Name__________________
Box____________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
______1. Flow cytometry can be used to measure:
A. cellular DNA
B. cell surface antigens
C. cell ultrastructure
D. tissue architecture
E. all of the above
F. A and B only
G. C and D only
______2. Some advantages of flow cytometry over other analytical methods include:
A. ability to make kinetics measurements on the same cells over several hours
B. ability to make rapid, quantitative measurements on single cells
C. ability to make several measurements simultaneously on the same cell
D. all of the above
E. A and B only
F. B and C only
______3. Some advantages of cell sorting over other methods of cell separation include:
A. ability to clone living cells on the basis of several parameters
B. ability to separate large numbers of cells in a short time for biochemical assays
C. ability to sort single cells for in-vitro expansion of a DNA sequence by polymerase chain reaction (PCR)
D. all of the above
E. A and B only
F. A and C only
______4. Flow cytometric measurements of cellular DNA can be useful to study the following in a patient with a tumor:
A. to determine the DNA index
B. to determine the fraction of proliferating (versus non-proliferating)
tumor cells
C. to determine the phases of the cell cycle of tumor cells
D. all of the above
E. A and C only
F. none of the above
Name__________________
Box____________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
_____5. Flow cytometers are used in clinics to:
A. monitor the immune system of AIDS patients
B. determine the phenotype of leukemias
C. determine if a patient is likely to reject a transplanted organ
D. all of the above
E. A and B only
F. A and C only
______6. In a contact sensitivity reaction to poison ivy (rhus), what happens first?
A. Monocytes become activated by direct contact with rhus oils.
B. Rhus specific IgM binds to keratinocytes causing chemotaxis of
monocytes.
C. T-cells bearing antigen receptors specific for rhus antigens are activated by contact with antigen.
D. Blood monocytes are recruited to the skin by cytokines released by T-cells.
______7. The most typical clinical features common to SLE and serum sickness include:
A. Skin rash, liver disease, arthritis
B. Pulmonary disease, uveitis, arthritis
C. Skin rash, arthritis, renal disease
D. Renal disease, arthritis, cerebral dysfunction
______8. All of the following except ONE have been shown to reduce the incidence of post bone marrow transplant graft vs host disease:
A. MHC matching of donor and recipient
B. T-cell depletion of recipient prior to bone marrow transplant
C. T-cell depletion of donor bone marrow
D. Treatment with cyclosporin A after bone marrow transplant
______9. Which of these statements regarding rheumatoid arthritis (RA) is most
accurate?
A. The cause of RA is unknown.
B. Rheumatoid factor production is specific for RA.
C. Rheumatoid arthritis is an autoimmune disease restricted to the joints.
D. The earliest pathologic feature of RA is fibrosis, causing restriction of joint movement.
Name__________________
Box____________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
_____10. Rheumatoid factor usually is:
A. An IgM antibody
B. An antibody to IgG
C. Both A and B
D. Neither A or B
_____11. The intensity of a cutaneous anaphylaxis reaction usually reaches its
maximum in:
A. 10 - 30 minutes
B. 2 - 5 hours
C. 1 - 2 days
D. 7 - 10 days
_____12. In most children with insulin-dependent diabetes mellitus (IDDM), which is the LAST to occur?
A. decreased insulin secretion
B. diagnosis of diabetes by the patient's physician
C. pathologic changes in the pancreatic islets
D. formation of anti-islet cell antibodies
E. triggering of autoimmunity by binding of self-peptide to MHC
_____13. Which statement about progressive systemic sclerosis (PSS, scleroderma) is LEAST accurate?
A. PSS is frequently associated with intimal thickening of small blood
vessels in a variety of organs.
B. PSS may be caused by an exaggerated secretion of growth stimulating cytokines during an immunologically mediated inflammatory reaction.
C. PSS is thought to be of autoimmune origin due to presence of several anti-nuclear antibodies.
D. Excessive fibrosis in PSS causes atrophy of hair follicles and adnexal glands.
E. PSS is caused by autoantibodies binding to epidermis.
_____14. Anti-nuclear antibodies.....
A. are specific for SLE (systemic lupus).
B. are never found in normal individuals.
C. bind to unknown antigens in the nucleus.
D. are a broad group of antibodies reacting to various mostly known
nuclear structures, a fact which is of practical diagnostic usefulness in certain diseases.
Name__________________
Box____________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
_____15. Which approach do you think holds the most promise of markedly increasing survival of patients who receive bone marrow transplantation for leukemia?
A. Give more chemotherapy to the recipient before transplant to kill a higher percentage of leukemic cells.
B. Deplete the donor bone marrow of a specifically selected subpopulation of T-cells.
C. Exhaustively deplete the donor bone marrow of all T-cells to reduce incidence of graft vs host disease.
D. Increase the dose of immunosuppressive therapy after bone marrow transplant.
_____16. Ionizing radiation produces injury in the body by any of the following EXCEPT:
A. Increasing internal body temperature to levels that are damaging
B. Excitation of electrons
C. Ionization of target molecules
D. Production of ionized water molecules
E. Production of free radicals
_____17. For low dose ionizing radiation, all of the following statements are true
EXCEPT:
A. "low dose" refers to doses of less than 100 centi-Gray (100cGy)
B. Effects vary in frequency but not in severity
C. There is no agreed threshold
D. All effects of low dose radiation are late effects
E. Relatively few cells are initially involved
_____18. In response to diagnostic use of x-rays of chest and breast, which of the
following statements is TRUE:
A. There is no association with increased risk of developing breast cancer.
B. There is a decreased risk of developing breast cancer.
C. Increased risk is identified only in patients already at risk for breast cancer.
D. Increased risk occurs in absence of other risk factors.
E. The risks associated with x-rays are not shared by gamma rays.
_____19. As a result of an accidental industrial exposure, a man receives an estimated dose of whole body ionizing radiation of 150 cGy (150 rads). You might expect to find that he shows all of the following within one week EXCEPT:
A. Lymphopenia
B. Granulocytopenia
C. Leukocytosis
D. Anemia
E. Polycythemia
Name__________________
Box____________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
_____20. Among survivors of exposure to atomic bomb blasts or tests, all of the following malignancies have occurred in excess compared to control populations, EXCEPT:
A. Acute lymphocytic leukemia
B. Acute myelocytic leukemia
C. Chronic lymphocytic leukemia
D. Chronic myelogenous leukemia
E. Multiple myeloma
_____21. Six months after receiving 50 Gy (5000 rads) of radiation therapy for a mediastinal tumor, a 50-year old man develops non-productive cough and shortness of breath. Chest radiograph shows diffuse increase in pulmonary density. Biopsy of lung shows congestion, fibrin-continuing alveolar proteinaceous exudate, and hyaline membranes. The most likely diagnosis is:
A. Acute bacterial bronchopneumonia
B. Acute viral pneumonia
C. Acute pulmonary thromboembolism
D. Radiation pneumonitis
E. Recurrence of malignancy
_____22. The average American receives the largest amount of ionizing radiation from:
A. Diagnostic radiology
B. Therapeutic radiology
C. Industrial release and contamination
D. Occupational exposure
E. Natural background
_____23. LET (linear energy transfer) values influence effects of ionizing radiation: All of the following statements regarding LET are true EXCEPT:
A. X-rays have relatively low LET
B. Gamma rays have relatively high LET
C. Alpha particles have high LET
D. Radiation damage induced by high LET radiation is less easily repaired than damage caused by low LET radiations
Name__________________
Box____________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
_____24. All of the following are general characteristics of malignant lesions EXCEPT:
A. Invasiveness
B. Encapsulation
C. Metastasis
D. Necrosis
_____25. Tumor cells grown in vitro have all of the following characteristics EXCEPT:
A. Reduced cohesiveness
B. Lack of density-dependent inhibition
C. Increased serum requirement for growth
D. Transplantability
_____26. A 28 year old woman presents with a soft mobile mass in her left arm. It appears to be arising from fat. The term that best describes this is:
A. Lipoma
B. Mixed tumor
C. Liposarcoma
D. Melanoma
_____27. Malignant neoplasms of epithelial cell origin are derived from which of the three germ cell layers:
A. Ectoderm
B. Mesoderm
C. Endoderm
D. All of the above
E. None of the above
_____28. A patient presents with a lung carcinoma. The most important guide to the patients prognosis in 1992 is:
A. Oncogene analysis
B. Proliferative index
C. Tumor Suppressor Analysis
D. DNA analysis
E. Stage and Morphology
_____29. A Choristoma is:
A. Malignant
B. An ectopic rest of normal tissue
C. Identical to an hamartoma
D. A benign tumor of the chorion
Name__________________
Box____________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
_____30. Deregulation of a proto-oncogene may arise from which of the following molecular events?
A. Mutations within the gene coding for this protein
B. DNA tumor virus integration within the genome
C. Translocation of the gene for the protein to an alterate chromosome location
D. Uncontrolled cell proliferation
E. A and C are both correct
_____31. Which of the following statements is true concerning kinases and phosphatases?
A. Both normal and malignant cell proliferation require these enzymatic activities to
be in a balanced equilibrium
B. Both enzymatic activities have roles in proliferation and growth suppression
C. Kinases are involved in receptor signal transduction but phosphatase primarily control nuclear oncogenes
_____32. Transformation by a DNA virus and an RNA virus differs in that......
A. Transformation by DNA viruses does not depend on host cell genome integration
B. DNA virus genomes code for cell cycle activating proteins but retroviral genomes do not
C. DNA viruses depend on host cell enzymes for viral transformation but RNA viruses do not
D. Transformation by DNA viruses involves host cell lysis but RNA viruses do not kill the host cell
_____33. Chromosomal abnormalities in neoplastic cells can be detected by the polymerase chain reaction........
A. Because all chromosomal aberrations involve changes in chromosome length
B. When the selection of primers for amplification flank the lesion
C. Only after specific R.F.L.P.s have been determined
D. Without prior knowledge of which genes may be affected
Name__________________
Box____________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
_____34. Which of the following are true of oncogenes?
A. They are normal cellular genes whose expression or product is uncoupled from normal cellular regulation mechanisms.
B. All cellular genes involved in cell growth should be considered as potential proto- oncogenes.
C. Usually deregulation of one proto-oncogene is not sufficient for neoplastic transformation.
D. All of the above are correct
_____35. Which of these adverse effects are NOT related to cigarette smoking?
A. Emphysema
B. Chronic bronchitis
C. Coronary heart disease
D. Bronchogenic carcinoma
E. Reduced birth weight
F. Mesothelioma
G. Acute gastritis
H. Increased carcinogenicity of asbestos
_____36. The amount of dust retained in the lungs is affected mainly by the:
A. Concentration of particles in the ambient air
B. The efficiency of oxygen absorption
C. The number of interstitial cells
D. All of the above
_____37. Which of the pulmonary cell type is mainly involved in alveolar particle clearance?
A. Fibroblast
B. Neutrophil
C. Macrophage
D. Lymphocyte
E. Epithelial cell type II
_____38. Mucociliary clearance of inhaled particles is effective only for:
A. Particles below 5 u in size
B. Particles above 5 u in size
C. Pollen
D. Bacteria
E. All of the above
Name__________________
Box____________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
_____39. Simple coal workers pneumoconiosis......
A. Can be completely cured
B. Leads to great functional deficit of the lungs
C. Is relatively benign
D. Ususally develops within six months
_____40. Silicosis may be complicated by tuberculosis. Suspicion of silico-tuberculosis should be raised when......
A. Bifringent particles of silica in pulmonary tissue are observed
B. Cavitation of the pulmonary tissue occurs
C. The patient has rheumatoid disease
D. No exposure to silica can be documented
_____41. Exposure to asbestos may lead to......
A. Diffuse interstitial fibrosis
B. Lung cancer
C. Mesothelioma
D. All of the above
_____42. In individuals of average size consumption of 180 ml (6 oz) of distilled spirits in a relatively brief time results in a blood alcohol level of approximately:
A. 10 mg/dl with little physiological effect
B. 100 mg/dl with ataxia and probably impairment of driving
C. 200 mg/dl with severe ataxia
D. 500 mg/dl with anethesia and probably death
_____43. Which of the following agents acts directly on hemoglobin to inhibit oxygen binding?
A. Cyanide
B. Arsenic
C. Mercury
D. Carbon Monoxide
E. Ethylalcohol
_____44. A young child with a history of abdominal cramps, anemia and increased radio- density of the epiphyses probably has been poisoned with:
A. Benzene
B. Arsenic
C. Lead
D. Carbon monoxide
E. Cadmium
Name__________________
Box____________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
_____45. An adenomatous polyp is best characterized by which of the following:
A. A benign neoplasm
B. A precancerous neoplasm
C. A glandular neoplasm
D. All of the above
_____46. The grade of a malignant neoplasm indicates:
A. The extent of spread of the malignant neoplasm
B. The histologic and/or cytologic features correlating with the aggressiveness of the malignant neoplasm
C. The size of the tumor
D. None of the above
_____47. Typical cytologic abnormalities associated with malignancy include:
A. Loss on intercellular polarity
B. Increased nuclear/cytoplasmic ratio
C. Nuclear pleomorphism
D. All of the above
_____48. Using the TNM anatomic staging system progressively higher T numbers (T1-T4) indicate:
A. Progressive degrees of metastatic spread
B. Increasing degrees of lymph node involvement
C. Size and local extension of primary malignant neoplasm
D. The grade of the tumor
_____49. A leukemia is characterized by all of the following except:
A. Bone marrow involvement by malignant cells
B. Blood involvement by malignant cells
C. A malignancy of hematopoietic cell lines including lymphoid, myeloid and red cell lines.
D. Origin from a hemangioma which has degenerated into a malignancy.
_____50. Grading and staging are important for all of the following reasons EXCEPT:
A. To determine therapy
B. To determine prognosis
C. To standardize for clinical trials
D. To predict tumor marker protein expression
Name__________________
Box____________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
_____51. Metastatic spread of sarcoma usually involves which one of the following pathways:
A. Lymphatic spread to lymph nodes
B. Blood borne metastases to distant organs
C. Seeding of the peritoneal or pleural cavities
D. Perineural invasion
_____52. Paraneoplastic syndromes include all of the following except:
A. Carcinoid syndrome
B. Myasthenia gravis
C. Leukemoid reaction
D. Disseminated chondromalacia
_____53. Tumor markers include all of the following EXCEPT:
A. Oncofetal antigens such as carcinoembryonic antigen
B. Secretory proteins such as prostatic specific antigen
C. Histochemical markers such as basic fuchsin and methylene blue
D. Hormones such as human chorionic gonadotropin
_____54. Carcinoma in-situ is best characterized by:
A. Malignant cells with a low potential for metastases
B. Malignant cells which have not yet invaded beyond the basement
membrane of the pre-existing epithelium
C. Carcinoma-like changes which are incapable of progressing
further to invasion
D. A precursor of severe metaplasia
_____55. A malignant tumor is best defined by:
A. Growth to a large size
B. Local recurrence
C. The potential for the development of distant metastases
D. Oncogene production and/or antioncogene suppression
Name__________________
Box____________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
_____56. The following statements concerning vitreous humor are true EXCEPT:
A. Because vitreous humor (K +) decreases post-mortem in a roughly
linear fashion, this level can be helpful in estimating the post-
mortem interval.
B. Very high vitreous glucose levels are consistent with diabetes mellitus.
C. In cases where a good blood sample is not available (eg. exsanguination), analysis of vitreous is often of great value in estimating the blood concentration of ethanol and certain other drugs.
D. All of the above are correct
E. None of the above are correct
_____57. The following intracranial pathologic conditions would be acceptable causes (for death certification) of unexpected natural death except:
A. Seizure disorder
B. Colloid cyst of 3rd ventricle
C. Subdural hematoma
D. Ruptured berry aneurysm
E. All of the above are acceptable
_____58. The following are acceptable means of positive identification of a decedant showing moderately advanced decomposition EXCEPT:
A. Fingerprinting
B. Forensic Odontological comparisons
C. Skull x-ray comparisons
D. Tattoos, scars and jewelry
E. All of the above are acceptable
_____59. The following statements regarding New York State Death Certification are true EXCEPT:
A. Death certificates MUST be completed and signed by a Medical Examiner (or Coroner) if the manner of death is anything but NATURAL.
B. The Medical Examiner may fill out a certificate as Pending Further Investigation while completing toxicology and microscopic studies.
C. Death Certificates should be accurately filled out as they provide important public health information.
D. MECHANISMS OF DEATH such as "Cardiac Arrest" are unacceptable causes of death.
E. All of the above are true
Name__________________
Box____________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
_____60. Although it is a cancer of relatively low prevalence, cervical squamous carcinoma has attracted a large amount of medical and public attention because:
A. Precursor lesions are easily detectable and treatable
B. Screening programs are difficult to implement
C. Papanicolaou smears are a foolproof method of cancer detection
D. Cervical cancer is associated with chemical carcinogen exposure
_____61. All of the following are morphologic cytologic criterion which are characteristically seen in a neoplastic process except:
A. Atypical mitotic figures
B. High nucleus to cytoplasmic ratio
C. Irregular chromatin pattern
D. Increase in the density of the cytoplasm
E. Presence of cellular discohesion
_____62. George Papanicolaou became interested in cervical cancer cytology while studying:
A. Cellular changes in the menstrual cycle
B. Human papillomavirus effects
C. Epidemiology of chlamydia sexual transmission
D. The effects of various chemical carcinogens on cervical epithelium
_____63. Which of the following statements regarding fine needle aspiration biopsy is FALSE:
A. The procedure requires a hospitalization.
B. Diagnoses obtained by the method are accurate.
C. The procedure requires no anesthesia.
D. Any organ may be sampled by the procedure.
E. Diagnoses are available virtually immediately.
_____64. Which of the following statements about cervical cancer is TRUE:
A. It is the largest killer of women under the age of 40.
B. Human papillomavirus DNA is found in most cervical cancer and its precursor lesions.
C. The disease has a high prevalence in upper socioeconomic groups.
D. Most cases are not preceeded by a dysplastic (preneoplastic) stage.
Name__________________
Box____________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
65. Sources of chemical carcinogen exposure in the U.S. are listed below.List them in order of impact on incidence of cancer today.
A. Environmental; e.g. combusion products, industrial chemicals
B. Habits; e.g. tobacco and ethanol use
C. Occupational; e.g. asbestos, arsenic
I._____
II._____
III._____
_____66. Below are listed some possible consequences of chemical carcinogen-induced DNA damage to a somatic cell. Which isTRUE?
A. Cell death
B. No phenotypic alteration
C. Initiation leading to clonal expansion
D. All of the above
E. A and C only
Carcinogens may cause different types of DNA damage including DNA strand breaks, adduct formation, or DNA-protein cross-links. Many carcinogens may cause more than one of these types of damage; however, most carcinogens induce a characteristic type of damage. Associate the listed carcinogen with its characteristic type of DNA damage:
A. Activated oxygen
B. Metals (cadmium, nickel)
C. Organic chemical carcinogen
_____67. DNA adducts
_____68. DNA strand breaks
_____69. DNA protein crosslinks
Name__________________
Box____________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
_____70. Direct carcinogens or activated indirect carcinogens bind to DNA to form adducts. The most common sites of adduction are to residues on the guanine base. The properties that determine the likelihood that a chemical carcinogen will bind to particular guanine residue include:
A. Solvolytic properties, i.e. the likelihood that the carcinogen dissociates into ionic intermediates.
B. Whether it is a nitrosamine or a polycyclic aromatic hydrocarbon
C. The nature of the ionic intermediate, i.e. whether it is localized (hard) as in the case of alkylating agents or delocalized (soft) as in the case of arylalkylating agents
D. All of the above
E. A and C only
_____71. Properties held in common by the vast majority of chemical carcinogens are that they either directly or as a result of metabolic activation:
A. Are chemically reactive
B. Bind only to the ribose structure on DNA
C. Are strong electrophiles, i.e. molecules with electron deficient atoms
D. None of the above
E. A and C only
_____72. Which of the following are promutations?
A. A bulky adduct that is formed when a procarcinogen such as benzo(a)pyrene, aflatoxin B1 or dimethylbenzanthracene is metabolically activated and binds to a residue on DNA.
B. A change from a guanine to an adenine in the twelfth codon of the H-ras oncogene.
C. A small adduct such as that formed when a small product is formed during metabolism of a procarcinogen (such as alkyldizonium [ethyl or methyl group] ions from N-nitrosamines) and binds to a residue
on DNA.
D. All of the above
E. A and C only
Name__________________
Box____________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
_____73. Many carcinogens require metabolic activation. Which of the following statements regarding metabolic activation of chemical carcinogens is TRUE?
A. Either phase I and or phase II enzymes may be involved.
B. The cytochrome p450 mixed function oxidase system is responsible for phase I metabolic activation of many carcinogens.
C. The ultimate carcinogen "electrophile" metabolic product derived from the procarcinogen benzo(a)pyrene and many other chemical carcinogens is an epoxide.
D. All of the above
E. A and C only
_____74. "This patient", says the intern, "is a newborn who was born at term. He has a number
of bizarre malformations, including an asymmetric cleft in his face, a cleft in his
abdominal wall, and amputation of the left leg. Note this his right hand has fusion of 3 digits and and amputation of one. All of these findings fit nicely with the diagnosis of
Amniotic Band Syndrome." "But ," you reply, "that shouldn't be called a syndrome,
you should call it a(n).....
A.....disruption."
B.....field defect."
C.....association."
D.....sequence."
E.....dysplasia."
_____75. "I disagree," says the intern, "it's a syndrome because it is a group of recognizable
physical features which occur together in the setting of a common etiology." "Where
did you go to medical school?", you reply, "you should know that a syndrome....
A.....is composed of malformations which all occur at the same embryologic stage."
B.....is composed of malformations which are the consequences of a single primary
malformation."
C.....is composed of deformations which are the consequences of a single primary
malformation."
D.....is composed of malformations which are related to each other by a common
etiology without being in a disruption, sequence or field."
E.....is composed of malformations which are statistically associated with each other."
Name________________________
Box__________________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
_____76. "Well," harrumps the intern, "this next patient is on a ventilator because her lungs are
hypoplastic. If you're so smart, tell me five possible causes of this condition." "Umm," you reply, "there might have been lack of normal intrauterine chest motion
necessary for normal lung development because of: oligohydramnios due to prolonged
rupture of placental membranes, oligohydramnios due to congential renal disease, bone
dysplasia with short Aab, congential muscular dystrophy with lack of chest motion, or
congenital severe neurologic disease with loss of chest innervation." "Ha! One of
those is wrong, smarty," says the intern. "Oh," you reply, "it must be....
A.....congenital renal disease."
B.....bone dysplasia."
C.....muscular dystrophy."
D.....neurologic disease."
E.....no, on second thought I think they are all possible causes."
_____77. "That's right," says the intern, "but, with this patient, it isn't any of those things. Note
that her abdomen is scaphoid (concave) instead of protuberant like a normal newborn
abdomen. That is because the left half of her diaphragm failed to form altogether and
her stomach, spleen, and a large portion of her intestines are herniated into her chest,
not leaving any room for her lungs to grow. In a few minutes she'll go to the O.R. for
the surgeons to repair her diaphragm. She may have enough lung to survive." "Wow!", you exclaim, "yet another example of pulmonary hypoplasia being part of a...
A.....disruption."
B.....field defect."
C.....association."
D.....sequence."
E.....syndrome."
_____78. "What do you notice about this next child?", the intern asks. "She's yellow, very badly
jaundiced," you reply, "is there something wrong with her liver? Is she unable to
conjugate bilirubin because of her prematurity?" "Yes, she's jaundiced, but she's not
premature, and as far as we can tell, her liver conjugates bilirubin normally. She doesn't have a congenital obstruction to her bile ducts either. I'll give you a hint....When she was born, she was very edematous, and her liver and spleen are enlarged." "Of course, erythroblastosis fetalis!", you exclaim, "I bet her mother is Rh negative." "No,says the intern, her mother is type O positive. Do you still think its hemolytic disease?" "Well," you reply, "in that case it's most likely to be due to antibodies against.....
A.....minor Rh group antigens."
B.....ABO group antigens."
C.....Kell group antigens."
D.....rare antigens inherited from the father."
E.....HLA related antigens."
Name________________________
Box__________________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
A 67 year old man had a several week history of difficulty voiding with dribbling of urine and of right hip pain. P.E. revealed an enlarged indurated prostate. His alkaline phosphatase, prostatic acid phosphatase and prostate specific antigen were all elevated. Xrays showed blastic metastases in the pelvis, both femurs, and elsewhere. A transrectal needle biopsy of the prostate was performed.
_____79. The needle biopsy is illustrated by this slide. From examining this poorly differentiated tumor you can tell it is a(n)
A. low grade adenocarcinoma.
B. high grade adenocarcinoma.
C. low grade squamous carcinoma.
D. high grade squamous carcinoma.
E. undifferentiated carcinoma.
The patient was treated with diethylstilbestrol and radiation over a 3 month period. His pain and urinary symptoms decreased, his radiographic lesions improved, and his prostatic acid phosphatase and prostate specific antigen levels decreased towards normal. He was maintained on diethylstilbestrol. Eighteen months later he returned with chest and spine pain, shortness of breath, abdominal pain and poor appetite. He bone metastases had progressed and he had adrenal and liver metastases as well. He received comfort care only and died.
_____80. This slide was also taken from his original biopsy. There is tumor infiltrating a nerve. This finding may explain
A. his vertebral metastases.
B. his spinal cord involvement.
C. his pain.
D. his poor appetite.
E. his adrenal involvement.
_____81. This slide was taken from his lungs at autopsy. Tumor is present in channels around a blood vessel. This typifies
A. carcinoma spread via lymphatics.
B. carcinoma spread via blood vessels.
C. carcinoma spread via lymphatics and blood vessels.
D. carcimoma spread via direct extension.
E. none of the above.
Name________________________
Box__________________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
A 57 year old woman underwent right radical mastectomy followed by chemotherapy for adenocarcinoma of the breast. Five years later the other breast was removed because of cancer. A femur metastasis was irradiated. Three years later she received more radiation and chemotherapy for multiple painful bone metastases. She was admitted because of "failure to thrive." She had proximal muscle weakness and peripheral edema. She had an infiltrate on chest Xray. Culture of urine and CSF grew Cryptococcus neoformans. She had progressive dyspnea and died 3 weeks later.
_____82. This slide is representative of tumor involvement of bone. Ways in which breast cancer differs from prostate cancer include all of the following except:
A. breast cancer has a tendency to be involve younger patients.
B. breast cancer is more likely to be responsive to hormonal therapy.
C. breast cancer has a tendency to form lytic as opposed to blastic metastases.
D. breast cancer is likely to be more aggressive.
_____83. This slide is a mucin stain from the patient's meninges. Similar organisms were found in her lungs. The most likely pathogenesis of this infection is:
A. inhaled organisms crossed the cribriform plate to infect the meninges, then disseminated via the blood.
B. ingested organisms entered the portal blood, infected the liver, then disseminated via the blood.
C. inhaled organisms infected the lungs, then disseminated via the blood.
D. organisms entered the bladder, possibly during catheterization, and spread retrograde to the kidney, then disseminated via the blood.
A 77 year old man was admitted with increasing abdominal girth, fatigue, diffuse abdominal pain, decreased appetite, and cough. He had a history of peptic ulcer disease, a 60 pack-year smoking history, and drank 4 shots of whiskey daily.
He had an enlarged tender liver, a firm inguinal lymph node, an enlarged non-tender prostate. Stool contained occult blood. Barium enema showed no evidence of tumor. Chest xray and CT scan showed a hilar mass, pleural effusion, and enlarged mediastinal lymph nodes. A liver biopsy was performed.
_____84. Suppose this slide were representative of the liver biopsy. With all of the foregoing diagnostic information, the least likely diagnosis would be:
A. Adenocarcinoma of the stomach with metastases to liver and lung.
B. Adenocarcinoma of the colon with metastases to liver and lung.
C. Adenocarcinoma of the pancreas with metastases to liver and lung.
D. Adenocarcinoma of the bile ducts with metastasis to the lung.
E. Adenocarcinoma of the lung with metastasis to liver.
Name________________________
Box__________________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
The liver biopsy (unlike the previous slide) showed undifferentiated carcinoma. Bronchoscopy showed bronchial narrowing. Sputum cytology showed atypical squamous cells.
_____85. This slide of bronchus is representative of a lesion that could yield a similar cytology result. The best diagnosis to be made is:
A. Normal.
B. Squamous metaplasia.
C. Dysplasia.
D. Carcinoma in situ.
A diagnosis of probable undifferentiated lung cancer was made. The patient died soon after. At autopsy there was a large hilar mass of anaplastic small-cell carcinoma of the lung with wide spread lymphatic metastases as well as metastases to bone and liver.
_____86. This is a slide of the patient's liver. Note the lack of apparent differentiation. These tumor cells are derived from:
A. Embryonic precursor cells of the bronchus.
B. Bronchial epithelial cells which lost all differentiation.
C. Bronchial epithelial cells which underwent squamous metaplasia and then lost all differentiation.
D. Bronchial neuroendrocrine cells.
A 46 year old man had a 30 pack year smoking history and multiple hospital admissions for chronic obstructive pulmonary disease, cor pulmonale, and pneumonia. Prior to admission he had attempted to shoot himself. Soon after he was brought to the E.D. in a stupor. He had an "ischemic seizure." After he apparently recovered he was sent home. He had a similar episode and returned to the hospital the same day. He then had a respiratory arrest. He was intubated and admitted.
Blood gasses showed severe hypercarbia and hypoxia. He also had hyponatremia and hypochloremia. He got medication for his seizures. CSF pressure was elevated, but with normal protein and glucose. He had waxing and waning mental status over 3 weeks. Blood gasses showed worsening hypoxia and hypercarbia. He became unresponsive, hypotensive, and died.
Autopsy showed chronic obstructive pulmonary disease. He had pleural effusions, and adhesions. The heart was enlarged with right ventricular hypertrophy. Spleen and liver were congested.
Name________________________
Box__________________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
_____87. This slide could represent a section of his lung. Among the features present, those which support a diagnosis of chronic obstructive pulmonary disease include all except:
A. Enlarged lacy airspaces.
B. Black pigment in airspaces.
C. Dilated bronchi.
D. Excessive bronchial mucus.
E. Thickened pulmonary artery walls.
_____88. This slide is from his lung. Note the hypertrophied arteriolar walls, indicative of pulmonary hypertension. All of the following comments about pulmonary hypertension are true except:
A. Loss of alveolar wall vasculature contributes to pulmonary hypertension.
B. Pulmonary hypertension causes right ventricular hypertrophy.
C. Pulmonary hypertension causes hypoxia and hypercarbia.
D. Hypoxia contributes to arteriolar vasoconstriction.
E. Pulmonary atherosclerosis is associated with pulmonary hypertension.
_____89. This slide illustrates emphysema. Emphysema can be associated with a number of environmental factors including inhalation of smoke and various dusts. The most important factor in production of emphysema is:
A. Release of elastase from neutrophils in inflamed lung.
B. Release of collagenase from neutrophils in inflamed lung.
C. Release of trypsin from neutrophils in inflamed lung.
D. Release of alpha-1-antitrypsin from neutrophils in inflamed lung.
A 49 year old man had a long history of idiopathic thrombocytopenic purpura, which had been treated with splenectomy and prednisone. He had recently been treated with vinblastine, but it was discontinued because of neutropenia and fever. He had a recent history of myocardial infarction, and got digoxin, captopril, and furosemide for his CHF, and amiodarone for arrhythmia. He had hypertension, diabetes, and Cushing's syndrome, secondary to prednisone.
He was admitted to hospital with ataxia, confusion, nausea, and hand tingling. He had signs of cerebellar dysfuncton. Serum creatinine was elevated. Chest xray had interstitial pulmonary fibrosis. Amiodarone was discontinued. He was treated with immunoglobulin for worsened thrombocytopenia, until he had acute pulmonary failure. Immunoglobulin was stopped. Pulmonary edema resolved with steroids and diuresis.
He developed fever and Staphylococcus aureus was grown from his blood. Echocardiogram diagnosed bacterial endocarditis. Antibiotics were started. Two weeks later, renal function decreased and continued to fall despite cessation of gentamicin. He died shortly after.
Name________________________
Box__________________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
_____90. This slide is from his mitral valve, showing acute endocarditis. Which of the following steps probably came fourth?
A. Cardiac turbulence due to arrhythmia.
B. Decreased defences from steroids and splenectomy.
C. Seeding of valve with Staphylococci.
D. Embolization of vegetation to coronary arteries.
E. Acute inflammation and fibrin deposition on valve.
F. Bacteremia from decubitus ulcer.
_____91. This slide is from his lung. The arrows indicate interstitial fibrosis. The alveoli contain pigmented macrophages. This pigment is most likely:
A. Carbon pigment acquired from living in a city.
B. Lipofuschin from cellular turnover.
C. Tar from cigarette smoking.
D. Hemosiderin due to multiple transfusions.
E. Hemosiderin from congestion due to CHF.
_____92. This slide is from his kidney. Fibrosis and vascular sclerosis may be due to any of the following except:
A. Immune complex deposition from immunoglobulin therapy.
B. Hypertension and diabetes due to steroids.
C. Decreased perfusion due to vasodilators.
D. Gentamicin toxicity.
A 7 year old boy had multiple upper respiratory infections during his first months of life, and delayed development. At 7 months of age his head circumference was noted to be enlarged and he had an abnormal facial appearance with prominent frontal bone, depressed nasal bridge, eyebrows meeting in the midline, low-set ears, mild corneal opacifications. He also had hepatosplenomegaly, limited extension of the joints, thoracolumbar kyphosis, and short stubby fingers. Urine contained dermatan sulfate and heparan sulfate. Cultured skin fibroblasts had absent alpha-L-Iduronidase activity, consistent with Hurler Syndrome.
He continued to have multiple respiratory and ear infections. His mental development was slow and began regressing by age 6 years. He was blind and deaf. He began to have seizures and apneic spells.
He was brought to the E.D. after an episode of gagging, choking, and paroxysmal coughing after eating. Radiographs showed narrowing of his upper airway by enlarged tonsils. There was no lung infiltrate, but he was treated for presumed aspiration. He was severely hypoxic and hypercarbic. ECG showed right atrial enlargement and right ventricular hypertrophy. Echocardiography showed a thickened mitral valve. Parents declined permission for tracheostomy. He developed peripheral edema, fever, and worsening respiratory distress and expired.
Name________________________
Box__________________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
_____93. This slide is from his enlarged liver. At this low magnification, the appearence would be consistent with all of these other entities except:
A. Fatty liver from drug or alcohol toxicity.
B. von Gierke's disease.
C. Hepatitis B.
D. Pompe's disease.
E. Gaucher's disease.
_____94. This is his heart. The mitral valve abnormalities are mostly related to
A. Large numbers of mucopolysaccharide laden cells.
B. Deposition of free mucopolysaccharide in the valve matrix.
C. Calcification of abnormal valve matrix.
D. Reactive fibrosis of stroma.
_____95. This slide is from his brain. These changes could be mistaken for changes from many of the lipid storage diseases. A feature which would distinguish this patient from patients with Tay-Sachs' or Gaucher's diseases is:
A. Loss of acquired mental development
B. Bone and joint abnormalities.
C. Hepatomegaly.
D. Splenomegaly
_____96. This is a gross photograph of his brain. It shows the additional abnormality of:
A. Meningitis due to increased susceptibility to infection.
B. Hydrocephalus due to meningeal mucopolysaccharide.
C. Gray matter loss due to vascular pseudoatherosis.
D. White matter loss due to vascular pseudoatherosis.
A 3 1/2 year old girl presented with a three day history of right-sided neck pain. Her mother noted a swelling in that area and took her to a pediatrician who initially suspected lymphadenitis, and treated her empirically with Amoxicillin. Two days later the mass persisted and a chest xray showed mediastinal adenopathy. On admission there was a 3.5 x 3 x 3 cm hard matted right supraclavicular mass and bilateral palpable cervical nodes. Liver was enlarged. Spleen was not palpable.
Hematocrit was 23, WBC 9,000 with occasional myelocytes, metamyelocytes, nucleated red cells, and atypical lymphocytes. LD and AST were elevated. A bone marrow biopsy was hypercellular (70-75%) with clusters of atypical cells, consistent with a small blue cell tumor.
Name________________________
Box__________________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
_____97. This slide (Giemsa stained) could have come from her bone marrow smear. At this point the differential diagnosis must include all of the following except:
A. Neuroblastoma.
B. Primative neuroectodermal tumor.
C. Undifferentiated lymphoma.
D. Hepatoblastoma.
E. Embryonal rhabdomyosarcoma.
Flow cytometry on the marrow showed that 65% of the cells present were CD45 (Pan-leukocyte Ag) negative with high 90[ring] light scatter consistent with a metastatic non-hematopoietic neoplasm. An excisional biopsy of the supraclavicular mass showed a lymph node completely replaced by a small cell tumor with extensive necrosis.
_____98. This is the lymph node biopsy. Features which suggest the diagnosis of neuroblastoma include all of the following except:
A. Neuropil like background substance.
B. Rare ganglion cell differentiation.
C. Pseudorosette formation.
D. Perivascular rosette formation.
Chest CT and MRI scans showed a bilateral paraspinal masses. Neuroblastoma stage IV was diagnosed. Urinary homovanillic acid (HVA)/creatinine ratio was normal, vanillylmandelic acid (VMA)/creatinine was elevated. She was begun on chemotherapy which she tolerated well except for vomiting and transient neutropenia, and was discharged on the 20th hospital day. After 4 months of therapy, her urinary HVA/creat and VMA/creat were normal. MRI showed almost complete resolution of the mass. Bone marrow aspirate and biopsy showed no tumor cells. She recieved an autologous bone marrow transplant and additional radiation to the site of the primary tumor and remains without evidence of tumor.
_____99. This is another slide from this patient's lymph node biopsy. Prognostic factors of importance in neuroblastoma include all of the following except:
A. Age at presentation.
B. Stage at presentation.
C. Histologic grade.
D. Ratio of VMA to HVA.
E. N-myc amplification.
Name________________________
Box__________________________
INSTRUCTIONS: Write the ONE best answer in the space provided to the left of each question:
____100. This slide is from another small blue cell tumor. When histologic clues of differentiation are lacking, useful studies can include all of the following except:
A. Electron microscopy.
B. Immunohistochemical staining of sections.
C. Chemical reactions on tumor tissue.
D. Karyotyping.
E. All of the above are valid.
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