1- A 52-year-old woman tells her physician that she is concerned about her risk for developing
endometrial cancer. Which of the following factors poses the largest risk for developing endometrial
cancer?"
1- Alcoholism
2- Early sexual activity
3- [Y]Prolonged unopposed estrogen use
4- Low-fiber diet
5- Multiparity
2- A 28-year-old married woman who has been trying to become pregnant for the past 5 months
presents to the emergency department with sudden and severe abdominal pain. Ultrasonography shows
a mass in her left fallopian tube with free fluid in the cul-de-sac. Previous infection by which of the
following agents most likely put this patient at a higher risk for developing this complication?
1- [Y]Chlamydia trachomatis
2- Escherichia coli
3- Herpes simplex virus
4- Human papilloma virus
5- Streptococcus agalactiae
3- A 1-month-old boy is brought to the pediatrician by his mother for a well-baby visit for the first time
since his birth. On examination, the doctor notes that the patient has cryptorchidism, with both testicles
remaining undescended. This patient is at increased risk for developing which of the following
conditions?
1- Hypogonadotropic hypogonadism
2- Indirect inguinal hernia
3- Retractile testis
4- [Y]Testicular cancer
5- Torsion of the spermatic cord
4- A 69-year-old man presents with urinary frequency, nocturia, dribbling, and difficulty in starting and
stopping urination. Rectal examination reveals the prostate to be enlarged, firm, and rubbery. A needle
biopsy reveals increased numbers of glandular elements and stromal tissue. The glands are found to
have a double layer of epithelial cells. Prominent nuclei or back-to-back glands are not seen. Which of
the following is the most likely diagnosis?
1- Atrophic prostatitis
2- Atypical small acinar proliferation
3- High-grade prostatic intraepithelial neoplasia
4- [Y]Benign prostatic hyperplasia
5- Prostatic adenocarcinoma
5-Pediatric urology's patient has a history of recurrent urinary tract infections. Urine cultures have
grown Escherichia coli, Proteus mirabilis, and Enterococcus. Physical examination now shows an
abnormal constricted opening of the urethra on the ventral aspect of the penis, 1.5 cm from the tip of
the glans penis. There also is a cryptorchid testis on the right and an inguinal hernia on the left. What
term best describes the child’s penile abnormality?"
1- Bowen disease
2- Paraphimosis
3- [Y]Hypospadias
4- Epispadias
5- Balanitis
6- The patient recently noticed a pale area of discoloration on the labia. Pelvic examination shows the
presence of a 0.6-cm flat, white area on the right labia majora. A biopsy specimen is obtained and on
microscopic examination shows dysplastic cells that occupy half the thickness of the squamous
epithelium, with minimal underlying chronic inflammation. In situ hybridization shows human
papillomavirus type 16 DNA in the epithelial cells. What is the most likely diagnosis?
1- [Y]Vulvar intraepithelial neoplasia
2- Chronic vulvitis
3- Condyloma acuminatum
4- Lichen sclerosus et atrophicus
5- Squamous hyperplasia
7- 45 year old woman patient has had menometrorrhagia for the past 1.5 months. She has no history of
prior irregular menstrual bleeding, and she has not yet reached menopause. On physical examination,
there are no vaginal or cervical lesions, and the uterus appears normal in size, but there is a right
adnexal mass. An abdominal ultrasound scan shows the presence of a 6.5-cm solid right adnexal mass.
Endometrial biopsy shows hyperplastic endometrium, but no cellular atypia. What is the most likely
lesion that underlies her menstrual abnormalities?"
1- Corpus luteum cyst
2- Mature cystic teratoma
3- Endometrioma
4- Metastasis
5- Polycystic ovarian syndrome
5- [Y]Granulosa-theca cell tumor
8- 80 year old patient, previously healthy woman feels a lump in her right breast. The physician palpates
a 2.5-cm firm mass in the upper outer quadrant. Nontender right axillary lymphadenopathy is present. A
lumpectomy with axillary lymph node dissection is performed. Microscopic examination shows that the
mass is an infiltrating ductal carcinoma. Three of 10 axillary nodes contain metastases. Flow cytometry
on the carcinoma cells shows a small aneuploid peak and high S-phase. Immunohistochemical tests
show that the tumor cells are positive for estrogen and progesterone receptor (ER/PR), negative for
HER2/neu expression, and positive for cathepsin D expression. What is the most important prognostic
factor for this patient?"
1- Lack of HER2/neu expression in the carcinoma
2- Histologic subtype of carcinoma
3- Expression of stromal proteases in the carcinoma
4- [Y]Presence of lymph node metastases
5- Age at diagnosis
6- DNA content in the carcinoma
7- Estrogen receptor positivity
9- 30 year old woman, gravida 3 para 3, comes to the office with worsening shortness of breath over the
past week. She had a recent episodes of hemoptysis. The patient has also had ongoing vaginal bleeding
after an uncomplicated vaginal delivery of her son 9 weeks ago. She has no bleeding elsewhere, and she
has not resumed sexual intercourse. On physical examination, the patient's uterus is enlarged and
adnexa are normal. Laboratory studies show markedly increased beta-hCG levels. Chest radiograph
shows multiple bilateral lung nodules. Which of the following would most likely be found on
endometrial curettage in this patient?
1- Bundles of smooth muscle cells with fibrosis
2- Diffusely hydropic chorionic villi
3- Fetal tissue with triploid karyotype
4- Glands lined by atypical columnar epithelial cells
5- [Y]Proliferation of cytotrophoblasts and syncytiotrophoblasts
10- 35 year old women, gravida 1, para 0, comes to the office for a routine prenatal checkup at
approximately 33 weeks gestation. The patient has started having persistent, throbbing headaches that
are not relieved by acetaminophen. She has no nausea, vomiting, or abdominal pain. She eats a
well-balanced diet, takes prenatal vitamins, and has normal bowel movements. Medical history is
unremarkable and prenatal care has been uneventful. Review of medical records show that her blood
pressure was 12/75 mm Hg at 28 weeks gestation. Today, blood pressure is 170/100 mm Hg, and heart
rate 95 per minute. Which of the following additional findings is most likely present in this patient?
1- [Y]Proteinuria
2- Splenomegaly
3- Thrombocytosis
4- Ketonuria
5- Fasting hyperglycemia
6- Arteriovenous nicking
11- A 35-year-old woman is seen 6 months after giving birth to a normal infant. She suffered severe
cervical lacerations during delivery, resulting in hemorrhagic shock. Following blood transfusion and
surgical repair, postpartum recovery has so far been uneventful. She now complains of continued
amenorrhea and loss of weight and muscle strength. Further investigation might be expected to
demonstrate which of the following findings?
1- [Y]Decreased serum cortisol
2- Hyperestrinism
3- Hyperglycemia
4- Increased hair growth in a male distribution pattern
12- During a yearlong training program, a 23-year-old female Air Force officer falls in class rank from first
place to last place. She has also noted a lower pitch to her voice and coarsening of her hair, along with
an increased tendency toward weight gain, menorrhagia, and increasing intolerance to cold. Which of
the following laboratory abnormalities is expected?"
1- Increased serum free T4
2- Increased serum T3 resin uptake
3- Increased saturation of thyroid hormone- binding sites on TBG
4- [Y]Increased serum TSH
13- A 32-year-old woman presents with amenorrhea, galactorrhea, and visual field defects, all of several
months’ duration. Magnetic resonance imaging reveals a hypophyseal mass impinging on the optic
chiasm. This is most likely a(n)
1- [Y]prolactinoma.
2- somatotropic adenoma
3- corticotropic adenoma.
4- craniopharyngioma.
14- A 23-year-old woman presents with tremor, restlessness, heat intolerance, palpitation, and
unexplained weight loss. The thyroid is symmetrically enlarged, the pulse is rapid, the skin is moist and
warm, and exophthalmos is apparent. This condition is considered to be
1- [Y]autoimmune.
2- congenital.
3- iatrogenic.
4- infectious.
15- A palpable mass is noted in the right lobe of the thyroid of a 45-year-old man who visits his physician
for a periodic checkup. A biopsy is performed and results in a diagnosis of medullary carcinoma of the
thyroid. Which of the following histologic features of thyroid disease would most likely be present in this
biopsy specimen?"
1- Tumor cells with “Orphan Annie” nuclei
2- Psammoma bodies
3- [Y]Tumor cells embedded in an amyloid-laden stroma
4- Infiltrates of lymphocytes with germinal center formation
16- On routine examination, it is discovered that a 35-year-old woman had been exposed in utero to DES
administered to her mother, who had had a history of recurrent spontaneous abortion. This history
suggests that the patient might be at increased risk of
1-adenomyosis.
2- [Y]clear cell adenocarcinoma.
3-lichen sclerosus.
4- squamous cell carcinoma
17- A 23-year-old African-American man who is known to have sickle cell anemia presents to the
emergency department with a painful erection. The patient explains that the erection had started 3
hours ago. This condition is referred to as
1- balanitis.
2- hypospadias.
3- Peyronie disease.
4- [Y]priapism.
18- A 3-year-old boy is brought to the pediatrician because his mother noticed an abnormal mass in his
scrotum while changing his diapers. Further workup demonstrates elevated levels of serum
α-fetoprotein. Which of the following is the most likely diagnosis?"
1- Choriocarcinoma
2- [Y]Endodermal sinus (yolk sac) tumor
3- Hepatocellular carcinoma
4- Teratoma
19- A 66-year-old man visits his family physician with complaints of urinary frequency, hesitancy, and
dysuria. Digital rectal examination reveals an enlarged prostate, and the consistency is rubbery and
nodular. Serum PSA is modestly increased. Which of the following is most closely related to the
pathogenesis of the likely disorder described here?
1- [Y]DHT
2- Estrogen
3- hCG
4- Progesterone
20- While on an international medical rotation, you encounter a pregnant woman in a rural village in
India who presents with fever, jaundice, and malaise. The patient unexpectedly expires. This is the
second case this month with a similar presentation. Which of the following is the most likely form of
hepatitis?
1- Hepatitis A
2- Hepatitis B
3- Hepatitis C
4- [Y]Hepatitis E
21- A 35-year-old man complains of difficulty swallowing and a tendency to regurgitate his food.
Endoscopy does not reveal any esophageal or gastric abnormalities. Manometric studies of the
esophagus show a complete absence of peristalsis, failure of the lower esophageal sphincter to relax
upon swallowing, and increased intraesophageal pressure. Which of the following is the most likely
diagnosis?
1- [Y]Achalasia
2- Barrett esophagus
3- Esophageal stricture
4- Mallory-Weiss syndrome
5- Schatzki ring
22- A 45-year-old woman presents with general discomfort and increasing tightness in the skin of her
face. She reports intermittent pain in the tips of her fingers when exposed to the cold. Physical
examination shows “stone facies” and edema of the fingers and hands. Serologic tests for antinuclear
and anti–Scl-70 antibodies are both positive. Which of the following gastrointestinal manifestations is
expected in this patient?
1- Adenocarcinoma of the esophagus
2- [Y]Dysphagia
3- Esophageal rupture
4- Esophageal varices
5- Squamous cell carcinoma of the esophagus
23- A 45-year-old man presents with long-standing heartburn and dyspepsia. An X-ray film of the chest
shows a retrocardiac, gas-filled structure. This patient most likely has which of the following conditions?
1- Boerhaave syndrome
2- Esophageal varices
3- Esophageal webs
4- [Y]Hiatal hernia
5- Mallory-Weiss syndrome
24- 6- A 3-week-old boy is brought to the physician by his parents, who report that he vomits forcefully
immediately after nursing. Physical examination reveals an “olive-like” palpable mass and visible
peristaltic movements within the infant’s abdomen. What is the most likely cause of projectile vomiting
in this infant?
1- Appendicitis
2- [Y]Congenital pyloric stenosis
3- Hirschsprung disease
4- Meconium ileus
5- Tracheoesophageal fistula
25- A 40-year-old woman presents with a 2-month history of burning epigastric pain that usually occurs
between meals. The pain can be relieved with antacids or food. The patient also reports a recent history
of tarry stools. She denies taking aspirin or NSAIDs. Laboratory studies show a microcytic, hypochromic
anemia (serum hemoglobin = 8.5 g/dL). Gastroscopy reveals a bleeding mucosal defect in the antrum
measuring 1.5 cm in diameter. An endoscopic biopsy shows that the lesion lacks mucosal lining cells and
is composed of amorphous, cellular debris and numerous neutrophils. Which of the following is the
most important factor in the pathogenesis of this patient’s disease?
1- Achlorohydria
2- Acute ischemia
3- Autoimmunity
4- Gastrinoma
5- [Y]Helicobacter pylori infection
26- A 60-year-old woman presents with several years of abdominal pain radiating to her back and a
5-day history of yellow skin and sclerae. She has lost 15 lb during the past several months, and her stools
have become lighter in color. On physical examination, the patient is cachectic and jaundiced. The liver
edge descends 1 cm below the right costal margin and is nontender. Her right calf is tender and
erythematous. Serum AST and ALT are at the upper limits of normal, but alkaline phosphatase is
increased to 430 U/L. A CT scan shows a mass in the head of the pancreas. What is the most likely cause
of jaundice in this patient?
1- Acute viral hepatitis
2- Alcoholic hepatitis
3- α1-Antitrypsin deficiency
4- Drug-induced hepatitis
5- [Y]Extrahepatic biliary obstruction
27- A previously healthy, 24-year-old woman presents with a 1-week history of intermittent fever,
lethargy, and yellow skin and sclerae. Physical examination shows jaundice. Laboratory studies reveal
decreased serum albumin (2.2 g/dL), extremely high levels of AST and ALT (1,200 and 1,800 U/L,
respectively), and elevated alkaline phosphatase (300 U/L). Her ceruloplasmin level is normal. She is
admitted to the hospital. Her condition progressively deteriorates, and she develops hepatic
encephalopathy and hepatorenal syndrome. Which of the following is the most likely diagnosis?
1- Extrahepatic biliary obstruction
2- Hereditary hemochromatosis
3- [Y]Massive hepatic necrosis
4- Primary biliary cirrhosis
5- Sclerosing cholangitis
28- A 47-year-old man suffers from long-standing peptic ulcer disease, which is largely unresponsive to
pharmacologic therapy. Endoscopic examination reveals multiple, nonhealed ulcerations of the
duodenum and jejunum. Which of the following is the most likely diagnosis?
1- Carcinoid syndrome
2- Insulinoma
3- Pancreatic adenocarcinoma
4- Verner-Morrison syndrome
5- [Y]Zollinger-Ellison syndrome
29- A 35-year-old woman presents with 6-month history of skin rash and fatigue. Physical examination
shows pallor and a necrotizing erythematous skin rash of her lower body. Laboratory studies reveal mild
anemia and fasting blood glucose of 160 mg/dL. A CT scan of the abdomen demonstrates a 2-cm mass in
the pancreas. Which of the following is the most likely diagnosis?
1- Carcinoid tumor
2- Gastrinoma
3- [Y]Glucagonoma
4- Insulinoma
5- Pancreatic polypeptide-secreting tumor
30- A 60-year-old woman with small cell carcinoma of the lung notes rounding of her face, upper truncal
obesity, and muscle weakness. Physical examination reveals thin, wrinkled skin, abdominal striae, and
multiple purpuric skin lesions. The patient’s blood pressure is 175/95 mm Hg. Laboratory studies will
likely show elevated serum levels of which of the following hormones?
1- Aldosterone
2- [Y]Corticotropin
3- Epinephrine
4- Prolactin
5- Thyrotropin
31- Which of the following anemia profiles is typical of thalassemia?
1- ↓ MCV, ↓ plasma iron, ↓ ferritin, ↓ total iron binding capacity (TIBC)
2- ↓ MCV, ↓ ferritin, ↑ plasma iron, normal TIBC
3- ↑ MCV, normal ferritin, normal plasma iron, normal TIBC
4- [Y]↓ MCV, normal ferritin, normal plasma iron, normal TIBC
32- A 12-year-old girl has the sudden onset of severe abdominal pain and back pain. On physical
examination her abdomen is diffusely tender, but there are no masses. She is afebrile. A CBC shows Hgb
6.5 g/dL, Hct 19.0%, MCV 99 fL, platelet count 149,000/microliter, and WBC count 11,200/microliter.
Examination of her peripheral blood smear shows nucleated RBCs and sickled RBCs. Which of the
following types of gene mutation is she most likely to have?
1- Deletion
2- Duplication
3- [Y]Missense
4- Insertion
5- Nonsense
33- Reed-Sternberg (RS )CD15 +and CD30+ seen in which of the following blood cell neoplasia?
1- Chronic myelogenous leukemia(CML )
2- Chronic lymphoblastic leukemia (CLL)
3- [Y]Hodgkin lymphoma (HL)
4- Non-Hodgkin lymphoma (NHL)
34- The osmotic fragility diagnostic test is used in which of the following anemias?
1- B12 deficiency anemia
2- [Y]Hereditary spherocytosis
3- Iron deficiency anemia
4- Aplastic anemia
5- Anemia chronic disease(ACD)
35- Which of the following is the BEST explanation of polycythemia?
1- An illegal way that professional athletes get a competitive edge
2- [Y]A blood disorder in which there are too many red blood cells
3- A blood disorder in which the red blood cells are lacking in enzymes
4- Ableeding disorder in which a person is missing important clotting factors.
36- A 65-year-old female was brought to the physician due to jaw claudication and headaches lasting
approximately a month. Laboratory shows markedly elevated ESR. which of the following is the most
likely diagnosis?
1- [Y]Blindness
2- Intermittent claudication
3- Necrosis of the index finger
4- Coronary artery aneurysm
37- A 4-year-old child from china was brought to the pediatrician due to fevers lasting 5 days. fever is
unresponsive to acetaminophen. Physical examination shows the desquamation of the skin on fingers,
as well as edema of the hands and feet. The patient has bilateral conjunctival injection, cervical
lymphadenopathy, erythema of the tongue. Immediate treatment with Aspirin and intravenous
immunoglobulin was started to avoid which of the following complications?
1- Buerger disease
2- Takayasu arteritis
3- [Y]Kawasaki disease
4- Polyarteritis nodosa
5- Behcet disease
38- A 32-year-old female was brought to the cardiologist with fever, night sweats, myalgias. Physical
examination shows diminished carotid and absent brachial pulsations. ESR was markedly elevated.
Treatment with prednisolone was started. Which of the following vasculitis does she have?
1- Obliteration of small vessels
2- [Y]Granulomatous thickening and narrowing of the aortic arch
3- Narrowing of small veins
4- Leukocytoclastic vasculitis
5- Infiltration of the small vessels by macrophages
39- A Young scientist studies chronic vasculitis, involving small and medium-sized arteries. The etiology
of this vasculitis is unknown, but in 30 % of cases, it is associated with Hepatitis B infection. This adult
type vasculitis does not involve pulmonary arteries and does not cause glomerulonephritis. There is
perivascular inflammation resulting in nodularity, mIcroaneurysms are seen in 50% of cases. Which of
the following most likely represents this vasculitis?
1- Churg strauss
2- Takayasu arteritis
3- [Y]Polyarteritis nodosa
4- Kawasaki disease
5- Wegener granulomatosis
40- A 34-year-old female was brought to the physician. The patient has sinusitis, cough, skin nodules,
significant purpura also noted on the extremities as well as carpal tunnel syndrome. The patient's CBC
shows eosinophilia. Pulmonary function tests show an obstructive pattern improved with beta-agonist
and diagnosis of asthma was made. Which of the following is correct about her condition?
1- Patient is positive to anti ds DNA antibodies
2- Patient has inflammation of the aortic arch
3- [Y]Patient has elevated IgE levels
4- Her condition is inherited as autosomal dominant pattern
5- She has vasculitis associated with hepatitis C infection.
41- A 50-year-old man experiences episodes of severe substernal chest pain every time he performs a
task that requires moderate exercise. The episodes have become more frequent and severe over the
past year, but they can be relieved by sublingual nitroglycerin. On physical examination, he is afebrile,
his pulse is 78/min and regular, and there are no murmurs or gallops. Laboratory studies show
creatinine, 1.1 mg/dL; glucose, 130 mg/dL; and total serum cholesterol, 223 mg/dL. Which of the
following cardiac lesions is most likely to be present?"
1- Rheumatic mitral stenosis
2- Serous pericarditis
3- Restrictive cardiomyopathy
4- [Y] Coronary atherosclerosis
42- A 19-year-old man has had a low-grade fever for 3 weeks. On physical examination, his temperature
is 38.3°C, pulse is 104/min, respirations are 28/min, and blood pressure is 95/60 mm Hg. A tender
spleen tip is palpable. There are splinter hemorrhages under the fingernails and tender hemorrhagic
nodules on the palms and soles. A heart murmur is heard on auscultation. Which of the following
infectious agents is most likely to be cultured from this patient's blood?
1- [Y] Viridans streptococci
2- Trypanosoma cruzi
3- Candida albicans
4- Mycobacterium tuberculosis
43- A 50-year-old man has sudden onset of severe substernal chest pain that radiates to the neck. On
physical examination, he is afebrile, but has tachycardia, hyperventilation, and hypotension. No cardiac
murmurs are heard on auscultation. Emergent coronary angiography shows a thrombotic occlusion of
the left circumflex artery and areas of 50% to 70% narrowing in the proximal circumflex and anterior
descending arteries. Which of the following complications of this disease is most likely to occur within 1
hour of these events?
1- Myocardial rupture
2- Thromboembolism
3- [Y]Ventricular fibrillation
4- Pericarditis
44- A 68-year-old man has had progressive dyspnea for the past year. On physical examination,
extensive rales are heard in all lung fields. An echocardiogram shows that the left ventricular wall is
markedly hypertrophied. A chest radiograph shows pulmonary edema and a prominent left-sided heart
shadow. Which of the following conditions has most likely produced these findings?
1- Centrilobular emphysema
2- Tricuspid valve regurgitation
3- Chronic alcoholism
4- [Y] Systemic hypertension
45-A 12-year-old boy is taken to the physician because he has had increasing abdominal distention and
pain for the past 3 days. Physical examination shows lower abdominal tenderness, and the abdomen is
tympanitic with reduced bowel sounds. An abdominal CT scan shows a 7-cm mass involving the region
of the ileocecal valve. Surgery is performed to remove the mass. Histologic examination of the mass
shows sheets of intermediate-sized lymphoid cells, with nuclei having coarse chromatin, several
nucleoli, and many mitoses. A bone marrow biopsy sample is negative for this cell population.
Cytogenetic analysis of the cells from the mass shows a t(8;14) karyotype. Flow cytometric analysis
reveals 40% of the cells are in S phase. The tumor shrinks dramatically in size after a course of
chemotherapy. Which of the following is the most likely diagnosis?
1- Diffuse large B-cell lymphoma
2- Follicular lymphoma
3- Acute lymphoblastic leukemia
4- [Y] Burkitt lymphoma
46- A 9-year-old boy living in Uganda has had increasing pain and swelling on the right side of his face
over the past 8 months. On physical examination, there is a large, nontender mass involving the
mandible, which deforms the right side of his face. There is no lymphadenopathy and no splenomegaly,
and he is afebrile. A biopsy of the mass is performed. Microscopically, the specimen is composed of
intermediate-sized lymphocytes with a high mitotic rate. A chromosome analysis shows a 46,XY,t(8;14)
karyotype in these cells. The hemoglobin concentration is 13.2 g/dL, platelet count is 272,000/mm3 ,
and WBC count is 5820/mm3. Infection with which of the following is most likely to be causally related
to the development of these findings?
1- Cytomegalovirus
2-[Y] Epstein-Barr virus
3- Human papillomavirus
4- Respiratory syncytial virus
47- A 58-year-old man from Nagasaki, Japan, has noted an increasing number of skin lesions for the past
8 months. On examination, there are scaling red-brown patches on all skin surfaces. He also has
generalized lymphadenopathy and hepatosplenomegaly. Laboratory studies show hemoglobin, 9.7 g/dL;
hematocrit, 31%; MCV, 89 µm3 ; platelet count, 177,000/mm3 ; and WBC count, 18,940/mm3 with
differential count of 35 segmented neutrophils, 2 band neutrophils, 58 lymphocytes, and 5 monocytes.
His serum calcium is 11.5 mg/dL. Examination of his peripheral blood smear shows multilobated
“cloverleaf” cells. Despite aggressive chemotherapy, his condition worsens with development of
paresthesias along with erythematous plaques and red-brown nodules on his skin. Which of the
following infectious agents most likely caused his illness?
1- Cytomegalovirus
2- Epstein-Barr virus (EBV)
3- [Y] HTLV-1
4- Rochalimaea henselae
48- A 76-year-old woman notices that small, pinpoint-to-blotchy areas of superficial hemorrhage have
appeared on her gums and on the skin of her arms and legs over the past 3 weeks. On physical
examination, she is afebrile and has no organomegaly. Laboratory studies show a normal prothrombin
time and partial thromboplastin time. CBC shows hemoglobin of 12.7 g/dL, hematocrit of 37.2%, MCV of
80 µm3 , platelet count of 276,000/mm3 , and WBC count of 5600/mm3. Platelet function studies and
fibrinogen level are normal, and no fibrin split products are detectable. Which of the following
conditions best explains these findings
1- Meningococcemia
2- Metastatic carcinoma
3- Macronodular cirrhosis
4- [Y] Vitamin C deficiency
49- A 23-year-old African-American man with a history since early childhood of severe anemia requiring
many transfusions has nonhealing leg ulcers and recurrent periods of abdominal and chest pain. These
signs and symptoms are most likely to be associated with which of the following laboratory
abnormalities?
1- Decreased erythropoietin
2- Increased erythrocyte osmotic fragility
3- [Y]Sickle cells on peripheral blood smear
4- Teardrop-shaped cells
50- A 9-year-old girl is diagnosed with acute rheumatic fever. Instead of recovering as expected, her
condition worsens, and she dies. Which of the following is the most likely cause of death?
1- Central nervous system involvement
2- Endocarditis
3- Streptococcal sepsis
4- [Y]Myocarditis
51- A previously healthy 67-year-old man presents to the emergency room with numbness of his left leg.
Temperature and blood pressure are normal. Physical examination shows pallor and a cool left leg with
absence of distal pulse. An ECG reveals no abnormalities. An arteriogram demonstrates a markedly
dilated abdominal aorta and occlusion of the left popliteal artery. The blockage is removed surgically,
and the patient recovers. Which of the following is the most likely source of the arterial
thromboembolus in this patient?
1- Deep venous thrombosis
2- Left ventricular mural thrombus
3- Nonbacterial endocarditis
4- Paradoxical emboli
5- [Y]Thrombus from an atheromatous aorta
52- A 45-year-old black man undergoes renal biopsy for evaluation of chronic renal failure. The patient
has a 60-pack-year history of smoking. Physical examination reveals a blood pressure of 190/120 mm
Hg. A renal biopsy shows thickening of small arteries and arterioles, as well as edematous intimal
expansion and fibrinoid necrosis. The Congo red stain is negative. Laboratory studies show hemoglobin
is 10.2 g/dL and serum cholesterol is 250 mg/dL. BUN and serum creatinine are 42 and 5.5 mg/dL,
respectively. Which of the following is the most likely cause of renal failure in this patient?
1- Amyloid nephropathy
2- Chronic pyelonephritis
3- [Y]Malignant hypertension
4- Polyarteritis nodosa
5- Proliferative glomerulonephritis
53- A 60-year-old man presents with dizziness, nausea, and severe shortness of breath of several
months’ duration. Physical examination shows hepatomegaly, ascites, and anasarca. His blood pressure
is 200/115 mm Hg. An X-ray film of the chest demonstrates cardiomegaly and mild pulmonary edema.
Although different mechanisms may have contributed to thepathogenesis of hypertension in this
patient, the common end result for all of them is which of the following?
1- Arterial cystic medial necrosis
2- Decreased plasma oncotic pressure
3- Generalized vasodilation
4- [Y]Increased peripheral vascular resistance
5- Increased vascular permeability
54- A 6-year-old girl presents with a 2-week history of a skin rash over her buttocks and legs and joint
pain. The parents report seeing blood in the urine. Physical examination reveals palpable purpuric skin
lesions and markedly swollen knees. The results of laboratory studies reveal abnormally high
erythrocyte sedimentation rate (30 mm/h), BUN of 25 mg/dL, and serum creatinine of 3 mg/dL.
Urinalysis demonstrates RBCs and RBC casts. The stool guaiac test is positive. Biopsy of lesional skin
reveals deposits of IgA in the walls of small blood vessels. Which of the following is the most likely
diagnosis?
1- [Y]Henoch-Schönlein purpura
2- Hypersensitivity vasculitis
3- Kawasaki disease
4- Polyarteritis nodosa
5- Poststreptococcal glomerulonephritis
55- A 10-year-old boy suffers head trauma and lies unconscious for 2 weeks. He is now intubated. His
temperature rises to 38.7°C (103°F), and oxygenation becomes more difficult. A chest X-ray reveals a
pleural effusion and multiple abscesses in the lung parenchyma. Which of the following microorganisms
is the most likely cause of this pulmonary infection?
1- Legionella pneumophila
2- Mycoplasma pneumoniae
3- Pneumocystis carinii
4- [Y]Staphylococcus aureus
5- Streptococcus pneumoniae
56- A 40-year-old woman with leukemia is treated with chemotherapy. During treatment she develops
increasing cough and shortness of breath. A chest X-ray shows diffuse lung infiltrates. Sputum cultures
are negative, and the patient does not respond to routine antibiotic therapy. An open lung biopsy is
diagnosed by the pathologist as viral pneumonia. Which of the following histopathologic findings would
be expected in the lungs of this patient?
1- Clusters of epithelioid macrophages
2- Confluent areas of caseous necrosis
3- Fibrous scarring of lung parenchyma
4- [Y]Hyaline membranes and interstitial inflammation
5- Sheets of bacilli-filled macrophages
57- A 50-year-old woman presents with a 4-week history of fever, shortness of breath, and dry cough.
She reports that her chest feels “tight.” The patient is a pigeon fancier. Blood tests show leukocytosis
and neutrophilia, an elevated erythrocyte sedimentation rate, and increased levels of immunoglobulins
and C-reactive protein. A lung biopsy reveals poorly formed granulomas composed of epithelioid
macrophages and multinucleated giant cells. Which of the following is the appropriate diagnosis?
1- Actinomycosis
2- Goodpasture syndrome
3- [Y]Hypersensitivity pneumonitis
4- Nocardiosis
5- Wegener granulomatosis
58- A 55-year-old man is admitted to the hospital with increasing shortness of breath and dry cough for
the past few years. He smokes 1.5 packs of cigarettes and drinks about four bottles of beer a day. He is
constantly “gasping for air” and now walks with difficulty because he becomes breathless after only a
few steps. Prolonged expiration with wheezing is noted. Physical examination shows a barrel chest,
hyperresonance on percussion, and clubbing of the digits. The patient’s face is puffy and red, and he has
pitting edema of the legs. A chest X-ray discloses hyperinflation, flattening of the diaphragm, and
increased retrosternal air space. Which of the following is the appropriate diagnosis?
1-Asthma
2- Chronic bronchitis
3-[Y]Emphysema
4- Hypersensitivity pneumonitis
5- Usual interstitial pneumonia
59- An 80-year-old man with long-standing diabetes and systemic hypertension dies of congestive heart
failure. The luminal surface of the abdominal aorta is shown in the image N1. Which of the following
pathologic changes would you expect to see on microscopic examination?
1- Acute inflammation of the vessel wall
2- Bacterial colonies in the vessel wall
3- Cystic medial necrosis
4- [Y]Lipid deposition and smooth muscle cell hyperplasia
5- Obliterative endarteritis of the vasa vasorum
60- A 45-year-old man presents with pain in the legs upon exercise and destruction of the tips of his
fingers. He has an 80-packyear history of smoking. Laboratory values include hemoglobin of 16 g/dL,
WBC of 8,500/μL, serum cholesterol of 220 mg/dL, fasting blood sugar of 90 mg/dL, and negative tests
for antinuclear antibodies. Biopsy of the affected area (shown in the image N2) reveals intraluminal
thrombi in medium-sized arteries and inflammation extending from arteries to neighboring veins and
nerves. What is the appropriate diagnosis?
1- [Y]Buerger disease
2- Churg-Strauss disease
3- Kawasaki disease
4- Polyarteritis nodosa
5- Takayasu arteritis
61- A 45-year-old man is brought to the emergency room with rapid pulse and cold and clammy skin.
Blood pressure is 90/50 mm Hg. An X-ray film of the chest demonstrates dilation of the ascending aorta.
Cardiac auscultation reveals a diastolic murmur in the aortic region. Laboratory studies show that serum
cholesterol is 160 mg/dL, hematocrit is 35%, and hemoglobin is 13.6 g/dL. The fluorescent Treponema
antibody test is positive. The patient suddenly becomes hypotensive and dies. The luminal surface of the
ascending aorta at autopsy is shown in the image N3. Which of the following was most likely involved in
the pathogenesis of this aortic lesion?
1- Arterial wall defect due to diabetes
2- Atherosclerosis
3- Congenital defect of the arterial wall
4- Cystic medial necrosis
5- [Y]Endarteritis of the vasa vasorum
62- A 33-year-old man with AIDS presents with multiple, purplecolored skin nodules on his hands and
feet. The lesions vary in size from 1 mm to 1 cm in diameter. Biopsy of lesional skin is shown in the
image N4. Which of the following viruses is implicated in the pathogenesis of this patient’s skin
neoplasm?
1- Cytomegalovirus
2- Human herpesvirus-6
3- [Y]Human herpesvirus-8
4- Human immunodeficiency virus
5- Human papillomavirus
63- A 70-year-old woman complains of a throbbing unilateral headache and vision problems. She reports
weight loss and mandibular pain while eating. The patient also has a history of recurrent bouts of fever
accompanied by malaise and muscle aches. Physical examination reveals nodular enlargement of the
temporal artery with pain on palpation. A biopsy is obtained (shown in the image N5). What is the
appropriate diagnosis?
1- [Y]Giant cell arteritis
2- Hypersensitivity angiitis
3- Kawasaki disease
4- Polyarteritis nodosa
5- Wegener granulomatosis
64- A 60-year-old woman with a 30-pack-year history of smoking and a 10-year history of emphysema
expires of congestive heart failure. There is no evidence of coronary artery disease or valvular heart
disease. The heart at autopsy is shown in the image N6. Which of the following is the most likely cause
of right ventricular hypertrophy?
1- Endocardial fibroelastosis
2- Essential hypertension
3- [Y]Pulmonary hypertension
4- Pulmonary stenosis
5- Systemic hypertension
65- A 50-year-old man with adenocarcinoma of the pancreas is brought to the emergency room in a
comatose state. A CT scan of the brain is consistent with a recent infarct in the left temporal lobe. Blood
cultures are negative. The patient never regains consciousness and expires 2 days later. The heart at
autopsy is shown in the image N7. Which of the following is the most likely underlying cause of stroke in
this patient?
1- Calcific aortic stenosis
2- Carcinoid heart disease
3- Cardiac metastases
4- [Y]Nonbacterial thrombotic endocarditis
5- Subacute bacterial endocarditis
66- A 50-year-old man underwent heart transplantation for low output heart failure that was
unresponsive to medical treatment. The affected heart at autopsy is shown in the image N8. It weighs
950 g (normal up to 350 g) and shows no evidence of coronary artery atherosclerosis. Histologically, the
myocardium demonstrates hypertrophic myocytes and foci of myocardial fibrosis but no evidence of
inflammation or myofiber disarray. Which of the following is the most likely diagnosis?
1- Cardiac amyloidosis
2- [Y]Dilated cardiomyopathy
3- Hypertrophic cardiomyopathy
4- Restrictive cardiomyopathy
5- Ventricular aneurysm
67- A 40-year-old woman presents with dyspnea, heart palpitations, and pitting edema. She was seen
for flu-like symptoms and prominent muscle pain 3 weeks ago. Physical examination shows tachycardia
and irregular heart beats. A chest X-ray reveals cardiomegaly and pulmonary edema. The patient
subsequently dies of cardiorespiratory failure. Histopathology of the heart muscle at autopsy is shown in
the image N9. What is the appropriate diagnosis?
1- Acute bacterial endocarditis
2- Acute myocardial infarction
3- Endocardial fibroelastosis
4- Rheumatic heart disease
5- [Y]Viral myocarditis
68- A 53-year-old woman presents with a 6-week history of fever, fatigue, and weight loss. Her
temperature is 38.7°C (103°F), pulse rate 110 per minute, and blood pressure 140/80 mm Hg. Physical
examination reveals petechiae and clubbing of the fingers. The patient develops mental status changes,
suffers a massive stroke, and expires. The mitral valve is examined at autopsy (shown in the image N10).
Which of the following is the appropriate pathologic diagnosis?
1- [Y]Bacterial endocarditis
2- Carcinoid heart disease
3- Libman-Sacks endocarditis
4- Marantic endocarditis
5- Mitral valve prolapse
69- A 36-year-old man with AIDS presents with fever, dry cough, and dyspnea. A chest X-ray shows
bilateral and diffuse infiltrates. Laboratory studies reveal a CD4+ cell count of less than 50/μL. A lung
biopsy discloses a chronic interstitial pneumonitis and an intra-alveolar foamy exudate. A silver stain of a
bronchoalveolar lavage is shown in the image N11. Which of the following organisms is the most likely
pathogen responsible for these pulmonary findings?
1- Cryptococcus neoformans
2- Cytomegalovirus
3- Histoplasma capsulatum
4- Mycoplasma pneumoniae
5- [Y]Pneumocystis jiroveci
70- A 22-year-old man who is being treated for leukemia complains of shortness of breath on exertion,
pleuritic chest pain, and a low-grade fever. Physical examination reveals crackles in both lung bases and
clubbing of the fingers. Bronchoalveolar lavage demonstrates PAS-positive material and elevated levels
of surfactant proteins. An open-lung biopsy is shown in the image N12. Which of the following is the
most likely diagnosis?
1- [Y]Alveolar proteinosis
2- Eosinophilic pneumonia
3- Goodpasture syndrome
4- Hyaline membrane disease
5- Radiation pneumonitis
71- A 10-year-old boy dies following a severe episode of status asthmaticus. Histologic examination of
the lung at autopsy is shown in the image N13. Which of the following best describes the pathologic
features evident in this autopsy specimen?
1- Destruction of the walls of airspaces without fibrosis
2- Hyaline membranes and interstitial edema
3- Interstitial fibrosis of the lung parenchyma
4- Intra-alveolar hemorrhage and exudates containing neutrophils
5- [Y]Smooth muscle hyperplasia and basement membrane thickening
72- A 25-year-old black woman presents with a 3-month history of cough and shortness of breath on
exertion. A chest X-ray reveals enlargement of hilar and mediastinal lymph nodes. Laboratory studies
show elevated serum levels of angiotensinconverting enzyme and an increase in 24-hour urine calcium
excretion. An open-lung biopsy is shown in the image N14. Stains for microorganisms in the tissue are
negative. Which of the following is the most likely diagnosis?
1- Goodpasture syndrome
2- [Y]Sarcoidosis
3- Silicosis
4- Tuberculosis
5- Wegener granulomatosis
73- A 23-year-old man complains of nasal obstruction, serosanguinous discharge, cough, and bloody
sputum. A chest X-ray shows cavitated lesions and multiple nodules over both lung fields. A CT scan
discloses obliteration of several maxillary sinuses. Urinalysis reveals hematuria and RBC casts.
Laboratory studies demonstrate anemia and elevated serum levels of C-ANCA. An open-lung biopsy is
shown in the image N15. Which of the following is the most likely diagnosis?
1- Adenocarcinoma of lung
2- Churg-Strauss syndrome
3- Necrotizing sarcoid granulomatosis
4- Tuberculosis
5- [Y]Wegener granulomatosis
74- A 10-year-old black girl is brought to the emergency room. She complains of severe pain in her chest,
abdomen, and bones. Physical examination reveals jaundice and anemia. Her parents state that she has
been anemic since birth. A CBC shows normocytic anemia with marked poikilocytosis. A peripheral blood
smear is shown in the image N16. Hemoglobin electrophoresis demonstrates hemoglobin S. This child’s
chest and bone pain is most likely caused by which of the following mechanisms?
1- Amyloidosis
2- Coagulopathy
3- Infection
4- [Y]Ischemia
5- Vasculitis
75- A 32-year-old man presents with mild fever and increasing fatigue. He is an immigrant from Russia
and worked in a benzene factory. Physical examination does not reveal lymphadenopathy or
splenomegaly, but petechial skin lesions are noted. A CBC demonstrates severe pancytopenia, with
normocytic red cell indices. A bone marrow biopsy is shown in the image N17. Which of the following is
the most likely underlying mechanism in the development of this patient’s anemia?
1- [Y]Damage to stem cells
2- Decreased erythropoietin production by the kidneys
3- Folate deficiency
4- Impaired globin chain synthesis
5- Neoplastic proliferation of committed stem cells
76- A 40-year-old woman complains of fatigue and nausea of 3 months in duration. Physical examination
reveals numerous pustules on the face, as well as splenomegaly and hepatomegaly. Laboratory studies
show hemoglobin of 6.3 g/dL and platelets of 50,000/mL. A peripheral smear shows malignant cells with
Auer rods (arrow) N18. The patient develops diffuse purpura, bleeding from the gums, and laboratory
features of disseminated intravascular coagulation (DIC). Which of the following is the appropriate
diagnosis?
1- Acute lymphoblastic leukemia
2- Acute megakaryocytic leukemia
3- [Y]Acute promyelocytic leukemia
4- Chronic myelogenous leukemia
5- Monocytic leukemia
77- A 40-year-old woman complains of fatigue and nausea of 3 months in duration. Physical examination
reveals numerous pustules on the face, as well as splenomegaly and hepatomegaly. Laboratory studies
show hemoglobin of 6.3 g/dL and platelets of 50,000/mL. A peripheral smear shows malignant cells with
Auer rods (arrow) N18. The patient develops diffuse purpura, bleeding from the gums, and laboratory
features of disseminated intravascular coagulation (DIC). Cytogenetic studies in malignant cells from this
patient demonstrate a chromosomal translocation. Which of the following genes is most likely found at
the translocation site?
1- abl
2- bcl-1
3- bcl-2
4- myc
5- [Y]Retinoic acid receptor
78- A 27-year-old man presents with an 8-week history of fevers, chills, pruritis, and night sweats. Two
months ago, he experienced a flu-like illness. A nagging cough with occasional hemoptysis persisted for
several weeks following resolution of his other symptoms. Physical examination reveals moderately
enlarged, firm, nontender lymph nodes located in the right supraclavicular region. A lymph node biopsy
is shown in the image N19. What is the appropriate diagnosis?
1- Acute myelogenous leukemia
2- Burkitt lymphoma
3- [Y]Hodgkin lymphoma
4- Infectious mononucleosis
5- Lymphoblastic lymphoma
79- An otherwise healthy 44-year-old man with no prior medical history has had increasing back pain
and right hip pain for the past decade. The pain is worse at the end of the day. On physical examination
he has bony enlargement of the distal interphalangeal joints. A radiograph of the spine reveals the
presence of prominent osteophytes involving the vertebral bodies. There is sclerosis with narrowing of
the joint space at the right acetabulum seen on a radiograph of the pelvis. Which of the following
diseases is he most likely to have?
1- Gout
2- Rheumatoid arthritis
3- [Y]Osteoarthritis
4- Pseudogout
80- An 80-year-old woman has had no major medical problems, but she has never been physically active
for most of her life. One day she falls out of bed and immediately notes a sharp pain in her left hip. She
is subsequently unable to ambulate without severe pain. Radiographs show not only a fracture of the
left femoral head, but also a compressed fracture of T10. Which of the following conditions is she most
likely to have?
1- Vitamin D deficiency
2- Osteomyelitis
3- Metastatic cacncer
4- [Y]Osteoporosis
81- A 51-year-old man has noted constant, dull right hip pain for the past 3 months. On physical
examination he has diminished range of motion of the right hip. A radiograph reveals a 10 x 13 cm mass
involving the right ischium of the pelvis. The mass has irregular borders and there are extensive areas of
bony destruction along with some scattered calcifications. The lesion is resected, and grossly the mass
has a bluish-white cut surface. Which of the following is the most likely diagnosis?
1- Osteochondroma
2- Osteoid osteoma
3- Osteoblastoma
4- [Y]Chondrosarcoma
82- A 58-year-old man has the sudden onset of severe pain in his left great toe. There is no history of
trauma. On examination there is edema with erythema and pain on movement of the left 1st
metatarsophalangeal joint, but there is no overlying skin ulceration. A joint aspirate is performed and on
microscopic examination reveals numerous neutrophils and needle-shaped crystals. Over the next 3
weeks, he has two more similar episodes. On physical examination between these attacks, there is
minimal loss of joint mobility. Which of the following laboratory test findings is most characteristic for
his underlying disease process?
1- Hyperglycemia
2- Hypercalcemia
3- [Y]Hyperuricemia
4- Positive antinucelar antibody
83- An 11-year-old boy has pain in his left leg that has persisted for 3 weeks. On physical examination his
temperature is 37.9°C. A radiograph of the leg reveals a mass in the diaphyseal region of the left femur
with overlying cortical erosion and soft tissue extension. A bone biopsy is performed and the lesion on
microscopic examination shows numerous small round blue cells. Karyotypic analysis of these cells
shows t(11;22). Which of the following neoplasms is he most likely to have?
1- [Y]Ewing sarcoma
2- Medulloblastoma
3- Chrondrosarcoma
4- Osteochondroma
84- A 14-year-old West African man has a history of multiple episodes of sudden onset of severe
abdominal pain and back pain lasting for hours. Each time this happens, his peripheral blood smear
demonstrates numerous sickled erythrocytes. A hemoglobin electrophoresis shows 94% Hgb S, 5% Hgb
F, and 1% Hgb A2. He now has a painful right hip that is tender to palpation. A radiograph reveals
irregular bony destruction of the femoral head. Which of the following infectious agents is most likely
responsible for his findings?
1- Yersenia pestis
2- Candida
3- [Y]Salmonella
4- Clostridium
85- A 16-year-old boy has noted pain in his left knee after each hockey practice session for the past
month. On examination there is tenderness to palpation of his left knee, with reduced range of motion.
A plain film radiograph of the left leg reveals a mass of the proximal tibial metaphysis that erodes bone
cortex, lifting up the periosteum where reactive new bone is apparent. The mass does not extend into
the epiphyseal region. A bone biopsy is performed and microscopic examination shows atypical,
elongated cells with hyperchromatic nuclei in an osteoid stroma. Which of the following neoplasms is he
most likely to have?
1- Ewing sarcoma
2- [Y]Osteosarcoma
3- Multiple myeloma
4- Seminoma
86- A 63-year-old woman has the sudden onset of 'knife-like' pain in the chest radiating to the back. She
has been previously healthy except for a history of poorly controlled hypertension. She is transported to
the hospital and on arrival she has a heart rate of 90/minute, respirations 20/minute, temperature
36.8°C, and blood pressure 150/100 mm Hg. No murmurs, rubs, or gallops are audible. A chest
radiograph reveals a widened mediastinum. Laboratory findings include a total serum creatine kinase of
55 U/L, creatinine 0.9 mg/dL, and glucose 123 mg/dL. Which of the following is the most likely
diagnosis?
1- Pericarditis
2- [Y]Aortic dissection
3- Myocardial infarction
4- Gastric ulcer rupture
87- A 45-year-old man was rushed to the hospital following the sudden onset of an episode of crushing
substernal chest pain. He receives advanced life support measures. An EKG shows changes consistent
with a large transmural anterolateral area of infarction involving wall of the left ventricle. He develops
cardiogenic shock. Which of the following microscopic findings is most likely to be present in this area 4
days following the onset of his chest pain?
1- Fibroblasts and collagen deposition
2- Granulomatous inflammation
3- Perivascular lymphocytic infiltrates
4- [Y] Myofiber necrosis with neutrophils
88- A 19-year-old woman has had increasing malaise for the past 5 months. On physical examination she
has a cardiac murmur characterized by a mid systolic click. An echocardiogram demonstrates mitral
insufficiency with upward displacement of one leaflet. There is aortic root dilation to 4 cm. She has a
dislocated right ocular crystalline lens. A year later she dies suddenly and unexpectedly. The medical
examiner finds a prolapsed mitral valve with elongation, thinning, and rupture of chordae tendineae. A
mutation involving which of the following genes is most likely to be present in this patient?
1- CFTR
2- Beta myosin
3- Spectrin
4- [Y]Fibrillin
89- A 72-year-old woman has had no major illnesses throughout her life. She has had 3 syncopal
episodes during the past 2 weeks. Over the past 2 days she has developed shortness of breath and a
cough with production of frothy white sputum. On physical examination she is afebrile. Her blood
pressure is 135/90 mm Hg. She has no peripheral edema. A chest radiograph reveals a prominent left
heart border in the region of the left ventricle, but the other chambers do not appear to be prominent.
There is marked pulmonary edema. Laboratory studies show a total serum cholesterol of 170 mg/dL.
Which of the following is the most likely diagnosis?
1- Acute rheumatic fever
2- Mitral valve insufficiency
3- [Y]Calcific aortic stenosis
4- Infective endocarditis
90- A 17-year-old girl is short in stature for her age. She has not yet shown any changes of puberty. On
physical examination her vital signs include T 37°C, RR 18/minute, P 75/minute, and BP 165/85 mm Hg.
She has a continuous murmur heard over both the front of the chest as well as her back. Her lower
extremities are cool with diminished pulses and poor capillary filling. She has a webbed neck. A chest
radiograph reveals a prominent left heart border, no edema or effusions, and rib notching. Which of the
following cardiovascular abnormalities is she most likely to have?
1- Shortening and thickening of chordae tendineae of the mitral valve
2- [Y]Narrowing of the aorta past the ductus arteriosus
3- Supravalvular narrowing in the aortic root
4- Lack of development of the spiral septum and partial absence of conus musculature
91-A 65-year-old man has sudden onset of severe abdominal pain that has persisted for 3 hours.
Physical examination reveals his temperature is 37°C, heart rate 110/minute, respirations 25/minute,
and blood pressure 145/100 mmHg. He has diminished pulses in the lower extremities. There is a
pulsatile abdominal mass. His serum creatine kinase is not elevated. He has had fasting blood glucose
measurements in the range of 140 to 180 mg/dL for over 20 years. Which of the following conditions is
he most likely to have?
1- Superior mesenteric artery thrombosis
2- [Y]Atherosclerotic aortic aneurysm
3- Polyarteritis nodosa
4- Monckeberg's medial calcific sclerosis
92- 49-year-old woman had atrial fibrillation that was poorly controlled, even with amiodarone therapy.
She suffered a 'stroke' and died. At autopsy, her 600 gm heart is noted to have a mitral valve with partial
fusion of the leaflets along with thickening and shortening of the chordae tendineae. There is an
enlarged left atrium filled with mural thrombus. Which of the following underlying causes of death is she
most likely to have?
1- Systemic lupus erythematosus
2- Marantic endocarditis
3- [Y] Rheumatic heart disease
4- Cardiac amyloidosis
93- A 27-year-old G2 P1 woman has a screening ultrasound performed at 18 weeks gestation. The fetus
is appropriate in size for 18 weeks. The fetal kidneys, liver, head, and extremities appear normal.
However, the fetus has a heart with a membranous ventricular septal defect, overriding aorta, and
marked pulmonic atresia. If the baby were to be liveborn, which of the following characteristics on
physical examination would most likely result from these cardiac defects?
1- Systemic hypertension
2- Weak lower extremity pulses
3- [Y]Cyanosis
4- Telangiectasias
94- A 44-year-old woman dies as a consequence of a 'stroke'. At autopsy, she is found to have a large
right basal ganglia hemorrhage. She has an enlarged 550 gm heart with predominantly left ventricular
hypertrophy. Her kidneys are small, about 80 gm each, with cortical scarring, and microscopically they
demonstrate small renal arterioles that have luminal narrowing from concentric intimal thickening.
Which of the following is the most likely condition associated with her findings?
1- Autosomal dominant polycystic kidney disease
2- Diabetes mellitus, type II
3- Hypercholesterolemia
4- [Y] Hypertensive emergency
95- A 2-year-old child has had failure to thrive for a year, becoming increasingly listless. On examination
she is found to have a soft, rumbling systolic ejection murmur. An echocardiogram reveals a large
membranous ventricular septal defect. Which of the following complications is she most likely to
experience as an adult 2 decades later if this lesion remains untreated?
1- Rib notching
2- Mitral valve prolapse
3- [Y]Pulmonary hypertension
4- Cardiac tamponade
96- A 66-year-old man has had congestive heart failure with increasing pulmonary congestion and
edema for the past year. He had been previously healthy all his life with no major illnesses. On physical
examination his blood pressure is 125/85 mm Hg and he is afebrile. A systolic ejection click is
auscultated. A chest x-ray shows cardiomegaly with a prominent left heart border and pulmonary
edema. Laboratory studies show a serum glucose of 95 mg/dL and total serum cholesterol of 175 mg/dL.
His serum creatine kinase is not elevated. Which of the following underlying diseases is he most likely to
have?
1- Alcoholic cardiomyopathy
2- Tricuspid valve endocarditis
3- Aortic dissection
4- [Y] Calcified bicuspid aortic valve
97- A 69-year-old woman with a 7 kg weight loss over the past 6 months now has developed painless
jaundice over the past 2 weeks. On physical examination she is afebrile. An abdominal CT scan shows a
large mass involving the head of the pancreas, along with widespread nodules in the liver. Nodules are
seen in both lungs by chest radiograph. Which of the following cardiac abnormalities is she most likely to
develop?
1- [Y]Non-bacterial thrombotic endocarditis
2- Endocardial fibrosis
3- Acute myocardial infarction
4- Dilated cardiomyopathy
98- A 51-year-old woman has had several syncopal episodes over the past year. Each episode is
characterized by sudden but brief loss of consciousness. She reports no chest pain. On physical
examination her vital signs show T 36.9°C, P 80/minute, RR 16/minute, and BP 110/75 mm Hg. She has
no pedal edema. On brain MR imaging there is a 1.5 cm cystic area in the left parietal cortex. A chest
radiograph shows no cardiac enlargement, and her lung fields are normal. Her serum total cholesterol is
165 mg/dL. Which of the following cardiac lesions is she most likely to have?
1- Cardiac amyloidosis
2- [Y]Left atrial myxoma
3- Tuberculous pericarditis
4- Mitral valve prolapse
99- A 58-year-old man develops deep venous thrombosis during a hospitalization for prostatectomy. He
exhibits decreased mental status 10 days postoperatively, with right hemiplegia. A CT scan of the head
shows an acute cerebral infarction in the distribution of the left middle cerebral artery. A chest
radiograph reveals cardiac enlargement and prominence of the main pulmonary arteries consistent with
pulmonary hypertension. Laboratory studies show a serum troponin I of <0.4 ng/mL. Which of the
following lesions is most likely to be present on echocardiography?
1- Coarctation of the aorta
2- Tetralogy of Fallot
3- [Y]Atrial septal defect
4- Dextrocardia
100- A 25-year-old man dies suddenly and unexpectedly while at a nightclub late one evening. The
medical examiner performs an autopsy. There is no evidence for trauma on external examination of the
body. There are no gross pathologic findings of internal organs. Postmortem toxicologic findings are
significant for high blood levels of cocaine and its metabolite benzoylecgonine. Which of the following is
the most likely histopathologic finding involving his heart?
1- [Y]Contraction band necrosis
2- Lymphocytic myocarditis
3- Myofiber disarray
4- Coronary thrombosis
101- A 31-year-old woman, who has two healthy children, notes that she has had no menstrual periods
for the past 6 months, but she is not pregnant and takes no medications. Within the past week, she has
noted some milk production from her breasts. She has been bothered by headaches for the past 3
months. After nearly hitting a bus while changing lanes driving her vehicle, she is concerned with her
vision. An optometrist finds her lateral vision to be reduced. On physical examination she is afebrile and
normotensive. Which of the following laboratory test findings is most likely to be present in this
woman?
1- Increased serum cortisol
2- Lack of growth hormone suppression
3- [Y]Hyperprolactinemia
4- Abnormal glucose tolerance test
102- A 28-year-old woman has had difficulty concentrating at work for the past month. She is constantly
getting up and walking around to visit co-workers. She complains that the work area is too hot. She
seems nervous and often spills her coffee. She has been eating more but has lost 5 kg in the past 2
months. On physical examination her temperature is 37.5°C, pulse 101/minute, respiratory rate
22/minute, and blood pressure 145/85 mm Hg. Which of the following laboratory findings is most likely
to be present in this woman?
1- Decreased catecholamines
2- Decreased iodine uptake
3- [Y] Decreased TSH
4- Increased ACTH
103- A 19-year-old previously healthy woman has had a mild pharyngitis followed by a high fever over
the past 24 hours. When seen in the emergency room, her skin now shows extensive areas of purpura.
Vital signs include temperature 39°C, pulse rate 102/minute, respiratory rate 21/minute, and blood
pressure 80/55 mm Hg. Laboratory studies show a serum sodium of 115 mmol/L, potassium 5.3 mmol/L,
chloride 92 mmol/L, CO2 22 mmol/L, glucose 42 mg/dL, and creatinine 1.1 mg/dL. Which of the
following is the most likely diagnosis?
1- [Y] Meningococcemia
2- Hemochromatosis
3- Idiopathic adrenalitis
4- Reactive systemic amyloidosis
104- A 40-year-old woman has noted enlargement of her anterior neck region over the past 8 months.
On physical examination her vital signs include T 36.8°C, P 64/minute, RR 16/minute, and BP 155/105
mm Hg. There is diffuse, symmetrical thyroid enlargement without tenderness. A chest radiograph is
normal. Fine needle aspiration of the thyroid yields cells consistent with a neoplasm. Laboratory studies
show that she is euthyroid, but her serum ionized calcium is elevated. She is taken to surgery and frozen
sections of several thyroid masses show a malignant neoplasm composed of polygonal cells in nests. A
thyroidectomy is performed. Immunostaining for calcitonin of the permanent sections is positive, and
the neoplasm has an amyloid stroma with Congo red staining. Which of the following neoplasms is she
most likely to have?
1- Anaplastic carcinoma
2- [Y]Medullary carcinoma
3- Papillary thyroid carcinoma
4- Anaplastic carcinoma
105- A 55-year-old woman has had a 4 kg weight loss over the past 3 months. She exhibits decreased
mentation over the past 10 days. On physical examination she is afebrile and hypotensive. Bilateral
papilledema is noted. A head CT scan shows marked diffuse cerebral edema with effacement of the
lateral ventricles. Laboratory studies show a sodium of 108 mmol/L, potassium 4.0 mmol/L, chloride 83
mmol/L, CO2 14 mmol/L, glucose 82 mg/dL, and creatinine 0.5 mg/dL. Which of the following is most
likely to cause these findings?
1- [Y]Small cell lung carcinoma
2- Blunt head trauma
3- Pituitary macroadenoma
4- Meningitis
106- A 29-year-old primigravida who received no prenatal care has marked vaginal bleeding after the
onset of labor at 38 weeks gestation. Cesarean section is performed and a lacerated low-lying placenta
is removed. She remains hypotensive for 6 hours and requires transfusion of 12 packed RBC units.
Postpartum, she becomes unable to breast-feed the infant. She does not have a resumption of normal
menstrual cycles. She becomes more sluggish and tired. Laboratory findings include hyponatremia,
hyperkalemia, and hypoglycemia. Which of the following pathologic lesions is she most likely to have
had following delivery?
1- Bilateral adrenal hemorrhage
2- [Y] Pituitary necrosis
3- Insulitis
4- Subacute thyroditis
107- A 58-year-old man with a history of diabetes mellitus has noted the presence of bone pain,
especially of his hands, for the past 6 months. On physical examination there is no swelling or redness of
his hands, no joint deformity, but the range of motion is slightly decreased. Laboratory studies show
sodium 139 mmol/L, potassium 4.0 mmol/L, chloride 98 mmol/L, C02 22 mmol/L, glucose 153 mg/dL,
creatinine 7.8 mg/dL, calcium 7.8 mg/dL, phosphorus 5.7 mg/dL, total protein 6.2 g/dL, and albumin 4.0
g/dL. Which of the following conditions is this man most likely to have?
1- Adrenal adenoma
2- Medullary thyroid carcinoma
3- Extra-adrenal pheochromocytoma
4- [Y] Parathyroid hyperplasia
108- A 49-year-old woman has had increasing cold intolerance, weight gain of 4 kg, and sluggishness
over the past two years. A physical examination reveals dry, coarse skin and alopecia of the scalp. Her
thyroid is not palpably enlarged. Her serum TSH is 11.7 mU/L with thyroxine of 2.1 micrograms/dL. A
year ago, anti-thyroglobulin and anti-microsomal autoantibodies were detected at high titer. Which of
the following thyroid diseases is she most likely to have?
1- DeQuervain disease
2- Papillary carcinoma
3- [Y]Hashimoto thyroiditis
4- Graves disease
109- A 48-year-old woman has experienced constant back pain exacerbated by movement over the past
month. She reports increasing weakness over the past 3 months. On physical examination her blood
pressure is 165/110 mm Hg. She is overweight, with a BMI of 28. A radiograph of the spine reveals a
compressed fracture at T10. Laboratory findings include a serum glucose of 155 mg/dL. Which of the
following pathologic lesions is most likely to explain her findings?
1- [Y]Adrenal cortical carcinoma
2- Anaplastic thyroid carcinoma
3- Empty sella syndrome
4- Pheochromocytoma
110- A 41-year-old man has a history of drinking 1 to 2 liters of whisky per day for the past 20 years. He
has had numerous episodes of nausea and vomiting in the past 5 years. He now experiences a bout of
prolonged vomiting, followed by massive hematemesis. On physical examination his vital signs are: T
36.9°C, P 110/min, RR 26/min, and BP 80/40 mm Hg lying down. His heart has a regular rate and rhythm
with no murmurs and his lungs are clear to auscultation. There is no abdominal tenderness or distension
and bowel sounds are present. His stool is negative for occult blood. Which of the following is the most
likely diagnosis?
1-
Hiatal hernia
2- [Y] Esophageal laceration
3- Esophageal pulsion diverticulum
4- Barrett esophagus
111- A 50-year-old man has had persistent nausea for 5 years with occasional vomiting. On physical
examination there are no abnormal findings. He undergoes upper GI endoscopy, and a small area of
gastric fundal mucosa has loss of rugal folds. Biopsies are taken and microscopically reveal
well-differentiated adenocarcinoma confined to the mucosa. An upper GI endoscopy performed 5 years
previously showed a pattern of gastritis and microscopically there was chronic inflammation with the
presence of. Which of the following is the most likely risk factor for his neoplasm?
1- Inherited APC gene mutation
2- [Y]Helicobacter pylori infection
3- Chronic alcohol abuse
4- Use of non-steroidal anti-inflammatory drugs
112- A 38-year-old man has had upper abdominal pain for 3 months. For the past week he has had
nausea. On physical examination a stool sample is positive for occult blood. An upper GI endoscopy
reveals no esophageal lesions, but there is a solitary 2 cm diameter shallow, sharply demarcated
ulceration of the stomach. Which of the following is most characteristic for this lesion?
1- [Y]Antral location
2- Potential for metastasis
3- No need for biopsy
4- Increased gastric acid
113- A 15-year-old boy from Ghana has the acute onset of right upper quadrant abdominal pain.
Abdominal ultrasound reveals a dilated gallbladder with thickened wall and filled with calculi. A
laparoscopic cholecystectomy is performed. The gallbladder is opened to reveal ten multifaceted 0.5 to
1 cm diameter dark, greenish-black gallstones. Which of the following underlying conditions does this
boy most likely have?
1- [Y]Sickle cell anemia
2- Crohn disease
3- Hypercholesterolemia
4- Hyperprolactinemia
114- A 32-year-old woman has a 10 year history of intermittent, bloody diarrhea. She has no other
major medical problems. On physical examination there are no lesions palpable on digital rectal
examination, but a stool sample is positive for occult blood. Colonoscopy reveals a friable, erythematous
mucosa with focal ulceration that extends from the rectum to the mid-transverse colon. Biopsies are
taken and all reveal mucosal acute and chronic inflammation with crypt distortion, occasional crypt
abscesses, and superficial mucosal ulceration. This patient is at greatest risk for development of which of
the following conditions?
1- Acute pancreatitis
2- Diverticulitis
3- [Y] Sclerosing cholangitis
4- Appendicitis
115- A 72-year-old woman notes increasing jaundice and nausea for the past month. On physical
examination she is afebrile, but scleral icterus is present. There is no abdominal pain on palpation. She
has active bowel sounds. A stool sample is negative for occult blood. Laboratory findings include total
protein 6.1 g/dL, albumin 3.3 g/dL, alkaline phosphatase 210 U/L, AST 49 U/L, ALT 40 U/L, total bilirubin
7.2 mg/dL, and direct bilirubin 6.3 mg/dL. Her serum lipase is 50 U/L. Which of the following conditions
is she most likely to have?
1- [Y]Pancreatic adenocarcinoma
2- Cystic fibrosis
3- Primary biliary cholangitis
4- Osteochondroma
116- A 45-year-old man has had a fever and a productive cough for the past 3 days. On physical
examination there is dullness to percussion over the right upper lung. His temperature is 37.9°C. A chest
radiograph reveals right upper lobe consolidation. Laboratory findings include serum total protein of 6.0
g/dL, albumin 2.7 g/dL, AST 185 U/L, ALT 98 U/L, total bilirubin 1.0 mg/dL, alkaline phosphatase 31 U/L,
and prothrombin time 20 sec. An abdominal CT scan shows hepatomegaly with decreased hepatic
attenuation. Which of the following conditions is the most likely underlying cause of death?
1- Alpha-1-antitrypsin deficiency
2- Wilson disease
3- Acute hepatitis C
4- [Y]Diabetes mellitus
117- A 62-year-old man has had anorexia, vomiting, and vague abdominal pain accompanied by weight
loss of 6 kg over the past 2 months. Physical examination reveals supraclavicular non-tender
lymphadenopathy. He becomes progressively cachectic. An abdominal CT scan shows the stomach is
shrunken with the gastric wall thickened to 1 cm and with extensive overlying mucosal erosions.
Multiple masses from 1 to 4 cm in size are scattered within the liver. Which of the following conditions
most likely preceded development of his illness?
1- Acquired immunodeficiency syndrome
2- Hyperglycemia
3- Chronic alcoholism
4- [Y]Pernicious anemia
118- An 8-year-old boy at birth appeared to be a normal term baby, but his neontal course was
complicated by the development of meconium ileus. His sweat chloride and immunoreactive
trypsinogen are both found to be elevated. Throughout childhood he has experienced multiple
increasingly severe bouts of pneumonia with a productive cough, often with Pseudomonas aeruginosa,
and later Burkholderia cepacea, cultured from sputum. He is at greatest risk for development of which
of the following pulmonary abnormalities?
1- Adenocarcinoma
2- [Y]Bronchiectasis
3- Lymphangiectasis
4- Pneumothorax