C Chronic glomerulonephritis
D Microscopic polyangiitis
E Nodular glomerulosclerosis
70) A 5-year-old boy has a history of recurrent urinary tract
infections. Urine cultures have grown Escherichia coli, Proteus
mirabilis, and Enterococcus. Physical examination now shows
an abnormal constricted opening of the urethra on the ventral
aspect of the penis, 1.5 cm from the tip of the glans penis.
There also is a cryptorchid testis on the right and an inguinal
hernia on the left. What term best describes the child’s penile
abnormality? 75) A 4-year-old girl is brought to the physician by her parents,
A Balanitis who noticed bloodstained underwear and “something”
B Bowen disease protruding from her external genitalia. On physical examination,
C Epispadias there are polypoid, grapelike masses projecting from the
D Hypospadias vagina. Histologic examination of a biopsy specimen from the
E Phimosis lesion shows small, round tumor cells, some of which have
eosinophilic
71) A 48-year-old man has noticed a reddish area on the straplike cytoplasm. Immunohistochemical staining
penis for the past 3 months. On physical examination, there shows desmin, vimentin, and myogenin in these cells. What is
is a solitary 0.8-cm, plaquelike, erythematous area on the distal the most likely diagnosis?
shaft of the penis. A routine microbiologic culture with a A Clear cell carcinoma
Gram-stained smear of the lesion shows normal skin flora. B Infiltrating squamous cell carcinoma
Microscopic examination of a biopsy specimen of the lesion C Neuroblastoma
shows dysplasia involving the full thickness of the epithelium. D Sarcoma botryoides
What is the most likely diagnosis? E Vulvar intraepithelial neoplasia
A Balanitis
B Bowen disease 76) A healthy 30-year-old woman comes to the physician for
C Condyloma acuminatum a routine health maintenance examination. No abnormalities
D Primary syphilis are found on physical examination. A screening Pap smear
E Soft chancre shows cells consistent with a low-grade squamous intraepithelial
lesion (LSIL). Subsequent cervical biopsy specimens confirm
72) Can’t find question. Choices: A. Atypical cells with hyperchromatic the presence of cervical intraepithelial neoplasia (CIN) I.
nuclei, B..Hyphae C.? D? Which of the following risk factors is most likely related to her
Pap smear findings?
73) A 25-year-old woman has experienced discomfort during A Diethylstilbestrol (DES) exposure
sexual intercourse for the past month. On physical examination, B Multiple sexual partners
there are no lesions of the external genitalia. Pelvic C Oral contraceptive use
examination shows a focal area of swelling on the left posterolateral D Prior treatment for a malignancy
inner labium that is very tender on palpation. A 3-cm E Vitamin B12 (cobalamin) deficiency
cystic lesion filled with purulent exudate is excised. In which of
the following structures is this lesion most likely to develop? 77) A 43-year-old woman has had postcoital bleeding for 6
A Bartholin gland months. She experienced menarche at age 11 years and has
B Gartner duct had 12 sexual partners during her life. She continues to have
C Hair follicle regular menstrual cycles without abnormal intermenstrual
D Urogenital diaphragm bleeding. Pelvic examination shows a focal, slightly raised
E Vestibular bulb area of erythema on the cervix at the 5 o’clock position. A Pap
smear shows a high-grade squamous intraepithelial lesion
74) A 57-year-old woman recently noticed a pale area of (HSIL), also termed severe cervical intraepithelial neoplasia (CIN
discoloration III). Analysis of cells from the cervix shows the presence of
on the labia. Pelvic examination shows the presence human papillomavirus type 16. Which of the following malignancies
of a 0.7-cm flat, white area on the right labia majora. A biopsy is she at greatest risk of developing if the lesion is not
specimen is obtained and on microscopic examination shows treated?
dysplastic cells that occupy half the thickness of the squamous A Clear cell carcinoma
epithelium, with minimal underlying chronic inflammation. B Immature teratoma
In situ hybridization shows human papillomavirus type 16 C Krukenberg tumor
DNA in the epithelial cells. What is the most likely diagnosis? D Leiomyosarcoma
A Chronic vulvitis E Sarcoma botryoides
B Condyloma acuminatum F Squamous cell carcinoma
C Lichen sclerosus et atrophicus
D Squamous hyperplasia 78) A 13-year-old girl began menstruation 1 year ago. She
E Vulvar intraepithelial neoplasia now has abnormal uterine bleeding, with menstrual periods
that are 2 to 7 days long and 2 to 6 weeks apart. The amount
An 18-year-old sexually active woman has had dyspareunia of bleeding varies from minimal spotting to a very heavy flow.
followed by vaginal bleeding for the past month. On On physical examination, there are no remarkable findings. A
pelvic examination, a red, friable, 2.5-cm nodular mass is seen pelvic ultrasound scan shows no abnormalities. Which of the
on the anterior wall of the upper third of the vagina. The microscopic following is most likely to produce these findings?
appearance of a biopsy specimen is shown in the A Anovulatory cycles
figure. Which of the following conditions is likely to have contributed B Ectopic pregnancy
most to the origin of this neoplasm? C Endometrial carcinoma
A Congenital adrenal hyperplasia D Endometrial polyp
B Diethylstilbestrol (DES) exposure E Uterine leiomyomata
C Human papillomavirus infection
D Polycystic ovary syndrome (PCOS) 79) A 32-year-old woman has cyclic abdominal pain that coincides
E Trichomonas vaginitis with her menses. Attempts to become pregnant have
failed over the past 5 years. There are no abnormal findings
USE DISCREETLY
on physical examination. Laparoscopic examination shows
numerous hemorrhagic 0.2- to 0.5-cm lesions over the peritoneal
surfaces of the uterus and ovaries. Which of the following
ovarian lesions is most likely to be associated with her
findings?
A Fibroma
B Brenner tumor
C Endometriotic cyst
D Krukenberg tumor
E Metastatic choriocarcinoma
F Mucinous cystadenocarcinoma
80) A 42-year-old woman has had menometrorrhagia for the
past 2 months. She has no history of prior irregular menstrual
bleeding, and she has not yet reached menopause. On physical
examination, there are no vaginal or cervical lesions, and
the uterus appears normal in size, but there is a right adnexal
mass. An abdominal ultrasound scan shows the presence of
a 7-cm solid right adnexal mass. Endometrial biopsy shows
hyperplastic endometrium, but no cellular atypia. What is the
most likely lesion that underlies her menstrual abnormalities?
A Corpus luteum cyst
B Endometrioma
C Granulosa-theca cell tumor
D Mature cystic teratoma
E Metastasis
F Polycystic ovarian syndrome
81) A 27-year-old woman feels a lump in her right breast.
She has normal menstrual cycles, she is G3, P3, and her last
child was born 5 years ago. On examination a 2-cm, irregular,
firm area is palpated beneath the lateral edge of the areola.
This lumpy area is not painful and is movable. There are no
lesions of the overlying skin and no axillary lymphadenopathy.
A biopsy specimen shows microscopic evidence of an
increased number of dilated ducts surrounded by fibrous connective
tissue. Fluid-filled ducts with apocrine metaplasia also
are present. What is the most likely diagnosis?
A Fibroadenoma
B Fibrocystic changes
C Infiltrating ductal carcinoma
D Mammary duct ectasia
E Traumatic fat necrosis
82) A 34-year-old woman has noticed a bloody discharge
from the nipple of her left breast for the past 3 days. On physical
examination, the skin of the breasts appears normal, and
no masses are palpable. There is no axillary lymphadenopathy.
She has regular menstrual cycles and is using oral contraceptives.
Excisional biopsy is most likely to show which of the
following lesions in her left breast?
A Acute mastitis
B Fibroadenoma
C Intraductal papilloma
D Phyllodes tumor
E Sclerosing adenosis
83) A 48-year-old woman has noticed a red, scaly area of
skin on her left breast that has grown slightly larger over the
past 4 months. On physical examination, there is a 1-cm area
of eczematous skin adjacent to the areola. The figure shows the
microscopic appearance of the skin biopsy specimen. What is
the most likely diagnosis?
A Apocrine metaplasia
USE DISCREETLY
B Fat necrosis
C Inflammatory carcinoma
D Lobular carcinoma in situ
E Paget disease of the breast
84) A 48-year-old woman has felt a poorly defined lump in
her right breast for the past year. On examination, she has a
nontender, firm, 6-cm mass in the upper inner quadrant of her
right breast. There are no lesions of the overlying skin and no
axillary lymphadenopathy. A biopsy is performed, and microscopic
examination of the specimen shows the findings in
the figure. The mass is excised with a wide margin, but recurs
1 year later. After further excision, the lesion does not recur.
What is the most likely diagnosis?
A Fibroadenoma
B Fibrocystic changes
C Lobular carcinoma
D Phyllodes tumor
E Tubular carcinoma
85) A 20-year-old woman and her twin sister both experience
increasing diplopia. Their conditions develop within
3 years of each other. On physical examination, they have
exophthalmos and weak extraocular muscle movement. The
thyroid gland is diffusely enlarged but painless in each sister,
and there is no lymphadenopathy in either woman. Which of
the following serum laboratory findings is most likely to be
reported in these sisters?
A Decreased free thyroxine level
B Decreased thyroid-stimulating hormone level
C High titer thyroid peroxidase autoantibodies
D Increased thyrotropin-releasing hormone level
E Increased triiodothyronine level
86) A 40-year-old man notes weight loss, increased appetite,
and double vision for 6 months. On physical examination, his
temperature is 37.7° C, pulse is 106/min, respirations are
20/min, and blood pressure is 140/80 mm Hg. A fine tremor
is observed in his outstretched hands. He has bilateral proptosis
and corneal ulceration. Laboratory findings include a
serum TSH level of 0.1 mU/L. A radioiodine scan indicates
increased diffuse uptake throughout the thyroid. He receives
propylthiouracil therapy, and his condition improves. Which
of the following best describes the microscopic appearance of
his thyroid gland before therapy?
A Destruction of follicles, lymphoid aggregates, and
Hurthle cell metaplasia
B Enlarged thyroid follicles lined by flattened epithelial
cells
C Follicular destruction with inflammatory infiltrates
containing giant cells
D Nodules with nests of cells separated by hyaline
stroma that stains with Congo red
E Papillary projections in thyroid follicles and lymphoid
aggregates in the stroma
87) A 45-year-old woman from Kathmandu, Nepal, reports
a feeling of fullness in her neck, but has no other concerns.
The enlargement has been gradual and painless for more than
1 year. Physical examination confirms diffuse enlargement of
the thyroid gland without any apparent masses or lymphadenopathy.
Laboratory studies of thyroid function show a normal
free T4 level and a slightly increased TSH level. What is
the most likely cause of these findings?
A Diffuse nontoxic goiter
B Follicular adenoma
C Hashimoto thyroiditis
D Papillary carcinoma
E Subacute granulomatous thyroiditis
F Toxic multinodular goiter
88)A 44-year-old man with no previous illnesses has been
bothered by progressive hoarseness, shortness of breath, and
stridor for the past 3 weeks. On physical examination, he has a
firm, large, tender mass involving the entire right thyroid lobe.
CT scan shows extension of this mass posterior to the trachea
and into the upper mediastinum. A fine-needle aspiration
biopsy of the mass is done, and microscopically shows pleomorphic
spindle cells. The mass is noted at surgery to have
infiltrated the adjacent skeletal muscle. Four of seven cervical
lymph nodes have metastases. Pulmonary metastases also are
identified on a chest radiograph. Which of the following neoplasms
is most likely to be present in this man?
A Anaplastic carcinoma
B Follicular carcinoma
C Medullary carcinoma
D Non-Hodgkin lymphoma
E Papillary carcinoma
89) A 39-year-old woman has a nodule on her back that has
become larger over the past 2 months. On physical examination,
there is a 2.1-cm pigmented lesion with irregular borders
and irregular brown to black areas. An excisional biopsy with
wide margins is performed, and microscopic examination of
the biopsy specimen shows a malignant melanoma composed
of epithelioid cells that extend 2 mm into the reticular dermis.
There is a band of lymphocytes beneath the lesion. Which of
the following is the most important determinant of prognosis
for this woman?
A Age at diagnosis
B Depth of the lesion
C Extent of radial growth
D Inflammatory response
E Location on the skin
90) A 31-year-old man notes a bump on the skin of the lower
abdomen that has enlarged over the past 4 years and has become
more painful in the past week. On physical examination,
there is a subcutaneous, movable, soft nodule at the belt line
anteriorly that elicits pain with pressure. The overlying skin
is intact. He states that the nodule began hurting about 1 day
after he vigorously squeezed it. The lesion is excised and does
not recur. Which of the following is the most likely diagnosis?
A Acne vulgaris
B Dermatofibroma
C Epidermal inclusion cyst
D Fibroepithelial polyp
E Trichoepithelioma
F Xanthoma
91) A 76-year-old man has had a slowly enlarging nodule on
his right eyelid for 4 years. On physical examination, there is a
0.3-cm pearly nodule on the upper eyelid near the lateral limbus
of the right eye. The lesion is excised, but multiple frozen
sections are made during the surgery to minimize the extent of
the resection and preserve the eyelid. The microscopic appearance
of the lesion is shown at low magnification in the figure.
What is the most likely diagnosis?
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A Actinic keratosis
B Basal cell carcinoma
C Dermatofibroma
D Malignant melanoma
E Nevocellular nevus
92) A 2-year-old child has a history of multiple bone fractures
with minor trauma. On examination he has hepatosplenomegaly
and palsies involving cranial nerves II, VII, and
VIII. Laboratory studies show pancytopenia. Radiographs
reveal diffusely and symmetrically sclerotic bones with poorly
formed metaphyses. Molecular analysis of his bone reveals
a defect in production of carbonic anhydrase to solubilize
hydroxyapatite crystal. He is treated with hematopoietic stem
cell transplantation. Which of the following cells in his bones
was most likely functionally deficient and replaced following
transplantation?
A Chondroblast
B Chondrocyte
C Osteoblast
D Osteoclast
E Osteocyte
93) A 38-year-old man has had chronic leg pain for the
past 4 months. He passed a urinary tract calculus a month
ago. On physical examination, there is local swelling with
tenderness just below the right patella. A radiograph of the
right lower leg shows a 4-cm cystic area in the right tibial
diaphysis without erosion of the cortex or soft-tissue mass.
Laboratory studies show serum calcium is 12.6 mg/dL, and
phosphorus is 2.1 mg/dL. A biopsy specimen of the lesion is
taken and microscopically shows increased osteoclasts and
fibroblast proliferation. Which of the following underlying
conditions is most likely to account for these findings?
A Chronic glomerulonephritis
B Chronic osteomyelitis
C Giant cell tumor of bone
D Paget disease of bone
E Parathyroid adenoma
94) A 7-year-old boy sustained an open compound fracture
of the right tibia and fibula in a fall from a barn loft to the
floor below. On physical examination, the lower tibia and fibula
can be seen protruding from the lower leg. The fracture is
set by external manipulation, and the skin wound is sutured,
but nothing more is done. One year later, he continues to have
pain in the right leg, and a draining sinus tract has developed
in the lateral lower right leg. A radiograph of the lower right
leg is now most likely to show which of the following?
A Cortical nidus with surrounding sclerosis
B Involucrum and sequestrum
C Osteolysis with osteosclerosis
D Soft-tissue hemorrhage and swelling
E Tumor mass with bony destruction
95) A 49-year-old woman has had a severe headache for 2
days. On physical examination, she is afebrile and normotensive.
Funduscopic examination shows papilledema on the right.
One day later, she has right pupillary dilation and impaired
ocular movement. She then becomes obtunded. Which of the
following lesions best explains these findings?
A Chronic subdural hematoma
B Frontal lobe abscess
C Glioblastoma with edema
D Hydrocephalus ex vacuo reddish, slightly swollen area over the occiput. She is arousable
E Occipital lobe infarction but somnolent. There are no motor or sensory deficits.
F Ruptured middle cerebral berry aneurysm There is no papilledema. CT scan of the head is performed.
Acute hemorrhage in which of the following locations is most
96) A 16-year-old boy with no prior medical problems has likely to be seen?
complained of headaches for the past 9 months. There are no A Basal ganglia
abnormal findings on physical examination. CT scan of the B Basis pontis
head shows enlargement of the lateral cerebral ventricles and C Cerebral ventricle
third ventricle. A lumbar puncture is performed with normal D Epidural space
opening pressure, and clear CSF is obtained, which has a E Inferior frontal lobe
slightly elevated protein, normal glucose, and no leukocytes. F Sella turcica
Which of the following intracranial lesions is most likely to
cause these findings? 99) A 26-year-old man has had severe visual impairment
A Aqueductal stenosis since birth. He is legally blind without his glasses, but his astigmatism
B Cerebral abscess in both eyes is so severe that he cannot get a correction
C Cryptococcal meningitis better than 20/100 with eyeglasses. He tries rigid contact
D Ependymoma lenses and gets a correction of 20/40. Which of the following
E Multiple sclerosis ocular conditions is he most likely to have?
F Vascular malformation A Keratoconus
B Pterygium
97) A 61-year-old man has had worsening mental function C Stromal dystrophy
with confusion for the past year, along with headaches. At D Trachoma
first the headaches occurred in the morning, but for the past E Vitamin A deficiency
3 months they have become continuous, along with nausea
and blurred vision. On physical examination there is bilateral 100) A 34-year-old man has had decreasing vision for the
papilledema. A head CT scan shows enlargement of the entire past 3 years and now has severely impaired vision in both
ventricular system. Which of the following prior illnesses most eyes. His brother is similarly affected. Both parents have normal
likely led to his current problems? vision. Ocular examination shows diffuse cloudiness of
A Aqueductal stenosis the anterior stroma with aggregates of gray-white opacities in
B Choroid plexus papilloma the axial region of the corneal stroma. He undergoes bilateral
C Cerebral infarction corneal transplantation. The diseased corneas show basophilic
D Dandy-Walker malformation deposits in the stroma that stain positively for keratan sulfate.
E HIV infection What is the most likely diagnosis?
F Pneumococcal meningitis A Cataract formation
B Keratomalacia
98) An 83-year-old woman slips in the bathtub in her home C Macular dystrophy
and falls backward, striking her head. She is taken to the D Pterygium
emergency department, where examination shows a 3-cm E Trachoma

The exam didn’t not look exactly like what this document contains. Because some questions and choices were modified.
Items are more than 100 because 90-95% sure – questions appeared in the exam – black.. Can’t remember if it really appeared, missing items – red
God bless! -MG

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