FOM - Exam 2
A 15-year-old girl with sickle cell anemia presents with a 2-day history of increased pain in her right hip. Examination reveals limited range of motion and tenderness on palpation. The most appropriate initial imaging study to evaluate her symptoms is: A. X-ray of the hip B. Ultrasound of the hip C. Magnetic resonance imaging (MRI) of the hip D. Computed tomography (CT) scan of the hip E. Bone scan of the hip
A
A 21-year-old woman presents to you with mild fatigue and weakness. Physical examination shows no abnormalities. Her hemoglobin concentration is 10.2 g/dL and mean corpuscular volume is 77 μm3. Hemoglobin electrophoresis shows 11% HbA2 (normal < 3.5%). Which of the following is the most likely diagnosis? A. Beta thalassemia minor B. Hemoglobin Barts disease C. Alpha thalassemia minima D. Hemoglobin H disease E. Sickle cell trait
A
A 22-year-old with leukemia undergoes bone marrow transplantation and receives partially mismatched donor marrow. One month later, she has a scaling skin rash. Examination of a skin biopsy specimen reveals the cellular change shown in the figure. This change most likely results from which of the following biochemical reactions? A. Activation of caspases B. Reduction of ATP synthesis C. Increase in glycolysis D. Activation of lipases E. Lipid peroxidation
A
A 25-year-old African American male presents to the emergency department with severe abdominal pain. Examination reveals tenderness in the right upper quadrant. Laboratory investigations show elevated serum bilirubin and alkaline phosphatase levels. The most likely cause of his symptoms is: A. Cholecystitis B. Peptic ulcer disease C. Acute pancreatitis D. Sickle cell crisis E. Appendicitis
A
A 28-year-old female with rheumatoid arthritis presents to the clinic for a routine follow-up visit. She has been receiving treatment with methotrexate (a dihydrofolate reductase inhibitor) for the past 6 months. Lately, she has been feeling more fatigued and notices that her hair is thinning. On examination, she appears pale, and conjunctival pallor is noted. Laboratory investigations reveal a hemoglobin level of 10.2 g/dL and an elevated mean corpuscular volume (MCV) of 105 fL. The patient's peripheral blood smear shows macrocytosis with hypersegmented neutrophils. Which of the following is the most likely cause of the patient's macrocytic anemia? A. Folate deficiency B. Vitamin B12 deficiency C. Iron deficiency D. Thiamine deficiency E. Riboflavin deficiency
A
A 35-year-old woman visits her primary care provider with complaints of easy fatigability, breathlessness on exertion, and altered sensations in her lower limbs. Past medical history is positive for hypertension. She takes hydrochlorothiazide and lisinopril, ethinyl estradiol-progestin, and a multivitamin every day. Family history is noncontributory. She drinks alcohol almost every day and smokes cigarettes when she drinks. Today her heart rate is 95/min, respiratory rate is 17/min, blood pressure is 130/92 mm Hg, and temperature of 37.0 degC (98.6 degF). Overall, she has marked pallor with slight bluing of her lips and distal fingertips. Her heart has a regular rate and rhythm and her lungs are clear to auscultation bilaterally. Additionally, she has loss of touch, and vibration sense in both of her lower limbs. Her CBC is as follows: Hemoglobin 8.0 g/dL (low) MCV 112 fL (high) WBC 2,500/mm3 (normal) Platelets 95,000/mm3 (low) What is the most likely diagnosis? A. Vitamin B12 deficiency B. Iron deficiency C. Folic acid deficiency D. Vitamin C deficiency E. Vitamin A deficiency
A
A 42-year-old female patient with a long-standing history of Crohn's disease presents to the gastroenterology clinic. She complains of persistent fatigue and weakness. Laboratory investigations reveal a normocytic, normochromic anemia with a low reticulocyte count. The patient's iron studies show normal serum iron levels, low total iron-binding capacity (TIBC), and increased ferritin levels. Which of the following best describes the pathogenesis of anemia of chronic disease (ACD) in this patient? A) Increased hepcidin levels leading to reduced iron absorption and release from macrophages B) Autoimmune destruction of red blood cells due to Crohn's disease C) Vitamin B12 deficiency resulting from malabsorption in Crohn's disease D) Reduced erythropoietin production due to chronic inflammation
A
A 43-year-old woman presents with increasing fatigue. Her past medical history is significant for systemic lupus erythematosus. Laboratory testing shows a low hemoglobin, a low serum iron level, a low total iron binding capacity level and an elevated serum ferritin. Which of the following is the most likely diagnosis? A. Anemia of chronic disease B. B12 deficiency C. Folate deficiency D. Iron deficiency E. Lead poisoning
A
A 5-year-old child presents with a high-grade fever, sore throat, and cervical lymphadenopathy (lymph node enlargement). You suspect a bacterial pharyngitis. If you are correct, you are most likely to see an increase in which type of white blood cell on the CBC? A. Neutrophils B. Lymphocytes C. Monocytes D. Eosinophils E. Basophils
A
A 53-year-old is investigated for hypertension and is found to have a left kidney that is smaller than normal. Contrast studies reveal stenosis (narrowing) of the left renal artery. The size change in the right kidney is an example of which of the following adaptive changes? A. Atrophy B. Hyperplasia C. Hypertrophy D. Metaplasia
A
A 55-year-old woman with a history of chronic kidney disease comes to you with increasing fatigue. Physical examination shows subconjunctival pallor. Labs reveal Hemoglobin= 8.4 g/dL (low) Mean corpuscular volume (MCV)= 84 μm3 (normal) Ferritin= 150 ng/mL (normal) Treatment with erythropoietin is begun. A peripheral blood smear is obtained one week after treatment. The prominent purple color of the intracellular structure in some of the cells is most likely the result of staining which of the following? A. Ribosomal RNA B. Denatured globin chain C. Golgi apparatus D. Remnants of the nucleus E. Lysosomes
A
A 55-year-old woman with a history of chronic kidney disease comes to you with increasing fatigue. Physical examination shows subconjunctival pallor. Labs reveal Hemoglobin= 8.4 g/dL (low) Mean corpuscular volume (MCV)= 84 μm3 (normal) Ferritin= 150 ng/mL (normal) Treatment with erythropoietin is begun. A peripheral blood smear is obtained one week after treatment. The prominent purple color of the intracellular structure in some of the cells is most likely the result of staining which of the following? A. Ribosomal RNA B. Denatured globin chain C. Golgi apparatus D. Remnants of the nucleus E. Lysosomes
A
A 57-year-old woman presents acutely with alterations in mental status and fever after 4 days of myalgia. In your office, she is lethargic. Her only current medication is atenolol 25 mg daily for hypertension. Her vital signs are as follows: blood pressure 158/95 mmHg, heart rate 112 bpm, temperature 38.7°C (101.7°F), respiratory rate 26 breaths/min, and oxygen saturation 92% on room air. No hepatosplenomegaly is present. There are petechiae on the lower extremities. Her labs shows: Hemoglobin= 9.1 g/dL (12-17g/dl) Hematocrit of 27.4% (36-50% WBC count= 10.2/mm3 (4-12/mm3) (89% polymorphonuclear cells, 10% lymphocytes, 1% monocytes) Platelets= 60,000/μL (150-400/μL) Sodium= 139 mEq/L (137-145 mEq/L) Potassium= 5.3 mEq/L (3.6-5.0 mEq/L) Chloride= 100 mEq/L (98-107 mEq/L) Bicarbonate= 18 mEq/L (22-30 mEq/L) BUN= 85 mg/dL (10-20 mEq/L) Creatinine= 3.1 mg/dL (0.6-1.5 mg/dl) A peripheral blood smear reveals schistocytes. Which of the following most correctly describes the pathogenesis of the patient's condition? A. Development of autoantibodies to a metalloproteinase that cleaves von Willebrand factor B. Development of autoantibodies to the heparin/platelet factor 4 complex C. Direct endo
A
A 6-month-old girl comes to the office for a well-child visit. Her mother asks about switching to solid foods. She does not want to place her child at risk of nutrient deficiencies, which she knows can occur at any age. In addition to counseling about sources of various vitamins and minerals, she inquires about routine lab tests that can indicate the onset of certain vitamin deficiencies. Which of the following would be most indicative of folate deficiency? A. Decreased serum homocysteine B. Decreased serum methylmalonic acid C. Elevated serum homocysteine alone D. Elevated serum methylmalonic acid E. Hypocalcemia
A
A 72-year-old died suddenly from congestive heart failure. At autopsy, the heart weighed 580 g (N=236-412 g) and showed marked left ventricular hypertrophy and minimal coronary arterial atherosclerosis. A serum chemistry panel ordered before death showed no abnormalities. Which of the following pathologic processes best accounts for the appearance of the aortic valve seen in the figure below? A. Dystrophic calcification B. Lipofuscin deposition C. Hemosiderosis D. Fatty change
A
A tissue preparation is experimentally subjected to a hypoxic environment. The cells in this tissue begin to swell, and chromatin begins to clump in the nucleus. ATPases are activated, and ATP production decreases. Which of the following ions released from mitochondria leads to these findings and to eventual cell death? A. Ca2+ B. Cl− C. HCO32− D. K+ E. Na+ F. PO42+
A
In the prior case, what is a characteristic finding that might be seen on peripheral blood smear? A. Target cells B. Howell-Jolly bodies C. Bite cells D. Basophilic stippling
A
On day 28 of her menstrual cycle, a 23-year-old experiences onset of menstrual bleeding that lasts for 6 days. The patient has had regular cycles for many years. Which of the following processes is most likely occurring in the endometrium just before the onset of bleeding? A. Apoptosis B. Caseous necrosis C. Heterophagocytosis D. Atrophy E. Liquefactive necrosis
A
Which of the following is NOT a characteristic of a reticulocyte? A. Presence of a nucleus B. Increased ribosome content C. Ability to produce hemoglobin D. Decreased size compared to mature RBCs
A
Which of the following is the most abundant hemoglobin subtype in adult humans? A. Hemoglobin A1 (HbA1) B. Hemoglobin A2 (HbA2) C. Hemoglobin F (HbF) D. Hemoglobin S (HbS)
A
Which of the following is the treatment of choice for thalassemia major? A. Blood transfusions B. Iron chelation therapy C. Folic acid supplementation D. Bone marrow transplantation
A
Which of the following populations is most commonly affected by microcytic anemia? A. Children under the age of 5 B. Elderly individuals over the age of 70 C. Pregnant women D. Men between the ages of 20-30
A
Which of the following statements accurately describes the transition from fetal hemoglobin to adult hemoglobin? A. Fetal hemoglobin is present at birth and is gradually replaced by adult hemoglobin over time. B. Fetal hemoglobin is absent at birth and gradually develops, eventually replacing adult hemoglobin. C. Fetal hemoglobin and adult hemoglobin coexist throughout life, with no replacement or transition. D. Fetal hemoglobin is only present during pregnancy and disappears shortly after birth.
A
A 16-year-old male with sickle cell anemia presents with pain and swelling in his right hand. X-ray shows no evidence of fractures or dislocations. The most likely cause of his symptoms is: A. Osteomyelitis B. Avascular necrosis C. Trigger finger D. Dupuytren's contracture E. Septic arthritis
B
A 2-year-old boy is brought to you with jaundice and exertional dyspnea. Examination shows a palpable spleen and labs reveal an anemia. A peripheral blood smear is obtained - showing uniform spherical RBCs. Which of the following is the most likely etiology of this patient's condition? A. A defect in a metabolic enzyme in red blood cells B. A defect in proteins located in the plasma membrane of red blood cells C. A point mutation on beta globulin resulting in a GAG to GUG change D. Complement mediated lysis of erythrocytes E. Impaired DNA synthesis in cells throughout the body
B
A 25-year-old man comes to the physician because of a 3-day history of jaundice and decreased exercise tolerance. Examination shows scleral icterus and pale mucous membranes. He has splenomegaly. His hemoglobin concentration is 8.2 g/dL (low), leukocyte is count 8300/mm3 (normal), and platelet count is 175,000/mm3 (normal). Direct antiglobulin and heterophile antibody tests are positive. Which of the following additional laboratory findings are most likely present in this patient? A. Decreased reticulocyte count B. Decreased haptoglobin levels C. Decreased mean corpuscular volume D. Increased direct to total bilirubin ratio E. Increased bleeding time
B
A 28-year-old female with sickle cell anemia presents with severe bone pain. She is currently taking hydroxyurea for disease management. The most appropriate intervention for her acute pain crisis is: A. Nonsteroidal anti-inflammatory drugs (NSAIDs) B. Opioids for pain relief C. Intravenous fluids and hydration D. Red blood cell transfusion E. Bone marrow transplant
B
A 28-year-old man presents with fatigue and irritability. He is currently being treated for a tuberculosis infection. Prussian blue staining of marrow reveals intra-mitochondrial prominence and a ring around the nuclei of cells. The results of his laboratory examinations are shown below: Hemoglobin= 8.8 g/dL (12-17 g/dl) Hematocrit 28.9% (36-50%) Mean cell volume 73 fL (80-100 fL) Total bilirubin 1.6 mg/dL (0.2-1.0 mg/dl) Direct bilirubin 0.2 mg/dL (<0.4 mg/dl) This patient's disease is due to a defect in A. Iron absorption B. Heme synthesis C. Hemoglobin degradation D. Red blood cell membrane structure
B
A 32-year-old man presents to the hematology clinic with a history of chronic anemia. He reports frequent episodes of fatigue, shortness of breath, and pale skin. His medical history is unremarkable, and there is no family history of anemia. Physical examination reveals mild jaundice and splenomegaly. Laboratory tests are ordered, and the results show microcytic anemia with elevated levels of hemoglobin A2 on hemoglobin electrophoresis. What is the cause of this patient's anemia? A. Impaired heme synthesis B. Defective globin chain synthesis C. Abnormal red blood cell shape D. Increased red blood cell destruction
B
A 4-year-old boy with sickle cell anemia presents with a fever and cough. On examination, he has increased respiratory rate, crackles on lung auscultation, and decreased breath sounds on the left side. The most likely diagnosis is: A. Pneumonia B. Acute chest syndrome C. Pulmonary embolism D. Asthma exacerbation E. Pleural effusion
B
A 40-year-old had undifferentiated carcinoma of the lung. Despite chemotherapy, the man died of widespread metastases. At autopsy, tumors were found in many organs. Histologic examination showed many foci in which individual tumor cells appeared shrunken and deeply eosinophilic. Their nuclei exhibited condensed aggregates of chromatin under the nuclear membrane. The process affecting these shrunken tumor cells was most likely triggered by the release of which of the following substances into the cytosol? A. Lipofuscin B. Cytochrome c C. Catalase D. Phospholipase E. BCL-2
B
A 47-year-old has had worsening dyspnea for the past 5 years. A chest CT scan shows panlobular emphysema. Laboratory studies show the PiZZ genotype of α1-antitrypsin (AAT) deficiency. A liver biopsy specimen examined microscopically shows abundant PAS-positive globules within periportal hepatocytes. Which of the following molecular mechanisms is most likely responsible for this finding in the hepatocytes? A. Excessive hepatic synthesis of AAT B. Retention of poorly folded AAT in the endoplasmic reticulum C. Decreased catabolism of AAT in lysosomes D. Inability to metabolize AAT E. Impaired dissociation of AAT from chaperones
B
A 50-year-old experienced an episode of chest pain 6 hours before their death. A histologic section of left ventricular myocardium taken at autopsy showed a deeply eosinophilic-staining area with loss of nuclei and cross-striations in myocardial fibers. There was no hemorrhage or inflammation. Which of the following conditions most likely produced these myocardial changes? A. Viral infection B. Coronary artery thrombosis C. Blunt chest trauma D. Antibodies directed against myocardium E. Protein-deficient diet
B
A 50-year-old woman comes to you with fatigue, lightheadedness and a physical exam showing bilateral brisk patellar reflexes, slightly ataxic gait, and impaired position and vibration sense in the feet bilaterally. Her hematocrit is 23% (low). Serologic studies are positive for anti-parietal cell antibodies. What would you expect to see on peripheral blood smear? A. Codocytes B. Hypersegmented neutrophils C. Howell-Jolly bodies D. Schistocytes E. Acanthocytes
B
A 54-year-old is referred because of skin hyperpigmentation, hepatic dysfunction, and diabetes mellitus. A diagnosis of hereditary hemochromatosis is made. Accumulation of which of the following substances causes damage to organs in this disorder? A. Bilirubin B. Iron C. Lead D. Lipofuscin E. Melanin
B
A chest radiograph of an asymptomatic 37-year-old showed a 3-cm nodule in the middle lobe of the right lung. The nodule was excised with a pulmonary wedge resection, and sectioning showed the nodule to be sharply circumscribed with a soft, white center. Culture of tissue from the nodule grew Mycobacterium tuberculosis. Which of the following pathologic processes has most likely occurred in this nodule? A. Apoptosis B. Caseous necrosis C. Coagulative necrosis D. Fat necrosis E. Fatty change F. Gangrenous necrosis G. Liquefactive necrosis
B
After the birth of her first child, a 29-year-old breastfed the infant for about 1 year. Which of the following processes that occurred in the breast during pregnancy allowed her to breastfeed the infant? A. Stromal hypertrophy B. Lobular hyperplasia C. Intracellular accumulation of hemosiderin D. Ductal epithelial metaplasia
B
An experiment introduces a "knockout" gene mutation into a cell line. The frequency of shrunken cells with chromatin clumping and cytoplasmic blebbing is increased compared with a cell line without the mutation. Overall survival of the mutant cell line is reduced. Which of the following genes is most likely to be affected by this mutation? A. BAX B. BCL-2 C. C-MYC D. FAS E. p53
B
In a clinical trial, a chemotherapeutic agent is given to patients with breast cancer metastases. Samples of the cancer cells are obtained and assessed for the presence of death of tumor cells by apoptosis. Mutational inactivation of which of the following products is most likely to render tumor cells resistant to the effects of such an agent? A. BCL-2 B. p53 C. NF-κB D. Cytochrome P-450 E. Granzyme B
B
In an experiment, cells are subjected to radiant energy in the form of x-rays. This results in cell injury caused by hydrolysis of water. Which of the following cellular enzymes protects the cells from this type of injury? A. Phospholipase B. Glutathione peroxidase C. Endonuclease D. Lactate dehydrogenase E. Protease
B
In the diagnostic evaluation of microcytic anemia, what laboratory test is most commonly used to assess iron stores? A. Serum iron levels B. Ferritin levels C. Total iron binding capacity (TIBC) D. Hemoglobin electrophoresis
B
Which of the following accurately describes the shift in sites of red blood cell (RBC) production between the fetus and adults? A. In the fetus, RBCs are primarily produced in the placenta, while in adults, RBC production occurs in the bone marrow. B. In the fetus, RBC production occurs in the liver and spleen, while in adults, it takes place in the bone marrow. C. RBC production occurs in the bone marrow both in the fetus and adults. D. RBC production primarily occurs in the thymus in the fetus, while in adults, it shifts to the bone marrow.
B
Why are there calcifications in the injured pancreas? A. Acute pancreatitis is associated with generalized (metastatic) hypercalcemia. B. Fatty acids released by fat necrosis (causing lipolysis of triglycerides) bind calcium (to form calcium soaps) C. Osseous metaplasia of the pancreas is seen in chronic pancreatitis.
B
You are seeing a 19-year-old patient who was treated 2 days ago with an oral cephalosporin for a skin infection. The patient's physical examination is notable for tachycardia and a palpable spleen. Stool is negative for occult blood. Laboratory examination is notable for a hemoglobin of 8 g/dL (low) with normal WBC and platelets. Peripheral blood smear shows an excess of spherocytes. Which of the following tests will most likely confirm the diagnosis? A. ADAMTS-13 activity assay B. Direct antiglobulin (Coombs) test C. Flow cytometry D. G6PD deficiency assay E. Hemoglobin electrophoresis
B
A 1-year-old boy is brought to you with shoulder pain for 1 day. He was treated twice in the emergency department for painful swelling of his hands and feet. He emigrated with his family from Kenya 2 years ago. His temperature is 99.1°F, pulse is 88/min, and blood pressure is 123/82 mm Hg. Physical examination shows no tenderness, erythema, or joint swelling of the shoulder. Laboratory studies show: Hemoglobin= 8.2 g/dL (11-14 g/dl) Mean corpuscular volume= 85 μm (80-96um) Reticulocyte count= 8% (high) Leukocyte count= 11,000/mm3 (4-12,000/mm3) A peripheral blood smear is most likely to show which of the following abnormalities (To answer this difficult question, consider that this patient has had this disease for a while)? A. Ring-shaped inclusions in erythrocytes B. Teardrop-shaped erythrocytes C. Nuclear remnants in erythrocytes D. Fragmentation of erythrocytes E. Erythrocytes with no central pallor
C
A 20-year-old man presents with a one-day history of dark urine, fever, chills, and back pain. He recently returned from a prolonged trip to Africa where he was treated for malaria with primaquine, starting four days ago. The symptoms began within hours of starting primaquine therapy. Laboratory results reveal: Hemglobin= 5.8 g/dl (Low) Leukocytes= 11,500 cells/mm3 (normal) Platelets= 280,000 cells/mm3 (normal) Reticulocytes= 10% (High) Blood smear shows deformed erythrocytes and a urine dipstick is positive for blood. Which of the following tests is most likely to identify the etiology of this man's pathology? A. Mean corpuscular hemoglobin concentration B. Direct Coomb's test C. Heinz body preparation D. Hemoglobin electrophoresis E. Serum ferritin concentration
C
A 22-year-old man with known sickle cell anemia is admitted to the intensive care unit with diffuse body pain, shortness of breath, fever, and cough. He started having a bone pain crisis 1 day ago and tried to treat it at home with oral hydration. On examination, his blood pressure and heart rate are elevated, and he is in obvious pain and respiratory discomfort. His room air arterial oxygen saturation (SaO2) is 83% and increases to 91% on a nonrebreather oxygen face mask. His chest radiograph shows bilateral diffuse alveolar infiltrates. This is his third similar episode in the last 12 months. All of the statements regarding his condition are true EXCEPT: A. Chronic therapy with oral hydroxyurea should be considered. B. He is having a sickle cell acute chest syndrome. C. He should receive daily sildenafil (viagra) D. Hematocrit should be maintained at >30%. E. Hydration should be continued.
C
A 25-year-old woman with a history of inflammatory bowel disease complains of worsening fatigue. Her IBD has been stable for the past year on infliximab and her physical examination is unremarkable. Stool testing for occult blood is negative. On laboratory analysis, her hemoglobin is low at 10.7g/dL. In addition, her serum iron and ferritin, which were both normal 6 months ago, are now low. Her blood smear reveals hypochromia and microcytosis. Which of the following is the most likely etiology of her anemia? A. Folate deficiency B. Inflammation C. Iron deficiency D. Sideroblastic anemia E. Vitamin B12 deficiency
C
A 30-year-old sustains a left femoral fracture in a skiing accident, and their leg is placed in a plaster cast. After the leg has been immobilized for several weeks, the diameter of the left calf has decreased. This change is most likely to result from which of the following alterations in the calf muscles? A. Aplasia B. Hypoplasia C. Atrophy D. Dystrophy
C
A 32-year-old experiences "heartburn" and gastric reflux after eating a large meal. After many months of symptoms, he undergoes upper gastrointestinal endoscopy, and a biopsy specimen of the esophageal epithelium is obtained. Which of the following pathologic changes, seen in the figure, has most likely occurred? A. Squamous metaplasia B. Mucosal hypertrophy C. Intestinal metaplasia with goblet cells D. Atrophy of lamina propria
C
A 35-year-old female with a history of chemotherapy treatment for breast cancer presents to the clinic with recurrent infections and persistent fever. Laboratory tests reveal an absolute neutrophil count (ANC) of 300 cells/mm3 (normal range: 1500-8000 cells/mm3). The patient is diagnosed with absolute neutropenia. Which of the following medications is most appropriate for inducing neutrophil development in this patient? A. Erythropoietin B. Interferon-alpha C. Granulocyte colony-stimulating factor (G-CSF) D. Interleukin-2 E. Prednisone
C
A 38-year-old man present to you with progressive fatigue, abdominal pain and sexual dysfunction. Serum analysis shows a decrease in serum haptoglobin, an elevated LDH, and a normocytic anemia with pancytopenia. Sucrose hemolysis test was positive. The patient's condition is most likely attributed to which of the following? A. Intrinsic hemolytic anemia with extravascular hemolysis B. Extrinsic hemolytic anemia with intravascular hemolysis C. Mixed intrinsic and extrinsic hemolytic anemia with intravascular hemolysis D. Extrinsic hemolytic anemia with extravascular hemolysis E. Positive direct Coomb's test with extravascular hemolysis
C
A 45-year-old with a long history of alcoholism presents with severe epigastric pain, nausea, vomiting, fever, and an increase in serum amylase. During a previous hospitalization for a similar episode, computed tomography (CT) scanning demonstrated calcifications in the pancreas. A diagnosis of acute pancreatitis superimposed on chronic pancreatitis was made. In this condition, which of the following types of necrosis is most characteristic? A. Caseous B. Coagulative C. Enzymatic (fat) D. Fibrinoid E. Liquefactive
C
A 55-year-old male presents with diarrhea and an abnormal white blood cell count differential after a trip to Southeast Asia. Based on his laboratory analysis, you tell him that you think that he likely has a parasitic gastrointestinal infection. You base this on an increase in which type of white blood cell on the differential? A. Neutrophils B. Monocytes C. Eosinophils D. Basophils E. Lymphocytes
C
A 62-year-old dies 24 hours after the onset of substernal chest pain radiating down their left arm. EKG and lab tests are consistent with myocardial infarct. Which of the following morphological myocardial findings is an indicator of irreversible cellular injury? A. Plasma membrane blebs B. Mitochondrial swelling C. Nuclear fragmentation D. Ribosomal disaggregation
C
A 65-year-old man comes to you with progressively worsening fatigue and unintentional weight loss (25lbs over 3 months). A FIT fecal occult blood test is positive and his hematocrit is low at 32%. Which of the following laboratory values is most likely to be decreased in this patient? A. Erythrocyte protoporphyrin B. Serum haptoglobin C. Serum iron D. Soluble transferrin receptor levels E. Total iron binding capacity
C
A 69-year-old has had difficulty with urination, including hesitancy and frequency, for the past 5 years. A digital rectal examination reveals that the prostate gland is palpably enlarged to about twice normal size. A transurethral resection of the prostate is performed, and the microscopic appearance of the prostate "chips" obtained is that of nodules of glands with intervening stroma. Which of the following pathologic processes has most likely occurred in the prostate? A. Apoptosis B. Fatty change C. Hyperplasia D. Hypertrophy E. Metaplasia
C
A 70-year-old presents with sudden onset of left-sided weakness, spasticity, and hyperactive pathologic reflexes. A clinical diagnosis of stroke is made. The most serious consequences of this disorder are the result of damage to which of the following cell types? A. Labile cells B. Multipotent adult progenitor cells C. Permanent cells D. Stable cells
C
An 8-year-old girl of Asian descent is brought to see you because her mother feels that her daughter fatigues easily. Physical examination shows pale conjunctivae. Laboratory studies show: Hemoglobin= 10.5 g/dl (low) Mean corpuscular volume (MCV)= 76 μm3 (low) Ferritin= 85 ng/ml (normal) Peripheral blood smear shows microcytic, hypochromic red blood cells. Hemoglobin electrophoresis is normal. Which of the following best describes the pathogenesis of your patient's disease? A. Decreased production of β-globin proteins B. Amino acid substitution in the β-globin protein C. Cis deletion of α-globin genes D. Inadequate intake of iron E. Acquired inhibition of heme synthesis
C
At autopsy, a 40-year-old has an enlarged (2200 g) liver with a yellow, waxy cut surface. The microscopic appearance of this liver is shown in the figure. Before death, the patient's total serum cholesterol and triglyceride levels were normal, but he had a decreased serum albumin concentration and increased prothrombin time. Which of the following activities most likely led to these findings? A. Injecting heroin B. Playing basketball C. Drinking excessive beer D. Smoking cigarettes
C
Flow cytometry can be used to analyze and differentiate white blood cell populations based on its ability to directly measure: A. Hemoglobin content B. Nucleus size C. Surface markers and antigens D. Presence of cytoplasmic granules E. Phagocytic activity
C
In an experiment, a large amount of a drug is administered to subjects and is converted by cytochrome P-450 to a toxic metabolite. The accumulation of this metabolite leads to increased lipid peroxidation within cells, causing damage to cell membranes and cell swelling. Depletion of which of the following substances by this mechanism within the cytosol exacerbates cellular injury? A. ADP B. Calcium C. Glutathione D. NADPH oxidase E. Nitric oxide synthase F. mRNA G. Sodium
C
Which dietary factor can enhance the absorption of non-heme iron in the management of microcytic anemia? A. Consuming iron-rich foods with calcium-rich foods B. Consuming iron-rich foods with caffeine-containing beverages C. Consuming iron-rich foods with vitamin C-rich foods D. Consuming iron-rich foods with high-fiber foods
C
A 11-year-old boy with sickle cell disease presents with trouble concentrating. An MRI, performed to confirm the suspected diagnosis, is likely to find what? A. A lesion to Wernicke area B. An astrocytoma in the parietal lobe C. Caudate head atrophy D. Evidence of cerebral infarction E. Excessive synchronized firing of a group of neurons
D
A 16-year-old sustained blunt trauma to the abdomen when the vehicle they were driving struck a bridge abutment at high speed. Peritoneal lavage shows a hemoperitoneum, and at laparotomy, a small portion of the left lobe of the liver is removed because of the injury. Several weeks later, a CT scan of the abdomen shows that the liver has nearly regained its size before the injury. Which of the following processes best explains this CT scan finding? A. Apoptosis B. Fatty change C. Hydropic change D. Hyperplasia E. Hypertrophy F. Metaplasia
D
A 35-year-old female presents to her primary care physician with symptoms of fatigue, weakness, and pale skin. Laboratory investigations reveal microcytic anemia with decreased serum iron levels, low ferritin levels, and a high total iron-binding capacity (TIBC). What is the most appropriate initial treatment for this patient's microcytic anemia? A. Blood transfusion B. Vitamin B12 supplementation C. Folic acid supplementation D. Oral iron supplementation
D
A 38-year-old man presents to you with dark-colored urine in the mornings which clears as the day progresses. He also reports severe abdominal pain, headaches, back pain and fatigue. Physical exam is unremarkable except for pallor. Labs reveal: Hemoglobin: 5.8 g/dL (12-17 g/dl) White blood cell count: 7,000/mm3 (4-12/mm3) Platelet count: 175,000/mm3 (150-400/mm3) Reticulocytes= 12% (high) Serum lactate dehydrogenase (LDH): 2240 U (high) Serum creatinine: 1.0 mg/dL (0.6-1.5mg/dl) Which of the following is the most likely diagnosis? A. Goodpasture syndrome B. Sickle cell anemia C. Congenital hemolytic anemia D. Paroxysmal nocturnal hemoglobinuria (PNH) E. Pyelonephritis
D
A 4-year old boy presents with scleral icterus after treatment of sulfadiazine for a urinary tract infection. A complete blood count reveals anemia and the blood smear shows Heinz bodies. Which of the following enzymes is the patient most likely deficient in? A. Aldolase B B. Galactokinase C. Galactose-1-phosphate uridyltransferase D. Glucose-6-phosphate dehydrogenase E. Pyruvate kinase
D
A 4-year-old boy is brought to you for jaundice for the past week as well as fatigue. Two weeks ago, he was treated for a urinary tract infection with antibiotics. His father has a history of undergoing a splenectomy in his childhood. Examination shows pale conjunctivae and jaundice. His abdomen is soft and nontender, but with splenomegaly. Laboratory studies show: Hemoglobin= 8.5 g/dl (low) Mean corpuscular volume (MCV)= 85 μm3 (normal) Mean corpuscular hemoglobin (MCH)= 32.0 pg/cell (27-31 pg/cell) Mean corpuscular hemoglobin concentration 37.0% Hb/cell Red cell distribution width (RDW) 22% (13-15%) Leukocytes= 7.1/mm3 (4-12/mm3) Platelets= 250,000/mm3 (150-400/mm3) Bilirubin total= 8.5 mg/dL (high) Bilirubin direct= 1.0 mg/dL (normal)Lactate dehydrogenase= 305 U/L (high) Which of the following is the most likely cause of these findings? A. Deficiency of pyruvate kinase B. Increased hemoglobin S C. Decreased synthesis of alpha chains of hemoglobin D. Deficient glucose-6 phosphate dehydrogenase E. Defective spectrin in the RBC membrane
D
A 44-year-old has a history of poorly controlled diabetes mellitus leading to coronary artery disease. He now has decreasing cardiac output. An increase in which of the following substances in his blood is most indicative of reversible cell injury from decreased perfusion of multiple organs and tissues? A. Carbon dioxide B. Creatinine C. Glucose D. Lactic acid E. Troponin I
D
A 45-year-old male patient presents with fatigue, weakness, and tingling sensations in his extremities. He is a long-time vegetarian and a heavy alcohol over-user. His medical history reveals a long-standing history of chronic pancreatitis. Laboratory tests show low serum vitamin B12 levels. He has recently had an upper endoscopy for upper abdominal pain with normal biopsies of his gastric mucosa. He has no history of autoimmune disease. What is the most likely cause of the patient's vitamin B12 deficiency? A) Dietary deficiency of vitamin B12 B) Autoimmune destruction of gastric parietal cells C) Inadequate absorption in the colon D) Impaired pancreatic function E) Genetic mutation affecting vitamin B12 metabolism
D
A 55-year-old man presents to you for evaluation of fatigue and shortness of breath. One year ago, a screening colonoscopy showed colonic polyps. His brother has a bicuspid aortic valve. On examination, a late systolic crescendo-decrescendo murmur is heard at the right upper sternal border. Laboratory studies show: Hemoglobin= 8.5 g/dl (low) BUN= 20 mg/dL (high) Creatinine= 1.0 mg/dL (minimally high) Bilirubin total= 2.2 mg/dL (high) Lactate dehydrogenase= 305 U/L (high) Haptoglobin 18 mg/dL (low) A peripheral blood smear shows schistocytes. Which of the following is the most likely cause of this patient's anemia? A. Gastrointestinal bleeding B. Autoimmune destruction of erythrocytes C. Erythrocyte membrane fragility D. Fragmentation of erythrocytes E. Erythrocyte enzyme defect
D
A 56-year-old experiences chest pain/angina following a workout in the gym. When evaluated in the Emergency Department of a nearby hospital, a myocardial infarct is ruled out, and he is referred to a cardiologist for management of angina that is reversed after medication. Had microscopic examination of the affected area of his heart been possible at the time of the event, which of the following would be the most likely cellular change to be found? A. Karyolysis B. Karyorrhexis C. Pyknosis D. Swelling of the endoplasmic reticulum
D
A 65-year-old man presents with balance problems. He follows a vegan diet (No meat, eggs, or dairy). Physical examination shows pale oral mucosa and conjunctivae. Neurologic examination shows normal strength in all extremities and decreased sense to vibration in his lower extremities bilaterally. A peripheral blood smear is shown. Which of the following enzymes is most likely impaired? A. Succinate dehydrogenase B. Propionyl-CoA carboxylase C. Pyruvate carboxylase D. Methylmalonyl-CoA mutase E. Dopamine beta-hydroxylase
D
A 75-year-old man comes to his primary care physician for a routine visit. Five months ago, his wife died from a stroke. The patient reports feeling depressed, and he has been consuming large quantities of vodka on a daily basis. He previously ate a balanced diet. However, he has had little motivation to cook since his wife passed away, and he currently eats crackers and beef jerky purchased from a convenience store. His temperature is 37.2°C (99.0°F), blood pressure is 117/81 mmHg, pulse is 71/min, and respiratory rate is 12/min. Complete blood count reveals a hemoglobin of 9.2 g/dL and a mean corpuscular volume (MCV) of 110 µm3. A peripheral smear is ordered, showing hypersegmented neutrophils: Which of the following is the most likely explanation for this patient's findings? A. Replacement of bone marrow by scar tissue B. Defect in homologous DNA recombination C. Iron deficiency secondary to bleeding in the gastrointestinal tract D. Impaired DNA synthesis resulting from vitamin B9 deficiency E. Liver disease
D
An 18-year-old woman presents with a 4-month history of fatigue. She had infectious mononucleosis 4 weeks ago. Menses occur at regular 28-day intervals and last 5 days with moderate flow. Her last menstrual period was 3 weeks ago. Her mother has Hashimoto thyroiditis. Examination shows pale conjunctivae, inflammation of the corners of the mouth, and brittle nails. The remainder of the examination shows no abnormalities. Laboratory studies show a low hemoglobin of 9.8 g/dL, a low MCV of 78, but normal platelet and white blood cell counts. Which of the following is the most appropriate next step in evaluating this patient's illness? A. Hemoglobin electrophoresis B. Direct Coombs test C. Vitamin B12 levels D. Ferritin levels E. Bone marrow biopsy
D
At autopsy, the heart of a 63-year-old weighs only 250 g and has small right and left ventricles. The myocardium is firm, with a dark chocolate-brown color throughout. The coronary arteries show minimal atherosclerotic changes. An excessive amount of which of the following substances would most likely be found in the myocardial fibers of this heart? A. Melanin B. Hemosiderin C. Glycogen D. Lipofuscin E. Bilirubin
D
Which of the following cell types is derived from the lymphoid lineage? A. Neutrophils B. Monocytes C. Eosinophils D. B cells E. Megakaryocytes
D
You are caring for a 10-year-old boy with frequent, severe nosebleeds. He takes no medications and has no history of serious medical illness Laboratory studies show: Hemoglobin= 9.0 g/dl (12-17g/dl) Platelets= 195,000/mm3 (150-400/mm3) PT= 12 sec (10-13 sec) PTT= 37 sec (26-38 sec) Fibrin split products= negative Bleeding time is prolonged at 11 minutes Which is the most appropriate therapy for your patient? A. Prothrombin complex concentrate B. Phytonadione C. Rituximab D. Desmopressin E. Intravenous immunoglobulin
D
You are seeing a 60-year-old male who presented with fatigue, dyspnea, and generalized weakness after a diagnosis of cancer. Labs reveal a decrease in WBCs, RBCs and platelets and you are concerned that his bone marrow has been replaced by cancer. You reason that other organs may have been enlisted in the process of hematopoiesis. If you perform a physical examination, which organ might be enlarged, due to the presence of extramedullary hematopoiesis? A. Lymph nodes B. Kidneys C. Adrenal glands D. Liver E. Thymus
D
You are seeing a patient with anemia and are concerned that the cause relates to a deficiency in the cytokine that is primarily responsible for stimulating red blood cell production. If so, which cytokine is deficient? A. Interleukin-2 (IL-2) B. Tumor necrosis factor-alpha (TNF-α) C. Interleukin-6 (IL-6) D. Erythropoietin (EPO) E. Thrombopoietin
D
A 20-year-old man comes to you with fatigue, back pain, jaundice and dark-colored urine for two days. He has no history of serious illness. He recently started taking ibuprofen for pain. Laboratory studies show a low hemoglobin concentration and elevated serum lactate dehydrogenase concentration. A photomicrograph of a peripheral blood smear with Wright's stain is shown. Which of the following is the most likely mode of inheritance for this patient's condition? A. Autosomal recessive B. X-linked dominant C. Autosomal dominant D. Mitochondrial inheritance E. X-linked recessive
E
A 28-year-old man presents with fatigue and irritability. He is currently being treated for a tuberculosis infection. Prussian blue staining of marrow reveals intra-mitochondrial prominence and a ring around the nuclei of cells. The results of his laboratory examinations are shown below: Hemoglobin= 8.8 g/dL (12-17 g/dl) Hematocrit 28.9% (36-50%) Mean cell volume 73 fL (80-100 fL) Total bilirubin 1.6 mg/dL (0.2-1.0 mg/dl) Direct bilirubin 0.2 mg/dL (<0.4 mg/dl) Which of the following is the most likely cause of this patient's symptoms? A. α-thalassemia B. β-thalassemia C. Hemolytic anemia D. Iron deficiency anemia E. Sideroblastic anemia
E
A 28-year-old woman presents to you with fatigue over the last 8 months. Her health is otherwise unchanged and she has regular menstrual cycles. Examination is unremarkable. Urine bHCG is negative (indicating that she is not pregnant). Laboratory studies show:Hemoglobin= 11.1 g/dL (low)Mean corpuscular volume 77 μm3/fL (low)Mean corpuscular hemoglobin 22.6 pg/cell (low)Ferritin 180ng/mL (normal)Serum iron 88 μg/dL (normal)Which is the most likely cause of her fatigue? A. Iron deficiency anemia B. Stress C. Vitamin B12 deficiency D. Alcoholism E. Alpha-thalassemia minor
E
A 3-year-old boy is brought to see you with a chronic normocytic anemia. A peripheral blood smear suggests a hemolytic anemia. His mother reports occasional difficulty with breathing, intermittent chest pain, and occasional pain in his fingers. Microscopy shows distortions of the red blood cell architecture. Which of the following pathophysiologic mechanisms best describes the underlying disease? A. A number of molecular defects in the genes encoding for the red blood cell spectrin proteins, leading to characteristic morphological changes B. An X-linked recessive disease in which the red blood cells demonstrate increased sensitivity to oxidative stress, leading to increased turnover C. Increased red blood cell sensitivity to complement activation, leading to increased propensity towards thrombotic events D. Secondarily caused by autoantibodies in response to prior infection, which subsequently attack the red blood cells, resulting in a hemolytic anemia E. A recessive beta-globin mutation causing morphological changes to the red blood cell
E
A 30-year-old woman presents with fatigue, pallor, and shortness of breath. Laboratory tests show a low hemoglobin level and a low reticulocyte count. The patient has a history of metastatic cancer. Which of the following mechanisms is most likely responsible for her anemia? A. Reduced erythropoietin production B. Destruction of erythrocyte progenitor cells C. Autoimmune damage to stem cells D. Viral infection of bone marrow E. Myelophthisis (bone marrow replacement) caused by metastatic cancer
E
A 34-year-old female presents to the clinic for tingling of her feet over the past 2 months. She reports that ever since her vacation to the Rocky Mountains 3 months ago, she began feeling"pins and needles" at her feet. She denies weight loss, fever, palpitations, chest pain, gastrointestinal symptoms, or rashes, but endorses lightheadedness and fatigue. Her past medical history is significant for gastric bypass surgery 4 year ago for weight loss. A physical examination demonstrates decreased vibration and pinprick sensation at the toes bilaterally. A peripheral blood revealed hypersegmented neutrophils. What is the most appropriate treatment for this patient? A. Oral folate B. Oral B12 C. Oral pyridoxine D. Parenteral folate E. Parenteral vitamin B12
E
A 38-year-old woman presents with fatigue and difficulty concentrating. She has hypertension and a 15-year history of Crohn disease with two terminal ileal resections, and she has long been asymptomatic. Current medications include an anti-TNF and a thiazide diuretic. Her vital signs are normal and exam shows a soft abdomen and pale conjunctivae. Rectal examination is unremarkable. Laboratory studies show: Hemoglobin= 8.5 g/dl (low) Mean corpuscular volume (MCV)= 105 μm3 (high) Leukocytes= 7.1/mm3 (4-12/mm3) Platelets= 180,000/mm3 (150-400/mm3) ESR= 35 mm/h (normal) Iron studies are normal Further evaluation of this patient is most likely to reveal which of the following findings? A) Tarry stools B) Impaired vision in her right eye C) Unexplained weight gain D) Dark-colored urine E) Decreased vibratory sensation
E
A 5-year-old boy comes to you for hematuria after a recent trip with his family to Africa. He was ill with high fevers and chills last week, and was given antimalarials. The boy has difficulty sitting still, because of back pain. What is likely to be seen on peripheral blood smear? A. Hypochromia B. Hypersegmented neutrophils C. Sickle cells D. Ringed sideroblasts E. Bite cells
E
A 54-year-old woman presents with increasing shortness of breath on exertion for the past few months. She also complains of associated fatigue and some balance issues. The patient denies swelling of her feet and difficulty breathing at night or while lying down. Physical examination is significant for conjunctival pallor. A peripheral blood smear reveals macrocytosis and hypersegmented granulocytes. Which of the following substances, if elevated in this patient's blood, would support the diagnosis of vitamin B12 deficiency? A. Methionine B. Cysteine C. Succinyl-CoA D. Homocysteine E. Methylmalonyl-CoA
E
A 58-year-old man presents with hematuria, fatigue and a sudden onset of back pain. This patient has an X-linked recessive disorder that causes his hemoglobin to precipitate into Heinz bodies. Which of the following causes the symptoms described? A. An increased oxygen-affinity of hemoglobin B. ATP accumulation C. Activation of complement D. Antibody mediated destruction of red blood cells E. Oxidative stress
E
A 64-year-old presents with fever, chills, headache, neck stiffness, vomiting, and confusion. Examination of the cerebrospinal fluid reveals changes consistent with bacterial meningitis, and brain imaging demonstrates a localized abscess. Which of the following types of necrosis is most characteristic of abscess formation? A. Caseous B. Coagulative C. Enzymatic D. Fibrinoid E. Liquefactive
E
On a routine visit to the physician, an otherwise healthy 51-year-old has a blood pressure of 150/95 mm Hg (N120/80mm hg). If their hypertension remains untreated for years, which of the following cellular alterations would most likely be seen in their myocardium? A. Atrophy B. Hyperplasia C. Metaplasia D. Hemosiderosis E. Hypertrophy
E
Which of the following does NOT represent the immature and mature form of the cell pairs A. Reticulocyte:RBC B. Band form:Neutrophil C. Megakaryocyte:Platelet D. Monocyte:Macrophage E. B cell: T cell
E
Which of the following is a cell of the myeloid lineage: A. B cell B. T lymphocyte C. NK cell D. Fibroblast E. RBC
E
Which of the following is a tool commonly used for the clinical evaluation of white blood cells in the peripheral blood that provides information about their composition? A. Complete blood count (CBC) without differential B. Erythrocyte sedimentation rate (ESR) C. C-reactive protein (CRP) level D. Bone marrow biopsy E. Flow cytometry
E
You are seeing a 45-year-old woman in the emergency room who was brought in with evidence of a stroke and confusion. She is febrile to 101°F, her pulse is 100/min, her respirations are 18/min, and blood pressure is 142/87 mm Hg. There are scattered petechiae over the chest, arms, and legs. Laboratory studies show: Hemoglobin= 7.1 mg/dl (12-17g/dl) WBCs= 10.2/mm3 (4-12/mm3) Platelets= 55,000/mm3 (150-400/mm3) Prothrombin time= 16 sec (10-13 sec) PTT= 35 sec (26-38 sec) Bilirubin (Total)= 3.5 mg/dl (0.2-1.0 mg/dl) Bilirubin (Direct)= 0.4 mg/dl (<0.4mg/dl) BUN= 30 mg/dl (10-20 mEq/L) Creatinine= 2.8 mg/dl (0.6-1.5 mg/dl) LDH= 1,100 U/L (140-280 U/L) A peripheral smear shows numerous schistocytes. Further evaluation is most likely going to show which of the following findings? A. Decreased megakaryocytes on bone marrow biopsy B. Antibodies against platelet factor 4 on serologic testing C. Enterohemorrhagic Escherichia coli on stool culture D. RBC agglutination on direct Coombs test E. Decreased ADAMTS13 activity in plasma
E
You are seeing a new patient, who brings with him, a lab report showing an isolated low platelet count. He is asymptomatic, has no excessive bleeding, has no past medical history, takes no medications, and does not use alcohol or illicit drugs. His peripheral blood smear is shown in the figure. Which of the following is the most likely diagnosis? A. Congenital thrombocytopenia B. Disseminated intravascular coagulopathy C. Drug-induced thrombocytopenia D. Idiopathic immune thrombocytopenia E. Pseudothrombocytopenia
E
A 2-year-old boy is brought to you for listlessness. He was breastfed until he was 14 months old. He currently eats some table foods and drinks 25 ounces (740 ml) of cow's milk daily. Examination shows mild conjunctival pallor. Examination shows redness and fissures of bilateral corners of the mouth. Laboratory studies are most likely to show which of the following? Mean corpuscular volume Red cell distribution width Total iron binding capacity Serum ferritin A Decreased Increased Decreased Increased B Normal Normal Decreased Increased C Normal Normal Increased Normal D Decreased Normal Decreased Increased E Increased Increased Normal Normal F Decreased Increased Increased Decreased
F
An experiment is conducted in which cells in tissue culture are subjected to high levels of ultraviolet radiant energy. Electron microscopy shows cellular damage in the form of increased cytosolic aggregates of denatured proteins. In situ hybridization reveals that protein components in these aggregates also are found in proteasomes. Which of the following substances is most likely to bind to the denatured proteins, targeting them for catabolism by cytosolic proteasomes? A. Adenosine monophosphate B. Calcium C. Caspase D. Granzyme B E. Hydrogen peroxide F. Ubiquitin
F
