1.

A 58-year-old woman comes to the physician for her first physical examination in 10
years. She states she has been in good health, and has no history of significant illness.
The patient denies a history of alcohol or tobacco use. On physical examination, a 2-cm
firm, fixed, and nontender right axillary lymph node is palpated. A biopsy of the lymph
node is performed.
Which of the following findings is pathologic examination of biopsy specimen most likely
to show?
A. Anastomosing sheets of pleomorphic cells that express HER2/neu
B. Clusters of small basophilic epithelial cells
C. Globular myxoma cells
D. Large germinal centers with numerous mitotic figures and necrotic cells
E. Proliferation of intralobular stroma distorting the associated epithelium

2. A 57-year-old woman who was diagnosed with lung cancer 4 months ago presents
with weight gain. She reports that her weight gain has caused her clothes to fit tighter
around the waist. Additionally, she has noticed purple streaks on the skin of her
abdomen, and her face has recently "ballooned." Physical examination shows facial hair
above the upper lip, fatty tissue deposits between the shoulders, and muscular atrophy
of her arms and legs.
Which of the following additional symptoms is this patient most likely experiencing?
A. Poor wound healing and facial plethora
B. Cold intolerance and constipation
C. Increased bone density
D. Nipple discharge
E. Proximal muscle weakness, diarrhea, and palpitations

3. A 34-year-old man comes to his primary care physician because of a low-grade fever,
drenching sweats at night, and an unintentional 5-kg (12-lb) weight loss over the past 3
months. He is up to date on all of his vaccinations, and he denies having any significant
past medical history. A CT scan of the chest reveals mediastinal lymphadenopathy.
Subsequent biopsy of an involved node is performed; a histopathologic image from the
specimen is shown.

Which of the following is part of the multidrug regimen that would be used to manage
this patient’s disease?
A. Vinblastine
B. All-trans retinoic acid
C. Cyclosporine
D. Imatinib
E. Isoniazid
4. A 71-year-old woman is brought to the emergency department by her husband due to
severe left thigh pain after sustaining a fall while walking on level ground. She states
that she is currently unable to bear weight on her left leg. She denies head trauma, loss
of consciousness, convulsions, tongue biting, or fever. She reports that she has
experienced constipation and abdominal pain for the past 4 weeks. The patient’s
husband reveals that his wife has become more confused during this period. On
examination, left thigh is tender, erythematous and swollen. Sensation, motor and
pulses are intact in the distal left extremity. An x-ray of left thigh shows a nondisplaced
fracture of the femoral shaft through a lytic lesion. An x-ray of the patient’s skull is also
taken and seen below. Laboratory studies are as follows:
Glucose: 95 mg/dL
BUN: 31 mg/dL
Creatinine:1.7 mg/dL
Calcium: 12.2 mg/dL
Sodium: 138 mg/dL
Potassium: 4.2 mEq/L
Chloride: 101 mEq/L
CO2: 27 mEq/L

Which of the following best describes the normal function of the cell with the primary
mutation in this patient?
A. Production of antibodies
B. Oxygen delivery
C. Phagocytosis of pathogens and cellular debris
D. Production of bone
E. Production of platelets
F. Resorption of bone
G. Secretion of histamine

5. Some undifferentiated neoplastic cells resemble their embryonic counterparts and

may elaborate proteins normally expressed only in embryonic or fetal life. Tartrate-
resistant acid phosphatase (TRAP) is such a protein.
Which of the following describes the signs and symptoms of the malignancy that would
be most likely to produce TRAP?
A. Easy bruising and recurrent infections
B. Enlarging moles
C. Focal weakness
D. Jaundice
E. Pencil-thin stools

6. A 36-year-old Asian man presents to a local community clinic with bilateral lower
extremity weakness, spastic gait, back pain, and urinary incontinence. The symptoms
have been constant, but have progressed gradually over the past several years.
Additionally, physical examination also reveals that he has an exudative eczematous
rash affecting his scalp, axillae, and groin. Laboratory results are shown.

Which of the following viruses is most likely associated with the patient’s condition?
A. Human T-cell lymphotrophic virus-1
B. Hepatitis B virus
C. Human herpesvirus-8
D. Human papillomavirus
E. JC virus

7. A 65-year-old man comes for evaluation because of a 3-month history of chronic

cough and irritation in his throat. His medical history is significant for hypertension, and
he has a 30-pack-year smoking history. As part of his work-up, a transbronchial biopsy
is performed. A photomicrograph from a biopsy specimen is shown below.
Which of the following terms best describes the findings shown in the photomicrograph?
A. Metaplasia
B. Anaplasia
C. Dysplasia
D. Hyperplasia
E. Neoplasia

8. A 45-year-old white male, with no significant past medical history, presents with a 3-
month history of waking at night drenched in sweat, and a 20-lb weight loss. He has
smoked 1 pack of cigarettes per day for the past 30 years. A recent chest X-ray did not
show any masses. Labs on admission demonstrated a hemoglobin of 12 g/dL,
hematocrit of 36%, MCV of 74 μm3, and platelet count of 250,000/mm3.
Urinalysis shows:
Osmolarity: 600 mOsm/kg H2O
Protein <0.15 g/24h
Sodium of 45 mEq/L/d
Negative ketones
Negative nitrites
Negative leukocyte esterase
20 RBC/hpf
<2 WBC/hpf
40 squamous cells
No casts, bacteria, or yeast
An intravenous pyelogram is inconclusive. The treating urologist acquires several
biopsies from the genitourinary system. The histopathologic preparation of one such
biopsy is shown.

What condition does this patient have?

A. Transitional cell carcinoma
B. Clear cell carcinoma
C. Oncocytoma
D. Small cell carcinoma
E. Squamous cell carcinoma of the bladder
F. Wilms tumor

9. A 66-year-old woman is brought to the emergency department by her family after

having a seizure. She reports that over the past year she has had headaches, which
have become more intense and frequent. She has also noticed visual deficits the past 3
months. Her family reports that she has become apathetic and inattentive recently as
well. An MRI is obtained and shown here.
The decision is made to remove the space-occupying lesion. The pathology report
describes whorls of fibrous tissue and calcified concentric rings.

Which of the following best describes the type of cell giving rise to the tumor seen in the
MRI?
A. Meningothelial
B. Astrocyte
C. Ependymal cell
D. Oligodendroglioma
E. Schwann cell

10. A 58-year-old postmenopausal woman comes to her gynecologist because of

vaginal bleeding. She took estrogen therapy for 2 years to reduce hot flashes, but
discontinued this therapy on the advice of her primary care doctor. She is obese and
has a history of type 2 diabetes mellitus and hypertension. She had one pregnancy,
which resulted in a miscarriage. Uterine curettage reveals the presence of a well-
differentiated carcinoma.
Which of the following factors can increase the risk of this patient’s condition?
A. Tamoxifen
B. Carboplatin
C. Cisplatin
D. Progestin
E. Tobacco use

11. A 16-year-old girl comes to her dermatologist with a skin lesion on her forearm
(shown in the image). She has had numerous skin lesions similar to this one removed
since childhood. While in the office, her dermatologist performs a brief physical
examination that, in addition to the skin finding, reveals an unsteady gait and signs of
numbness in the extremities.

Which of the following is most likely to be found in this patient?

A. Defective nucleotide excision repair
B. BRCA mutation
C. DNA mismatch repair
D. Defective nonhomologous end joining
E. p53 mutation

12. A 57-year-old woman presents to the office complaining of a neck lump. She has no
significant past medical history and appears healthy with no other complaints. Physical
examination shows a nodule in the left lobe of her thyroid. Thyroid-stimulating hormone
level is normal. Thyroid ultrasound reveals a 2.0-cm solitary nodule in the left superior
pole. Fine-needle aspiration of the nodule is performed, and cytology shows several
extracellular, calcified, spherical bodies. A surgical excision of the nodule is scheduled.
In addition to the findings described, which of the following will also be seen on
histologic examination of the nodule?
A. Finely dispersed, optically clear nuclei
B. Acellular, amyloid deposits
C. Granular cells with eosinophilic cytoplasm
D. Osteoclast-like, multinucleate giant cells
E. Uniform follicles containing colloid

13. A 58-year-old woman (gravida 2, para 2), who went through menopause 2 years
ago, presents to her physician after discovering a lump in her left breast. She first
noticed the lump about 4 weeks ago. She has no family history of breast cancer and
has been otherwise healthy. Gynecologic history is unremarkable except for two
uncomplicated vaginal deliveries. The physician examines the lump and finds it to be
hard, nontender, and movable.
Which of the following increases this woman’s risk for breast cancer?
A. Late menopause
B. Daily St. John's wort intake
C. Excess caffeine intake
D. History of a cyst with straw-colored fluid
E. History of fibroadenoma in the right breast
F. Multiparity

14. A 36-year-old woman presents to her primary care provider and reports that she has
experienced multiple episodes of sweating, palpitations, and headaches at random
intervals for the past year. On physical examination, flushing and diaphoresis are noted;
her heart rate is 117/min, and blood pressure is 210/110 mm Hg. Further questioning
reveals that both her father and brother have had similar symptoms. The result of a 24-
hour urine vanillylmandelic acid collection is 22.1 mg/g creatinine (normal: 2–7 mg/g
creatinine).
Which of the following other conditions is associated with this patient’s disorder?
A. Mucosal neoplasm
B. Growth hormone adenoma
C. Pancreatic islet cell carcinoma
D. Prolactinoma
E. Zollinger-Ellison syndrome

15. A 7-year-old boy is brought to the neurologist by his mother who has been
concerned about his increased clumsiness and unsteadiness while walking for the past
3 months. Laboratory values are as follows:
Na: 136 mEq/L
K: 3.6 mEq/L
Cl: 100 mEq/L
BUN: 12 mg/dL
Cr: 0.7 mg/dL
Glucose: 84 mg/dL
Hemoglobin: 18.9 g/dL
Hematocrit: 55%
The neurologist orders a gadolinium scan of the brain, which reveals a primary brain
tumor. A biopsy specimen of the tumor shows foamy stromal cells within a highly
vascular neoplasm.
What chromosome is implicated in this child’s disease?
A. Chromosome 3
B. Chromosome 13
C. Chromosome 17
D. Chromosome 22
E. Chromosome 5

16. A 61-year-old man comes for evaluation because of a 2-week history of constant
and severe headaches that are most severe when he wakes in the morning. He also
notes changes in vision associated with the headaches. He takes medication for high
cholesterol but is otherwise healthy. The patient has noted a black-to-tan lesion on his
right forearm that is approximately 5 cm in size but has grown. He states, "At first it was
just a dark spot, but as it grew larger, I told my wife that it looked like a map of the state
of Oregon!" Physical examination shows papilledema in the left eye, a right-sided
pronator drift, and weakness of the right arm. A CT scan of the head confirms
intracranial hemorrhage.
Which risk factor of this patient most likely predisposed this patient to his malignancy?
A. Extensive work outside in the garden
B. Asbestos exposure
C. Exposure to aniline dyes
D. Ingestion of smoked foods
E. Working with polyvinyl chloride (PVC) piping

17. A 7-year-old girl is brought to the emergency department by her parents because of
concerns that she is not growing or developing appropriately. Her parents say that she
has cold intolerance, is easily fatigued, and produces large amounts of urine. A physical
examination is notable for short stature and bilateral papilledema. Thyroid function tests
are notable for low levels of triiodothyronine, thyroxine, and thyroid-stimulating
hormone. An MRI shows findings like those in the images.

Which of the following is the most likely diagnosis?

A. Craniopharyngioma
B. Ependymoma
C. Hemangioblastoma
D. Prolactinoma
E. Thyrotropinoma

18. A 69-year-old smoker presents with double vision, lower extremity muscle weakness
that improves with exertion, and diminished deep tendon reflexes. Results of neurologic,
cardiovascular, and ophthalmologic examinations are negative. An X-ray of the chest is
shown. A full cancer work-up reveals metastases throughout the body.
Which of the following is the most likely cause for this man’s diplopia and weakness?
A. Antibodies against presynaptic calcium channels at the neuromuscular junction
B. Autoantibodies to acetylcholine receptors at the neuromuscular junction
C. Autoimmune disease with anti-double-stranded DNA, anti-DNA, and anti-Smith
antibodies
D. Inflammatory disorder of synovial joints with pannus formation
E. Reactivation of a peripheral subpleural parenchymal lesion and hilar lymph nodes

19. A 7-year-old girl is brought to her pediatrician because of a 2-week history of fevers,
aches in her bones, and fatigue. Physical examination shows generalized
lymphadenopathy and diffuse petechiae over her trunk and lower limbs. The lymph
nodes are fixed, firm, and non-tender. Results of laboratory studies and a peripheral
blood smear are shown.
WBC count: 34,000/mm3
Hemoglobin: 8.8 g/dL
Hematocrit: 26%
Platelet count: 90,000/mm3

Which of the following is a predisposing risk factor for this patient's likely condition?
A. Trisomy 21
B. Deficiency of folic acid
C. Deletion of the VHL gene
D. Infection by a herpesvirus
E. Retroviral infection of T lymphocytes

20. A 58-year-old man with a 74-pack-year smoking history comes to the physician
because of a 4-month history of anorexia, weight loss, generalized weakness, and
painless jaundice. One week ago, he had pain in his left calf associated with swelling
and warmth. Today, the patient reports his left calf has healed, but his right forearm is
now swollen and painful. Physical examination reveals a painless enlargement in the
right upper quadrant of his abdomen.
This patient is at the greatest risk for developing which of the following conditions?
A. Pulmonary embolism
B. Cellulitis
C. Fulminant hepatitis
D. Pancreatic pseudocyst
E. Seizures secondary to hypocalcemia

21. A 49-year-old man comes to the emergency department because he says his skin
"has turned yellow" for the past 2 days. The patient also reports an unintentional weight
loss of 6.8 kg (15 lb) during the past 3 months. He has no other symptoms. Physical
examination reveals scleral icterus and jaundice; Murphy sign is negative. He has
smoked two packs of cigarettes per day for the past 20 years. He does not drink alcohol
and has no recent travel history. He does not use illicit drugs. A small non-tender mass
is palpable in the right upper quadrant, and a CT scan is ordered. Laboratory values are
as follows:
AST: 45 U/L
ALT: 50 U/L
Alkaline phosphatase: 315 U/L
Total bilirubin: 7.2 mg/dL
Direct bilirubin: 4.1 mg/dL
Indirect bilirubin: 3.0 mg/dL
Given the findings described, which of the following is the most likely diagnosis?
A. Pancreatic cancer
B. Acute hepatitis
C. Choledocholithiasis
D. Cholelithiasis
E. Hemolytic anemia

22. A 52-year-old woman presents to the physician because of an ulcerated lesion of

the left nipple. She says the lesion is itchy and appeared within the last several months.
She tried applying over-the-counter ointment and topical steroids with no symptom
relief. She has no significant past medical history and takes no medications. Family
history is negative for gynecological malignancies. She had two uncomplicated vaginal
deliveries in her 30s; she did not breastfeed either infant. Menses began at age 13
years, and her last menstrual period was 3 years ago. Physical examination reveals the
skin lesion on the left breast shown below.
For which of the following underlying conditions should she be evaluated?
A. Ductal breast carcinoma
B. Fibrocystic changes of the breast
C. Intraductal papilloma
D. Lobular breast carcinoma
E. Phyllodes tumor

23. A 45-year old man presents to his primary care physician with weakness and a 15-lb
(6.8 kg) unintentional weight loss over the past 5 months. Additionally, he complains of
having persistent cold symptoms and occasional night sweats during this period. His
physical exam is unremarkable, except that his clothes fit loosely. The physician orders
a complete blood count (CBC) and blood smear, both shown below.
WBC: 95,000/mm3
Hb: 9.2 g/dL
Hct 28%
Platelets: 108,000/mm3
A cytogenetic study is also obtained, and it demonstrates a common translocation.

If this condition continues to progress, what would be the most likely complication?
A. Disseminated intravascular coagulation
B. Autoimmune hemolytic anemia
C. Lytic bone lesions
D. Proteinuria
E. Recurrent otitis media

24. A 48-year-old woman who has recently emigrated from China comes to the clinic
because of a 3-month history of vague abdominal pain accompanied by weight loss and
a feeling of fullness after eating a small amount of food. She has no significant past
medical or social history. Physical examination reveals a palpable mass in the right
upper quadrant of the abdomen. The examination is negative for jaundice, shifting
dullness, and spider angiomata. Fecal occult blood test is negative. CT scan of the
abdomen shows a large mass in the liver. Laboratory tests show:
AST: 175 IU/mL
ALT: 218 IU/mL
α-fetoprotein: 4500 ng/mL
Which of the following is the most likely etiologic factor contributing to this patient’s
disease?
A. Hepadnavirus infection
B. Alcohol abuse
C. Flavivirus infection
D. Fungal infection
E. Low-fiber, high-fat diet

25. A 65-year-old woman comes to the physician because of a 2-month history of

cough, severe left-sided shoulder pain, and hoarseness. However, the patient is most
concerned about the droop of her left eyelid, which developed during the past few
weeks. The patient worked as a teacher before retiring last year. She has never smoked
and drinks an occasional glass of wine at dinner. On ocular examination, her right pupil
is larger than her left. A CT scan of the chest reveals a 3-cm nodule in one lung.
Complete blood count and electrolytes are within normal limits.
Which of the following is the most likely type and location of this patient's tumor?
A. Adenocarcinoma located in the apex of the left lung
B. Adenocarcinoma located in the apex of the right lung
C. Small cell carcinoma located in the apex of left lung
D. Squamous cell carcinoma located in the apex of the right lung
E. Squamous cell carcinoma located in the hilum of the left lung

26. A fair-skinned 56-year-old man who works as a farmer comes to the clinic because
of a scaly, indurated, ulcerated nodule just below his lower lip. A biopsy of the skin
lesion is obtained. A histopathologic image is shown.

Which of the following is the most likely diagnosis?

A. Squamous cell carcinoma
B. Acral lentiginous melanoma
C. Actinic keratosis
D. Basal cell carcinoma
E. Melanoma

27. A 60-year-old man presents to his primary care physician with increased fatigue and
loss of appetite for the past month. His past medical history includes well-controlled
hypertension, but the physician notes that the patient has lost 5 lb since his annual
physical last month. On physical exam, he has nontender, enlarged lymph nodes, and
his spleen is noticeably palpable in the left upper quadrant. A complete blood count is
obtained:
WBC 20,000 /mm
Hbg 9.1 g/dL
Hct 28%
Platlets 105,000/mm3
Neutrophils 37%
Lymphocytes 58%
Eosinophils 1%
Basophils 1%
Monocytes 3%
A peripheral blood smear is shown in the image.

What is the normal function of the abnormal cells seen in this patient’s condition?
A. Humoral immunity
B. To activate cytotoxic T lymphocytes or B lymphocytes by costimulation
C. To engulf bacteria and kill with an oxidative respiratory burst
D. To recognize antigens on virus-infected host cells and destroy the infected cells
E. To serve as the primary mode of oxygen transport in the body

28. A 35-year-old woman with a history of recurrent kidney stones presents to her
physician with complaints of epigastric pain that wakes her from sleep but goes away
after she eats. She is also having bouts of diarrhea. Physical examination reveals that
the abdomen is not tender, distended, or enlarged. She drinks 2–3 alcoholic beverages
per week and does not smoke. Laboratory tests reveal an elevated serum gastrin level
of 1400 pg/mL (normal <100 pg/mL).
Which of the following additional findings is this patient most likely to have?
A. Elevated serum prolactin levels
B. Elevated T4 levels
C. Elevated serum catecholamine levels
D. Increased serum phosphate levels
29. A 5-month-old boy is brought to the clinic for his well baby visit. His antenatal and
birth history are unremarkable. Developmental history reveals that he smiles
spontaneously, has begun to babble, tracks objects with his eyes from side to side, and
holds his head steady unsupported.
His vital signs are within normal limits, and he is in no acute distress. His cardiac exam
shows regular rate and rhythm without murmurs, rubs, or gallops. Lungs are clear to
auscultation bilaterally with good air movement. Abdomen is soft, nontender,
nondistended, and without masses. Neurologic exam is within normal limits. An
ophthalmoscopic exam, like that shown below, is reported to the ophthalmologist.

Which of the following tumors is this patient at greatest risk of developing?

A. Femoral osteosarcoma
B. Esophageal adenocarcinoma
C. Medullary carcinoma of the thyroid
D. Renal cell carcinoma
E. Squamous cell carcinoma of the lung
F. Urothelial carcinoma

30. A 2-year-old boy is brought to a clinic because of a painless abdominal mass that
his mother noticed while bathing him. She explains that the patient has been eating well
and producing normal amounts of urine and stool. Development is normal and the
patient has met all of his milestones. On evaluation today, vital signs are within normal
limits. Physical examination is normal without focal deficits, but a right abdominal pass
is palpated. While performing an ultrasound, the technician notes that the kidney
calyces on the right are highly distorted by a mass. A CT scan of the child's abdomen is
shown below.
Which of the following is the cause of this patient´s most likely diagnosis?
A. Abnormal proliferation of the metanephric blastema
B. A mutation of the PKD1 gene on chromosome 16
C. Malignant transformation of renal tubular cells
D. Malignant transformation of uroepithelial cells
E. Primitive neural crest cells

31. A 65-year-old woman who recently immigrated from China presents to her physician
with a swollen abdomen. Her appetite is poor, and she reports a weight loss of 6.8 kg
(15 lb) during the past 6 months. The patient denies alcohol use, and she has no family
history of malignancy. On physical examination, the patient has scleral icterus,
abdominal distension, and a positive fluid wave. Laboratory studies demonstrate the
following:
HBsAg negative
Anti-HBc negative
Anti-HBs positive
HCV antibody negative
Anti-HAV IgM negative
Anti-HAV IgG negative
Given this patient’s background, exposure to which of the following environmental
substances is MOST likely linked to her underlying condition?
A. Aflatoxin
B. Arsenic
C. Asbestos
D. Naphthalene (aniline) dyes
E. Nitrosamines

32. A 1-year-old girl is brought to her pediatrician’s office because her parents are
concerned about her “crossed eyes.” They worry that she is having difficulty focusing on
objects in her line of sight. These issues were not present until recently. Physical
examination reveals positive white pupillary reflex in the right eye and red reflex in the
left eye. Additionally, strabismus is observed.
For this child to have begun having symptoms, which of the following processes mostly
likely occurred recently?
A. Sporadic mutation of a gene
B. Amplification of a trinucleotide repeat
C. Chromosomal nondisjunction
D. Inheritance of a mutated tumor suppressor gene
E. Inheritance of an oncogene
F. Maternal imprinting of a genetic defect

33. A 12-year-old girl who recently emigrated from Nigeria presents to the clinic with a
6-month history of intermittent fever, fatigue, and night sweats. Her adoptive mother is
unaware of any other significant medical or family history. She has a large, nontender
mass on her right mandible, but physical exam is otherwise unremarkable. The mass is
biopsied and results are shown.
The infective agent in the patient's disorder can also cause what other pathology?
A. Nasopharyngeal carcinoma
B. Adult T-cell lymphoma
C. Cervical adenocarcinoma
D. Hepatocellular carcinoma
E. Kaposi sarcoma

34. A 50-year-old woman comes to her physician’s office complaining of headaches that
are localized on the right side of her head. The pain increases when she gets out of bed
in the morning. Her symptoms have gradually worsened over the past 6 months. MRI
demonstrates a tumor attached to the dura mater. She is referred to a neurosurgeon
who resects the mass, confirming that the tumor arises from the arachnoid.
Which of the following histologic features of this tumor is most likely to be observed?
A. Psammoma bodies
B. Atypical melanocytes organized in well-circumscribed nodules
C. Cells with “fried egg” appearance
D. Perivascular pseudorosettes
E. Pseudopalisading tumor cells
F. Small blue cells

35. A 42-year-old woman (gravida 1, para 1) presents to her physician with an

unintentional weight loss of 15 lb over the past 3 months. She reports that her appetite
has increased, and she has had to change shirts more often because of frequent
perspiration. Physical examination reveals a pelvic mass that is tender to palpation. On
further workup, the mass is resected and sent for pathologic examination. The
specimen is shown in the image.
Which of the following is the most likely diagnosis?
A. Struma ovarii
B. Immature teratoma
C. Krukenberg tumor
D. Ovarian choriocarcinoma
E. Thecoma-fibroma

36. A mother brings in her 3-year-old son to a local clinic because of a mass that she
felt in his abdomen while bathing him. On examination, the mass is nontender, and the
physician notes a partial loss of the child’s iris on the upper segment. The rest of the
eye examination is normal. An abdominal CT shows a large, right-sided kidney mass.
Which of the following is the most likely diagnosis?
A. WAGR syndrome
B. Autosomal recessive polycystic kidney disease
C. Neuroblastoma
D. Renal cell carcinoma
E. Renal oncocytoma
F. von Hippel-Lindau syndrome

37. A 30-year-old woman comes to the physician because of severe knee pain that has
persisted for the past several months. However, she does not recall falling or injuring
her knee prior to the onset of pain. Physical examination of her knee reveals a tender
effusion. X-ray of the knee reveals a lesion at the distal femoral epiphysis. The lesion is
is expansile, osteolytic, and radiolucent with a nonsclerotic, sharply defined border.
Which of the following is the most likely diagnosis?
A. Giant cell tumor
B. Chondrosarcoma
C. Ewing sarcoma
D. Osteochondroma
E. Osteosarcoma

38. A 61-year-old man presents with chronic cough, difficulty swallowing, and new-onset
voice change. In recent months he has experienced fatigue and an unintentional 20-lb
(9.07-kg) weight loss. He also complains of postprandial indigestion, especially while
lying down. He is a retired rock singer, and he admits to smoking one pack of cigarettes
per day for the past 40 years and drinking “more than his share” of alcohol. In addition,
he reports unprotected sex with multiple partners in the past. The patient is found to
have a mass arising from the left true vocal fold, as shown in the image. Biopsy
confirms the presence of a neoplastic process.

Which of the following risk factors is most closely associated with the development of
this patient’s condition?
A. Gastroesophageal reflux disease
B. Chronic excessive alcohol consumption
C. Chronic irritation from professional singing
D. Infection with human papillomavirus types 6 and 11
E. Smoking history
F. Untreated Helicobacter pylori infection

39. A 51-year-old man visits his physician with an unexplained 15-lb weight loss in the
past 2 months. The patient reports that he intermittently wakes up in soaked sheets and
with chills. On exam, his temperature is 38.1° C (100.6° F), his heart rate is 70/min, and
his respiratory rate is 16 breaths/min. The patient’s blood pressure is 136/82 mm Hg.
The physician notices nontender cervical, axillary, inguinal, and femoral
lymphadenopathy. The patient reports the size of the nodes has waxed and waned over
the past several months. He never came in to get them checked, because they did not
cause him any pain. A lymph node biopsy is performed and the results are shown.
Which of the following oncogenes and translocations is associated with this type of
lymphoma?
A. BCL-2; t(14;18)
B. BCR-ABL; t(9:22)
C. Cyclin D1-heavy chain Ig gene; t(11:14)
D. PML-RARA; t(15;17)
E. c-myc; t(8,14)

40. A 66-year-old man is brought to the emergency department after an acute episode
of severe hip pain that caused him to fall while walking at home. An x-ray shows
multiple areas of lucency and a pathologic fracture of the pelvis. Pathologic findings of a
biopsy taken at the site of the pathologic fracture are shown in the image. In recent
months, the patient has felt very fatigued and has had constant dull pain in his hips,
back, and head. Laboratory studies show a serum calcium concentration of 13.5 mg/dL
and an alkaline phosphatase concentration of 60 U/L.

Which of the following additional findings would most likely be found in this this patient?
A. Proteinuria
B. Facial muscle contraction on tapping the facial nerve
C. Hard prostatic nodule on digital rectal examination
D. Palpable parathyroid nodule
E. Unilateral leg weakness

41. A 67-year-old woman visits her doctor because of fatigue and weight loss. The
result of a fecal occult blood test is positive, and she undergoes a colonoscopy, which
reveals a mass in the left sigmoidal colon. Subsequent imaging reveals metastases to
her liver. In their discussion of treatment options, the physician explains that one
possible approach is to administer an infusion of a monoclonal antibody. The
monoclonal antibody is directed against a cellular factor that is also involved in wet age-
related macular degeneration (AMD) and can be used as a treatment for this eye
condition.
Which of the following is this antibody most likely directed against?
A.Vascular endothelial growth factor
B.Epidermal growth factor
C.Interleukin-1 (IL-1)
D.Interleukin-6 (IL-6)
E.Tumor necrosis factor-α (TNF-α)

42. An 18-year-old woman who is a college freshman comes for evaluation because of
progressive hearing loss and tinnitus. She has had increasing difficulty hearing her
professors in class during the past few months. She undergoes an MRI of the head,
which is shown in the image.

What other symptom does this patient most likely have on presentation?
A. Blurry or cloudy vision
B. Abnormal Rinne test
C. Galactorrhea
D. Nevus flammeus
E. Pigmented nodules of the iris

43. A 55-year-old man presents to his primary care physician with the complaint of
increasing muscle weakness, especially in his legs, over the past 3 weeks. He also
admits to some difficulty in swallowing, and at times, he finds himself having difficulty
remaining alert and keeping his eyes open. He states that his legs feel less weak as he
walks for a short distance. Findings on physical examination are shown in the video.
What type of malignant disease is most likely responsible for this patient’s symptoms?
A. Small cell lung carcinoma
B. Breast carcinoma
C. Renal cell carcinoma
D. Squamous cell lung carcinoma
E. Thyroid carcinoma

44. An 18-year-old man comes for evaluation because of a gradually worsening gait
abnormality for the past several months. He denies any trauma or injury. He reports that
his mother had a brain tumor, although he is unaware of the specific details. On
physical examination, the patient has slightly decreased visual acuity in his right eye
with preserved extraocular movement. In addition, significant left-sided ataxia is noted.
Fundoscopic examination is performed and the results for his right eye are shown
below.

Given the typical evolution of this patient’s disease, this patient is most likely to develop
which of the following?
A. Renal cell carcinoma
B. Astrocytoma
C. Colon cancer
D. Depression
E. Hamartomas

45. A 4-year-old boy is brought to his pediatrician after his parents notice that he does
not respond well to visual stimuli on the left side. Examination reveals diminished visual
acuity and a white pupillary reflex in the left eye. Subsequent investigation reveals a
malignancy of the eye. The patient is successfully treated with radiation, but is found to
have a similar malignancy in the right eye 2 years later.
This patient is at increased risk for developing which of the following malignancies in the
future?
A. Osteosarcoma
B. Acute promyelocytic leukemia
C. Gastric cancer
D. Medulloblastoma
E. Pancreatic cancer

46. A 4-year-old girl is brought to the emergency department with an 8-hour history of
projectile vomiting and headache. Her parents say that the patient was well until 2
months ago, when they noted that she was becoming increasingly clumsy. Physical
examination shows nystagmus in all directions of gaze, as well as truncal ataxia.
Complete blood count shows a WBC count of 7200/mm 3, a hemoglobin level of 12.3
g/dL, and a platelet count of 225,000/mm3. An MRI of the brain is performed.
Based on epidemiologic evidence, which of the following histologic findings is most
likely associated with this child’s diagnosis?
A. Deeply staining nuclei with scant cytoplasm arranged in pseudorosettes
B. Pleomorphic, anaplastic cells with foci of necrosis in a palisading pattern
C. Regular round cells with spherical nuclei with finely granular chromatin in clear
cytoplasm
D. Stratified squamous epithelium in spongy reticular stroma with prominent peripheral
gliosis
E. Whorls of cells with oval nuclei with indistinct cytoplasm and psammoma bodies

47. A 59-year-old man presents with increasing lethargy, weakness, and bony pain over
the past 2 years. During this time, he has been urinating 12–15 times per day and
describes his urine as yellow and frothy with no traces of blood. History reveals a
pathologic hip fracture 1 year ago. X-ray studies show several small, hypodense lesions
in the hip and spine. Further tests show a serum protein level of 9 g/dL, and serum
protein electrophoresis yields increased γ-globulins. The physician decides to order a
kidney biopsy.
A. Fibrillary deposits in the mesangium and subendothelium that stain positive with
Congo red
Which of the following would most likely be found on this patient’s biopsy?
B. Destruction of glomeruli with crescents of proliferating cells adherent to Bowman
capsule
C. Focal lesions involving collapse of the basement membrane, increase in matrix, and
deposition of hyaline masses, with detachment of the epithelial cells from the basement
membrane
D. Normal appearance under light microscopy but with foot process effacement evident
under electron microscopy
E. Ovoid hyaline masses located in the periphery of the glomerulus, with prominent wire
looping wisps

48. A 55-year-old man comes to his physician for a routine health maintenance
examination. He has a remote history of smoking (started at age 18, quit at age 23) and
consumes 2–3 alcoholic drinks per week. Toward the end of the visit, he tells his
physician that he has worked in the textile industry for 30 years. He knows that he has
been exposed to coloring agents and is concerned about how this may affect his health.
This patient’s exposure history increases his risk for which of the following neoplasms?
A. Transitional cell carcinoma of the bladder
B. Esophageal adenocarcinoma
C. Hepatocellular carcinoma
D. Mesothelioma
E. Nasopharyngeal carcinoma
49. A 56-year-old man who works in healthcare presents to his physician with vague
abdominal discomfort and fatigue. A physical examination reveals a tender liver,
palpable to 6 cm below the costal margin, and scleral icterus. He does not smoke
cigarettes, and has consumed two beers per night for the past 10 years. Laboratory
tests show:
Aspartate aminotransferase 200 U/L
Alanine aminotransferase of 450 U/L
Total serum bilirubin 2.8 mg/dL
Direct bilirubin 2.2 mg/dL
Serum alkaline phosphatase Normal
A CT scan of the abdomen is shown in the image.

The tumor marker most likely to be increased in this patient is also likely to be elevated
in which of the following malignancies?
A. Yolk sac carcinoma
B. Choriocarcinoma
C. Colorectal carcinoma
D. Melanoma
E. Neuroblastoma
F. Prostate carcinoma

50. A 26-year-old man visits a physician because of progressively worsening vision in

his right eye and slightly decreased balance over the past few months.
Ophthalmoscopic examination reveals the image shown. MRI of the brain shows a
small, vascular mass in the cerebellum. The physician also finds a cavernous
hemangioma on the patient's right arm. The patient notes that his father suffered from a
similar decline in vision and was treated surgically.
Which of the following symptoms is the patient most likely to develop in the future?
A. Hematuria
B. Aortic dissection
C. Café-au-lait spots
D. Gastric ulcers
E. Hypocalcemia
F. Port-wine stain of the face

51. A 59-year-old man comes for evaluation because of intermittent dysphagia during
the past year. He reports a 30-year history of postprandial heartburn and regurgitation,
and he states his symptoms are worsened when lying down or leaning forward. He
denies smoking or alcohol use. His family history is negative for malignancy. He
undergoes an endoscopic study of the esophagus. A biopsy specimen is obtained from
a red, irregular lesion in the distal esophagus.
Which of the following pathologic findings on examination of the lesion is most likely?
A. Mucin-positive cells
B. Absent myenteric ganglia
C. Dilated veins in submucosa
D. Linear irregular lacerations
E. Proliferation of squamous cells

52. A 60-year-old man comes to the physician because of a persistent headache that
has worsened over the past several months. He is also experiencing worsening erectile
dysfunction. He mentions that he feels “clumsy” at times. He also says that he
repeatedly collides into door frames because he cannot see out of the corners of his
eyes. This has led to frequent falls, including one while carrying groceries, which led to
a pelvic fracture. Physical examination discloses deficits in the his lateral peripheral
vision bilaterally.
What additional symptom is the patient most likely to report?
A. Gynecomastia
B. Dropping things with his right hand
C. Inability to raise the right corner of his mouth when smiling
D. Painful swallowing
E. Urinary incontinence

53. A 63-year-old woman visits her primary care physician because of progressively
worsening back pain during the past several weeks. She also notes having urinary
urgency and pain with urination. She also wakes frequently during the night to urinate.
Laboratory studies and a CT scan of the spine are shown below.
Na+ 139 mEq/L
K+ 4.8 mEq/L
Creatinine 1.7 mg/dL
Ca2+ 13.1 mg/dL
Total protein 10.4 g/dL
WBC 10,500 /mm3
Hemoglobin 10.2 g/dL
Hematocrit 31%
Platelets 155,000 /mm3

Which of the following is the most likely explanation for this patient's increased total
protein concentration?
A. Increased production of IgG molecules
B. Increased production of IgM molecules
C. Increased production of albumin
D. Increased production of clotting factors and acute-phase reactants
E. Severe dehydration

54. A 63-year-old woman presents with a generalized tonic-clonic seizure. In the past
few days, she has experienced weakness, headache, lethargy, and a decreased
appetite. She has also had a dry, nonproductive cough and occasional hemoptysis for
the past 2 weeks. She does not drink, but has a 25-pack-year smoking history.
Additionally, she was employed for 30 years in a factory where she worked with alanine
dyes. She has no previous history of seizures. Her lung examination shows prolonged
expiration with end expiratory wheezing, as well as decreased breath sounds in the left
lung fields. Laboratory studies show the following:
WBC count: 6400/mm3
Hematocrit: 36.2%
Hemoglobin: 12.1 g/dL
Platelet count: 200,000/mm3
Sodium: 118 mEq/L
Potassium: 3.8 mEq/L
Chloride: 97 mEq/L
Bicarbonate: 20 mEq/L
Calcium: 8.6 mg/dL
Magnesium: 1.9 mg/dL
Blood urea nitrogen: 6 mg/dL
Creatinine: 0.8 mg/dL
Glucose: 100 mg/dL
Which of the following is the most likely diagnosis?
A. Small cell lung cancer
B. Bronchial carcinoid tumor
C. Insulinoma
D. Ovarian teratoma
E. Pituitary microadenoma
F. Squamous cell lung carcinoma

55. An 18-year-old woman who is a college freshman comes for evaluation because of
progressive hearing loss and tinnitus. She has had increasing difficulty hearing her
professors in class during the past few months. She undergoes an MRI of the head,
which is shown in the image.
What other symptom does this patient most likely have on presentation?
A. Blurry or cloudy vision
B. Abnormal Rinne test
C. Galactorrhea
D. Nevus flammeus
E. Pigmented nodules of the iris

56. A 52-year-old female presents to her primary care physician with a 2-month history
of recurrent nonbloody diarrhea, unintentional weight loss, wheezing, and flushing. She
has no history of prior gastrointestinal problems or asthma. Physical examination did
confirm respiratory wheezes, and her abdomen showed minimal tenderness to
palpation. Cardiac auscultation revealed a right-side murmur. A CT scan is ordered
(shown here) and demonstrates a 6-cm mass in her small bowel, near the ileocecal
junction.

Which of the following findings would also be expected on the patient’s CT scan?
A. Liver metastases
B. Bowel obstruction
C. Intracranial mass
D. Lung metastases
E. Pancreatic masses

57. A 64-year-old woman visits her primary care physician because of fatigue,
weakness, and a weight loss of 4.5 kg (10 lb) during the past 4 months. Her vision has
deteriorated during that time as well, and she has had several severe nosebleeds.
Physical examination reveals hepatosplenomegaly, but is otherwise unremarkable.
Results of laboratory studies are shown below. Serum protein electrophoresis reveals a
large spike in the gamma region. A skeletal survey is negative.
Na+ 139 mEq/L
K+ 4 mEq/L
Cl- 102 mEq/L
HCO3- 25 mEq/L
BUN 15 mg/dL
Creatinine 0.9 mg/dL
Glucose 88 mg/dL
Ca2+ 9.8 mg/dL
Total protein 9.8 g/dL
Which of the following is the most likely diagnosis?
A. Waldenström macroglobulinemia
B. Chronic lymphocytic leukemia
C. Monoclonal gammopathy of undetermined significance
D. Multiple myeloma
E. Primary amyloidosis

58. An 18-year-old white man comes to the clinic because of bumps that are forming on
his back, shoulders, and arms. Physical examination reveals a dozen small, bumpy
prominences on his upper back and shoulders. They are nontender, nonmobile, and
firm to the touch. The physician also notices unusual freckling patterns in the patient's
axilla and groin area, as well as four areas of hyperpigmentation on his upper arms and
lower back, similar to those shown in the image.

Which of the following abnormalities is most likely to be found in this patient?

A. Pigmented nodules on the iris
B. Cranial nerve VIII schwannomas
C. Misproduction of the gene product merlin
D. Mutation in the tumor suppressor gene on chromosome 22
E. Mutation of p53 gene on chromosome 17

59. A 69-year-old man presents to his physician with complaints of recently worsening
back pain, jaundice, fever, night sweats, and anorexia. He also reports strange pain and
swelling in his arms and legs that lasts for 2–3 days in a single spot, which disappears
and then arises in a new spot a few days later.
He has a 40-pack-year smoking history and drinks 2–3 alcoholic beverages per week.
Physical examination reveals marked tenderness in the superficial veins of the right leg
with erythema and swelling. Imaging studies reveal a metastatic tumor.
Which of the following is most likely contributing to this patient's presentation?
A. Tissue factor
B. ACTH
C. ADH
D. Erythropoietin
E. Parathyroid hormone–related peptide

60. A 72-year-old farmer comes into the office with a sore on his right cheek. The sore
bleeds and oozes and has been growing slowly over the past 2 years. He has a 20-
pack-year smoking history, but his medical history is otherwise insignificant. Physical
examination reveals a 1.5-cm lesion on his cheek. A full-thickness biopsy specimen was
obtained, and histologic findings are shown in the image.

Which of the following is the most likely gross description of the skin lesion?
A. Raised, pearly borders surrounded by fine telangiectasias
B. 5- to 10-mm oval, tan-brown patch that does not darken with exposure to sunlight
C. Sharply defined red, scaling plaque
D. Tan-brown, rough lesion <1 cm in diameter
E. Thickened, hyperpigmented skin with velvet-like texture

61. A 46-year-old woman comes to her primary care physician after visiting the
optometrist. While being fitted for new glasses, the patient was found to have persistent
constriction of the right pupil. The patient also complains of a chronic nonproductive
cough for the past 4 months.
She has a temperature of 37.3° C (99° F), her heart rate is 78/min, and her respiratory
rate is 18/min. Her blood pressure is 135/78 mm Hg, and pulse oximetry is 97%. There
is marked drooping of the right eyelid. An X-ray of the chest is ordered, and results are
shown.
Disruption of which of the following explains this patient's symptoms?
A. Second-order (preganglionic) sympathetic neuron
B. Cranial nerve II
C. Cranial nerve III
D. First-order sympathetic neuron
E. Third-order (postganglionic) sympathetic neuron

62. A 60-year-old woman is referred to an oncologist because of painless lumps in

multiple areas of her body. She reports that these lumps have become larger and
smaller in size during the past 5 years. On physical examination, peripheral adenopathy
is noted in the cervical, axillary, inguinal, and femoral regions. After biopsy and
cytogenetic studies, she is diagnosed with follicular B-cell lymphoma. Genetic analysis
shows a t(14;18) translocation.
Which of the following is the normal function of the protein produced by the involved
locus on chromosome 18?
A. Inhibition of apoptosis
B. Cellular adhesion
C. Immune regulation
D. Inhibition of signal transduction
E. Positive regulation of signal transduction

63. A 53-year-old woman presents to the clinic because of abdominal pain and a 5.4-kg
(12-lb) weight loss during the past month. She has noticed new facial hair during the
same period of time. Further history reveals onset of menses at age 12 years, three
uncomplicated vaginal deliveries after which she breastfed each infant, and completion
of menopause 2 years ago. Review of family history is negative for gynecologic
malignancies in her immediate family. On abdominal examination, there is tenderness
over the lower left and right quadrants. Ultrasonography shows bilateral ovarian masses
consistent with malignancy. On histopathologic examination of the malignancy,
metasasis is suspected due to the presence of off-center nuclei and cytoplasm that
stains heavily for mucin.
Which of the following is a drug that acts on the organ most likely to be the site of the
primary tumor?
A. Omeprazole
B. Albuterol
C. Methimazole
D. N-Acetylcysteine
E. Phenytoin

64. A 5-year-old girl is brought to the emergency department with acute onset of
projectile vomiting and a severe headache. Her parents also report that she has had
trouble walking over the past couple of months. She has not had any fevers or nuchal
rigidity. Her medical history is negative for seizures. Physical examination is notable for
truncal ataxia and papilledema. Magnetic resonance imaging (MRI) of the head reveals
a mass as demonstrated in the image.
Which of the following is most likely to be seen on histologic examination of tissue from
this mass?
A. Small cells with a high nuclear-to-cytoplasm ratio surrounding a neuropil
B. Cells with round, regular, centrally located nuclei surrounded by a perinuclear halo
C. Prolific vasculature and foamy cells
D. Rod-shaped perinuclear inclusions
E. Round calcifications

65. A 33-year-old man presents with a 3-month history of night sweats. He has had a
decreased appetite and has lost 6.8 kg (15 lb) over the past few months. Temperature
is 37.6°C (99.7°F). Several painless but enlarged cervical lymph nodes are found. A
cancer workup is initiated, and the patient is diagnosed with a lymphoma. The
pathologist confirms the diagnosis by means of biopsy. The biopsy specimen shows
large multinucleated cells containing prominent eosinophilic nucleoli.
Which of the following features indicates the poorest prognosis, given this patient’s
diagnosis?
B. A more advanced tumor stage
A. A higher tumor grade
C. Lymph node enlargement
D. Presence of systemic symptoms
E. Younger age at time of diagnosis

66. A 60-year-old man comes to the clinic because a 6-week history of vague epigastric
pain. The patient also reports fatigue and mentions that the epigastric pain is mostly
postprandial. Fecal occult blood test is positive. Gastroduodenoscopy shows a mass in
the pyloric region. The tumor is centered near the pyloric sphincter on the lesser
curvature. Biopsies from the margin of the mass are consistent with adenocarcinoma.
Which of the following physical examination findings is most likely to be seen in this
patient due to the mass effect of the tumor?
A. Jaundice
B. Decreased bowel sounds
C. Koilonychia
D. Palpable cord in the calf
E. Periumbilical nodule

67. A 40-year-old man comes to the physician because of a 2-week history of gradually
worsening fatigue, nausea, vomiting, and abdominal distention. Physical examination is
remarkable for scleral icterus; sublingual jaundice; a nodular, palpable liver; and a
flapping tremor with wrist extension. Abdominal imaging reveals a large, irregular lesion
in the caudate lobe of the liver.
Which of the following is most representative of the severity of organ involvement?
A. Increased prothrombin time
B. Decreased estrogen level
C. Decreased level of circulating von Willebrand factor
D. Elevated transaminases
E. Increased β-human chorionic gonadotropin level
F. Increased serum albumin level

68. A 19-year-old college student presents for evaluation of persistently enlarged

nontender supraclavicular lymph nodes. She says she is otherwise healthy and
provides no significant medical history. She is experiencing night sweats and has had a
4.5-kg (10-lb) weight loss over the past 3 months. Three supraclavicular lymph nodes
are palpable above her right clavicle. No other lymphadenopathy is noted. An x-ray of
the chest reveals mediastinal lymphadenopathy. Results of a lymph node biopsy are
shown in the image.

Which of the following is the most likely diagnosis?

A. Hodgkin lymphoma
B. Burkitt lymphoma
C. Diffuse large B-cell lymphoma
D. Follicular lymphoma
E. T-lymphocyte lymphoblastic lymphoma

69. A 69-year-old man complains that he has been experiencing dizziness, tinnitus, and
poor balance for the past 3 months. On CT scan he is found to have a 2-cm, sharply
circumscribed mass at the cerebellopontine angle. The mass is surgically removed, and
the specimen appears as multiple irregular fragments of tan-pink soft tissue. A
photomicrograph of the specimen is shown below.
Which of the following tumors would most likely result in these findings?
A. Schwannoma
B. Medulloblastoma
C. Meningioma
D. Neurofibroma
E. Oligodendroglioma

70. A 50-year-old man who has a 50 pack-year smoking history comes to his physician
because of flank tenderness. He has no history of signifcant illness. Family history is
significant for myocardial infarction in his paternal grandfather at age 76 years, and
breast cancer in his sister at age 58 years. On physical examination, the patient has
flank tenderness and a palpable abdominal mass. A CT scan is shown.

Which of the following is the most likely diagnosis?

A. Renal cell carcinoma
B. Angiomyolipoma
C. Autosomal dominant polycystic kidney disease
D. Neuroblastoma
E. Wilms tumor

71. A 35-year-old man comes to his primary care provider because of a 2-month history
of fever, a 7-kg (15-lb) weight loss, and night sweats. Physical examination shows
painless generalized lymphadenopathy. Cytotoxic chemotherapy is initiated; however, 4
days into his treatment the patient develops severe pain in his left great toe, which is
accompanied by nausea. He also has developed a rash and now has multiple
excoriations on his extremities. Results of laboratory studies are shown.
Na+: 140 mEq/L
K+: 6.5 mEq/L
Ca2+: 7.5 mEq/L
Phosphorus: 5.1mg/dL (normal: 3.0 - 4.5mg/dL)
Uric acid: 23 mg/dL (normal: 3.5 - 8.0 mg/dL)
Lactate dehydrogenase: 5000 U/L (normal: 118 - 273 U/L)
Given this patient’s current presentation, he is at greatest risk for which of the following
complications?
A. Cardiac arrhythmia
B. Disorientation and/or coma
C. Hemorrhagic cystitis
D. Myelosuppression
E. Pulmonary fibrosis

72. A 40-year-old woman comes for evaluation because of a 2-month history of

persistent cough. She reports a 6.8-kg (15-lb) unintentional weight loss and general loss
of appetite. She drinks two glasses of wine per week, and has never smoked cigarettes.
The patient has worked as an insurance agent for the past 15 years. She does not
recall any first- or second-degree relatives diagnosed with cancer. An x-ray of the chest
reveals a single 2-cm peripheral opacity.
Which of the following cell types is most likely to be involved in the diagnosis?
A. Mucus-producing cells of the lung
B. Airway epithelial cells
C. Ductal epithelium of the breast
D. Undifferentiated neuroendocrine cells of the lung
E. Well-differentiated neuroendocrine cells that arise from the lung or digestive tract

73. A 69-year-old man comes to his primary care physician because of increasing
fatigue and a 15-lb unintentional weight loss over the past 2 months. On physical
examination, he is noted to have an enlarged, smooth liver edge and a palpable spleen.
Specific laboratory results include:
Hemoglobin: 8.7 g/dL
Platelets: 156,000/mm3
Leukocytes: 66,500/mm3
Neutrophils: 32%
Bands: 12%
Eosinophils: 3%
Basophils: 5%
Monocytes: 4%
Metamyelocytes: 12%
Myelocytes: 23%
Lymphocytes: 9%
Leukocyte alkaline phosphatase activity: low
A diagnosis is made, and the patient is treated with imatinib. This drug is a specific
inhibitor of a fusion protein that is present only in cancerous cells.
Which of the following most accurately describes this fusion protein?
A. Activation of a proto-oncogene
B. DNA repair enzyme
C. Free radical scavenger
D. Product of a tumor suppressor gene
E. Transcription factor

74. A 41-year-old gravida 3, para 2 pregnant woman comes to the obstetrician because
of new-onset vaginal bleeding, nausea, and vomiting. Although she is only at 18 weeks
gestation, her doctor notes that her uterus is the size usually seen at 25 weeks
gestation. Maternal blood work shows a β-human chorionic gonadotropin level > 5 times
the upper limit of normal. Vitals taken at the visit include temperature of 98.4°F
(36.8°C), heart rate of 86/min, respiratory rate of 20/min, blood pressure of 118/76 mm
Hg, and oxygen saturation of 97% on room air.
If left untreated, which of the following is the most likely potential consequence of the
patient’s condition?
A. Choriocarcinoma
B. Endometritis
C. Fetal neural tube defects
D. Ovarian cancer
E. Rupture of the fallopian tube

75. A 40-year-old man comes to the physician because he is having difficulty

articulating when he speaks and has worsening headaches associated with nausea and
vomiting. An MRI of the head shows an irregularly enhancing left-sided mass with areas
of necrosis and localized edema. Results of a stereotactic biopsy of the left hemisphere
are shown in the photomicrograph.

Which of the following is the most likely diagnosis?

A. Glioblastoma multiforme
B. Anaplastic astrocytoma
C. Anaplastic oligodendroglioma
D. Myxopapillary ependymomas
E. Pilocytic astrocytoma

76. A 35-year-old man who was adopted as a child is brought to the emergency
department by ambulance after having a tonic-clonic seizure at work. The patient
reports that he has always been healthy, and has never had a seizure before today. He
reports having gradual-onset headaches during the past month that worsen when lying
down. The headaches have awakened him on several occasions, and have been
accompanied by nausea and vomiting. On further questioning, the patient reports that
he has been having intermittent bloody stools for the past 4 months with an associated
15-lb (6.8-kg) weight loss. Physical examination reveals pale conjunctivae and mucosa.
He also has a soft systolic murmur that disappears when the patient rises from the
supine position. A CT scan of the head reveals a single, well-circumscribed mass in the
left hemisphere.
Which of the following is the most likely diagnosis?
A. Turcot syndrome
B. Familial adenomatous polyposis
C. Gardner syndrome
D. Hereditary nonpolyposis colorectal carcinoma
E. Tuberous sclerosis

77. A 48-year-old woman who has recently emigrated from China comes to the clinic
because of a 3-month history of vague abdominal pain accompanied by weight loss and
a feeling of fullness after eating a small amount of food. She has no significant past
medical or social history. Physical examination reveals a palpable mass in the right
upper quadrant of the abdomen. The examination is negative for jaundice, shifting
dullness, and spider angiomata. Fecal occult blood test is negative. CT scan of the
abdomen shows a large mass in the liver. Laboratory tests show:
AST: 175 IU/mL
ALT: 218 IU/mL
α-fetoprotein: 4500 ng/mL
Which of the following is the most likely etiologic factor contributing to this patient’s
disease?
A. Hepadnavirus infection
B. Alcohol abuse
C. Flavivirus infection
D. Fungal infection
E. Low-fiber, high-fat diet

78. A 67-year-old former landscaper is referred to the dermatologist for a lesion on his
right forearm. The lesion is a flesh-colored, shiny lesion approximately 1.5 cm in
diameter. A biopsy is taken, and the results are shown in the image.
Which of the following is the most likely diagnosis?
A. Basal cell carcinoma
B. Actinic keratosis
C. Dermatitis herpetiformis
D. Melanoma
E. Seborrheic keratosis
F. Squamous cell carcinoma

79. A 59-year-old man presents to his physician complaining of severe headaches that
are worse in the morning. Physical exam shows weakness and increased tone of the
right upper extremity. The physician orders an MRI of the brain, which shows a mass in
the left frontal lobe. Findings of the brain biopsy are shown.

What is the normal function of the tumor cells seen in this histologic slide?
A. Myelination of axons in the central nervous system
B. Antigen presentation
C. Myelination of a single axon in the peripheral nervous system
D. Phagocytosis
E. Production of antibodies specific to particular antigens
F. Production of cerebrospinal fluid
80. A 2-month-old girl is seen by a new physician to establish care. She is accompanied
by her mother, a recent immigrant from Mexico who did not receive prenatal care. On
physical examination, the infant is found to have small ears, a flat nasal bridge,
upslanting palpebral fissures, and a protruding tongue. A cardiac examination reveals a
harsh holosystolic murmur, but no signs of perioral cyanosis or respiratory distress.
Additionally, there is an abnormal space noticed between the first and second toes on
both feet. Further questioning does not reveal any family history of intellectual disability
or genetic disorders.
Which of the following are signs or symptoms of the neoplasm that the patient is at
increased risk of having?
A. Fatigue, easy bruising, weight loss, and fever
B. Absence of a red light reflex in one eye
C. Dyspnea on exertion with a "plop" on cardiac auscultation
D. Jaundice and ascites
E. Night sweats, fevers, and unintentional weight loss

81. An otherwise healthy 8-year-old boy is brought to the pediatrician because of

headaches during the past 7-10 days. Physical examination shows normal vital signs.
However, the patient is in the 5 th percentile of the growth curve, even though he was in
the 60th percentile last year. Neurologic examination reveals the patient is not able to
notice the movement of the physician’s fingers in the temporal visual field of both sides.
The rest of the physical examination is unremarkable. A non-contrast CT scan of the
head is shown.

Which of the following laboratory findings is most likely in this patient?

A. Decreased growth hormone level
B. Decreased aldosterone level
C. Decreased prolactin level
D. Elevated testosterone level
E. Elevated thyroid-stimulating hormone level

82. A 55-year-old woman comes to her physician’s office because off recent-onset
galactorrhea and abdominal pain that is relieved by eating. Further questioning reveals
that she has developed multiple kidney stones and depression over the past two years;
she had no previous history of either condition. On further questioning she explains that
her brother used to faint frequently “because of some pancreas tumor, but that was 10
years ago, and he’s fine now.”
Which of the following laboratory findings is most likely to be present in this patient?
A. Hypercalcemia
B. Hyperglycemia
C. Hyperphosphatemia
D. Hyperuricemia
E. Hyponatremia

83. A 60-year-old postmenopausal woman comes to her gynecologist because of

abnormal vaginal bleeding. The bleeding has occurred for the past 6 months and has
been accompanied by decreased appetite with a 7-kg (15-lb) weight loss. Further
history reveals onset of menses at age 12 years with normal 28-day cycles; completion
of menopause occurred at age 52 years. She also had three uncomplicated vaginal
deliveries. Review of family history is negative for gynecologic malignancies in her first
and second-degree relatives. Physical examination reveals a discrete mass in the
uterus. The patient undergoes hysterectomy and a postoperative biopsy specimen is
shown in the image.

Based on the patient's symptoms and pathological findings, which of the following is the
most likely diagnosis?
A. Sarcoma
B. Adenocarcinoma
C. Papilloma
D. Teratoma
E. Urothelial carcinoma
84. A 57-year-old man presents to his physician with skin lesions on his ear. These
lesions are removed and sent for pathologic examination, but results indicate they are
not cancerous. Within 6 months of removal, one of the lesions reappears, and is shown
in the image below. The physician explains to the patient that he may be at risk for
developing a type of skin neoplasm that carries a risk of metastasis.

Which of the following is a feature of the malignancy this patient is at risk for
developing?
A. Keratin formation in well-differentiated cases
B. Likelihood of metastasis is based on Breslow depth
C. Palisading cells at tumor periphery
D. Pearly papule with telangiectasias
E. Pinpoint areas of bleeding from exposure of dermal papillae

85. A 66-year-old male presents at the emergency department complaining of recent-

onset fever, productive cough, and pleurisy. He admits to not feeling well in the past few
weeks with new-onset bone pain and fatigue with exertion. The bony pain is prominent
in his back and is exacerbated with changes in position.
He is a nonsmoker and was in good health until the last few weeks. On exam, his
temperature is 38.4°C (101.1°F), pulse is 107/min, respiratory rate is 23/min, and his
blood pressure is 110/90 mm Hg. On exam the patient appears as a thin, elderly male in
mild respiratory distress with crackles and fremitus at the left lower base.
Basic lab values follow:
Hb: 8.9 g/dL
Hct: 27.5%
MCV: 88 fL
WBC: 13.3 × 109/L
Plts: 100 × 109/L
Na+: 138 mEq/L
K+: 4.0 mEq/L
Cl–: 101 mmol/L
HCO3–: 24 mmol/L
BUN: 19 mg/dL
Cr: 1.4 mg/dL
Glucose: 98 mg/dL
Ca2+: 10.3 mg/dL
A serum protein electrophoresis is obtained, and is shown.
Posteroanterior and lateral chest X-rays reveal consolidation of the left lower lobe and
hypodense lesions of the vertebral bodies.

Which of the following is the primary pathologic process leading to his condition?
A. A neoplastic proliferation of plasma cells
B. A neoplastic proliferation of myeloblasts
C. A neoplastic proliferation of plasmacytoid lymphocytes
D. Parathyroid carcinoma with metastatic bone disease
E. Prostatic adenocarcinoma with metastatic bone disease
F. Squamous cell lung carcinoma with metastatic bone disease