At autopsy, the spleen of a patient is noted to have a thickened capsule and many small, scarred areas.

Microscopic examination of the scarred areas reveals fibrosis with hemosiderin and calcium
deposition. This type
of spleen is usually seen in conjunction with which of the following disorders?
A. Hepatic cirrhosis
B. Hodgkin's disease
C. Rheumatoid arthritis
D. Sickle cell anemia
E. Trauma
Explanation:
The correct answer is A. The spleen shows the changes of chronic congestive splenomegaly, typically
associated with hepatic cirrhosis. The described small scars are called Gandy-Gamma nodules, and
are
thought to be the result of organization of old hemorrhages.
Hodgkin's disease (choice B) produces large splenic nodules in which Reed-Sternberg cells can be
found
surrounded by mature lymphocytes, eosinophils, and neutrophils.
Rheumatoid arthritis (choice C) and many other chronic inflammatory disorders induce reactive
hyperplasia of
the spleen with formation of many large germinal centers in the splenic follicles.
Sickle cell anemia (choice D) produces many small (often triangularly shaped) infarctions in the
spleen.
Trauma (choice E) can cause splenic rupture.

A 30-year-old man with an undiagnosed cardiac anomaly has been unable to do strenuous exercise
throughout
his life. Auscultation demonstrates an immediate diastolic murmur, which has been be present since
childhood.
The patient has never been cyanotic. Which of the following disorders would most likely cause the
patient's
findings?
A. Bicuspid aortic valve
B. Common pattern transposition of the great arteries
C. Patent ductus arteriosus
D. Tricuspid atresia

E. Truncus arteriosus
Explanation:
The correct answer is A. Isolated bicuspid aortic value is a very common congenital anomaly, which
may be
completely asymptomatic or may cause modest noncyanotic obstruction related to stenosis. It is
associated with
an immediate diastolic murmur, related to some degree of aortic insufficiency that is often recognized
in early
childhood. Surgical correction of even mild to moderate stenosis or insufficiency is now
recommended to
prevent long-term damage to the heart muscle.
The common pattern of transposition (choice B) of the great vessels produces early cyanosis.
Uncorrected patent ductus arteriosus (choice C) produces a continuous ("machinery") murmur and
late
cyanosis.
Tricuspid atresia (choice D), which is usually accompanied by an atrial septal defect, produces early
cyanosis.
Truncus arteriosus (choice E) produces early cyanosis.

A 60-year-old male presents to the dermatologist with a complaint of tender blisters on his arm and flank.
Physical examination reveals blisters and flaccid bullae; a few have ruptured, leaving red, sore,
denuded areas.
Which of the following findings would suggest the diagnosis of pemphigus vulgaris as opposed to
bullous
pemphigoid?
A. Eosinophils within bullae
B. IgA deposits on basement membrane
C. IgG autoantibody activity
D. Negative Nikolsky sign
E. Oral mucosal lesions
Explanation:
The correct answer is E. Pemphigus vulgaris is associated with chronic, severe bullae formation on
the skin and
oral mucosa. Mucosal lesions are extremely rare in bullous pemphigoid. This can be used clinically to
guide
therapy, although a skin biopsy should be taken to confirm the diagnosis. Both diseases are
characterized by

formation of tender bullae that can rupture, leaving red, raw areas. Pemphigus vulgaris patients
eventually
become febrile and lose weight, and if untreated, most will die within one year. Bullous pemphigoid
lesions tend
to heal and the patients do very well. This prognostic difference is an important distinction in
dermatologic
medicine.
Eosinophils within blisters (choice A) provide an important clue supporting bullous pemphigoid as
the diagnosis
which must be ascertained with histologic examination. The vesicles in pemphigus vulgaris mostly
contain
rounded acantholytic keratinocytes "floating" within.
IgA deposits seen with immunofluorescence on the basement membrane (choice B) is characteristic
of a third
bullae-forming disease known as dermatitis herpetiformis. Vesicles form between the dermalepidermal junction.
The disease is associated with gluten sensitivity and celiac disease.
IgG autoantibody activity (choice C) is common to both pemphigus vulgaris and bullous pemphigoid.
Nikolsky's sign consists of separation of the epidermis upon manual stroking of the skin. Bullous
pemphigoid is
characterized by a negative Nikolsky's sign (choice D), but Nikolsky's sign is positive in pemphigus
vulgaris due
to the IgG-mediated destruction of intercellular bridges between keratinocytes.

A five-year-old girl is brought to a pediatrician because she is developing breasts. Physical examination
shows
large hyperpigmented macules with irregular margins on one side of her back. Which of the following
bony
abnormalities would most be likely associated with these symptoms?
A. A combination of osteitis fibrosa cystica and osteomalacia
B. A generalized thinning of bony spicules
C. Excessive bony deposition with obliteration of marrow
D. Formation of new bone beneath the periosteum of phalanges
E. Multiple localized whorls of connective tissue
Explanation:
The correct answer is E. McCune-Albright syndrome is the combination of precocious sexual
development,
irregularly shaped ("coast of Maine") pigmented skin macules, and polyostotic fibrous dysplasia. The
latter
condition is characterized by local bony defects containing unmineralized whorls of connective tissue.

Renal osteodystrophy refers to a constellation of bony changes occurring in the context of chronic
renal failure.
Features may include those of osteitis fibrosa cystica (marrow fibrosis, bony resorption and cyst
formation
within the marrow cavity) and osteomalacia (choice A).
Osteomalacia results from vitamin D deficiency in adults, and is characterized by a generalized
thinning of bony
spicules (choice B).
Osteopetrosis is characterized by excessive bony deposition that can obliterate marrow (choice C),
causing
anemia.
Formation of new bone beneath the periosteum of the phalanges (choice D) is characteristic of
hypertrophic
osteoarthropathy, which may be associated with thoracic cancer, chronic lung disease, and chronic
liver
disease.
During a pelvic examination, a gynecologist discovers an adnexal mass in a 32-year-old woman. Resection
of the
mass demonstrates a malignant ovarian tumor. The tumor suppressor gene strongly associated with
this tumor is
also associated with cancer of which other organ or tissue?
A. Breast
B. Colon
C. Pancreas
D. Peripheral nerve
E. Stomach
Explanation:
The correct answer is A. The tumor suppressor gene most strongly associated with ovarian carcinoma
is
BRCA-1, which is also associated with breast cancer. This tumor suppressor gene is located on 17q.
Associate APC (5q), DCC (18q), and p53 (17p) with colon cancer (choice B).
Associate DPC (18q) with pancreatic cancer (choice C).
Associate NF-1 (17q) with neurofibromatosis type I, which is associated with peripheral nerve tumors
(choice D).
Associate DCC (18q) with stomach cancer (choice E).

A 30-year-old woman presents to a physician with rather non-specific complaints of fatigue, malaise, lowgrade
fever, and arthralgias. Screening serum chemistries demonstrate an elevated BUN. The urine shows
proteinuria.
Testing for which of the following will be most helpful for making the diagnosis?
A. Anticentromeric antibody
B. Antimitochondrial antibody
C. Antinuclear antibody
D. Anti-TSH receptor antibody
E. Rheumatoid factor
Explanation:
The correct answer is C. Systemic lupus erythematosus is a favorite on board examinations, and
should be
considered in any 15- to 45-year-old woman with chronic, poorly defined symptoms. Clues that help
are malar
rash, anti-double-stranded DNA antibodies, and renal involvement. Antinuclear antibody is a good
screening
test (it is also positive in some other autoimmune diseases) and should be used first in working this
patient up.
Renal involvement is unusual in most other autoimmune diseases.
Anticentromeric antibody (choice A) is a marker for the CREST form of scleroderma.
Antimitochondrial antibody (choice B) is a marker for primary biliary cirrhosis.
Anti-TSH receptor antibody (choice D) is a marker for Graves' disease.
Rheumatoid factor (choice E) is a marker for rheumatoid arthritis.

An adult with newly diagnosed tuberculosis is most likely to have which of the following types of lesions?
A. A single lesion in a lung apex
B. A single lesion in the gastrointestinal tract
C. A single lesion subjacent to the pleura
D. Both a lesion subjacent to the pleura in the lower part of an upper lobe and active disease in
the
mediastinal lymph nodes
E. Multiple tiny masses throughout the body

Explanation:
The correct answer is A. This is something of a trick question, but it stresses an important fact many
medical
students do not realize. Primary tuberculosis infection characteristically involves the lung subjacent to
the
pleura in either the lower part of the upper lobe or the upper part of a lower lobe of one lung. The
mediastinal
nodes are also usually involved (choice D), rather than having a single lesion subjacent to the pleura
(choice
C) without lymph node involvement. However, the "trick" part of this question rests on the fact that
roughly 80%
of newly diagnosed pulmonary tuberculosis cases in adults are actually due to reactivation of an often
clinically
unsuspected infection acquired years-to-decades previously. The reinfection site usually is in the apex
of the
lung.
You should also be aware that the lungs are not the only site where tuberculosis can occur (it can
occur
throughout the body), and isolated gastrointestinal involvement (choice B) is (uncommonly) also
seen.
Miliary tuberculosis (rare) is a widely disseminated and dangerous form of tuberculosis characterized
by small
lesions throughout the body (choice E).

A 40-year-old woman has the following family and personal history: her mother died of breast cancer at
age 64,
she smokes one pack/day, she drinks five or more cups of coffee/day, she has no children, and she
takes birth
control pills. Which of the following is the most significant risk factor for breast cancer in this
patient?
A. Birth control pills
B. Caffeine consumption
C. Cigarette smoking
D. Family history
E. Nulliparity
Explanation:
The correct answer is D. Positive family history is definitively the most significant risk factor of
developing breast
cancer among the ones mentioned in the list. About 5% to 10% of cases are attributable to inheritance
of

autosomal dominant genes. Most hereditary cases of breast cancer are due to two genes, BRCA1 and
BRCA2,
which are tumor suppressor genes probably involved in DNA repair. There are additional rare
"susceptibility"
genes, namely those causing Li-Fraumeni syndrome (mutations of p53), Cowden syndrome
(mutations of a
gene on chromosome 10), and ataxia-telangiectasia (mutations of ATM gene). Note, however, that
80% to 90%
of women with breast cancer do not have a positive family history.
The role of exogenous estrogens, including those administered with birth control pills (choice A) or
postmenopausal replacement therapy, is still debated. If there is any associated risk for breast cancer,
this is
minimal.
There is no convincing evidence linking caffeine consumption or cigarette smoking (choices B and C)
to breast
cancer.
Breast cancer is more frequent in nulliparous women than in multiparous women. Nulliparity (choice
E) is
therefore a risk factor, but its role is considered less important than family history. Similar to a long
duration of
reproductive life and late age at first intercourse, nulliparity seems to increase breast cancer risk by
increasing
exposure to endogenous estrogen during the menstrual cycle.

Biopsy of a small, rounded rectal polyp demonstrates glands and sawtooth crypts composed of a
proliferation of
goblet and columnar epithelial cells. No atypia is seen. This polyp is best classified as which of the
following?
A. Hyperplastic polyp
B. Peutz-Jeghers polyp
C. Tubular adenoma
D. Tubulovillous adenoma
E. Villous adenoma
Explanation:
The correct answer is A. This is a hyperplastic polyp; these polyps comprise 90% of all colonic
polyps and have
no malignant potential.
Peutz-Jeghers polyps (choice B) also have no malignant potential, but tend to be larger and have a
complex
branching pattern.

Tubular adenomas, tubulovillous adenomas, and villous adenomas (choices C, D, and E) are all true
neoplastic
polyps containing dysplastic epithelium; the malignant potential of these polyps increases with size
and the
percentage of the polyp which has a villous configuration.

A 52-year-old Caucasian male presents with sinus pain and drainage, bloody nasal discharge, and nasal
mucosal ulceration. On laboratory examination, the man is found to have proteinuria, hematuria, and
red blood
cell casts. A biopsy of the upper airway tissue reveals granulomatous inflammation with necrosis.
Renal biopsy
confirms the existence of glomerulonephritis. Blood tests show the presence of antineutrophil
cytoplasmic
antibodies (c-ANCA). What is the most likely diagnosis?
A. Allergic angiitis
B. Goodpasture's syndrome
C. Non-infectious granulomatous disease
D. Tumors of the upper airway
E. Wegener's granulomatosis
Explanation:
The correct answer is E. Antineutrophil cytoplasmic antibodies yielding a cytoplasmic
immunofluorescence
pattern (c-ANCA) are found in over 90% of patients with Wegener's granulomatosis. The classic
clinicopathologic complex of Wegener's granulomatosis usually provides ready differentiation from
other
disorders in which c-ANCA is positive. c-ANCA is not considered pathognomonic, but has a very
strong
association with Wegener's and is not found in any of the other diseases listed.
c-ANCA is generally negative in patients with allergic angiitis (choice A), non-infectious
granulomatous disease
(choice C), and tumors of the upper airway (choice D).
c-ANCA is typically negative in Goodpasture's syndrome (choice B), but p-ANCA have been
detected in some
patients with Goodpasture's syndrome.

A tall man with gynecomastia and testicular atrophy has a testicular biopsy that shows sparse, completely
hyalinized seminiferous tubules with a complete absence of germ cells and only rare Sertoli cells.
Leydig cells are
present in large clumps between the hyalinized tubules. Which of the following genetic disorders
should be
suspected?

A. Testicular feminization syndrome

B. Trisomy 18
C. Trisomy 21
D. 45, XO
E. 47, XXY
Explanation:
The correct answer is E. The testicular changes described are those observed in Klinefelter's
syndrome, most
often due to 47, XXY genetics.
Testicular feminization syndrome (choice A) is due to a genetically determined unresponsiveness to
testosterone that produces a phenotypic female in an individual with 46, XY chromosomes.
Trisomy 18 (choice B) is Edwards' syndrome, characterized by facial features that are small and
delicate.
Trisomy 21 (choice C) is Down syndrome, the most common trisomy. Characteristics include oblique
palpebral
fissures, epicanthal folds, endocardial cushion defects, simian creases, and high-arched palate, among
other
anomalies.
Turner's syndrome, 45, XO (choice D), produces a sterile but phenotypic female individual of short
stature with
webbing of the neck.

A 54-year-old woman presents with complaints of abdominal fullness and early satiety. She denies a change
in
bowel habits and says that constipation is her normal state. A radiographic bowel series shows an
"apple core"
lesion in her sigmoid colon. Which of the following markers is expected to be elevated in this patient?
A. Alpha-fetoprotein (AFP)
B. Carcinoembryonic antigen (CEA)
C. Human chorionic gonadotropin (hCG)
D. Lactate dehydrogenase (LDH)
E. Prostatic acid phosphatase (PAP)
Explanation:

The correct answer is B. CEA is a glycoprotein (200,000 daltons) that is found in the gastrointestinal
mucosal
cells and pancreatobiliary system secretions. It becomes elevated when breaks in the mucosal
basement
membrane occur due to tumor growth. Some other conditions can also cause elevations of CEA (e.g.,
cirrhosis,
pancreatitis). The patient described above has colonic carcinoma, and the "apple core" lesion is the
classic
radiographic finding of this tumor. Although CEA is not used for screening because of the large
number of false
positives, it can be used to guide treatment in known cases. It returns to normal levels 30-45 days
after tumor
resection. If it begins to rise again, tumor recurrence is likely.
AFP (choice A), or alpha-fetoprotein, is an alpha globulin (70,000 daltons) made by the liver and yolk
sac of the
human fetus. It is elevated with hepatocellular carcinoma and germ cell neoplasms. It is not
particularly specific.
hCG (choice C), or human chorionic gonadotropin, is a glycoprotein secreted by trophoblastic
epithelium of the
placenta. It is useful (sensitive and specific) for germ cell tumors of the testis and ovary.
LDH (choice D), or lactate dehydrogenase, is a very non-specific test that can be elevated in many
conditions,
including malignancy.
PAP (choice E), or prostatic acid phosphatase, is a sensitive marker used for detecting prostatic
adenocarcinoma.

A 54-year-old man is admitted to the hospital with cough and dyspnea, which over a period of years has led
to
marked respiratory embarrassment and cyanosis. Chest x-ray film of the lungs shows bilateral lower
lobe
ground-glass infiltrates. Wedge biopsy of the lung demonstrates airspaces filled with macrophages
containing
lipid, periodic acid-Schiff (PAS)-positive granules, and lamellar bodies. There is an accompanying
interstitial
pneumonitis, hyperplasia of the septal lining epithelial cells, and desquamation of epithelial cells into
alveoli. The
lamellar bodies within the macrophages are composed of which of the following?
A. Amyloid
B. Calcitonin
C. Fibrin
D. Hemosiderin
E. Surfactant

Explanation:
The correct answer is E. The disease is desquamative interstitial pneumonitis (DIP), which is an
idiopathic
process related to idiopathic interstitial fibrosis. DIP may respond to steroid therapy but may also
progress to
end-stage lung disease. The lamellar (layered) bodies within macrophages contain surfactant derived
from type
II pneumocytes.
Amyloid (choice A) is deposited extracellularly and is not part of the DIP process.
Calcitonin (choice B) is found in medullary carcinoma of the thyroid.
Fibrin deposition (choice C) can be part of the DIP process, but occurs as eosinophilic extracellular
deposits,
rather than as intracellular lamellar bodies.
Hemosiderin (choice D) can accumulate in pulmonary macrophages, usually in the setting of
congestive heart
failure with microhemorrhages, and produces golden brown granules.

Over a one month period, a 35-year-old man develops symptoms of hyperthyroidism with tachycardia and
heat
intolerance. Thyroid biopsy demonstrates a heavy mononuclear cell infiltrate with multinucleated
giant cells,
follicular disruption, and loss of colloid. About one month later, the patient develops symptoms of
hypothyroidism.
To which of the following is this patient's condition thought to be most closely related?
A. Blocking TSH receptor autoantibodies
B. Carcinoma
C. Lymphoma
D. Stimulating TSH receptor autoantibodies
E. Viral infection
Explanation:
The correct answer is E. The patient has subacute thyroiditis, also known as granulomatous giant cell
or de
Quervain's thyroiditis. This condition is thought to be due to viral infection of the thyroid gland, and
may follow
an upper respiratory infection. Early in the process, the follicular destruction causes inappropriate
release of
thyroid hormone with resulting hyperthyroidism. Later, the destruction can proceed to the point that
hypothyroidism occurs.

Antibodies that block the TSH receptor (choice A) are a feature of Hashimoto's disease.
Thyroid carcinoma (choice B) usually does not produce hyperthyroidism.
Lymphoma (choice C) of the thyroid is more likely to occur in the setting of Hashimoto's disease.
Stimulating TSH receptor antibodies (choice D) are a feature of Graves disease.

A 3-year-old boy with an enlarging, left-sided, abdominal mass undergoes diagnostic biopsy. The tumor
reveals a
variety of cellular patterns: dense immature islands of epithelial cells, ribbons of spindled fibroblastlike stromal
cells, and poorly formed tubular structures. This triphasic histology is most suggestive of which of the
following
childhood neoplasms?
A. Embryonal rhabdomyosarcoma
B. Ewing's sarcoma
C. Hodgkin's disease
D. Neuroblastoma
E. Wilms' tumor
Explanation:
The correct answer is E. Wilms' tumor, a neoplasm of the embryonic renal blastema, contains both a
neoplastic
epithelial and stromal component. In addition to organizing as islands of stromal or epithelial cells,
these cells
characteristically organize into recognizable glomerular and/or tubular structures that may represent a
minority
or sizeable component of the tumor.
Rhabdomyosarcoma (choice A) is a malignancy of skeletal muscle origin, and the cells are recognized
by their
cytoplasmic content of eosinophilic muscle proteins (thin and thick filaments). Rhabdomyosarcoma
has an
embryonal, alveolar, and pleomorphic variant, but none demonstrates a triphasic histology.
Ewing's sarcoma (choice B) appears as a monotonous mass of primitive, small, round cells with a thin
rim of
clear cytoplasm. Ewing's sarcoma is a tumor of bone; presentation as an abdominal mass is distinctly
unusual.
Hodgkin's disease (choice C) is a lymphoid malignancy that presents with lymphadenopathy, typically
in the
cervical or mediastinal nodes. The cellular component contains varying amounts of inflammatory
cells and
Reed-Sternberg cells.

Neuroblastoma (choice D) frequently presents as an abdominal mass in children; however, it does not
have an
epithelial component. The cell population of neuroblastoma ranges from primitive, small, blue, round
cells to
well-differentiated neuritic cells resembling ganglion cells.

A 60-year-old man presents to a physician because of difficulty in reading and coming down stairs, which
he
attributes to an inability to "look down." Physical examination reveals that the patient looks around by
moving his
head rather than his eyes and also shows a distinctive axial rigidity of neck, trunk, and proximal limb
muscles. He
shows poverty of movement and dysarthric speech. Mentally, the patient responds very slowly but has
better
memory and intellect than are initially apparent. Which of the following pathologic findings of the
brain would most
likely be present?
A. Depigmentation of the substantia nigra and locus ceruleus
B. Diffuse cortical atrophy with relative sparing of primary motor and sensory areas
C. Selective frontal and temporal lobe atrophy
D. Striking degeneration of the caudate nucleus
E. Widespread neuronal loss and gliosis in subcortical sites
Explanation:
The correct answer is E. The disease is progressive supranuclear palsy, a degenerative disorder
characterized
by ophthalmoplegia, pseudobulbar palsy, axial dystonia, and bradykinesia. The presentation described
in the
question is typical. The pathologic changes consist of widespread neuronal loss and gliosis in
subcortical sites
with sparing of the cerebral and cerebellar cortices.
Pigmented neurons in the substantia nigra (pars compacta) and locus ceruleus (choice A) selectively
degenerate in Parkinson's disease.
In Alzheimer's disease, there is diffuse cortical atrophy (choice B), especially over the association
cortex of
frontal, temporal, and parietal lobes, with relative sparing of primary sensory and motor areas.
Selective frontal and temporal lobe atrophy (choice C) is characteristic of Pick's disease.
The caudate nucleus and putamen undergo severe atrophy (choice D) in Huntington's disease. Cortical
atrophy occurs to a lesser extent.

A 2-year-old girl is evaluated because of deteriorating vision. On physical examination, a whitish hue is
noted in
the right pupil, along with strabismus. Palpation of the eye elicits apparent pain and tenderness. The
patient is
referred to an ophthalmologist, who schedules surgery, and removes a multifocal tumor from the right
eye. The
pathology report notes the presence of rosettes composed of cuboidal-to-columnar cells surrounding a
central
lumen in the tumor. In all likelihood, this child's condition stems from a mutation in a gene on
chromosome
A. 5
B. 7
C. 9
D. 13
E. 21
Explanation:
The correct answer is D. The description of this case is classic for retinoblastoma, the most common
malignant
eye tumor of childhood. Retinoblastoma presents as in the question, and microscopically is composed
of
neuroepithelial cells that form characteristic rosettes (Flexner-Wintersteiner rosettes). Familial
retinoblastoma is
often bilateral or multifocal, as in this case. A preexisting mutation of a tumor suppressor gene, Rb,
located on
chromosome 13 (13q14) is present, but causes no symptoms. A second, somatic mutation in a retinal
cell leads
to loss of a nuclear protein that prevents the retinal cell from exiting G1, allowing development of the
tumor. In
cases of sporadic retinoblastoma, mutations must occur in both chromosomes 13 of a somatic cell, a
rare event,
hence sporadic retinoblastoma is always unifocal and unilateral.

A 25-year-old man presents to the emergency room with severe abdominal pain. Guaiac test on stool
demonstrates occult blood. The patient is taken to exploratory laparotomy, at which a small area of
infarcted
small bowel is found and surgically removed. Histologic studies on the removed section of bowel
demonstrate a
recent thrombus occluding a small muscular artery. The adjacent vessel wall shows fibrinoid necrosis
with a
mixed inflammatory infiltrate containing neutrophils, eosinophils, and mononuclear cells. Which of
the following is
the most likely cause of the small bowel infarction?

A. Atherosclerosis
B. Cystic medial necrosis
C. Mnckeberg's arteriosclerosis
D. Polyarteritis nodosa
E. Wegener's granulomatosus
Explanation:
The correct answer is D. The lesion described is that of polyarteritis nodosa. This condition is often
considered
to be the prototype for the vasculitides, and characteristically affects small or medium-sized muscular
arteries,
with a predilection for the gastrointestinal tract and kidney (causing hematuria, albuminuria, or renal
failure).
Patients are typically young adult males, although both sexes and all ages may have the condition.
Characteristically, vascular lesions of different stages may be present. Corticosteroid and
cyclophosphamide
therapy has improved a formerly poor prognosis.
Atherosclerosis (choice A) can cause bowel infarction, but the histologic description would be that of
a plaque.
Cystic medial necrosis (choice B) predisposes for dissecting aortic aneurysm.
Mnckeberg's arteriosclerosis (choice C) is a benign condition characterized by ring-like
calcifications of vessel
walls.
Wegener's granulomatosus (choice E) affects the lungs, upper airways, and kidneys.

Which of the following is most likely to cause a hypochromic microcytic anemia?

A. Folate deficiency
B. Hereditary spherocytosis
C. Iron deficiency anemia
D. Sickle cell anemia
E. Vitamin B12 deficiency
Explanation:
The correct answer is C. Conditions that produce microcytic anemia include iron deficiency,
thalassemia minor,

anemia of chronic disease, and the anemia produced by erythrocyte fragmentation.

Folate deficiency (choice A) usually produces a macrocytic anemia.
Hereditary spherocytosis (choice B) usually produces an anemia with cells of normal volume.
Sickle cell anemia (choice D) usually produces an anemia with cells of normal volume.
Vitamin B12 deficiency (choice E) usually produces a macrocytic anemia.

A 28-year-old female presents to the doctor complaining of syncopal episodes that last a few minutes. She
is not
taking any medications and has no previous medical history. EEG and EKG studies are performed and
are
unremarkable. An echocardiogram shows a single ball-shaped mass dangling in the left atrium near the
mitral
valve. The most likely diagnosis is
A. angiosarcoma
B. mesothelioma
C. myxoma
D. rhabdomyoma
E. rhabdomyosarcoma
Explanation:
The correct answer is C. The vignette illustrates a typical presentation for a tumor of the heart.
Primary cardiac
tumors are rare and usually require an intensive work-up to pinpoint the diagnosis. 75% of primary
cardiac
tumors are benign and among these, myxoma is the most common. The tumors are usually single; the
most
common location is the left atrium. They may cause syncopal episodes or even shock and death due to
obstruction by a "ball valve" mechanism.
Angiosarcoma (choice A) is a malignant tumor of vascular origin that can occur as a primary cardiac
tumor. It is
the most common malignant primary cardiac tumor, but it is still very rare. Angiosarcoma usually
affects the right
side of the heart.
Mesothelioma (choice B) is a benign tumor of mesothelial origin that can rarely present as a primary
cardiac
tumor. It is usually a small intramyocardial tumor that presents with disturbances of the conduction
system of the
heart.

Rhabdomyoma (choice D) is a benign tumor of muscle origin. It can occur as a primary cardiac
tumor, typically
in infants and children, in whom it may be associated with tuberous sclerosis. It usually occurs in the
ventricles.
Rhabdomyosarcoma (choice E) is a malignant neoplasm that can also occur as a rare primary cardiac
tumor. It
is of muscle origin and usually affects the right heart.

The day after playing in the high grasses of a neighbor's fields, an 8-year-old boy develops a weeping,
vesicular,
erythematous, and itchy rash on his arms, legs, and neck. Which of the following best describes this
inflammatory
response?
A. Erythema nodosum
B. Pemphigus
C. Psoriasis
D. Spongiotic dermatitis
E. Urticaria
Explanation:
The correct answer is D. Spongiotic dermatitis is seen in cases of contact dermatitis, such as poison
ivy
exposure. The accumulation of inflammatory cells in the superficial dermis causes marked edema,
which splays
epidermal keratinocytes apart and giving a spongy appearance to intercellular bridges. Grossly, the
skin has a
weepy appearance with frequent blistering.
Erythema nodosum (choice A) is a form of panniculitis, which is chronic inflammation in the
subcutaneous fat
lobules. Erythema nodosum presents as painful erythematous nodules, often with fever and malaise. It
is
associated with infections and drug reactions, and is not a contact dermatitis.
Pemphigus (choice B) is a genetic blistering disorder due to the production of antibodies to the
intercellular
cement substances in skin and mucous membranes.
Psoriasis (choice C) is a common chronic inflammatory disease causing plaques and scales, typically
on
elbows, knees, and scalp. The pathogenesis of psoriasis is still unclear; it may be a complementmediated
autoimmune process.

Urticaria (choice E) is an IgE-driven hypersensitivity process, usually occurring in adults between 20

and 40
years old. Urticaria is characterized by wheals (edematous pruritic plaques), and typically affects the
trunk and
distal extremities.

A 30-year-old woman presents complaining of nosebleeds. She also notes easy bruising and excessively
heavy
bleeding during her periods. The patient denies taking any medications. Physical examination is
remarkable for
scattered petechiae. The spleen is normal-sized. Laboratory examination is remarkable for a platelet
count of
45,000/microliter and a bleeding time of 17 minutes. The bone marrow shows an increased number of
megakaryocytes. Antinuclear antibody is negative. Autoantibodies directed against which of the
following
antigens would likely be found in this patient's serum?
A. Acetylcholine receptor
B. Erythrocyte membrane protein
C. Glycoprotein IIb/IIIa
D. Intrinsic factor
E. Type IV collagen
Explanation:
The correct answer is C. The history of nosebleeds and menorrhagia, the petechiae, thrombocytopenia
and
increased bleeding time all suggest a platelet disorder. The decreased platelet count suggests a
thrombocytopenic disorder rather than a platelet function disorder. The absence of antinuclear
antibody argues
against systemic lupus erythematosus (a significant cause of thrombocytopenia). The negative drug
history
rules out drug-associated thrombocytopenia. After other causes have been ruled out, a tentative
diagnosis of
idiopathic thrombocytopenic purpura can be made. This disorder, also called immune
thrombocytopenic
purpura, is an acquired thrombocytopenia caused by formation of autoantibodies directed against the
platelet
membrane proteins glycoprotein IIb/IIIa, followed by splenic destruction of opsonized platelets. The
disease
typically occurs in women from 20-40 years of age. Splenectomy and immunosuppressive therapy
can generally
control the thrombocytopenia.
Antibodies to the acetylcholine receptor (choice A) are seen in myasthenia gravis.
Antibodies to erythrocyte membrane proteins (choice B) are seen in autoimmune hemolytic anemia.

Antibodies to intrinsic factor (choice D) are seen in pernicious anemia.

Antibodies to Type IV collagen (choice E) are seen in Goodpasture's syndrome.

A 37-year-old woman has cyclical premenstrual pain. Her breasts have a "lumpy-bumpy" texture on
palpation. A
biopsy is performed. The histopathologic features include small cysts lined by epithelial cells with
apocrine
metaplasia, calcium deposits, areas of fibrosis, increased number of acini (adenosis), and foci of florid
hyperplasia of ductal epithelium. Which of these changes increase the risk of breast cancer?
A. Adenosis
B. Apocrine metaplasia
C. Calcium deposits
D. Cysts
E. Epithelial hyperplasia
Explanation:
The correct answer is E. Fibrocystic changes usually come to clinical attention by causing pain (often
cyclical,
in premenstrual phase), palpable lumps, or mammographic densities and calcifications. A "lumpybumpy"
texture is caused by cysts and fibrosis. Fibrocystic changes, per se, do not increase the risk of
developing
breast cancer, unless there are associated proliferative changes. Epithelial hyperplasia is defined as an
increase in the number of epithelial cell layers in the ductal epithelium. Florid epithelial hyperplasia
leads to an
increased risk of developing carcinoma, especially if there is associated cellular atypia (atypical
ductal
hyperplasia).
Adenosis (choice A) refers to an increase in the number of acini and can be observed in fibrocystic
changes as
well as in other breast conditions, such as sclerosing adenosis. Physiologic adenosis is part of the
changes
that occur during pregnancy. Adenosis is not associated with increased risk of breast cancer, except as
a
component of sclerosing adenosis.
Apocrine metaplasia (choice B) describes a benign change of breast epithelial cells that come to
resemble the
apocrine epithelium of sweat glands. Apocrine cells have abundant granular eosinophilic cytoplasm.
Apocrine
metaplasia is seen frequently in fibrocystic changes, as well as in normal breast.
Calcium deposition (choice C) is a nonspecific finding that may occur in a number of both benign and
malignant

breast changes, including fibrocystic changes, ductal carcinoma in situ, and invasive carcinoma.
Calcification is
not clinically significant except for its diagnostic value. Mammographic detection of calcium may
serve to guide
biopsy procedures.
Cysts (choice D) are frequent in fibrocystic changes and result from dilatation of ducts. The
nodularity of
breasts with fibrocystic changes is due in part to the presence of cysts of various sizes. A classic gross
description is that of blue-dome cysts, which appear brown to blue because of their turbid fluid
content. The
epithelial lining may undergo apocrine metaplasia or produce papillary projections. There is no direct
link
between cyst formation and breast cancer.

A patient has had years of intermittent diarrhea and abdominal pain, but has never consulted a physician.
Eventually, he begins to pass fecal material in his urine and he seeks medical attention. Which of the
following
diseases is most likely to cause this complication?
A. Celiac disease
B. Crohn's disease
C. Diverticulitis
D. Ulcerative colitis
E. Whipple's disease
Explanation:
The correct answer is B. Passing fecal material in urine strongly suggests the possibility of a fistula
between
the bowel and bladder. Of the diseases listed, only Crohn's disease (a type of inflammatory bowel
disease)
commonly produces fistulas. Fistulas are produced in Crohn's because the disease affects the entire
thickness
of the bowel wall, rather than being restricted to the mucosa (e.g., ulcerative colitis).
Celiac disease (choice A) is a mucosal disorder of the small intestine caused by intolerance to certain
components of gluten from wheat and other grains.
Diverticulitis (choice C) can cause bowel perforation with peritonitis but does not usually cause
fistula
formation.
Ulcerative colitis (choice D) is much less commonly associated with fistula formation than is Crohn's
disease.
Whipple's disease (choice E) is a small intestinal disorder caused by infection with Tropheryma
whippelii.

A 29-year-old man presents with hemoptysis and hematuria. Renal biopsy shows inflammation of the
glomeruli.
X-ray shows focal pulmonary infiltrates. Which of the following is likely to be found with an
immunofluorescence
study of the glomeruli and alveoli?
A. Electron-dense humps on epithelial side of basement membrane
B. Linear IgG deposits on alveolar and glomerular basement membranes
C. Mesangial deposition of IgA
D. Spike and dome IgG deposits on the glomerular basement membrane
Explanation:
The correct answer is B. This is a classic case of Goodpasture's syndrome. It is autoimmune in origin
and is
characterized by hemorrhagic pneumonitis leading to hemoptysis and glomerulonephritis progressing
to renal
failure. Most cases involve the presence of anti-basement membrane antibodies. It occurs mostly in
young men.
Under immunofluorescence, there are linear deposits of IgG on alveolar and glomerular basement
membranes.
Electron-dense humps (choice A) are found under electron microscopy, not with
immunofluorescence. These
humps are found in poststreptococcal glomerulonephritis; immunofluorescence in this case would
show C3, IgM,
and IgG granular deposits.
Mesangial deposition of IgA (choice C) occurs in Berger's disease or IgA nephropathy.
Spike and dome IgG deposits (choice D) are found in membranous nephropathy, a cause of the
nephrotic
syndrome.

A patient presents to a physician because of a markedly inflamed and painful great toe. Physical
examination
additionally demonstrates small nodules on the patient's external ear. Aspiration of the metatarsalphalangeal
joint of the affected toe demonstrates needle-shaped, negatively birefringent crystals. Of which of the
following
are the crystals most likely composed?
A. Bile pigments
B. Calcium pyrophosphate

C. Cystine
D. Monosodium urate
E. Struvite
Explanation:
The correct answer is D. The patient has gout, which is due to precipitation of monosodium urate
crystals in
joint spaces (notably the great toe) and soft tissues (causing tophi, which are often found on the
external ears).
Bile pigments (choice A) are found in some gallstones.
Calcium pyrophosphate (choice B) crystals are deposited in pseudogout, which classically affects the
knee or
other large joints.
Cystine (choice C) and struvite (choice E) can form kidney stones.

Which of the following features characterizes apoptosis but not necrosis?

A. Disaggregation of polyribosomes
B. Eosinophilia
C. Inflammation
D. Karyolysis
E. Peripheral aggregation of chromatin
Explanation:
The correct answer is E. Apoptosis is a form of cell death that serves to eliminate unwanted cells
during
development, maintain cell numbers in intact organs or tissues, and eliminate immune cells after an
immune
response has faded. Apoptosis also occurs in response to noxious agents and in the aging process. The
process is the result of execution of an internal program mediated by the expression of a number of
different
genes. In the process of apoptosis, cells shrink and cytoplasmic organelles become more densely
packed.
Cytoplasmic blebs may form, and apoptotic bodies (membrane-bound cellular fragments) can be
produced.
The most characteristic feature of apoptosis is a distinctive peripheral aggregation of chromatin,
sometimes
accompanied by breaking up of the nucleus into several fragments. In necrosis, the chromatin may
become

more pale (karyolysis; choice D), or form irregular clumps, and the nucleus itself may shrink into a
dense
pyknotic body.
Disaggregation of polyribosomes (choice A) is characteristic of the initial stages of cellular injury and
necrosis.
Eosinophilia (choice B) characterizes both apoptosis and necrosis.
Inflammation (choice C) is typically absent in apoptosis, in contrast to necrosis.

A man living in southern Japan contracts HTLV-1 infection through sexual contact. Twenty-five years later
he
develops generalized lymphadenopathy with hepatosplenomegaly, a skin rash, hypercalcemia, and an
elevated
white blood count. This man has most likely developed which of the following?
A. AIDS
B. Autoimmunity
C. Delayed hypersensitivity reaction
D. Leukemia
E. Recurrent infection
Explanation:
The correct answer is D. HTLV-1, or human T-cell lymphotrophic virus 1, is an enveloped, singlestranded, RNA
retrovirus endemic to southern Japan and the Caribbean basin, but sporadically seen in the United
States.
Infection by HTLV-1 can lead to T-cell leukemia 20-30 years after the infection. The HTLVassociated T-cell
leukemia generally presents as described above, and is very aggressive, progressing to death in under
1 year.
AIDS (choice A), acquired immunodeficiency syndrome, is transmitted through the HIV virus.
Although both
viruses are RNA retroviruses and both infect CD4+ T cells, the diseases they produce are distinct.
Autoimmune diseases (choice B) produced after infection are typified by rheumatic fever after
infection with
Streptococcus. There is speculation that EBV virus (Epstein-Barr virus) may produce the autoimmune
reactions
in rheumatoid arthritis, but autoimmunity plays no role in leukemia after HTLV-1 infection.
Delayed hypersensitivity reactions (choice C) are T-cell-mediated immune responses typified by the
subcutaneous reaction to tuberculin in sensitized individuals. It characteristically occurs 2-3 days after
an
exposure, and is a local lymphocytic response.

Recurrent infections (choice E) occur when latent viruses are reactivated in the host at the site of
primary
infection. Recurrent infections are most common with the herpesviruses, especially HSV-1, HSV-2,
and VZV
(varicella-zoster virus).

A 25-year-old female presents with a 12-month history of palpitations, intermittent diarrhea, anxiety, and a
1-month history of "bulging of both eyes." What is the most likely cause of her symptoms?
A. Graves' disease
B. Hashimoto's thyroiditis
C. Multinodular toxic goiter
D. Papillary carcinoma
E. Subacute thyroiditis
Explanation:
The correct answer is A. Graves' disease is the most common cause of hyperthyroidism in a young
female and
is the only one that causes exophthalmos ("bulging of both eyes"). Grave's disease is an autoimmune
disorder
in which a thyroid-stimulating IgG immunoglobulin (TSI) binds to the TSH receptors causing
increased release
of thyroid hormone. The exophthalmos is caused by lymphocytic infiltration of the extraocular
muscles.
Hashimoto's thyroiditis (choice B) results in hypothyroidism and is associated with a diffusely
enlarged thyroid
gland and antimicrosomal antibodies against the thyroid parenchyma.
Multinodular toxic goiter (choice C) causes hyperthyroidism, but does not result in exophthalmos.
Papillary carcinoma (choice D) will only very rarely present as a hypersecreting nodule. Most cases
will be
nonsecreting, cold nodules. There is no exophthalmos. This is the most common thyroid cancer and
has the
best prognosis of all thyroid cancers.
Subacute thyroiditis (choice E) is an uncommon form of thyroiditis that lasts approximately 8 months
and is
self-limited. Early on, with destruction of thyroid tissue, there may be release of thyroid hormone and
symptoms
of hyperthyroidism, but exophthalmos is generally absent.

The 10-year-old daughter of a United Nations ambassador in Turkey develops a severe sore throat, which

resolves after a few days. 10 days later, the mother notices dark stains on the child's underwear, and
takes her to
the pediatrician. A urine sample is smoky in color, and red cell casts are noted in the urinary sediment.
If a renal
biopsy were obtained from this child it would probably show
A. dense deposits
B. fusion of podocyte foot processes
C. linear deposition of IgG
D. mesangial IgA deposits
E. subepithelial humps
Explanation:
The correct answer is E. The history suggests streptococcal pharyngitis, followed by poststreptococcal
glomerulonephritis. Subepithelial humps composed of proteinaceous material can be seen projecting
outward
from the outer capillary wall to the urinary space by light, or especially, electron microscopy.
Granular deposits
of IgG and C3 can be seen by immunofluorescence microscopy.
Dense deposits (choice A) are characteristic of Type II membranoproliferative glomerulonephritis.
Fusion of podocyte processes (choice B) is seen in minimal change disease.
Linear deposition of IgG (choice C) is seen in Goodpasture's syndrome.
Mesangial IgA deposits (choice D) are characteristic of Berger's disease.

A 40-year-old woman has severe, disabling rheumatoid arthritis. Rheumatoid factor is positive. What would
a
biopsy of the synovium of her knee most likely reveal?
A. A nearly normal synovium with scattered inflammatory cells
B. A non-proliferative synovitis with abscess formation
C. A non-proliferative synovitis with many neutrophils
D. A proliferative synovitis with many eosinophils, neutrophils, and plasma cells
E. A proliferative synovitis with many lymphocytes, macrophages, and plasma cells
Explanation:

The correct answer is E. Severe rheumatoid arthritis causes a proliferative synovitis with extensive
damage to
the synovium of the joint. The synovial membrane becomes markedly thickened (pannus formation),
with
edematous villous projections that extend into the joint space. The intense inflammatory infiltrate that
is present
is typically composed of plasma cells, lymphocytes, and macrophages.

A 3-year-old child is seen by a pediatrician because he has developed multiple isolated lesions on his face
and
neck. Physical examination reveals many lesions up to 4 cm in diameter with golden crusts, while in
other sites
small blisters and weeping areas are seen. Which of the following is the most likely diagnosis?
A. Aphthous ulcers
B. Erysipelas
C. Herpes simplex I
D. Impetigo
E. Measles
Explanation:
The correct answer is D. This is impetigo, which is typically seen in preschool children with poor
hygiene,
particularly in the summer in warm climates. The characteristic lesion has a large golden crust. Most
cases are
caused by Staphylococcus aureus; Streptococcus pyogenes is occasionally implicated. Impetigo is
highly
infectious, and mini-epidemics can occur in daycare settings. The initial treatment is typically with
penicillins and
topical preparations. Methicillin-resistant strains are presently rare in this setting, but can occur.
Aphthous ulcers (choice A), commonly known as "canker sores," are painful, shallow ulcers of the
oral cavity.
Erysipelas (choice B) is a different type of skin infection, often caused by Streptococcus pyogenes
(also
sometimes others including Staphylococcus), and is characterized by large erythematous patches.
Herpes simplex I (choice C) causes tiny oral and perioral vesicles, but not large golden crusts.
Measles (choice E) causes a blotchy erythematous rash.

A 6-year-old girl manifests acute vomiting and nuchal rigidity. MRI reveals a tumor in the posterior fossa
consisting of a large cyst with a nodular mass attached to its wall (cyst with "mural nodule").
Histologic

examination shows elongated astrocytes with long bipolar processes and numerous Rosenthal fibers.
Which of
the following is the most likely diagnosis?
A. Astrocytoma, WHO grade II
B. Ependymoma
C. Glioblastoma multiforme
D. Medulloblastoma
E. Pilocytic astrocytoma
Explanation:
The correct answer is E. Location, gross appearance, and histologic features are typical of pilocytic
astrocytoma, an astrocytic tumor with an indolent growth pattern that usually affects children.
Cerebellar and
hypothalamic regions are the most frequent locations. The presence of Rosenthal fibers is an
important
histopathologic clue. Rosenthal fibers are corkscrew-shaped, intensely eosinophilic structures
deriving from
accumulation of αβ-crystallin within astrocytic processes. Rosenthal fibers are found in
pilocytic
astrocytoma, reactive gliosis (especially around tumors and vascular malformations), and a rare
leukodystrophy
known as Alexander disease. Pilocytic astrocytomas have excellent prognosis in the posterior fossa,
but
complete surgical excision is difficult with tumors in the hypothalamic region. The tumor is classified
as a grade I
astrocytoma in the WHO system. Remember: a tumor in the cerebellum appearing as a cyst with a
mural nodule
and containing abundant Rosenthal fibers = Pilocytic astrocytoma.
Astrocytoma, grade II (choice A) and glioblastoma (choice C) are both astrocytomas, ie, tumors of
astrocytic
origin. Glioblastoma is grade IV according to the WHO system. As their grades suggest, grade II
astrocytoma is
less anaplastic (ie, less malignant) than grade IV astrocytoma. These tumors grow in a diffuse manner,
do not
possess a cystic component, and usually arise in the white matter of the centrum semiovale.
Ependymoma (choice B) originates from the ependyma and develops near the ventricular walls (4th
ventricle in
children). Ependymomas of the 4th ventricle fill the ventricular cavity but can be easily differentiated
from
pilocytic astrocytomas in their histologic appearance: ependymal cells organized around small vessels
(perivascular pseudorosettes) or around small lumina (true ependymal rosettes), mimicking the
primordial
ependymal canal.
Medulloblastoma (choice D) refers to a malignant neoplasm of childhood that presumably originates
from

immature glioneuronal precursors. It is located in the midline posterior fossa and infiltrates the
cerebellar
vermis. This tumor is solid (not cystic) and consists of undifferentiated small cells arranged in
patternless
sheets.
A 36-year-old male presents with a complaint of passing dark-reddish urine. He states that yesterday he
played
racquetball for 4 hours, which was the first time he had exercised in 4 months. He awoke this morning
with sore
muscles and discolored urine. Physical examination is unremarkable. The urine is reddish-brown in
color; dipstick
test for blood is positive, the pH is 5.1, the specific gravity 1.03. Microscopic examination of the
urine reveals no
red blood cells. What is the most likely etiology for this presentation?
A. Hemolyzed blood in the urine
B. Ingestion of foods that contained red dye
C. Myoglobinuria
D. Nephrolithiasis
E. Prostatitis
Explanation:
The correct answer is C. The appearance of a dark-reddish urine is suggestive of a number of
conditions,
including hematuria; however, there are no red blood cells present on microscopic examination.
Furthermore,
the dipstick test for blood is positive, which is suggestive of myoglobinuria. Myoglobin is a pigment
that, if
present in the urine, will produce a positive dipstick test, even in the absence of red blood cells.
Myoglobinuria
can be caused when an unconditioned individual partakes in intense physical exertion. This extreme
physical
activity leads to muscle cell breakdown and the release of myoglobin into the blood, which is then
filtered by the
kidneys and excreted into the urine.
If there was hemolyzed blood in the urine (choice A), a few red blood cells should have been detected
on
urinalysis.
Ingestion of foods that contained red dye (choice B) can discolor the urine; however, it would not
produce a
positive dipstick test.
Nephrolithiasis (choice D) generally results in the appearance of blood cells in the urine.

Prostatitis (choice E), an inflammation of the prostate gland, is generally caused by an infection.
Prostatitis
produces symptoms of dysuria, urinary frequency, and cloudy urine; hematuria is rare.

A woman who is heterozygous for glucose-6-phosphate dehydrogenase (G6PD), a polymorphic enzyme

transcribed from the X chromosome, develops chronic myeloid leukemia. Restriction fragment length
polymorphism (RFLP) studies on the tumor cells for G6PD reveal that only a single form of the
enzyme is
transcribed. This finding supports which of the following features of neoplasia?
A. Genetic mutation
B. Monoclonality
C. Mosaicism
D. Oncogene activation
E. Point mutation
Explanation:
The correct answer is B. G6PD is an enzyme involved in carbohydrate metabolism-it is neither an
oncogene nor
a tumor suppressor, and its altered expression in tumor cells is solely due to its location on the X
chromosome.
Each somatic cell expresses only one X chromosome, and thus only one of the two isotypes of G6PD.
The
presence of only one form of G6PD in the tumor cells reflects the monoclonal origin of the cells.
Cells contained
in the neoplasm express only a single isotype of G6PD because they are all derived from a single
progenitor
cell.
Genetic mutation (choice A) does not underlie the monotypic expression of G6PD in the tumor cells.
The allele
for G6PD not expressed in the monoclonal cell line was inactivated in embryogenesis (in the Barr
body).
Although genetic mutation is a requirement of neoplasia, it is not demonstrated by this phenomenon.
Mosaicism (choice C) is the expression of two or more different phenotypes heterogeneously
throughout an
organ or organism. Mosaicism usually reflects an asymmetry of mitotic division in embryogenesis.
G6PD is not an oncogene (choice D), it is a metabolic enzyme expressed constitutively in all cells.
Altered
expression of G6PD does not produce any growth advantage in a cell.
Although point mutations (choice E) underlie much of the genetics involved in neoplasia, no point
mutation is
required for monoclonal expression of G6PD.

1. contralateral sup. quadrantanopsia. where is the lesion

2. surgeon injures the nearest structure of the desecending aorta on the right while trying to
repair a bleeding just above it's entry to abdomen. what will be the consequence.......
3. stab in the mid scapular line just below the 11th thoracic ver. 4 inch deep. what structure
most likely injured....
4. ovarian artery runs through which mesentery?
5. severe pain around anal canal of a woman. examination shows tender mass on the lateral
anal wall. what is the Dx ?
6. young woman with severe lower abd. pain. vaginal discharge, bilateral tender adnexal mass,
guarding and another sign (i can't remember)....Dx?
detail mechanism of making a T cell dependent HIB vaccine.....
picture of LDL receptor.....locate exact site of mutation in familial hypercholesterolemia

Drug causing acute tubular necrosis

a. one cephlosporin (i can't remember which one it was)
b. gentamicin
c. picarcillin
d. aztreanam
e. another drug for gm -ve (can't remember)

K+ channel blocker works on which segment of the ECG ?