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Question 2 of 5
The woman's physician initially suggests that the patient avoid milk products, but
her symptoms fail to improve. This finding is consistent with
which of the following conditions?
/A. Adenomatous polyps
/B. Appendicitis
/C. Celiac disease
/D. Cystic fibrosis
/E. UIcerative colitis
Explanation - Q: 1.2
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Which of the following is an example of a food that the patient should avoid?
/A. Apple
/B. Bread
/C. Carrot
/D. Lettuce
/E. Steak
Explanation - Q: 1.4
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Several years later, the patient cheats on her dietary restrictions and develops a
blistering, intensely itchy skin rash that has a symmetrical
distribution and is found on her elbows, knees, and buttocks. This is most likely
which of the following?
/A. Dermatitis herpetiformis
/B. Herpes simplex
/C. Herpes zoster
/D. Molluscum contagiosum
/E. Psoriasis
Explanation - Q: 1.5
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The correct answer is A. Dermatitis herpetiformis is a skin condition known
to be associated with celiac disease, and, interestingly, may also be the
presenting complaint for celiac disease. The diagnosis can be confirmed by
skin biopsy with demonstration of IgA in the biopsy tissues. More than 85% of
patients with dermatitis herpetiformis also have (obviously symptomatic or
not) gluten sensitivity, and removal of gluten from the diet may improve the
skin disease. Untreated or poorly treated celiac disease is also associated
with anemia (due to iron, folate, or vitamin B12 deficiency), osteoporosis,
vitamin K deficiency with risk of hemorrhage, nervous system disorders
secondary to nutrient deficiencies, pancreatic insufficiency, and intestinal
lymphomas. Other disorders, in addition to dermatitis herpetiformis with which
celiac disease is associated, include diabetes mellitus, thyroid disease, lupus,
IgA nephropathy, primary biliary cirrhosis, and less commonly chronic active
Explanation - Q: 2.1
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The correct answer is D. All of the protozoa listed in the choices are
intestinal parasites that can cause chronic diarrhea. Giardia lamblia is the
most frequent cause of protozoal diarrhea in North America. The case history
illustrates the typical course in children who acquire the infection in a day
care setting and then go on to develop chronic infection. Giardia lamblia is an
interesting protozoal parasite whose life cycle alternates between trophozoite
and cyst stages. While most bacterial infections require inoculating doses of
hundreds to thousands of organisms or more to produce disease, giardiasis
A thorough stool exam for ova and parasites is most likely to reveal which of the
following?
/A. Acid fast oocyst that are 5 microns in diameter
/B. Acid fast oocysts that are 10 microns in diameter
/C. Oval cysts with up to 4 nuclei
/D. Round cysts containing no more than 4 nuclei
/E. Round cysts, including some with 5 to 8 nuclei
Explanation - Q: 2.2
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The correct answer is C. The cysts of Giardia lamblia are oval, have
prominent cell walls, and up to 4 nuclei. A diagnosis of giardiasis can be
made by finding either the trophozoites and/or the cysts in a stool sample.
However, organisms are only found in 50% of cases if only one stool sample
is used. If three stool samples obtained on three different days are used, the
detection rate is approximately 90%. If stools are negative, Giardia can be
detected in duodenal material that can be sampled using the Enterotest. A
gelatin capsule that is attached to a nylon string is swallowed. After 4 to 6
hours, the string is removed and examined under the microscope for
trophozoites.
Choice A describes the oocysts of Cryptosporidium parvum, a common
cause of mild diarrheal illness. It causes incurable, protracted diarrhea in
AIDS patients. The diagnosis of cryptosporidiosis is made by finding oocysts
in the feces using a modified acid fast or auramine stain.
Choice B describes the oocysts of Cyclospora cayetanensis, a protozoa that
has recently been identified as a cause of diarrheal illness. In 1995 and 1996,
it caused major outbreaks in the United States that were later traced to
contaminated raspberries from Guatemala. Diagnosis of cyclosporiasis can
be made by finding the acid fast oocyst in stool. Its oocyst is much larger than
How long, after exposure to this organism, do most people who develop clinical
disease exhibit symptoms?
/A. 1-2 days
/B. 3-5 days
/C. 1-3 weeks
/D. 4-6 weeks
/E. 2-3 months
Explanation - Q: 2.3
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Which of the following drugs would be most effective in the treatment of this
child?
/A. Diloxanide furoate
/B. Iodoquinol
/C. Metronidazole
/D. Paromycin
/E. Trimethoprim-sulfamethoxazole
Explanation - Q: 2.4
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This disease would most likely contribute to the patient's death if which of the
following diseases were also present?
/A. AIDS
/B. Crohn disease
/C. Goodpasture's syndrome
/D. Measles
/E. Minimal change disease
Explanation - Q: 2.5
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The correct answer is A. Patients who have had rectal contact during sex
with an infected partner may easily acquire giardiasis. If these patients also
have AIDS, a particularly overwhelming infection may occur, with essentially
"wall-to-wall" colonization of the intestinal mucosal surface with Giardia. In
these severe cases, the malabsorption that is produced may be sufficiently
severe to induce malnutrition, which will exacerbate the AIDS patient's
already high vulnerability to other infectious disease. The diseases listed in
the other choices are distracters that have no particular link to giardiasis.
Approximately how many Americans in the United States are diagnosed with this
disorder each year?
/A. 280
/B. 2,800
/C. 28,000
/D. 280,000
/E. 2,800,000
Explanation - Q: 3.1
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Which of the following is an important risk factor for developing this disorder?
/A. Aflatoxin exposure
/B. AIcohol use
/C. Caffeine ingestion
/D. Cigarette smoking
/E. Hepatitis B infection
Explanation - Q: 3.2
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In patients with this man's condition with intractable pain referred to the back, the
network of nerves around the aorta is sometimes blocked
with alcohoI. This network is known as which of the following?
/A. Celiac plexus
/B. Choroid plexus
/C. Esophageal plexus
/D. Hepatic plexus
/E. Mesenteric plexus
Explanation - Q: 3.3
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The correct answer is A. The celiac plexus contains the nerves around the
aorta that may be stimulated by either pressure or direct involvement by
tumor, and so produce pain.
The choroid plexus (choice B) is a vascular plexus of the eye, and is also a
vascular plexus extending into the ventricles.
The esophageal plexus (choice C) refers to the nerve plexus around the
esophagus.
The hepatic plexus (choice D) is the division of the celiac plexus that
accompanies the hepatic artery and portal vein to the liver.
There are actually two mesenteric plexuses (choice E), which accompany
the superior and inferior mesenteric arteries.
Question 4 of 4
Which of the following surgical methods is used most often to treat patients with
small tumors of the head of the pancreas with no evidence of
metastasis?
/A. Billroth l procedure
Explanation - Q: 3.4
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The correct answer is E. While you do not need to know a great deal about
surgery for the Step 1 USMLE examination, a few operations may be
mentioned. Among these is the Whipple procedure, also known as a
pancreaticoduodenectomy. In this surgical procedure, the duodenum,
proximal pancreas, gallbladder, and sometimes, the distal stomach are
resected. The remaining pancreas, biliary tree, and stomach are then
reattached to the small intestine. The Whipple procedure is only performed in
the relatively small percentage of patients who may have resectable disease.
Tumors of the tail of the pancreas might, in theory, be more easily resected,
but this area tends to not produce any signs or symptoms until late in the
disease, after metastasis has occurred. Pancreatic cancers that are not
resectable can be treated with chemotherapy and radiation therapy.
Immunotherapy using a vaccine based on the patient's own cancer cells is
also being tried experimentally, and shows promise. An important thing to
remember when treating these patients (and other poor prognosis patients) is
that long-term survivors have occurred, and that even if death eventually
intervenes, a survival of several years may be very much worthwhile to both
the patient and his family (particularly if young children are indirectly
involved).
The Billroth I and II procedures (choices A and B ) are used to treat gastric
carcinomas and intractable peptic ulcers of the duodenum and stomach.
While you could argue that the gastric resection part of the Whipple
procedure resembles a Billroth II operation, you should pick the Whipple
procedure if both answers are available, because it is much more specific for
pancreatic carcinoma.
The Roux-en-Y gastric bypass (choice C) and vertical banded gastroplasty
(choice D) are used to treat obesity by reducing the effective stomach
volume.
A 14-year-old girl asks her pediatrician if there is anything she can do about the
large amounts of gas she passes during class at schooI. She
states that her flatulence is worse in the afternoon, and she often has diarrhea
when she goes home from schooI. Her symptoms generally
subside by morning, and she thinks she is better on weekends. She has been
having these problems for four or five years, but has the
impression that they are worse now than when she was younger.
Question 1 of 5
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A consulting dietician identifies a major food group that should be avoided by the
young patient and further cautions that avoiding these foods
may put her at risk for a secondary dietary deficiency. If the patient removes the
offending food from her diet, she is at greatest risk of
developing a deficiency of which of the following?
/A. Calcium
/B. Chloride
/C. Iron
/D. Potassium
/E. Sodium
Explanation - Q: 4.2
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Meats are the most important dietary source of iron (choice C).
Dietary deficiencies of potassium (choice D) are usually only seen if severe
restriction of all fruits and vegetables is present or if the patient is taking a Klosing diuretic.
Question 3 of 5
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The undigested carbohydrate passing into the colon will induce enzymes for its
metabolism in resident E. Coli. The mechanism that induces
gene expression for these enzymes most directly involves the carbohydrate
/A. binding to a repressor protein
/B. binding to an activator protein
/C. binding to an enhancer element associated with the gene region
/D. decreasing cAMP within the E. Coli
/E. increasing cAMP within the E.Coli
Explanation - Q: 4.4
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Explanation - Q: 4.5
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