IMCQ
A 16-year-old girl is brought to the physician because of primary amenorrhea. She is phenotypically female, and she dresses, behaves, and has the psychosocial outlook of a normal teenage girl. Physical examination shows a female external genitalia, but her vagina ends as a blind pouch. MR imaging of the pelvic region shows no internal genitalia but there are intrapelvic gonads. Histologic examination of these gonads shows testicular tissue. Karyotype of the patient is 46,XY. Which of the following sets of plasma hormonal changes is most likely in this patient? A. High Testosterone, High LH & Normal FSH B. High Testosterone, Low LH & Low FSH C. Low Testosterone, Low LH & Low FSH D. Low Testosterone, High LH & High FSH E. Normal Testosterone, Normal LH & High FSH
A
A 27-year-old man comes to the physician because of a low sperm count. Physical examination shows absence of testes in his scrotum. Ultrasound examination shows that his left testis is located in the inguinal canal and right testis near the internal inguinal ring. Plasma testosterone and pituitary gonadotropins are normal. Low sperm count of this patient is related to the failure of which of the following? A. Maintaining lower temperature in the testes B. Secretion of androgen binding protein C. Secretion of Inhibin D. The blood-testis barrier E. Conversion of testosterone to DHT
A
A 28-year-old man is being evaluated for a low sperm count. He had mumps orchitis when he was 14. Serologic studies show anti-sperm antibodies. Normal testicular histology is shown in the attached figure. Damage to a structure formed by which of the following cells is most likely the cause of his infertility? SEE IMAGE A. Cell A B. Cell B C. Cell C D. Cell D E. Cell E
A
A 30-year-old woman comes to her primary care physician complaining of recurrent white oral patches accompanied by joint pains, especially in her knees and wrists. She also states a 10-year history of Hypertension, which was been managed with Lisinopril up until two months ago when another doctor decided to change her to Hydralazine, shortly after which she started presenting with the current signs and symptoms. On examination, the doctor noticed presence of a rash over the bridge of her nose. Taking into consideration this patient's history and physical examination, what test would confirm the diagnosis ? A. Anti-histone Ab B. Anti-Centromere Ab C. Anti-SSA Ab D. ANA Ab E. Anti-Jo Ab
A
A 32-year-old man comes to the physician because of a 3-month history of visual disturbances and headaches. He also has recurrent colicky pain in his left flank. He was diagnosed to have renal stones 6 months ago. MRI of his head shows enlargement of the pituitary gland. Perimetric studies show visual field defects. An x-ray of the abdomen shows radio-opaque shadows in the left kidney. Lab studies show elevated serum calcium and PTH. This patient is at risk to develop which of the following? A. Gastrinoma of the pancreas B. Papillary carcinoma of the thyroid C. Follicular carcinoma of the thyroid D. Medullary carcinoma of the thyroid E. Pheochromocytoma
A
A male child with recurrent infections comes to your clinic. His blood is sent for flow cytometric study to enumerate and phenotype peripheral blood WBC. The absolute lymphocyte count was 800 cells/mm3, with approximately equal numbers of B and NK cells. T cells were absent. What is the most likely genetic defect ? A. IL-7R deficiency B. ADA deficiency C. γc deficiency (X-SCID) D. JAK-3 deficiency E. IKBKB mutation
A
A 51-year-old man has a history of chronic diarrhea with weight loss for over a year. There was an increase in the osmotic gap (> 125) and stool fat 27 g/24 hours (normal less than 7 g/day), stool weight is 500gm/day. The D-xylose test showed presence of D-Xylose in the urine. Which of the following is most likely diagnosis in this patient? A. Pancreatic insufficiency B. Lactose intolerance C. Laxative abuse (for secondary gain) D. Chronic secretory diarrhea E. Irritable bowel syndrome - diarrhea predominant
A Rational: Chronic Osmotic diarrhea, stools with high fat content suggests indigestion. D-xylose show up in the urine suggests intestinal surface is normal, therefore the likely defect may be with the Pancreas ability to secrete digestive enzymes.
A 32-yr-old woman comes because of chronic fatigue, malaise and right upper quadrant pain. Her liver enzymes, AST & ALT are elevated. She is cured of infection after appropriate treatment for 3 months. The pathogenic agent causing her illness is found to be a virus that does not make a DNA copy of itself in the host. Which of the following is most likely? A. Hepatitis-C B. HIV C. Hepatitis-B D. Hepatitis-A E. CMV
A Feedback:Hepatitis C is a RNA, positive stranded, flavivirus which can be cured with appropriate treatment. Initial symptoms of hepatitis C are often extrahepatic, most commonly involving the joints, muscle, and skin which may manifest as Arthralgias, Paresthesias, Myalgias and Pruritus
A 40 -year-old man comes to the physician because of decrease appetite, nausea, and abdominal discomfort. Patient is a social drinker but admits consuming large amounts of alcohol recently. His blood pressure is 130/82 mmHg and pulse is 86/min; Physical examination shows hepatomegaly. He undergoes a liver biopsy which shows macrovesicular steatosis with hepatocytes containing eccentric position nucleus with cytoplasmatic vacuoles. Which of the following is the most likely cause of this patient's condition? A. Increased NADH production B. Increased phospholipid catabolism C. Enhanced lipoprotein assembly D. Stimulation of autophagy E. Decrease triglyceride synthesis
A Feedback:Increased NADH production. Decreased fatty acid oxidation occurs secondary to an excess NADH. This results in macrovesicular steatosis.
A 55-year-old man presents to his family physician for epigastric abdominal pain associated with diarrhea. Physical exam reveals abdominal tenderness without rebound or rigidity. He has been smoking 2 packs per day for the past 10 years. He occasionally drinks alcohol. He denies illegal drug use and multiple sexual partners. His past history is significant for chronic duodenal ulcers. The endoscopy shows prominent gastric folds, chronic duodenal ulcer, and upper jejunal ulceration. What would be the best initial step to confirm the diagnosis? A. Fasting serum gastrin concentration B. Serum chromogranin A C. Secretin stimulation test D. Gastric acid secretion study E. Serum VIP levels
A Rational : Adult with epigastric pain and diarrhea, abdominal tenderness, h/o duodenal ulcer, endoscopy finding of multiple duodenal ulcers, jejunal ulcers. based on the findings, the likely appropriate test would be Fasting Gastrin to look for Gastrinoma.
A 55-year-old man comes with an 18-month history of progressive dysphagia to both liquids and solids, heartburn, regurgitation of food and weight loss. Barium swallow study shows a spasm of the lower esophageal sphincter (LES) with dilatation and stasis of barium in the lower esophagus. Which of the following is the most likely cause for his condition? A. Defective myenteric plexus in LES B. Tightening of phrenoesophageal membrane C. Defective Meissner's plexus in LES D. Plummer vinson syndrome E. Defective vagal nerve function
A Rational : Chronic progressive dysphagia to both solids and liquids, barium study finding of Lower Esophageal sphincter spasm and dialated esophageal lumen in an adult here likely suggestive of achalasia cardia.
42-year-old Caucasian male presents with a worsening heartburn for the last 2 years. He says that the symptoms are worst when he lies down. He has tried number of over the counter antacids with no success. Investigations suggest the diagnosis of hiatus hernia, however the patient is reluctant to take any sort of treatment. If his condition is left untreated, in long run, he is at risk for which of the following? A. Adenocarcinoma of esophagus B. Mallory Weiss syndrome C. Aspiration pneumonia D. Peptic ulceration E. Squamous cell carcinoma of esophagus
A Rational : Hiatal hernia increases the risk of Adenocarcinoma of the esophagus.
A 21-year-old girl comes because of a 2-month history of passing bulky, floating, foul smelling stools, flatulence, weight loss, bone pains, pallor and fatigue. Physical examination reveals loss of subcutaneous fat, pallor, hyperkeratosis and abdominal distension with hyperactive bowel sounds. The laboratory studies show: Serum iron: 25ug/dL (N: 50-150), serum ferritin: 25 ng/mL(N:100-200) and serum total iron binding capacity: 600 ug/dL (N:300-360 ug/dL). PT is prolonged. Serological test is most likely positive for which of the following? A. Anti-tissue transglutaminase IgA antibodies B. Anti-Scl-70 antibodies C. Antinuclear antibodies D. Anti-centromere antibodies E. Anti-mitochondrial antibodies
A Rational : Recent onset diarrhea, fat, mineral and vitamins malabsorption, likely cause can be celiac disease. Other options do not support the history, as other organ systems related presentation not shown.
A 16-year-old girl is diagnosed to have diabetic ketoacidosis. Increased activity of which of the following enzymes at pathway G is most likely in her? SEE IMAGE A. Acetyl Co-A carboxylase B. Pyruvate carboxylase C. Phosphoenolpyruvate carboxykinase D. Hormone sensitive lipase E. Pyruvate kinase
B
A 22-year-old woman comes to the physician because of menstrual irregularities and progressive increase in body hair like male pattern. Her blood pressure is 160/92 mmHg. Physical examination shows masculinized features, hyperpigmentation of skin, acne and hypertrophy of the clitoris. Laboratory studies show high serum sodium, low serum potassium and metabolic alkalosis. Her karyotype is 46,XX. Elevated serum level of which of the following is also most likely in this patient? A. Renin B. Deoxycortisol C. Cortisol D. Corticosterone E. Aldosterone
B
A 23-year-old man comes to the physician because of delayed puberty. There is no history of headaches, visual disturbances or chronic sinusitis. His elder brother also has decreased sense of smell and delayed onset of puberty. Physical examination shows tall stature, underdeveloped male secondary sex characteristics and small testicles. He has a markedly reduced sense of smell. Blood studies show low testosterone and LH levels. Which of the following gene defects is most likely in this patient? A. Long arm of Y chromosome B. KAL gene C. AR gene D. GnRH-receptor gene E. AZF gene deletion
B
A 26-year-old recent immigrant, a G2P1 woman, comes for her first prenatal visit at 31 weeks of gestation. On review of her laboratory panel, her blood type was group O Rhesus D-negative. Her atypical antibody screen (Indirect Coomb's test) was positive in a dilution of 1: 512. She did not receive RhoGAM during her last pregnancy. Serial ultrasound scan revealed gross fetal edema and ascites at 33 weeks gestation. Which of the following pathogenetic mechanism is responsible for fetal ascites on ultrasound? A. Immune suppression of fetal erythropoiesis B. Severe hypoproteinemia C. Impaired renal function D. Complement-mediated hemolysis E. Unconjugated hyperbilirubinemia
B
A 28-year-old man comes to the physician because of erectile dysfunction since puberty. PE shows underdeveloped male genitalia, scanty pubic and axillary hairs, gynecomastia and small testes. Vasography suggests nonobstructive azospermia. Chromosomal analysis shows 46,XX karyotype. Which of the following genetic defects best explains his condition? A. Nondysjunction during meiosis B. Chromosomal translocation C. Androgen receptor insensitivity D. Deletion of long arm of Y chromosome E. Deletion of AZF region of Y chromosome
B
A 28-year-old woman (G1 P0) comes because of vaginal bleeding of two hours duration. Her last menstrual period was 8 weeks ago and home pregnancy test last week was positive. Vaginal bleeding is mild and is not associated with pains. Ultrasound scan confirms an intrauterine pregnancy. She develops abdominal cramps and passage of clots six hours later. Which of the following pathogenetic mechanisms is most commonly responsible for the etiology of her condition? A. Estrogen deficiency B. Chromosomal abnormality of the fetus C. Antiphospholipid antibody D. X-linked recessive disorder E. Rhesus isoimmunization
B
A 29-year-old nulliparous woman is being evaluated for heavy menstrual bleeding associated with passage of clots and severe, cramping pelvic pains. Her uterus is enlarged, corresponding to 14 weeks' size, irregular in outline, nodular and hard in consistency. A diagnosis of uterine fibroid is made. Which of the following locations of uterine fibroid is most likely associated with her menstrual disturbance? A. Intramural B. Submucous C. Subserous D. Pedunculated E. Cervical
B
A 35-year-old man comes with severe pain in the right iliac fossa of 24 hrs duration. He reports loss of appetite, weight loss, and increasing lethargy over the preceding months, with intermittent constipation. Physical examination shows numerous inexpert tattoos, cachexia, rash, right iliac fossa tenderness, and lower limb sensory neuropathy. Laboratory studies show Leukocytosis, ↑ C-reactive protein, ↑ ESR, ↑ Rheumatoid factor; Low C3 and C4 levels; Low titer of ANCA. A CT scan of his abdomen shows old splenic infarction and thickening of ascending colon. A diagnostic laparotomy was performed. Right hemicolon demonstrated acute ischemic necrosis with a stricture indicative of preceding chronic ischemia. This part of the colon was resected. Biopsy of a medium-sized mesenteric artery showed cellular inflammatory infiltrate, intimal proliferation, and thrombosis. What is the most likely diagnosis? A. Giant cell arteritis B. Polyarteritis nodosa C. Takayasu arteritis D. Kawasaki disease E. Microscopic polyangiitis
B
A 35-year-old woman is being evaluated for an unexplained hypertension of 9-month duration. She does not have headache, dizziness, excessive sweating, palpitations, weight change, muscle weakness or menstrual irregularities. Her blood pressure is 186/106 mmHg. Lab studies show: low serum potassium and high serum bicarbonate. Measurement of which of the following would be the next step to confirm the diagnosis? A. Plasma metanephrine B. Aldosterone to Renin ratio C. Cortisol D. Renin E. Repeat potassium F. Aldosterone
B
A 37-year-old nulliparous woman comes because of inability to conceive for the past three years. She also complains of severe, deep dyspareunia and painful menstruation. Breast examination reveals normal findings. Pelvic examination is normal. She has acanthosis nigricans and hirsutism with increased acne. Her husband's seminal fluid analysis reveals normal values. Her pelvic ultrasound scan shows enlarged ovaries with 14 - 15 ovarian cysts that measures 6 mm in diameter. Which of the following pathogenetic mechanism is most likely responsible for initiating her condition? A. Impaired sperm motility in the female genital tract B. Insulin resistance C. Chronic anovulation D. Obliteration of the endometrial cavity E. Change in consistency of cervical mucus
B
A 51-year-old man comes to the physician because of a 5-month history of headache, blurred vision and frequent urination. His blood pressure is 158/94 mmHg. His BMI is 37 kg/M2 (normal: 19-25). Physical examination shows increased pigmentation around his neck and axillae. Laboratory studies show: Fasting blood glucose of 240 mg/dL (normal: 90-110) and serum free fatty acid of 2.4 mmol/L (normal: 0.05-0.72). Which of the following cellular signaling mechanisms is most likely active in him? A. Tyrosine kinase mediated insulin receptor substrate phosphorylation B. Serine kinase mediated insulin receptor substrate phosphorylation C. Direct stimulation of insulin receptor by plasma free fatty acids D. Incorporation of GLUT-4 transporters to the cell membrane E. Adenylyl cyclase mediated diacyl glycerol phosphorylation
B
A 61-year-old woman develops abdominal discomfort, loss of appetite and weight loss for the past 6 months. Her pelvic ultrasound reveals bilateral ovarian tumors. Histology of the ovarian tumor shows poorly-differentiated tumor cells arranged in cords with cytoplasmic inclusions of mucin that displace the nuclei to the periphery of the cells. The results of the upper GI series are suggestive of a gastric malignancy. What is the most likely diagnosis of her condition? A. Brenner tumor B. Krukenberg tumor C. Choriocarcinoma D. Mucinous adenocarcinoma E. Hilus cell tumor
B
A 63-year-old man comes to the physician because of a nodule in the front of his neck. Physical examination shows a hard nodule for palpation in the left lobe of his thyroid. Laboratory studies show normal serum T3 and T4. A biopsy of this nodule is shown in the attached figure. Which of the following is the most likely diagnosis? SEE IMAGE A. Follicular carcinoma B. Papillary carcinoma C. Medullary carcinoma D. Anaplastic carcinoma E. Follicular adenoma
B
Physical examination of a 27-year-old man in a health fair shows a solitary nodule in his right lobe of thyroid. Patient has no symptoms and his vital signs are normal. A thyroid scan shows normal uptake of radioactive iodine by the nodule. Which of the following is the most likely diagnosis? A. Hashimoto's thyroiditis B. Follicular adenoma C. Subacute thyroiditis D. Medullary carcinoma E. Papillary carcinoma F. Follicular carcinoma
B
A 52-year-old man is brought to the emergency department because of altered mental status and abdominal distension. He is and unable to provide an adequate information. He has a past history of alcohol abuse and of chronic hepatitis B. Physical examination shows an ill looking man with a sweet, feculent odor breath, gynecomastia and palmar erythema. The abdomen is severely distended with dilated periumbilical veins, splenomegaly; pitting bilateral lower extremity edema. Neurologic examination shows disorientation and asterixis;. Which of the following findings in this patient has the same pathogenesis as his palmar erythema? A. Lower extremity edema B. Spider angiomata C. Dilated periumbilical veins D. Splenomegaly E. Altered mental status F. Sweet, feculent breath odor
B Feedback: Hyperestrogenemia also may explain spider angiomata and palmar erythema.
A 59-year-old woman comes to the emergency room because of severe colicky upper abdominal pain, nausea and vomiting. She has a past history of similar abdominal pain. She does not use illicit drugs nor spoke. Physical exam shows right upper quadrant tenderness. Ultrasound of the abdomen shows several mobile echogenic foci within the gallbladder lumen. A cholecystectomy is performed. Which of the following sets of conditions is most likely present within this patient's gallbladder? A. ↑Bile acids ↓Phosphatidylcholine ↓Cholesterol B. ↓Bile acids ↓Phosphatidylcholine ↑Cholesterol C. ↑Bile acids ↑Phosphatidylcholine ↓Cholesterol D. ↑Bile acids ↓Phosphatidylcholine ↑Cholesterol E. ↓Bile acids ↑Phosphatidylcholine ↑Cholesterol
B Feedback:Supersaturationof bile with cholesterol is essential for the formation of cholesterol gallstones
A 23-year-old male presents to his family physician because of yellowing of his skin a day before his USMLE step 1 exam. He had a similar episode two years ago after the Manhattan marathon. He is a social drinker, 3 days ago he had consumed 6 beers. His physical examination is unremarkable except for mild jaundice. Lab investigation shows total bilirubin 2.8 mg/dL (0.8-1.0 mg/dL), indirect bilirubin 2 mg/dL, AST 26 U/L (8-20 U/L), ALT 32 U/L. This patient most likely suffers from which of the following? A. Crigler-Najjar syndrome B. Gilbert syndrome C. Wilson's disease D. Dubin-Johnson syndrome E. Alcoholic hepatitis
B Gilbert syndrome is a common benign inherited disorder that causes unconjugated hyperbilirubinemia due to bilirubin UDP-glucuronosyltransferase (UGT) deficiency. Kernicterus rarely occurs
A 25-year-old male presents with fatigue, shortness of breath on exertion and dizziness for 2 months. He also reports stools that are voluminous, non- bloody and frothy in nature. He noticed that his clothes are now too big and that he has intermittent bone pain. Physical examination reveals a young man with muscle wasting and pallor. investigation shows FOBT- negative, microcytic hypochromic RBCs without sideroblast, low serum iron and increased TIBC. Which of the following diseases is responsible for his anemia? A. Chronic Pancreatitis B. Celiac Disease C. Haemochromatosis D. Colon Cancer E. lead poisoning
B Rational : Predominant GI system symptoms of malabsorption leading to mineral, vitamin deficiency findings, weight loss, negative FOBT suggests Celiac disease as the best option.
A 1-month-old child is brought to the physician with a bacterial infection. On questioning the mother reveals decreased feeding,low weight gain, history of recurrent bacterial, fungal, and viral infections. Blood is drawn and sent for laboratory analysis, which reveals all levels of immune cells (eg. T lymphocytes, B lymphocytes) are low. Which of the following conditions is most likely to have caused the patient's symptoms? A. Thymic aplasia B. Bruton's agammaglobulinemia C. Severe combined immunodeficiency D. Chediak-Higashi disease E. Wiskott-Aldrich syndrome
C
A 2-yr-old girl is brought to the pediatrician with a long history of recurrent painful boils on her skin. She has silver hair and pale skin. A neutrophil from the peripheral blood is shown in the attached figure. Her condition is the result of which of the following? SEE IMAGE A. Inability to absorb dietary copper B. Defective melanin production C. Defective microtubule function D. Impaired immunity to encapsulated organisms E. Poor opsonization of bacteria
C
A 26-year-old man and his wife have been trying to start a family for the past 2 years without success. His past medical history is significant for receiving chemotherapy for acute myelogenous leukemia at the age of 23. Physical examination shows normal post-pubertal male secondary sexual characteristics. His serum testosterone is 17 nmol/L (Normal: 9-25 nmol/L); serum LH is 7 IU/L (Normal: 2-9 IU/L) and a serum FSH is 34 IU/L (Normal: 2-9 IU/L). What is the most likely cause of infertility in this man? A. Defective Leydig cell function B. Primary pituitary hypofunction C. Defective seminiferous tubular function D. 5-alpha reductase deficiency E. Primary hypogonadism
C
A 27-year-old woman comes because of a 6-month history of secondary amenorrhea. She has a 4-year old child. On physical examination, her vital signs are normal. Breast examination reveals expressible galactorrhea from both breasts. Her pelvic examination reveals normal findings. Examination of her visual fields shows bitemporal hemianopsia. Which of the following pathogenetic mechanism is most likely responsible for her infertility? A. Impaired ciliary transport of the fertilized ovum B. Impaired implantation due to endometrial damage C. Ineffective dopamine inhibition of the pitutary D. Impaired synthesis of ovarian steroids E. Impaired synthesis of adrenocortical hormones
C
A 31-year-old woman (G2 P0 Ab1) comes to the birthing unit at 34 weeks gestation complaining of "waking up in a pool of blood". She denies any history of trauma, pain or uterine contractions. She had an uncomplicated induced abortion at 10 weeks gestation 10 years ago. Her pulse is 90/min and BP 120/80 mmHg. Examination reveals a soft uterus and a fetus in oblique lie. Fetal heart tones are normal. Her vulva is smeared with blood. Which pathogenetic mechanism best explain the etiology of her condition? A. Fetal congenital malformation B. Increased placental mass C. Abnormal placental Implantation D. Obliteration of the endometrial cavity E. Abnormal fetal lie
C
A 33-year-old woman comes to the physician because of a 5-week history of palpitations, restlessness, sweating, weight loss and fine tremors of her hands. Her temperature is 38°C, pulse is 102/min and blood pressure is 130/80 mmHg. Physical examination shows fine tremors of hands, lid lag and stare look, pretibial myxedema and a diffusely enlarged non-tender thyroid. A bruit is heard over the gland. Blood studies show an undetectable serum level of thyroid-stimulating hormone (TSH) and an increased free T4. Thyroid gland uptake in radionuclide scanning is shown in the figure attached. Which of the following best explains the pathophysiological basis of the eye findings in this patient? SEE IMAGE A. Retro-orbital adipose tissue deposition B. Retro-orbital hemorrhage C. Retro-orbital mucopolysaccharide infiltration D. Oculomotor nerve palsy E. Internuclear ophthalmoplegia
C
A 34-year old Caucasian male experiences mild urethritis that resolves spontaneously. Urethral swabs obtained from the patient are negative for gonococcal infection. Two weeks later, he develops acute conjunctivitis, right knee pain and vesicular rash on his palms and soles. This patient's condition is most likely to be associated with which of the following? A. Hyperparathyroidism B. Polymyositis C. Sacroilitis D. Esophageal dysmotility E. Tabes dorsalis
C
A 41-year-old man comes to the physician because of tiredness, weight gain, bradycardia, hoarseness of voice, constipation and cold intolerance. He also has gynecomastia, galactorrhea and decreased libido. Laboratory studies show a markedly decreased serum thyroid stimulating hormone (TSH). Which of the following additional lab findings is also most likely? A. Increased T4 B. Increased T3 C. Increased TRH D. Increased GnRH E. Increased CRH
C
A 45-year-old woman comes to the physician because of a 2-week history of pain in her right middle finger. She also has a history of recurrent kidney stones for the last one year. Physical examination shows tenderness in the proximal phalanx of her right middle finger. Laboratory studies show: Serum calcium: 13.7 mg/dL (N=8.5-10.5), Serum creatinine: 1.1 mg/dL (N=0.1-1.2), Serum albumin: 4.8 g/dL (N=4.5-6), Serum PTH: Elevated. Which of the following lab findings is also most likely? A. Increased radio-density of bones on X-ray B. Elevated urinary hydroxyproline C. Elevated 24-hour urinary phosphate excretion D. Long QT-interval in ECG E. Elevated serum alkaline phosphatase
C
A 54-year-old woman comes to the gynecological clinic because of hot flashes and insomnia for the past one year. She also complains of decreased drive and loss of libido. Her menstrual periods became irregular three years ago and ceased completely 15 months ago. Which of the following findings on her serum hormonal assay will confirm her diagnosis? A. Low FSH and low estrogen levels B. High LH and low estrogen levels C. High FSH and low estrogen levels D. High FSH and high estrogen levels E. High LH and high androgen levels
C
A 62-year-old nulliparous Caucasian woman comes because of postmenopausal bleeding. She states that she was treated twice for infertility with ovulation induction medications. Her menarche occurred at the age of 10 and attained menopause at the age 54 years. Her medical history is significant for well controlled hypertension and Type-2 diabetes mellitus. On physical examination, she is obese (BMI 32kg/m2). Her vital signs are normal. Speculum examination reveals normal vulva, vagina and cervix. Her uterus is normal in size. Which of the following investigation would be diagnostic of her condition? A. HbA1C B. Pelvic ultrasound scan C. Endometrial biopsy D. Papanicolaou smear E. CA 125
C
A 63-year old man was brought to the emergency room because of vomiting of large amount of blood. The patient died two days later. An autopsy was performed and the gross examination of the liver is shown in the attached figure. This patient condition is most likely the result of which of the following processes? SEE IMAGE A. Pigment accumulation within the liver B. Granulomatous destruction of the bile ducts C. Fibrosis and nodular parenchymal regeneration D. High-grade venous congestion and centrilobular liver cell atrophy
C Feedback:Fibrosis and nodular parenchymal regeneration. Cirrhosis represents a late stage of progressive hepatic fibrosis characterized by distortion of the hepatic architecture and the formation of regenerative nodules. Major complications of cirrhosis include Variceal hemorrhage, Ascites, Spontaneous bacterial peritonitis, Hepatic encephalopathy, Hepatocellular carcinoma, Hepatorenal syndrome, Hepatopulmonary syndrome.
A 50-year-old male is brought to the emergency room because of dyspnea and jaundice. Has a past history of prolonged neonatal jaundice. He does not smoke nor use any recreational drug. He drinks 4-5 glasses of wine a week. His temperature is 37C, pulse 76/min, blood pressure 100/80 mm Hg. Physical examination shows increase in anterior to posterior diameter of lung, diffuse wheezing, and diffusely diminished breath sounds. This patient most likely suffers from which of the following disorder? A. Gilbert's syndrome B. Dubin-Johnson's syndrome C. Alpha-1-antitrypsin deficiency D. Crigler-Najjar syndrome type 1 E. Wilson's disease
C Patient presented with signs and symptoms suggestive of COPD and liver disease with past history of neonatal jaundice
A 53-year-old man is brought to the emergency room because of severe mid-epigastric abdominal pain that radiates to the back. The pain improves when the patient leans forward and worsens with deep inspiration and movement. He also complains of nausea, vomiting, and anorexia. He has a history of recent heavy alcoholic intake this past week. His temperature is 38.8C, pulse 120/min, blood pressure 90/58 mm Hg. Physical examination shows tenderness over the epigastrium. CT of the abdomen shows pancreatic enlargement. The activation of which of the following most likely initiated this patient's condition? A. Chymotrypsinogen B. Lipase C. Trypsinogen D. Proelastase E. Amylase
C Premature activation of proteolitic enzymes e.g. trypsinogen within the substance of the pancreas unleash proenzymes (e.g., phospholipases and elastases), leading to tissue injury and inflammation. Abdominal pain (cardinal symptom) in acute pancreatitis is characteristically dull, boring, and steady; usually sudden in onset and gradually becoming more severe until reaching a constant ache; most often located in the upper abdomen and may radiate directly through to the back. Other symptoms maybe nausea and vomiting, sometimes with anorexia,Diarrhea
A 57-year-old white man presents with weight loss, abdominal pain and diarrhea with bulky, foul smelling stools, abdominal distension and flatulence. He also has arthralgias and chronic cough. Physical examination reveals generalized lymphadenopathy, skin hyperpigmentation and a diastolic murmur. Small bowel biopsy shows yellowish color of villi with numerous PAS-positive materials in lamina propria and villous atrophy. What is the most likely diagnosis in this patient? A. Crohn's disease B. Cystic fibrosis C. Whipple's disease D. Celiac disease E. Tropical sprue
C Rational : Malabsorption with skin, heart and lymph node involment, PAS positive material in lamina propria on biopsy, suggests Whipple's disease
A 24-year-old man with partial deficiency of 21-Hydroxylase has an elevated plasma level of adrenal androgens. Select the letter in the attached figure that best fits the relationship between plasma testosterone (of testicular origin) and LH in this patient? SEE IMAGE
D
A 28-year-old man comes to the physician because of infertility. Physical examination shows nonpalpable testis on the left side and testis palpable in the superficial inguinal pouch on the right side. Light microscopic examination of his testis shows intratubular germ cell neoplasia. Immunohistochemical staining of these germ cells is most likely positive for which of the following tumor markers? A. Alpha fetoprotein B. Placental acid phosphatase C. Human chorionic gonadotropin D. Placental alkaline phosphatase E. Lactate dehydrogenase
D
A 3-year-old boy presents to the hospital with a severe upper respiratory infection requiring hospitalization. Chart review reveals that he has presented multiple times to the emergency room and primary care physician's office for a variety of infections, including otitis media, upper respiratory infections, pneumonia, and sinusitis. When detailing family history, it is found that his maternal uncle died of an infection as a child. Lab findings include decreased levels of IgG, IgM, and IgA. Analysis of peripheral leukocytes would most likely show what? A. Predominance of immature lymphoblast cells. B. Presence of abnormal giant lysosomal inclusion in granulocytes and platelets. C. Low T cell count. D. Absence of mature B cells. E. Defect in an adhesion protein important for extravasation of phagocytes.
D
A 47-year-old man comes to the physician because of a 6-month history of decreased libido and erectile dysfunction. Physical examination shows mild pallor. Plasma prolactin is elevated. Semen analysis shows a low sperm count. A CT scan of his head shows a mass in the sellar region. Which of the following sets of the hormonal profile is most likely in this patient? A. High testosterone; High LH and High FSH B. High testosterone; Low LH and Low FSH C. Low testosterone; High LH and High FSH D. Low testosterone; Low LH and Low FSH E. Low testosterone; Low LH and High FSH
D
A 53-year-old man comes to the physician because of an 8-month history of painful urination and sexual intercourse, and a dull aching pain in the perineum. There is no history of fever. Digital rectal examination shows a normal prostate. Laboratory studies show: Total white cell count: 6,400/mm3; Culture of midstream urine sample is negative for growth of an organism; Culture of fluid obtained from prostate massage is also negative for any pathogens; Microscopy of this fluid shows 22 white blood cells/high power field. What is the most likely diagnosis? A. Benign prostatic hyperplasia B. Acute bacterial prostatitis C. Chronic bacterial prostatitis D. Chronic non-bacterial prostatitis-Inflammatory type E. Chronic non-bacterial prostatitis-Noninflammatory type
D
A 62-year-old man comes to the physician because of a 4-week history of bone pain, fatigue, nausea and vomiting, constipation and polyuria. Lab studies show pancytopenia. Bone marrow study shows increased plasma cells. His electrocardiogram (ECG) shows shortened QT interval. Which of the following pathogenic mechanisms best explain the clinical features of this patient? A. Elevated PTH B. Increased 1-alpha hydroxylase activity C. Elevated PTHrP from neoplastic cells D. Osteoclast-activating cytokine release E. Vit D synthesis by tumor cells
D
A 67-year-old multiparous woman comes because of abdominal fullness. She attained menopause at the age of 52 years. Physical examination reveals bilateral breast fullness but no lumps, and normal vulva, vagina, and cervix. Pelvic ultrasound shows a solid right ovarian mass measuring 7 cm in diameter. Surgical staging of her tumors reveals an ovarian tumor. Histology of the right ovary shows nests of cancer cells (Call-Exner bodies). Which of the following tumor markers is associated with her condition? A. Lactate dehydrogenase B. β-human chorionic gonadotrophin C. α-fetoprotein D. Inhibin E. Androstenedione
D
An 18-year old female college student is hospitalized because of high fever, headache, and skin rash. She has had these symptoms for the past 24 hours. She has a history of recurrent infections, including bacterial meningitis 6 months ago that was successfully treated with ceftriaxone. She takes no medication at home. She denies recent travel and insect bites. She does not use tobacco, alcohol or illicit drugs. Her temperature is 39.1 C (102.4 F), blood pressure is 104/70 mmHg, and pulse is 110 bpm and regular. General physical examination reveals a petechial rash on the trunk and extremities, including the palms and soles. Neurologic examination shows lethargy, alertness, fluent speech, and ability to follow commands. She has evidence of neck stiffness and photophobia. Which of the following immune system impairments is the most likely explanation for her symptoms? A. Pure T-cell dysfunction B. Ineffective intracellular killing C. Insufficient IgA production D. Inability to form the membrane attack complex E. B Cell functional deficit
D
An 8-year-old girl is brought to the clinic because of a skin rash for the past week. She has been wearing a new pair of earrings received from her best friend as a birthday present. She had no similar episodes in the past. Physical examination shows an erythematous, indurated scaly plaque over her earlobes in a symmetric pattern. Which of the following best describes the mechanism of the reaction in this patient? A. Type I hypersensitivity B. Type III hypersensitivity C. Type II hypersensitivity D. Type IV hypersensitivity E. Type V hypersensitivity
D
Liam is a 25-year-old desk clerk at the local post office who went to see her GP because of a recent fever, night sweats, joint pains and feeling fatigued despite eating her regular meals. On examination, the doctor observed claudication in her arms, a decreased pulse of the brachial artery with a difference of greater than 10 mmHg in systolic pressure between the arms. In addition, there was a bruit over the subclavian arteries and clear breath sounds. An arteriographic study was ordered and the results are shown in the attached figure. There is no past-history of asthma. Which of the following is the most likely diagnosis? SEE IMAGE A. Giant cell arteritis B. Churg-Strauss syndrome C. Temporal arteritis D. Takayasu's arteritis E. Wegener granulomatosis
D
A 35-year-old man is brought to his family physician because of fatigue and severe pruritus that slowly progressive over the past 8 months. He says that pruritus is especially prominent over palms and soles and is unbearable during the night. He was recently diagnosed with inflammatory bowel disease. Laboratory testing shows total bilirubin 1.5 mg/dL (0.1-1.0 mg/dL); Alkaline phosphatase 680 U/L (20-70 U/L); Aspartate aminotransferase 50 U/L (8-20 U/L); Alanine aminotransferase 42 U/L (8-20 U/L). This patient most likely suffers from? A. Primary biliary cirrhosis B. Alcoholic hepatitis C. Budd-Chiari syndrome D. Primary sclerosing cholangitis E. Hemochromatosis
D 70% males, age 20-40, progressive obstructive jaundice, affect intra and extrahepatic ducts with fibrosis of duct causing obstruction
A 43-year-old man comes to the office due to yellowing of the skin over the past several days. He has had no fever or abdominal pain and has not traveled or received blood transfusion. The patient has experienced increased shortness of breath over the past few months. He father died of liver disease because of alcohol abuse. Physical examination show wheezing of both lung field. Which of the following is the most likely underlying cause of this patient symptoms? A. Autoimmune injury of the intrahepatic bile ducts B. Decreased UDP-glucuronosyltransferase activity C. Defective transport and accumulation of coper D. Inherited deficiency of a serine protease inhibitor E. Unregulated GI iron absorption
D Alpha1-antitrypsin deficiency (AATD) is an inherited condition that increases the risk of lung and liver disease. Alpha1-antitrypsin is the prototype member of the serine protease inhibitor (serpin) superfamily of proteins.
A patient is hospitalized for evaluation of a medical condition. A liver biopsy is taken, and light microscopy shows extensive lymphocyte infiltration and granulomatous destruction of interlobular bile ducts. The biopsy was most likely taken from which of the following patients? A. A 35-year-old homeless man with fever, abdominal pain and jaundice B. A 38-year-old man with a long history of ulcerative colitis who has fatigue and an elevated alkaline phosphatase C. A 45-year-old obese woman with fever and a prolonged episode of severe - right upper abdominal pain after fatty meal ingestion D. A 45-year-old woman with a long history of pruritus and fatigue who has pale stools and xanthelasma E. A 65-year-old woman with weight loss, abdominal discomfort, jaundice and an epigastric mass
D Feedback:In PBC the cause of obstruction is granulomatous inflammation destroying the bile duct. Common presentations are pruritus, fatigue
A 40-year-old man comes to his physician because of a fatigue and malaise for the past 6 weeks. The patient has no significant past medical history. He drinks 1 or 2 alcoholic beverages daily and has used illicit intravenous drugs in the past. He has been sexually active with different female partners in the past few months. His family history is significant for diabetes. His temperature is 36.7 C (98 F). blood pressure is 110/70 mm Hg, pulse is 65/min and respirations are 18/min. Physical examination shows tenderness in the right upper quadrant. Which of the following is most likely to be present in this patient? A. Serum anti-HBsAg IgG B. Hepatitis C virus RNA viral load in blood C. Serum anti-hepatitis D virus IgG D. Serum HBsAg E. HAV in the stool
D Feedback:Patient is at risk of hepatitis B infection because of his signs and symptoms and considering his sexual history suggestive of multiple sexual partners. HBsAg is positive in acutely infected and chronically infected patient
A 75-year-old Caucasian man presents with complaint of painless intermittent rectal bleeding. He describes the bleeding as bright red in color. There is no nausea, or vomiting. Physical examination shows no abdominal tenderness. Colonoscopy reveals a cherry red fern-like pattern of blood vessels that appear to radiate from a central feeding vessel. Which of the following is the most likely cause for the bleeding? A. Ischemic colitis B. Carcinoma colon C. Hemorrhoids D. Angiodysplasia E. Diverticulosis
D Rational : Elderly, Painless intermittent bleeding, frank blood, no physical abdominal signs, colonoscopy shows telengiectasias, often suggests vascular malformations like angiodysplasia.
A 32-year-old Caucasian woman comes because of severe heartburn that is resistant to over-the-counter antacids. Physical Exam reveals multiple talangiectasias and ulcerations in her finger tips. Which of the following defects is most likely in this patient? A. Periodic non-peristaltic esophageal muscle contractions B. Increased gastric acid production C. Abnormal location of gastroesophageal junction D. Fibrous replacement of the muscularis of the esophagus E. Increased resting lower esophageal sphincter tone
D Rational: Female Gender, GE-Reflux disease along with talangiectasias and finger ulcerations suggest CREST syndrome.
A 66-year-old woman received and completed a course of amoxicillin (broad spectrum antibiotic) for a recent urinary tract infection. Ten days later she developed a profuse watery, non-bloody diarrhea associated with abdominal cramps. There were some WBCs in the stool. Which of the following is the most likely cause of this patient's diarrhea? A. An acute community-acquired bacterial infection B. E. coli 0157:H7 C. An acute viral infection D. Pseudomembranous colitis related to C.difficle E. Related to the new onset of Crohn's disease
D Rational: Significant history of antibiotics usage within last 2 weeks, non-bloody, profuse watery diarrhea with cramps suggests likely cause being Pseudomembranous colitis.
A 32-year-old nulliparous woman comes to the gynecological clinic because of painful menstruation, infertility and deep dyspareunia of 3 years duration. Pelvic pain precedes menses by 5 days and lasts through her menses. Pelvic examination reveals slightly enlarged left ovary and tender induration of the uterosacral ligaments. Which of the following pathogenetic mechanism is responsible for her menstrual pain? A. Chronic infection and inflammation B. Disordered estrogen-progesterone balance C. Increased gonadotropin secretion D. Increased secretion of prostaglandin E2 E. Ectopic, functional endometrial tissue
E
A 38-year-old woman comes to the gynecological clinic because of excessive, irregular, vaginal bleeding of 6 days duration. There is no associated cramping and no dyspareunia. Her last normal menses was three weeks ago and lasted 4 days. Physical examination reveals no abnormal finding. Serum pregnancy test is negative and pelvic ultrasound scan reveals normal findings. Histology of endometrial biopsy shows proliferative endometrium. Which of the following is the most likely etiology of her condition? A. vonWillebrand disease B. Endometrial hyperplasia C. Atrophic endometritis D. Endometrial cancer E. Dysfunctional Uterine Bleeding
E
A 44-year-old woman complains of sandy feeling in the eyes that has been present for the last year. She also says that she has difficulty swallowing. On examination, bilateral enlargement of parotid glands was noted. What is the single most likely diagnosis? A. Systemic Lupus Erythematosus B. Sarcoidosis C. Primary immunodeficiency D. C1 esterase deficiency E. Sjogren's syndrome
E
A 50-year-old man underwent orchiectomy because of a testicular mass. On cut section, the mass shows solid areas and cystic loculations. Histologic examination shows well-defined cartilage, thyroid, and neural tissues. Areas of clear-cut squamous cell carcinoma are also seen in these sections. Which of the following primary testicular tumors is most likely? A. Dermoid cyst B. Embryonal carcinoma C. Immature teratoma D. Solid mature teratoma E. Teratoma with somatic-type malignancy
E
A 55-year-old man with Autosomal Dominant Polycystic kidney disease with end-stage renal disease receives left kidney transplant. On blood grouping, donor blood group is B positive and recipient is blood group A positive with an HLA match of 6/6. Two hours after the surgery, the patient develops fever and leukocytosis with no urine output. Biopsy of the kidney reveals interstitial hemorrhage with neutrophilic infiltration, edema, vascular necrosis and fibrin-platelet thrombi. Which of the following is the most likely mechanism involved in this condition? A. Hyperacute rejection due to type I hypersensitivity. B. Chronic rejection due to cell-mediated immunity to minor HLA antigens. C. Acute rejection due to cell-mediated immunity. D. Acute rejection due to antibody-mediated immunity. E. Hyperacute rejection due to type II hypersensitivity.
E
A 76-year-old man comes to the physician because of a 6-week history of hematuria and weight loss. Digital rectal examination shows a palpable hard mass arising from his prostate. Histologic examination of a biopsy of this mass shows adenocarcinoma. Which of the following diagnostic findings is most likely in this patient? A. Serum PSA of 9 ng/mL B. Radiolucent foci in skeletal x-ray C. Proteinuria D. Decrease in Testosterone/Estrogen ratio E. Radiodense foci in skeletal x-ray
E
A 37-year-old woman comes to the physician because of a 2-month history of progressive muscle weakness, pigmentation of her knuckles and old scars. Her blood pressure is 98/62 mmHg. Her serum sodium is 128 mEq/L (Normal:135-145) and serum glucose is 60 mg/dL (Normal: 70-90). Sets of options showing changes in ECF/ICF volume and osmolality are shown in the attached table. Which of the options in the table is consistent with her condition when compared with a normal person? MUST SEE GRAPH FOR THIS ONE
E Decreased ECF Volume, ECF Osmolality, Inc. ICF Volume, Dec. ICF osmolality
A 30 year-old woman presents with an 10 month history of periodic bloody diarrhea, flatulence and abdominal pain despite changing to a gluten free diet. Her family history is significant for similar symptoms. Physical examination is unremarkable except for tenderness in the left lower quadrant of the abdomen. A colonoscopy is recommended Which of the following findings would most likely suggest Crohn's disease in this patient? A. Toxic megacolon B. Non-granulomatous transmural inflammation C. Continuous lesions with rectal sparing D. Continuous mucosal involvement E. Granulomatous Transmural inflammation
E Rational : Chronic intermittent bloody diarrhea, celiac disease ruled out , biopsy findings of Granulomatous Transmural inflammation will suggest Crohn's disease.
A 22-year-old man has a history of intermittent dysphagia for the last 2 years. Two years ago an upper GI barium x-ray was done and he was told that it was normal. Nevertheless, his symptoms continued including episodes of brief food impactions which cleared spontaneously. His medical history is significant for hay fever. Dysphagia in this patient is most likely due to which of the following? A. Barrett's esophagus B. Schatzki's ring C. Herpetic esophagitis D. Peptic stricture of the esophagus due to gastroesophageal reflux E. Eosinophilic esophagitis
E Rational : Intermittent dysphagia, H/O Hay fever, normal barium study ( endoscopy would be more suggestive) likely suggests eosinophilic esophagitis.
A 54-year-old women experiences episodes of flushing. It starts in her face and goes from red to deep violet. She also complains of diarrhea, cramps, and nausea. Lab reports a stool osmotic gap of 20mOsm/Kg and an elevated 24-hour urinary excretion of 5-Hydroxyindoleacetic acid. What is the most likely diagnosis? A. Zollinger-Ellison syndrome B. Pheochromocytoma C. Multiple endocrine neoplasia D. VIPoma E. Carcinoid tumor
E Rational: Episodic flushing, Cramps with secretory diarrhea and elevated 5-HIAA suggests Carcinoid tumor.
