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306 Cards in this Set
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In house fires associated with smoke inhalation, patients frequently develop carbon monoxide and cyanide poisoning, the latter from incineration of polyurethane products. Which of the following biochemical or laboratory abnormalities are associated with both carbon monoxide and cyanide poisoning? SELECT 2
A. Decreased arterial oxygen saturation (SaO2) B. Increased anion gap metabolic acidosis C. Left-shifted oxygen binding curve (OBC) D. Inhibition of cytochrome oxidase (cyto a + a3) E. Decreased partial pressure of arterial oxygen (PaO2) |
Answers: B, D- B. increased anion gap metabolic acidosis: yes, lactic acidosis develops from tissue hypoxia
D. inhibition of cytochrome oxidase (cyto a + a3): yes, both inhibit the enzyme, which causes the electron transport chain (ETC) to cease functioning. A. Decreased arterial oxygen saturation (SaO2): no, CO does decrease SaO2 but CN does not C. Left-shifted oxygen binding curve (OBC): no, CO does but CN does not E. Decreased partial pressure of arterial oxygen (PaO2): no, neither one lower PaO2 A. Co; not CN, B lactice acidosis=tissue hypoxia, C=CO; not CN; D. Co and CN; E: neither |
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A 62-yr-old man with poorly controlled type 2 diabetes mellitus complains of a black, right big toe. The toe is dry and no crepitance (gas in the subcutaneous tissue) is palpated in the underlying tissue. The dorsalis pedis and posterior tibial arteries in both the left and right foot are absent.
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Answer: C- coagulation necrosis (dry gangrene): the absence of infection (no crepitus from gas producing anaerobes like Clostridium perfringens or Bacteroides fragilis) makes this coagulation necrosis. If infection was present, then it would be liquefactive necrosis.
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A 40-yr-old male with a long history of alcohol abuse and chronic upper abdominal pain has a 2 day history of severe, epigastric pain. The pain radiates into the back and is described as "knife-like". An abdominal x-ray exhibits multiple densities in the left upper quadrant. SELECT 2
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Answers: A- dystrophic calcification: in the setting of acute pancreatitis (enzymatic fat necrosis) related to alcohol abuse, dystrophic calcification is responsible for the multiple densities (calcium + fatty acids) in the pancreas, which is a retroperitoneal organ in the left upper quadrant. Pain radiates into the back because of its retroperitoneal location.
H. enzymatic fat necrosis: alcohol activates lipase causing degradation of fat into fatty acids. |
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A febrile and obese 40-yr-old woman develops a sudden onset of severe, crampy right upper quadrant pain. An ultrasound shows stones in the gallbladder. A cholecystectomy is performed. On postoperative day 5, she experiences a sudden onset of fever, dyspnea (difficulty breathing), tachypnea (rapid breathing), and severe right lower lobe pleuritic-type (knife-like) chest pain. The pain increases with inspiration. Physical exam shows a friction rub (scratchy sound) in the right lower lung. A wedge-shaped area of hypovascularity of the right lower lobe is noted on a chest x-ray. A ventilation scan shows normal uptake of air in all lung fields; however, the perfusion scan shows no perfusion of the right lower lobe. An arterial blood gas uncovers a mild respiratory alkalosis and mild hypoxemia. The Alveolar-arterial gradient is prolonged.
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Answer: C- coagulation necrosis: the patient has a hemorrhagic infarction of the lung (pulmonary embolus with infarction), which is responsible for the wedge-shaped area of hypovascularity of the right lower lobe and perfusion scan demonstrating no perfusion of the right lower lobe. Recall that most emboli to the lung are in the lower lobes, since perfusion is greater than ventilation. The venous clots responsible for the lung infarction most commonly originate in the femoral vein. Note the relationship of a post-surgical patient with this event. Prolonged bed rest predisposes to clot formation in the lower extremities, particularly in the deep veins of the calf. The PaO2 is decreased because of a perfusion defect. The difference between the alveolar PO2 and the arterial PO2 (Alveolar-arterial gradient) is greater because there is a perfusion defect causing a greater discrepancy between the two pressures. Normally, alveolar PO2 is 100 mm Hg and arterial PO2 is 95 mm Hg; therefore, the A-a gradient is 5 mm Hg.. Rapid breathing (tachypnea) due to activation of intrinsic reflexes in the lungs blows off more CO2 than normal, which produces respiratory alkalosis. Also, hypoxemia stimulates peripheral chemoreceptors to increase respiratory rate.
LOW O2=PERIPHERAL RECEPTORS |
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A 69-yr-old man with a long history of coronary artery and carotid artery disease, transient ischemic attacks, and peripheral vascular disease develops a sudden onset of hemiparesis and sensory loss in the right arm and face. His eyes are deviated to the left.
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Answer: D - liquefactive necrosis: the patient has an atherosclerotic stroke, which is most commonly a pale infarct. Most atherosclerotic strokes are due to a platelet thrombus overlying an atherosclerotic plaque at the bifurcation of the carotid artery and/or the middle cerebral artery. Transient ischemic attacks are due to cholesterol emboli from atheromatous plaque material in the carotid artery. Recall that the brain only undergoes liquefactive necrosis with infarction.
BRAIN, brown recluse=LIQUEFACTIVE |
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destribe TB cavitations
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CD4-->release gamma-TNF-->act macs-->kill TB
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McArdle's disease
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no inc in LA after exercise AR, no muscle phosphorlyase prevents the release of glucose form glycogen via glycogenolysis
mm w/o glucose ruptures rhabdomyolysis, release serum CK and myoglobin in the blood |
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A 22-yr-old man died of a car accident. At autopsy, the liver is enlarged and yellow brown. Histologic sections with H:E staining demonstrate hepatocytes with clear spaces and nuclei pushed to the periphery of the cells. Most of these changes occur around the central vein.
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Answer: D- an increase in VLDL: the patient has a fatty liver, most likely secondary to alcohol ingestion. Recall that alcohol leads to increased synthesis of VLDL (liver synthesized triglyceride), which accumulates in the hepatocytes and pushes the nuclei to the periphery of the cells. The increase in NADH is alcohol metabolism causes DHAP to convert to glycerol 3-phosphate, which is the precursor substrate for synthesizing triglyceride. Acetyl CoA, the end-product of alcohol metabolism, is used to synthesize fatty acids. Three acetylated fatty acids added to glycerol 3-phosphate produces triglyceride. Alcohol is also a mitochondrial toxin and decreases b-oxidation of fatty acids, which allows more fatty acids to be used for TG synthesis.
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hemosiderin
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degradation product of ferritin stains blue w/ prussian blue; inc hydroxyl FR damaged the liver porduce cirrhosis
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A 62-yr-old man with a 40 year history of smoking has a recurrent history of indigestion and burning pain in the epigastrium (below xiphoid) that increases after drinking coffee, eating fatty foods, and when lying down flat in bed at night. The pain is relieved when he sleeps upright on pillows. Endoscopy shows extensive ulceration of the distal esophagus consistent with gastroesophageal reflux disease (GERD). A biopsy of the distal esophagus shows ulceration, acute inflammation, and multifocal areas of mucus secreting cells and goblet cells intermixed with inflamed and thickened squamous epithelium.
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Answer: H- glandular metaplasia: acid injury to the squamous epithelium leads to glandular (intestinal) metaplasia (Barrett's esophagus) as a protective device against acid. GERD is due to a relaxed lower esophageal sphincter from smoking, coffee, and fatty foods. A Barrett's esophagus may result in scarring and inability to pass solids/liquids into the stomach (stricture) as well as cancer of the distal esophagus (adenocarcinoma). Treatment of GERD decreases the risk for developing distal adenocarcinoma.
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A 68-year-old black man has urinary retention due to an enlarged prostate gland. Cystoscopy shows thickening of the wall of the urinary bladder.
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Answer: F- hyperplasia: an enlarged prostate gland is not normal. A slight excess in dihydrotestosterone is responsible for the hyperplasia of the parenchymal tissue. Both glandular tissue and smooth muscle undergo hyperplasia in BPH. BPH does not progress to prostate cancer.
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2 diseases w/ ubiquination
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mallory and lewy
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A healthy 29-yr-old year-round resident in Breckenridge, Colorado has a higher than normal hemoglobin, hematocrit, and RBC count.
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Answer: F- hyperplasia: patients at high altitudes have physiologic hyperplasia of RBCs in their marrow leading to higher than normal hemoglobins, hematocrits, and RBC counts. Recall that at high altitudes the percent oxygen is still 21%, but the atmospheric pressure is < 760 mm Hg.
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A 14-yr-old boy with cystic fibrosis dies of sepsis related to pneumonia. At autopsy, the pancreas is fibrotic. Histologic sections reveal dilated ducts filled with inspissated mucus. The surrounding stroma is fibrotic.
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Answer: D- atrophy: patients with cystic fibrosis have very thick secretions that block lumens. The build up of pressure behind the obstructed lumens produces pressure atrophy of the glands (similar in concept to compression atrophy of the cortex and medulla of the kidney in hydronephrosis). The actual process of cell death is apoptosis.
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chediak higashi
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membrane protein fusion defect tranferring primary lysosomal enzymes into phagocytic vacuoles; defect in MT polymerizaiton
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I cell disease
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severe psychomotor retardation, leukocytes shows inclusion into the cytosol and lysosomes w/o enzymes; golgi apparatus; M6P marker missing phosphotranferase
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A 23-yr-old hiker, who recently returned from a camping trip in the high country of Colorado, has cyanosis of the skin and mucous membranes. Administration of 100% oxygen does not improve the clinical appearance of the patient. Which of the following most likely apply to this patient? SELECT 2
A. PaO2 is decreased B. SaO2 is decreased C. Ventilation abnormality in the lungs D. Correction with methylene blue E. Diffusion defect in the lungs |
Answers B, D: B. SaO2 is decreased: yes, the patient most likely has methemoglobinemia from drinking water contaminated by nitrates. Since iron is +3, oxygen does not correct the cyanosis
D. correction with methylene blue: yes, along with ascorbic acid to reduce iron back to +2, so it can bind to oxygen. A. PaO2 is decreased: no, it is normal, since gas exchange is normal C. Ventilation abnormality in the lungs: no, it is normal E. Diffusion defect in the lungs: no, it is normal |
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PICTURE
Which of the following are characteristic findings in apoptosis? SELECT 3 A. Inflammatory infiltrate B. Coagulation necrosis C. Nuclear pyknosis D. Cytoplasmic eosinophilia E. Phagocytosed apoptotic bodies F. Early disruption of cell membranes |
Answers C, D, E: C. Nuclear pyknosis: yes, it is a key feature followed by nuclear fragmentation
D. Cytoplasmic eosinophilia: yes, eosin has a high affinity for cytosol lacking RNA or for proteins that are denatured E. Phagocytosed apoptotic bodies: yes, neighboring cells and macrophages phagocytose and destroy apoptotic bodies, which are plasma membrane bound bodies containing cytosol, packed organelles, with or without nuclear fragments. A. Inflammatory infiltrate: no, this is characteristic of widespread necrosis of tissue B. Coagulation necrosis: no, this occurs in large vessel thrombosis/embolism, heavy metal poisonings, or ionizing radiation F. Early disruption of cell membranes: no, this is a feature of hypoxic injury to a cell or FR injury to a cell. The plasma membrane in apoptotic cells remains intact until the very end, when apoptotic bodies are destroyed in lysosomes. |
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ADHESION molecules activated by?
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C3a, C5a, LTB4
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endothelial activation by?
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IL1 /TNF
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selectins do what?
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slowing down leukocytes in rolling
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A newborn child has failure of separation of the umbilical cord. Histologic sections of the surgically removed cord demonstrate an absence of neutrophil margination and diapedesis into the interstitial tissue. Which of the following correctly describes the defect responsible for this child's clinical condition?
A. Defect in activation of the complement system B. Deficiency of adhesion molecules on leukocytes C. Defect in microtubule polymerization D. Absent respiratory burst mechanism E. Deficiency of myeloperoxidase |
Answer: B. Deficiency of adhesion molecules on leukocytes: if neutrophils cannot stick they cannot transmigrate into tissue. Defects may be in the b-integrins or the selectins. These patients also have problems with wound healing.
A. Defect in activation of the complement system: no, the history is classic for an adhesion molecule defect C. Defect in microtubule polymerization: no, that would not effect margination of neutrophils, which is related to rouleaux pushing the neutrophils to the periphery and activation of adhesion molecules on neutrophils and endothelial cells. D. Absent respiratory burst mechanism: no, this is not chronic granulomatous disease of childhood, which is a problem in killing bacteria and not in their ability to adhere or transmigrate into tissue. E. Deficiency of myeloperoxidase: no, there would be margination and cells in the umbilical cord in this condition. The problem is in killing bacteria. |
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9. These cells are the precursors of the epithelioid and multinucleated giant cells in a granuloma. PICTURE
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Answer: F: macrophages: when macrophages are activated by g-interferon released from helper T cells, they look like epithelial cells, hence the term epithelioid cells (look like epithelial cells but are not epithelial cells). Activated macrophages often fuse together to produce multinucleated giant cells.
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what type of hypersensity for worms?
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T2HS w/eos and IgE
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The chemical mediator released by these cells is responsible for the calor, rubor, and tumor of acute inflammation.
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: A. mast cells: they release histamine leading to the calor (warm skin related to vasodilatation), rubor (redness related to vasodilatation), and tumor (swelling of tissue related to increased venular permeability).
mast cells-->histamine |
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Bronchoconstriction of the terminal bronchioles in bronchial asthmatics is primarily due to which of the following chemical mediators?
A. LTB4 B. Nitric oxide C. Interleukin-1 D. Prostaglandins E. Leukotrienes C4, D4, E4 |
Answer: E. leukotrienes C4, D4, E4: these are also called slow reacting substance of anaphylaxis
A. LTB4: no, this is a chemotactic agent and activates leukocyte adhesion molecules B. Nitric oxide: no, this relaxes smooth muscle C. Interleukin-1: no, this cytokine is not associated with smooth muscle contraction D. Prostaglandins: no, none of the PGs produce bronchoconstriction |
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how to make a tuberculous granumoa
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alveolar macs phagocytose TB present to helper D; CD4 T relesae gamma IFN and MIF-->alveolar macs also release IL-12 which causes TH1 subset CD4 cells to devleop that have memory o fthe event; CD4 release IFNgamma and macs release IL12
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SED rate
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more RBCs=less rouleaux; anemia=more rouleux
RA chronic inflmamation; acute appendicitive favor rouleazx and inc ESR MM-inc gamma globs favor rouleaux and inc ESR; sick cell dec ESR |
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eicosanoid synthesize in palcenta for PDA and pain in acute inflammation
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PGE2 vasodilate pain in acute inflammation
VD of eff arteirole in the kidneys |
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34. These compounds play an important role in expiratory wheezes in patients with bronchial asthma
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Answer: G. LTC-D-E4: these are potent bronchoconstrictors
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38. This leukotriene has a similar neutrophil function as C5a in acute inflammation
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Answer: F. LTB4: both C5a and LTB4 are chemotactic and promote activation of leukocyte adhesion molecules.
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42. An opsonization defect would most directly result in defective…
A. leukocyte adhesion B. leukocyte transmigration C. leukocyte chemotaxis D. leukocyte phagocytosis E. leukocyte mechanisms for killing of bacteria |
Answer: D: leukocyte phagocytosis: opsonization by IgG and/or C3b aids neutrophils, monocytes, and macrophages to bind to bacteria via their receptors for IgG and C3b.
A. leukocyte adhesion: no, adhesion interferes with neutrophil rolling (involves selectins) and margination, not opsonization B. leukocyte transmigration: no, loss of opsonization would have no effect on neutrophil transmigration (ability of the neutrophil to move through the venular basement membrane into the interstitial tissue) C. leukocyte chemotaxis: no, leukocytes can still respond to receptor-mediated directed chemotaxis. Microtubule dysfunction (e.g., Chediak-Higashi) would effect this function. E. leukocyte mechanisms for killing of bacteria: no, since the leukocyte still has the capacity to kill the bacteria if phagocytosed via O2-dependent and independent mechanisms. |
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43. A patient with a flat -globulin curve on a serum protein electrophoresis would most likely have a defect in…
A. leukocyte adhesion B. opsonizing bacteria C. directed chemotaxis D. microtubule polymerization E. leukocyte production of peroxide |
Answer: B: opsonizing bacteria: yes, since the g-globulin curve is primarily due to IgG, IgG, an opsonin, would be absent. This occurs in Bruton's agammaglobulinemia.
A. leukocyte adhesion: no, it is not affected by low IgG levels C. directed chemotaxis: no, IgG is not chemotactic D. microtubule polymerization: no, microtubule polymerization depends on assembly and disassembly of tubulin E. leukocyte production of peroxide: no, low IgG levels does not affect the respiratory burst mechanism where molecular O2 is converted to peroxide. |
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44. Which of the following characterize chronic granulomatous disease of childhood rather than myeloperoxidase deficiency? SELECT 3
A. Absence of peroxide B. X-linked recessive C. Microbicidal defect D. Cell membrane enzyme deficiency E. Normal nitroblue tetrazolium dye test |
Answers A, B, D: A. Absence of peroxide: yes, it is absent in CGD (as well as superoxide FRs) but present in MPO deficiency
B. X-linked recessive: CGD is X-R recessive while MPO deficiency is an AR trait D. Cell membrane enzyme deficiency: NADPH oxidase is a cell membrane enzyme that is deficient in CGD, while MPO is a lysosomal enzyme. C. Microbicidal defect: no, both disorders are microbicidal defects E. Normal nitroblue tetrazolium dye test: no, CGD has an abnormal NBT due to an absent respiratory burst, while MPO deficiency has a normal NBT, since the burst is present. |
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49. Certain patients who are placed on angiotensin-converting enzyme inhibitors develop a cough and angioedema. The mechanism for both complications is directly attributed to…
A. Thromboxane A2 B. Nitric oxide C. Bradykinin D. LTC-D-E4 E. Serotonin |
Answer: C. Bradykinin: ACE enzyme normally degrades bradykinin, hence blocking the enzyme increases bradykinin. Bradykinin causes vasodilatation + increased vessel permeability (reason for angioedema) and cough (? mechanism). This can be circumvented by giving the patient an angiotensin II receptor blocker. ACE enzymes have nothing to do with the other choices listed: TXA2, nitric oxide, LTC-D-E4, or serotonin metabolism
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55. The pathogenesis of the type of inflammation associated with diphtheria infections is most similar in pathogenesis to the inflammation associated with…
A. Clostridium difficile infections B. Entameba histolytica infections C. Clostridium perfringens infections D. Pseudomonas aeruginosa infections E. Enterotoxigenic Escherichia coli infections |
Answer: A. Clostridium difficile infections: both are associated with toxin-induced damage of mucosa and submucosa producing pseudomembranes. They are not invasive bacteria. All the other choices do not produce pseudomembranous inflammation- B. Entameba histolytica infections, C. Clostridium perfringens infections, D. Pseudomonas aeruginosa infections, E. Enterotoxigenic Escherichia coli infections: the toxin stimulates guanylate and adenylate cyclase and is not associated with an inflammatory reaction.
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59. A 3-year-old child with a recurrent history of pathologic fractures since birth presents with an area of swelling in the distal portion of the radius. While examining the patient, you notice bluish discoloration of the sclera in both eyes. The pathogenesis for this patient's clinical condition is most closely associated with…
A. a defect in synthesis of type I collagen B. parental abuse of the child C. a defect in osteoclasts D. a defect in cross-bridging collagen E. a poor diet |
Answers: A. a defect in synthesis of type I collagen: the patient has osteogenesis imperfecta, which is an autosomal dominant disease with a defect in synthesizing type I collagen, which is the primary collagen in bone (hence the reason for the pathologic fractures). The bluish discoloration of the sclera is due to the loss of type I collagen in the sclera, so the underlying choroidal veins give a bluish discoloration, similar to the way the veins look blue under the skin.
B. parental abuse of the child: no, the blue sclera is the key to rule this out C. a defect in osteoclasts: no, this is present in osteopetrosis, where too much bone is made D. a defect in cross-bridging collagen: no, this is associated with scurvy and copper deficiency E. a poor diet: no, this would not explain all the findings in the patient primary collagen in bone bluish loss of T1 collagen |
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64. The cell producing gliosis in the brain after an atherosclerotic stroke is analogous in function to which of the following cells in the healing of a primary intention wound?
A. Mast cell B. Fibroblast C. Neutrophil D. Macrophage E. Endothelial cell |
Answer: B. Fibroblast: the cell in the brain is the astrocyte, which does not make collagen but uses its protoplasmic process to provide tissue support. Fibroblasts produce collagen. None of the other choices are correct- A. Mast cell, C. Neutrophil, D. Macrophage, E. Endothelial cell
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66. In repair of a transected peripheral nerve, which of the following cells is most responsible for directing proximal axonal sprouts leading to regeneration and remyelination of the axon?
A. Astrocyte B. Macrophages C. Schwann cells D. Nerve cell body E. Oligodendrocyte |
Answer: C. Schwann cells. None of the other choices are correct-A. Astrocyte: they are in the CNS, B. Macrophages, D. Nerve cell body, E. Oligodendrocyte: no, they are in the CNS. Wallerian degeneration occurs in transection of a nerve.
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Inactivation of the TP53 suppressor gene on chromosome 17 causes cells to enter which phase of the cell cycle?
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Answer: C- inactivation of the TP53 suppressor gene on chromosome 17 causes cells to enter the S phase of the cycle: TP53 protein product causes transcription of p21, which normally inhibits activated Cdk4. Inactivation of TP53 causes the RB protein to be phosphorylated by Cdk4, which allows unrestricted entry of the cell to the S phase. This increases the chance for malignancy. In addition, inactivation of the TP53 suppressor gene means that the BAX apoptosis gene will not be activated, therefore, the BCL2 antiapoptosis gene will not be inhibited and the cell becomes immortal.
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84. A 4-year-old boy with a family history of seasonal allergies develops erythema, itching, and swelling of the skin after a subcutaneous injection of Bermuda grass pollen. Which of the following chemical mediators is most responsible for this skin reaction?
A. Bradykinin B. Complement C. Histamine D. Nitric oxide E. Prostaglandins |
Answer: C (histamine) is correct. Histamine released from mast cells is the primary chemical mediator of type I hypersensitivity reactions. Histamine vasodilates arterioles, which produces redness of the skin, and contracts venular endothelial cells causing increased vessel permeability leading to swelling of tissue. The patient's skin reaction to subcutaneous injection is the classic "wheal and flare" response of a type I hypersensitivity reaction.
Option A (bradykinin) is incorrect. Activated coagulation factor XII converts high-molecular-weight kininogen to bradykinin. Bradykinin causes vasodilation of arterioles, increased vessel permeability, and pain in acute inflammation. Bradykinin is not released from mast cells in type I hypersensitivity reactions. Option B (complement) is incorrect. Complement is synthesized by the liver and has many functions in acute inflammatory reactions. Anaphylatoxins C3a and C5a directly stimulate mast cell release of histamine, however, histamine is primarily responsible for the initial skin reaction. Option D (nitric oxide) is incorrect. Nitric oxide (NO), a free radical gas produced mainly by macrophages and endothelial cells, is released during conversion of arginine to citrulline by NO synthase. NO causes vasodilation of arterioles, however, it is not a chemical mediator in type I hypersensitivity reactions. Option E (prostaglandins) is incorrect. Prostaglandins are produced by leukocytes, endothelial cells, and platelets. Arachidonic acid is converted to PGG2 by cyclooxygenase, and PGG2 is then converted to PGH2, the major precursor of prostaglandins. Prostaglandins produce vasodilation (PGE2, PGI2), pain (PGE2), and fever (PGE2) in acute inflammation. In type I hypersensitivity reactions, prostaglandins further enhance the inflammatory reaction after they are synthesized and released by mast cells. |
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85. A 5-year-old boy has recurrent infections caused by Staphylococcus aureus. The peripheral blood leukocytes are normal in number and morphology, however, a leukocyte nitroblue tetrazolium (NBT) test is abnormal. Which of the following best describes the pathogenesis of the recurrent infections?
A. Defect in phagolysosome formation B. Defect in producing hydrogen peroxide C. Deficiency of complement C3 D. Deficiency of immunoglobulins E. Deficiency of myeloperoxidase |
Answer: B (defect in producing hydrogen peroxide) is correct. The patient has chronic granulomatous disease, which is an X-linked recessive disease caused by a deficiency of NADPH oxidase in the cell membrane of neutrophils and monocytes. In normal individuals, phagocytosis of bacteria activates NADPH oxidase in the cell membrane. The enzyme oxidizes reduced NADPH, which converts molecular O2 to superoxide free radicals (O2•). The energy released during this reaction is called the respiratory (oxidative) burst. Superoxide is converted to hydrogen peroxide by superoxide dismutase in the phagolysosomes of neutrophils and monocytes. Myeloperoxidase (MPO), a lysosomal enzyme, catalyzes a reaction that combines hydrogen peroxide with chloride anions to form hypochlorous acid free radicals that kill the phagocytosed bacteria. The leukocyte nitroblue tetrazolium test (NBT) evaluates whether the conversion of molecular O2 to superoxide free radicals is intact. A colorless dye is added to a test tube containing neutrophils. Normal neutrophils phagocytose the dye and produce superoxide free radicals that convert the dye to a blue color. A much more sensitive test is the oxidation of dihydrorhodamine to fluorescent rhodamine. In chronic granulomatous disease, the respiratory burst is absent (abnormal leukocyte nitroblue tetrazolium test) and superoxide free radicals and hydrogen peroxide are not produced resulting in a defect in microbicidal activity (cannot kill Staphylococcus aureus).
Option A (defect in phagolysosome formation) is incorrect. Phagolysosomes are formed when lysosomes merge with phagosomes. Although a defect in phagolysosome formation causes a microbicidal defect, the respiratory burst is still intact and the leukocyte NBT test is normal. Option C (deficiency of complement C3) is incorrect. Complement C3b is an opsonizing agent that binds to the surface of bacteria and assists leukocytes in phagocytosis and the formation of phagosomes. Deficiency of complement C3 causes defects in phagocytosis, however, the leukocyte NBT test is normal. Option D (deficiency of immunoglobulins) is incorrect. IgG is an opsonizing agent that binds to the surface of bacteria and assists leukocytes in phagocytosis and the formation of phagosomes. Deficiency of immunoglobulins (e.g., Bruton's agammaglobulinemia) causes defects in phagocytosis. The NBT dye test is normal. Option E (deficiency of myeloperoxidase) is incorrect. Deficiency of MPO (AR inheritance pattern or acquired) causes decreased synthesis of hypochlorous acid free radicals, which causes a defect in microbicidal activity. However, the respiratory (oxidative) burst is intact, the NBT test is normal, and hydrogen peroxide is produced in phagolysosomes. |
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86. A 14-year-old girl, who is a gymnast, is brought to a pediatrician with a complaint of fluttering in the chest. Additional history reveals that she has dislocated her right shoulder seven times over the past few months. Physical exam demonstrates hyperelastic skin, hyperextensibility of the fingers and other joints, multiple bruises over the skin, and mitral valve prolapse. Which of the following best describes the pathogenesis of the clinical findings?
A. Acquired defect in cross-bridging of collagen B. Acquired defect in hydroxylation of lysyl residues in collagen C. Acquired defect in lysyl oxidase D. Genetic defect in synthesis or structure of collagen |
Answer: D (genetic defect in synthesis or structure of collagen) is correct. The patient has Ehlers-Danlos syndrome, which is a group of predominantly autosomal dominant genetic disorders characterized by defects in collagen synthesis and structure. Classic findings include hyperelastic skin, hyperextensible joints, easy bruising, and mitral valve prolapse. Palpitations (fluttering the chest) are a common symptom of mitral valve prolapse.
Option A (acquired defect in cross-bridging of collagen) is incorrect. An acquired defect in cross-bridging of tropocollagen fibers occurs in scurvy, which is caused by deficiency of vitamin C (ascorbic acid). Scurvy is associated with vascular instability of small vessels, leading to skin and joint hemorrhages and bleeding gums with the loss of teeth. Hyperelastic skin and hyperextensible joints do not occur in scurvy. Option B (acquired defect in hydroxylation of lysyl residues in collagen) is incorrect. An acquired defect in the hydroxylation of lysyl residues in collagen occurs in scurvy, which is caused by deficiency of vitamin C (ascorbic acid). Scurvy is associated with vascular instability of small vessels leading to skin and joint hemorrhages and bleeding gums with the loss of teeth. Hyperelastic skin and hyperextensible joints do not occur in scurvy. Option C (acquired defect in lysyl oxidase) is incorrect. Lysyl oxidase is important in producing intermolecular cross-links between tropocollagen which increases the tensile strength of collagen. Since copper is a coenzyme for lysyl oxidase, deficiency of copper produces weakening of collagen resulting in problems with wound healing. Hyperelastic skin and hyperextensible joints do not occur in copper deficiency. |
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3. A block at this site interferes with the generation of free water and non-parathyroid hormone-related reabsorption of calcium.
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Answer: C. Thick ascending limb: medullary segment with Na+/K+/2Cl- symporter: this is the primary site for generation of free water and is also the site for non-PTH reabsorption of calcium. Obligated water is removed from sodium, potassium, and chloride and remains in the tubule lumens as free water. Block of chloride binding with loop diuretics not only results in loss of sodium, potassium, and chloride but also calcium (useful in the treatment of hypercalcemia).
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15. A 19-year-old man with type I diabetes mellitus develops diabetic ketoacidosis. Physical exam demonstrates signs of volume depletion. The serum glucose is 1000 mg/dL and ketone bodies are increased in the plasma and urine. Which of the following changes in electrolyte and volume status is most likely present in this patient?
POsm PNa+ ECF Compartment ICF Compartment A. Increased Decreased Contracted Contracted B. Increased Decreased Expanded Contracted C. Increased Increased Expanded Contracted D. Decreased Decreased Expanded Expanded E. Decreased Decreased Contracted Expanded |
Answer: A. the patient has type 1 diabetes mellitus and is in diabetic ketoacidosis with signs of volume depletion. Glucose has surpassed sodium as the major osmotic force and increases POsm. Serum sodium is low due to water shift out of the ICF into the ECF producing a dilutional hyponatremia. The ECF is contracted owing to osmotic diuresis leading to volume depletion. ICF is contracted due to increased POsm from glucose. Correlates with diagram E in the study questions
POsm PNa+ ECF ICF A. Increased Decreased Contracted Contracted |
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17. A 72-year-old woman is currently taking a thiazide diuretic for hypertension. She complains of dizziness when standing up too quickly. Physical exam demonstrates a blood pressure of 130/88 mm Hg and a pulse of 100 bpm when lying down and a blood pressure of 110/80 mm Hg and a pulse of 150 bpm when sitting up. The mucous membranes are dry and skin turgor is poor. Which of the following changes in electrolyte and volume status is most likely present in this patient?
POsm PNa+ ECF Compartment ICF Compartment A. Normal Normal Contracted Normal B. Decreased Decreased Contracted Contracted C. Increased Increased Expanded Contracted D. Decreased Decreased Expanded Expanded E. Decreased Decreased Contracted Expanded |
Answer: E. Hypertonic loss of fluid from diuretic leading to hyponatremia. Correlates with diagram B in the study questions. The gradient favors movement of water into the ICF compartment. Note the positive tilt test (BP dropped and pulse increased when sitting up) indicating significant volume depletion.
POsm PNa+ ECF ICF E. Decreased Decreased Contracted Expanded |
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19. A 63-year-old man with a 48 year history of smoking complains of headache and confusion. Physical exam is unremarkable except for scattered sibilant rhonchi in the lungs that clear with coughing. A chest x-ray exhibits a prominent right hilar mass. An MRI of the brain is negative for space occupying lesions. A sputum cytology report indicates the presence of small, hyperchromatic cells intermixed with necrotic debris consistent with a small cell carcinoma of the lung. Which of the following changes in electrolyte and volume status is most likely present in this patient?
POsm PNa+ ECF Compartment ICF Compartment A. Decreased Decreased Expanded Contracted B. Decreased Decreased Expanded Expanded C. Normal Normal Contracted Normal D. Increased Increased Contracted Contracted E. Decreased Decreased Contracted Expanded |
Answer: D. the patient has SiADH due to a small cell carcinoma of the lung. The MRI rules out metastasis to the brain, so the mental status problems relate to cerebral edema from hyponatremia related to water moving out of the ECF into the ICF. There is a hypotonic gain of pure water, therefore, the TBNa is normal and the skin turgor is normal. This patient would be treated with demeclocycline (produces nephrogenic diabetes insipidus) rather than water restriction, since he will die in a short period of time. Correlates with diagram D in the study questions.
POsm PNa+ ECF ICF B. Decreased Decreased Expanded Expanded |
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20. A 19-year-old hiker, who has been lost in the Sonoran desert for 3 days, has signs of volume depletion. Which of the following changes in electrolyte and volume status is most likely present in this patient?
POsm PNa+ ECF Compartment ICF Compartment A. Increased High Contracted Contracted B. Increased Increased Expanded Expanded C. Normal Normal Contracted Normal D. Increased Increased Expanded Contracted E. Decreased Decreased Contracted Expanded |
Answer: A. sweating will cause loss of a hypotonic salt solution leading to hypernatremia. Correlates with diagram E in the study guide. The first step in managing this patient is infusion of normal saline until the signs of volume depletion disappeared. Then he would be given 0.45 normal saline, which matches the tonicity of the sweat that he lost.
POsm PNa+ ECF ICF A. Increased Increased Contracted Contracted |
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21. A 62-year-old woman has both left-sided and right-sided heart failure. Physical exam demonstrates jugular vein distention, pitting edema, and bibasilar crepitant crackles. Which of the following changes in electrolyte and volume status is most likely present in this patient?
POsm PNa+ ECF Compartment ICF Compartment A. Increased Increased Expanded Contracted B. Decreased Decreased Contracted Expanded C. Decreased Decreased Expanded Expanded D. Increased Increased Contracted Contracted E. Decreased Decreased Contracted Normal |
Answer: C. Hypotonic gain of more water than salt leads to hyponatremia. Correlates with diagram D. The hypotonic gain is from the fluid retained by the kidney when the EABV is decreased. A hypotonic gain (greater increase in TBW than TBNa) translates into a hyponatremia. The Starling's force abnormalities are related to an increase in hydrostatic pressure in the pulmonary capillaries and in the venous system behind the right heart. The difference from SiADH is that pitting edema is present in this case (increased TBNa+) but not SiADH (normal TBNa+). Rx is water and salt restriction plus diuretics.
POsm PNa+ ECF ICF C. Decreased Decreased Expanded Expanded |
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25. A 22-year-old man with type 1 diabetes mellitus has diabetic ketoacidosis and vomiting.
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Answer: B. diabetic ketoacidosis (metabolic acidosis: ¯ pH, ¯ PCO2 [respiratory alkalosis],
¯¯ bicarbonate [metabolic acidosis]) and vomiting (metabolic alkalosis: pH, PCO2 [respiratory acidosis], bicarbonate [metabolic alkalosis]). They neutralize each other. pH PCO2 Bicarbonate B. Normal Normal Normal |
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37. A 52-year-old type 2 diabetic on chlorpropamide has mental status abnormalities. Physical exam is otherwise normal.
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Answer: A. Classic SiADH from chlorpropamide, which enhances ADH release. Look for everything to be decreased from dilution. Any serum sodium < 120 mEq/L is highly suspect for SiADH.
Serum Na+ (135-147) Serum K+ (3.5-5.0) Serum Cl- (95-105) Serum HCO3- (22-28) A. 118 3.0 88 21 |
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40. Which of the following volume disorders represents a transudate secondary to a decrease in oncotic pressure and increase in hydrostatic pressure?
A. Patient with cirrhosis, dependent pitting edema, and ascites B. Patient with a pulmonary infarction who has a pleural effusion C. Patient with edema of the arm post-modified radical mastectomy D. Patient with congestive heart failure who has dependent pitting edema E. Patient with congestive heart failure who has bilateral pleural effusions |
Answer: A. Patient with cirrhosis, dependent pitting edema, and ascites: portal hypertension increases hydrostatic pressure leading to ascites and decreased albumin synthesis produces a decrease in oncotic pressure leading to dependent pitting edema and ascites
B. Patient with a pulmonary infarction who has a pleural effusion: no, this is an exudate (protein and cell rich fluid) C. Patient with edema of the arm post-modified radical mastectomy: no, this is lymphedema D. Patient with congestive heart failure who has dependent pitting edema: no, this is associated with an increase in hydrostatic pressure from right-sided heart failure E. Patient with congestive heart failure who has bilateral pleural effusions: no, this is due to an increase in hydrostatic pressure |
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46. A 22-yr-old man who suffered a head injury in a car accident now has increased thirst and polyuria.
the POsm vs ADH |
Answer: B: central diabetes insipidus with no ADH. Loss of pure water leads to hypernatremia (increased POsm). The patient is diluting urine when they should be concentrating urine. Opposite of SiADH.
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49. A 35-year-old recently divorced woman overdoses on barbiturates.
pH (7.35-7.45) PCO2 (33-45 mm Hg) HCO3- (22-28 mEq/L) A. 7.00 52 12 B. 7.27 60 26 C. 7.25 80 34 D. 7.26 26 11 E. 7.38 70 40 F. 7.38 40 24 G. 7.42 22 14 H. 7.56 24 21 I. 7.58 49 39 |
Answer: B. Barbiturates depress the respiratory center producing an acute respiratory acidosis without compensation.
pH (7.35-7.45) PCO2 (33-45 mm Hg) HCO3- (22-28 mEq/L) B. 7.27 60 26 |
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51. A 19-year-old type 1 diabetic is in ketoacidosis and is vomiting.
pH (7.35-7.45) PCO2 (33-45 mm Hg) HCO3- (22-28 mEq/L) 7.00 52 12 7.27 60 26 7.25 80 34 7.26 26 11 7.38 70 40 7.38 40 24 7.42 22 14 7.56 24 21 7.58 49 39 |
Answer: F. ketoacidosis is an increased AG metabolic acidosis and vomiting produces metabolic alkalosis. These 2 disorder neutralize each other. Note that the normal pH is on the acid side, so the ketoacidosis is a little worse than the metabolic alkalosis.
pH (7.35-7.45) PCO2 (33-45 mm Hg) HCO3- (22-28 mEq/L) F. 7.38 40 24 |
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55. A 35-yr-old migrant worker inadvertently drinks methyl alcohol. He develops gastric upset and blurry vision.
pH (7.35-7.45) PCO2 (33-45 mm Hg) HCO3- (22-28 mEq/L) 7.00 52 12 7.27 60 26 7.25 80 34 7.26 26 11 7.38 70 40 7.38 40 24 7.42 22 14 7.56 24 21 7.58 49 39 |
Answer: D. methyl alcohol produces an increased AG metabolic acidosis, because it is metabolized by alcohol dehydrogenase to formic acid, which produces optic neuritis and a potential for blindness.
pH (7.35-7.45) PCO2 (33-45 mm Hg) HCO3- (22-28 mEq/L) D. 7.26 26 11 |
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61. A 75-year-old man with a known history of an abdominal aortic aneurysm experiences a sudden onset of left flank pain and dizziness. He is brought to the emergency room and has a heart rate of 140 beats/minute, blood pressure of 60/40 mm Hg, and a pulsatile mass in his abdomen. You suspect a ruptured abdominal aortic aneurysm.
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Answer: A. the patient is in hypovolemic shock. The key difference from cardiogenic shock is the low PCWP. MVO2 is low since the decreased cardiac output allows tissue to extract most of the oxygen out of the blood. SVR is increased owing to vasoconstriction of the peripheral resistance arterioles, which decreases the radius to the 4th power.
MVO2 PCWP SVR Cardiac output A. Decreased Decreased Increased Decreased |
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63. In treating a 65-year-old man with pulmonary edema patient, neck vein distention and dependent pitting edema, which of the following is the MOST APPROPRIATE management of the patient’s sodium and water intake?
Sodium intake Water intake A. No change No change B. Decrease No change C. Decrease Decrease D. No change Decrease E. Increase Increase |
Answer: C. the patient has left-sided heart failure (pulmonary edema) and right-sided heart failure (neck vein distention and dependent pitting edema). In either case, there is an alteration is Starling's forces (increased hydrostatic pressure) and a decreased cardiac output leading to retention of a slightly hypotonic salt-containing solution ( TBNa / TBW). Owing to the increase in hydrostatic pressure in the venous system in right-sided heart failure, most of this hypotonic fluid will move into the interstitial space and worsen the dependent pitting edema. Since both TBNa and TBW are increased, the best non-pharmacologic treatment for this patient and any other similar type of edema state (e.g., cirrhosis, nephrotic syndrome) is to restrict both water and salt. Diuretics are the most useful pharmacologic treatment.
Sodium intake Water intake C. Decrease Decrease |
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expand both ECF and ICF
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HF
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79. A 23-yr-old man is placed in the intensive care unit after sustaining femoral bone fractures, multiple pelvic fractures, and a laceration of the spleen from a motorcycle accident. Forty eight hours later, he develops a sudden onset of dyspnea, petechial lesions on the thorax, and mental status alterations. Laboratory studies reveal hypoxemia and thrombocytopenia. The prothrombin time and partial thromboplastin time are both normal. The patient most likely has which of the following disorders?
A. Disseminated intravascular coagulation B. Pulmonary embolism C. Fat embolization D. Air embolization E. Pneumonia |
Answer: C. Fat embolization: this is a classic case with all the clinical findings. Microglobules of fat from the marrow and surrounding adipose enter the microcirculation and circulate throughout the body, since they are small enough to move through capillaries. The fatty acids released from the fat damages the endothelial cells in the microvasculature causing platelet adherence to the damaged endothelium, hence they are used up and produce thrombocytopenia. Blockage of the microcirculation is therefore, due to the microglobules of fat as well as tiny platelet thrombi. The endothelial cell damage does not occur immediately and requires at least 24-48 hrs, hence the delay in symptoms in fat embolization. Dyspnea is due to blockage of the pulmonary capillaries (perfusion defect leading to hypoxemia). Thrombocytopenia is due to increased utilization in the formation of platelet thrombi. Thrombocytopenia is also the cause of the petechial lesions (pinpoint areas of hemorrhage) in the patient. Mental status abnormalities are due to minute hemorrhages into the brain from the blocked capillaries leading to cerebral edema.
A. Disseminated intravascular coagulation: this may occur in the setting of trauma, however, since the coagulation system is activated in this disorder resulting in the formation of fibrin-clots, the prothrombin time and partial thromboplastin time should be prolonged (fibrinogen, II, V, and VIII are consumed) B. Pulmonary embolism: this may also occur in severely traumatized patients, however, there is no history of calf tenderness (sign of deep venous thrombosis) or pleuritic chest pain, which invariably accompanies a pulmonary embolus. In addition, a PE does not produce thrombocytopenia. D. Air embolization: the clinical setting in this patient is not one for air embolism. This usually occurs in head and neck types of surgery. E. Pneumonia: the clinical setting is one of trauma, not infection. There is no mention of physical findings in the lung that would lead one to suspect a pneumonia: e.g., signs of consolidation in the lung, crackles in the lung with inspiration. |
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80. A 23-yr-old scuba diver, who is diving in 100 feet of water, is forced to ascend to the surface owing to mechanical difficulties with his diving gear. Within 10-15 minutes after resurfacing, blood begins to ooze out of both ear canals, his skin becomes mottled and pruritic, and he begins to lose both bladder and bowel control. The pathogenesis of these findings most closely correlates with which of the following factors? SELECT 2
A. Fat embolization B. Carbon dioxide narcosis C. Nitrogen gas bubbles in tissue/vessels D. Movement from a high to lower atmospheric pressure |
Answers C, D: C. Nitrogen gas bubbles in tissue/vessels: atmospheric pressure increase by 1 for every 33 feet descent into the water, which drives nitrogen into tissues. Rapid ascent causes the nitrogen to come out of solution to form bubbles that block vessels and damage tissue,
D. Movement from a high to lower atmospheric pressure A. Fat embolization: no, this usually occurs in the setting of trauma with fractures of the pelvic bones or femur B. Carbon dioxide narcosis: no, this is a feature of respiratory acidosis leading to retention of CO2 and severe hypoxemia. |
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82. Which of the following is the greatest risk factor for a venous clot in the lower extremity in a patient who is 5 days post-operative for removal of a gangrenous gallbladder?
A. Turbulent blood flow B. Stasis of blood flow C. Increased plasma viscosity D. Septicemia |
Answer: B. Stasis of blood flow: lack of movement of the patient in bed predisposes to stasis and venous thrombi that most commonly develop initially in the deep veins of the calf, hence the importance of ambulation in the patient as soon as possible.
A. Turbulent blood flow: no, turbulent blood flow more often occurs in the arterial system at sites of bifurcation and overlying atheromatous plaques. Platelet thrombi are more likely to develop in this setting leading to a myocardial infarction or stroke. C. Increased plasma viscosity: although this would predispose to venous clots, the clinical setting in this patient would not lend towards a viscosity problem due to an increase in IgM (Waldenstrom's macroglobulinemia, a malignant disorder of lymphoplasmacytoid cells) or a disorder involving globulins that often congeal in cold temperatures (cryoglobulins) D. Septicemia: although sepsis is a common finding in a gangrenous gallbladder, it would most likely predispose to disseminated intravascular coagulation, with fibrin clots developing in capillaries throughout the entire body |
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95. Patient who is unconscious after overdosing on barbiturates
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Answer: A. acute respiratory acidosis: due to hypoventilation
inc Co2, acidosis, non compensated |
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98. Patient who is on a loop diuretic and is not taking potassium supplements
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Answer: C. metabolic alkalosis: related to increase sodium exchange for protons with an increase in bicarbonate.
losing H--alkylotic |
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23. An Achilles tendon xanthoma is pathognomonic for this genetic hyperlipoproteinemia
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Answer B. Type II hyperlipoproteinemia- it is pathognomonic for familial hypercholesterolemia, an AD disorder with absent LDL receptors and very high LDL levels. Type IIb (increase in TG < 300 mg/dL as well as CH) is seen in familial combined hypercholesterolemia, which begins to manifest itself around puberty. It is not associated with Achilles’ tendon xanthomas.
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24. Yellow papular lesions called eruptive xanthomas may be associated with this hyperlipoproteinemia that has a turbid infranate and absent supranate
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Answer: D. Type IV hyperlipoproteinemia- turbid infranate is due to an increase in VLDL. This is the most common hyperlipoproteinemia and is due to reduced catabolism of VLDL or increased synthesis of VLDL. It is commonly observed in alcoholics, where there is increased synthesis of VLDL. Other acquired causes include the progesterone in oral contraceptives and diabetes mellitus.
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26. This dysbetalipoproteinemia has a defective/absent apolipoprotein E causing an accumulation of chylomicron remnants and intermediate density lipoproteins in the plasma
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Answer: D. Type III hyperlipoproteinemia- serum CH and TG levels are often equally elevated.
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27. This hyperlipoproteinemia is associated with eruptive xanthomas in the setting of diabetic ketoacidosis and the presence of both a supranate and infranate
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Answer: E. Type V hyperlipoproteinemia- turbid supranate is due to an increase in chylomicrons and a turbid infranate reflects an increase in VLDL. This is most commonly seen in DKA owing to the absence of insulin, which normally increases the synthesis of capillary lipoprotein lipase, which hydrolyzes these lipids. Apo CII activates the enzyme. Type V hyperlipoproteinemia is associated with the hyperchylomicronemia syndrome, which causes visual disturbances (lipemia retinalis), dyspnea, and acute pancreatitis. The blood looks like milk.
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40. A 65-year-old man on the 5th day of hospitalization for an acute anterior myocardial infarction has recurrence of chest pain and an increase in both CK-MB and troponin-I and T. The patient MOST LIKELY has...
A. papillary muscle dysfunction B. a right ventricular infarct C. a ventricular aneurysm D. a myocardial rupture E. reinfarction |
Answer: E. reinfarction: note the reappearance of CK-MB after 3 days. Troponin-I lasts for a week and troponin-T for 10-14 days, so the troponins should be increased and cannot diagnose reinfarction
A. papillary muscle dysfunction: should be a pansystolic murmur of MV regurgitation B. a right ventricular infarct: should be signs of right-sided heart failure C. a ventricular aneurysm: does not occur this early D. a myocardial rupture: should be neck vein distention and muffled heart sounds |
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42. A 2-yr-old boy has a history of a systolic heart murmur at birth that disappeared within a few months without any treatment
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Answer: B- history is consistent with a VSD, which is a left to right shunt through a defect in the membranous septum with oxygenated blood entering the RV and PA
Normal SaO2 % Patient B Right atrium 75 75 Right ventricle 75 80 Pulmonary artery 75 80 Pulmonary vein 95 95 Left ventricle 95 95 Aorta 95 95 |
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43. A 28-yr-old man has fixed splitting of S2 and a systolic murmur. He is at risk for developing paradoxical embolization.
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Answer: E- history is consistent with an ASD, where there is a left to right shunt with oxygenated blood entering the RA, RV, PA. An ASD is the most common adult congenital heart disease. A VSD would not be expected in an adult.
Normal SaO2 % Patient E Right atrium 75 80 Right ventricle 75 80 Pulmonary artery 75 80 Pulmonary vein 95 95 Left ventricle 95 95 Aorta 95 95 |
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44. A 2-mth-old child with a previous history of respiratory distress syndrome at birth, had a murmur that was present during systole and diastole. The patient recovered from RDS and the murmur disappeared after treatment with indomethacin.
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Answer: D- the patient has a PDA, where there is a left to right shunt with oxygenated blood in the aorta entering the PA (left to right). In a fetus, the shunt is right to left. Indomethacin is a non-steroidal that blocks PGE2 (vasodilator), hence causing the ductus to close and eventually form the ligamentum arteriosum.
Normal SaO2 % Patient D Right atrium 75 75 Right ventricle 75 75 Pulmonary artery 75 80 Pulmonary vein 95 95 Left ventricle 95 95 Aorta 95 95 |
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45. A woman delivers a newborn boy with cyanosis. The baby has murmurs consistent with an atrial septal defect, ventricular septal defect, and patent ductus arteriosus. The clinician suspects transposition of the great vessels.
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Answer: C- the patient has a complete transposition where oxygenated blood from the LA enters the RA (step up), which empties into the RV (step up, emptied by the aorta), and then some of it crosses over into the LV (step down, emptied by the pulmonary artery) through a VSD. In a transposition, the left atrium receives oxygenated blood. The transposed vessels are only those emptying the ventricles: the aorta empties the RV and the PA empties the LV.
Normal SaO2 % Patient C Right atrium 75 80 Right ventricle 75 80 Pulmonary artery 75 80 Pulmonary vein 95 95 Left ventricle 95 80 Aorta 95 80 |
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46. A 2-yr-old child with cyanosis since birth has had numerous episodes of dyspnea, worsening cyanosis, and restlessness over the last year. The child squats whenever these episodes occur and has resolution of these symptoms.
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Answer: A- this is a classic history for tetralogy of Fallot, where unoxygenated blood from the RV enters the LV through a VSD. The degree of pulmonic stenosis determines whether cyanosis is present. If it is severe, more blood is shunted into the LV. If it is mild, more blood enters the PA to get oxygenated in the lungs and less goes into the LV, which may result in the absence of cyanosis. Squatting reverses the shunt by increasing systemic vascular resistance. Blood is forced into the right ventricle and up the pulmonary artery into the lungs for oxygenation.
Normal SaO2 % Patient A Right atrium 75 75 Right ventricle 75 75 Pulmonary artery 75 75 Pulmonary vein 95 95 Left ventricle 95 80 Aorta 95 80 |
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Items 4246
Normal SaO2 % Patient A Patient B Patient C Patient D Patient E Right atrium 75 75 75 80 75 80 Right ventricle 75 75 80 80 75 80 Pulmonary artery 75 75 80 80 80 80 Pulmonary vein 95 95 95 95 95 95 Left ventricle 95 80 95 80 95 95 Aorta 95 80 95 80 95 95 |
A-tet
B VSD C-inverted D PDA R-L E aSD L-->R |
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A 30-year-old man develops a viral myocarditis and has generalized enlargement of the heart. He develops hypotension, neck vein distention, a drop in blood pressure on inspiration, and muffled heart sounds.
The most likely diagnosis is… A. hypertrophic cardiomyopathy B. an aortic dissection C. restrictive cardiomyopathy D. constrictive pericarditis E. a pericardial effusion |
Answer: E. a pericardial effusion: note the classic Beck's triad. Coxsackievirus is the MCC. A lymphocytic infiltrate would be present in the myocardium if an endocardial biopsy was performed. It commonly progresses into both left and right-sided heart failure (dilated cardiomyopathy)
A. hypertrophic cardiomyopathy: none of the above findings suggest this diagnosis B. an aortic dissection: no, association with a viral myocarditis C. restrictive cardiomyopathy: the heart would not have generalized enlargement D. constrictive pericarditis: a pericardial knock would have been present and signs of a drop in blood pressure (pulsus paradoxus) would not be present |
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53. A 70-yr-old man has diminished pulses and a history of angina and syncope with exercise. Physical exam demonstrates a systolic ejection type murmur over the right 2nd intercostal space with radiation into the carotid arteries. An S4 heart sound is present.
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Answer: B. Aortic stenosis: note the relationship with angina and syncope. Angina occurs because exercise increases heart rate, which decreases diastole and filling up of the coronary arteries. There is less blood available to oxygenate the concentrically thickened left ventricle causing subendocardial ischemia. Syncope occurs owing to the reduced stroke volume and flow of blood to the brain through the stenotic valve. Unlike hypertrophic cardiomyopathy, standing up decreases the intensity of the murmur, since less blood is in the ventricle.
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54. A 69-yr-old man with chronic ischemic heart disease has an S3 and S4 heart sound and a pansystolic murmur located at the apex that radiates into the axilla. Murmur intensity remains the same with deep held inspiration and holding of the breath.
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Answer: D. Mitral regurgitation: in chronic ischemic heart disease, there is progressive CHF resulting from long-term ischemic damage to myocardial tissue related to severe coronary artery disease. Lack of change of the murmur intensity with deep, held inspiration indicates that the murmur is left-sided.
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A 42-yr-old woman has had repeated attacks of pharyngitis since early childhood. She comes with hemoptysis and rusty colored sputum, dysphagia for solids and not liquids, and a "strange sensation in my chest." Physical exam demonstrates malar congestion, an irregularly irregular pulse, and tachycardia. Cardiac exam exhibits an opening snap followed by a mid-diastolic rumble heard best at the apex in the lateral decubitus position.
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Answer: A. Mitral stenosis: she has had repeated bouts of rheumatic fever involving the MV. She has left atrial dilatation leading to atrial fibrillation. The enlarged left atrium is also compressing her esophagus producing dysphagia for solids. Remember that the LA is the most posterior chamber in the heart and is best evaluated with transesophageal ultrasound. Also remember that in mitral stenosis there is underfilling of the LV, hence hypertrophy is not usually present.
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59. A 25-yr-old woman complains of chest pain. Physical exam demonstrates and mid-systolic click followed by a murmur heard best at the apex. The click and murmur move closer to S1 with the patient standing and closer to S2 when the patient is supine.
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Answer: G. Mitral valve prolapse: Standing decreases preload and causes the click and murmur to come close to S1. Lying supine increases preload and causes the click and murmur to come closer to S2.
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61. An intravenous drug abuser with chronic hepatitis B has painful nodules on his lower extremities with ulceration overlying the nodules, hematuria, and bloody diarrhea.
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Answer: F. Polyarteritis nodosa: PAN is a necrotizing vasculitis involving small to medium muscular arteries. Note the relationship with HBsAg. The vasculitis is producing the painful nodules and ischemic ulceration overlying the nodules. Recall that the vasculitis has all stages of healing present, unlike microscopic polyangiitis, where the vasculitis is at the same stage. The renal disease is due to infarctions of the kidneys. Recall that PAN, unlike microscopic polyangiitis, does not have glomerulonephritis. HBV is the MC systemic infection in IVDA. Recall that classic PAN does not have p-ANCA antibodies, while microscopic polyangiitis does have these antibodies.
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62. A 42-yr-old man has repeated sinus infections, absent nasal hairs, a saddle nose deformity, angiocentric, nodular masses in the lungs, and glomerulonephritis with RBC casts. An antibody study is pending.
PICTURE |
Answer: B. Wegener's granulomatosis: necrotizing vasculitis involving small vessels and small muscular arteries. Note involvement of the sinuses, nasopharynx, lungs, and kidneys. Also has necrotizing granulomas. The antibody study is c-ANCA. Cyclophosphamide is the Rx of choice. Cyclophosphamides predispose to hemorrhagic cystitis and transitional cell carcinoma of the bladder.
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65. A 7-year-old boy develops a low-grade fever, arthralgias, colicky abdominal pain, and a palpable purpuric rash limited to the lower extremities. Laboratory studies demonstrate a guaiac-positive stool, a urinalysis with red blood cell (RBC) casts, hematuria, and mild proteinuria. A CBC and platelet count is normal.
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Answer: L. Henoch-Schönlein purpura: palpable purpura is type III immunocomplex disease (IgA immunocomplexes) involving small vessels. HSP is the MC vasculitis in children. IgA glomerulonephritis is common as well as involvement of the GI tract and joints. The polyarthritis goes along with a differential of rheumatic fever and juvenile rheumatoid arthritis. Note the palpable purpura, a classic sign of a small vessel vasculitis.
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67. An elderly man develops blue colored ears, tip of nose, and fingers when in cold weather that resolves when he comes indoors. He contracted chronic hepatitis C 10 years ago after receiving 20 units of blood for a ruptured abdominal aortic aneurysm. Physical exam demonstrates palpable purpura involving the extremities, chest, and back. SELECT 2
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Answers: J. Raynaud's phenomenon: digital vessel blood flow is decreased due to increased plasma viscosity, N. Cryoglobulinemia: this is a cold reacting globulin that causes gelling of the plasma in vessels exposed to cold temperatures leading to Raynaud's and cyanosis of the ears and nose. Immunocomplexes also produce a small vessel vasculitis. There is a strong relationship with HCV and type I membranoproliferative glomerulonephritis (not mentioned in the notes).
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78. A 58-year-old man has a rusty colored dermatitis around his left ankle with focal areas of ulceration. Superficial varicosities are also noted in the leg.
PICTURE |
Answer: J. Deep venous thrombosis: another name for the patients condition is stasis dermatitis or post phlebitic syndrome. The backup of venous blood into the ankles ruptures the penetrating vessels leading to ulceration and hemosiderin deposition from breakdown of Hgb. The excess blood returning into the superficial venous system causes secondary varicosities. Recall that venous blood flow in the ankles is from the deep veins to the superficial veins through the penetrating branches
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80. A 52-yr-old man has bounding pulses, a brassy cough, and a pulsatile mass on his anterior chest. A grade III high pitched diastolic blowing murmur is heard in the right second intercostal space. The PMI is laterally displaced. An RPR and FTA-ABS are both positive.
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Answer: D. Syphilitic aortic aneurysm: treponemes invade the vasa vasorum and produce endarteritis obliterans with a heavy plasma cell infiltrate around the vessels. This causes ischemia to the arch of the aorta and aneurysmal outpouching that stretches the AV ring leading to aortic regurgitation and the bounding pulses. The left recurrent laryngeal nerve is stretched by the aneurysm leading to the cough.
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81. An autopsy finding in the kidneys of a 58-yr-old man with diabetic nephropathy and hypertension demonstrates widespread small vessel disease, glomerulosclerosis, and tubular atrophy primarily involving the cortex.
PICTURE |
Answer: A. Hyaline arteriolosclerosis: this is a small vessel (arteriole) type of "hardening of the arteries". In diabetics, it is caused by non-enzymatic glycosylation leading to increased basement membrane permeability to proteins that enter the wall of the vessel producing hyaline change and narrowing of the vessel lumen. In hypertension, it is caused by intraluminal pressure pushing proteins into the walls of the arterioles.
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88. A 22-yr-old man with AIDS has a few raised, red lesions on the hard palate.
PICTURE |
Answer: I. Kaposi's sarcoma: this is due to human herpesvirus 8. The hard palate is the MC location in the GI tract. KS is an AIDS defining lesion. It is a malignancy of the vessels.
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92. A 48-yr-old man with alcoholic cirrhosis has bilateral gynecomastia and numerous vascular lesions on the skin which disappear when the central body of the lesion is compressed.
PICTURE |
Answer: R. Spider telangiectasias: these are due to estrogen excess and represent arteriovenous fistulas. They are normal in pregnancy. In cirrhosis, they are due to the liver not being able to metabolize estrogen as well as 17-ketosteroids, which are aromatized in the adipose into estrogen.
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96. A 24-yr-old man develops fever and fatigue. Physical exam demonstrates a diminished pulse and bibasilar inspiratory crackles with neck vein distention. A chest x-ray exhibits generalized cardiomegaly. An endocardial biopsy is performed and demonstrates a benign lymphocyte infiltrate in the cardiac muscle. The pathogen most likely responsible for this patient's cardiac disease is a…
A. virus B. bacteria C. helminth D. rickettsia E. protozoan |
Answer: A. virus: the patient most likely has coxsackievirus myocarditis which has developed into both left and right-sided heart failure:
B. bacteria: produces a neutrophilic infiltrate C. helminth: produces an eosinophilic infiltrate D. rickettsia: produces a mononuclear infiltrate E. protozoan: produces a mononuclear infiltrate. Chagas' disease is the best example (Trypanosoma cruzi). |
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99. A 28-yr-old man complains of bilateral calf claudication when walking that is relieved by resting. Physical exam demonstrates greater muscle development in the upper than lower body and a disparity in the blood pressure and pulse amplitude in the upper versus the lower extremities. Additional findings you would expect in this patient include… SELECT 3
A. rib notching on a chest x-ray B. proximal dilatation of the aorta C. diminished carotid artery pulse D. widening of the aortic valve root E. concentric left ventricular hypertrophy F. diastolic hypertension with low plasma renin activity |
Answers A, B, D: A. rib notching on a chest x-ray: the patient has a coarctation and intercostal arteries are used to bypass the obstruction. Anterior intercostal arteries are branches of the internal thoracic artery while posterior intercostal arteries are branches of the aorta.
B. proximal dilation of the aorta: yes, due to increased pressure D. widening of the aortic valve root: yes, leads to aortic regurgitation and predisposes to dissection. C. diminished carotid artery pulse: no, it is bounding owing to the increase in pressure proximal to the constriction. It may lead to a berry aneurysm in the cerebral vessels. E. concentric left ventricular hypertrophy: no, it is usually dilated and hypertrophied owing to the aortic regurgitation F. diastolic hypertension with low plasma renin activity: no, the PRA is usually high owing to the reduced blood flow to the renal artery causing activation of the RAA system. |
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108. Three months following an acute anterior wall myocardial infarction, a 68-yr-old man has an abnormal bulge on the precordium that only occurs during systole. An ECG demonstrates persistence of the ST wave. Complications that commonly arise in this patient’s cardiac condition include… SELECT 3
A. ventricular thrombus B. myocardial rupture C. systolic dysfunction D. chronic heart failure E. infective endocarditis F. mitral valve dysfunction |
Answers A, C, D: A. ventricular thrombus: the patient has a ventricular aneurysm. Stasis of blood could predispose to clot formation in the ventricle, C. systolic dysfunction: yes, contractility and ejection fraction decrease, D. chronic heart failure: yes, there is not much left ventricle left to contract. This is the MC cause of death
B. myocardial rupture: no, scar tissue does not predispose to rupture E. infective endocarditis: no, this is not a complication as it would be with valvular damage in congenital heart disease F. mitral valve dysfunction: no, there is no reason for an aneurysm to interfere with MV function |
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110. In a recently married 24-yr-old woman with diastolic hypertension and an otherwise normal physical exam, which of the following questions would MOST LIKELY uncover the cause of her blood pressure problem?
A. “Do you smoke?” B. “Are you pregnant?” C. “Are you taking birth control pills?” D. “Are you having marital problems?” E. “Are you currently taking any decongestants?” |
Answer: C. “Are you taking birth control pills?”: yes, this is the MCC of hypertension in young women. Estrogen increases the synthesis of angiotensinogen.
A. “Do you smoke?”: this can cause hypertension but is not the best choice in this scenario B. “Are you pregnant?”: no relation to hypertension unless the patient has preeclampsia D. “Are you having marital problems?”: no relation to hypertension E. “Are you currently taking any decongestants?”: this can cause hypertension, but there is nothing in the stem that suggests a chronic upper respiratory problem requiring these drugs |
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111. Concentric ventricular hypertrophy would MOST LIKELY occur in a patient with… SELECT 2
A. aortic stenosis B. mitral stenosis C. aortic regurgitation D. essential hypertension E. tricuspid regurgitation F. ventricular septal defect G. congestive cardiomyopathy |
Answers A, D: A. aortic stenosis: yes, concentric hypertrophy relates to hypertrophy due to increased afterload, in this case, the stenotic aortic valve
D. essential hypertension: yes, this is the MCC of concentric hypertrophy (due to increased TPR). B. mitral stenosis: there is no ventricular hypertrophy, unless there is a significant regurgitation component, wherein, the hypertrophy would be due to volume overload- dilatation and hypertrophy C. aortic regurgitation: volume overload with dilatation and hypertrophy E. tricuspid regurgitation: volume overload with dilatation and hypertrophy F. ventricular septal defect: increased return of blood to the left ventricle leading to dilatation and hypertrophy G. congestive cardiomyopathy: there is no hypertrophy, since the heart cannot contract properly |
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116. A 55-yr-old man is hospitalized with an acute myocardial infarction. On day 4, he experiences a sudden onset of dyspnea. Physical exam uncovers a S3 and S4 heart sound, and bibasilar crackles at both lung bases. A grade III pansystolic murmur is present at the apex, which radiates into the axilla. The neck veins are not distended. Laboratory studies confirm the absence of creatine kinase (CK) isoenzyme MB and presence of troponin-I and T. Which of the following apply to this case? SELECT 3
A. Reinfarction B. Left-sided heart failure C. Right-sided heart failure D. Mitral regurgitation E. Right coronary artery thrombosis |
Answers B, D, E: B. Left-sided heart failure: yes, note the crackles and S3 and S4. The patient has either ruptured the posteromedial papillary muscle or caused it to become dysfunctional
D. Mitral regurgitation: yes, due to papillary muscle rupture/dysfunction E. Right coronary artery thrombosis: yes, it supplies the papillary muscle. A. Reinfarction: no, CK-MB did not reappear C. Right-sided heart failure: no, the neck veins are not distended |
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126. A 65-yr-old man with a history of unstable angina suddenly clutched his chest and fell over dead while at home. You would expect which of the following gross/microscopic/ laboratory abnormalities in this patient?
A. Elevated troponin-I and T B. Pallor of the myocardial tissue C. Severe coronary artery atherosclerosis D. Coagulation necrosis of myocardial tissue E. Occlusive coronary artery thrombosis in one of the coronary arteries |
Answer: C. Severe coronary artery atherosclerosis: this is sudden cardiac death, which is defined as instantaneous death or death within 24 hrs
A. Elevated troponin-I and T: no, they initially increase 3-12 hrs after an AMI, hence the reason for repeating the study every 8 hrs B. Pallor of the myocardial tissue: no, that begins between 18-24 hrs. D. Coagulation necrosis of myocardial tissue: no, that begins between 4-12 hrs E. Occlusive coronary artery thrombosis in one of the coronary arteries: no, thrombosis is usually absent in > 80% of cases. Patient's die of a ventricular arrhythmia. |
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134. In a thin 52-year-old woman with diastolic hypertension, hypernatremia, hypokalemia, and metabolic alkalosis, the diagnosis that should be highest on your differential list is...
A. pheochromocytoma B. Cushing's syndrome C. essential hypertension D. primary aldosteronism E. renovascular hypertension |
Answer: D. primary aldosteronism: note the electrolytes findings of hypernatremia, hypokalemia and metabolic alkalosis + hypertension all of which strongly suggest mineralocorticoid excess.
A. pheochromocytoma: no electrolyte abnormalities, only hypertension B. Cushing's syndrome: no history of purple stria, otherwise, it could produce this symptom complex C. essential hypertension: no electrolyte abnormalities E. renovascular hypertension: there may be hypokalemia related to slightly increased aldosterone, but not the other findings |
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137. Valvular vegetations containing bacterial pathogens are associated with… SELECT 3
A. colon cancer B. ischemic heart disease C. intravenous drug abuse D. congenital heart disease E. systemic lupus erythematosus F. group A streptococcal oropharyngeal infections |
Answers A, C, D: A. colon cancer: due to Streptococcus bovis, group D Strep
C. intravenous drug abuse: usually Staphylococcus aureus D. congenital heart disease: yes, any congenital heart disease has an increased incidence of infective endocarditis. B. ischemic heart disease: no predisposition to vegetations E. systemic lupus erythematosus: Libman-Sack's is non-infectious (immunocomplex type III) F. group A streptococcal oropharyngeal infections: rheumatic fever is non-infectious (type II hypersensitivity) |
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140. A patient with congestive heart failure develops a non-productive cough and angioedema. Which of the following drugs is the patient most likely taking to produce these findings?
A. Hydralazine B. ACE inhibitor C. 1-adrenergic blocker D. -adrenergic blocker E. Calcium channel blocker |
Answer: B. ACE inhibitor: blocks degradation of bradykinin (increases vessel permeability) by angiotensin converting enzyme, which causes the above side-effects. Swelling of laryngeal tissue produces cough and swelling of subcutaneous tissue produces angioedema. Use of angiotensin II receptor inhibitors circumvents these side-effects. Incorrect answers are not associated with an increase in bradykinin
A. Hydralazine C. a1-adrenergic blocker D. b-adrenergic blocker E. Calcium channel blocker |
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A 62-year-old woman has complaints of extreme fatigue and a sore mouth. Physical exam demonstrates a beefy red tongue with fissuring along the lateral edges. Vibratory sensation is absent in both lower extremities. She has a history of chronic gastritis involving the body and fundus. A CBC exhibits pancytopenia and an MCV of 120 m3 (80100 m3). Which of the following laboratory alterations would you expect in this patient? SELECT 3
A. Decreased serum folate B. Decreased serum homocysteine C. Decreased serum vitamin B12 D. Decreased serum gastrin E. Hypersegmented neutrophils F. Abnormal Schilling's test corrected by adding intrinsic factor G. Normal serum lactate dehydrogenase (LDH) levels |
Answers: C, E, F- patient has PA due to the history of chronic gastritis of the body and fundus
C. Decreased serum vitamin B12 E. Hypersegmented neutrophils F. Abnormal Schilling's test corrected by adding intrinsic factor: IF is missing in PA due to autoimmune destruction of parietal cells, which also causes achlorhydria and chronic atrophic gastritis of the body and fundus often leading to gastric cancer. A. Decreased serum folate: it is not folate deficiency due to neurologic findings of decreased vibratory sensation (posterior column disease) and gastritis B. Decreased serum homocysteine: increased, since deficiency of vitamin B12 results in no transfer of methyl groups to homocysteine D. Decreased serum gastrin: increased due to achlorhydria and negative feedback relationship with gastrin G. Normal serum lactate dehydrogenase (LDH) levels: markedly increased due to destruction of megaloblastic hematopoietic cells in the bone marrow (ineffective erythropoiesis) by macrophages and apoptosis |
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A 28-year-old medical student has a long history of recurrent right lower quadrant colicky pain and diarrhea that is exacerbated by stress. Physical exam demonstrates mild right lower quadrant tenderness to palpation. A fecal occult blood test and qualitative stool for fat are both negative. The CBC exhibits a mild macrocytic anemia with hypersegmented neutrophils and macroovalocytes present in the peripheral blood.
4. Based on the history and laboratory findings, which of the following Schilling's test results would you most expect in this patient? A. Abnormal Schilling's test with correction after the addition of intrinsic factor B. Abnormal Schilling's test with correction after consumption of pancreatic extract C. Abnormal Schilling's test with correction after broad spectrum antibiotic therapy D. Abnormal Schilling's test with no correction from the any of the above factors E. Normal Schilling's test after administration of radioactive vitamin B12 |
Answer: D. Abnormal Schilling's test with no correction from the any of the above factors: the patient has terminal ileal disease due to Crohn's disease, hence nothing will correct the reabsorption of vitamin B12.
A. Abnormal Schilling's test with correction after the addition of intrinsic factor: PA B. Abnormal Schilling's test with correction after consumption of pancreatic extract: pancreatic insufficiency C. Abnormal Schilling's test with correction after broad spectrum antibiotic therapy: bacterial overgrowth E. Normal Schilling's test after administration of radioactive vitamin B12: there is a malabsorption of vitamin B12, so there would be no uptake of the radioactive material |
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A patient with steatorrhea and a positive anti-gliadin antibody test has an anemia with a mean corpuscular volume (MCV) of 90 m3 (80100 m3) and corrected reticulocyte count <3%. The peripheral smear report states that a dimorphic population of red blood cells is present including microcytic and macrocytic cells. Hypersegmented neutrophils are also noted. The patient's neurological exam is normal. A stool for occult blood is negative. Which of the following groups of laboratory test results are most likely present in this patient?
Serum ferritin Serum folate Serum vitamin B12 A Decreased Decreased Normal B Decreased Normal Decreased C Decreased Decreased Decreased D Normal Decreased Normal E Normal Normal Decreased F. Normal Decreased Decreased |
Answer: A-the patient has celiac disease with involvement of the duodenum (reabsorbs iron) and jejunum (reabsorbs folate) leading to malabsorption of iron (cause of the microcytic cells) and folate (cause of macrocytic cells) resulting in a dimorphic RBC population and combined anemia. Note the normal MCV. The RDW would be increased because of the RBC size variation. Do not worry about the other choices.
Serum ferritin Serum folate Serum vitamin B12 A Decreased Decreased Normal |
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A 28-year-old woman develops fever, scleral icterus, and crampy right upper quadrant pain. Physical exam demonstrates tenderness to palpation in the right upper quadrant and mild splenomegaly. A hemogram exhibits a total leukocyte count of 23,000/mm3, hemoglobin of 10.0 g/dL (12.016.0 g/dL), a corrected reticulocyte count of 6% (0.51.5%), a mean corpuscular volume (MCV) of 80 m3 (80100 m3), and a mean corpuscular hemoglobin concentration (MCHC) of 38% (3136% Hb/cell). The total bilirubin is 3.2 mg/dL (0.11.0 mg/dL) with a direct (conjugated) fraction of 0.4 mg/dL (0.00.3 mg/dL). Serum alanine aminotransferase is 20 U/L (820 U/L). An ultrasound demonstrates numerous stones in the gallbladder. The common bile duct is not dilated. Based on these findings, which of the apply to this case? SELECT 3
A. Increased RBC osmotic fragility B. Calcium bilirubinate stones C. Decreased serum ferritin D. RBCs with a defect in ankyrin E. Positive direct Coombs' F. Increased conjugated bilirubin |
Answers: A, B, D- the patient has hereditary spherocytosis. Increased extravascular hemolysis increases the amount of bilirubin in bile leading to calcium bilirubinate stones and cholecystitis:
A. Increased RBC osmotic fragility: cells lack cell membrane, hence a little excess water in the cell results in hemolysis B. Calcium bilirubinate stones D. RBCs with a defect in ankyrin: AD inheritance C. Decreased serum ferritin: normal E. Positive direct Coombs': positive in autoimmune hemolytic anemia F. Increased conjugated bilirubin: increased unconjugated bilirubin |
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A significant number of employees in a pottery factor develop abdominal colic and diarrhea. In addition, a few of the employees complain of burning feet and muscle weakness in the upper and lower extremities. Based on these findings, which of the following are expected laboratory findings in these patients? SELECT 4
A. Normocytic anemia B. Coarse basophilic stippling C. Decreased serum ferritin D. Increased blood Pb levels E. Increased RBC protoporphyrin levels F. Increased plasma homocysteine levels G. Ringed sideroblasts |
Answers: B, D, E, G- they have Pb poisoning with peripheral neuropathy, abdominal colic, and diarrhea. The paint used in pottery often contains Pb.
B. Coarse basophilic stippling: Pb denatures ribonuclease, hence ribosomes persist D. Increased blood Pb levels: gold standard screening and confirmatory test E. Increased RBC protoporphyrin levels: protoporphyrin is proximal to the block of ferrochelatase: used to be the screening test for Pb poisoning, but it is also increased in iron deficiency and anemia of chronic disease G. Ringed sideroblasts: iron enters mitochondria and cannot get out A. Normocytic anemia: microcytic C. Decreased serum ferritin: increased because iron stores are increased F. Increased plasma homocysteine levels: normal |
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An asymptomatic, normotensive 21-year-old black woman has microscopic hematuria on an otherwise normal physical exam. The urine culture returns negative. A renal ultrasound is reported as normal. Her hemoglobin concentration is 12.5 g/dL (12.016.0 g/dL) and the peripheral smear is reported as normal. Based on these findings, which of the following is the next best step in the management of this patient?
A. Sickle cell preparation B. Reticulocyte count C. Renal biopsy D. Cystoscopy E. No further work-up |
Answer: A- the patient has sickle cell trait with microinfarctions in the renal medulla. O2 tension is low enough in the medulla to induce sickling in the peritubular capillaries- A. Sickle cell preparation
B. Reticulocyte count: there is no anemia present C. Renal biopsy: it may be necessary if the sickle prep was negative D. Cystoscopy: as above E. No further work-up: hematuria is never left undiagnosed |
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Serum iron TIBC Percent saturation Serum ferritin
Decreased Decreased Decreased Increased Decreased Increased Decreased Decreased Decreased Decreased Decreased Normal Normal Normal Normal Normal Increased Decreased Increased Increased 15. A 58-yr-old woman with rheumatoid arthritis (chronic disease) has anemia. The stool guaiac is negative (excludes iron deficiency) |
Answer: A- the patient has anemia of chronic disease (hepcidin inhibits release of iron from macrophages) The negative stool guaiac rules out iron deficiency from a GI bleed related to any NSAIDs the patient may be taking.
Serum iron TIBC Percent saturation Serum ferritin A. Decreased Decreased Decreased Increased |
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Items 1418
Serum iron TIBC Percent saturation Serum ferritin A. Decreased Decreased Decreased Increased B. Decreased Increased Decreased Decreased C. Decreased Decreased Decreased Normal D. Normal Normal Normal Normal E. Increased Decreased Increased Increased 17. The patient is a 24-yr-old pregnant Asian woman with a mild microcytic anemia with a normal RDW and increased RBC count (thalassemia). The Hgb electrophoresis is normal. |
Answer: D- the patient has a-thalassemia. Hgb electrophoresis is normal since all hemoglobins need a-globin chains. There are no problems with iron.
Serum iron TIBC Percent saturation Serum ferritin D. Normal Normal Normal Normal |
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A 4-year-old black child with sickle cell anemia develops a high fever and nuchal rigidity. Scleral icterus and hepatosplenomegaly are present. A CBC demonstrates a moderately severe normocytic anemia and a WBC count of 21,000 cells/L with left shift. A urinalysis is normal. A spinal tap demonstrates turbidity, increased protein, and neutrophils. You would expect a gram stain of CSF and a blood culture to demonstrate…
A. gram positive diplococci B. gram negative diplococci C. gram positive cocci D. gram positive rods E. gram negative coccobacilli |
Answer A: Streptococcus pneumoniae-
A. gram positive diplococci: due to splenic dysfunction, reason for giving prophylactic antibiotics and Pneumovax vaccination at 2 yrs of age |
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A 19-year-old black woman develops fatigue and exercise intolerance. She has a history of menorrhagia and sporadically takes ferrous sulfate tablets. A CBC demonstrates a mild normocytic anemia, a low normal WBC count, a normal platelet count, and normal RBC morphology. A corrected reticulocyte count is < 3%. The next most important step is a
A. serum ferritin B. Coombs' test C. serum folate/vitamin B12 D. Hgb electrophoresis E. sickle cell preparation |
Answer A: early stage of iron deficiency-
A. serum ferritin: all the iron studies are abnormal before the patient even has a normocytic anemia B. Coombs' test: not an autoimmune hemolytic anemia if the corrected reticulocyte count is low C. serum folate/vitamin B12: not a macrocytic anemia D. Hgb electrophoresis: sickle cell trait does not have anemia E. sickle cell preparation: as above |
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27. A 25-year-old woman develops jaundice. Physical exam demonstrates scleral icterus and splenomegaly. A CBC exhibits a Hb of 10 g/dL, a normal MCV, an increased MCHC, and an uncorrected reticulocyte count of 12%. The peripheral smear demonstrates numerous, small, densely stained RBCs with no central area of pallor and the presence of polychromasia. A direct Coombs’ test is negative. A urine dipstick for bilirubin and blood is negative. Which of the following tests would MOST LIKELY be abnormal?
A. Plasma haptoglobin B. Hb electrophoresis C. Osmotic fragility D. Sugar water test E. Serum ferritin |
Answer: C- correction for anemia and polychromasia is: 30/45 x 12 = 8%, 8%/2 = 4%; patient has hereditary spherocytosis (note increased MCHC)-
C. Osmotic fragility A. Plasma haptoglobin: it is usually normal in extravascular hemolysis B. Hb electrophoresis: not necessary D. Sugar water test: used as a screen for PNH E. Serum ferritin: no iron problems in spherocytosis *********** |
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28. An afebrile 80-year-old man with the myelodysplastic syndrome is symptomatic with a 7 gm/dL hemoglobin. He is given 3 units of packed RBCs and on the following day has a hemoglobin of 8 gm/dL. His direct Coombs’ test is negative. A dipstick of urine for blood is negative. The MOST LIKELY cause for only a 1 gm/dL rise in the post-transfusion hemoglobin concentration is...
A. destruction of the RBCs in the bone marrow B. a microangiopathic hemolytic anemia C. an autoimmune hemolytic anemia D. destruction of the RBCs in spleen E. a gastrointestinal bleed |
Answer: E- think most common; lack of response to transfusion is most commonly due to a GI bleed
E. a gastrointestinal bleed A. destruction of the RBCs in the bone marrow: possible but not the best answer B. a microangiopathic hemolytic anemia: no association of MDS with schistocytes C. an autoimmune hemolytic anemia: negative Coombs test excludes the diagnosis D. destruction of the RBCs in spleen: possible but not the best answer INTRAABDOMINAL BLEED |
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31. In which of the following clinical scenarios is the anemia related to a type II-hypersensitivity reaction? SELECT 2
A. Patient with rheumatoid arthritis develops anemia B. Patient on chloramphenicol develops anemia C. Patient on penicillin develops anemia D. Patient with acute progranulocytic leukemia develops anemia E. Patient eating fava beans develops anemia with hemoglobinuria F. Patient with SLE has a normocytic anemia with an elevated corrected reticulocyte count |
Answers: C, F (warm autoimmune hemolytic anemia)-
C. Patient on penicillin develops anemia: IgG antibody against the drug on the RBC membrane F. Patient with SLE has a normocytic anemia with an increased corrected reticulocyte count A. Patient with rheumatoid arthritis develops anemia: anemia of chronic disease B. Patient on chloramphenicol develops anemia: aplastic anemia D. Patient with acute progranulocytic leukemia develops anemia: DIC with consumption of RBCs in fibrin clots + bleeding E. Patient eating fava beans develops anemia with hemoglobinuria: Mediterranean type of G6PD deficiency |
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Items 41
A. Intrinsic hemolytic anemia Extravascular hemolysis B. Extrinsic hemolytic anemia Extravascular hemolysis C. Intrinsic hemolytic anemia Intravascular hemolysis D. Extrinsic hemolytic anemia Intravascular hemolysis 41. A patient with a normocytic anemia has pancytopenia and episodic hemoglobinuria in the first morning void |
Answer: C- paroxysmal nocturnal hemoglobinuria
C. Intrinsic hemolytic anemia: membrane defect, absent decay accelerating factor Intravascular hemolysis: activation of complement pathway with destruction of RBC |
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46. A 3-year-old child from the inner city develops abdominal colic, and a severe microcytic anemia. A peripheral smear demonstrates coarse basophilic stippling. Which of the following laboratory/x-ray abnormalities would you expect in this patient? SELECT 2
A. Decreased serum ferritin B. Increased blood Pb level C. Densities in the epiphyses D. Decreased free RBC protoporphyrin E. Increased serum iron, TIBC, and percent saturation |
Answers B, C: Pb poisoning
B. Increased blood Pb level C. Densities in the epiphyses A. Decreased serum ferritin: increased since there is iron overload from sideroblastic anemia D. Decreased free RBC protoporphyrin: increased E. Increased serum iron, TIBC, and percent saturation: yes on everything, except TIBC is decreased when iron stores are increased |
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47. Which of the following distinguishes thalassemia minor from BOTH iron deficiency and -thalassemia? SELECT 2
A. Normal RDW B. Increased HgbF C. Decreased HgbA D. Increased HgbA2 E. Normal serum ferritin |
Answers: B, D-
B. Increased Hgb F D. Increased Hgb A2 A. Normal RDW: it is normal in a-thal as well C. Decreased HgbA: it is decreased in a-thal as well E. Normal serum ferritin: it is normal in a-thal as well |
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48. A 2-year-old black child with growth retardation develops a high fever and no localizing signs of infection. Scleral icterus and hepatosplenomegaly are present. A CBC demonstrates a moderately severe normocytic anemia, a corrected reticulocyte count of 12%, a WBC count of 23,000 cells/L, and thrombocytosis. The peripheral smear exhibits numerous target cells, boat shaped RBCs, Howell Jolly bodies, and occasional nucleated RBCs. There is an absolute neutrophilic leukocytosis with 20% band neutrophils and prominent toxic granulation. A spinal tap and urinalysis are reported as normal. Which of the following additional tests should be performed at this time?
A. Leukocyte alkaline phosphatase score B. Bone marrow aspirate C. Direct Coombs D. Blood cultures |
Answer: D. patient has sickle cell disease and pneumococcal sepsis- D. Blood cultures
A. Leukocyte alkaline phosphatase score: this is to rule out or in chronic myelogenous leukemia (CML) B. Bone marrow aspirate: not necessary C. Direct Coombs: as above |
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62. Which of the following tests are most indicated in the initial work-up of a macrocytic anemia associated with hypersegmented neutrophils, pancytopenia, and macroovalocytes? SELECT 3
A. Serum vitamin B12 B. RBC folate C. Bone marrow exam D. Serum folate E. Direct Coombs test F. Schilling's test |
Answers: A, B, D:
A. Serum vitamin B12 B. RBC folate: best test for folate deficiency D. Serum folate C. Bone marrow exam: hardly ever indicated |
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A 19-yr-old black man with sickle cell disease develops bone pain in the femur. A radionuclide bone scan demonstrates a lytic lesion in the metaphysis of the femur. The pathogen most likely responsible for the patient's bone disorder is…
A. Staphylococcus aureus B. Streptococcus pneumoniae C. Salmonella species D. Pseudomonas aeruginosa E. Hemophilus influenzae |
Answer: C. Salmonella species: osteomyelitis; the spleen is required to remove Salmonella from the blood; therefore, a dysfunctional spleen will predispose to Salmonella sepsis
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72. Presence of these cells indicates oxidant injury to the RBCs.
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Answer: A. bite cell: macrophage removes Heinz bodies attached to RBC membrane leaving a defect in the RBC membrane. Distinctive finding in G6PD deficiency.
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74. These cells are markers of a hemoglobinopathy or macrocytes in alcoholic liver disease.
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Answer: P. target cell: due to excess RBC membrane, which bulges in the center
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79. These cells are markers of bone marrow fibrosis, but may also be seen in thalassemia.
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Answer: R. tear drop cell80.
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80. These RBCs are the classic finding in folate or vitamin B12 deficiency.
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Answer: G. macroovalocyte- egg-shaped
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82. These cells have a decreased MCHC.
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Answer: H. microcytic RBC
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83. These cells are the marker of a defect in mitochondrial heme synthesis.
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Answer: L. ringed sideroblast. Marker of sideroblastic anemias. Mitochondria filled with iron encircle a nucleated RBC in the bone marrow.
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A 65-year-old man in an intensive care unit is recovering from surgery for a ruptured abdominal aortic aneurysm. The patient required 12 units of packed red blood cells prior to surgery in order to stabilize his blood pressure. On the 5th postoperative day, he develops fever, scleral icterus, and low back pain. Physical exam shows scattered rhonchi throughout both lung fields but no areas of consolidation. A urine sample taken from his indwelling urinary catheter exhibits pyuria. Cultures isolated E. coli. A CBC shows a 3 g/dL drop in his hemoglobin concentration when compared to his postoperative levels. A direct Coombs' test is positive. No hemoglobin is noted in plasma. The total bilirubin is 4 mg/dL with a direct (conjugated) bilirubin of 0.4 mg/dL (0.00.3 mg/dL). The serum alanine aminotransferase concentration is 20 U/L (820 U/L). Which of the following apply to the patient's clinical condition? SELECT 3
A. Febrile transfusion reaction B. Posttransfusion hepatitis C. Delayed hemolytic transfusion reaction D. Type II hypersensitivity reaction E. Conjugated type of hyperbilirubinemia F. Extravascular hemolysis |
Answers: C, D, F: the patient has had a delayed hemolytic transfusion reaction (HTR) due to an antibody directed against an antigen on the donor RBCs.
C. Delayed hemolytic transfusion reaction D. Type II hypersensitivity reaction F. Extravascular hemolysis: macrophage removal of RBCs A. Febrile transfusion reaction: there has been a drop in Hgb and a positive direct Coomb's which does not occur in a febrile reaction B. Posttransfusion hepatitis: it is too early and does not explain the drop in Hgb or direct Coomb's E. Conjugated type of hyperbilirubinemia: it is primarily unconjugated due to macrophage phagocytosis of RBCs |
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A group O, Rh negative 32-year-old woman develops fever of 1030 F while receiving a unit of O, Rh negative packed red blood cells after a hysterectomy. A transfusion reaction workup on the patient shows the following:
Antibody screen negative Direct Coombs' negative Plasma normal color Urinalysis dipstick negative for blood Pretransfusion hemoglobin 7 g/dL (12.016.0 g/dL) Post-transfusion hemoglobin 8 g/dL (12.016.0 g/dL) Which of the following apply to this case? SELECT 2 A. Donor blood contamination with Yersinia enterocolitica B. Type I hypersensitivity reaction C. Patient should receive leukocyte poor blood for further transfusions D. Hemolytic transfusion reaction due to antibody destruction of donor RBCs E. Patient anti-HLA antibodies are directed against donor leukocytes |
Answers: C, E: febrile reaction, patient must have been exposed to blood products at some time in her life for antibodies to develop (common in multiparous women who commonly have fetomaternal bleeds during delivery).
C. Patient should receive leukocyte poor blood for further transfusions: this is easily accomplished by using a micropore filter for all blood transfusions. It removes all the donor leukocytes. E. Patient anti-HLA antibodies are directed against donor leukocytes. Mature RBCs do not have HLA antigens on their surface. A. Donor blood contamination with Yersinia enterocolitica: the blood is not contaminated. She would be more septic. B. Type I hypersensitivity reaction: type II D. Hemolytic transfusion reaction due to antibody destruction of donor RBCs: Coomb's test is negative and urinalysis does not show blood. Her posttransfusion Hgb has increased by the expected 1 gm/dL per unit of packed RBCs. |
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6. An 82-yr-old woman with blood group A inadvertently receives blood group B blood. He does not develop a hemolytic transfusion reaction. This is most likely due…
A. absence of isohemagglutinins with old age B. a defect in cellular immunity C. Bruton's agammaglobulinemia D. antithrombin III deficiency E. absent anti-A IgM titers in the donor unit |
Answer: A. absence of isohemagglutinins with old age: elderly people often (not always) lose their isohemagglutinins, hence they may not develop hemolytic TRs even with an ABO mismatch.
B. a defect in cellular immunity: the only problems in old age with cellular immunity are slightly decreased CD8 T suppressor cells C. Bruton's agammaglobulinemia: this is an X-linked recessive disorder that would have been present since birth D. antithrombin III deficiency: AT III neutralizes serine protease coagulation factors and is associated with vessel thrombosis E. absent anti-A IgM titers in the donor unit: it is the absence of the patient's anti-B IgM |
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8. Which of the following is more often associated with Rh hemolytic disease of the newborn due to anti-D antibodies rather than ABO incompatibility? SELECT 2
A. No risk for hemolytic disease of the newborn during the first pregnancy B. Positive direct Coombs’ on the babies cord RBCs C. Spherocytes in the newborn’s peripheral blood D. Severe anemia requiring blood transfusion E. Unconjugated hyperbilirubinemia F. Type II hypersensitivity reaction |
Answers: A, D:
A. No risk for hemolytic disease of the newborn during the first pregnancy: mother's get sensitized against Rh antigen in their first Rh incompatible pregnancy, but this does not affect that baby but does affect future babies. First pregnancy may be affected in ABO HDN D. Severe anemia requiring blood transfusion: Rh HDN produces more severe anemias than ABO HDN B. Positive direct Coombs’ on the babies cord RBCs: both have this C. Spherocytes in the newborn’s peripheral blood: this is only in ABO HDN E. Unconjugated hyperbilirubinemia: both have this F. Type II hypersensitivity reaction: both have this |
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A blood group O, Rh negative 65 old-year-old man with known diverticulosis develops a massive lower GI bleed (hematochezia). He has an estimated blood loss of greater than 600 mL over the last few hours. An intravenous line with 0.9% normal saline is in place, while blood is being crossmatched in the blood bank. His Hgb is 6 g/dL. Physical exam shows cold, clammy skin, a blood pressure of 70/40 mm Hg, and a weak pulse with a rate of 120 bpm. Owing to a shortage of O, Rh negative blood only 1 of the 5 units of packed RBCs are O, Rh negative, while the remaining 4 units are O, Rh positive. The patient has no history of a previous transfusion or exposure to blood products. Midway through the second unit of blood, which is the first of the four units of O, Rh positive blood, he develops wheezing, dyspnea, and swelling of his face. The transfusion is stopped, a subcutaneous injection of aqueous epinephrine at a 1:1000 dilution is given to the patient, and a transfusion reaction work-up is ordered. The transfusion reaction work-up on a post-transfusion specimen of patient blood is as follows:
Patient temperature: 100.0 o F Patient blood pressure: 60/40 mm Hg Patient pulse: 130 bpm Patient plasma: clear Patient antibody screen: Negative Patient direct Coombs': negative Patient urine: negative dipstick for blood The pathogenesis of this patient's transfusion reaction is most closely related to… SELECT 2 A anti-D antibodies destroying donor D antigen positive RBCs B patient anti-HLA antibodies reacting against donor leukocytes C a patient IgE-mediated reaction against a donor allergen D a type I hypersensitivity reaction E an intravascular hemolytic anemia |
Answers: C, D:
C. a patient IgE-mediated reaction against a donor allergen: this is an allergic reaction. Note that the transfusion work-up has a negative direct Coomb's and no hemoglobin is in the urine D. a type I hypersensitivity reaction A anti-D antibodies destroying donor D antigen positive RBCs: the antibody screen is negative and the direct Coomb's. Antibodies cannot develop that quickly. D antibodies do not develop that fast. B patient anti-HLA antibodies reacting against donor leukocytes: it is not a febrile reaction E an intravascular hemolytic anemia: there is no hemoglobinuria |
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Which of the following correctly describes a major crossmatch? SELECT 3
A. prevents post-transfusion hepatitis due to hepatitis C B. does not guarantee survival of the infused donor RBCs C. rules out the possibility of a febrile transfusion reaction D. does not prevent patient antibodies developing against donor RBC antigens E. prevents antibodies in the donor from destroying patient RBCs F. detects the presence of patient antibodies against donor RBC antigens |
Answers: B, D, F:
B. does not guarantee survival of the infused donor RBCs D. does not prevent patient antibodies developing against donor RBC antigens: in fact, it is very likely that the patient will develop antibodies, because most patients do not receive blood from an identical twin, F. detects the presence of patient antibodies against donor RBC antigens: that would show up as an incompatible crossmatch. A. prevents post-transfusion hepatitis due to hepatitis C: even though the donor units are screened for HCV, there still can be false negatives because of the incubation period of the virus and lack of antibody formation during that time C. rules out the possibility of a febrile transfusion reaction: they are due to anti-HLA antibodies E. prevents antibodies in the donor from destroying patient RBCs: this possibility is not checked |
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15. A patient with this blood group can receive any blood group for transfusion
Items 12-17 Forward type using Back type using anti-A anti-B A RBCs B RBCs A. positive negative negative positive B. positive positive negative negative C. negative positive positive negative D. negative negative positive positive |
Answer: B: AB people are universal recipients.
Forward type using Back type using anti-A anti-B A RBCs B RBCs B. positive positive negative negative |
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1. A 28-year-old, non-smoking man with chronic lung disease limited to the lower lobes of the lungs and a negative sweat test has an abnormality noted in a serum protein electrophoresis SELECT 3
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Answers B, C, D: AAT deficiency with a panacinar emphysema involving-
B. Respiratory bronchiole C. Alveolar duct D. Alveoli: the a1 globulin peak is absent on a serum protein electrophoresis |
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9. Which of the following is MORE LIKELY to be a feature of atypical pneumonia rather than a pneumonia due to Streptococcus pneumoniae? SELECT 2
A. High fever B. Non-productive cough C. Positive Gram stain of sputum D. Sudden onset E. Increased tactile fremitus F. Positive e to a sign G. Interstitial pattern on chest x-ray |
Answers B, F -
B. Non-productive cough F. Interstitial pattern on chest x-ray: Atypical pneumonias producing interstitial inflammation and rarely have an alveolar infiltrate, therefore, signs of consolidation are not present A. High fever: typical pneumonia has a high fever, atypical pneumonia is usually lower C. Positive Gram stain of sputum: typical pneumonia; atypical pneumonias are caused by Mycoplasma, Chlamydia, and viruses D. Sudden onset: typical pneumonia; atypical have an insidious onset and flu-like symptoms E. Increased tactile fremitus: typical pneumonia because there is an alveolar consolidation which transmits sound and vibrations very well G. Positive e to a sign: typical because there is an alveolar consolidation which transmits sound and vibrations very well |
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Greenish discoloration of the sputum in a febrile 4-year-old child with cystic fibrosis is MOST LIKELY due to which of the following pathogens?
A. Staphylococcus aureus B. Serratia marcescens C. Pseudomonas aeruginosa D. Hemophilus influenzae E. Prevotella melanogenicus F. Moraxella catarrhalis |
Answer- C. Pseudomonas aeruginosa: pyocyanin
A. Staphylococcus aureus: yellow sputum; gram positive rod B. Serratia marcescens: red sputum; only present in immunocompromised host D. Hemophilus influenzae: no specific color; most common organism causing epiglottitis and acute exacerbation in chronic bronchitis; gram negative rod E. Prevotella melanogenicus: no specific color; melanogenicus is located above the diaphragm and fragilis below the diaphragm; it is associated with lung abscesses due to aspiration of oropharyngeal material; gram negative anaerobe F. Moraxella catarrhalis: no specific color; second most common cause of acute exacerbation of chronic bronchitis; common cause of otitis media; gram negative diplococcus |
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Which of the following pathogens is easily identified with the standard Gram stain?
A. Streptococcus pneumoniae B. Legionella pneumophila C. Pneumocystis jiroveci D. Chlamydia trachomatis |
Answer- A. Streptococcus pneumoniae: gram positive diplococcus
B. Legionella pneumophila: gram negative that is visualized best with a Dieterle silver stain or direct immunofluorescence; antigens can also be detected in urine C. Pneumocystis jiroveci: it is a fungus that requires a silver stain or Giemsa stain D. Chlamydia trachomatis: Chlamydia can be stained with Giemsa and Pap stains, which identify the reticulate body |
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A 65-year-old cave explorer for Indian artifacts in the Sonoran desert of Arizona develops fever, flu-like symptoms, a non-productive cough and painful red nodules on the anterior aspect of his lower left leg. A solitary coin lesion with an egg shell-like cavity is noted in the upper portion of his left lower lobe on a chest x-ray. You would expect a biopsy of this lung lesion to show which of the following?
A. Metastatic disease B. Spherules with endospores C. Narrow angled septate hyphae with fruiting bodies D. Hemorrhagic infarction secondary to a pulmonary embolus |
Answer B- Coccidioidomycosis-
B. spherules with endospores: contracted by breathing in arthrospores in dust. Painful nodules are erythema nodosum, an inflammatory lesion involving subcutaneous fat. It very commonly occurs with this infection as well as TB and sarcoidosis. A. metastatic disease: wrong history C. narrow angled septate hyphae with fruiting bodies: this describes Aspergillus D. hemorrhagic infarction secondary to a pulmonary embolus: wrong history |
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An asymptomatic, afebrile 48-year-old black man, who has lived all of his life in Ohio, is noted to have multiple calcifications throughout both lung fields and in the spleen. You suspect that the patient has/had which of the following infections?
A. Histoplasmosis B. Blastomycosis C. Miliary tuberculosis D. Cryptococcosis E. Sarcoidosis |
Answer- A. histoplasmosis: very characteristic dystrophic calcification in the granulomas
B. blastomycosis: primarily in Southeastern states and around the Great Lakes C. miliary tuberculosis: the patient does not have signs of active disease D. cryptococcosis: it is associated with pigeons, no calcifications, and is not likely to have miliary spread like histoplasmosis E. sarcoidosis: calcifications may occur in the granulomas and the lungs and spleen are often involved, however, this complication is not as common as in histoplasmosis |
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A 52-year-old Hispanic man complains of fever, weight loss and cough. He lives in Fresno, California and works on a farm worker in the San Joachim valley. He has a 40- year history of smoking cigarettes. His father, who also had similar clinical findings, recently died from exsanguination from an intrapulmonary bleed related to a lesion in the right upper lobe. The patient has a similar lesion in the left upper lobe. Which of the following is highest on your differential list of diseases pending further studies on the patient?
A. Reactivation tuberculosis B. Primary squamous cell carcinoma C. Histoplasmosis D. Metastatic adenocarcinoma E. Coccidioidomycosis |
B. Primary squamous cell carcinoma: father's history and fever are against cancer
C. Histoplasmosis: wrong area of the country D. Metastatic adenocarcinoma: similar to B discussion E. Coccidioidomycosis: right area of the country but massive hemoptysis is not a key finding |
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23. Pathogen that is contracted when the newborn passes through the birth canal. It produces a pneumonia characterized an abrupt onset of tachypnea, staccato cough, wheezing, hyperaeration, eosinophilia and a conspicuous lack of fever. It is often associated with a conjunctivitis.
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Answer: G. Chlamydia trachomatis
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Water loving pathogen that is most commonly seen in men over 40-years-old who are smokers and in organ transplant patients. It produces a confluent bronchopneumonia, with high fever, non-productive cough, hemoptysis, and other systemic signs and symptoms. It commonly produces hyponatremia related to development of interstitial nephritis leading to hyporeninemic hypoaldosteronism. The pathogen is best visualized with direct immunofluorescence or a silver stain:
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Answer: O. Legionella pneumophila: interstitial nephritis damages the JG apparatus causing a type IV renal tubular acidosis.
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27. Respiratory pathogen with a significant mortality in those over 55-years-old and who have underlying renal, cardiac or lung problems. It produces a severe, exudative pneumonia with a propensity for secondary bacterial invasion. There is an association with Reye’s syndrome in children that take aspirin.
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Answer: D. Influenza. S. aureus is the usual bacteria that may superimpose on the influenza pneumonia. Minor mutations in hemagglutinin/neuraminidase (antigen drift) do not require a new vaccine, while a major mutation of hemagglutinin/ neuraminidase (antigen shift) does require a new vaccine against the A virus.
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30. Respiratory pathogen transmitted by droplet infection. It accounts for approximately 10% of community acquired atypical pneumonias and a smaller percentage of cases of bronchitis. Cold agglutinins are not associated with this pathogen. There is an association with coronary artery disease.
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Answer: H. Chlamydia pneumoniae (TWAR)
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39. Pathogen that produces pseudomembranous that produces a toxin that inhibits elongation factor 2.
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Answer: R. Corynebacterium diphtheriae. EF-2 normally elongates proteins.
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An executive in an office in New York City has a window air conditioner that is a favorite roost for pigeons. She and her secretary both develop lung disease. Which of the following pathogens is the most likely the causative agent?
A. Candida albicans B. Coccidioides immitis C. Cryptococcus neoformans D. Chlamydia trachomatis E. Histoplasma capsulatum |
Answer- C. Cryptococcus neoformans; pigeons carry Cryptococcus in the excreta. Pigeons commonly live under bridges.
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In which of the following clinical scenarios involving patients with lung disease would you expect pulmonary function studies to exhibit decreased compliance, increased elasticity, and an increased FEV1sec/FVC ratio?
A. 6-year-old child with recurrent respiratory infections and steatorrhea B. 28-year-old non-smoking male with bilateral lower lobe emphysema C. 56-year-old smoker with productive cough, dyspnea, and cyanosis D. 10-year-old girl with bronchial asthma requiring a corticosteroid medihaler E. 39-year-old dyspneic black with bilateral hilar nodes |
Answer E- restrictive lung disease
E. 39-year-old dyspneic black with bilateral hilar nodes : sarcoidosis with restrictive lung disease findings A. 6-year-old child with recurrent respiratory infections and steatorrhea: cystic fibrosis with obstructive disease B. 28-year-old non-smoking male with bilateral lower lobe emphysema: AAT deficiency causing panacinar emphysema with obstructive disease C. 56-year-old smoker with productive cough, dyspnea, and cyanosis: chronic bronchitis, obstructive lung disease D. 10-year-old girl with bronchial asthma requiring a corticosteroid medihaler: obstructive disease |
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A 45-year-old woman 24-hours post-cholecystectomy develops fever and dyspnea. Physical exam demonstrates decreased percussion, absent tactile fremitus, and absent breath sounds in the right lower lobe. The diaphragm is elevated and there is inspiratory lag on the right side. The patient MOST LIKELY has which of the following diagnoses?
A. Atelectasis B. Lung abscess C. Bronchopneumonia D. Pulmonary infarction E. Spontaneous pneumothorax |
Answer- A. atelectasis: note the decrease in percussion and absence of signs of consolidation. Recall that the most common cause of fever within 24-36 hrs after surgery is resorption atelectasis from mucus plugs in the small airways and resorption of air out of the distal airways through the pores of Kohn in the alveoli.
B. lung abscess: usually has no signs of consolidation and has productive cough C. bronchopneumonia: bronchopneumonia develops after 3 days D. pulmonary infarction: physical findings are of pleuritic pain and there are no signs of consolidation. Usually they occur 4-5 days after surgery. E. spontaneous pneumothorax: there is hyperresonance to percussion |
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An afebrile 23-year-old man develops a sudden onset of left-sided, stabbing chest pain with dyspnea. Physical exam of the left chest demonstrates hyperresonance to percussion, deviation of the trachea to the left, elevation of the diaphragm, absent tactile fremitus, and absent breath sounds. Which of the following is the most likely diagnosis?
A. Pleural effusion B. Bronchopneumonia C. Tension pneumothorax D. Pulmonary infarction E. Spontaneous pneumothorax |
Answer- E. spontaneous pneumothorax: usually due to a ruptured subpleural bleb (paraseptal emphysema) or intrapleural bleb leaving a hole in the pleura. Pleural space pressure is the same as the atmospheric pressure, so the lung collapses.
A. pleural effusion: dullness to percussion B. bronchopneumonia: signs of consolidation C. tension pneumothorax: trachea deviated to other side and diaphragm is depressed D. a pulmonary infarction: usually a pleural effusion is present, which has dullness to percussion and deviation of the trachea to the opposite side. |
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A 58-year-old smoker complains of weight loss and cough. Physical exam demonstrates a mild lid lag on the left and a pinpoint pupil, scattered sibilant rhonchi throughout all lung fields that clear with coughing, and an increased anteroposterior diameter. Based on these findings, you suspect the patient has which of the following diagnoses?
A. a superior sulcus tumor B. a thoracic outlet syndrome C. the superior vena caval syndrome D. obstructive lung disease with metastatic cancer from another primary site |
Answer- A. a superior sulcus tumor (Pancoast tumor): Horner's syndrome is present due to destruction of the superior cervical ganglion in the posterior mediastinum by a primary squamous cancer of lung with local extension into the lower brachial plexus as well.
B. a thoracic outlet syndrome: no lid lag is present. C. the superior vena caval syndrome: no neck vein distention and red face is present D. obstructive lung disease with metastatic cancer from another primary site: metastasis is not the most common cause of the superior sulcus tumor |
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A 65-year-old man with urinary retention secondary to prostatic hyperplasia, develops spiking fever, and tachypnea. Physical exam demonstrates intercostal muscle retractions and bilateral inspiratory crackles. A chest x-ray exhibits bilateral interstitial and alveolar infiltrates. ABGs demonstrate severe hypoxemia.
47. You expect the blood culture was positive for which of the following pathogens? A. Gram positive diplococci B. Gram negative diplococci C. Gram positive cocci D. Gram negative rods E. Gram positive rods |
Answer- D. gram negative rods: Gram negative sepsis due to E. coli that developed into an ARDS
A. gram positive diplococci: Streptococcus pneumoniae is not a uropathogen B. gram negative diplococci: Neisseria species can produce septic shock but not as commonly as E. coli. C. gram positive cocci: S. aureus is not a uropathogen E. gram positive rods: Bacillus/Clostridia species are not uropathogens |
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A bridge painter in Brooklyn, New York develops a pulmonary infiltrate. Which of the following pathogens is most likely responsible?
A. Histoplasma capsulatum B. Coccidioides immitis C. Chlamydia psittaci D. Cryptococcus neoformans E. Aspergillus fumigatus |
Answer- D. Cryptococcus neoformans: pigeons roost under bridges.
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Which of the following blood gas abnormalities would be present at the present time?
A. Primary metabolic acidosis B. Primary respiratory acidosis C. Primary metabolic alkalosis D. Primary respiratory alkalosis E. Mixed primary respiratory alkalosis and primary metabolic acidosis |
Answer D: bronchial asthma-
D. primary respiratory alkalosis: initial ABG is respiratory alkalosis, but it could develop into respiratory acidosis if the patient becomes too tired to breathe. |
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The findings of an increased AP diameter, hyperresonance to percussion, and flattened diaphragms on the chest x-ray are MOST CLOSELY related to which of the following spirometry findings? SELECT 2
A. Increase in tidal volume B. Increase in residual volume C. Increase in total lung capacity D. Increase in FEV1 sec E. Increase in vital capacity |
Answers B, C-
B. increase in residual volume C. increase in total lung capacity: obstructive lung disease pattern A. increase in tidal volume: decreased D. increase in FEV1sec: decreased E. increase in vital capacity: decreased |
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The reason for the patient's most recent acute exacerbation of coughing MOST CLOSELY relates to which of the following conditions?
A. Acute bronchitis secondary to Klebsiella pneumoniae B. Acute bronchitis secondary to Hemophilus influenzae C. Bronchiectasis superimposed on his primary lung disease D. Viral pneumonia with a secondary Staphylococcus aureus pneumonia Pulmonary function studies in this patient are as follows: Total lung capacity 7.10 liters (130% of predicted) Residual volume 3.90 liters (170% of predicted) Forced vital capacity (FVC) 3.0 liters (74% of predicted) Forced expiratory volume 1 sec (FEV1 sec) 1.0 liter (20% of predicted) FEV1sec / FVC ratio 33% (75% of predicted) |
Answer- B. acute bronchitis secondary to Hemophilus influenzae NOTE: Moraxella catarrhalis is the second most common cause, but it is a gram negative diplococcus
A. acute bronchitis secondary to Klebsiella pneumoniae: Klebsiella is a fat gram negative rod C. bronchiectasis superimposed on his primary lung disease: it is not present D. a viral pneumonia with a secondary Staphylococcus aureus pneumonia: S. aureus is a gram positive coccus |
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Which of the following is more often associated with a "blue bloater" rather than a "pink puffer"? SELECT 3
A. Greater ventilation/perfusion defect B. Greater degree of hypoxemia C. Normal to low PaCO2 D. Lower arterial oxygen saturation E. Greater degree of hyperinflation F. Normal to increased arterial pH |
Answers A, B, D-
A. Greater ventilation/perfusion defect: yes, it has a more proximal site of obstruction in the terminal bronchiole vs the respiratory unit in emphysema which is distal to the terminal bronchiole. In emphysema, there are matched losses of the respiratory unit and pulmonary capillary bed, which explains why hypoxemia is a late finding B. Greater degree of hypoxemia: yes, due to respiratory acidosis D. Lower arterial oxygen saturation: yes, follows hypoxemia C. Normal to low PaCO2: it is high in CB, while in emphysema it is normal to low (obstruction is in the respiratory unit) E. Greater degree of hyperinflation: emphysema does F. Normal to increased arterial pH: emphysema does, since a low PCO2 is associated with respiratory alkalosis related to hyperventilation |
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Which of the following occur in both bronchial asthma and chronic bronchitis due to cigarette smoking? SELECT 2
A. Associated with IgE mediated inflammation B. Characterized by episodic seasonal flare ups C. Initially present with respiratory alkalosis D. Produce obstruction to airflow in the small caliber airways E. Respond to bronchodilator therapy F. Productive cough throughout most of the year G. Eosinophils play a major role in the disease process H. CD4 T2H cells have a major role in the disease process |
Answers D, E-
D. produce obstruction to airflow in the small caliber airways E. respond to bronchodilator therapy A. associated with IgE mediated inflammation: only asthma B. characterized by episodic seasonal flare ups: only asthma C. initially present with respiratory alkalosis: only asthma F. productive cough throughout most of the year: only CB G. Eosinophils play a major role in the disease process: only asthma. Eosinophils release major basic protein and cationic protein, which damage epithelial cells. H. CD4 T2H cells have a major role in the disease process: only asthma. Antigen activation of these cells causes the release of IL-4 and IL-5, which are very important in initiating the type I hypersensitivity response. |
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Which of the following conditions are often associated with wheezing? SELECT 2
A. Right-sided heart failure B. Pulmonary embolus C. Chlamydia pneumoniae pneumonia D. Respiratory syncytial virus infection E. Acute epiglottis F. Sarcoidosis |
Answers B, D-
B. a pulmonary embolus D. respiratory syncytial virus infection (bronchiolitis). Other causes of wheezing include bronchial asthma and chronic bronchitis. A. right-sided heart failure: LHF has wheezing from peribronchiolar edema C. Chlamydia pneumoniae pneumonia: Chlamydia trachomatis in a newborn has small airway involvement E. acute epiglottis: inspiratory stridor F. sarcoidosis: no wheezing |
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A 29-year-old African-American woman develops dyspnea, blurry vision, and bilateral parotid gland enlargement. Nodular lesions are noted over the chest and back. Fine, dry inspiratory crackles are heard at both lung bases. A chest x-ray demonstrates bilateral hilar adenopathy and bibasilar reticulonodular infiltrates. Which of the following apply to this patient's disorder? SELECT 4
A. Decreased angiotensin converting enzyme levels B. Anergy to skin testing with common antigens C. Inflammation of the uveal tract in the eye D. Non-caseating granulomas in the nodular skin lesions E. Potential for hypercalcemia F. Decreased FEV1sec/FVC ratio G. Low pH with increased PaCO2 |
Answers B, C, D, E- sarcoidosis
B. Anergy to skin testing with common antigens: due to low CD4 T cell count (used up in forming granulomas) C. Inflammation of the uveal tract in the eye: blurry vision; may cause blindness D. Non-caseating granulomas in the nodular skin lesions; they also develop erythematous lesions on the nose and face called lupus pernio E. Potential for hypercalcemia: yes, macrophages synthesize 1-a-hydroxylase, which converts vitamin D into its active form A. Decreased angiotensin converting enzyme levels: increased and an excellent sign of increased disease activity F. Decreased FEV1sec/FVC ratio: increased (restrictive) G. Low pH with increased PaCO2: respiratory alkalosis not respiratory acidosis |
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A 29-yr-old man is stabbed in the left lung with a knife. He develops severe respiratory distress. There is widening of the intercostal muscles, hyperresonance to percussion, and absent breath sounds on the left. The trachea in the sternal notch is deviated to the right. What is the most likely diagnosis?
A. Left pleural effusion B. Cardiac tamponade C. Spontaneous pneumothorax D. Tension pneumothorax E. Saddle embolus |
Answer- D. tension pneumothorax: classic tension pneumothorax. Knife wound produced a flap so air goes into the pleural cavity on inspiration and then the flap closes on expiration, similar to putting air into a tire. Positive pressure in the pleural cavity produces compression atelectasis and pushes the mediastinum to the opposite side.
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A 26-year-old man develops a sudden onset of 103o F temperature, dyspnea, cough productive of blood-tinged sputum, and pleuritic chest pain in the right upper lung. A chest x-ray demonstrates a right upper lobe consolidation. A gram stain of sputum is pending. If the patient has no drug allergies, which of the following is your treatment of choice?
A. Tetracycline B. Ceftriaxone C. Azithromycin D. Trimethoprim/sulfamethoxazole |
Answer C- Streptococcus pneumoniae typical pneumonia - C. Azithromycin
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A 68-year-old retired Navy chief has a chest x-ray exhibiting diffuse interstitial fibrosis in both lungs and the presence of calcified pleural plaques. A transbronchial biopsy demonstrates a dumbbell-shaped brown structure trapped in a small respiratory bronchiole. It stains positive for iron. You suspect that this patient had exposure to which of the following environmental agents?
A. Thermophilic actinomycetes bacteria B. Silica C. Anthracotic pigment D. Asbestos E. Nitrogen dioxide |
Answer- D. asbestos: probably worked in a ship yard around pipe fittings which were insulated with asbestos. Serpentine fibers are curly, while amphibole fibers are straight, hence the latter fibers are more likely to extend more peripherally. When macrophages try to phagocytose the fibers, the ferritin in the macrophage coats the fiber producing a ferruginous or asbestos body.
A. Thermophilic actinomycetes bacteria: cause of Farmer's lung. Organisms are present in moldy hay. B. Silica: silicosis has nodular lesions in the lung rather than diffuse interstitial fibrosis. C. Anthracotic pigment: coal worker's pneumoconiosis. Dust cells (macrophages with anthracotic pigment) are present. E. Nitrogen dioxide: silo filler's disease |
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81. In a patient who is lying on their back, aspirated material would most likely localize to this segment of the lung:
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Answer: B. Right lower lobe superior segment: most common overall site for aspiration
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You would expect a normal A-a gradient in the presence of hypoxemia in which of the following clinical conditions? SELECT 3
A. Chronic obstructive pulmonary disease B. Pulmonary embolus C. Paralysis of the diaphragms D. Acute respiratory distress syndrome E. Barbiturate overdose F. Obstructive sleep apnea |
Answers C, E, F- Hypoxemia must involve the respiratory center, upper airways or chest bellows in order to have a normal A-a gradient-
C. Paralysis of the diaphragms E. Barbiturate overdose F. Obstructive sleep apnea due to enlarged tonsils. Each of these disorders has respiratory acidosis causing the hypoxemia. A. Chronic obstructive pulmonary disease: increased gradient B. Pulmonary embolus: increased gradient D. Acute respiratory distress syndrome: increased gradient |
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110. A morbidly obese 28-yr-old man has a history of falling asleep while at work. He has a long history of missing work owing to headaches when he wakes up in the morning. His co-workers state that the patient snores loudly when he falls asleep at his desk and that there are short intervals of time where he stops breathing. Which of the following apply to this patient's condition? SELECT 4
A. Patient should be evaluated by polysomnography B. Intermittent episodes of respiratory acidosis C. Intermittent episodes of hypoxemia D. Potential for cor pulmonale E. Best treated with surgery |
Answers A, B, C, D- obstructive sleep apnea:
A. Patient should be evaluated by polysomnography B. Intermittent episodes of respiratory acidosis: related to the periods of apnea C. Intermittent episodes of hypoxemia: due to respiratory acidosis D. Potential for cor pulmonale E. Best treated with surgery: continuous positive airway pressure and weight loss is the first step and then if there is an anatomical reason |
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A 62-yr-old smoker and drinker develops hoarseness. Direct laryngoscopy demonstrates an ulcerated lesion on the right vocal cord. A biopsy is taken and demonstrates a well-differentiated squamous cell carcinoma. Which of the following risk factors are most responsible for this man's condition?
A. Smoking alone B. Alcohol alone C. Smoking and alcohol D. Age over 50 E. Family history |
Answer- C. Smoking and alcohol: each can produce laryngeal carcinoma, but together, they have a synergistic effect
A. Smoking alone: second best answer B. Alcohol alone: third best answer D. Age over 50: no age relationship E. Family history: no family history relationship |
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Which of the following systemic fungi with broad-based buds presents with a skin disorder simulating squamous carcinoma as well as lung disease?
A. Coccidioides immitis B. Blastomyces dermatitidis C. Histoplasma capsulatum D. Cryptococcus neoformans E. Candida albicans |
Answer- B. Blastomyces dermatitidis: skin lesion is usually on the face and looks like squamous cancer- remember-broad, based, bud, blasto
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Which of the following systemic fungi most simulates primary and reactivation TB and has yeast forms phagocytosed by alveolar macrophages?
A. Coccidioides immitis B. Blastomyces dermatitidis C. Histoplasma capsulatum D. Cryptococcus neoformans E. Candida albicans |
Answer- C. Histoplasma capsulatum: only one with phagocytosed yeasts
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Which of the following pulmonary pathogens are vessel invaders and have the capacity to produce pulmonary infarctions? SELECT 3
A. Pseudomonas aeruginosa B. Aspergillus fumigatus C. Mucor species D. Staphylococcus aureus |
A. Pseudomonas aeruginosa
B. Aspergillus fumigatus C. Mucor species. Candida albicans is also a vessel invader. |
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A cave explorer in the Sonoran desert in Arizona develops fever and a non-productive cough. Painful nodules are present on his lower legs. What is the most likely diagnosis?
A. Histoplasma capsulatum B. Coccidioides immitis C. Cryptococcus neoformans D. Aspergillus fumigatus |
Answer: B. Coccidioides immitis: even though it is a cave, Histoplasma cannot survive in a dry climate. Southwest = Coccidioides
A. Histoplasma capsulatum C. Cryptococcus neoformans: think pigeons D. Aspergillus fumigatus: think asthma, fungus ball, pneumonia |
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A 23-year-old man requires a root canal for an abscessed tooth. On the day prior to the procedure, he develops a severe nosebleed, which prompts his dentist to order a few laboratory studies, which are listed below.
Partial thromboplastin time (PTT) 35 sec (2840 sec) Prothrombin time (PT) 13 sec (1115 sec) Bleeding time 16 min (27 min) Platelet count 300,000 mm3 (150,000400,000 mm) Hemoglobin 15.5 g/dL (13.517.5 g/dL) 4. Which of the following hemostasis abnormalities is most likely present in this patient? A. Von Willebrand's disease B. Hemophilia A C. Factor IX deficiency D. Acquired platelet defect E. Acquired vascular defect |
Answer: D. Acquired platelet defect: patient is probably on an NSAID for pain an no temporary platelet plug is being formed. Note the prolonged BT and normal coagulation studies.
A. Von Willebrand's disease: PTT is normal B. Hemophilia A: as above C. Factor IX deficiency: as above E. Acquired vascular defect: no signs of a vascular defect |
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A 23-year-old man requires a root canal for an abscessed tooth. On the day prior to the procedure, he develops a severe nosebleed, which prompts his dentist to order a few laboratory studies, which are listed below.
Partial thromboplastin time (PTT) 35 sec (2840 sec) Prothrombin time (PT) 13 sec (1115 sec) Bleeding time 16 min (27 min) Platelet count 300,000 mm3 (150,000400,000 mm) Hemoglobin 15.5 g/dL (13.517.5 g/dL) 5. Which of the following best describe the mechanisms for this patient's bleeding disorder? SELECT 3 A. Platelet adhesion molecule defect B. Defect in platelet aggregation C. Decreased synthesis of TXA2 D. Defect in producing a temporary platelet plug E. Defect in converting fibrinogen into fibrin |
Answers: B, C, D:
B. Defect in platelet aggregation: platelet is not synthesizing TXA2 C. Decreased synthesis of TXA2 D. Defect in producing a temporary platelet plug: there is no temporary platelet plug A. Platelet adhesion molecule defect: this is not VWD. The PTT is normal. E. Defect in converting fibrinogen into fibrin: this is not a coagulation disorder |
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A 23-year-old man requires a root canal for an abscessed tooth. On the day prior to the procedure, he develops a severe nosebleed, which prompts his dentist to order a few laboratory studies, which are listed below.
Partial thromboplastin time (PTT) 35 sec (2840 sec) Prothrombin time (PT) 13 sec (1115 sec) Bleeding time 16 min (27 min) Platelet count 300,000 mm3 (150,000400,000 mm) Hemoglobin 15.5 g/dL (13.517.5 g/dL) If this patient experienced a life-threatening bleed related to his disorder, which of the following treatments would stop the bleeding? A. Infusion of fresh frozen plasma B. Infusion of platelets C. Infusion of cryoprecipitate D. Infusion of packed RBCs E. Infusion of whole blood |
Answer: B. Infusion of platelets: only platelets that are functioning can stop the bleeding
A. Infusion of fresh frozen plasma: it is not a coagulation defect C. Infusion of cryoprecipitate: as above D. Infusion of packed RBCs: does not contain enough platelets E. Infusion of whole blood: as above |
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A 63-year-old man with urinary retention secondary to benign prostatic hyperplasia develops fever and chills shortly after insertion of an indwelling catheter. Physical exam demonstrates warm skin and a bounding pulse. Within 24 hours, he begins oozing blood out of venipuncture sites and from his mucous membranes. Ecchymoses appear over his trunk and extremities. His urine output decreases to <400 mL/day. Laboratory studies show the following:
Hemoglobin 10 g/dL (13.517.5 g/dL) Leukocyte count 2,000/mm3 (4,50011,000/mm3) Platelet count 140,000/mm3 (150,000400,000/mm3) Partial thromboplastin time 42 sec (2840 sec) Prothrombin time 18 sec (1115 sec) Plasma fibrinogen 150 mg/dL (200400 mg/dL) Fibrin(ogen) degradation products >10 g/mL (<10 g/mL) D-dimers positive (negative) Blood cultures pending Serum blood urea nitrogen 80 mg/dL (718 mg/dL) Serum creatinine 8 mg/dL (0.61.2 mg/dL) 8. Which of the following apply to this case? SELECT 4 A. Thrombotic thrombocytopenic purpura B. Disseminated intravascular coagulation C. Consumption of coagulation factors D. Prerenal azotemia E. Secondary fibrinolysis F. Decreased production of platelets G. Increased total peripheral resistance H. Endotoxic shock |
Answers: B, C, E, H: the patient has DIC and is in renal failure (BUN/creatinine ratio < 15:1)
B. Disseminated intravascular coagulation: endotoxic shock is the most common cause. Note oozing from all sites. C. Consumption of coagulation factors: I, II, V, VIII E. Secondary fibrinolysis: via XIIa converting prekallikrein to kallikrein, which, in turn, activates plasminogen H. Endotoxic shock: E. coli, is the most common organism. A. Thrombotic thrombocytopenic purpura: the PTT and PT are not prolonged in TTP and the fibrinogen is normal. D. Prerenal azotemia: the ratio is < 15:1 not 15:1 F. Decreased production of platelets: they are being consumed G. Increased total peripheral resistance: it is decreased due to vasodilatation from NO, anaphylatoxins, PGI2. |
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A 63-year-old man with urinary retention secondary to benign prostatic hyperplasia develops fever and chills shortly after insertion of an indwelling catheter. Physical exam demonstrates warm skin and a bounding pulse. Within 24 hours, he begins oozing blood out of venipuncture sites and from his mucous membranes. Ecchymoses appear over his trunk and extremities. His urine output decreases to <400 mL/day. Laboratory studies show the following: Hemoglobin 10 g/dL (13.517.5 g/dL) Leukocyte count 2,000/mm3 (4,50011,000/mm3) Platelet count 140,000/mm3 (150,000400,000/mm3) Partial thromboplastin time 42 sec (2840 sec) Prothrombin time 18 sec (1115 sec) Plasma fibrinogen 150 mg/dL (200400 mg/dL) Fibrin(ogen) degradation products >10 g/mL (<10 g/mL) D-dimers positive (negative) Blood cultures pending Serum blood urea nitrogen 80 mg/dL (718 mg/dL) Serum creatinine 8 mg/dL (0.61.2 mg/dL) Which of the following is the most effective treatment for this patient? A. Fresh frozen plasma B. Packed red blood cells C. Platelet concentrates D. Low dose heparin E. Antibiotics |
Answer: E. Antibiotics: in DIC, the most effective Rx is to Rx the cause of the DIC, in this case, endotoxic shock secondary to E. coli. The blood components listed below are also indicated, but essentially feed the fire and keep the patient alive until the underlying disease is eradicated.
A. Fresh frozen plasma: provides all the coagulation factors B. Packed red blood cells: corrects anemia C. Platelet concentrates: corrects thrombocytopenia D. Low dose heparin: prevents fibrin clots from forming, hence they are not consumed anymore |
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Which of the following laboratory test results are more often associated with classical von Willebrand's disease rather than mild hemophilia A? SELECT 2
A. Normal prothrombin time B. Decreased factor VIII:coagulant activity C. Abnormal ristocetin cofactor assay D. Prolonged partial thromboplastin time E. Prolonged bleeding time F. Normal platelet count G. Response to desmopressin acetate |
Answers: C, E:
C. Abnormal ristocetin cofactor assay: measures presence of VIII:vWF E. Prolonged bleeding time: due to platelet adhesion defect, A. Normal prothrombin time: both have this B. Decreased factor VIII:coagulant activity: as above D. Prolonged partial thromboplastin time: as above F. Normal platelet count: as above G. Response to desmopressin acetate: as above |
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Items 1119
Platelet count Bleeding time PTT PT A. Decreased Prolonged Normal Normal B. Decreased Prolonged Prolonged Prolonged C. Normal Prolonged Prolonged Normal D. Normal Normal Prolonged Normal E. Normal Normal Prolonged Prolonged F. Normal Normal Normal Prolonged G. Normal Prolonged Normal Normal 12. A 54-yr-old man is on heparin to prevent deep venous thrombosis |
Answer: E- heparin enhances AT III, which neutralizes most intrinsic factors and most of the final common pathway factors, hence both PT and PTT are prolonged
E. Normal Normal Prolonged Prolonged |
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Platelet count Bleeding time PTT PT
A. Decreased Prolonged Normal Normal B. Decreased Prolonged Prolonged Prolonged C. Normal Prolonged Prolonged Normal D. Normal Normal Prolonged Normal E. Normal Normal Prolonged Prolonged F. Normal Normal Normal Prolonged G. Normal Prolonged Normal Normal 14. A 28-yr-old man has been envenomated by a rattlesnake and is bleeding from all orifices and all needle stick sites |
Answer: B: the patient has DIC. BT is prolonged due to Decreased platelets and FDPs interfering with aggregation.
B. Decreased Prolonged Prolonged Prolonged |
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Platelet count Bleeding time PTT PT
A. Decreased Prolonged Normal Normal B. Decreased Prolonged Prolonged Prolonged C. Normal Prolonged Prolonged Normal D. Normal Normal Prolonged Normal E. Normal Normal Prolonged Prolonged F. Normal Normal Normal Prolonged G. Normal Prolonged Normal Normal 15. A child has eaten raw hamburgers and now has a hemolytic anemia and renal failure |
Answer: A: HUS due to 0157: H7 serotype of E. coli: platelet, not coagulation factor consumption.
Platelet count Bleeding time PTT PT A. Decreased Prolonged Normal Normal |
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Platelet count Bleeding time PTT PT
A. Decreased Prolonged Normal Normal B. Decreased Prolonged Prolonged Prolonged C. Normal Prolonged Prolonged Normal D. Normal Normal Prolonged Normal E. Normal Normal Prolonged Prolonged F. Normal Normal Normal Prolonged G. Normal Prolonged Normal Normal 18. A 49-yr-old woman with fibromyalgia is taking NSAIDS for pain |
Answer: G: NSAIDs block platelet cyclooxygenase
Platelet count Bleeding time PTT PT G. Normal Prolonged Normal Normal |
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An afebrile 8-year-old boy develops epistaxis 1 week after an upper respiratory infection. Physical examination demonstrates scattered petechia and ecchymoses over his trunk. There is no lymphadenopathy or hepatosplenomegaly. A stool for occult blood is negative. His CBC exhibits a hemoglobin of 13 g/dL (12.015.0 g/dL), leukocyte count of 8,500/mm3 (4,50013,500/mm3) with a normal differential count, and a platelet count of 10,000/mm3 (150,000400,000/mm3). Which of the following apply to this case? SELECT 3
A. Endothelial cell damage secondary to a toxin B. Megakaryocytes are present in the marrow C. Type II hypersensitivity reaction against platelets D. Best treated with corticosteroids E. Multiple coagulation factor deficiencies |
Answers: B, C, D: the patient has acute ITP due to IgG antibodies directed against platelet GPIIb/IIIa receptors for fibrinogen
B. Megakaryocytes are present in the marrow: they are usually increased C. Type II hypersensitivity reaction against platelets D. Best treated with corticosteroids A. Endothelial cell damage secondary to a toxin: that is either TTP or HUS. In TTP it is associated with absence of VWF metalloprotease, which degrades VWF, while in HUS it is due to the Shiga toxin. E. Multiple coagulation factor deficiencies: the PT and PTT are normal with primary platelet problems and would likely be prolonged with coagulation factor deficiencies. |
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21. A 38-year-old woman develops fever, mental status alterations, and epistaxis. Physical examination demonstrates retinal hemorrhages, widespread petechia and ecchymoses, and a positive stool for occult blood. There is no lymphadenopathy or hepatosplenomegaly. The CBC report indicates a normocytic anemia and a normal leukocyte count. The corrected reticulocyte count is 12%. The peripheral smear exhibits numerous fragmented RBCs, polychromasia, and a reduced number of platelets. A bone marrow biopsy contains vascular channels containing platelet thrombi. There is a positive urine dipstick for blood and numerous RBCs are present in the sediment. The serum blood urea nitrogen is 40 mg/dL (718 mg/dL) and the serum creatinine is 4 mg/dL (0.61.2 mg/dL). Which of the following apply to this case? SELECT 3
A. Endothelial cell damage secondary to a toxin B. Type II hypersensitivity reaction C. Consumption of coagulation factors D. Consumption of platelets E. Intravascular hemolytic anemia F. Prerenal azotemia |
Answers: A, D, E: the patient has TTP- remember that it is not DIC. It is an acquired or genetic deficiency in vWF-cleaving metalloprotease in endothelial cells. Increase in circulating multimers of vWF increases platelet adhesion to areas of endothelial injury at arteriole-capillary junctions. Platelets are consumed owing to production of platelet thrombi in areas of injury (not DIC). Enhanced by other factors that damage endothelial cells (e.g., clopidogrel, hypertension). The PT and PTT are normal.
A. Endothelial cell damage secondary to a toxin D. Consumption of platelets E. Intravascular hemolytic anemia: microangiopathic with schistocytes. B. Type II hypersensitivity reaction: no antibodies are involved C. Consumption of coagulation factors: DIC F. Prerenal azotemia: the ratio is 10/1 and represents acute renal failure (< 15/1) |
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23. Which of the following characterize BOTH classical von Willebrand's disease and mild hemophilia A? SELECT 4
A. Bleeding from superficial scratches B. Bleeding post-molar tooth extraction C. Palpable purpura D. Recurrent epistaxis E. Bleeding into joints F. Normal PT G. Normal platelet count |
Answers: B, D, F, G: the VIII:C deficiency in VWD is always mild.
B. Bleeding post-molar tooth extraction: yes, VWD has both a platelet abnormality and coagulation deficiency D. Recurrent epistaxis F. Normal PT G. Normal platelet count A. Bleeding from superficial scratches: hemophilia A does not have this C. Palpable purpura: neither have this, since it represents immunocomplex vasculitis of small vessels E. Bleeding into joints: only severe hemophilia A would have this |
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Vitamin K deficiency is an expected finding in which of the following clinical settings? SELECT 4
A. Patient with steatorrhea secondary to gluten sensitivity B. Patient on intravenous heparin therapy C. Patient with sigmoid diverticulosis D. Patient on broad spectrum antibiotics E. Newborn who is 3 days old F. Alcoholic with cirrhosis and chronic pancreatitis |
Answers: A, D, E, F: broad spectrum antibiotics is the MCC in a hospital setting.
A. Patient with steatorrhea secondary to gluten sensitivity: this produces malabsorption of vitamin K D. Patient on broad spectrum antibiotics E. Newborn who is 3 days old: all the vitamin K from mommy is gone and no bacteria have colonized the bowel of the baby by this time to synthesize vitamin K F. Alcoholic with cirrhosis and chronic pancreatitis: bile salt deficiency and inability to activate vitamin K by epoxide reductase from cirrhosis and maldigestion of fats from chronic pancreatitis lead to malabsorption of vitamin K B. Patient on intravenous heparin therapy: no effect on K C. Patient with sigmoid diverticulosis: no effect on K synthesis |
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An 18-year-old smoking male has deep venous thrombosis (DVT) involving the right lower calf. He has a family history of recurrent DVTs and pulmonary emboli in his mother and maternal grandfather. His PTT and PT are normal prior to receiving a standard dose of heparin intravenously. The PTT remains normal 1 hour after infusing heparin. The pathogenesis of his hemostasis abnormality is most likely related to…
A. antiphospholipid antibodies B. a thrombohemorrhagic disorder C. a deficiency of antithrombin III D. a deficiency of a vitamin K-dependent factor E. antibodies directed against heparin |
Answer: C. a deficiency of antithrombin III: the patient has hereditary AT III deficiency. Heparin cannot anticoagulate without AT III. The pearl is the lack of increase in the PTT with heparin. Rx is to give massive doses of heparin, which will activate what little ATIII is present.
A. antiphospholipid antibodies: this usually occurs in patients with SLE; PTT would prolong with heparin B. a thrombohemorrhagic disorder: this is not DIC D. a deficiency of a vitamin K-dependent factor: this is not protein C or S deficiency. Heparin would have prolonged the PTT. E. antibodies directed against heparin: that produces thrombocytopenia |
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Which of the following cells produces a chemical that is operative in normal hemostasis in small vessel injury, Prinzmetal's angina, and wheezing in patient's with a pulmonary embolus?
A. Endothelial cell B. Macrophage C. Platelet D. Neutrophils E. Hepatocyte |
Answer: C. Platelet: it produces TXA2 is a vasoconstrictor, bronchoconstrictor, and a platelet aggregator
A. Endothelial cell: it is operative in normal hemostasis in small vessel injury by providing VIII:vWF, but no to the rest B. Macrophage: it is not involved in hemostasis at all D. Neutrophils: as above E. Hepatocyte: it does produce coagulation factors but no, it does not have anything to do with angina or a PE |
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A 23-year-old woman has a history of recurrent epistaxis and iron deficiency with guaiac positive stools. Other members in her family of both sexes have similar problems. Her bleeding time, PT, PTT, and platelet count are all normal. Examination of her oral mucosa and endoscopic evaluation of her upper GI tract demonstrates a similar abnormality. The pathogenesis of her abnormality is most likely related to… C 7
A. a coagulation factor deficiency B. a vascular disorder C. a quantitative platelet disorder D. an autoimmune disorder E. a platelet adhesion defect |
Answer: B. a vascular disorder: she has Osler-Weber-Rendu disease alias hereditary telangiectasia, an AD disorder. Telangiectasis in the GI tract lead to chronic iron deficiency.
A. a coagulation factor deficiency: PT and PTT are normal in OWR C. a quantitative platelet disorder: BT is normal in OWR D. an autoimmune disorder: OWR is a genetic disease E. a platelet adhesion defect: it is not VWD |
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A 58-year-old alcoholic man has fatigue, hepatomegaly with a nodular surface and a positive stool guaiac. His prostate gland is diffusely enlarged but no areas of induration are present. Hematologic findings show thrombocytosis, a mild microcytic anemia, and a decreased serum ferritin. A biochemical profile exhibits a normal bilirubin, normal transaminases (AST and ALT), increased alkaline phosphatase, increased -glutamyltransferase, and an increased LDH. Which of the following tests is most indicated in this patient to arrive at the cause of his anemia and liver function abnormalities?
A. Bone marrow aspirate and biopsy B. CT scan of the liver C. Colonoscopy D. Hepatitis serological tests E. Prostate specific antigen |
Answer: C. Colonoscopy: he has colon cancer metastatic to liver (note increased ALP, GGT, and LDH, but normal total bilirubin and transaminases indicating a malignant space occupying lesion). Note the iron deficiency anemia with thrombocytosis. Thrombocytosis could be due to the malignancy or the iron deficiency.
A. Bone marrow aspirate and biopsy: not necessary B. CT scan of the liver: it would be necessary to document the metastasis, but no, it does not document the cause of the anemia, which is colon cancer D. Hepatitis serological tests: the enzyme profile is wrong for hepatitis (bilirubin and transaminases would be increased). E. Prostate specific antigen: he probably has hyperplasia |
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Which of the following gastrointestinal disorders is commonly associated with a prolonged PT? SELECT 4
A. Bacterial overgrowth in the duodenum B. Crohn’s disease involving the terminal ileum C. Chronic pancreatitis with maldigestion of fat D. Osmotic diarrhea secondary to laxative abuse E. Celiac disease involving the jejunum and terminal ileum |
Answers: A, B, C, E: all of these have malabsorption of fat soluble vitamins except for laxative abuse
A. Bacterial overgrowth in the duodenum: depletes bile salts B. Crohn’s disease involving the terminal ileum: depletes bile salts C. Chronic pancreatitis with maldigestion of fat: malabsorption of vitamin K E. Celiac disease involving the jejunum and terminal ileum: malabsorption of vitamin K D. Osmotic diarrhea secondary to laxative abuse: does not cause vitamin K malabsorption |
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The rationale for beginning heparin and warfarin at the same time is that...
A. previously activated vitamin K-dependent factors have long half-lives B. inactivation of epoxide reductase by warfarin requires 35 days C. warfarin enhances activation of antithrombin III by heparin D. warfarin reduces the complications associated with heparin E. heparin requires 24 hrs to fully anticoagulate the patient |
Answer: A. previously activated vitamin K-dependent factors have long half-lives: the shortest are factor VII and protein C and the longest is prothrombin
B. inactivation of epoxide reductase by warfarin requires 35 days: it is immediate C. warfarin enhances activation of antithrombin III by heparin: no D. warfarin reduces the complications associated with heparin: no E. heparin requires 24 hrs to fully anticoagulate the patient: it is immediate |
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A 23-yr-old woman has a positive RPR and negative FTA-ABS for syphilis. She has a history of repeated spontaneous abortions. Which of the following apply to this patient? SELECT 4
A. Antibodies against phospholipids are present B. Thrombi of placental vessels caused the abortions C. Lupus anticoagulant caused false positive RPR D. Stroke and deep vein thrombosis are common E. Anticardiolipin antibodies cross the placenta |
Answers: A, B, D, E: the patient has the antiphospholipid syndrome due to the LA and anti cardiolipin antibodies, the latter responsible for the FP RPR.
A. Antibodies against phospholipids are present B. Thrombosis of placental vessels caused the abortions D. Stroke and deep vein thrombosis are common E. Anticardiolipin antibodies cross the placenta C. Lupus anticoagulant caused false positive RPR: anticardiolipin antibodies crossreact with beef cardiolipin used in the test system |
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A 24-year-old woman with chronic idiopathic thrombocytopenia delivers a newborn baby girl, who develops petechial lesions and ecchymoses 24 hours after delivery. What is the mechanism for the newborn's disorder?
A. Transplacental passage of IgG antibodies against PlA1 positive platelets: this is not an alloimmune thrombocytopenia B. Transplacental passage of IgM antibodies against PlA1 positive platelets: IgM antibodies do not cross the placenta. C. Transplacental passage of IgG antibodies against platelet fibrinogen receptors D. Transplacental passage of IgM antibodies against platelet fibrinogen receptors |
Answer: C: Transplacental passage of IgG antibodies against platelet fibrinogen receptors. Newborn infants of mothers with ITP may have transient thrombocytopenia due to transplacental passage of IgG antibodies, which are directed against the GpIIb:IIIa fibrinogen receptors.
A. Transplacental passage of IgG antibodies against PlA1 positive platelets: this is not an alloimmune thrombocytopenia B. Transplacental passage of IgM antibodies against PlA1 positive platelets: IgM antibodies do not cross the placenta. D. Transplacental passage of IgM antibodies against platelet fibrinogen receptors: IgM antibodies do not cross the placenta. |
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A 55-year-old woman with breast cancer has an infiltrating ductal carcinoma that is 2 cm in size, estrogen receptor assay (ERA) and progesterone receptor assay (PRA) positive, metastatic to 5 out of 20 axillary lymph nodes, and metastatic to both the vertebral column and liver. Which of the following most influences the ultimate prognosis in this patient?
A. Her age B. ERA/PRA status C. Size of the tumor D. Axillary node involvement E. Bone and liver involvement |
Answer- E. Bone and liver involvement: M of the TNM system has greatest prognostic value
A. Her age: greatest risk factor B. ERA/PRA status: important but not most important C. Size of the tumor: T of the TNM system D. Axillary node involvement: N of the TNM system |
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Which of the following cancers is prevented by immunization with a vaccine? SELECT 2
A. Pancreatic carcinoma B. Stomach carcinoma C. Transitional cell carcinoma D. Hepatocellular carcinoma E. Cervical carcinoma |
Answer- D. Hepatocellular carcinoma: HBV vaccine prevents HBV, HDV, hepatocellular carcinoma related to HBV postnecrotic cirrhosis; E. Cervical carcinoma: new HPV vaccine against HPV 16 and 18
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Which of the following hereditary disorders is associated with DNA splicing defects resulting in skin cancers?
A. Xeroderma pigmentosum B. Fanconi’s syndrome D. Ataxia telangiectasia D. Bloom’s syndrome |
Answer- A. Xeroderma pigmentosum: AR, DNA repair enzyme defect
B. Fanconi’s syndrome: AR, DNA repair defect, acute leukemia D. Ataxia telangiectasia: AR, chromosome instability, malignant lymphoma D. Bloom’s syndrome: AR, chromosome instability, acute leukemia |
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Which of the following cancer : oncogenic virus relationships are correct? SELECT 3
A. Anal carcinoma in homosexuals : HIV B. Hepatocellular carcinoma : hepatitis B and hepatitis C C. Nasopharyngeal carcinoma : Epstein Barr virus D. Kaposi's sarcoma : cytomegalovirus E. Cervical carcinoma : human papilloma virus F. CNS lymphoma : herpesvirus 8 |
Answers B, C, E-
B. Hepatocellular carcinoma: hepatitis B and hepatitis C C. Nasopharyngeal carcinoma: Epstein Barr virus E. Cervical carcinoma: human papilloma virus: yes, 16, 18 A. Anal carcinoma in homosexuals : HIV: no, HPV 16, 18 D. Kaposi's sarcoma : cytomegalovirus: no HHV 8 F. CNS lymphoma : herpesvirus 8: no, EBV in a patient with HIV |
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Which of the following screening tests has contributed most to the decline in the incidence of a specific cancer in the United States?
A. Mammography B. Stool guaiac C. Cervical Papanicolaou smear D. Rectal exam E. Prostate specific antigen |
Answer- C. Cervical Papanicolaou smear: detects squamous dysplasia, the precursor for squamous cancer
A. Mammography: initially increased incidence of breast cancer B. Stool guaiac: initially increased incidence of prostate cancer D. Rectal exam: initially increased incidence of prostate cancer E. Prostate specific antigen: increased incidence of prostate cancer |
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Which of the following bacterial organisms has been implicated as a cause of an adenocarcinoma and a malignant lymphoma?
A. Pseudomonas aeruginosa B. Staphylococcus aureus C. Mycobacterium tuberculosis D. Helicobacter pylori E. Treponema pallidum |
Answer- D. Helicobacter pylori; cytokine injury to the mucosa
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A 75-yr-old man with point tenderness in the lower vertebral column has an increased serum alkaline phosphatase. Which of the following tests or procedures would be your first step in the evaluation of this patient?
A. Prostate specific antigen B. Prostatic acid phosphatase C. Radionuclide bone scan D. Digital rectal exam E. Colonoscopy |
Answer- D. Digital rectal exam: think cheap, bone tenderness implies stage IV disease and DRE should be positive; other choices (PSA, bone scan, bone marrow exam) are correct but would not be your first step
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A vertebral metastasis in a woman would most likely be due to a primary cancer located in the…
A. lung B. breast C. lymph node D. thyroid E. kidney |
Answer- B. breast (due to the Batson venous plexus which communicates with the vena cava and vertebral bodies
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Metastatic cancer in the liver in a non-smoking woman would most likely originate from which of the following primary sites?
A. Lung B. Colon C. Breast D. Kidney E. Esophagus |
Answer- B. Colon: answer would be lung (A) if patient was a smoker
C. Breast: colon beats out breast for liver mets D. Kidney: likes the lungs and is most commonly due to smoking E. Esophagus: colon beats out esophagus |
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A solitary, non-neoplastic process that is commonly confused on an x-ray with a primary or metastatic cancer would most likely be located in the…
A. bone marrow B. stomach C. lung D. spleen E. brain |
Answer- C. lung: e.g., bronchial hamartoma or granuloma; none of the other choices make any sense
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A 15-yr-old girl develops a sudden onset of right lower abdominal pain. A pregnancy test is negative. An ultrasound is performed and reveals a cystic mass with bone and calcifications in the right ovary. Which of the following apply to this ovarian mass? SELECT 2
A. Mixed tumor B. Non-neoplastic cyst C. Neoplastic cyst D. Teratoma E. Hamartoma F. Heterotopic rest G. Trophoblastic tumor |
Answers C, D-
C. Neoplastic cyst: called a cystic teratoma, commonly twist on themselves and infarct D. Teratoma: also a germ cell tumor, since germ cells are totipotential; mixed tumors have two different components in tissue but both derive from the same cell layer. Heterotopic rests are normal tissue in a place it should not be--e.g., pancreas in wall of stomach |
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A chest x-ray in a dyspneic 52-yr-old woman is reported to have multiple densities throughout both lungs and bilateral pleural effusions. She is a non-smoker. Ten years ago, she had a right modified radical mastectomy for a 1 cm infiltrating ductal carcinoma. No axillary lymph nodes were involved with cancer. Which of the following is the most likely cause of this patient's current lung disease?
A. Primary lung cancer B. Metastatic breast cancer C. Metastatic cancer of non-breast origin D. Infectious process with miliary spread |
Answer- B. Metastatic breast cancer: breast cancer commonly metastasizes after 5-10 yrs
A. Primary lung cancer: no, patient was a non-smoker C. Metastatic cancer of non-breast origin: second best answer D. Infectious process with miliary spread: unlikely with multiple densities and effusion |
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In a 58-yr-old man, who has a microcytic anemia, which of the following tests or procedure would be your first step in the evaluation of the patient?
A. Serum ferritin B. Reticulocyte count C. Bone marrow exam D. Stool guaiac E. Colonoscopy |
Answer- D. Stool guaiac: colon cancer is MCC of iron deficiency after 50, cheapest initial test is a stool guaiac
A. Serum ferritin: eventually B. Reticulocyte count: eventually C. Bone marrow exam: not likely necessary E. Colonoscopy: eventually |
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Which of the following country : most common cancer relationships is correctly matched? SELECT 4
A. China : nasopharyngeal carcinoma, esophageal cancer B. Southeast Asia : hepatocellular carcinoma, stomach cancer C. Egypt : squamous cell carcinoma of the bladder, renal cell carcinoma D. Japan : stomach cancer E. Africa : Burkitt’s lymphoma, Kaposi sarcoma F. Australia : malignant melanoma |
Answers A, D, E, F-
A. China: nasopharyngeal carcinoma: EBV, esophageal cancer D. Japan: stomach cancer: carcinogens in smoked fish E. Africa: Burkitt’s lymphoma: EBV, Kaposi sarcoma: herpesvirus 8 in patients with AIDS F. Australia: malignant melanoma B. Southeast Asia : hepatocellular carcinoma: yes, HBV related, stomach cancer: no C. Egypt: squamous cell carcinoma of the bladder: yes, Schistosoma hematobium, renal cell carcinoma: no |
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An ulcerated lesion that develops in a keloid secondary to a third degree burn or an ulcer located at the orifice of a chronically draining sinus that does not respond to medical management is most likely due to…
A. development of a basal cell carcinoma B. development of a squamous cell carcinoma C. development of a malignant melanoma D. an anaerobic infection |
Answer- B. development of a squamous cell carcinoma: due to constant irritation of squamous epithelium
A. development of a basal cell carcinoma: no, invariably a squamous cancer C. development of a malignant melanoma: no, more UVB light related cancer D. an anaerobic infection: should not be resistant to medical Rx |
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Hematuria in a 58-yr-old smoker would most likely be associated with which of the following groups of cancers?
A. Prostate cancer/renal cell carcinoma B. Transitional cell carcinoma of the bladder/prostate cancer C. Renal cell carcinoma/transitional cell carcinoma of the bladder D. Testicular cancer/ transitional cell carcinoma of the bladder E. Renal cell carcinoma/testicular cancer |
Answer- C. Renal cell carcinoma/transitional cell carcinoma of the bladder: both are most commonly due to smoking and both would be expected to produce hematuria owing to their access to urine
A. Prostate cancer: as above /renal cell carcinoma: as above B. Transitional cell carcinoma of the bladder: yes, and has strong smoking relationship/prostate cancer: yes, hematuria may be present but there is not a strong smoking relationship D. Testicular cancer: no smoking relationship or hematuria/ transitional cell carcinoma of the bladder: as above E. Renal cell carcinoma: as above/testicular cancer: as above |
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The presence of nucleated RBCs and immature neutrophils (e.g., myeloblasts, progranulocytes) in the peripheral blood of a non-smoking 52-yr-old woman with bone pain would most likely be due to…
A. acute leukemia B. metastatic breast cancer to bone C. metastatic lung cancer to bone D. ectopic secretion of erythropoietin E. a fracture related to osteoporosis |
Answer: B. metastatic breast cancer to bone: called a leukoerythroblastic smear, metastasis pushes hematopoietic cells out into the peripheral blood; called myelophthisic anemia
A. acute leukemia: possible but not the best answer C. metastatic lung cancer to bone: patient is a non-smoker D. ectopic secretion of erythropoietin: secondary polycythemia, no increase in immature leukocytes E. a fracture related to osteoporosis: highly unlikely |
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Which of the following is most responsible for the increased incidence of basal cell carcinoma in the United States?
A. Actinic (solar) keratosis B. Sun exposure beginning at an early age C. Genetic defect in DNA repair enzymes D. Radiation to the head and neck area E. Family history of skin cancer |
Answer- B. Sun exposure beginning at an early age: also true for malignant melanoma
A. Actinic (solar) keratosis: precursor for squamous cancer C. Genetic defect in DNA repair enzymes: xeroderma pigmentosum is very rare D. Radiation to the head and neck area: more likely to produce papillary cancer of thyroid E. Family history of skin cancer: dysplastic nevus syndrome is associated with malignant melanomas |
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Cancer related to inactivation of the RB suppressor gene in a non-smoking 19-yr-old woman would most likely be located in the…
A. lymph nodes B. lungs C. breast D. distal femur E. thyroid |
Answer: D. distal femur: osteogenic sarcoma; other RB relationships include retinoblastoma (young child) and breast cancer (> 50-yrs-old)
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Which of the following most enhances the development of a primary cancer in the oropharynx, esophagus, and larynx in a smoker?
A. Human papilloma virus B. Asbestos C. Alcohol D. Herpes virus E. Nitrites |
Answer: C. Alcohol: second MCC in these sites, synergistic with smoking
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A 65-yr-old smoker, who has been a roofer for the past 30 yrs, would most likely develop a primary cancer in which of the following sites?
A. Pleura B. Lung C. Larynx D. Mouth E. Esophagus |
Answer- B. Lung: asbestos was present in roofing material in that time-frame, mesotheliomas of pleura are not related to smoking, primary lung cancer is the MC cancer related to asbestos exposure with or without smoking. Asbestos is not a risk factor for cancers of the mouth, larynx, or esophagus.
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Treatment of which of the following will decrease the risk for developing cancer? SELECT 2
A. Gastroesophageal reflux B. Peptic ulcer disease C. Myocardial infarction D. Urinary tract infection E. Iron deficiency |
Answers A, B:
A. Gastroesophageal reflux: treatment of glandular metaplasia (Barrett’s esophagus) with proton blockers decreases the risk for developing distal esophageal adenocarcinoma. B. Peptic ulcer disease: H. pylori is the MCC of peptic ulcer disease; therefore, eradication of H. pylori will decrease the risk for developing gastric lymphoma and stomach adenocarcinoma. None of the other choices have any relationship with cancer. |
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A 65-year-old woman develops fatigue and pain in her lower back and ribs. She states that her urine flow has also decreased dramatically in the last few days. Physical examination demonstrates sternal and vertebral percussion tenderness and bilateral conjunctival pallor. A CBC exhibits extensive rouleau, a hemoglobin of 7.5 g/dL (12.016.0 g/dL), a total leukocyte count of 4,300/mm3 (450011,000/mm3), and a platelet count of 125,000/mm3 (150,000400,000/mm). A urinalysis exhibits a 1+ dipstick for protein and 4+ precipitation using sulfosalicylic acid (SSA). Renal tubular casts are noted in the sediment. Serum BUN is 80 mg/dL and serum creatinine 8 mg/dL. A chest x-ray demonstrates generalized osteopenia in the ribs and vertebra as well as multiple lytic lesions in the ribs.
1. Based on the patient's history and preliminary laboratory findings, which of the following additional abnormalities would you expect? SELECT 3 A. Hypercalcemia B. Normal erythrocyte sedimentation rate C. IgM monoclonal spike in serum D. Increased light chains in the urine E. Malignant plasma cells in a bone marrow aspirate F. Low total serum protein G. Prerenal azotemia |
Answers: A, D, E: the patient has multiple myeloma.
A. Hypercalcemia: due to increased osteoclastic activity D. Increased light chains (BJ protein) in the urine: • note the 1+ dipstick protein and 4+ SSA urine findings. SSA detects albumin and globulins (light chains), while the dipstick only detects albumin. A marked disparity in the reaction, as in this case, is a good sign of BJ protein in the urine., • tubular casts in the urine imply that acute tubular necrosis has already occurred E. Malignant plasma cells in a bone marrow aspirate B. Normal erythrocyte sedimentation rate: it would be increased due to rouleau C. IgM monoclonal spike in serum: that is Waldenstrom's macroglobulinemia F. Low total serum protein: they are high due to increased g-globulins H. Prerenal azotemia: the BUN/creatinine ratio is 10/1 indicating acute tubular necrosis. Also note that renal tubular casts are present in the urine. |
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A 68-year-old man develops with multiple plaque-like lesions on his skin, generalized lymphadenopathy, and hepatosplenomegaly. A biopsy demonstrates abnormal lymphocytes infiltrating the epidermis.
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Answer: A. mycosis fungoides: The skin infiltrate is called Pautrier's microabscesses and represent neoplastic CD4 T helper cells. Neoplastic CD4 positive lymphocytes with prominent nuclear clefts in the peripheral blood is called Sezary syndrome.
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7. A 4-year-old child develops with exophthalmos, polyuria, and multiple lytic lesions in the skull. A bone marrow aspirate demonstrates an infiltrate of neoplastic cells that are CD1 positive.
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Answer: H-Hand-Christian-Christian disease: malignant histiocytosis; note the triad
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8. A 60-year-old man has a normocytic anemia, an elevated erythrocyte sedimentation rate, generalized, non-tender lymphadenopathy, hepatosplenomegaly, hyperviscosity syndrome, and an abnormal finding on a serum protein electrophoresis and in his urine. No lytic lesions are present in bone.
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Answer: K- Waldenstrom's macroglobulinemia: lymphoplasmacytoid malignancy. The abnormal finding in the serum is an IgM monoclonal spike and in the urine, Bence Jones proteinuria. Myeloma does not have lymphadenopathy and does have lytic lesions in bone.
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9. A 55-yr-old man develops painless lymphadenopathy in his cervical and para-aortic lymph nodes. A biopsy demonstrates neoplastic germinal follicles. Abnormal lymphocytes are noted in the peripheral blood and in the bone marrow.
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Answer: B. follicular lymphoma: most common NHL B cell lymphoma. Chromosomes studies exhibit a t(14;18) translocation. The BCL-2 antiapoptosis gene is overexpressed, hence preventing the movement of mitochondrial cytochrome c into the cytosol and preventing apoptosis of the B cell.
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11. A 25-year-old, non-smoking, afebrile woman complains of enlarged, nontender right supraclavicular lymph nodes. A lateral chest x-ray demonstrates a mass in the anterior mediastinum.
PICTURE OF RS CELL |
Answer: C. Hodgkin's lymphoma: the patient has nodular sclerosing type of lymphoma, the most common variant of Hodgkin’s lymphoma. Lacunar variants of RS cells are present, but classic RS cells are uncommon.
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14. A 2-yr-old child develops with an eczematous rash, generalized non-tender lymphadenopathy, hepatosplenomegaly, and lytic lesions in bone. A biopsy of a lymph node exhibits neoplastic cells that contain Birbeck granules on electron microscopy.
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Answer: I. Letterer-Siwe disease: malignant Langerhans histiocytosis. True histiocytes are CD1 positive.
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You would expect a normal-sized spleen in a... SELECT 2
A. 45-year-old man with alcoholic cirrhosis B. 25-year-old woman with systemic lupus erythematosus C. 65-year-old man with chronic lymphocytic leukemia D. 18-year-old college student with infectious mononucleosis E. 23-year-old African-American woman with sickle cell trait F. 28-yr-old man with hemophilia A |
Answers E, F:
E. 23-year-old black woman with sickle cell trait: there is no anemia or splenomegaly in trait F. 28-yr-old man with hemophilia A: there is no reason for the spleen to be enlarged in a coagulation disorder A. 45-year-old man with alcoholic cirrhosis: portal hypertension leads to congestive splenomegaly B. 25-year-old woman with systemic lupus erythematosus: splenomegaly is invariably present in SLE C. 65-year-old man with chronic lymphocytic leukemia: all leukemias have splenomegaly D. 18-year-old college student with infectious mononucleosis: splenomegaly is invariably present in mono. |
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21. Malignancies associated with a t(14;18) translocation and t(8;14) translocations
what is the location of it? |
Answer: C. germinal follicle: follicular B cell lymphoma and Burkitt's lymphoma, respectively initially involve the germinal follicle
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Which of the following pathogens is associated with a low grade lymphoma in the stomach that often ulcerates and infiltrates into the gastric mucosa?
A. Epstein Barr virus B. Human immunodeficiency virus C. Helicobacter pylori D. Cytomegalovirus E. Human papilloma virus |
Answer: C. Helicobacter pylori: it is a low grade B cell lymphoma (extranodal marginal zone lymphoma). Recall that the stomach is the MC extranodal site for lymphoma. H. pylori is also the MCC of peptic ulcers and stomach cancer.
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A 92-yr-old man with a small IgG monoclonal spike, absence of Bence Jones protein in the urine, and a normal Hgb and Hct most likely diagnosis has
A. multiple myeloma B. monoclonal gammopathy of undetermined significance C. Waldenstrom's macroglobulinemia D. heavy chain disease E. amyloidosis |
Answer: B. monoclonal gammopathy of undetermined significance: this is the most common cause of a monoclonal gammopathy. Patient's should have a bone marrow aspirate to make sure there are no malignant plasma cells. They should be followed on an annual basis, because it is considered to be a precursor lesion for multiple myeloma.
A. multiple myeloma: the patient does not have anemia or BJ protein C. Waldenstrom's macroglobulinemia: IgM is not increased and there is no anemia or BJ protein D. heavy chain disease: does not fit any of the clinical scenarios for heavy chain diseases E. amyloidosis: does not have any of the systemic signs of amyloidosis |
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Which of the following findings is present in both Waldenstrom's macroglobulinemia and multiple myeloma? SELECT 3
A. Bence Jones protein B. Lymphadenopathy C. Monoclonal spike D. Anemia E. Lytic bone lesions |
Answers: A, C, D:
A. Bence Jones protein C. Monoclonal spike: in WM, it is an IgM spike D. Anemia B. Lymphadenopathy: only WM, which is a type of malignant lymphoma F. Lytic bone lesions: only MM |
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39. A 53-yr-old woman has massive splenomegaly. She has a leukoerythroblastic blood smear with numerous tear drop cells present. A bone marrow aspirate is dry, however, a bone marrow biopsy reveals marrow fibrosis.
picture1!!! |
Answer: D. myelofibrosis and myeloid metaplasia: the splenomegaly is an example of extramedullary hematopoiesis.
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A febrile 12-year-old boy with a viral infection lapses into coma. Physical exam shows papilledema and hepatomegaly. The serum transaminases are elevated and the PT is prolonged. Additional findings that are expected include which of the following? SELECT 3
A. Elevated serum ammonia B. Fatty change in the liver C. Salicylate poisoning D. Cerebral edema . Serum AST > ALT |
Answers: A, B, D: Reye's syndrome:
A. elevated serum ammonia: the urea cycle is defective due to salicylates which are mitochondrial poisons B. fatty change in the liver: microvesicular type; b-oxidation of fatty acids occurs in the mitochondria. A defect in b-oxidation leaves fatty acids available to synthesize triglyceride D. cerebral edema: encephalopathy, MC cause of death; due to increase in aromatic amino acids, false neurotransmitters, and ammonia C. salicylate poisoning: just taking salicylates along with having chickenpox or flu is sufficient . serum AST > ALT: no, ALT > AST. This is not alcoholic liver disease. |
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An afebrile 42-year-old migrant worker from Mexico develops bloody diarrhea, right upper quadrant pain, and ultrasound evidence of a cystic mass in the right lobe of liver. What additional findings would you expect? SELECT 2
A. Curved gram negative rods in the stool B. Trophozoites with erythrophagocytosis C. Good clinical response to metronidazole D. Colorectal cancer on colonoscopy exam |
Answers: B, D: amebiasis:
B. Trophozoites with erythrophagocytosis: pathognomonic finding D. Good clinical response to metronidazole: yes, Rx of choice A. Curved gram negative rods in the stool: that is cholera or Campylobacter D. Colorectal cancer on colonoscopy exam: it is clearly an invasive enterocolitis, not cancer |
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In which of the following diseases would you expect a conjugated bilirubin >50% of the total bilirubin? SELECT 3
A. Gilbert's syndrome B. Chronic viral hepatitis C. Dubin-Johnson syndrome D. Stone in the common bile duct E. Extravascular hemolytic anemia F. Primary sclerosing cholangitis G. Crigler-Najjar syndrome H. ABO and Rh hemolytic disease of newborn |
Answers: C, D, F:
C. Dubin-Johnson syndrome: defect in secretion of CB into bile canaliculi, black liver D. Stone in the common bile duct: MCC of extrahepatic cholestasis F. Primary sclerosing cholangitis: strictures of CBD associated with UC A. Gilbert's syndrome: primarily UCB; problem with uptake and conjugation B. Chronic viral hepatitis: mixture of CB and UCB E. Extravascular hemolytic anemia: primarily UCB G. Crigler-Najjar syndrome: primarily UCB from conjugating enzyme deficiency H. ABO and Rh hemolytic disease of newborn: primarily UCB from extravascular hemolytic anemia |
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A 45-year-old man develops hepatomegaly, increased skin pigmentation, malabsorption, and diabetes mellitus. Expected findings include...SELECT 2
A. high total iron binding capacity B. pigment cirrhosis C. high serum ferritin levels D. ringed sideroblasts in the bone marrow E. low ceruloplasmin and high serum copper PICTURE |
Answers: B, C: hemochromatosis:
B. pigment cirrhosis C. high serum ferritin levels A. high total iron binding capacity: as iron stores increase, transferrin synthesis (TIBC) decreases D. ringed sideroblasts in the bone marrow: this is not a defect in heme synthesis E. low ceruloplasmin and high serum copper: it is not Wilson's disease |
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A 38-year-old woman develops chronic liver disease, greenish-brown deposits in the limbus of the eye, and choreoathetotic movements. Expected findings include... SELECT 2
A. high total copper levels B. increased percent iron saturation C. anti-HCV IgG antibodies D. low ceruloplasmin levels E. degenerative disease in the lenticular nuclei PICTURE |
Answers: D, E: Wilson's disease:
D. low ceruloplasmin levels: decreased synthesis E. degenerative disease in the lenticular nuclei: due to free copper toxicity to neurons. Copper, like iron, causes increase in hydroxyl free radical formation leading to tissue damage. A. high total copper levels: low due to low ceruloplasmin. High free copper levels. B. increased percent iron saturation: this is not hemochromatosis C. anti-HCV IgG antibodies: this is not chronic HCV; HCV relationship is more common with iron overload |
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A 55-year-old woman develops generalized pruritus, non-tender hepatomegaly, and yellow papular lesions scattered over her skin. She has marked elevation of serum alkaline phosphatase and -glutamyltransferase, a normal total bilirubin, slightly elevated serum transaminases, and a severe hyperlipidemia. An endoscopic retrograde cholangiopancreatography (ERCP) study of the common bile duct is negative for stones. Which of the following are expected findings? SELECT 3
A. Hypertriglyceridemia B. Biliary cirrhosis C. Antimitochondrial antibodies D. Increased serum IgG levels E. Granulomatous inflammation |
Answers: B, C, E: primary biliary cirrhosis:
B. Biliary cirrhosis C. Antimitochondrial antibodies: also an increase in IgM (the antimitochondrial antibody is IgM) E. Granulomatous inflammation: destruction of bile ducts in portal triads A. Hypertriglyceridemia: hypercholesterolemia. CH is in bile. D. Increased serum IgG levels: IgM |
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A 29-year-old man with a long and continued history of intravenous drug abuse and stable chronic hepatitis B suddenly develops mental status abnormalities, further prolongation of the PT, and a sudden drop in serum transaminases. Which of the following BEST explain these findings? SELECT 2
A. Superinfection with hepatitis D B. Recovery from hepatitis B C. Hepatocellular carcinoma D. Vitamin K deficiency E. Fulminant liver failure |
Answers: A, E: patient has HDV, an incomplete RNA virus that requires HBsAg:
A. Superinfection with hepatitis D: already had HBV; HDV is cytolytic to hepatocytes, hence the rapid liver failure E. Fulminant liver failure: note the drop in transaminases (not enough remaining hepatocytes to release transaminases) and prolongation in PT B. Recovery from hepatitis B: all the cells with HBsAg are being destroyed since HDV is cytolytic C. Hepatocellular carcinoma: too abrupt a history D. Vitamin K deficiency: too abrupt a history |
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Items 3841
Urine Bilirubin Urine UBG AST ALT ALP GGT * negative normal normal normal normal A. negative normal normal normal B. negative C. D. E. negative normal normal normal normal Normal * top row of values are normal values and the number of arrows relates to the degree of elevation, ALP = alkaline phosphatase, ALT = synonymous with SGPT, AST = synonymous with SGOT, GGT = gamma glutamyltransferase 38. A 24-year-old woman has congenital spherocytosis and jaundice |
Answer: A: extravascular hemolysis: CB < 20%; AST is present in RBCs; UBG increased due to increased production of CB by the liver and increased conversion of CB to UBG in colon.
Urine Bilirubin Urine UBG AST ALT ALP GGT * negative ¬ normal normal normal normal A. negative normal normal normal |
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A 25-year-old medical student returns from a trip to Mexico on spring break. Three weeks later, he develops low-grade fever and jaundice. Physical exam shows painful hepatomegaly. The urine is dark yellow and the stool is normal
Items 3841 Urine Bilirubin Urine UBG AST ALT ALP GGT * negative normal normal normal normal A. negative normal normal normal B. negative C. D. E. negative normal normal normal normal Normal |
Answer: D: probable hepatitis B; mixed jaundice (CB% 20-50%); UBG increased since UBG that is normally recycled back to the liver is not reabsorbed, so all of it ends up in the urine.
Urine Bilirubin Urine UBG AST ALT ALP GGT * negative ¬ normal normal normal normal D. |
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40. A 32-year-old alcoholic has fever, jaundice, and tender hepatomegaly. A liver biopsy exhibits fatty change, Mallory bodies, and a neutrophilic infiltrate.
Items 3841 Urine Bilirubin Urine UBG AST ALT ALP GGT * negative normal normal normal normal A. negative normal normal normal B. negative C. D. E. negative normal normal normal normal Normal |
Answer: C: alcoholic hepatitis; mixed jaundice. CB% 20-50; UBG increased due to sick liver recycling UBG into the urine
Urine Bilirubin Urine UBG AST ALT ALP GGT * negative normal normal normal normal C. |
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Items 3841
Urine Bilirubin Urine UBG AST ALT ALP GGT * negative normal normal normal normal A. negative normal normal normal B. negative C. D. E. negative normal normal normal normal Normal 41. A 22-year-old medical student only develops jaundice whenever he pulls an all nighter for studying for an exam. His physical exam is totally normal. All hepatitis serology tests are negative. |
Answer: E: Gilbert's disease; primarily unconjugated type of jaundice (CB% < 20)
Urine Bilirubin Urine UBG AST ALT ALP GGT * negative ¬ normal normal normal normal E. negative normal normal normal normal normal |
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A 40-year-old man with alcoholic cirrhosis has bilateral gynecomastia. Which of the physical findings listed below share the same underlying pathogenesis as gynecomastia? SELECT 3
A. Palmar erythema B. Asterixis C. Spider angiomata D. Female hair distribution E. Dependent pitting edema |
Answers: A, C, D: gynecomastia is a sign of hyperestrinism:
A. Palmar erythema C. Spider angiomata (telangiectasia) D. Female hair distribution (hair does not extend to umbilicus) B. Asterixis: finding of encephalopathy, flapping tremor and cannot sustain posture E. Dependent pitting edema: due to decreased oncotic pressure from hypoalbuminemia |
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A 42-year-old Asian man with postnecrotic necrosis secondary to chronic hepatitis B has a low grade fever, weight loss, and a rapid development of ascites. A peritoneal tap shows bloody ascitic fluid. The fluid WBC count is normal and bacteria are not present on Gram stain. The fetoprotein level is 500 ng/mL (normal < 6 ng/mL). The MOST LIKELY diagnosis is...
A. primary gallbladder cancer B. hepatocellular carcinoma C. metastatic liver disease D. spontaneous peritonitis E. cholangiocarcinoma |
Answer: B. hepatocellular carcinoma
A. primary gallbladder cancer: AFP not elevated C. metastatic liver disease: AFP not elevated D. spontaneous peritonitis: normal peritoneal tap E. cholangiocarcinoma: no, AFP not elevated |
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44. A patient living in a Basque community in Southern Arizona has a history of recurrent right upper quadrant pain. An ultrasound of his liver shows a cystic mass in the liver with calcifications in the lining of the cyst. Which of the following additional findings would you expect in this patient? SELECT 2
A. He is a sheepherder B. His dog is an intermediate host C. He is a definitive host D. His dog ate an infected sheep PICTURE |
Answers: A, D: echinococcosis: host with the larva is always intermediate, while the host with the adult worms or eggs is definitive:
A. He is a sheepherder that pet the dog and eggs developed into larva (intermediate host) D. His dog ate an infected sheep that contained the larva that became adults (definitive host) B. His dog is an intermediate host: definitive host since the dog ate the sheep with the larva, which developed into adults C. He is a definitive host: intermediate host. He ate the eggs which became larva. |
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A child with cirrhosis and a family history of both liver and lung disease most likely has… SELECT 2
A. a defect in reabsorption of iron B. an autosomal codominant disease C. extrahepatic biliary atresia D. defective secretion of 1-antitrypsin from hepatocytes PICTURE |
Answers: B, E: AAT deficiency. Panacinar emphysema is associated with decreased synthesis of AAT.
B. an autosomal codominant disease E. defective secretion of 1-antitrypsin from hepatocytes: mutant form of AAT shows up with a PAS stain. A. a defect in reabsorption of iron: it is not hemochromatosis C. extrahepatic biliary atresia: it is a cause of neonatal cholestasis, however, the patient does not have extrahepatic biliary atresia where there is proliferation of bile ducts in the liver and no radioactive dye enters the small bowel |
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49. A 22-yr-old woman overdoses on acetaminophen and lapses into coma. Initially, the transaminases were elevated but then the transaminases fell and the prothrombin time became markedly prolonged.
PICTURE |
Answer: K. fulminant hepatic failure: MC drug causing FHF. Liver shrunken and not enough parenchyma left to increase transaminases. PT prolonged because synthesis of coagulation factors is impaired.
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53. A 45-yr-old man from a developing country has caput medusae, hepatosplenomegaly, ascites, and esophageal varices. A CBC shows marked eosinophilia. A liver biopsy shows concentric fibrosis around portal vein radicles.
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Answer: Y. schistosomiasis due to S. mansoni: adults live in portal vein radicals and lay eggs that incite fibrosis of portal vein (pipestem cirrhosis) with development of portal vein hypertension causing above findings.
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54. A 32-yr-old black man with restrictive lung disease and uveitis has hepatomegaly. Biopsies show non-caseating granulomas.
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Answer: L. granulomatous hepatitis due to sarcoidosis the MC non-infectious cause of hepatitis (TB is the MC infectious cause)
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57. A 31-yr-old man with ulcerative colitis develops jaundice. A dye study is performed on the common bile duct and shows a "beading" effect of the common bile duct.
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Answer: X. primary sclerosing cholangitis. Fibrosis is around the common bile duct, so the lumen is narrowed. Uninvolved parts of CBD fill normally. Similar in concept to beading effect of renal artery in fibromuscular hyperplasia. PSC predisposes to cirrhosis and cholangiocarcinoma (carcinoma of CBD).
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59. A 26-yr-old man with acute appendicitis develops ascites and splenomegaly. A CT scan of the abdomen shows air in the portal vein. The liver is not enlarged.
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Answer: W. portal vein thrombosis. Acute appendicitis is MCC of pylephlebitis (inflammation of portal vein). Gas producing bacteria produces air in portal vein. Phlebitis causes portal vein thrombosis. Example of prehepatic obstruction to bile flow. Note that the liver is not enlarged.
NO HEPATOMEGALY |
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61. A 32-yr-old who has been on oral contraceptives for the past 10 years becomes pregnant shortly after she discontinues the pills. Midway through her pregnancy she suddenly develops hypovolemic shock due to intraperitoneal hemorrhage from a mass in the liver.
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Answer: S. liver cell adenoma. Oral contraceptives predisposes to this development of this benign tumor, which has a tendency to rupture and produce intraperitoneal hemorrhage.
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64. A 29-yr-old man develops jaundice, fever, and painful hepatomegaly. The conjugated bilirubin percentage if 40%, serum AST is higher than serum ALT, and serum GGT is elevated. A CBC shows neutrophilic leukocytosis. A liver biopsy reveals fatty change, liver cell necrosis, a neutrophilic infiltrate, and pink staining material in the hepatocytes. Fibrosis is noted around some of the central veins.
PICTURE |
Answer: B. alcoholic hepatitis: pink staining material is Mallory bodies (damaged keratin filaments). Fatty change, neutrophilic infiltrate, perivenular fibrosis.
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68. A 62-yr-old smoker with weight loss and cough develops has a mass in the right main stem bronchus and pain in the right upper quadrant. A CT scan shows multiple nodular densities in the liver.
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Answer: T. metastatic disease: primary lung cancer has metastasized to the liver. Metastasis is the most common cancer of the liver and lung cancer is the most common primary site followed by colorectal cancer.
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Which of the following is the most cost effective way of treating hepatic encephalopathy and eliminating excess sodium and water in a patient with alcoholic cirrhosis and ascites? SELECT 2
A. Oral neomycin B. Restrict protein C. Oral lactulose D. Loop diuretic E. Aldosterone blocker |
Answers: B, E:
B. restrict protein: most cost effective method for reducing ammonia production by urease producing bacteria in the colon E. aldosterone blocker: blocks sodium reabsorption (diuretic effect), retains potassium (potassium sparer), and retains hydrogen ions producing metabolic acidosis. Excess hydrogen ions cause ammonium (NH4) to be produced in the colon, which cannot be reabsorbed into the portal vein. A. Oral neomycin: sterilizes the bowel, hence decreasing ammonia production; not most cost-effective method C. Oral lactulose: during its degradation in the colon it releases protons that bind to NH3 to produce NH4, which is excreted D. Loop diuretic: produces metabolic alkalosis, which could precipitate hepatic encephalopathy, since less hydrogen ions means more NH3 is produced in the colon which is reabsorbed into the portal vein. Loop diuretics are used in therapy, but care is taken in looking for signs of encephalopathy. |
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A 30-year-old IRS agent with a recent history of epigastric pain that wakens him at night develops a sudden onset of severe epigastric pain with radiation of pain into his left shoulder. Physical examination shows absent bowel sounds and abdominal rigidity with rebound tenderness. The stool is dark, tarry and guaiac positive. Which of the following would you expect? SELECT 3
A. Air under the diaphragm B. Referred pain C. Abnormal CT of the pancreas D. Bleeding gastric ulcer E. Perforated duodenal ulcer PICTURE |
Answers: A, B, E: classic history of a duodenal ulcer with pain awakening at night. He now has a perforation and peritonitis (rebound tenderness and ileus):
A. Air under the diaphragm: irritates the diaphragm B. Referred pain: due to irritation of the diaphragm. E. Perforated duodenal ulcer: most duodenal ulcers are anterior. C. Abnormal CT of the pancreas: only posterior ulcers may produce acute pancreatitis, which would cause pain radiating into the back and an increase in amylase/lipase. D. Bleeding gastric ulcer: the history is classic for duodenal, which is more likely to perforate |
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A 4-week-old male infant has history of projectile vomiting of non-bile-stained fluid. Hyperperistalsis of the abdomen is visible and a small ovoid mass is palpable in the left upper quadrant. The stool guaiac is negative. Which of the following apply to this case? SELECT 2
A. Multifactorial inheritance B. Hypertrophy of pyloric muscle C. Atresia of the proximal duodenum D. Distal esophagus connects with the trachea E. Leiomyoma of stomach PICTURE |
Answers: A, B: congenital pyloric stenosis.
A. Multifactorial inheritance B. Hypertrophy of pyloric muscle C. Atresia of the proximal duodenum: duodenal atresia presents at birth with vomiting of bile stained fluid + x-ray evidence of a double bubble sign and maternal polyhydramnios. D. Distal esophagus connects with the trachea: it is not a TE fistula E. Leiomyoma of stomach: they are usually asymptomatic and if symptomatic, they usually bleed. |
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A 38-year-old man with a 10 year history of ulcerative colitis has had persistently elevated levels of alkaline phosphatase and -glutamyl transferase. He develops jaundice, generalized pruritus, and light colored stools. The conjugated bilirubin fraction is > 50% of the total bilirubin. Which of the following apply to this case? SELECT 3
A. Obstruction of the common bile duct B. Carcinoma of the head of pancreas C. Stone in the common bile duct D. Primary sclerosing cholangitis E. Conjugated type of hyperbilirubinemia |
Answers: A, D, E: patient has primary sclerosing cholangitis involving the common bile duct.
A. Obstruction of the common bile duct: due to fibrosis around the duct. Note the light colored stools and increased ALP and GGT. D. Primary sclerosing cholangitis E. Conjugated type of hyperbilirubinemia: > 50%, so you would expect it in the urine. B. Carcinoma of the head of pancreas: the patient has a UC history and is not a smoker, so this is unlikely. C. Stone in the common bile duct: as above |
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10. A 28-year-old man with AIDS presents with chronic, recurrent, profuse, nonbloody, watery diarrhea. An Entero-Test (string test) shows oocysts that are partially acid-fast positive.
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Answer: I: Cryptosporidium parvum: sporozoan
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A 35-year-old executive of an up and coming computer company develops a sudden onset of severe epigastric pain with radiation of the pain into the back. He describes the pain as knife-like. In addition, he feels nauseous and has vomited non-bile stained fluid on two occasions. Physical exam shows tenderness in the epigastric area but no rebound tenderness. There is mild tender hepatomegaly. A flat plate of the abdomen shows a dilated loop of small bowel in the left upper quadrant. An ultrasound shows no stones in the gallbladder and a normal diameter of the common bile duct. A stool guaiac is negative. Serum AST is higher than serum ALT. What test is most indicated in this patient?
A. Upper gastrointestinal endoscopy B. Serum amylase and/or lipase C. HIDA (radionuclide) scan to R/O a cystic duct stone D. Hepatitis serologies E. Surgical consult to R/O small bowel obstruction |
Answer: B: acute pancreatitis:
B. Serum amylase and/or lipase A. Upper gastrointestinal endoscopy: not peptic ulcer disease C. HIDA (radionuclide) scan to R/O a cystic duct stone: ultrasound was negative for stones D. Hepatitis serologies: alcohol pattern for transaminases; probably has fatty liver. E. Surgical consult to R/O small bowel obstruction: no colicky pain |
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Which of the following are risk factors for developing cholesterol gallstones? SELECT 3
A. Hypercholesterolemia B. Extravascular hemolytic anemia C. Patient on birth control pills D. Patient with ascending cholangitis E. Patient taking a fibric acid derivative PICTURE |
Answers: A, C, E: risks are too much CH in bile (e.g., obesity), too little lecithin and/or bile salts/lecithin:
A. Hypercholesterolemia C. Patient on birth control pills: too much CH E. Patient taking a fibric acid derivative: too much CH B. Extravascular hemolytic anemia: black calcium bilirubinate stones D. Patient with ascending cholangitis: brown pigment stones |
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Which of the following are risk factors for carcinoma of the gallbladder? SELECT 2
A. Chronic cholecystitis B. Cholesterolosis C. Porcelain gallbladder D. Chronic pancreatitis E. Primary sclerosing cholangitis |
Answers: A, C:
A. Chronic cholecystitis C. Porcelain gallbladder: dystrophic calcification of GB. Immediate indication for cholecystectomy. B. Cholesterolosis: refers to CH deposited in macrophages giving GB a speckled yellow appearance D. Chronic pancreatitis: no association E. Primary sclerosing cholangitis: cholangiocarcinoma |
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8. Child with abdominal pain, intermittent jaundice, cirrhosis, and cysts in the biliary tract.
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Answer: F- choledochal cyst
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10. HIDA radionuclide scan is useful in confirming the diagnosis of this disorder
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Answer: A- acute cholecystitis. HIDA scan identifies the stone in the cystic duct. Stone produces increased intraluminal pressure and ischemia to gallbladder wall predisposing to mucosal ulceration and infection by E. coli.
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A 38-year-old man with a 10 year history of ulcerative colitis has had persistently elevated levels of alkaline phosphatase and -glutamyl transferase. He develops jaundice, generalized pruritus, and light colored stools. The conjugated bilirubin fraction is > 50% of the total bilirubin. Which of the following apply to this case? SELECT 3
A. Obstruction of the common bile duct B. Carcinoma of the head of pancreas C. Stone in the common bile duct D. Primary sclerosing cholangitis E. Conjugated type of hyperbilirubinemia |
Answers: A, D, E: patient has primary sclerosing cholangitis involving the common bile duct.
A. Obstruction of the common bile duct: due to fibrosis around the duct. Note the light colored stools and increased ALP and GGT. D. Primary sclerosing cholangitis E. Conjugated type of hyperbilirubinemia: > 50%, so you would expect it in the urine. B. Carcinoma of the head of pancreas: the patient has a UC history and is not a smoker, so this is unlikely. C. Stone in the common bile duct: as above |
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Which of the following are precursor lesions for cancer in the gastrointestinal tract? SELECT 2
A. Hairy leukoplakia B. Villous adenoma C. Hyperplastic polyp D. Tubular adenoma E. Peutz-Jegher's polyp picture |
Answers: B, D:
B. Villous adenoma: greatest risk factor due to increased villous component. D. Tubular adenoma: particularly if > 2cm and multiple A. Hairy cell leukoplakia: EBV-induced glossitis that is a pre-AIDS infectious disease C. Hyperplastic polyp: they are hamartomas and do not predispose to cancer E. Peutz-Jegher's polyp: as above; however there is an increased incidence of de novo colorectal cancer |
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A 3-year-old child develops an abrupt onset of mid-epigastric colicky abdominal pain, abdominal distention, and bloody stools. A sausage-shaped mass is palpable in the midepigastrium. Which of the following apply to this case? SELECT 3
A. Congenital pyloric stenosis B. Meckel’s diverticulitis C. Hyperplasia of Peyer's patches D. Intussusception E. Obstruction and strangulation |
Answers: C, D, E: the patient has an intussusception
C. Hyperplasia of Peyer's patches: this is the usual nidus for the intussusception. Hyperplasia of the lymphoid tissue is normal in children, since this site is where most of the antibodies are made. D. Intussusception E. Obstruction and strangulation |
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Dysphagia for solids and liquids is expected in which of the following patients? SELECT 3
A. Plummer Vinson syndrome B. Achalasia C. Myasthenia gravis D. Zenker’s diverticulum E. Systemic sclerosis F. Lye strictures G. Esophageal cancer |
Answers: B, C, E: others are dysphagia for solids but not liquids:
B. Achalasia: mid-distal esophagus C. Myasthenia gravis: upper esophagus due to striated muscle weakness E. Systemic sclerosis: mid-distal esophagus A. Plummer Vinson syndrome: solids only D. Zenker’s diverticulum: odynophagia F. Lye strictures: solids only G. Esophageal cancer: solids only in initial stages |
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10. A 28-year-old man with AIDS presents with chronic, recurrent, profuse, nonbloody, watery diarrhea. An Entero-Test (string test) shows oocysts that are partially acid-fast positive.
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Answer: I: Cryptosporidium parvum: sporozoan
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11. An afebrile 22-year-old man and several other members of his family developed severe vomiting without diarrhea ~16 hours after eating potato salad at a picnic. They all recovered uneventfully 1224 hours later.
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Answer: G: S. aureus with preformed toxin: culture food not stool
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12. A 23-year-old man developed explosive, watery diarrhea with blood, leukocytes, and mucus ~3 days after eating chicken that was improperly cooked. Comma-shaped organisms are noted in the fecal smear of stool along with RBCs and leukocytes.
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Answer: E: Campylobacter jejunii: MC invasive diarrhea
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14. An afebrile 28-year-old medical student develops vomiting and diarrhea ~4 hours after eating rewarmed fried rice from a Mexican restaurant. Gram positive rods are present in his stool. He recovers uneventfully in 12 hours.
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Answer: B: Bacillus cereus: preformed toxin
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15. A 25-year-old medical student during Spring break in Tijuana, Mexico develops fever, vomiting, abdominal cramps, and watery diarrhea ~14 hours after eating a few tacos purchased from a street vendor. He recovers uneventfully in 48 hours.
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Answer: H: enterotoxigenic E. coli: secretory diarrhea with some strains having toxin stimulation of guanylate cyclase producing cGMP or other strains having toxin stimulation of adenylate cyclase producing cAMP. Bowel mucosa is normal.
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16. An afebrile 30-year-old man develops profuse watery diarrhea, with abdominal cramps ~48 hours after eating a dozen raw oysters at a cafe along the Louisiana coast. He is hypotensive, volume depleted, and has a hypokalemic normal anion gap metabolic acidosis.
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Answer: A: Vibrio cholerae: secretory diarrhea with toxin stimulating adenylate cyclase with production of cAMP. Must replace with oral hypotonic salt solutions containing glucose due to cotransport of sodium with glucose. Bowel mucosa is normal.
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17. On a trip to India, a man develops a high fever associated with bradycardia, absolute neutropenia, and splenomegaly. A blood culture is positive for a gram negative organism.
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Answer: D: Salmonella typhi: note the classic triad. Blood culture is better than stool culture at this stage.
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18. A 28-yr-old man develops diarrhea with mucus and blood. A stool for fecal leukocytes shows blood and neutrophils. Pseudomembranes are noted in a colonoscopy. SELECT 2
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Answers C, E:
C. (Shigella sonnei) E. (Campylobacter jejuni): both are invasive diarrheas that produce a dysentery type picture and pseudomembranes |
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19. A patient with AIDS develops diarrhea with steatorrhea. A biopsy shows macrophages with a foamy cytoplasm.
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Answer: J. Mycobacterium avium-intracellulare with Whipples-like syndrome: common cause of AIDS diarrhea with CD4 count is < 100.
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A 42-year-old woman complains of increasing pain and difficulty swallowing liquids and solids over the past several months. She has lost 15 pounds in the past three months and has occasionally experienced acute substernal pain and regurgitation of food into her mouth when lying down at night. Esophageal manometry shows aperistalsis of the lower esophagus and increased pressure in the lower esophageal sphincter (LES). Which of the following apply to this case? SELECT 2
A. Elevation in anti-centromere antibodies B. Involves striated muscle in upper esophagus C. Absence of ganglion cells in the LES myenteric plexus D. Bird's beak appearance on barium study E. Adenocarcinoma of the distal esophagus |
Answers: C, D: achalasia:
C. Absence of ganglion cells in the LES myenteric plexus: ganglion cells contain nitric oxide synthase which synthesizes nitric oxide, which normally relaxes the LES D. Bird's beak appearance on barium study A. Elevation in anti-centromere antibodies: not CREST or systemic sclerosis B. Involves striated muscle in upper esophagus: involves smooth muscle. Myasthenia, stroke, dermatomyositis involve striated muscle E. Adenocarcinoma of the distal esophagus: wrong history |
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A 50-year-old man with flushing of the face, watery diarrhea, weight loss, and multiple mass lesions in his liver. Which of the following apply to this case? SELECT 3
A. Increased 5-HIAA B. Tumor in appendix C. Increased serotonin D. Benign tumor E. Neurosecretory granules |
Answers: A, C, E: carcinoid syndrome with primary tumor in terminal ileum that has metastasized to the liver. Right sided cardiac lesions may occur: tricuspid regurgitation and pulmonic stenosis:
A. Increased 5-HIAA: metabolite of serotonin C. Increased serotonin E. Neurosecretory granules. Remember that 5-HIAA is being produced by carcinoid tumors without metastasizing to liver; however, serotonin is being removed by hepatocytes from the sinusoidal blood and then metabolized to 5-HIAA without gaining access to the systemic circulation. B. Tumor in appendix: MC location but not the MC site for carcinoid syndrome since the tumors are rarely > 2 cm and rarely metastasize to the liver. D. Benign tumor: all carcinoid tumors are malignant |
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A febrile 68-year-old man with a long history of chronic constipation complains of a steady pain in the left lower abdomen. He has had frequent attacks of pain in the same area for several months and one episode of bloody stools that spontaneously resolved. Physical exam shows rebound tenderness and a palpable mass in the left lower quadrant. A stool guaiac is negative. A CBC exhibits an absolute neutrophilic leukocytosis and left shift. A flat plate is reported to show no air under the diaphragm. Which of the following apply to this case? SELECT 2
A. Volvulus B. Colon cancer C. Ischemic colitis D. Pulsion diverticulum E. Acute diverticulitis |
Answers: D, E: classic acute diverticulitis or "left-sided appendicitis":
D. Pulsion diverticulum E. Acute diverticulitis A. Volvulus: no signs of obstruction and strangulation are noted B. Colon cancer: the presentation is inflammation not cancer C. Ischemic colitis: there is no bloody diarrhea and pain is not in the splenic flexure area |
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A 42-year-old man complains of cough that keeps him up at night and indigestion with epigastric distress especially after drinking coffee, beer, or fatty foods. Endoscopy shows ulceration of the distal esophagus. Multiple biopsies of the distal esophagus performed by Dr. Boerhaave, exhibit metaplastic glandular epithelium interspersed with thickened squamous epithelium. Which of the following apply to this case? SELECT 2
A. Chronic atrophic gastritis with reflux B. Relaxation of the LES and acid injury C. Barrett's esophagitis D. Failure of relaxation of the LES and acid injury E. Helicobacter pylori-related peptic ulcer disease with reflux |
Answers: B, C: GERD:
B. Relaxation of the LES and acid injury C. Barrett's esophagitis A. Chronic atrophic gastritis with reflux: not associated with GERD D. Failure of relaxation of the LES and acid injury: it is not achalasia E. Helicobacter pylori-related peptic ulcer disease with reflux: it is not associated with reflux but with type B chronic atrophic gastritis of the pylorus and antrum. |
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A 38-year-old Asian woman has a long history of explosive diarrhea and abdominal distention after eating dairy products. Which of the following apply to this case? SELECT 3
A. Antigliadin antibodies B. Alkaline stool pH C. Intraluminal osmotically active solutes D. Stool osmotic gap > 100 mOsm/kg E. Mucosal injury with increased permeability F. Disaccharidase enzyme deficiency |
Answers: C, D, F: classic lactase deficiency:
C. Intraluminal osmotically active solutes: lactose D. Stool osmotic gap > 100 mOsm/kg: it is osmotic diarrhea with a hypotonic loss of fluid F. Disaccharidase enzyme deficiency: it is a disaccharidase and brush border enzyme. Lactic acid and hydrogen gas are produced by the colonic bacteria. A. Antigliadin antibodies: it is not celiac disease B. Alkaline stool pH: it is acid due to production of lactic acid by bacteria E. Mucosal injury with increased permeability: it is an osmotic, not an invasive diarrhea |
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An elderly man has a 3 month history of weight loss due to fear of postprandial pain in the splenic flexure area of the abdomen. He now presents with a rapid onset of severe pain in this same area associated with bloody stools. An abdominal bruit is heard in the epigastrium. Which of the following apply to this case? SELECT 2
A. Ischemic colitis B. Angiodysplasia C. Diverticulosis D. Colon cancer E. Mesenteric angina |
Answers: A, E:
A. Ischemic colitis: note localization to the overlap area in the splenic flexure. Also note bruit from atherosclerosis of the orifice of SMA E. Mesenteric angina B. Angiodysplasia: wrong history C. Diverticulosis: wrong history D. Colon cancer: wrong history |
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Which of the following complications is common to both diverticular disease in the colon and angiodysplasia?
A. Fistula formation B. Perforation C. Hematochezia D. Left lower quadrant pain E. Abscess formation |
Answer: C. Hematochezia: painless bleeding per rectum. Diverticulosis (not -it is) is the MCC.
A. Fistula formation: no, diverticular disease B. Perforation: no, diverticular disease D. Left lower quadrant pain: no, diverticular disease E. Abscess formation: no, diverticular disease |
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44. A 65-year-old man with a chronic arrhythmia has a sudden onset of severe abdominal pain associated with vomiting, abdominal distention, and bloody diarrhea. Physical exam shows hypotension, absent bowel sounds, no rebound tenderness, and a guaiac positive, liquid stool. A complete blood cell count exhibits a white blood cell count of 35,000 cells/uL with an absolute neutrophilic leukocytosis and left shift. The serum amylase is elevated. Which of the following apply to this case? SELECT 2
A. Small bowel infarction B. Embolus-related disease C. Ischemic colitis D. Acute appendicitis with perforation E. Hemorrhagic pancreatitis |
Answers: A, B:
A. Small bowel infarction B. Embolus-related disease: arrhythmia is atrial fibrillation C. Ischemic colitis: the pain is localized to the splenic flexure D. Acute appendicitis with perforation: pain should be in RLQ E. Hemorrhagic pancreatitis: amylase is present in small bowel |
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50. Most common cause of diarrhea in children during the winter months that has an ELISA test for aid in its diagnosis
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Answer: A. Rotavirus: secretory diarrhea
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52. Most common cause of viral gastroenteritis in adults
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Answer: B. Norwalk virus
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53. Most common cause of a secretory diarrhea when visiting developing countries
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Answer: D. Enterotoxigenic E. coli
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61. Farmer and his wife develop paralysis. Pupils are dilated.
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Answer: M. Clostridium botulinum: ingested the preformed toxin most likely from canned foods.
Prevents release of acetylcholine. |
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62. 25-yr-old man went to a picnic and developed severe vomiting and gastroenteritis.
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Answer: N. Salmonella enteritidis: MCC of food poisoning in the United States. Bacteria must colonize the bowel first before producing the toxin. Clostridium perfringens is also a common cause of picnic food poisoning.
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64. Produces eosinophilia in its transmigration through the lungs and bowel obstruction in its adult form
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Answer: G. Ascaris lumbricoides
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65. Invasive helminth that is associated with rectal prolapse in children
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Answer: F. : Trichuris trichiura
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67. Sporozoan that is partially acid fast that is associated with diarrhea and biliary tract disease in AIDS
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Answer: C. Cryptosporidia; also Isospora belli
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69. Invasive helminth associated with iron deficiency
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Answer: H. Necator americanus
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71. Invasive helminth where the adult can be the definitive host in one manifestation of the disease and the intermediate host in another manifestation of the disease associated with focal epileptic seizures
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Answer: L. Taenia solium
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74. Non-invasive helminth associated with pruritus ani, appendicitis, and urethritis in little girls
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Answer: E. Enterobius vermicularis
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75. Most common polyposis syndrome associated with oral pigmentation and hamartomas in the small bowel.
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Answer: H. Peutz-Jegher's syndrome
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81. Pre-AIDS defining lesion associated with Epstein-Barr virus
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Answer: U. hairy leukoplakia: not precancerous.
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98. Newborn child coughs and becomes cyanotic after breast feeding. The stomach is distended and tympanitic. The mother has a history of polyhydramnios.
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Answer: A. tracheoesophageal fistula: the proximal esophagus ends blindly and the distal arises from the trachea.
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99. 52-yr-old woman from South America regurgitates undigested food at night. Esophageal studies demonstrate a dilated distal esophagus with absent peristalsis and increased LES contraction. A biopsy of the LES exhibits an inflammatory lesion with leishmanial forms present.
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Answer: E. achalasia: due to Trypanosoma cruzi- Chagas disease with destruction of the ganglion cells in the myenteric plexus.
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102. 52-yr-old woman complains of dysphagia for solids and liquids. She has intermittent problems with Raynaud's phenomenon. Her fingers exhibit sclerodactyly and telangiectasias. An antibody study is ordered.
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Answer: D. systemic sclerosis/CREST: the antibody study is an anti-centromere antibody. Anti-topoisomerase antibodies are also useful for diagnosing systemic sclerosis
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104. 49-yr-old man has a long history of acid indigestion after drinking coffee and eating fatty foods. Lately he has had dysphagia for solids but not liquids. Endoscopy exhibits ulceration and stricture of the distal esophagus. A biopsy demonstrates goblet cells, and mucus secreting cells.
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Answer: G. Barrett's esophagus: the patient has GERD and developed Barrett's esophagitis with ulceration and stricture formation. It may be a precursor for distal adenocarcinoma, which is the MC esophageal cancer.
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105. 52-yr-old alcoholic vomits up blood with clots. Endoscopy demonstrates blood originating from the distal esophagus.
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Answer: K. esophageal varices: MC due to portal hypertension from cirrhosis. Bleeding is from the left gastric coronary vein, which drains into the portal vein.
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110. Child with Down syndrome fails to pass meconium. Rectal exam exhibits an empty rectal vault.
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Answer: L. Hirschsprung's disease: association with Down syndrome. Absent ganglion cells in submucosal and myenteric plexus of rectum. Proximal bowel has motility. Can be acquired in Chagas disease.
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111. Patient visiting Louisiana gorges himself on seafood and develops severe diarrhea. S shaped organisms are noted in the stool. Stool osmotic gap is < 50.
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Answer: J. secretory diarrhea: patient developed cholera from Vibrio cholerae. Toxin stimulates adenylate cyclase, which produces cAMP. No bowel inflammation. Must have glucose in the hypotonic salt solution to reabsorb sodium.
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113. Down syndrome patient develops projectile vomiting of bile stained fluid shortly after birth. A flat plate of the abdomen exhibits air in the stomach and proximal duodenum. No air is distal to the proximal duodenum. Mother has a history of polyhydramnios
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Answer: M. duodenal atresia: atresia is distal to the ampulla of Vater. Association with Down syndrome. Note the double bubble sign.
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122. 48-yr-old man ate undercooked chicken at a picnic and developed bloody diarrhea. S shaped organisms with neutrophils are noted in the fecal smear of leukocytes.
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Answer: I. invasive diarrhea: patient has gastroenteritis due to Campylobacter jejuni, which is an S shaped G - rod.
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124. 22-yr-old power lifter develops sudden onset of abdominal pain when doing heavy squats. Abdominal surgery exhibits a portion of small bowel entrapped and infarcted in the internal inguinal ring in the right lower quadrant.
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Answer: Q. indirect inguinal hernia: second MCC of small bowel obstruction. Indirect inguinal hernias are lateral to the superficial epigastric artery and extend into the scrotal sac.
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129. 52-yr-old man with alteration in bowel habits, weight loss, and dragging sensation in the right upper quadrant. Physical exam exhibits an enlarged liver and a positive stool guaiac.
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Answer: E. colorectal adenocarcinoma: a positive stool guaiac after 50 is highly suspect for cancer. Hepatomegaly is most likely related to metastasis. Weight loss and alteration in bowel habits suggests a left sided cancer. "Left side obstructs, right side bleeds."
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131. 65-yr-old man complains of fever and left lower quadrant pain. Physical exam exhibits rebound tenderness in the LLQ. A CBC demonstrates absolute neutrophilic leukocytosis and left shift with toxic granulation.
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Answer: N. diverticulitis: diverticulitis, the MC complication of diverticulosis, presents like "left sided appendicitis".
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132. A 2-yr-old child with frequent respiratory infections and chronic diarrhea presents with a sausage-shaped mass protruding from the anus.
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Answer: K. rectal prolapse: the patient most likely has cystic fibrosis, which is commonly associated with rectal prolapse. Whooping cough and trichuriasis are other causes.
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139. 42-yr-old man complains of blood coating his stool and a reducible mass that protrudes from his anus when he strains at stool. Occasionally he notes blood on the toilet paper when he wipes himself. Rectal exam is unremarkable. Stool guaiac is positive. A flexible sigmoidoscopy exhibits mucosal and submucosal masses located above the dentate line.
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Answer: H. internal hemorrhoids: derive from the superior hemorrhoidal vein. Commonly produce painless bleeding and coating of the stools with blood. Internal hemorrhoids commonly prolapse out of the anus during stooling. Never assume blood coating stools is internal hemorrhoids unless it can be documented by proctoscopy or flexible sigmoidoscopy to rule out other causes, like cancer.
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