Test Conventional Units SI Units
Hematology—cont'd Hematocrit (Hct) Hemoglobin Alc Hemoglobin, blood (Hb) Hemoglobin, plasma Leukocyte count and
differential Leukocyte count Segmented neutrophils Bands
Eosinophils Basophils Lymphocytes Monocytes
Mean corpuscular hemo- globin (MCH)
Mean corpuscular hemo- globin concentration (MCHC)
Mean corpuscular volume (MCV)
Partial thromboplastin time (activated) (aPTT) Platelet count Prothrombin time (PT) Reticulocyte count Thrombin time Volume
Plasma Red cell Sweat Chloride Urine Calcium
Creatinine clearance Estriol, total (in pregnancy)
30 wk 35 wk 40 wk
17-Hydroxycorticosteroids 17-Ketosteroids, total Osmolality
Oxalate Proteins, total
Male: 40%-54%
Female: 37%-47%
5. 6%
Male: 13.5-17.5 g/dL Female: 12.0-16.0 g/dL 1-4 mg/dL
4500-11,000/mm3 54%-62%
3%-5%
1% -3%
0%-0.75%
25%-33%
3%-7%
25.4-34.6 pg/cell 31%-37% Hb/cell 80-100 pm3 25-40 sec
150,000-400,000/mm3 12-14 sec
0.5%-1.5% of red cells
<2 sec deviation from control
Male: 25-43 mL/kg Female: 28-45 mL/kg Male: 20-36 mL/kg Female: 19-31 mL/kg 0-35 mmol/L 100-300 mg/24 hr Male: 97-137 mL/min Female: 88-128 mL/min 6-18 mg/24 hr
9-28 mg/24 hr 13-42 mg/24 hr Male: 3.0-9.0 mg/24 hr Female: 2.0-8.0 mg/24 hr Male: 8-22 mg/24 hr Female: 6-15 mg/24 hr 50-1400 mOsm/kg 8-40 p.g/mL
< 150 mg/24 hr
0.40-0.54 0.37-0.47 0.06%
2.09-2.71 mmol/L 1.86-2.48 mmol/L 0.16-0.62 mmol/L 4.5-11.0 x 109/L 0.54-0.62 0.03-0.05 0.01-0.03 0-0.0075 0.25-0.33 0.03-0.07
0.39-0.54 fmol/cell 4.81-5.74 mmol Hb/L 80-100 fl
25-40 sec 150-400 x 109/L 12-14 sec 0.005-0.015
< 2 sec deviation from control
0.025-0.043 L/kg 0.028-0.045 L/kg 0.020-0.036 L/kg 0.019-0.031 L/kg 0-35 mmol/L 2.5-7.5 mmol/24 hr
21-62 p.mo1/24 hr 31-97 pmo1/24 hr 45-146 1.tmol/24 hr 8.2-25.0 pmo1/24 hr 5.5-22.0 pmo1/24 hr 28-76 pmo1/24 hr 21-52 pmo1/24 hr 90-445 pmol/L
< 0.15 g/24 hr
TEST 1 S
DIRECTIONS: Each numbered item or incomplete statement is followed by options ar- ranged in alphabetical or logical order. Select the best answer to each question. Some options may be partially correct, but there is only ONE BEST answer.
1. A 58-year-old man with a history of alcohol abuse has tenderness in the right upper quadrant. Physical examination shows tender hepatomegaly. Serum bili- rubin is normal, but serum transaminases, particularly aspartate aminotransferase, are slightly elevated. The figure shows a section of the liver obtained on biopsy.
Which of the following best explains the pathogenesis of the liver disease?
O A. Decreased hydrolysis of adipose O B. Decreased synthesis of fatty acids O C. Increased concentration of glycerol
3-phosphate
O D. Increased 13-oxidation of fatty acids O E. Increased protein intake
2. Physical examination of a 2-year-old child with severe mental retardation shows a flat occiput, epicanthal folds, and a flat nasal bridge. There is a simian crease in both palms. Chromosome analysis shows 46 chromosomes. Which of the follow- ing types of genetic mutation is responsible for this condition?
O A. Balanced translocation O B. Frameshift mutation O C. Microdeletion O D. Nondisjunction O E. Point mutation
3. A 26-year-old man is scuba diving off the coast of Bermuda in water 30-60 feet deep when he develops problems with his air tank and must ascend quickly to the surface. One hour later, he has pain in the muscles and joints in the legs. Which of the following is most likely responsi- ble for these symptoms?
O A. Deep venous thrombosis O B. Disseminated intravascular
coagulation
•D C. Fat embolization
O D. Hemorrhage into muscles and joints O E. Nitrogen gas embolism
343
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344 Pathology
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4. The figure shows two children, each with a different nutritional disorder. Which of the following findings would most likely be reported only in child A?
O A. Decrease in serum albumin O B. Decrease in somatic protein stores O C. Decrease in subcutaneous fat O D. Decrease in total calorie intake 5. A 52-year-old woman has a history of chronic left-sided and right-sided heart failure. The autopsy specimen shows a thickening of the mitral valve leaflets and fusion of the commissures. Which of the following is the most likely cause of mitral valve disease in this patient?
O A. Immune reaction in systemic lupus erythematosus (SLE)
O B. Ischemic heart disease O C. Myxomatous degeneration O D. Recurrent bacterial endocarditis O E. Recurrent immune reaction against
group A streptococci
6. A 48-year-old man has fever, weight loss, sweating, and a dragging sensation in the abdomen. Physical examination shows generalized lymphadenopathy and massive hepatosplenomegaly. Laboratory studies show a normocytic anemia and throm- bocytopenia, and a WBC count of 110,000/
mm3 . A bone marrow biopsy shows
hypercellularity and the presence of neutro- phils at all stages of development; less than 2% of the WBCs are myeloblasts. The figure shows a peripheral blood smear.
Which of the following laboratory findings would most likely be positive?
O A. Leukocytes for alkaline phosphatase O B. Leukocytes for CD10
O C. Leukocytes for Philadelphia chromosome
O D. Leukocytes for tartrate-resistant acid phosphatase
O E. Leukocytes for terminal deoxy- nucleotidyl transferase
Test 1 345
7. A 56-year-old woman who has smoked two packs of cigarettes daily for 35 years has chronic dyspnea. She has an emaciated ap- pearance and pink discoloration of the skin.
It is difficult to hear heart and lung sounds because of the increase in the anteropos- tefior diameter of the chest cavity. A chest radiograph shows hyperinflation in both lung fields, depression of both diaphragms, and a vertically oriented cardiac silhou- ette. Which of the following results of pul- monary function tests would be reported?
O A. Decreased functional residual capacity O B. Decreased total lung capacity
O C. Increased FEV 1 :FVC ratio O D. Increased residual volume O E. Increased tidal volume
8. A 46-year-old man develops pneumonia shortly after repainting a bridge. A silver- stained specimen from the lung shows yeast forms with narrow-based buds. Which of the following pathogens is the most likely cause of this patient's pneumonia?
O A. Aspergillus fumigatus
O B. Coccidioides immitis
O C. Cryptococcus neoformans
O D. Histoplasma capsulatum
O E. Pneumocystis carinii
9. The arrow in the figure points to an intraluminal mass in a left anterior descend- ing coronary artery. Which of the follow- ing drugs is most likely to be used to prevent the formation of such a mass?
O A. Aspirin
O B. Glycoprotein Hb/IIIa inhibitor O C. Heparin
O D. Tissue plasminogen activator (tPA) O E. Warfarin
346 Pathology
10. Physical examination of a 72-year-old man shows severe hypertension, an epi- gastric bruit, and diminished amplitude of pedal pulses. Plasma renin activity is increased. Angiogram of the renal artery shows decreased uptake of dye and a small kidney on the left side and normal uptake of the dye and a normal-sized kidney on the right side. Which of the following best describes the pathogenesis of the hyper- tension?
) A. Adrenal tumor that produces excess aldosterone
0 B. Adrenal tumor that produces excess catecholamines
0 C. Essential hypertension with bilateral nephrosclerosis
3 D. Unilateral renal artery stenosis caused by atherosclerosis
1) E. Unilateral renal artery stenosis caused by fibromuscular hyperplasia
11. Shortly after a trip to the desert in the southwestern United States, a 58-year- old archaeologist develops a dry cough, fatigue, and painful nodules in the lower extremities. A biopsy of the lung shows granulomatous inflammation, with numer- ous spherules containing endospores.
Which of the following is the most likely cause of the respiratory disorder?
) A. Aspergillosis
B. Coccidioidomycosis 0 C. Cryptococcosis
) D. Histoplasmosis ,) E. Tuberculosis
12. A 35-year-old woman complains of colicky abdominal pain and vomiting. She has had surgery for Crohn's disease. A plain abdominal radiograph is taken of the patient in an erect position and shows mul- tiple air-fluid levels with a stepladder con- figuration. Which of the following is the most likely cause of the abdominal pain?
) A. Direct inguinal hernia ) B. Intussusception ) C. Large bowel infarction
) D. Small bowel adhesions ) E. Volvulus
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13. A 28-year-old man has fever, fatigue, difficulty breathing, and substernal chest pain while walking or at rest. The patient has a history of alcohol abuse. Physical examination shows bibasilar rales, disten- tion of the jugular neck vein, hepato- megaly, and dependent pitting edema.
A chest radiograph shows generalized cardiac enlargement. Laboratory studies show an increase in cardiac-specific
troponins. The figure shows a biopsy speci- men of myocardial tissue. Which of the following is the most likely cause of this patient's heart disease?
) A. Congestive cardiomyopathy ) B. Coronary artery thrombosis ) C. Ischemic heart disease
D. Rheumatic fever E. Viral myocarditis
Test 1 347
14. A 25-year-old man develops hemop- tysis. A few weeks later, he experiences sudden onset of acute renal failure and dies.
Prior to his death, urinalysis shows mild proteinuria, hematuria, and RBC casts.
The figure shows an immunofluorescence study of a representative glomerulus in a section of kidney removed at autopsy.
Which of the following is the most likely diagnosis?
O A. Diffuse membranous glomerulo- nephritis
O B. Focal segmental glomerulosclerosis O C. Goodpasture's syndrome
O D. IgA glomerulonephritis O E. Minimal change disease
15. A 56-year-old man with a lengthy history of alcohol abuse has chronic epi- gastric pain and chronic diarrhea associated with bloating and fatty stools. Physical examination shows malnutrition, abdomi- nal distention, and tender hepatomegaly.
A plain radiograph of the abdomen shows irregular densities in the left upper quadrant. Which of the following is the most likely diagnosis?
O A. Celiac disease O B. Chronic pancreatitis 0 C. Crohn's disease O D. Pancreatic carcinoma O E. Peptic ulcer disease
16. A 23-year-old African-American woman with a history of dysfunctional uterine bleeding complains of fatigue when exercis- ing. Laboratory studies show a mild micro- cytic anemia and increased RBC distribution width. The figure shows a peripheral blood smear. Which of the following investiga- tive studies is most useful in this diagnosis?
O A. Bone marrow aspiration biopsy O B. Hemoglobin electrophoresis
D C. Osmotic fragility test O D. Serum ferritin test O E. Sickle cell screening
17. The retina of a 35-year-old man who has a 15-year history of type 1 diabetes mel- litus shows microaneurysms and retinal hemorrhages. Which of the following is the pathogenesis of the lesions in the retina?
O A. Increased intraocular pressure O B. Inflammation of the optic nerve O C. Microangiopathy
D D. Nonenzymatic glycosylation 3 E. Osmotic damage
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348 Pathology
18. The figure shows the uterus, fallo- pian tubes, and cervix removed from a 55-year-old woman who experienced postmenopausal bleeding. Which of the following is the most likely pathogenesis of the lesion in the endometrial cavity?
O A. Adenomyosis
O B. Herpes simplex virus type 2 (HSV-2) infection
O C. Human papillomavirus (HPV) infection
O D. Multiparity
O E. Unopposed estrogen exposure 19. A febrile 42-year-old man has pain and swelling in the meta tarsophalangeal joint of the great toe. He has a 20-year history of alcohol abuse. A complete blood cell count shows an absolute neutrophilic leukocy- tosis with > 10% band neutrophils. Which of the following microscopic findings is most likely to be present in the synovial fluid?
O A. Neutrophils with phagocytosed gram-negative diplococci O B. Neutrophils with phagocytosed
gram-positive cocci
O C. Neutrophils with phagocytosed negative birefringent crystals O D. Neutrophils with phagocytosed
positive birefringent crystals O E. Neutrophils with phagocytosed
rheumatoid factor immunocomplexes
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20. A 52-year-old woman has a 10-year history of progressively worsening arthritis in the hands and knees, which has led to ankylosis. The figure shows a section of sy- novial tissue removed from the knee joint.
Which of the following types of inflam- mation is evident in this tissue?
21. A sexually active 19-year-old woman complains of frequency and a burning sen- sation upon urination. Pelvic examina- tion shows inflammation of the exocervix and an exudate in the cervical os. Urinalysis shows numerous neutrophils but no bacte- ria. A cervical Pap smear shows metaplas- tic squamous cells with a cytoplasmic phagosome containing an inclusion. Which of the following pathogens is the causal agent?
A. Candida albicans O B. Chlamydia trachomatis
O C. Human papillomavirus (HPV) O D. Neisseria gonorrhoeae
D E. Trichomonas vaginalis
• • Test 1 349
22. A 48-year-old man complains of
extreme fatigue, weakness, and lightheaded- ness when he stands up quickly from a seated position. The patient is normoten- sive when lying down; when sitting, his blood pressure drops and his pulse rate in- creases. There is diffuse brown pigmenta- tion of the buccal mucosa. The physician suspects a disorder involving the adrenal glands. Which of the following laboratory findings would most likely be reported?
O A. Decreased plasma ACTH and 11-deoxycortisol after metyrapone stimulation
O B. Decreased serum sodium and serum potassium
O C. Increased plasma ACTH and de- creased serum cortisol
0 D. Increased plasma ACTH and 11-deoxycortisol after metyrapone stimulation
O E. Increased urine 17-hydroxycorticoids with prolonged ACTH stimulation
23. A 45-year-old woman has fever, night sweats, and weight loss. The figure shows a biopsy specimen of lung tissue with evidence of necrosis. Which of the follow- ing best describes this necrosis?
O A. Gaseous necrosis a B. Coagulation necrosis 0 C. Enzymatic fat necrosis O D. Fibrinoid necrosis 0 E. Liquefactive necrosis
24. A centrally located lung mass is removed from a 58-year-old man who has smoked two packs of cigarettes a day for 30 years. An H&E-stained section of the mass shows round- to spindle-shaped baso- philic cells, increased mitotic activity, and necrotic foci. Which of the following endo- crinopathies is frequently associated with this type of tumor?
O A. Carcinoid syndrome O B. Hypercalcemia O C. Hypocalcemia
O D. Inappropriate antidiuretic hormone secretion
O E. Polycythemia
25. A 23-year-old woman states that she is extremely tired and has drooping eyelids and double vision toward the end of the workday. She also has difficulty swallowing solids and liquids and states that food seems to "stick near my Adam's apple."
Which of the following terms best describes this patient's clinical disorder?
O A. Demyelinating O B. Electrolyte a C. Motor neuron O D. Neuromuscular O E. Primary muscular
26. A 10-year-old boy has muscle weakness that became symptomatic 5 years ago.
When placed in a prone position, he must
"walk" his hands to his feet and up the front of his legs to stand. Which of the fol- lowing is the pathogenesis of this clinical disorder?
O A. Antibodies against acetylcholine receptors
O B. Deficiency of dystrophin O C. Demyelinating disorder O D. Inflammatory myopathy O E. Motor neuron disorder
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350 Pathology
27. A 65-year-old man has a ruptured ab- dominal aortic aneurysm and is in hypo- volemic shock. Which of the following is a reversible cellular event that is most likely to occur in the straight portion of the proxi- mal tubular cells of the kidneys?
O A. Ca2+ moving into the cytosol O B. Cytochrome c diffusing out of the
mitochondria
O C. Intracellular pH increasing
O D. Na' and H 20 moving into the cytosol O E. Phospholipase damaging the cell
membrane
28. A 22-year-old woman with a history of chronic diarrhea describes her stools as greasy. She recently developed a pruritic vesicular lesion on her elbow. The figure shows an endoscopic biopsy specimen of the jejunum. Which of the following will be most useful in identifying the cause of the diarrhea?
O A. Antigliadin antibodies O B. Antinuclear antibodies O C. Fecal smear for leukocytes O D. Stool for ova and parasites O E. Stool osmotic gap
29. An afebrile 48-year-old man has a 25-year history of lower back pain that began in the sacroiliac joints. He has been taking nonsteroidal anti-inflammatory drugs intermittently. Physical examination shows a stooped posture and tenderness in all the vertebral joints. A high-pitched early diastolic murmur is heard in the second intercostal space on the right. A radiograph of the spine shows forward curvature of the spine with fusion of the lumbar vertebrae. Which of the following laboratory findings is most likely to be reported?
O A. Antibodies against Borrelia burgdorferi
O B. HLA-B27 genotype O C. Hyperuricemia O D. Positive blood culture O E. Rheumatoid factor
30. A 12-year-old boy has an episodic history of developing pink-staining urine shortly after an upper respiratory infection.
The patient is normotensive and afebrile.
The urine dipstick test is positive for blood and shows mild to moderate amounts of protein. The anti–streptolysin 0 titer, the anti–DNAse B titer, and the serum anti- nuclear antibody (ANA) test are all negative.
Urinalysis shows RBCs and RBC casts.
Which of the following is the most likely diagnosis?
O A. Diffuse membranous glomerulo- nephritis
O B. Glomerulonephritis in systemic lupus erythematosus (SLE)
O C. IgA glomerulonephritis O D. Minimal change disease
O E. Poststreptococcal glomerulonephritis
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Test 1 351
31. The figure shows painless and non- pruritic lesions on the left side of the neck of an afebrile 25-year-old man with AIDS.
Similar lesions are also present on the hard palate. Which of the following is the most likely causal organism?
) A. BartowIla henselae ) B. Cytomegalovirus O C. Epstein-Barr virus
) D. Herpesvirus 8 E. HIV
32. A 48-year-old man with alcoholic cir- rhosis has ascites and dependent pitting edema in the lower legs. Fluid accumulation in the peritoneal cavity and legs occurs by which of the following mechanisms?
O A. Decreased plasma oncotic pressure O B. Increased plasma hydrostatic pressure ,_) C. Increased vessel permeability due to
histamine
O D. Lymphatic obstruction with lymphedema
E. Movement of water into the intra- cellular compartment
33. A 53-year-old man with type 1 diabetes mellitus and cirrhosis also has chronic diarrhea. The patient has a 58-year-old sister with similar problems. His skin is pale gray in color, and this is most obvious on his hands. Which of the following laboratory findings would most likely be reported?
D A. Decreased serum ceruloplasmin ) B. Decreased serum iron
D C. Decreased small bowel reabsorption of o-xylose
O D. Increased serum ferritin
• E. Increased total iron-binding capacity
34. The figure shows a valvular lesion on the left side of the heart of a 25-year-old woman. Which of the following heart sounds is most likely to be associated with this lesion?
D A. Diastolic blowing murmur after S2
D B. Midsystolic click followed by a murmur
) C. Opening snap followed by a mid-diastolic rumbling murmur
• D. Pansystolic murmur at the apex 7 E. Systolic ejection murmur
352 Pathology
35. A 9-month-old girl has an infection on her face that began as erythematous macules. She later develops pustules that rupture and cause honey-colored crusted lesions. The girl's 5-year-old brother devel- ops similar lesions. Which of the follow- ing is the causal agent?
O A. Group A 0-hemolytic streptococcus O B. Herpes simplex virus type 1
O C. Malassezia furfur O D. Propionibacterium acnes O E. Trichophyton rubrum
36. A 42-year-old man complains of head- aches and dyspnea. Physical examina- tion shows enlargement of the nose and supraorbital ridge and jutting out of the lower jaw. The hands and feet are enlarged.
A chest radiograph shows generalized en- largement of the heart. Which of the following is the most sensitive screening test for this patient's disorder?
O A. Serum cortisol O B. Serum glucose
O C. Serum insulin-like growth factor—I O D. Serum prolactin
O E. Serum thyroid-stimulating hormone (TSH)
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37. Which of the following clinical dis- orders is most compatible with the distribu- tion of affected patients shown in this pedigree?
O A. Congenital spherocytosis
O B. Glucose-6-phosphate dehydrogenase (G6PD) deficiency
O C. Hemochromatosis O D. Neurofibromatosis O E. Type 2 diabetes mellitus
38. For the past 15 years, a 72-year-old woman has experienced a loss in height and has had a chronic backache, resulting in forward curvature of the spine. Radio- graphs of the vertebral column show de- creased bone density and wedge-shaped flattening of the vertebral bodies in the midthoracic region. Which of the following is the pathogenesis of this clinical
condition?
O A. Decreased estrogen
O B. Genetic defect in osteoclasts O C. Hypovitaminosis D
O D. Metastasis to bone
Test 1 353 39. A 1-year-old boy has painful vesicular
lesions on the upper and lower lips. One of the vesicles was unroofed, and a scraping of cells from the base of the lesion was smeared onto a glass slide. The material on the slide was stained with a Pap stain.
Which of the following best describes the cytologic findings in this smear?
O A. Dysplastic squamous cells with in- creased nuclear chromatin
O B. Enlarged individual squamous cells with intranuclear inclusions
O C. Multinucleated squamous cells with intranuclear inclusions
O D. Neoplastic squamous cells with atypi- cal mitotic figures
O E. Normal basal cells without intra- nuclear inclusions
40. A febrile 30-year-old woman sees her physician because of a rash on the thigh (see figure) that developed at the site where she was bitten by an insect when on a camping trip about 4 weeks ago. The woman lives in the northeastern United States. Which of the following is the most likely causal pathogen?
O A. Babesia micron O B. Borrelia burgdorferi O C. Borrelia recurrentis O D. Ehrlichia chaffeensis O E. Rickettsia rickettsii
41. A 36-year-old man has a history of chronic liver disease and a movement disor- der. Physical examination shows a rim of brown pigment around the perimeter of the cornea. Which of the following laboratory findings would most likely be reported?
O A. Decreased serum ceruloplasmin O B. Decreased serum iron
O C. Increased serum ferritin O D. Increased total serum copper O E. Normal serum prothrombin time
42. A 25-year-old man develops a pruritic lesion on the trunk. The lesion has an oval shape with an erythematous margin, and the central area has fine white scales. A KOH examination of skin scrapings taken from the leading edge of the lesion is nega- tive for fungal organisms. Two weeks later, the patient develops a more widespread truncal eruption that follows the lines of cleavage of the skin. Which of the following is the most likely diagnosis?
O A. Eczema O B. Pityriasis rosea O C. Secondary syphilis O D. Tinea corporis O E. Tinea versicolor