GI and Hemagology & Oncology Quiz

1

1- A 19-year-old woman comes to the emergency department because of right lower

abdominal pain for 10hours. Her temperature is 39 C (102.1 F). Abdominal examination

shows rebound tenderness of the right lower quadrant. She is admitted to the hospital, and

an emergency exploratory operation is done. A photograph of the removed appendix is

shown. Which of the following best describes the process involved in her condition?

A- Acute inflammation

B- Catarrhal inflammation

C- Chronic inflammation

D- Granulomatous inflammation

E- Serous inflammation

2- A 15-month-old girl is brought to the physician because of a 6-month history of progressive

weakness and fatigue. Physical examination shows tachycardia, scleral icterus, and

hepatosplenomegaly. Her hemoglobin concentration is 5.6 g/dL (N = 11.5=14.5), and serum

indirect bilirubin concentration is 3 mg/dL (Total bilirubin normal range = 0.1-1.3). A

peripheral blood smear shows hypochromia, nucleated erythrocytes, and microcytosis. DNA

analysis shows an A G point mutation within the TATA box of the beta-globin gene

promoter. Which of the following sets of additional laboratory findings is most likely in this

patient?

Hemoglobin F (22) Hemoglobin A2/hemoglobin A ratio Reticulocyte count

A-

B-

C-

D-

E-

F-

G-

2

3- A 27-year-old woman goes to the clinic for evaluation of worsening abdominal pain and

diarrhea. For several months, she has had mild, intermittent abdominal pain that is often

accompanied by watery diarrhea and low-grade fever. In the last week, the abdominal

cramps have worsened and she has seen streaks of dark blood in her watery-brown stools.

She has lost 4.5 kg (10 lb) in the past 2 months. She denies changes in diet or recent travel.

Physical examination shows mucosal ulcers in her mouth and a small anal fissure.

Endoscopic examination of the colon shows areas of mucosal ulceration with deep fissures.

Microscopic examination of biopsies from the diseased area of bowel shows acute and

chronic colitis with noncaseating granulomas. Which of the following sites in the

gastrointestinal tract is the most common location of this disease process?

A- Esophagus

B- Gastric antrum

C- Ileum

D- Pylorus

E- Rectum

F- Sigmoid colon

4- A 72-year-old woman comes to the physician because of an 8-month history of burning

chest pain and bitter taste in her mouth; both symptoms occur at night when she lies down.

The pain does not radiate and is not associated with shortness of breath. Physical

examination shows no abnormalities. Which of the following is most likely to be associated

with her symptoms?

A- Atrophic gastritis

B- Helicobacter pylori infection

C- Impaired relaxation of the lower esophageal sphincter

D- Metaplasia of the esophageal epithelium

E- Spasm of the esophageal smooth muscle

5- A 47-year-old man comes to the emergency department because of a 2-hour history of

vomiting bright red blood. He has a 20-year history of alcoholism. Physical examination

shows jaundice and scleral icterus. Endoscopy shows esophageal bleeding from the mucosa.

The most likely cause of the bleeding is an indirect shunting of portal blood to the superior

vena cava via which of the following veins?

A- Hepatic

B- Inferior mesenteric

C- Left gastric

D- Right gastroepiploic

E- Splenic

F- Superior mesenteric

3

6- A 32-year-old man is brought to the emergency department 20 minutes after having a

generalized tonic-clonic seizure. He has a 24-hour history of fever, headache, and

intolerance of light. He is alert. His temperature is 40 C (104 F), pulse is 140/min,

respirations are 24/min, and blood pressure is 90/45 mm Hg. He appears acutely ill.

Neurologic examination shows no focal findings. Intravenous fluids are administered, and

there is persistent bleeding around the intravenous site. Laboratory studies show:

Prothrombin time: 16 sec (N = 11-15 sec)

Partial thromboplastin time: 33 sec (N = 25-40 sec)

Fibrin degradation products: increased

D-Dimer (fibrin degradation product): increased

Which of the following changes is most likely in the blood coagulation process of this

patient?

A- Decreased fibrinolysis

B- Decreased microvascular thrombus formation

C- Decreased thrombin production

D- Increased circulating coagulation factors

E- Increased plasmin generation

F- Increased platelet count

7- A healthy 21-year-old man is undergoing initial screening for intestinal polyps.

Sigmoidoscopy shows multiple sessile and pedunculated (with stalk) polyps through the

rectum and sigmoid colon. Physical examination shows poor dentition and several osteomas

in the mandible and skin. Which of the following is the most likely diagnosis?

A- Cowden disease

B- Cronkhite-Canada syndrome

C- Gardner syndrome

D- Inflammatory mucosal polyps

E- Juvenile polyposis

F- Peutz-Jeghers syndrome

8- A 52-year-old woman comes to the physician because of nausea, intermittent bloating, and

diarrhea for 5 days. She underwent a gastric bypass operation 1 month ago and has had a 9-

kg (20 lb) weight loss since then. Abdominal examination shows mild distention. Which of

the following is the most likely cause of this patients symptoms?

A- Absence of functional parasympathetic ganglia in the large bowel

B- Hypersecretion of acid

C- Rapid emptying of hyperosmolar chime into the small bowel

D- Spasm of the pyloric sphincter

E- Surgical interruption of vagal fibers to the stomach

4

9- A 20-year-old woman is admitted to the hospital because of weakness of the legs,

generalized severe abdominal pain, persistent vomiting, and port-wide-colored urine for 8

hours. She began taking an oral contraceptive 1 month ago. She has a history of 3 similar

episodes for which she did not seek medical attention. Physical examination shows

abdominal tenderness and guarding. There is weakness of the lower extremities and

decreased muscle stretch reflexes. Urine studies are most likely to show an increased

concentration of which of the following?

A- Bilirubin

B- Cystine

C- Homogentisic acid

D- Porphobilinogen

E- Uric acid

10- A healthy 24-year-old man is participating in a study of swallowing. The manometric

pressure changes that occur while this man swallows are shown. Which of the following best

represents the muscle activity in the upper esophageal sphincter, considering it opens to

allow the bolus enter the esophagus and then contracts to prevent it from regurgitating?

11- A 71-year-old man has a palpable, pulsatile mass just above the umbilicus. Transabdominal

ultrasonography shows a 6.5 cm infrarenal aortic aneurysm that extends to the iliac

bifurcation. Which of the following arteries is most likely involved in the aneurysm wall?

A- Inferior mesenteric

B- Inferior phrenic

C- Left gastroepiploic

D- Splenic

E- Superior mesenteric

5

12- A 21-year-old woman has received numerous transfusions of packed erythrocytes for

treatment of homozygous beta-thalassemia. Laboratory monitoring of her iron stores is

necessary to avoid secondary iron overload. Which of the following laboratory

measurements is most sensitive in assessing her iron stores?

A- Ferritin

B- Haptaglobin

C- Iron saturation

D- Prealbumin

E- Transferrin

13- A 35-year-old man comes to the physician because of a painful perianal mass for 2 weeks.

His vital signs are within normal limits. Physical examination shows a 2-cm erythematous,

warm, swollen mass superior to the anal verge. Lancing of the mass releases a sanguineous

exudate. The wound is irrigated and bandaged, and antibiotics are administered. Which of

the following inflammatory mediators is most likely released form the aggregated platelets

in this patient?

A- Interleukin-1

B- Nitric oxide

C- Prostacyclin (PGI2)

D- Thrombin

E- Thromboxane A2

14- A 54-year-old woman comes to the physician because of a 2-week history of severe

heartburn and regurgitation of gastric contents at bedtime. Use of an over-the-counter

antacid decreased her symptoms but caused moderately severe diarrhea in the morning.

Which of the following ingredients in the antacid is the most likely cause of the diarrhea in

this patient?

A- Aluminium hydroxide

B- Calcium carbonate

C- Magnesium trisilicate

D- Simethicone

E- Sodium bicarbonate

15- A 45-year-old man who was diagnosed with small cell carcinoma of the lung 1 week ago

comes to the physician to discuss treatment. The physician recommends chemotherapy that

includes cyclophosphamide, doxorubicin, vincristine and cisplatin. He will be pretreated with

dexamethasone and ondansetron as antiemetics and mesna to help prevent cystitis. Which

of the following drugs has the greatest potential to produce both nephrotoxicity and

ototoxicity in this patient?

A- Cisplatin

B- Cyclophosphamide

C- Doxorubicin

D- Ondansetron

E- Vincristine

6

16- A 58-year-old man comes to the physician because of a 6-month history of a gurgling noise

in his throat as he eats, which often requires repeated coughing and throat clearing to

eradicate. He occasionally regurgitates undigested food 1 hour after eating. He has a 2-year

history of well-controlled type 2 diabetes mellitus and a 6-month history of intermittent mild

dysphagia and progressive halitosis. He has not had any weight loss. His vital signs are within

normal limits. Physical examination shows no abnormalities. Which of the following is the

most likely diagnosis?

A- Barrett esophagus

B- Diffuse esophageal spasm

C- Esophageal cancer

D- Gastroesophageal reflux disease

E- Zenker diverticulum

17- A 55-year-old man comes to the physician because of maroon-colored stool for 3 weeks.

Physical examination shows no abnormalities. Test of the stool for occult blood is positive.

Colonoscopy shows a 4-cm mass at the splenic flexure. A biopsy specimen of the mass shows

adenocarcinoma. This patients cancer is most likely to next spread to which of the following

organs?

A- Bone

B- Brain

C- Liver

D- Lung

E- Spleen

18- A previously healthy 55-year-old man comes to the emergency department because of a 3-

hour history of chest pressure. He states My chest is burning. I drank some whole milk, but

it didnt help. His father died suddenly at the age of 45 years. His pulse is 95/min, and

blood pressure is 156/96 mm Hg. Physical examination shows no jugular venous distention.

Crackles are heard one quarter of the way up both lung fields posteriorly. Cardiac

examination shows a soft S4 gallop most prominent at the apex. An ECG shows ST-segment

elevation in leads I, AVL, and V5-V6 without PR depression. Initial therapy with antiplatelet

agents administered prior to arrival fails to resolve the acute EC changes. Which of the

following agent is the most appropriate next pharmacotherapy?

A- Clopidogrel

B- Protein C

C- Simvastatin

D- Tissue plasminogen activator

E- Warfarin

7

19- A healthy 27-year-old woman comes to the physician for her first prenatal visit. She reports

feeling tired but otherwise feels well. She has followed a strict vegetarian diet for 5 years.

Laboratory studies show:

Hemoglobin: 9.1 g/dL

Hematocrit: 27%

Leukocyte count: 3200/mm3

Platelet count: 110,000/mm3

A wright-stained peripheral blood smear is shown. The

nutrient deficiency most likely responsible for her

hematologic abnormalities significantly impairs which

of the following cellular processes?

A- Bilirubin conjugation

B- DNA synthesis

C- Fatty acid oxidation

D- Gluconeogenesis

E- Heme production

20- A 47-year-old woman comes to the physician because of 3 episodes of right-sided abdominal

pain during the past 2 weeks. She says that the pain is steady, radiates to the right shoulder,

and lasts 60-90 minutes. She has had an intentional 18-kg (40 lb) weight loss during the past

10 weeks. She has not had fever or chills. Current medications include gemfibrozil for

hypertriglyceridemia. She is 168 cm (5 ft 6 in) tall and weighs 93 kg (205 lb); BMI is 33 kg/m2.

Abdominal examination shows mild right upper quadrant tenderness. Serum studies show

an alkaline phosphatase activity of 85 U/L (N = 38-126) and amylase activity of 60 U/L (N =

30-110). Which of the following is the most likely diagnosis?

A- Acute pancreatitis

B- Cholelithiasis

C- Chronic pancreatitis

D- Crohn disease

E- Drug-induced hepatitis

F- Peptic ulcer

21- A patient with a peptic ulcer is treated with drug X. several weeks later, the patient is also

given diazepam for treatment of anxiety, tension and insomnia. The patient falls asleep

much more quickly and sleeps for a longer period of time than normally experienced with

diazepam. Drug X is most likely to be which of the following?

A- Atropine

B- Cimetidine

C- Omeprazole

D- Propantheline

E- Ranitidine

8

22- A 32-year-old woman receives a dose of warfarin orally for a large deep venous thrombus of

the right leg. She is currently taking an oral contraceptive. Her prothrombin time is 12 sec (N

= 12-15 sec). Which of the following best explains why this patients prothrombin time did

not change?

A- The large thrombus increases the dose of warfarin required

B- Oral contraceptives accelerate the clearance of warfarin

C- Preexisting circulating coagulation factors have not been cleared

D- Prothrombin time is not a measure of the efficacy of warfarin

E- Warfarin should have been administered intravenously

23- Which of the following best describes the mechanism of action of vinblastine?

A- Alkylates DNA

B- Causes single-and double-stranded DNA breaks

C- Destroys asparagine

D- Inhibits dihydrofolate reductase

E- Prevents microtubule polymerization

24- A 41-year-old man has had diarrhea, weight loss, and diplopia for 3 months. Physical

examination shows hyperpigmentation and synovitis of the knees and ankles. Stool fat

content is increased. Small intestinal tissue stained with periodic acid-Schiff (PAS)shows

macrophages containing diastase-resistant PAS-positive sickle-form particles; electron

microscopy shows the particles to be rod-shaped bacilli. Which of the following is the most

likely diagnosis?

A- Amyloidosis

B- Bacterial overgrowth

C- Celiac sprue

D- Crohn disease

E- Hypogammaglobulinemia

F- Intestinal insufficiency

G- Systemic mastocytosis

H- Tropical sprue

I- Whipples disease

25- A 35-year-old man has had burning epigastric pain for 1 year. Initially, the pain occurred a

few hours after meals, but recently it has become persistent. The pain has not responded to

H2-receptor antagonists or antibiotic treatment for Helicobacter pylori. A CT scan of the

abdomen shows a mass in the head of the pancreas; the surgically removed mass is shown.

Which of the following pancreatic tumors is most likely?

A- Acinar carcinoma

B- Ductal adenocarcinoma

C- Gastrinoma

D- Glucagonoma

E- VIPoma

9

26- A 42-year-old man comes to the physician because of a 2-year history of heartburn, which is

worse at night. He has smoked 2 packs of cigarettes daily for the past 30 years. Upper

endoscopy shows esophageal erosions. Tissue obtained on biopsy of the lower esophagus is

shown. Which of the following is the most likely complication of his disease?

A- Adenocarcinoma

B- Kaposi sarcoma

C- Leiomyosarcoma

D- Malignant lymphoma

E- Squamous cell carcinoma

27- A 37-year-old man comes to the physician because of progressive heartburn over the past 6

months. The symptoms are most severe after eating large or spicy meals and are partially

relieved with antacid therapy. An endoscopic biopsy of the lower esophagus shows

esophagitis. The most likely cause of the esophageal changes is a substance secreted by

which of the following cell types?

A- Chief cells

B- G cells

C- Goblet cells

D- Mucous cells

E- Parietal cells

28- A 54-year-old man has acute pain several hours after rubber band ligation of a prolapsing

hemorrhoid. Which of the following is the most likely explanation for the pain?

A- The ligation involved the mucous lining of the anal canal

B- The ligation stopped blood supply to the hemorrhoid

C- The ligation was done at the level of the anal columns

D- The ligation was done inferior to the pectinate (mucocutaneous) line

E- The ligation

10

29- A 23-year-old woman has a 6-year history of intermittent episodes of fever, crampy

abdominal pain, and frequent, loose stools. A section of bowel resected after a recent

severe episode is shown. Which of the following is the most likely diagnosis?

A- Acute appendicitis

B- Adenocarcinoma

C- Celiac disease

D- Crohn disease

E- Ulcerative colitis

30- The condensation reaction between succinyl-CoA and glycine is the rate-limiting reaction in

the biosynthesis of which of the following compounds?

A- Cholesterol

B- Heme

C- Urea

D- Vitamin D

31- During a meal, the vagus nerve stimulates secretion of acetylcholine, which stimulates the

stomach to secrete HCl in a second-messenger pathway derived directly from membrane

phospholipids. Which of the following 2nd messengers is involved?

A- cAMP

B- cGMP

C- Choline

D- G protein

E- Inositol 1,4,5-triphosphate

32- A 37-year-old woman develops pancytopenia after exposure to a benzene-containing agent.

Tissue obtained on a bone marrow biopsy is most likely to show replacement of normal

hematopoietic cells by which of the following cells?

A- Adipocytes

B- Lymphocytes

C- Monocytes

D- Osteoblasts

E- Reticuloendothelial cells

11

33- A 60-year-old man with signs and symptoms of an obstruction in the large bowel undergoes

surgical resection. The presence of a malignant neoplasm is most strongly supported by

which of the following features seen in the photograph of the resected segment of the

colon?

A- Fibrosis of the wall

B- Invasion of the submucosa and muscular layer

C- Narrowing of the lumen

D- Sharp demarcation from the normal mucosa

E- Ulceration of the mucosa

34- A 50-year-old woman has a 1-year history of recurrent hemorrhages and thrombosis. She

has a bruise on the forehead secondary to minor trauma. Evaluation for underlying

inflammatory and neoplastic disease is negative. Laboratory studies show:

Hemoglobin: 12 g/dL


Segmented neutrophils: 60%

Band forms: 5%

Lymphocytes: 30%

Monocytes: 5%

Platelet count: 2,000,000/mm3 ( N = 150,000-400,000)

Erythrocyte morphology: normal

Which of the following is the most likely diagnosis?

A- Chronic myelogenous leukemia

B- Essential thrombocythemia (thrombocytosis)

C- Myelofibrosis

D- Polycythemia vera

E- Reactive thrombocytosis

35- In organ transplantation, graft-versus-host disease may be induced by donor T-lymphocytes.

Which of the following disease-specific organ transplants is most likely to derive some

benefit from this graft-versus-host response?

A- Bone marrow transplant for acute myelogenous leukemia

B- Heart transplant for viral cardiomyopathy

C- Islet cell transplant for type 1 diabetes mellitus

D- Kidney transplant for membranous glomerulonephritis

E- Lung transplant for primary pulmonary hypertension

12

36- A 27-year-old woman comes to the clinic because of a 7-day history of intermittent

headaches, abdominal pain and bloating, low back pain, diarrhea, pain during sexual

intercourse, decreased interest in sex, and difficulty with balance. She tells the physician

that she is so frustrated because she cannot work due to her symptoms. She has seen 12

physicians in the past 5 years, none of whom have been able to diagnose her condition. The

patient most likely has which of the following disorders?

A- Autoimmune vasculitis

B- Chronic cadmium toxicity

C- Factitious disorder

D- Crohn disease


F- Fibromyalgia

G- Paraneoplastic syndrome

H- Somatization disorder

I- Schizophrenia

J- Irritable bowel syndrome

37- A 60-year-old woman has had progressive weakness and back pain over the past 8 weeks.

Complete blood count shows:


Leukocyte count: 15,000/mm3

Segmented neutrophils: 65%

Lymphocytes: 25%

Monocytes: 10%

Erythrocytes: rouleaux present

Erythrosedimentation rate: 40 mm/hour


60% of bone marrow cells have features similar to those shown. Which of the following

additional findings is most likely to be present?

A- Antinuclear antibodies

B- Heterophile antibodies

C- Increased leukocyte alkaline phosphatase activity

D- light chain proteinuria

E- reciprocal chromosomal translocations: 9;22

13

38- An 18-month-old boy who is chubby is brought to the physicians office for a routine

examination. His weight is above the 90th percentile. Laboratory studies show:

Hematocrit: 30% (low)


Mean corpuscular volume (MCV): 60 m3 (N = 78-102)


Which of the following laboratory values is most likely to be abnormal?

A- Cholesterol

B- Folate

C- Iron

D- Vitamin B12

E- Vitamin E

39- A 33-year-old man who is seropositive for HIV comes to the physician because of a lesion on

his forehead for 4 weeks. He has a 10-year history of intravenous drug abuse. Physical

examination shows a 1-cm, irregularly shaped, raised, indurated lesion on the forehead. A

photomicrograph of a biopsy specimen of the lesion is shown. Which of the following is the

most likely causal organism of this lesion?

A- Aspergillus fumigatus

B- Cytomegalovirus

C- Herpesvirus type 8

D- Mycobacterium avium-intracellulare

E- Pneumocystis jiroveci

F- Toxoplasma gondii

14

40- A 10-year-old girl is brought to the emergency department 1 hour after she fell from her

bicycle. Physical examination shows a 2-cm deep laceration over the left forearm. As a result

of the tissue trauma, which of the following plasma proteins most likely bound clotting

factor XII (Hageman factor) and kininogen, allowing autocatalytic amplification of the

inflammatory system in this patient?

A- Bradykinin

B- Fibrinogen

C- Immunoglobulin

D- Kallikrein

E- Alpha-macroglobulin

F- Plasmin

G- Thrombin

H- von Willebrand factor

41- A 17-year-old girl is evaluated because of a boil on her left shoulder. Examination shows an

erythematous, painful, fluctuant lesion; a yellow-green liquid material is drained surgically.

The pain and erythema gradually subside. Which of the following cells contributes most to

the tissue changes present in the lesion 5 days after drainage?

A- Eosinophils

B- Lymphocytes

C- Neutrophils

D- Plasma cells

E- Mast cells

42- The erythrocyte is prone to injury by reduced oxygen metabolites that are produced after

spontaneous oxidation of oxyhemoglobin. Which of the following reactions or processes is

most critical in protecting the erythrocyte from injury by these oxidation products?

A- Dissociation of methemoglobin into metheme and globin chains

B- Glucose 6-phosphate dehydrogenase-catalyzed generation of NADPH

C- Inactivation of hydroxyl free radicals by beta carotene

D- Synthesis of ubiquinone

E- Vitamin C-dependent reduction of methemoglobin to hemoglobin

43- Prostacyclin (PGI2) produced by endothelial cells promotes which of the following?

A- Adhesion of platelets

B- Expression of selectins

C- Priming of leukocytes

D- Production of nitric oxide

E- Vasodilation

15

44- A 52-year-old man is admitted to the hospital because of an acute myocardial infarction.

Coronary catheterization shows a lesion in the left anterior descending coronary artery.

After a balloon angioplasty is performed, abciximab is administered. Blockade of which of

the following is most likely to occur in this patient?

A- Gamma-carboxylation of clotting factors

B- Factor Xa formation

C- Fibrinogen to fibrin conversion

D- Platelet glycoprotein IIb/IIIa receptor function

E- Platelet thromboxane A2 production

45- Which of the following agents inhibits both the production of interleukin-2 in resting T

lymphocytes and the production of gamma-interferon in activated T-lymphocytes?

A- Azathioprine

B- Cisplatin

C- Cyclophosphamide

D- Cyclosporine

E- Mercaptopurine

46- Which of the following is the most likely explanation for the emergence of HIV variants

resistant to antiviral drugs?

A- CD4 is expressed on many cells

B- HIV can bind many co-receptors

C- HIV reverse transcriptase is error-prone, and may produce completely new variants of

viral enzymes and other drug molecular targets

D- Nef is capable of decreasing cell-surface expression of many proteins

E- Rev efficiently exports viral mRNAs from the nucleus

47- 5-fluoruracil is effective as an antineoplastic agent because it prevents which of the

following?

A- Amidation of phosphoribosylpyrophosphate

B- Conversion of ribonucleotides to deoxyribonucleotides

C- Incorporation of a methyl group into N5, N10 tetrahydrofolate

D- Methyl group transfer to dUMP to form dTMP

E- Reduction of dihydrofolate to tetrahydrofolate

16

48- A 23-year-old man with sickle cell disease is admitted to the hospital because of acute vaso-

occlusive crisis and acute sickle chest syndrome. Oxygen and intravenous fluids are started,

and a blood transfusion and an analgesic are administered. Five days later, leukocyte count

is 6500/mm3 and a platelet count is 120,000/mm3, and he is discharged with a prescription

for a drug to decrease the frequency of acute crisis by increasing the synthesis of fetal

hemoglobin (HbF, 22). 6 weeks later, leukocyte count is 1800/mm3 and platelet count is

60,000/mm3. Which of the following drugs is most likely responsible for the decreased

leukocyte and platelet counts in this patient?

A- Erythropoietin

B- Folic acid

C- Hydroxyurea

D- Interferon-alpha

E- Meperidine

49- A 10-year-old boy has chronic iron-deficiency anemia. A test of stool for occult blood is

positive. A barium enema with air contrast shows no abnormalities. Findings on upper

endoscopy examination are normal. His condition improves with H2-receptor antagonist

therapy. Which of the following is the most likely cause of the bleeding?

A- Arteriovenous malformation

B- Congenital megacolon (Hirschsprung disease)

C- Esophageal reflux

D- Meckel diverticulum


50- A 60-year-old woman is admitted to the hospital with a pulmonary embolism. Treatment

with enoxaparin is begun. The patient says, Thats not the heparin my other doctor gave

me. Why am I getting this newfangled stuff? . Compared with heparin, which of the

following best explains the appropriateness of enoxaparin for this patient?

A- Available orally

B- Larger loading dose required

C- Less expensive for each days therapy

D- Less monitoring required

17

51- A 49-year-old woman comes to the physician because of a 1-year history of intermittent

blood-stained diarrhea with cramping in the lower abdomen. Results of sigmoidoscopy are

shown. Culture of stool and biopsy of mucosa show no evidence of bacterial, amebic or viral

infection. The most appropriate maintenance therapy includes administration of which of

the following drugs?

A- Ciprofloxacin

B- Dapsone

C- Doxycycline

D- Ethambutol

E- Gentamycin

F- Streptomycin

G- Sulfadiazine

H- Sulfasalazine

52- A 30-year-old woman who takes ibuprofen for arthritis has a marked increase in menstrual

cramping after starting a drug to prevent peptic ulcer. Which of the following drugs most

likely caused this adverse effect?

A- Aluminium hydroxide

B- Magnesium hydroxide

C- Methacoline

D- Misoprostol

E- Omeprazole

F- Ranitidine

G- Sodium bicarbonate

H- Sucralfate

53- Perforation of which of the following structures will produce retroperitoneal gas?

A- Ascending colon

B- Cecum

C- Jejunum

D- Terminal ileum

E- Transverse colon

18

54- A 38-year-old man comes to the physician 24-hours after vomiting coffee-ground like

material (hematemesis). He has a 6-month history of intermittent, dull epigastric pain that is

temporarily relieved with the use of antacids. Physical examination shows mild epigastric

tenderness. Upper gastrointestinal endoscopy shows a duodenal ulcer. Serum studies show

markedly increased circulating concentrations of gastrin. Gastrin-mediated hyperstimulation

of which of the following cell types has contributed the most to the development of a

duodenal ulcer in this patient?

A- Acinar cells of Brunner glands

B- Centroacinar cells

C- Enteroendocrine cells

D- Gastric chief cells

E- Mucous neck cells

F- Paneth cells

G- Parietal cells

H- Surface mucous cells

55- A healthy 25-year-old man has a sample of blood drawn 1 hour after he eats a baked potato.

The concentration of which of the following substances is most likely increased in the blood

sample?

A- Amylose

B- Glucose

C- Limit dextrin

D- Pectin

E- Sucrose

56- A 67-year-old woman with pernicious anemia has absent gastric parietal cells. An increase in

which of the following is the most likely additional finding?

A- Gastrin in blood

B- Protein digestion in the stomach

C- Secretin in blood

D- Secretion of gastric acid

E- Secretion of intrinsic factor

57- An 8-year-old boy is brought to the emergency department by his mother because he has

had intermittent abdominal pain for the past 24 hours. Within the past 2 hours the pain has

become more severe and constant, and he has developed a temperature of 38 C (100.4 F).

Physical examination shows tenderness and guarding in the right lower quadrant. A

diagnosis of acute appendicitis is made and a laparotomy is performed. The appendix is

found to be normal; however, an inflamed ileal diverticulum is removed. Which of the

following developmental defects is most likely responsible for this finding?

A- Abnormal fixation of the intestinal mesentery

B- A defect in the longitudinal layer of the intestinal muscularis

C- Failure of normal recanalization leading to duplication of the intestinal lumen

D- Failure of the midgut loop to rotate as it enters the abdomen

19

E- Persistance of a remnant of the proximal portion of the yolk sac

58- A newborn is evaluated by a pediatrician because of jaundice. His serum total bilirubin

concentration is 2.5 mg/dL, with a direct component of 2 mg/dL. His feces are acolic and his

urine looks very dark. An ultrasound confirms the diagnosis of biliary atresia. If left

untreated, deficiency of which of the following compounds is more likely?

A- Vitamin B12

B- Vitamin B6

C- Vitamin B1

D- Folic acid

E- Vitamin E

59- A 13-year-old boy is brought to the physician because he developed jaundice 2 days ago

following a Boy Scout survival outing in which he was required to fast for 30 hours. He has

had intermittent mild jaundice since early childhood. There is no history of medication use

or substance abuse. Physical examination shows jaundice and mild scleral icterus. There is

no hepatosplenomegaly. His serum total bilirubin concentration is 3.8 mg/dL with a direct

component of 0.5 mg/dL. Imaging studies of the liver show no abnormalities. Which of the

following is the most likely diagnosis?

A- Autoimmune hemolytic anemia

B- Chronic familial nonhemolytic jaundice

C- Dubin-johnson syndrome

D- Gilbert syndrome

E- Beta-thalassemia

60- Malformation of the embryonic cloaca may lead to which of the following congenital

malformations?

A- Congenital hemorrhoids and rectal prolapse

B- Imperforate anus and rectovesical fistula

C- Double ureter and posterior urethral valves

D- Bifid clitoris and absent vestibular bulbs

E- Pelvic arteriovenous malformations

61- A 24-year-old woman is admitted to the hospital because of a temperature of 40 C (104 F),

generalized rash, and altered mental status. On admission, her platelet count, prothrombin

time (PT) and partial thromboplastin time (PT) are within the reference ranges. During the

next 24 hours, her blood and cerebrospinal fluid cultures grow Neisseria meningitidis.

Despite therapy, she becomes comatose and begins bleeding from all venipuncture sites and

from mucous membranes. Her PT and PTT are now markedly prolonged and platelet count is

less than 20,000/mm3. Which of the following plasma values is most likely to be increased in

this patient?

A- Activated protein C

B- D-dimer

C- Factor VII

D- Fibrinogen

20

E- Plasminogen

62- The graph shows gastric acid secretion response versus concentration of histamine

administered before (solid curve) and after (dashed curve) the administration of drug X.

Drug X is most likely which of the following?

A- Atropine

B- Cimetidine

C- Diphenhydramine

D- Misoprostol

E- Omeprazole

F- Sucralfate

63- The sickling of erythrocytes in patients with sickle cell disease results from which of the

following?

A- Aggregation and polymerization of the sickle cell hemoglobin (HbS)

B- Inability of HbS to bind heme

C- Inability of HbS molecules to form a tetramer

D- Instability of the HbS molecules

64- A 77-year-old man has had repeated episodes of difficulty speaking, facial numbness, and

clumsiness of the left hand. Doppler ultrasonography of his carotid arteries shows no

abnormalities. Which of the following drugs is the most appropriate therapy to prevent

future episodes?

A- Aspirin

B- Diflunisal

C- Methyl salicylate

D- Olsalazine

E- Salicylic acid

F- Salsalate

G- Sodium salicylate

H- Sulfasalazine

21

65- A 74-year-old man with a 5-year history of pernicious anemia develops a gastric ulcer on the

lesser curvature of the fundus. Biopsy of the lesion shows adenocarcinoma. Microscopic

examination of the adjacent gastric mucosa is most likely to show absence of which of the

following cells?

A- Chief cells

B- Mucous neck cells

C- Parietal cells

D- Small B lymphocytes

E- Transformed B lymphocytes

66- A 65-year-old woman with chronic constipation comes to the emergency department

because of a 3-day history of abdominal pain. Abdominal examination shows distention with

tenderness in the left lower quadrant. Sigmoidoscopy shows no tumors, but the scope

cannot be inserted beyond 15 cm because of abrupt luminal narrowing. Which of the


A- Appendicitis

B- Diverticulosis

C- Small bowel obstruction

D- Volvulus of the cecum

E- Volvulus of the sigmoid colon

67- A 32-year-old man dies after an episode of massive upper gastrointestinal bleeding. He had

episodes of facial flushing, diarrhea and bronchospasm for the past year. A yellow

submucosal nodule is identified in the terminal ileum. The liver as seen at autopsy is shown.

Which of the following features of the neoplasms stage is demostrated?

A- Blood-borne metastases

B- Direct seeding

C- Lymphatic spread

D- Peritoneal implants

E- Size of the primary tumor

22

68- An 11-year-old boy has a mass in the jaw and cervical lymphadenopathy. A peripheral blood

smear shows abnormal vacuolated lymphoid cells. Tissue obtained on biopsy of the jaw mas

is shown. A karyotype suggests an 8;14 chromosomal reciprocal translocation. Which of the


A- Burkitt lymphoma

B- Chronic lymphocytic leukemia

C- Hodgkin lymphoma

D- Mycosis fungoides

E- T-cell lymphoblastic leukemia

F- Waldestrom

macroglobulinemia

69- A 75-year-old man has intermittent pain in his right groin. Examination shows a large

inguinal hernia that extends to the scrotum. Repair is recommended because the hernia may

be incarcerated or strangled. During the operation, which of the following arteries is the

most useful landmark for locating the deep inguinal ring?

A- External iliac

B- Femoral

C- Inferior epigastric

D- Obturator

E- Superior mesenteric

70- A 25-year-old woman brings her 1-month-old son to the physician because he has been

vomiting with increasing forcefulness during or immediately after his findings for the past

week. The infant has no fever and seems relatively content but hungry after vomiting. He

has not had a bowel movement for the past 2 days. The mother is concerned because the

infants father had a similar problem at his age and had to have an operation. Physical

examination shows normal chest sounds and a palpable ovoid mass in the upper abdomen.

Which of the following is the most likely cause of his condition?

A- Achalasia

B- Congenital duodenal or jejunal atresia

C- Congenital megacolon (Hirschsprung disease)

D- Congenital tracheoesophageal fistula

E- Diaphragmatic herniation

F- Pyloric stenosis

23

71- A 17-year-old boy comes to the physician because of early satiety when eating, intermittent

nausea and vomiting of undigested, bile-stained food for the past 3 months. He has a 10-

year history of type 1 diabetes mellitus. Findings on physical exam are unremarkable.

Hemoglobin A1C is 18%, and fasting serum glucose concentration is 180 mg/dL. Which of the

following is the most likely cause of his symptoms?

A- Autonomic dysfunction

B- Chronic gastritis

C- Gastric carcinoma

D- Microangiopathy

E- Peptic ulcer disease

72- As part of the digestive process in the human, pancreatic proteinases within the small

intestine are normally activated. Which of the following substances from the duodenal

epithelium triggers this activation?

A- Calcium ion

B- Carboxypeptidase

C- Elastase

D- Enteropeptidase

E- Secretin

F- Trypsin

73- A 70-year-old man has easy fatigability, malaise, and an ataxic gait. He is pale and has a sore

tongue, absent vibratory sense up to his knees, and bilateral plantar reflexes. A peripheral

blood smear is shown. Which of the following is the most likely cause of this patients

disorder?

A- Acquired deficiency of intrinsic factor

B- Carcinoma of the colon

C- Congenital absence of transcobalamin II

D- Congenital malabsorption of vitamin B12

E- Hookworm infestation

24

74- An 18-year-old woman has had pharyngitis, fever, and lethargy for 3 days. Leukocyte count

is 11,500/mm3. The photomicrograph shows the type of cell that is predominant in her

peripheral blood smear. Which of the following is the most likely diagnosis?

A- Acute lymphoblastic leukemia

B- Acute monocytic leukemia

C- Acute myelogeous leukemia

D- Bacterial pharyngitis

E- Infectious mononucleosis

75- A 1-day-old newborn has bilious vomiting that began 1 hour after birth. Physical

examination shows upward slanting eyes, short small fingers, and a wide space between the

1st and 2nd toes. Peristaltic waves are seen, but no abdominal distention. Which of the

following is the most likely additional finding in this patient?

A- Congenital aganglionic megacolon

B- Duodenal atresia

C- Meconium ileus

D- Pyloric stenosis

E- Tracheoesophageal fistula

76- A 30-year-old woman has a 12-hour history of chills and abdominal pain. Her last menstrual

period was 2 weeks ago. Her temperature is 38.8 C (101.8 F), pulse is 120/min, respirations

are 18/min, and blood pressure is 132/82 mm Hg. Abdominal and pelvic examinations show

tenderness on palpation of the right lower quadrant, pain in the right lower quadrant after

pressure is quickly released from the left lower quadrant, pain in the lower quadrant when

the right hip is flexed against resistance (psoas sign), and tenderness in the right rectal wall.

Bowel sounds are absent. Test of stool for occult blood is negative. Which of the following is

the most likely diagnosis?

A- Appendicitis

B- Cystitis

C- Diverticulitis

D- Ectopic pregnancy

E- Pelvic inflammatory disease

77- A 57-year-old man comes to the physician because of a 3-month history of increased

abdominal girth, hemorrhoids, and swelling of his feet after periods of standing or sitting. He

has a 20-year history of alcoholism and hypertension. Current medications include

hydrochlorothiazide. Physical examination shows scleral icterus and jaundice. The abdomen

is round and distended, with a fluid wave and palpable spleen tip. Which of the following

best explains the patients splenomegaly?

A- Ascitis

B- Blockade of afferent splenic lymphatics

C- Decreased osmotic pressure in the hepatic veins

D- Hyperactivity of splenic macrophages

E- Hyperplasia in the periarterial lymphoid sheaths

F- Hyperplasia in the peripheral white pulp

25

G- Increased hydrostatic pressure in the splenic vein

H- Stenosis of the splenic artery

78- A 45-year-old woman has increasing dyspnea and fatigue. She is pale. Hemoglobin

concentration is 7.5 g/dL, leukocyte count is 4,500/mm3, and platelet count is 89,000/mm3.

A peripheral blood smear is shown. Based on these

findings, which of the following additional findings is most

likely?

A- Antiparietal cell antibodies in serum

B- Decreased serum concentration of iron

C- Increased hemoglobin A2 on hemoglobin

electrophoresis

D- Increased osmotic fragility of the erythrocytes

E- Positive direct antiglobulin test

79- An 85-year-old woman has a malignant neoplasm in the wall of the sigmoid colon. To which

of the following groups of lymph nodes is the neoplasm most likely to metastasize initially?

A- Celiac

B- Inferior mesenteric

C- Inguinal

D- Internal iliac

E- Lateral lumbar (aortic)

F- Superior mesenteric

26

80- A 16-year-old girl is brought to the physician because of sore throat, fever, and malaise. She

has cervical lymphadenopathy, and a tender, slightly enlarged spleen. Laboratory studies

show:


Hematocrit: 33.2%


A peripheral blood smear is shown. Which of the following is the most likely diagnosis?

A- Acute lymphoblastic leukemia

B- Acute myelogenous leukemia

C- Hairy cell leukemia

D- Infectious mononucleosis

E- Follicular lymphoma

81- A 32-year-old man has dysphagia and odynophagia after ingesting drain cleaner containing

sodium hydroxide pallets. Which of the following is the most likely associated finding 3

months later?

A- Aspiration pneumonia

B- Blindness

C- Esophageal stricture

D- Gastric perforation

E- Hemolytic anemia

F- Renal failure

G- Systemic acid-base imbalance

27

82- A 49-year-old man comes to the physician because of fatigue, lightheadedness on standing

or sitting up rapidly, and dark-colored stools for the past 4 days. He moved to the USA from

southeastern Asia 2 years ago. His history includes chronic hepatitis B infection. Examination

shows pale mucous membranes, an enlarged liver, a prominent periumbilical venous

pattern, and nonbleeding internal hemorrhoids. Hemoglobin concentration is 7.8 g/dL.

Upper endoscopy shows circumferentially prominent tortuous veins with an adherent clot at

the gastroesophageal junction. Which of the following mechanisms best explains the blood

loss in this patient?

A- Acute inflammation of the gastroesophageal mucosa

B- Arteriovenous fistula at the gastroesophageal junction

C- Hepatic artery obstruction with increased celiac pressure

D- Increased flow through collateral hepatic veins

E- Increased pressure in submucosal esophageal veins

83- A 60-year-old woman develops anemia several years after a subtotal gastrectomy. Which of

the following is the most likely finding on a peripheral blood smear?

A- Basophilic stippling

B- Helmet cells

C- Macrocytosis of erythrocytes

D- Microcytosis of erythrocytes

E- Reticulocytosis

84- A 2-year-old boy with normal size, weight, and development is brought to the physician

because of a painful, swollen left knee for the past week. He has had 2 episodes of

asymptomatic hematuria during the past 6 months. Both parents are healthy. He has

achieved developmental milestones at appropriate ages. His height and weight are at the

70th percentile. Examination shows bruises and resolving hematomas on both elbows and

sighs of cutaneous hemorrhages at the site of a deep splinter. Laboratory studies show:

Hemoglobin: 12 g/dL (N= 13.8-17.2)

Erythrocyte count: normal

Leukocyte count: normal

Bleeding time: 4 min (N= 2-7 min)

Partial thromboplastin time: 30 sec (N = 15-40 sec)

Prothrombin time: 10 sec (N= 9-12.5 sec)

The most likely diagnosis can be proven by the therapeutic response to a single injection of

which of the following?

A- Vitamin K

B- Vitamin C

C- Folic acid

D- Factor VIII (Antihemophilic factor)

E- Factor I (Fibrinogen)

28

85- A 4-year-old girl requires a splenectomy after an automobile collision. Which of the

following is most likely to be a long-term complication in this patient?

A- Cytomegalovirus infection

B- Lymphopenia

C- Non-Hodgkin lymphoma

D- Streptococcal infection

E- Thrombocytopenia

86- A 73-year-old man is brought to the emergency department because of excruciating low

back pain that began while he was painting his garage 1 day ago. He visits the physician

every 6 months for monitoring of hypertension well controlled with a diuretic. An x-ray of

the spine shows several osteoblastic lesions in the vertebrae. A complete blood count shows

mild normocytic anemia. Immunoglobulin levels are within the normal reference values.

There is no lymphadenopathy. Which of the following is the most likely diagnosis?

A- Malignant lymphoma

B- Metastatic lung carcinoma

C- Metastatic prostate carcinoma

D- Multiple myeloma

E- Osteosarcoma

87- A 4-year-old boy has had recurrent watery diarrhea, abdominal distention, and increased

borborygmi (bowel sounds) for 3 months. The elimination of most dairy products form his

diet causes his symptoms to abate. In which of the following portions of the gastrointestinal

tract is an enzyme deficiency most likely?

A- Colon

B- Jejunum

C- Liver

D- Pancreas

E- Stomach

88- A 42-year-old man who is a resident of the USA comes to the physician because of greasy

foul-smelling stools and a 5.5 kg (12-lb) weight loss over the past 6 months. He has a 6-year

history of chronic abdominal and back pain. The epigastrium is tender on deep palpation. A

CT scan of the abdomen shows pancreatic atrophy and calcifications. Which of the following

is the most likely cause of his disease?

A- Alcohol dependence

B- Congenital pancreatic cyst

C- Diabetes mellitus

D- Gallstones

E- Heredity

F- Pancreas divisum

G- Protein-calorie malnutrition

29

89- Vitamin B6 (pyridoxine) is required for the enzyme that catalyzes the rate-limiting step in

heme synthesis. Which of the following labeled compounds in the diagram is synthesized in

this reaction?

90- A 1-year-old boy is brought to the emergency department because he is having difficulty

breathing after drinking water that contains nitrates. He is cyanotic. Blood drawn for

laboratory studies is chocolate-colored. His hemoglobin most likely has which of the

following properties?

A- Decreased glycosylation

B- Increased binding of 2,3-biphosphoglycerate

C- Increased proportion of Fe+++ (ferric)

D- Presence of beta subunits only

E- Sickle cell mutation

91- A 26-year-old man comes to the physicians office because he has had shortness of breath

and a cough for the past week. He received combination chemotherapy for testicular

carcinoma 4 months ago. Auscultation of the lungs discloses fine crackles at the bases. X-ray

of the chest shows diffuse pulmonary infiltrates. Which of the following chemotherapeutic

drugs is most likely responsible for his symptoms?

A- Bleomycin

B- Cisplatin

C- Cyclophosphamide

D- Daunorubicin

E- Etoposide

F- Ifosfamide

G- Paclitaxel

H- Vinblastine

30

92- A 10-month-old boy with hemoglobin SS disease is brought to the emergency department by

his parents because of severe pain in his feet for 2 hours. He appears acutely ill and is crying.

Vital signs are normal except for a pulse of 160/min. physical examination shows

splenomegaly and edematous, tender feet. Laboratory studies show a hemoglobin

concentration of 7 g/dL and a reticulocyte count of 12%. A peripheral blood smear shows

target cells, poikilocytes, and sickled erythrocytes. Which of the following processes most

likely caused the sickled erythrocytes in this patient?

A- Decreased interaction of hemoglobin S with spectrin upon deoxygenation

B- Inability of abnormal beta chains to form tetramers upon deoxygenation

C- Inability of abnormal beta chains to form tetramers upon oxygenation

D- Increased interaction of hemoglobin S with spectrin upon deoxygenation

E- Spontaneous polymerization of hemoglobin S upon deoxygenation

F- Spontaneous polymerization of hemoglobin S upon oxygenation

93- A 62-year-old man comes to the physician because of a 10-day history of mild, diffuse

abdominal pain and a rapidly progressive increase in abdominal girth. He has a 10-year

history of cirrhosis caused by hepatitis C and alcohol abuse. He stopped all alcohol

consumption 8 years ago has been well until recently. Examination of the abdomen shows

massive ascitis and a small liver with an irregular texture. A discrete 2-cm nodule is palpated

on the liver. Which of the following measurements in this patients serum is most

appropriate to establish a diagnosis?

A- GABA

B- CA-19-9

C- CA 125

D- CEA

E- Alpha-fetoprotein

F- PSA

94- Which of the following hormones, produced by the duodenal and proximal jejunal mucosa,

stimulates the release of pancreatic juice rich in digestive enzymes?

A- Cholecystokinin

B- Glucagon

C- Pancreatic polypeptide

D- Secretin

E- Vasoactive intestinal polypeptide

95- An asymptomatic 56-year-old woman has occult blood in her stool. Barium studies of her

transverse colon show an intraluminal mass. The surgical specimen is shown. Which of the


A- Adenocarcinoma

B- Carcinoid tumor

C- Polypoid leiomyoma

D- Tubular adenoma

E- Villous adenoma

31

96- An asymptomatic 56-year-old woman has occult blood in her stool. Barium studies of her

transverse colon show an intraluminal mass. The surgical specimen is shown. Which of the


A- Adenocarcinoma

B- Carcinoid tumor

C- Polypoid leiomyoma

D- Tubular adenoma

E- Villous adenoma

97- A 94-year-old man has been taking ibuprofen for osteoarthritis for the past 5 years. 2 years

ago, he developed renal failure, and serum creatinine concentration increased from 1.2 to 2

mg/dL. He recently developed gastrointestinal hemorrhage from a gastric ulcer. He wants to

continue taking the ibuprofen. Which of the following drugs is most likely to decrease this

patients risk for ibuprofen-induced gastric ulceration?

A- Ampicillin

B- Metronidazole

C- Misoprostol (PGE1)

D- Sucralfate

E- Vitamin B6

98- Which of the following antiemetic drugs may induce parkinsonian signs such as dystonia and

tardive dyskinesia?

A- Dronabinol

B- Dimenhydrinate

C- Metoclopramide

D- Ondansetron

32

99- A 25-year-old girl has fever, nausea, and acute abdominal pain and tenderness. Laboratory

studies show a neutrophilic leukemoid reaction. A laparotomy and appendectomy are done.

Which of the following histologic findings will establish the diagnosis of acute appendicitis?

A- Follicular lymphoid hyperplasia

B- Histiocytic infiltrate of the lamina propria

C- Lymphoid infiltrate of the mucosa

D- Mucosal ulceration

E- Neutrophilic infiltrate of the muscularis

100- The diagram shows a liver lobule. Long-term destruction of the hepatocytes, collapse of the

histologic architecture, and production of fibrous material in the areas indicated by the

arrow is most likely to result in which of the following?

A- Decreased intestinal motility

B- Gallstones

C- Increased central venous pressure

D- Increased hepatic venous pressure

E- Increased portal pressure

101- After several courses of treatment for non-Hodgkins lymphoma, a 33-year-old man

develops gross hematuria. Which of the following drugs is most likely to be responsible for

this adverse effect?

A- Carmustine

B- Cyclophosphamide

C- Daunorubicin

D- Methotrexate

E- Vincristine

33

102- A 20-year-old man has gastrointestinal bleeding due to Meckels diverticulum. Histologic

evaluation of the resected diverticulum is most likely to show:

A- Acute bacterial inflammation

B- Carcinoid tumor

C- Gastric mucosa

D- An impacted enterolith

E- Varices at the neck of the diverticulum

103- A 16-year-old boy is brought to the emergency department because of respiratory distress.

Examination shows a large mediastinal mass and 3-cm firm cervical lymph nodes bilaterally.

Examination of tissue obtained on cervical lymph node biopsy shows small lymphocytes

interspersed with binucleate cells with clear chromatin and large eosinophilic nucleoli. The

most likely diagnosis is:

A- Burkitts lymphoma

B- Diffuse non-cleaved cell lymphoma

C- Follicular lymphoma

D- Hodgkins lymphoma

E- Lymphoblastic lymphoma

104- A 3-year-old boy has a 5-week history of weight loss and bulky, frothy, foul-smelling stools.

Dietary modification including exclusion of gluten-containing foods from the diet results in

clinical improvement. Which of the following is the most likely finding on examination of a

biopsy specimen from the small intestine?

A- Atrophy of villi an microvilli

B- Degenerative changes of the myenteric plexus

C- Multiple outpouchings through the muscle coat

D- Numerous ulceration and pseudopolyps

E- Pseudomembrane covering the luminal surface

105- A 3-year-old boy with cystic fibrosis is evaluated for the acute onset of an uncontrollable

nosebleed. There is no family history of a bleeding disorder. A few large bruises are seen on

the legs; no other abnormalities are noted. Prothrombin and partial thromboplastin times

are prolonged. The patients abnormalities are likely to improve with treatment using a

cofactor for which process?

A- Carboxylation of prothrombin

B- Conversion of homocysteine to methionine

C- Farnesylation of ras

D- Hydroxylation of procollagen

E- Phosphorylation of pyruvate dehydrogenase

34

106- A 45-year-old woman has a 7-month history of moderate abdominal pain that is exacerbated

by eating. She has used alcohol heavily for the past 10 years. X-ray films of the abdomen

show diffuse retroperitoneal calcifications. The most likely diagnosis is:

A- Cholangitis

B- Chronic pancreatitis

C- Pancreatic islet cell neoplasm

D- Perforated gastric ulcer


107- The absorption of calcium from the intestinal tract results principally from the direct action

of which of the following?

A- Calcitonin

B- cAMP

C- 1,25-dihydroxycholecalciferol

D- 25-hydroxycholecalciferol

E- Parathyroid hormone

108- A 3-week-old infant has milk intolerance due to a defect in the enzymes that digest lactose.

This enzyme is located at which of the following sites in enterocytes?

A- At the apical surfaces

B- At the basolateral surfaces

C- Within the Golgi complex

D- Within lysosomes

E- Within peroxisomes

109- A 40-year-old woman has a fever and petechial. Laboratory studies show:

Hemoglobin: 9 g/dL (N = 12-15.6)


Neutrophils: 10%

Lymphocytes: 20%

Blasts: 70%


A peripheral blood smear shows

Auer rods. The most likely diagnosis

is:

A- Acute lymphoid (lymphoblastic)

leukemia

B- Acute myeloid (myeloblastic) leukemia

C- Chronic lymphocytic leukemia

D- Chronic myelogenous leukemia

E- Leukemoid reaction

35

110- In the previous case, treating the diagnosed condition appropriately is most likely to be

complicated by:

A- Metabolic acidosis with increased anion gap

B- Kernicterus

C- Disseminated intravascular coagulation

D- Thrombocytosis

E- Splenic infarction

111- A 34-year-old woman comes to the physicians office because she has had a cough, fatigue,

low grade fever, mild dyspnea, and aching joints for the past month. Physical examination

shows no abnormalities. X-ray film of the chest shows bilateral hilar lymphadenopathy with

mild diffuse parenchymal infiltrates. Examination of tissue obtained by transbronchial biopsy

during bronchoscopy shows noncaseating granulomas. Which of the following is the most

appropriate therapy?

A- Azathioprine

B- Methotrexate

C- Prednisone

D- Rifampin

E- Zidovudine

112- Fetal and maternal erythrocytes have the same concentration of 2,3-biphosphoglycerate.

Whoever, compared with maternal hemoglobin (HbA), fetal hemoglobin (HbF) has a higher

affinity, which facilitates transplacental diffusion of oxygen. The presence of which of the

following polypeptide chains in HbF accounts for this finding?

A- Alpha chains alone

B- Beta chains alone

C- Gamma chains

D- Both alpha and beta chains

36

113- A 64-year-old woman comes to the physicians office because of gradually worsening

abdominal cramps, nausea, diarrhea, flushing of the skin and heart palpitations. 24 hour

urinary 5-hydroxyindolacetic acid excretion is increased. The most likely cause of these

findings is a neoplasm originating in which of the following organs?

A- Adrenal gland

B- Esophagus

C- Kidney

D- Small intestine

E- Spleen

F- Thyroid

114- A hyperactive 6-year-old girl develops microcytic anemia, cerebral edema, and ataxia.

Determination of which of the following serum enzyme activities is most likely to confirm

the diagnosis?

A- 5-aminolevulinic acid (-ALA) dehydrogenase (dehydratase)

B- Glucose 6-phosphate dehydrogenase

C- Glutathione transferase

D- Lactate dehydrogenase

E- Pyruvate kinase

115- An alcohol-dependent 40-year-old woman who is a health care worker has had episodic

symptoms of hypoglycemia for the past year. During one of those episodes, plasma glucose

concentration is decreased, plasma insulin concentration is increased, and serum C-peptide

concentration is not detectable. Which of the following is the most likely cause of the

hypoglycemia?

A- Acute hepatic failure

B- Ingestion of a sulfonylurea

C- Pancreatic beta cell neoplasm

D- Retroperitoneal fibrosarcoma

E- Surreptitious (factitious) use of insulin

116- A 50-year-old woman is evaluated for occult blood in the stool. Colonoscopy shows a 5-cm

sessile mass with a velvety surface that projects about 2 cm above the mucosa of the

rectosigmoid. Microscopic examination of tissue obtained on biopsy of the mass shows

papillae composed of delicate fibrovascular cores covered by dysplastic columnar

epithelium, a finding consistent with a villous adenoma. This patient is at increased risk for

which of the following colonic neoplasms?

A- Adenocarcinoma

B- Carcinoid

C- Fibrosarcoma

D- Leiomyosarcoma

E- Lymphoma

F- Squamous cell carcinoma

37

117- A 55-year-old man has had patchy leukoplakia (a premalignant lesion) of the anterior floor of

his mouth for 4 years. He now has a raised, firm white lesion in the same area. Examination

of the tissue obtained on biopsy of this new lesion is most likely to show:

A- Aphthous ulcer

B- Burkitts lymphoma

C- Candida infection

D- Kaposis sarcoma

E- Mixed tumor of the parotid gland

F- Squamous cell carcinoma

G- Warthins tumor

118- A 32-year-old man has had malaise, a low-grade fever, and a 4.5 kg (10 lb) weight loss over

the past 3 months. He has unilateral cervical lymphadenopathy. Laboratory studies show:

Hemoglobin: 11 g/dL

Hematocrit: 33%

Mean corpuscular volume: 80 M3

Reticulocyte count: 0.5%

Serum iron: 25 g/dL

Total iron binding capacity: 150 g/dL (N = 250-460)

Examination of tissue obtained on biopsy of a lymph node shows Hodgkins lymphoma,

nodular sclerosing type. The most likely cause of the anemia is:

A- Abnormal utilization of iron

B- Extravascular hemolysis

C- Folate deficiency

D- Iron deficiency

E- Vitamin B6 deficiency

119- What is the mechanism of intravenous heparin in treating deep venous thrombosis?

A- Activation of plasmin

B- Facilitation of inactivation of thrombin by antithrombin III

C- Inhibition of activation of tissue plasminogen

D- Inhibition of vitamin K-dependent coagulation factors

E- Reversible inhibition of protein C and protein S activity

120- Which of the following cells share a common progenitor cell with macrophages?

A- Astrocytes

B- Ependymal cells

C- Microglia

D- Mullers fibers

E- Oligodendrocytes

38

121- A 70-year-old man has severe atherosclerotic disease of the abdominal aorta that obstructs

the ostia of the superior and inferior mesenteric arteries. He has intermittent episodes of

abdominal pain and bloody diarrhea. Which of the following regions of the bowel is likely to

be most severely affected?

A- Ascending colon

B- Descending colon

C- Hepatic flexure

D- Splenic flexure

E- Transverse colon

122- A 45-year-old man has nausea, vomiting, and abdominal pain. He has tachycardia, absent

bowel sounds, and involuntary guarding and rebound tenderness of the abdomen. The most

likely cause of these findings is:

A- Cholecystitis

B- Gastritis

C- Gastroenteritis

D- Peritonitis

E- Small bowel obstruction

123- A 47-year-old man undergoes resection of his entire stomach for intractable bleeding from a

gastric ulcer. After recovery, he is at increased risk for which of the following?

A- Copper deficiency

B- Vitamin A deficiency

C- Vitamin B6 deficiency

D- Vitamin B12 deficiency

E- Vitamin C deficiency

124- Several clinical trials have suggested that retinoic acid (vitamin A) can induce remission in

patients with acute promyelocytic leukemia, evidenced by the decreased number of

myeloblasts in blood and bone marrow. Such remission is related to the ability of retinoic

acid to promote which of the following?

A- Differentiation of leukemic cells

B- Differentiation of monocytes into macrophages

C- Generation of cytotoxic T lymphocytes

D- Production of interferon

E- Repair of DNA damage

125- A 32-year-old man has a family history of bleeding. Partial thromboplastin and bleeding

times are prolonged, aggregation of platelets with ristocetin is absent, and factor VIII

(antihemophilic factor) concentration is decreased. Prothrombin time is normal. The most

likely diagnosis is:

A- Deficiency of antithrombin III

B- Disseminated intravascular coagulation

C- Hemophilia A

D- Hepatic failure

39

E- von Willebrands disease

126- A 25-year-old woman, gravida 1, para 0, who is RH negative delivers a full-term RH positive

neonate. The mother is given prophylactic anti Rho (D) immune globulin immediately post-

partum. During her 2nd pregnancy 3 years later, she is screened each trimester for RH (D)

antibodies. An indirect antiglobulin test done during the 3rd trimester indicates the presence

of anti Rh (D) antibodies in her serum. Which of the following is the most likely mechanism

for the occurrence of these maternal antibodies?

A- Anamnestic (due to previous stimulation) production of maternal anti Rh (D)

immunoglobulin

B- Intrauterine transplacental fetal-maternal hemorrhages during the 2nd pregnancy

C- Residual circulating prophylactic anti Rh (D) immunoglobulin

D- Transplacental passage of fetal IgG anti Rh (D) antibodies

127- A 42-year-old man with pneumococcal pneumonia has acute fibrinous pleuritis. Which of the

following proteolytic enzymes is required to eliminate the exudate and restore normal

pleural anatomy?

A- Collagenase

B- Plasmin

C- Stromeolysin

D- Thrombin

E- Lipase

128- A 10-year-old girl has fever, fatigue, and easy bruising. Laboratory studies show:


Hematocrit: 20%



A photomicrograph of the bone marrow obtained on biopsy is shown. The most likely

diagnosis is:

A- Aleukemic leukemia

B- Aplastic anemia

C- Immune thrombocytopenic purpura

D- Myelofibrosis

E- Vitamin B12 deficiency

40

129- Actively dividing fibroblasts in culture are transferred from a 37 C incubator to a 0 C ice bath,

and colchicine is added to the culture medium. After 30 minutes, many cells have been

arrested in mitosis. Which of the following cytoskeletal proteins is most likely to be

involved?

A- Actin

B- Desmin

C- Dynein

D- Keratin

E- Kinesins

F- Lamins

G- Myosin

H- Neurofilament proteins

I- Tubulin

130- A 27-year-old man with recurrent peptic ulcer disease has a small pancreatic neoplasm that

produces large amounts of gastrin. While awaiting operation, the patient should be treated

with:

A- Chenodeoxycholic acid

B- Methacoline

C- Metoclopramide

D- Omeprazole

E- Sucralfate

131- A 32-year-old woman who is an editor for a publishing company comes to the physician

because of intermittent diarrhea for the past 10 years, which occurs 3-4 times per year, lasts

2-4 days, and is associated with deadlines at work. During these episodes, the stool is loose

and contains no melena or bright blood. Between episodes of diarrhea, she occasionally has

one bowel movement every 4-7 days, the stool is hard and pellet-like. She drinks 1 glass of

wine daily. Physical examination shows no abnormalities. Laboratory studies show:


Hematocrit: 43%


Erythrocyte sedimentation rate: 7 mm/h

Which of the following is the most likely diagnosis?

A- Crohns disease

B- Colon cancer

C- Diverticulitis

D- Irritable bowel syndrome

E- Small bowel lymphoma

F- Ulcerative colitis

41

132- An adults hemoglobin is 98% saturated with oxygen, PaO2 is normal, but arterial oxygen

content is decreased. The most likely cause of this condition is:

A- Anemia

B- Arteriovenous shunt

C- Hemoglobinopathy

D- High-altitude hypoxia

E- Pulmonary diffusion defect

133- A 58-year-old male is seen because of intermittent claudication in lower limbs. His doctor

prescribes Cilostazol, a drug that will inhibit platelet aggregation and cause arteriolar

vasodilation. Which of the following is the mechanism of this drug?

A- Inhibition of COX-2, deceasing Prostacyclin (PGI2)

B- Enhancement of insoluble fibrin monomer formation

C- Increased platelet release of ADP, increasing GP IIb/IIIa expression

D- Inhibition of phosphodiesterase III, increased AMP in platelets and blood vessels

E- Increasing the release of von-Willebrand factor

134- A 62-year-old female is found to have a bruit on her left carotid artery. Angiography

confirms atherosclerosis. Her physician explains to her that the best course of action would

be surgical removal of the atheroma because it increases her risk of stroke, and immediately

prescribes aspirin in combination with another anti-platelet agent with vasodilator

properties, dipirydamole, explaining to her that this will decrease such risk before surgery.

Which of the following describes the mechanism of dipyridamole?

A- Inhibits thromboxane synthase, phosphodiesterase 5, and adenosine deaminase

B- Inhibits COX-2 and nitric oxide synthase

C- Increases the expression of GP Ia and GP Ib

D- Decreases megakaryocyte production by the bone marrow

E- Activates anti-thrombin III and plasminogen

Documents

GI and Hemagology & Oncology Quiz