FUNDAMENTALS OF CLINICAL MEDICINE
BLOCK EXAMINATION VI
VERSION A
MULTIPLE CHOICE; SINGLE BEST ANSWER:
1. Each one of the following statements regarding proteoglycans in articular hyaline
cartilage matrix is true EXCEPT:
A. Are tightly packed into the matrix, pulling water in with them as a result.
E. Are extruded into synovial fluid with weight bearing (loading) and
reabsorbed back into the matrix upon unloading.
C. Provide a swelling pressure, which is critical to maintaining cartilage
function.
D. Have a high density of negative charges, which provide a strong
electrostatic repulsive force when loading drives them closer together.
2. A 42 year old white man presents with a one year history of pain and swelling of
the second and third metacarpal-phalangeal (MCP) joints bilaterally. He has no
other joint symptoms and otherwise feels well. He is an accountant and does not
engage in manual labor. Examination shows bony swelling of these painful joints
and X-rays show changes of osteoarthritis. Which one of the following is the most
likely diagnosis?
A. Primary osteoarthritis
B. Rheumatoid arthritis
C. Gouty arthritis
D, Reiter's syndrome
E. Hemochromatosis
3. Which one of the following is the primary defect in the pathogenesis of a Heberden's node in an 80
year old woman?
A. A mutation in type II collagen
B. Calcium pyrophosphate dihydrate (CPPD) deposition
C. An inflammatory process of the synovium
D. Degeneration of articular cartilage
E. An enthesopathy
4. Each on of the following is an indication for allopurinol rather than uricosuric
(probenecid) therapy in a person with gout EXCEPT:
A. A serum uric acid of 12 mg/dI
B. Tophaceous deposits
C. A history of renal insufficiency and/or stones
5. Hyperuricemia and gout may occur secondary to each one of the following EXCEPT:
A. Renal insufficiency
B. Sickle cell anemia
C. Hemochromatosis
D. Psoriasis
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6. A 22 year old white woman presents with a 24 hour history of pain and swelling
of the right wrist. She also has had chills and fever to 102°. Physical examination
reveals marked swelling, heat, erythema and tenderness of the wrist. Which ONE
of the following is most likely to provide the most specific diagnostic information?
A. Synovial fluid gram stain and culture
B. Synovial fluid examination for crystals
C. Synovial fluid white blood cell count
D. Synovial fluid glucose
E. A serum total hemolytic complement level
7. Which one of the following types of arthritis is most likely to involve the first
carpal-metacarpal joint at the base of the thumb?
A. Rheumatoid arthritis
B. Osteoarthritis
C. Psoriatic arthritis
D. Pseudogout
E. Infectious arthritis
2
8. A 20 year-old African-American woman comes to your office for evaluation of
fever and a rash on her face. Her temperature is 100.8 F. Skin examination reveals
a scaly, erythematous confluent eruption over both cheeks and the bridge of the
nose. There is tenderness over several of the small joints of the hands, and over
the right knee. Appropriate screening laboratory studies for possible lupus should
include:
A. ANA, CBC and UA
B. ANA, CBC and anti-single stranded DNA
C. Anti-double stranded DNA, anti-Sm and anti-RNP
D. CBC, chem 19 and SPEP (Serum protein electrophoresis)
E. CBC, UA and RPR
9. Which ONE of the following tests is specific for SLE:
A. ANA
B. Anti-ssDNA (Anti-single stranded DNA)
C. Anti-Ro (SSA)
D. Anti-Sm
E. Anti-cardiolipin
10. Which of the following autoantibodies is likely to be directly involved in the
pathogenesis of lupus glomerulonephritis:
ANA
B Anti-double stranded DNA
C. Anti-Ro (SSA)
D. Anti-RNP
E. Anti-Sm
11. Hydroxychloroquine sulfate affects the immune system by:
A. cytotoxic effects on leukocytes
B. inhibition of cyclooxygenase
C. neutralization of antibodies
D. impaired cytotoxic T cell activity
E. impaired antigen processing and presentation by macrophages
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12. Which of the following mechanisms does ni play a role in corticosteroid-induced
osteoporosis:
A. increased urinary excretion of calcium
B. reduced intestinal absorption of calcium
C. reduced number of osteoblasts
D. reduced collagen synthesis by osteoblasts
E. diminished levels of parathyroid hormone
13. A 40 year-old man is seen in his physician's office for a 2 week history of swelling,
pain and stiffness in the MCP and PIP joints of the hands, the wrists and the knees.
He has also noticed fevers of up to 100°F and unusual fatigue.
Possible infectious causes of his condition include all of the following EXCEPT:
A hepatitis B
B. rubella
C. mycobacterium tuberculosis
D. parvovirus B19
E. HIV
14. Which of the following is NOT known to participate in the pathogenesis of rheumatoid synovitis?
A. interleukin-1
B. interleukin-6
C. tumor necrosis factor alpha
D. collagenase
E. prostaglandin E2
15. Rheumatoid factors may contribute to joint inflammation by:
A. activating CD4+ T lymphocytes
B. activating osteoblasts
C. suppressing collagen formation
D. interleukin-2 receptor expression on T lymphocytes
E. stimulating the release of prostaglandins from phagocytes
16. All of the following adverse effects may result from administration of methotrexate
in the treatment of rheumatoid arthritis with the EXCEPTION OF:
A. proteinuria
B. neutropenia
C. cirrhosis of the liver
D. hypersensitivity pneumonitis
E. diarrhea
17. Which of the following agents is likely to reduce the toxicity of methotrexate:
A. ethanol
B. aspirin
C. folic acid
D. vitamin B12
E. sulfamethoxazole
18. Which one of the following is typical of drug eruptions?
A. The rash is always maculopapular.
B. Typically occurs within the first 24 hours of initiation of a drug.
C. May begin 7 - 10 days after initiation of a drug.
D. Are always pruritic.
E. Is associated with a decrease in eosinophils.
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19. Concerning the erythrocyte sedimentation rate (ESR) each one of the following
statements is true EXCEPT:
A. The ESR has little value in screening asymptomatic patients for disease
B. The ESR measures the length of fall of the top of a column of erythrocytes
in a given time interval
C. The ESR is commonly elevated to a moderate extent in active inflammatory
diseases
D. The ESR is unaffected by the size, shape and the concentration of RBC's
E. The ESR may be useful in monitoring therapy in rheumatoid arthritis
20. The "anemia of chronic disease" in most cases is:
A. The result of IgG autoantibodies formed secondary to the underlying disease
process
B. Associated with low serum iron and reduced total iron-binding capacity
C. Caused by decreased absorption of folic acid with a subsequent
megaloblastic anemia
D. A microangiopathic anemia caused by narrowing or obstruction of the
vasculature from the primary disease process
E. A result of immune-complex formation, from the patients drug therapy,
attaching to the red cell membrane causing hemolysis
21. Concerning the pathologic findings seen in SLE each one of the following statements is true
EXCEPT:
A. Immune complexes may be deposited in the mesangial, intramembranous,
subepithelial or subendothelial areas of the glomerulus
B. In membranous glomerulonephritis, histologic findings are a widespread
thickening of the capillary walls
C. Diffuse proliferative glomerulonephritis is the mildest of the five patterns
seen in SLE
D. Crescent formation can be seen in diffuse proliferative glomerulonephritis
E. Immunofluorescence can be useful in the diagnosis
QUESTIONS 22. TRUE / FALSE
22. Monosodium urate crystals are positively birefringent when viewed under polarized light.
A. TRUE
B. FALSE
QUESTION 23 - 25, MATCHING.
EACH CHOICE MAY BE USED ONCE OR NOT AT ALL.
For the following dermatologic findings match the systemic or underlying disease that is
most likely to have produced these specific findings.
SKIN LESION
SYSTEMIC DISEASE
23. Recurrent Erythema Multiforme minor
A. Staphylococcal Scalded
skin syndrome
24. Mouth ulcers, fever sore throat,
macular exanthem on upper trunk.
B. Herpes Simplex labialis
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C. Sezary Syndrome
25. Geographic lesions of Palpable purpura
on foot in young adult with sudden
illness and fever
D. Meningococcemia
E. Primary HIV seroconversion
reaction
MULTIPLE CHOICE; SINGLE BEST ANSWER:
26. Each one of the following statements regarding skin lesions in association with
underlying malignancy is true EXCEPT:
A. The presence of multiple seborrheic keratoses in an old person is usually a
sign of internal malignancy.
B. A patient with Paget's disease of the breast usually has an underlying ductal
carcinoma.
C. Pancreatic carcinoma may be associated with panniculitis as well as with
necrotizing migratory erythema.
D. A female with cobblestone lesions of the gums with a family history of
cancer needs baseline mammography and frequent breast exams.
E. A young adult with sudden onset of ichthyosis vulgaris and itching should
be checked for Hodgkin's disease and for HIV.
27. Bullous impetigo:
A. Is always a mixed infection
B. Always resolves spontaneously
C. Is due to Trichophyton tonsurans
D. Is caused by Staphylococcus aureus
E. Is caused by Herpes simplex virus.
28. The body louse is called:
A. Pediculosis capitis
B. Pediculosis corporis
C. Pediculus humanus humanus
D. Pediculus humanus capitis
E. Phthirus pubis
29. Which of the following separates a true hematopoietic stem cell from committed hematopoietic
progenitors.
A. Capacity to differentiate
B. Self-renewal
C. BothAandB.
D. Neither A and B.
30. Erythropoietin:
A. Is regulated by blood O2 saturation levels.
B. Is regulated by the Hemoglobin level in the blood.
C. Is suppressed in polycythemia vera by feedback inhibition.
D. Is produced principally in the liver in response to tissue hypoxia.
E. Is increased in polycythemia vera resulting in abnormally increased red cell number.
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31. Which one of the following statements regarding HbSS disease (Sickle Cell disease)
is FALSE:
A. The single animo acid substitution at the 136 position in the 13-chain of the
globin moiety in HbSS disease is valine for glutamic acid.
B. Hyposplenism in HbSS disease makes the patients more susceptible to
infections with Streptococcus viridans.
C. Hyposplenism in HbSS disease makes the patients more susceptible to
infections with Hemophilus influenza-B.
D. Hyposplenism in HbSS disease makes the patients more susceptible to
infections with Streptococcus pneumoniae.
32. A rheumatologist studied the effect of copper bracelets on 10 patients with arthritis. He measured 26
variables and found a significant lowering of blood levels for rheumatoid factor, but no effect on pain or
function. He concluded that copper can effect blood levels of rheumatoid factor, but nothing else. Do you
believe him?
A. Yes, the more variables measured, the better the design.
B. No, one needs many more patients when measuring so many variables.
C. No, one can never measure the effects of more than one variable at a time.
D. Yes, rheumatology is a complex discipline, and any result is useful for
patient care.
33. Measures of central tendency establish ways to describe a set of data points.
Among the following which is not a measure of central tendency?
A. mean
B. standard deviation
C. mode
D. median
34. You analyze the impact of a new treatment in your practice. You find that the
effect is approximately the same on a number of patients, but 2 of them have
results that are far from the average. You should
A. Include all of the patients in the same analysis.
B. Discard the data from the patients who are far from the mean.
C. Analyze the first group with the usual tools and save the 2 patients for interesting case studies.
D. Conclude that study is flawed, discard all the data and start anew.
TRUE / FALSE:
35. The box-and-whisker plot displays medians, upper and lower quartile values, fences
and specially marked outliers. This plot is useful in separating our data into sets
that need special attention.
A. TRUE.
B. FALSE.
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MULTIPLE CHOICE; SINGLE BEST ANSWER:
36. The distribution of the mean number of anginal-attacks per week of a large group
of patients is plotted against time. The distribution is obviously confined to
positive values of time and has a long tall in the direction of increasing time. You
want to represent for your colleagues the center of the distribution. The center of
the distribution is best represented by the:
A. standard error of the mean.
B. the median value.
C. the mean value.
D. the standard deviation.
E. the kurtosis value
37. Regression of several variables is frequently used to statistically control for
variables that may effect the outcome of a treatment. We have computed the
least-squared equation for a group of patients and found two coefficients that are
statistically significantly different from zero. The equation is
y = 20 - 4 x1 + 3x2 where
y = serum chol (mg/100cc)
x1 = wt in kilos
x2 = sys bp
Controlling for wt and sys bp, what would we expect the serum chol (mg/100 cc)
of a 60 kilo patient with a sys bp of 120 to be?
A. 130
B. 140
C. 150
D. 160
E. 170
38. Alpha and beta errors are measures of protection against false positives and false
negatives. Remember that the power of a test is 1- beta. Standard values for
alpha and the power are:
A. .05 and .5
B. .5 and .05
C. .05 and .8
D. .05 and .05
E. .05 and .01
39. I am participating in a clinical trial of a potent new medication that shows promise
to interrupt a devastating disease process, but has serious side effects. The design
of the trial should consider protection against sampling errors by adjusting the size
of the treatment and placebo groups so that the alpha error and power (1-beta
error) are:
A. .05 and .8
B. .1 and .8
C. .001 and .2
D. .001 and .8
E. .05 and .95
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Questions 40 - 41 refer to the following patient information.
An 1 8-year-old woman had noticed bleeding from her gums when she brushed her teeth
for the past three days. She sought medical attention when she developed epistaxis (nose
bleed). She had no prior history of bleeding problems, and there was no family history of
bleeding.
40. Based on this information, the most likely reason for her bleeding is
A. congenital platelet abnormality
B, acquired platelet abnormality
C. congenital factor VIII deficiency
D. acquired factor VIII deficiency
E. fibrinogen abnormality
41. The most helpful preliminary tests would be:
A. platelet count, PT, aPTT
B. fibrinogen and fibrin split products (FSP)
C. 1:1 mixing study
D. lupus anticoagulant test
E. template bleeding time
42. Each of the following coagulation factors is dependent on the availability of vitamin K, EXCEPT:
A. factor VII
B. factor IX
C. fibrinogen
D. factor X
E. prothrombin
Questions 43 - 44 refer to the following patient information.
Justin, a ten-year-old boy homozygous for hemoglobin S is admitted in a hemolytic crisis.
43. Common complications of this disease which this child may develop include each
of the following, EXCEPT:
A. gallstones
B. iron deficiency
C. growth retardation
D. chronic leg ulcers
E. splenic atrophy
44. Justin's brother has sickle cell trait. Which of the following findings would you
likely see for him?
A. a positive sickle cell screen (Sickle-dex)
B. sickled red blood cells on the peripheral smear
C. predominance (>50%) of HbS on hemoglobin electrophoresis
D. normal hemoglobin electrophoresis
E. splenic atrophy
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QUESTION 45 - 47 refer to the following patient information:
Twenty-two year-old Diane Harris was recently diagnosed as having Hodgkin's disease by biopsy
of a cervical lymph node.
45. Which of the following would indicate a poor prognosis?
A. low LDH
B. three centimeter lymph node on biopsy
C. mixed cellularity histology
D. temperature of 98.6
E. five pound weight gain over the past 6 months
46. Diane is found to have involvement of mediastinal and retroperitoneal lymph nodes.
The stage is:
A. I
B. II
C. III
D. IV
E. V
47. Characteristic findings in Hodgkin's disease include each of the following, EXCEPT:
A. bimodal age incidence
B. Reed-Sternberg cells invariably present
C. T-cell immunologic deficiency
D. specific cytogenetic abnormality in tumor cells
E. frequent presence of mediastinal mass in certain subtypes
48. Potential complications from chemotherapy include:
A. bone marrow suppression
B. infertility
C. a second, therapy-related malignancy
D. kidney damage
E. all of the above
49. The relative incidence of cancers in children < 15 years of age is:
A. Leukemia > lymphoma > brain tumors
B. Lymphoma > leukemia > lymphoma
C. Brain tumors > leukemia > lymphoma
D. Leukemia > brain tumors >
50. The survival rate of childhood cancer is approximately:
A. 20%
B. 35%
C. 50%
D. 65%
E. 80%
51. Each of the following are TRUE about the epidemiology of childhood cancer EXCEPT:
A. Between 1 in every 300 to 350 children develop cancer before age 20.
B. Cancer is the most common cause of death in children due to disease
C. Cancer is more common than human immunodeficiency virus infection
D. Most cases are due to environmental factors
E. The incidence of leukemia and brain tumors
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52. Most physiological coagulation is initiated by:
A. Factor XII and contact activation factors
B. Factor IX and factor VIII
C„ Factor X and factor V
D. Factor VII and tissue factor
E. Factor VII, factor X and TFPI
53. Which one of the following is associated with moderate thrombocytopenia (20-50,000 platelets / uL):
A. 1-3 mm red skin lesions that blanch under pressure
B. 1-3 mm red skin lesions that do not blanch under pressure
C. spontaneous hemarthroses
54. A 20% factor VIII level in a woman is most likely due to:
A, mild hemophilia A
B. mild hemophilia B
C. an intragenic homologous recombination of the factor VIII gene
D. von Willebrand's disease
E. a lupus anticoagulant
55. You are working in an Emergency Room and a 22 year old man presents with a swollen, ecchymotic
jaw and continual bleeding from the socket where his wisdom tooth was removed yesterday afternoon.
Your history elicits that he was diagnosed with systemic lupus last year. Your physical reveals a typical
malar rash and mild inflammation of his PIP joints in addition to a massively swollen, ecchymotic left
cheek and a slow ooze of blood from a wisdom tooth socket. The laboratory shows a hemoglobin of 10.5
gm%, a platelet count of 225 K / µl, a PT of 11.2 seconds and an aPTT of 58 seconds (PT normal 10.512.5 sec; aPTT normal 25-35 sec). Your next order is:
A. a factor VIII level
B. a lupus anticoagulant test (Russell viper venom time)
C. a thrombin time and fibrinogen level
D. 2 units of single donor fresh frozen plasma
E. a 1:1 mix of the aPTT with normal plasma
56. Primary hemostasis, the combination of the vascular and platelet phases of
coagulation, is strengthened by a fibrin meshwork (secondary hemostasis). The
crosslinked fibrin polymer is completed and responsible for the strength of the clot
after:
A. 5-10 seconds
B. 5-10 minutes
C. 5-10 hours
D. 5-10 days
E. a few weeks
57. Before treating a patient with breast cancer using chemotherapy, hormones, cytokines or radiation it is
necessary to first obtain a:
A. fine needle or surgical biopsy of the lesion
B. mammogram that demonstrates micro calcifications
C. Tc-MIBI nuclear scan of mitochondrial receptors
58. The prognosis of any type of cancer is dependent on the:
A. lymph node involvement
B. presence of distant metastases
C. lymphatic invasion
D. vascular invasion
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E. all of the above
59. Each one of the following are Oncological Emergencies EXCEPT:
A. Superior vena caval syndrome
B. Spinal cord compression
C. Hypercalcemia
D. Anemia
E. Renal failure
60. The probability of recurrent disease in node negative breast cancer is approximately: A. 1 %
B. 5 %
C. 18 %
D. 35 %
E. 50%
61. 5-fluorouracil (5-FU) causes which characteristic normal tissue toxicity? Choose one answer.
A. Kidney proximal tubular dysfunction
B. Kidney glomerular toxicity
C. Pulmonary diffusion impairment
D. Cardiomyopathy
E. Mucositis
62. In an Oncological emergency the following are true:
A.Neither radiation nor chemotherapy are given until after a specific diagnosis
of the type of primary malignancy is made using histo-pathological material.
B.Treatment with surgery, radiotherapy or chemotherapy begins as soon as
the emergency is recognized.
C. Radiation is only given to treat the emergency Mon-Fri, from 8:00 am to 5:00 pm.
D. If the emergency is metabolic in nature, such as hypercalcemia, metabolic therapy begins
immediately.
63. Why do cancer cells proliferate at the expense of normal cells?
A. The doubling time of cancer cells is very much shorter than normal cell
doubling time.
B. Cancer cells do not differentiate and therefore do not senesce, whereas
normal cells differentiate, undergo senescence and die.
C. Cancer cells utilize energy more efficiently than normal cells.
D. Damaged DNA of cancer cells is repaired more rapidly than DNA of normal cells.
QUESTIONS 64 - 66:
TRUE / FALSE
64. Cells in Go are least sensitive to chemotherapy-induced cytotoxicity.
A. TRUE.
B. FALSE
65. Rapidly proliferating cancer cells are least sensitive to chemotherapy-induced
cytotoxicity.
A. TRUE.
B. FALSE
66. Poorly oxygenated cells are least sensitive to chemotherapy-induced cytotoxicity.
A. TRUE.
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B. FALSE
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ANSWERS:
1. B
2. E
3. D
4. A
5. C
6. A
7. B
8. A
9. D
10. B
11. E
12. E
13. C
14. B
15. E
16. A
17. C
18. C
19. E
20. B
21. C
22. B
23. B
24. E
25. D
26. D
27. D
28. C
29. B
30. E
31. B
32. B
33. B
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
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C
A
B
B
C
D
B
A
C
B
A
C
C
D
E
D
E
D
D
B
D
E
C
A
E
D
C
E
D
B
A
B
A