Pathological Anatomy MCQ PDF

PATHOLOGY MCQ FOR MD31, 2nd Semester (IU) 1. A 31-year-old woman, who has two healthy children, notes that she has had no menstrual periods for the past 6 months, but she is not pregnant and takes no medication. Within the past week, she has noted some milk production from her breasts. She ha...

PATHOLOGY MCQ FOR MD31, 2nd Semester (IU) 1. A 31-year-old woman, who has two healthy children, notes that she has had no menstrual periods for the past 6 months, but she is not pregnant and takes no medication. Within the past week, she has noted some milk production from her breasts. She has been bothered by headaches for the past 3 months. After nearly hitting a bus while changing lanes driving her vehicle, she is concerned with her vision. An optometrist finds her lateral vision to be reduced. On physical examination she is afebrile and normotensive. Which of the following laboratory test findings is most likely to be present in this woman? A. Increased serum cortisol B. Lack of growth hormone suppression C. Increased serum alkaline phosphatase D. Hyperprolactinemia E. Hyponatremia F. Abnormal glucose tolerance test G. Decreased serum TSH 2. A 28-year-old woman has had difficulty concentrating at work for the past month. She is constantly getting up and walking around to visit co-workers. She complains that the work area is too hot. She seems nervous and often spills her coffee. She has been eating more but has lost 5 kg in the past 2 months. On physical examination her temperature is 37.5°C, pulse 101/minute, respiratory rate 22/minute, and blood pressure 145/85 mm Hg. Which of the following laboratory findings is most likely to be present in this woman? A. Decreased catecholamines B. Decreased iodine uptake C. Decreased plasma insulin D. Decreased TSH E. Increased ACTH F. Increased calcitonin 3. A 19-year-old previously healthy woman has had a mild pharyngitis followed by a high fever over the past 24 hours. When seen in the emergency room, her skin now shows extensive areas of purpura. Vital signs include temperature 39°C, pulse rate 102/minute, respiratory rate 21/minute, and blood pressure 80/55 mm Hg. Laboratory studies show a serum sodium of 115 mmol/L, potassium 5.3 mmol/L, chloride 92 mmol/L, CO2 22 mmol/L, glucose 42 mg/dL, and creatinine 1.1 mg/dL. Which of the following is the most likely diagnosis? A. Idiopathic adrenalitis B. Disseminated tuberculosis C. Reactive systemic amyloidosis D. Sheehan syndrome E. Meningococcemia F. Hemochromatosis 4. A 40-year-old woman has noted enlargement of her anterior neck region over the past 8 months. On physical examination her vital signs include T 36.8°C, P 64/minute, RR 16/minute, and BP 155/105 mm Hg. There is diffuse, symmetrical thyroid enlargement without tenderness. A chest radiograph is normal. Fine needle aspiration of the thyroid yields cells consistent with a neoplasm. Laboratory studies show that she is euthyroid, but her serum ionized calcium is elevated. She is taken to surgery and frozen sections of several thyroid masses show a malignant neoplasm composed of polygonal cells in nests. A thyroidectomy is performed. Immunostaining for calcitonin of the permanent sections is positive, and the neoplasm has an amyloid stroma with Congo red staining. Which of the following neoplasms is she most likely to have? A. Anaplastic carcinoma B. Medullary carcinoma C. Papillary thyroid carcinoma D. Metastatic renal cell carcinoma E. Parathyroid carcinoma F. Follicular carcinoma 5. A 37-year-old man experiences abdominal pain, nausea, and constipation for the past 3 days. On physical examination he has no palpable abdominal masses and bowel sounds are present. His lungs are clear to auscultation. He has a heart rate of 80/min with an irregular rhythm. An electrocardiogram demonstrates a shortened QT(corrected) interval and a prolonged PR interval. He has a stool positive for occult blood. Upper GI endoscopy reveals multiple 1 cm diameter shallow ulcerations of the gastric antrum. Which of the following laboratory test findings is most likely to be present in this man? A. Thyroid peroxidase antibody of 4 IU/mL B. Serum calcium of 12.4 mg/dL C. Blood glucose of 225 mg/dL D. Total serum thyroxine of 21 ng/mL E. Plasma cortisol of 45 microgm/dL at 8 am F. Urine normetanephrine of 692 microgm/gm of creatinine G. Plasma renin activity (upright) of 6.8 ng/mL/hr 6. A 55-year-old woman has had a 4 kg weight loss over the past 3 months. She exhibits decreased mentation over the past 10 days. On physical examination she is afebrile and hypotensive. Bilateral papilledema is noted. A head CT scan shows marked diffuse cerebral edema with effacement of the lateral ventricles. Laboratory studies show a sodium of 108 mmol/L, potassium 4.0 mmol/L, chloride 83 mmol/L, CO2 14 mmol/L, glucose 82 mg/dL, and creatinine 0.5 mg/dL. Which of the following is most likely to cause these findings? A. Small cell lung carcinoma B. Blunt head trauma C. Hypothalamic glioma  D. Meningitis E. Pituitary macroadenoma 7. A 29-year-old primigravida who received no prenatal care has marked vaginal bleeding after the onset of labor at 38 weeks gestation. Cesarean section is performed and a lacerated low- lying placenta is removed. She remains hypotensive for 6 hours and requires transfusion of 12 packed RBC units. Postpartum, she becomes unable to breast-feed the infant. She does not have a resumption of normal menstrual cycles. She becomes more sluggish and tired. Laboratory findings include hyponatremia, hyperkalemia, and hypoglycemia. Which of the following pathologic lesions is she most likely to have had following delivery? A. Bilateral adrenal hemorrhage B. Pituitary necrosis C. Subacute thyroiditis D. Metastatic choriocarcinoma E. Insulitis 8. A 58-year-old man with a history of diabetes mellitus has noted the presence of bone pain, especially of his hands, for the past 6 months. On physical examination there is no swelling or redness of his hands, no joint deformity, but the range of motion is slightly decreased. Laboratory studies show sodium 139 mmol/L, potassium 4.0 mmol/L, chloride 98 mmol/L, C02 22 mmol/L, glucose 153 mg/dL, creatinine 7.8 mg/dL, calcium 7.8 mg/dL, phosphorus 5.7 mg/dL, total protein 6.2 g/dL, and albumin 4.0 g/dL. Which of the following conditions is this man most likely to have? A. Adrenal adenoma B. Medullary thyroid carcinoma C. Extra-adrenal pheochromocytoma D. Parathyroid hyperplasia E. Pituitary adenoma 9. A 49-year-old woman has had increasing cold intolerance, weight gain of 4 kg, and sluggishness over the past two years. A physical examination reveals dry, coarse skin and alopecia of the scalp. Her thyroid is not palpably enlarged. Her serum TSH is 11.7 mU/L with thyroxine of 2.1 micrograms/dL. A year ago, anti-thyroglobulin and anti-microsomal autoantibodies were detected at high titer. Which of the following thyroid diseases is she most likely to have? A. DeQuervain disease B. Papillary carcinoma C. Hashimoto thyroiditis D. Multinodular goiter E. Graves’ disease 10. A 48-year-old woman has experienced constant back pain exacerbated by movement over the past month. She reports increasing weakness over the past 3 months. On physical examination her blood pressure is 165/110 mm Hg. She is overweight, with a BMI of 28. A radiograph of the spine reveals a compressed fracture at T10. Laboratory findings include a serum glucose of 155 mg/dL. Which of the following pathologic lesions is most likely to explain her findings? A. Adrenal cortical carcinoma B. Anaplastic thyroid carcinoma C. Empty sella syndrome D. Pheochromocytoma E. Multinodular goiter 11. A 33-year-old woman has noted a weight gain of 6 kg over the past year. She has normal menstrual periods. On physical examination her blood pressure is 170/105 mm Hg. Her skin shows marked plethora. Abdominal striae are present. A serum electrolyte panel shows sodium 141 mmol/L, potassium 4.4 mmol/L, chloride 100 mmol/L, CO2 25 mmol/L, glucose 181 mg/dL, and creatinine 1.0 mg/dL. Which of the following radiologic findings would you most expect to be present in this patient? A. 2 cm right adrenal mass with abdominal CT scan B. 4 cm mass at aortic bifurcation with MR imaging C. Multiple pulmonary nodules on chest radiograph D. 10 cm cystic right ovarian lesion by abdominal ultrasound E. 2 cm 'hot' thyroid nodule with Tc99 scintigraphic scan 12. A 35-year-old woman has had insomnia for the past 4 months, as well as episodes of diarrhea with up to 4 loose stools per day. On physical examination, she exhibits bilateral proptosis. Her outstretched hands have a fine tremor. On palpation of her neck, the thyroid gland does not appear to be enlarged and no masses are palpable. Laboratory studies show a serum TSH of 8.8 microU/mL in association with a serum total thyroxine of 15.1 microgram/dL. Which of the following is the most likely diagnosis? A. Graves’ disease B. Pituitary adenoma C. Chronic thyroiditis D. Prior thyroidectomy E. Multinodular goiter 13. A 25-year-old woman has had a 7 kg weight loss over the past 6 months without dieting or trying to lose weight. On physical examination she appears anxious and worried. Her hands are warm and tremulous. Vital signs show her temperature to be 37.4°C, pulse 105/minute,  respirations 23/minute, and blood pressure 135/75 mm Hg. Serum laboratory data include glucose 78 mg/dL and creatinine 0.8 mg/dL. Which of the following additional laboratory test findings is most likely to be present in this woman? A. Plasma cortisol of 40 microgm/dL at 8 am B. Serum antinuclear antibody of 1:256 C. Urinary free catecholamines of 500 microgm/24 hr D. Serum gastrin of 200 pg/mL E. Serum total thyroxine of 14 microgm/dL 14. A 50-year-old man has episodic headaches for 3 months. On physical examination his blood pressure is 185/110 mm Hg, with no other remarkable findings. Laboratory studies show sodium 145 mmol/L, potassium 4.3 mmol/L, chloride 103 mmol/L, C02 26 mmol/L, glucose 91 mg/dL, and creatinine 1.3 mg/dL. An abdominal CT scan shows a 7 cm left adrenal mass. During surgery, as the left adrenal gland is removed, there a marked rise in blood pressure. Which of the following laboratory test findings most likely explains his findings? A. Decreased serum cortisol B. Decreased urinary homovanillic acid C. Increased serum ACTH D. Increased urinary free catecholamines E. Elevated serum ANCA 15. A 47-year-old woman feels a 'lump' in her neck that she didn't notice 5 months before. Her physician palpates a firm nodule about 2 cm in size to the left of midline in the region of the thyroid gland. By scintigraphic scanning this nodule appears 'cold' with normal activity in the surrounding normally sized thyroid gland. Which of the following is the most likely diagnosis? A. Papillary carcinoma B. Follicular adenoma C. Thyroglossal duct cyst D. Toxic nodular goiter E. Granulomatous thyroiditis F. Hashimoto thyroiditis 16. A 56-year-old woman has had diffuse, dull, constant abdominal pain for the past 2 months. On physical examination no abnormal findings are noted. An abdominal CT scan shows a 3 cm right adrenal mass. The right adrenal is excised and on microscopic examination the mass is composed of cells resembling adrenal cortex. Which of the following features is the most reliable indicator that this mass is malignant? A. Cellular atypia B. Presence of mitoses  C. Invasion D. Size of the mass E. Cellular necrosis 17. A 49-year-old woman has had multiple episodes of lower abdominal pain for the past year. On 3 occasions she passed a urinary tract stone during or following an episode of pain. During the past month she has had pain in her right middle finger. On physical examination there is pain on palpation of her right 3rd proximal phalanx. Laboratory studies show a serum calcium of 13.7 mg/dL, phosphorus of 1.9 mg/dL, creatinine 1.1 mg/dL, and albumin 4.8 g/dL. Which of the following bone lesions is she most likely to have? A. Osteitis fibrosa cystica B. Osteoid osteoma C. Osteochondroma D. Osteomyelitis E. Osteoporosis F. Osteosarcoma 18. A 40-year-old woman notes increasing enlargement and discomfort in her neck over the past week. The nurse practitioner palpates diffuse, symmetrical enlargement with tenderness in the region of the thyroid gland. Thyroid function tests show serum TSH of 0.8 mU/L and thyroxine of 11.9 micrograms/dL. She is referred to an endocrinologist, but the next available appointment is in 8 weeks. When examined by the endocrinologist her thyroid is no longer palpable and there is no pain. Repeat thyroid function tests reveal a serum TSH of 3.8 mU/L and thyroxine of 5.7 micrograms/dL. Which of the following thyroid diseases is most likely to produce these findings? A. Nodular goiter B. Non-Hodgkin lymphoma C. DeQuervain disease D. Hashimoto thyroiditis E. Graves disease F. Riedel thyroiditis G. Iodine deficiency 19. A 33-year-old previously healthy man has lateral visual field deficits, but his residual vision is 20/20. His facial features have changed over the past year. His shoe size has increased. A head CT scan reveals enlargement of the sella turcica. Which of the following hormones is most likely being secreted in excessive amounts in this man? A. Antidiuretic hormone B. Prolactin C. ACTH D. Growth hormone  E. Luteinizing hormone 20. A 47-year-old woman has felt a 'lump' in her neck for the past 2 months. On physical examination there is a firm nodule in the right lobe of her thyroid. Following fine needle aspiration and cytologic diagnosis of a neoplasm, a thyroidectomy is performed. Grossly, there is a 3 cm mass in the right lower pole that on sectioning is cystic and has papillary excrescences. Which of the following microscopic pathologic findings is most typical for this lesion? A. Giant cells B. Amyloid stroma C. Small thyroid follicles D. Clear nuclear chromatin E. Pleomorphic spindle cells 21. The mother of an 11-month-old infant had noted enlargement of the baby's abdomen within the past month. This is confirmed by the osteopathic physician, who notes that the baby is otherwise normally developed. An abdominal CT scan reveals a 6 cm mass, with some scattered calcifications, above the right kidney. Laboratory studies show a greatly elevated urinary vanillylmandelic acid (VMA), while the urinary homovanillic acid (HVA) is only slightly increased. The mass is removed and microscopically is composed of sheets of small blue cells. What is the most likely diagnosis? A. Congenital adrenal hyperplasia B. Adrenal cortical carcinoma C. Neuroblastoma D. Non-Hodgkin lymphoma E. Pheochromocytoma F. Aldosteronoma 22. A 53-year-old woman has pain in her neck for the past month. On physical examination her vital signs include T 37°C, P 77/minute, RR 16/minute, and BP 130/80 mm Hg. There is an irregular firm mass palpable in her left neck. A CT scan shows an infiltrative mass involving the left lobe of the thyroid and extending into adjacent soft tissues. Laboratory studies show TSH 2.9 mU/L, total serum thyroxine 8.6 microgm/dL, calcium 8.7 mg/dL, and phosphorus 2.8 mg/dL. A fine needle aspiration biopsy of the mass shows malignant spindle-shaped cells present that demonstrate a p53 mutation immunohistochemically. Which of the following neoplasms is this woman most likely to have? A. Anaplastic carcinoma B. Follicular carcinoma C. Medullary carcinoma D. Non-Hodgkin lymphoma E. Papillary carcinoma  F. Parathyroid carcinoma 23. A 45-year-old man has a 4 month history of nonfocal, generalized headaches. On physical examination he is found to have a blood pressure of 170/110 mm Hg. Laboratory studies show a serum sodium of 146 mmol/L, potassium 2.3 mmol/L, chloride 103 mmol/L, CO2 27 mmol/L, glucose 82 mg/dL, and creatinine 1.2 mg/dL. His plasma renin activity is 0.1 ng/mL/hr and his serum aldosterone 65 ng/mL. Which of the following is the most likely cause for his findings? A. 21-hydroxylase enzyme deficiency B. Adrenal cortical adenoma C. Pituitary adenoma D. Exogenous corticosteroid administration E. Renal cell carcinoma 24. A 40-year-old woman has noted painless swelling of her neck for the past 3 weeks. On physical examination there is diffuse enlargement of her thyroid. Laboratory studies show an increased titer of anti-thyroid peroxidase and anti-thyroglobulin antibodies. Within a month, the swelling has diminished. Which of the following complications is she most likely to develop? A. Amyloidosis B. Hypothyroidism C. Non-Hodgkin lymphoma D. Papillary carcinoma E. Riedel thyroiditis 25. A 45-year-old woman with severe rheumatoid arthritis has been on chronic corticosteroid therapy for the past 15 years. She is admitted for an orthopedic procedure to correct joint deformity from her disease. She continues to receive her regular dosage of 5 mg of prednisone per day. Three days postoperatively, she develops an aspiration pneumonia with Klebsiella pneumoniae cultured from sputum. Five days following the surgery, she becomes obtunded. Laboratory findings at that time include: sodium 105 mmol/L, potassium 5.4 mmol/L, chloride 87 mmol/L, CO2 16 mmol/L, glucose 40 mg/dL, and creatinine 1.1 mg/dL. Which of the following complications is most likely to have occurred in this patient? A. Anterior pituitary necrosis B. Waterhouse-Friderichsen syndrome C. Acute Addisonian crisis D. Conn syndrome E. 21-hydroxylase deficiency 26. A 38-year-old woman has had a feeling of fullness in her neck for the past year. She is otherwise asymptomatic. Her physician's assistant palpates a symmetrically enlarged but nontender thyroid gland. She has no difficulty swallowing. There is no palpable lymphadenopathy. She is afebrile. Her serum TSH is 3.5 mU/L with total thyroxine of 8.2 micrograms/dL. Thyroid peroxidase antibody is not detected. Two years later, her thyroid has not appreciably changed in size. Which of the following conditions is she most likely to have? A. Graves disease B. Nodular goiter C. Hashimoto thyroiditis D. Anaplastic carcinoma E. Follicular adenoma F. Papillary carcinoma 27. A 15-year-old boy has had worsening headaches for 2 months. On examination he has diminished peripheral vision, but no loss of visual acuity. A head CT scan reveals a 4 cm mass expanding the sella turcica and eroding the sphenoid bone. The mass is cystic with scattered calcifications. Which of the following is the most likely diagnosis? A. Prolactinoma B. Metastatic seminoma C. Empty sella syndrome D. Anaplastic astrocytoma E. Craniopharyngioma F. Osteosarcoma 28. A 52-year-old man has weight of 4 kg over the past 6 months, along with bruises on his skin with even minor trauma and back pain. He has smoked 2 packs a cigarettes per day for 35 years. On physical examination he has obesity in a truncal distribution, plethora, and a blood pressure of 160/110 mm Hg. A radiograph of the spine reveals a compressed fracture of T11. Which of the following neoplasms is he most likely to have? A. Pheochromocytoma of bladder B. Follicular carcinoma of thyroid C. Osteosarcoma of femur D. Small cell anaplastic carcinoma of lung E. Neuroendocrine carcinoma of pancreas 29. A 41-year-old man has been drinking large quantities of water--up to 20 liters per day--for the past week. On physical examination he has diminished skin turgor and dry mucous membranes. Laboratory studies show sodium 162 mmol/L, potassium 4.1 mmol/L, chloride 121 mmol/L, and bicarbonate 27 mmol/L. His serum glucose is 75 mg/dL and creatinine 1.0  mg/dL. His serum osmolality is 343 mOsm/kg. A deficiency of which of the following hormones is most likely present in this man? A. Vasopressin B. Oxytocin C. Insulin D. Growth hormone E. Prolactin 30. A 50-year-old man has a lump on his neck found at physical examination. A fine needle aspirate of this lump shows a follicular neoplasm of the thyroid. He undergoes a total thyroidectomy. Within a day following surgery, he is noted to have tingling sensations and neuromuscular irritability. Which of the following serum laboratory tests should be ordered immediately to determine further therapy for this man? A. TSH B. Parathormone C. Thyroxine D. Calcium E. Calcitonin F. Iodine 31. A 30-year-old woman from Barcelona has noted enlargement of her neck over the past 4 months. On physical examination, she has a diffusely enlarged thyroid that is not painful to palpation. Her TSH level is 0.2 mU/L. A subtotal thyroidectomy is performed and histologically the tissue shows follicles with papillary infoldings lined by tall columnar cells. Which of the following is the most likely diagnosis? A. Subacute granulomatous thyroiditis B. Papillary carcinoma C. Multinodular goiter D. Hashimoto thyroiditis E. Graves disease 32. A 57-year-old man is found comatose. On physical examination he has decreased skin turgor. Laboratory studies show a blood glucose of 780 mg/dL. Urinalysis reveals no ketosis or proteinuria, though there is 4+ glucosuria. Which of the following is the most likely diagnosis? A. Neuroendocrine tumor secreting glucagon B. Type I diabetes mellitus C. Cushing syndrome D. Ingestion of a large quantity of sugar E. Type II diabetes mellitus 33. A 23-year-old man wants to increase his muscle mass for playing physical contact sports. He attempts to accomplish this by injections of a substance obtained from a 'friend'. Over the next year he develops acne, icterus, and increased fatigue. An infertility workup reveals hypospermia. Laboratory studies show Hgb 19.2 g/dL, Hct 58.1.4%, platelet count 330,300/microliter, and WBC count 7410/microliter. Which of the following neoplasms is he at greatest risk for developing in the future? A. Hepatocellular carcinoma B. Papillary carcinoma C. Renal cell carcinoma D. Rhabdomyosarcoma E. Seminoma 34. A 33-year old woman has had increased anxiety with headaches and diaphoresis over the past 2 months. On physical examination she is afebrile, with a heart rate of 90/minute and blood pressure 150/90 mm Hg. Laboratory studies show elevated urinary catecholamines, elevated plasma renin activity, and normal TSH. Her plasma cortisol level is normal. An abdominal CT scan is performed. At which of the following locations is a mass lesion most likely to be found? A. Aortic bifurcation B. Hepatic capsule C. Pancreatic tail D. Mediastinum E. Splenic hilum 35. A 2-year-old child living in Odessa is small for its age and exhibits profound intellectual disability. On physical examination he has dry, coarse skin. Which of the following pathologic features involving the thyroid gland is this child most likely to have? A. Papillary adenoma B. Diffuse hyperplasia C. Granulomatous inflammation D. Metastatic carcinoma E. Marked atrophy 36. A 35-year-old G3 P3 woman has increasing fullness in her neck for the past 5 months since delivery of her last infant. On physical examination her thyroid gland is diffusely enlarged but not painful to palpation. Laboratory studies show an anti-thyroglobulin titer of 1:256 and an anti-thyroid peroxidase titer of 1:512. Her TSH and thyroxine are normal. Which of the following is the most likely diagnosis?  A. Riedel thyroiditis B. Adenovirus infection C. Subacute lymphocytic thyroiditis D. Cretinism E. Subacute granulomatous thyroiditis F. Diffuse goiter 37. A clinical study is performed involving subjects who developed Addision disease. They were recorded to have laboratory studies with hyponatremia, hyperkalemia, hypoglycemia, and decreased plasma cortisol. They became hypotensive. In some subjects, this disease had an acute onset over less than 2 days' time. Which of the following conditions is most likely to produce this acute course? A. Waterhouse-Friderichsen syndrome B. Metastatic small cell anaplastic carcinoma C. Disseminated Mycobacterium tuberculosis infection D. Reactive systemic amyloidosis E. Blunt force abdominal trauma 38. A 39-year-old woman has noted discomfort with fullness to her neck over the past year. On physical examination she is afebrile and normotensive. There is irregular enlargement of her thyroid gland, but no tenderness on palpation. A scintigraphic scan shows normal uptake except for increased uptake in a 1 cm area in the left lower lobe. Her anti-thyroid peroxidase antibody is negative. Which of the following complications is she most likely to develop? A. Thyrotoxicosis B. Papillary carcinoma C. Graves disease D. Subacute thyroiditis E. Hypothyroidism 39. A 42-year-old man has enlargement of his neck for the past 7 months. He is concerned, because a sister and maternal aunt had thyroid cancer. On physical examination, his thyroid is palpably nodular but nontender. A fine needle aspiration biopsy is performed and cytologic examination shows cells present consistent with a neoplasm. He undergoes total thyroidectomy. Sectioning the resected thyroid reveals four distinct tumor masses from 0.5 to 3 cm in size. These masses are solid and firm, with a tan cut surface. On microscopic examination an immunostain for calcitonin is positive in the nests of dark blue cells of these masses. He is at greatest risk for developing which of the following neoplasms in the future? A. Astrocytoma B. Pheochromocytoma C. Angiosarcoma D. Gastrinoma E. Renal cell carcinoma 40. A 17-year-old girl with Goodpasture syndrome progressed to chronic renal failure and was placed on chronic hemodialysis. She developed severe hypertension. However, she had difficulty accepting the reality of her disease, and she missed dialysis appointments and did not take her antihypertensive medication regularly. Laboratory studies now show her serum ionized calcium is 5.9 mg/dL with phosphorus 6.2 mg/dL and albumin 3.6 g/dL. Which of the following complications of her illness is she most likely to have? A. Depression B. Icterus C. Skin rash D. Dyspnea E. Joint pain 41. A 1-year-old male child has been irritable for the past day. On physical examination he has a right inguinal hernia with incarceration of a loop of small intestine. A laparotomy is performed and the defect is closed. The tissue from the hernia sac is excised. The surgical pathology report indicates the presence of a focus of adrenal cortex in the excised hernia sac. Which of the following is the most likely diagnosis? A. Congenital adrenal hyperplasia B. Adrenal cortical carcinoma metastasis C. Incidental ectopia D. Risk for subsequent adrenocortical insufficiency E. Multiple endocrine neoplasia syndrome 42. A 14-year-old boy has felt a 'bump' in his neck for the past year. On physical examination just anterior to the trachea in the midline is a palpable non-tender 2 cm mass. A fine needle aspirate of the mass yields only clear, mucoid fluid. Which of the following is the most likely diagnosis? A. Thyroglossal duct cyst B. Lymph node metastasis of follicular carcinoma C. Follicular adenoma D. Nodule of a multinodular goiter E. Branchial cleft cyst 43. A clinical study is performed of subjects from birth to age 80 years who were documented by laboratory testing to have hypocalcemia. The medical records of these subjects are analyzed and the disease conditions documented in these subjects recorded. A subset of these patients  had hypocalcemia documented in infancy. Which of the following conditions is most likely to have been present in this subset of patients? A. Parathyroid carcinoma B. Vitamin D deficiency C. Chronic renal failure D. DiGeorge syndrome E. Parathyroid adenoma 44. A 5-month-old female infant was the product of an uncomplicated pregnancy and was born at term. However, the baby has failure to thrive. On physical examination there is clitoral hypertrophy and poor skin turgor. The baby appears neurologically normal. Laboratory studies show serum sodium 116 mmol/L, potassium 6.2 mmol/L, chloride 83 mmol/L, and CO2 22 mmol/L. There is no history of diarrhea or vomiting. Which of the following inborn errors of metabolism is this infant most likely to have? A. 21-hydroxylase deficiency B. Phenylalanine transferase deficiency C. Galactose-1-uridyl transferase deficiency D. Glucose-6-phosphatase deficiency E. Iodine peroxidase deficiency 45. A 41-year-old man has a history of drinking 1 to 2 liters of whisky per day for the past 20 years. He has had numerous episodes of nausea and vomiting in the past 5 years. He now experiences a bout of prolonged vomiting, followed by massive hematemesis. On physical examination his vital signs are: T 36.9°C, P 110/min, RR 26/min, and BP 80/40 mm Hg lying down. His heart has a regular rate and rhythm with no murmurs and his lungs are clear to auscultation. There is no abdominal tenderness or distension and bowel sounds are present. His stool is negative for occult blood. Which of the following is the most likely diagnosis? A. Hiatal hernia B. Esophageal laceration C. Esophageal pulsion diverticulum D. Barrett esophagus E. Esophageal squamous cell carcinoma F. Esophageal stricture 46. A 50-year-old man has had persistent nausea for 5 years with occasional vomiting. On physical examination there are no abnormal findings. He undergoes upper GI endoscopy, and a small area of gastric fundal mucosa has loss of rugal folds. Biopsies are taken and microscopically reveal well-differentiated adenocarcinoma confined to the mucosa. An upper GI endoscopy performed 5 years previously showed a pattern of gastritis and microscopically there was chronic inflammation with the presence of. Which of the following is the most likely risk factor for his neoplasm?  A. Inherited APC gene mutation B. Helicobacter pylori infection C. Chronic alcohol abuse D. Use of non-steroidal anti-inflammatory drugs E. Vitamin B12 deficiency 47. A 58-year-old man has had increasing difficulty swallowing for the past 6 months and has lost 5 kg. No abnormal physical examination findings are noted. Upper GI endoscopy reveals a nearly circumferential mass with overlying ulceration in the mid esophageal region. Biopsy of the mass reveals pink polygonal cells with marked hyperchromatism and pleomorphism. Which of the following is the most likely risk factor for development of his disease? A. Iron deficiency B. Helicobacter pylori infection C. Chronic alcohol abuse D. High fruit diet E. Zenker diverticulum 48. A 31-year-old man with a stab wound to the abdomen is taken to surgery. While repairing the small intestine, the surgeon notices the presence of a 1 cm circumscribed submucosal mass in the ileum. The lesion is resected and on gross examination has a firm, yellow-tan cut surface. Microscopically, the mass is composed of nests of cells with uniform small round nuclei and cytoplasm with small purple granules. The cytoplasm is positive with antibody to chromogranin on immunohistochemical staining. Which of the following pathologic findings is most likely to accompany this man's lesion? A. Liver metastases B. Another similar lesion C. Multiple gastric ulcerations D. Pancreatic adenocarcinoma E. Inflammatory bowel disease F. Tropheryma whippelii infection 49. A 38-year-old man has had upper abdominal pain for 3 months. For the past week he has had nausea. On physical examination a stool sample is positive for occult blood. An upper GI endoscopy reveals no esophageal lesions, but there is a solitary 2 cm diameter shallow, sharply demarcated ulceration of the stomach. Which of the following is most characteristic for this lesion? A. Antral location B. Potential for metastases C. Increased gastric acid production D. No need for biopsy E. Accompanying pancreatic gastrinoma 50. A 35-year-old healthy woman develops sudden severe abdominal pain. On physical examination she is afebrile. On palpation the pain is centered in the mid-epigastric region, though there is marked diffuse tenderness in all quadrants. Bowel sounds are absent. No masses are palpable. Laboratory studies show her serum amylase is 410 U/L and lipase is 610 U/L. Which of the following laboratory test findings is most likely to indicate the risk factor for this woman's illness? A. Hypercholesterolemia B. Positive urea breath test C. Hypercalcemia D. Elevated sweat chloride E. Positive serology for HBsAg 51. A 45-year-old man has had vague abdominal pain and nausea for the past 3 years. This pain is unrelieved by antacid medications. He has no difficulty swallowing and no heartburn following meals. On physical examination there are no abnormal findings. Upper GI endoscopy reveals antral mucosal erythema, but no ulcerations or masses. Biopsies are taken, and microscopically there is a chronic non-specific gastritis. Which of the following conditions is most likely to be present in this man? A. Zollinger-Ellison syndrome B. Pernicious anemia C. Helicobacter pylori infection D. Adenocarcinoma E. Crohn disease F. Mixed connective tissue disease 52. A 25-year-old man has noted cramping abdominal pain for the past week associated with fever and low-volume diarrhea. On physical examination, there is right lower quadrant tenderness. Bowel sounds are present. His stool is positive for occult blood. A colonoscopy reveals mucosal edema and ulceration in the ascending colon, but the transverse and descending portions of the colon are not affected. Laboratory studies show serum anti- Saccharomyces cerevisiae antibodies. Which of the following microscopic findings is most likely to be present in biopsies from his colon? A. Crypt abscesses B. Entameba histolytica organisms C. Adenocarcinoma D. Band-like mucosal fibrosis E. Non-caseating granulomas F. Necrotizing vasculitis 53. A 32-year-old woman has a 10 year history of intermittent, bloody diarrhea. She has no other major medical problems. On physical examination there are no lesions palpable on digital rectal examination, but a stool sample is positive for occult blood. Colonoscopy reveals a friable, erythematous mucosa with focal ulceration that extends from the rectum to the mid- transverse colon. Biopsies are taken and all reveal mucosal acute and chronic inflammation with crypt distortion, occasional crypt abscesses, and superficial mucosal ulceration. This patient is at greatest risk for development of which of the following conditions? A. Acute pancreatitis B. Diverticulitis C. Sclerosing cholangitis D. Appendicitis E. Perirectal fistula F. Non-Hodgkin lymphoma 54. A 72-year-old woman notes increasing jaundice and nausea for the past month. On physical examination she is afebrile, but scleral icterus is present. There is no abdominal pain on palpation. She has active bowel sounds. A stool sample is negative for occult blood. Laboratory findings include total protein 6.1 g/dL, albumin 3.3 g/dL, alkaline phosphatase 210 U/L, AST 49 U/L, ALT 40 U/L, total bilirubin 7.2 mg/dL, and direct bilirubin 6.3 mg/dL. Her serum lipase is 50 U/L. Which of the following conditions is she most likely to have? A. Pancreatic adenocarcinoma B. Cystic fibrosis C. Chronic active hepatitis D. Primary biliary cirrhosis E. Chronic persistent hepatitis F. Autoimmune hemolytic anemia 55. A 33-year-old woman taking oral contraceptives for a year has noted vaginal bleeding that is not severe, but it occurs nearly every day over the past 5 weeks. On pelvic examination, there is a 0.7 cm polypoid mass noted to extend outward from the endocervical region. The ectocervix appears normal. The uterus is normal in size. The adnexa have no palpable masses. A biopsy of this lesion is performed. Which of the following microscopic findings is most likely to be found in this lesion? A. Endocervical adenocarcinoma B. Clear cell adenocarcinoma C. Microglandular hyperplasia D. Sarcoma botryoides E. Endocervical polyp F. Follicular cervicitis 56. A 48-year-old woman has noted a small amount of irregular vaginal bleeding for the past 2 months. She has a pelvic examination that reveals no cervical lesions, and a Pap smear that shows no abnormal cells. Next, an endometrial biopsy is performed, and there is microscopic evidence for endometrial hyperplasia. An abdominal ultrasound reveals a solid right ovarian mass. Which of the following neoplasms is this woman is most likely to have? A. Mature cystic teratoma B. Choriocarcinoma C. Sertoli-Leydig cell tumor D. Fibrothecoma E. Krukenberg tumor F. Cystadenocarcinoma 57. A 51-year-old perimenopausal woman has had vaginal bleeding for the past 6 months. On physical examination she has an enlarged, nodular uterus. A hysterectomy is performed. The surgeon notes several 0.2 to 1 cm translucent, smooth-surfaced, thin-walled, fluid-filled cysts near the fimbriated end of the right fallopian tube. Which of the following is the most likely diagnosis for these cysts? A. Gartner duct cysts B. Krukenberg tumors C. Parovarian cysts D. Pelvic inflammatory disease E. Mucinous cystadenomas F. Fibrocystic disease G. Omphalomesenteric duct cyst 58. A 36-year-old woman has had episodes of lower abdominal and pelvic pain for the past 10 years. A bimanual pelvic examination reveals no abnormalities. A Pap smear is negative. She has an abdominal ultrasound scan that reveals no abnormalities. She undergoes laparoscopy, and several 0.2 to 0.5 cm brown nodular lesions are seen on serosal surfaces of the uterus, fallopian tubes, and appendix. These lesions are excised. Which of the following microscopic findings is most likely to be present in these lesions? A. Endometrial stroma B. Mesothelial cells C. Metastatic adenocarcinoma D. Capillary proliferation E. Granulomatous inflammation 59. A 47-year-old woman has noted a pressure sensation, but no pain, in her pelvic region for the past 5 months. On physical examination there is a right adnexal mass. An ultrasound scan shows a 10 cm fluid-filled cystic mass in the right ovary, along with ascitic fluid. A fine needle aspirate of the mass is performed and cytologic examination of clear fluid aspirated  from the mass reveals clusters of malignant epithelial cells surrounding psammoma bodies. Which of the following neoplasms is she most likely to have? A. Endometrioid carcinoma B. Serous cystadenocarcinoma C. Malignant mesothelioma D. Mature cystic teratoma E. Squamous cell carcinoma 60. A 30-year-old infertile woman has had episodic lower abdominal and pelvic pain for 2 years. A physical examination, including pelvic exam, reveals no abnormalities. A Pap smear shows only a few trichomonads and no dysplastic cells. A laparoscopy is performed, and the gynecologist notes the presence of several blue to red 0.2 to 0.4 cm slighted raised lesions scattered on the pelvic peritoneum in the cul-de-sac and broad ligaments. Which of the following is the most likely diagnosis? A. Metastatic adenocarcinoma B. Neisseria gonorrheae infection C. Endometriosis D. Candidiasis E. Leiomyomata 61. A 43-year-old woman has noted menstrual periods that have been exceptionally heavy, lasting 6 to 8 days, for 4 months. She has also noted minor intermenstrual bleeding. On physical examination her uterine cervix appears normal, and a Pap smear shows no abnormal cells. Pelvic examination reveals that the uterus is enlarged to twice normal size and is nodular. There are no adnexal masses. Which of the following is the most likely diagnosis? A. Endometrial carcinoma B. Leiomyomata C. Ectopic pregnancy D. Endometriosis E. Secondary syphilis 62. A 43-year-old woman has noted increasing abdominal discomfort for the past year. On physical examination, there is no tenderness. Bowel sounds are present. She has no vaginal bleeding. An abdominal ultrasound reveals a 7 cm left adnexal mass. A total abdominal hysterectomy is performed. Pathologic examination of the ovarian mass reveals it is unilocular, filled with watery fluid, and lined with papillary excrescences. On microscopic examination there is no infiltration of the underlying stroma. Which of the following neoplasms is this woman most likely to have? A. Granulosa-theca cell tumors B. Mature cystic teratomas  C. Fibrosarcoma with metastases D. Borderline serous tumor E. Clear cell carcinomas 63. A 28-year-old sexually active woman undergoes a routine examination. Pelvic examination reveals no abnormalities. A Pap smear is obtained. The cytopathology report indicates the presence of severely dysplastic cells (high grade squamous intraepithelial lesion, or HSIL). A biopsy of the cervix is performed, and on microscopic examination shows cervical intraepithelial neoplasia III (CIN III). Infection with which of the following organisms is most likely to cause her disease? A. Herpes simplex virus infection B. Epstein-Barr virus C. Candida albicans D. Human papillomavirus E. Trichomonas vaginalis F. Gardnerella vaginalis 64. A 23-year-old woman has a 1 day history of increasing obtundation. On physical examination her temperature is 37.3°C, pulse 96/minute, respirations 18/minute, and blood pressure 90/45 mm Hg. A culdocentesis yields no blood. Abdominal ultrasound shows an intrauterine gestational sac and 12 week fetus. Laboratory studies show a positive pregnancy test. She has a WBC count of 11,400/microliter, Hgb 10.6 g/dL, Hct 31.1%, MCV 95 fL, and platelet count 26,400/microliter. Schistocytes are noted on her peripheral blood smear. Her protime is 44 sec, partial thromboplastin time 61 sec, and D-Dimer 16 microgm/mL. A urinalysis dipstick examination shows no blood, protein, or glucose. Which of the following complications of pregnancy is most likely to explain her condition? A. Placental infarction B. Eclampsia C. Amniotic fluid embolus D. Retained dead fetus E. Ruptured tubal ectopic 65. A 22-year-old woman passes grape-like masses of tissue per vagina in the 16th week of her first pregnancy. She had not felt any fetal movement at any time. On physical examination she measures 18 weeks in size. A D&C is performed, yielding 1000 cc of 0.5 to 1.5 cm fluid- filled vesicles. Microscopic examination of this tissue shows large avascular villi along with trophoblastic proliferation. Which of the following is the best method to employ for her follow-up care? A. Chest radiograph B. Serum beta-HCG C. Endometrial biopsy  D. Pelvic ultrasound E. Pap smear 66. A 23-year-old woman has the sudden onset of lower abdominal pain. Pelvic examination reveals a normal sized uterus and normal appearing cervix and vagina. However, there is marked tenderness upon palpation of the left adnexal region. A transvaginal ultrasound shows no intrauterine gestational sac, but there is a 2 cm left adnexal mass. Culdoscocentesis yields bloody fluid. Which of the following is most useful procedure to aid in diagnosis? A. Serum complement determination B. Microscopic urinalysis C. Pap smear D. Serum beta-HCG E. Endometrial biopsy F. WBC count 67. A 20-year-old woman has had irregular menstrual bleeding for the past 6 months. On physical examination there are no abnormal findings. Laboratory studies show a negative pregnancy test. A D&C is performed and microscopic examination shows dyssynchronous endometrial glands and stroma of anovulatory cycles. Following the procedure she ceases to have menstrual bleeding. Which of the following is the most likely diagnosis? A. Endometriosis B. Asherman syndrome C. Prolactinoma D. Ovarian failure E. Oral contraceptive use 68. A 14-year-old girl has had pelvic pain for the past 3 months. She has not yet noted passing menstrual blood. She has not had any sexual activity. She refuses physical examination, but an abdominal ultrasound shows fluid distending the vagina. Which of the following is the most likely diagnosis? A. Cervical condyloma B. Endometriosis C. Cervical gonorrhea D. Imperforate hymen E. Ruptured Bartholin cyst 69. A 64-year-old woman has had itching with irritation of the vulvar region, along with vaginal dryness, for the past 8 months. On physical examination she has pale grey patches from 1 to 2 cm in size on the vulva. Biopsy of one lesion is performed and on microscopic examination  shows epithelial thinning, dermal fibrosis, and perivascular chronic inflammation. Which of the following is the most likely diagnosis? A. Squamous cell carcinoma B. Lichen sclerosus C. Condyloma acuminatum D. Adenosis E. Extramammary Paget disease F. Dermatophyte infection 70. For the past year, a 50-year-old woman has noted that her menstrual periods have been exceptionally heavy and last 7 to 9 days. She has noted occasional minor intermenstrual bleeding. For the past 3 months, she has been taking supplemental dietary iron for iron deficiency anemia. On pelvic examination, the uterine cervix appears normal, but the uterus is enlarged to twice normal size. Transvaginal ultrasound reveals the presence of a 9 cm solid mass in the uterus. A hysterectomy is performed, and on gross inspection with sectioning the uterus a reddish-tan mass is found with a fleshy cut surface. Microscopically the mass is highly cellular, with spindle cells having hyperchromatic nuclei and 10 to 20 mitoses per high power field. Which of the following is the most likely diagnosis? A. Endometrial polyp B. Adenomyosis C. Embryonal rhabdomyosarcoma D. Atypical hyperplasia E. Leiomyosarcoma F. Malignant mixed mullerian tumor 71. A 31-year-old G3 P2 woman is at 14 weeks gestation, but has noted a small amount of vaginal bleeding for the past 2 weeks. Laboratory studies show an HCG level of 650,000 U/L. An ultrasound shows a 'snowstorm' for intrauterine contents but no identifiable fetus. A D&C is performed with evacuation of 500 mL of grape-like vesicles. A month later her vaginal bleeding persists and her serum beta-HCG is 35,000 U/L. Which of the following pathologic abnormalities is most likely to be present in this woman? A. Pulmonary metastases B. Tubal ectopic pregnancy C. Endometritis D. Placental site trophoblastic tumor E. Invasive mole 72. A 33-year-old woman and her husband have wanted a child, but she has been unable to conceive for the past 10 years. She has mild pelvic pain, but regular menstrual cycles. On physical examination the cervix and vagina appear normal. The uterus and adnexal regions are normal on palpation. A pelvic ultrasound shows no lesions. A Pap smear is normal. Her  husband's sperm count is normal. Which of the following is most likely to be the cause for her infertility? A. Adenomyosis B. Adenohypophyseal prolactinoma C. Pelvic inflammatory disease D. Mature cystic teratoma E. Chronic cervicitis 73. A 38-year-old woman has noted intermenstrual spotting of blood for the past 3 months. On pelvic examination, she has a nodular 2 x 3 cm mass in the upper vagina. Biopsy of the mass is performed and on microscopic examination shows a clear cell carcinoma. Which of the following risk factors probably preceded development of this carcinoma? A. Human papilloma virus infection B. Endometriosis C. Irregular menstrual cycles D. Diethylstilbestrol exposure E. Precocious pseudopuberty 74. A 19-year-old woman has noted increasing size and number of warty lesions on her external genitalia for the past 5 years. On physical examination she has several pink-tan rounded 1 to 2 cm slightly raised, rough lesions on the perineum and vulva. Biopsy of one lesion is performed and on microscopic examination shows acanthosis of squamous epithelium along with koilocytosis. Which of the following is the most likely risk factor for these lesions? A. Irritant chemical exposure B. Oral contraceptive use C. Candida vulvovaginitis D. Multiple sexual partners E. Turner syndrome 75. A 40-year-old woman has experienced pelvic discomfort for over a month, along with a 4 kg weight loss, nervousness, and diaphoresis. A pelvic examination reveals a large left adnexal mass that, on transvaginal ultrasound, appears as a discrete 10 cm cystic and solid mass. The uterus appears normal in size. A Pap smear is normal. The mass is removed and on gross pathologic examination is filled with hair and sebum, along with solid tan areas next to the smooth-surfaced outer wall. Which of the following laboratory test findings is most likely to have been present just prior to her surgery? A. Thyroxine of 11.3 microgm/dL B. HCG of 45,000 IU/L C. Potassium of 2.9 mmol/L D. Estradiol of 1700 pg/mL  E. Cancer antigen 125 of 540 U/mL 76. A 32-year-old G3 P2 woman goes for a routine prenatal check at 12 weeks gestation. On physical examination she is found to be large for dates, and no fetal heart tones are audible. An ultrasound is performed and revealed that no fetus was present, only many echogenic cystic areas within the uterus. Which of the following is the most likely diagnosis? A. Invasive mole B. Partial hydatidiform mole C. Placental site trophoblastic tumor D. Choriocarcinoma E. Complete hydatidiform mole 77. A 37-year-old woman goes to her physician for a routine checkup. On physical examination there are no abnormal findings. A Pap smear is taken and cytologically there are dysplastic cells present. A cervical biopsy is performed. Microscopic examination shows dysplasia involving the full thickness of the cervical epithelium. Which of the following is the most likely diagnosis? A. High grade squamous intraepithelial lesion (HSIL) B. Severe chronic cervicitis with herpes simplex virus (HSV) C. Diethylstilbestrol (DES) exposure D. Endocervical adenocarcinoma E. Extramammary Paget disease 78. Two weeks after delivery of a normal healthy term infant boy following an uncomplicated pregnancy, a 25-year-old woman still has a vaginal discharge consisting of dark brown, foul- smelling material. Her temperature is 37.4°C. On pelvic examination, the uterus is slightly enlarged and she has pelvic tenderness. Laboratory studies show her serum beta-HCG is negative. Which of the following conditions is she most likely to have? A. Invasive mole B. Degenerating uterine leiomyoma C. Postpartum pituitary necrosis D. Endometriosis E. Retained products of conception 79. A 39-year-old woman has had dysmenorrhea for 7 months. On pelvic examination, there are no adnexal masses, and the cervix appears normal, but the uterus is three times normal size. The uterus appears to be symmetrically enlarged on abdominal ultrasound, with no masses present and an endometrial cavity that is nearly normal in size. A Pap smear is normal. Her  serum pregnancy test is negative. A total abdominal hysterectomy is performed. Which of the following microscopic findings is most likely to be present in her uterus? A. Atypical glands invading through the uterine wall B. Large avascular villi with trophoblastic proliferation C. Hyperchromatic and pleomorphic smooth muscle cells D. Extensive acute inflammation E. Endometrial glands and stroma in the myometrium 80. A 15-year-old girl has had irregular menstrual cycles for 5 months. She had menarche at age 13. There are no abnormal physical examination findings. An endometrial biopsy is taken on post-ovulatory day 9 and shows proliferative phase endometrium. Which of the following is the most likely diagnosis? A. Adenomyosis B. Anovulatory cycles C. Endometrial adenocarcinoma D. Leiomyomata E. Oral contraceptive use F. Ovarian thecoma 81. A 29-year-old woman has had dyspareunia for the past 2 months. She has had only one sexual partner--her husband. She is G2 P2. On physical examination there are no abnormal findings except for a small but slightly tender 1.5 cm mass located in the right lateral wall of her vagina. The lesion is excised. On gross examination this mass is cystic and fluid filled. On microscopic examination the cyst is lined by a cuboidal epithelium. Which of the following is the most likely etiology for this lesion? A. Bacterial vaginosis B. Embryologic remnant C. Gonoccocal infection D. Metastatic adenocarcinoma E. Oral contraceptive use F. Foreign body 82. A 33-year-old woman has an infertility workup. Her BMI is 32. Hirsutims is noted. On pelvic examination, bilateral adnexal masses are palpated. Transvaginal ultrasound examination shows a normal sized uterus, but the ovaries are enlarged and have a dozen peripheral echogeni follicles. Laboratory studies show hyperglycemia and increased androgenic steroids. For which of the following conditions is she at greatest risk? A. Endometrial hyperplasia B. Adenomyosis C. Malignant mixed mullerian tumor  D. Chronic endometritis E. Borderline mucinous tumor 83. A 24-year-old woman is G2 P1. Her first pregnancy resulted in a normal term birth. Now at 15 weeks gestation, a prenatal checkup reveals that she has a blood pressure of 140/90 mm Hg. An ultrasound is performed that reveals no fetal cardiac motion. Misoprostol induction is performed for termination of the pregnancy. Examination of the malformed stillborn fetus reveals that it is small for gestational age and has 3,4 syndactyly bilaterally, an indented nasal bridge, and a two vessel cord. The placenta is small for gestation and has scattered 0.5 cm grape-like villi. A chromosome analysis performed on the placental tissue will most likely demonstrate which of the following karyotypes? A. 46, XX B. 69, XXY C. 45, X D. 47, XX, +18 E. 23, X F. 47, XYY G. 47, XXX 84. A 16-year-old girl has not begun menstruation. Physical examination reveals that she has breast development, but a short vagina and no palpable uterus or adnexa, only bilateral inguinal masses. She appears otherwise normally developed. Which of the following laboratory tests would be most appropriate to order on this girl? A. Chromosome analysis B. Serum estrogen C. Assay for luteinizing hormone D. Serum cortisol E. Serum testosterone F. Magnetic resonance imaging of brain 85. A 38-year-old healthy woman has had a white, curd-like vaginal discharge for the past week. There is no bleeding. A Pap smear demonstrates normal appearing squamous epithelial cells along with scattered neutrophils and budding cells with pseudohyphae. Which of the following infectious agents is most likely to be present in this woman? A. Treponema pallidum B. Neisseria gonorrhea C. Chlamydia trachomatis D. Herpes simplex virus E. Escherichia coli F. Gardnerella vaginalis G. Trichomonas vaginalis  H. Candida albicans I. Human papillomavirus Answer: H 86. A 35-year-old woman has had dull pelvic pain for 4 months. A pelvic examination reveals a normal appearing cervix, a normal sized uterus, and a large tender right adnexal mass. Ultrasound reveals an 8 cm cystic, fluid-filled mass involving the right adnexal region. At laparotomy, there are many filmy fibrous adhesions in the pelvis. The mass is excised and on gross examination is found to have a thin wall and is filled with purulent exudate. Microscopically, there are thin remnants of fallopian tube and ovary comprising the wall of the mass, with numerous neutrophils filling the lumen. Which of the following infectious agents is most likely to have produced these findings? A. Human papillomavirus B. Mycobacterium tuberculosis C. Trichomonas vaginalis D. Candida albicans E. Neisseria gonorrheae 87. Abnormal bleeding per vagina for the past 5 months prompts a 62-year-old woman to see her physician. She has never been pregnant and went through menopause 10 years previously. On physical examination her BMI is 33. There are no abnormal findings on physical examination. An endometrial biopsy is performed and on microscopic examination shows a well-differentiated endometrial adenocarcinoma. Which of the following ovarian neoplasms is she most likely to have? A. Papillary serous cystadenocarcinoma B. Krukenberg tumor C. Mucinous cystadenoma D. Granulosa cell tumor E. Immature teratoma 88. A 28-year-old woman develops the sudden onset of severe lower abdominal pain. On physical examination there is tenderness to palpation of the right lower quadrant. Laboratory studies show her serum pregnancy test is positive. An ultrasound scan does not reveal a gestational sac in the uterus, but there is a right adnexal mass. The development of these findings is most closely related to past infection with which of the following organisms? A. Treponema pallidum B. Human papillomavirus C. Neisseria gonorrheae D. Candida albicans E. Group B Streptococcus 89. A 44-year-old woman has had irregular menstrual periods for the past 9 months. On physical examination she has an enlarged uterus. An ultrasound scan shows a 9 cm solitary, solid mass in the uterus. A total abdominal hysterectomy is performed. Gross examination of the irregular reddish-tan mass located in the myometrium shows bundles of smooth muscle cells along with heterogenous elements of pleomorphic cartilaginous cells. There are also areas with poorly differentiated gland formation. Mitotic figures are frequent. Which of the following neoplasms is she most likely to have? A. Leiomyosarcoma B. Sarcoma botryoides C. Malignant mixed mullerian tumor D. Endolymphatic stromal myosis E. Leiomyoma with focal degeneration 90. A 72-year-old woman has had fatigue for the past year, along with episodes of vaginal bleeding. On physical examination there are no abnormal findings. Laboratory studies show Hgb 9.1 g/dL, Hct 26.5%, MCV 72 fL, platelet count 158,000/microliter, and WBC count 7150/microliter. An endometrial biopsy is performed and on microscopic examination shows atypical adenomatous hyperplasia. Which of the following is the most likely risk factor for development of her disease? A. Human papillomavirus infection B. Long term intrauterine contraceptive device use C. Chronic endometritis D. Pelvic inflammatory disease E. Unopposed estrogenic stimulation 91. A 56-year-old G0 P0 woman reports vaginal bleeding in the past 2 months. Her last menstrual period was 6 years ago. On physical examination there are no abnormal findings. Which of the following procedures is most appropriate to perform on this woman? A. Endometrial biopsy B. Pap smear C. Vaginal culture D. Colposcopy E. CT scan 92. A 50-year-old woman has experienced mild pelvic discomfort for 3 months. On physical examination there are bilateral adnexal masses. A pelvic CT scan reveals irregular unilocular cystic, bilateral mass lesions in the region of the ovaries. One is 10 cm and the other is 8 cm in size. Which of the following types of neoplasm is most likely to be present in this woman? A. Mature cystic teratoma  B. Serous cystadenocarcinoma C. Endometrioid carcinoma D. Fibrothecoma E. Mucinous cystadenoma 93. A 53-year-old man has passed darker urine for the past week. On physical examination there are no abnormal findings. A urinalysis shows pH 5.5, specific gravity 1.013, 2+ blood, no protein, and no glucose. A urine cytology is performed and there are atypical cells seen. A cystoscopy is performed, but no mucosal lesions are noted. He has a 60 pack year history of smoking cigarettes. Which of the following is the most likely diagnosis? A. Adenocarcinoma of prostate B. Urothelial carcinoma of renal pelvis C. Acute interstitial nephritis D. Nodular glomerulosclerosis E. Squamous cell carcinoma of penis 94. A 62-year-old man has had back pain for the past 8 months. He has had a productive cough for the past 2 days. On physical examination his temperature is 39°C and there is dullness to percussion at the right lung base. Laboratory studies show 4+ gram-positive diplococci in the sputum. A chest radiograph shows right lower lobe consolidation. An abdominal CT scan shows multiple lytic lesions of the vertebrae. On the day prior to death his serum urea nitrogen was 63 mg/dL with creatinine 7.1 mg/dL. A dipstick urinalysis was normal. At autopsy, his kidneys are firm and pale. Microscopically, there is abundant pink hyaline material in glomeruli and around small vessels. This material stains positively with Congo red. Which of the following laboratory findings was most likely to have been present in this patient in the week prior to death? A. Positive antinuclear antibody test B. Serum glucose of 210 mg/dL C. CD4 lymphocyte count of 110/microliter D. Total serum protein of 9.2 g/dL E. Serum prostate specific antigen of 11.8 ng/mL 95. A 52-year-old previously healthy man has experienced episodes of discomfort with urination for 3 months. There are no remarkable findings on physical examination. Laboratory studies include a urinalysis that reveals 1+ blood. Microscopic urine examination shows numerous RBCs, a few WBCs, and no casts. A urine culture is negative. A plain film radiograph of the pelvis shows a rounded, 1 cm radiopaque lesion in the region of the bladder. Which of the following laboratory test findings is most likely to be present in this man? A. Albuminuria B. Hypercalciuria C. Transaminasemia  D. Hemoglobinuria E. Hyperuricemia 96. A 72-year-old man has been feeling tired and lethargic for 5 months. He has noted increasing hesitancy with urination. On physical examination his prostate is diffusely enlarged. Laboratory studies show sodium 139 mmol/L, potassium 4.0 mmol/L, chloride 104 mmol/L, CO2 25 mmol/L, creatinine 1.9 mg/dL, and glucose 81 mg/dL. Which of the following renal abnormalities is most likely to be present in this man? A. Cortical atrophy B. Glomerulonephritis C. Papillary necrosis D. Polycystic change E. Renal cell carcinoma 97. A 36-year-old woman has urinary frequency with dysuria for the past 4 days. On physical examination she has no flank pain or tenderness. A urinalysis reveals sp. gr. 1.014, pH 7.5, no glucose, no protein, no blood, nitrite positive, and many WBC's. She has a serum creatinine of 0.9 mg/dL. Which of the following is the most likely diagnosis? A. Lupus nephritis B. Urinary lithiasis C. Acute cystitis D. Malakoplakia E. Urothelial carcinoma 98. A 69-year-old man incurs blunt force trauma from a fall. On physical examination he has a contusion on his lower back. An abdominal CT scan shows 3 peripheral 1 to 2 cm cysts in his kidneys. The kidneys are normal in size. Laboratory studies show a serum urea nitrogen of 16 mg/dL and creatinine of 1.1 mg/dL. A urinalysis reveals no blood, ketones, protein, or glucose. Microscopic urinalysis reveals a few oxalate crystals. Which of the following is the most likely diagnosis? A. Polycystic kidney disease B. Hydronephrosis C. Renal atherosclerosis D. Simple cortical cysts E. Recurrent pyelonephritis infection 99. A clinical study is performed with pediatric subjects who had a diagnosis of minimal change disease. These patients were observed to have prominent periorbital edema at diagnosis.  Laboratory test findings from serum and urine tests were analyzed. Which of the following urinalysis test findings is most likely to have been consistently present in these subjects?. A. Nitrite positive B. Proteinuria >3.5 gm/24 hours C. Hematuria with >10 RBC/hpf D. Calcium oxalate crystsls E. Renal tubular epithelial cells and casts 100. A 12-year-old boy is a member of a family with a history of renal disease, with males more severely affected than females. He is found to have auditory nerve deafness, corneal dystrophy, and ocular lens dislocation. A urinalysis shows microscopic hematuria. A renal biopsy is performed. Microscopically, the glomeruli show glomerular capillaries with irregular basement membrane thickening and attenuation with splitting of the lamina densa. The mesangial matrix is increased and epithelial cells may appear foamy. Which of the following is the most likely diagnosis? A. Goodpasture syndrome B. IgA nephropathy C. Alport syndrome D. Dominant polycystic kidney disease E. Diabetes mellitus, type I 101. A clinical study is performed of laboratory findings in subjects with renal diseases. Loss of physiologic function accompanies many diseases. One renal physiologic function affects thirst. Loss of which of the following renal functions is most likely to be identified by laboratory measurement of the urine specific gravity following water deprivation? A. Filtration B. Reabsorption C. Secretion D. Concentration E. Blood flow 102. A 45-year-old woman has had increasing malaise for the past year. On physical examination her blood pressure is 265/150 mm Hg. Laboratory studies show a plasma renin activity of 9 ng/mL/hr. She then suffers a 'stroke' with a right basal ganglia hemorrhage and dies. At autopsy the kidneys are bilaterally small with granular surfaces. Microscopically they show hyperplastic arteriolosclerosis with fibrinoid necrosis, petechial hemorrhages, and microinfarcts in the cortices. Which of the following conditions is most likely to be her underlying cause of death? A. Diabetes mellitus, type II B. Fibromuscular dysplasia  C. Factor V Leiden mutation D. Analgesic abuse E. Systemic sclerosis 103. A 3-year-old child has become more irritable over the past two months and does not want to eat much at meals. On physical examination the pediatrician notes an enlarged abdomen and can palpate a mass on the right. An abdominal CT scan reveals a 10 cm solid mass involving the right kidney. The resected mass has a microscopic appearance with sheets of small blue cells along with primitive tubular structures. The child receives chemotherapy and radiation therapy, and there is no recurrence. Which of the following neoplasms is this child most likely to have had? A. Angiomyolipoma B. Renal cell carcinoma C. Urothelial carcinoma D. Wilms tumor E. Medullary fibroma 104. A 5-year-old boy is noted to have increased puffiness around his eyes for the past week, and he has been less active than normal. On physical examination he has periorbital edema. Vital signs include T 37°C, P 75/minute, RR 22/minute, and BP 140/90 mm Hg. A urinalysis reveals sp. gr. 1.010, pH 6.5, no glucose, 4+ protein, no blood, no casts, and no ketones. Microscopic urinalysis reveals oval fat bodies, but no WBC's or RBC's. He improves following a course of corticosteroid therapy. Which of the following renal lesions is most likely to have been present in this boy? A Glomerular crescent formation B Podocyte foot process effacement C Patchy acute tubular necrosis D Hyperplastic arteriolosclerosis E Mesangial immune complex deposition 105. A clinical study is performed involving subjects with glomerulonephritis. One group of subjects has a diagnosis of crescentic glomerulonephritis and another group has membranous nephropathy. Which one of the following laboratory findings is most likely to be found in the absence of other findings in subjects with membranous nephropathy? A. Rapid onset B. Red blood cell casts C. Oliguria D. Albuminuria E. Hypertension 106. A 51-year-old man is hospitalized for acute myocardial infarction. He has decreased cardiac output with hypotension requiring multiple pressor agents. His urine output drops over the next 3 days. His serum urea nitrogen increases to 59 mg/dL, with creatinine of 2.9 mg/dL. Urinalysis reveals no protein or glucose, a trace blood, and numerous hyaline casts. Five days later, he develops polyuria and his serum urea nitrogen declines. Which of the following pathologic findings in his kidneys is most likely to have caused his azotemia? A. Patchy tubular necrosis B. Podocyte foot process effacement C. Glomerular crescent formation D. Hyperplastic arteriolosclerosis E. Mesangial immune complex deposition 107. A clinical study is performed to determine the value of percutaneous renal biopsy. The medical records of subjects with renal diseases are analyzed to note the circumstances in which the results of a renal biopsy facilitated choice of therapy that improved prognosis. In which of the following situations is a percutaneous needle biopsy of the kidney most useful? A. Fever and flank pain with suspected acute pyelonephritis B. Prostatic hyperplasia with suspected hydronephrosis C. Premature neonate with suspected polycystic kidney disease D. Abdominal pain with suspected renal cyst E. Acute renal failure with suspected systemic lupus erythematosus 108. A 56-year-old man complains of dull flank pain for the past month. On physical examination he has tenderness to percussion at the right costovertebral angle. Laboratory studies show microscopic hematuria but no proteinuria or glucosuria. A urine cytology shows no atypical cells. A CBC shows WBC count 7800/microliter, Hgb 21.1 g/dL, Hct 63.5%, MCV 94 fL, and platelet count 195,000/microliter. His serum urea nitrogen is 15 mg/dL and creatinine 1 mg/dL. Which of the following radiographic findings is most likely to be present in this man? A. Hydronephrosis on intravenous pyelogram B. Renal mass on abdominal CT scan C. Radiopaque ureteral calculus on an abdominal plain film D. Enlarged, multicystic kidneys on abdominal ultrasound E. Pelvic abscess below the bladder on MR imaging 109. A 43-year-old man goes to his physician for a routine check of his health status. He is found to have a blood pressure of 150/95 mm Hg. His urinalysis shows pH 6.5, specific gravity 1.015, no glucose, blood, or protein, and no casts. His serum creatinine is 1.4 mg/dL. If he is not treated, which of the following conditions will most likely cause his death? A. Intracerebral hemorrhage (stroke)  B. Aortic aneurysm rupture C. Congestive heart failure D. Chronic renal failure E. Intracranial aneurysm rupture 110. A 20-year-old previously healthy man has been feeling tired for the past 5 days. He then passes dark-colored urine. On physical examination his blood pressure is 160/90 mm Hg. Laboratory studies show his serum creatinine is 4.4 mg/dL and BUN 40 mg/dL. A urinalysis reveals pH 6, specific gravity 1.011, 3+ blood, 1+ protein, no glucose, and no ketones. On urine microscopic examination there are numerous RBC casts. Which of the following pathologic findings on renal biopsy is most likely to be present in this man? A. Glomerular crescents B. Widened proximal tubules C. Neutrophilic infiltrates D. Basememt membrane thickening E. IgA deposited in glomerular capillaries 111. A 43-year-old man has had increasing malaise for the past 3 weeks. On physical examination he has a blood pressure of 150/95 mm Hg and 1+ pitting edema of the lower extremities to the knees. Dipstick urinalysis shows no glucose, blood, ketones, nitrite, or urobilinogen, and the microscopic urinalysis reveals no RBC/hpf and only 1 WBC/hpf. Additional laboratory studies show a 24 hour urine protein of 4.1 gm. His serum creatinine is 3.5 mg/dL with urea nitrogen of 38 mg/dL. His hepatitis B surface antigen is positive. Which of the following is the most likely diagnosis? A. Membranous nephropathy B. Systemic lupus erythematosus C. Acute tubular necrosis D. Diabetic nephropathy E. Post-streptococcal glomerulonephritis 112. A 60-year-old woman is admitted with sudden onset of chest pain and is diagnosed with an acute myocardial infarction. There is difficulty maintaining adequate blood pressure and tissue perfusion for 3 days. Her serum lactate becomes elevated. Her serum urea nitrogen increases to 44 mg/dL and creatinine to 2.2 mg/dL. Granular and hyaline casts are present on microscopic urinalysis. Which of the following renal lesions is most likely to be present in this situation? A. Chronic pyelonephritis B. Acute tubular necrosis C. Nodular glomerulosclerosis D. Renal vein thrombosis E. Minimal change disease 113. A 50-year-old man was diagnosed at age 15 with type 1 diabetes mellitus. His disease has been poorly controlled, as evidenced by elevated hemoglobin A1C levels. He develops a non-healing ulcer of his foot at age 35. At age 45, he has an increasing serum urea nitrogen and a urinalysis shows sp gr 1.012, pH 6.5, 1+ protein, no blood, 1+ glucose, negative leukocyte esterase, negative nitrite, and no ketones. Which of the following renal diseases is he most likely to have? A. Nodular glomerulosclerosis B. Hyperplastic arteriolosclerosis C. Papillary necrosis D. Crescentic glomerulonephritis E. Pyelonephritis 114. A 39-year-old woman is found to have a blood pressure of 160/105 mm Hg while at a free health screening clinic. She feels fine and has had no major medical problems in her life. An abdominal ultrasound reveals that the left kidney is smaller than the right, but that neither is cystic and no masses appear to be present. MR angiography reveals focal narrowing with thickening and beading of the left main renal artery. A urinalysis reveals no abnormal findings. She has an elevated plasma renin. Which of the following is the most likely diagnosis? A. Diabetes mellitus B. Antiphospholipid syndrome C. Fibromuscular dysplasia D. Thrombotic thrombocytopenic purpura E. Cholesterol emboli syndrome 115. A 70-year-old woman has had a fever for the past 3 days. She has burning dysuria. On physical examination her temperature is 37.8°C and there is dull pain on palpation of her left lower back. Laboratory studies show Hgb 13.3 g/dL, Hct 40.2%, and WBC count 12,300/microliter with differential count 72 segs, 9 bands, 13 lymphs, 5 monos, and 1 eosinophil. A urine dipstick analysis shows sp gr. 1.017, pH 6, leukocyte esterase positive, nitrite positive, protein negative, glucose negative, and blood negative. Which of the following microscopic urinalysis findings would be most diagnostic for her renal disease? A. Dysmorphic red blood cells B. Oval fat bodies C. Renal tubular epithelial cells D. White blood cell casts E. Triple phosphate crystals 116. A 53-year-old woman has had chronic arthritis pain for the past 3 years. She has taken 2 gm of phenacetin and acetaminophen a day for her pain over that time. She now has increasing fatigue. There are no abnormal findings on physical examination. Laboratory studies show her serum urea nitrogen is 52 mg/dL and creatinine 5.4 mg/dL. Which of the following pathologic findings is most likely to occur in her kidneys? A. Papillary necrosis B. Focal segmental glomerulosclerosis C. Nephrocalcinosis D. Acute interstitial nephritis E. Arteriolosclerosis 117. A 25-year-old woman has been hospitalized for treatment of a Staphylococcus aureus abscess of her left thigh complicating a puncture wound. The wound is incised and drained and she receives antibiotic therapy. She is improving and discharged home a week later, but the next day she develops a fever. On physical examination her temperature is 38.1°C and there is a diffuse erythematous skin rash of her trunk and extremities. A urinalysis shows sp gr 1.020, pH 6.5, 1+ blood, 1+ protein, no glucose, and no ketones. There are 10-20 WBCs/hpf and 1-5 RBCs/hpf, and a few eosinophils are noted on urine microscopic examination. Which of the following is the most likely diagnosis? A. Acute tubular necrosis B. Septicemia with pyelonephritis C. Drug-induced interstitial nephritis D. Hemolytic-uremic syndrome E. Post-infectious glomerulonephritis F. Urinary tract infection 118. A 39-year-old previously healthy man has the sudden onset of severe right flank pain that comes in waves all night long. When he is seen in the emergency room, after waiting for two hours, he is exhausted. On physical examination there are no abnormal findings. Urinalysis reveals no ketones, glucose, protein, nitrite, or urobilinogen, but blood is present. Urine microscopic examination shows many RBCs but few WBCs. The specific gravity is 1.015 and the pH is 5.5. Which of the following is the most likely diagnosis? A. Nodular prostatic hyperplasia B. Membranous nephropathy C. Ureteral calculus D. Renal angiomyolipoma E. Urothelial carcinoma of bladder 119. A 15-year-old girl has had increasing lethargy following a bout of the 'flu' 3 weeks ago. On physical examination there are no abnormal findings. Her condition does not improve after 3 weeks on corticosteroid therapy, so a renal biopsy is performed and microscopic  examination shows segmental sclerosis of 3 of 10 glomeruli. Immunofluorescence studies and electron microscopy do not show immune deposits. Which of the following is the most likely outcome for this girl's condition? A. Progression to chronic renal failure B. Improvement with additional corticosteroid therapy C. Development of restrictive lung disease D. Discovery of an underlying malignancy E. Remission following dietary change 120. A 59-year-old man notes blood in his urine for the past week. On physical examination there are no abnormal findings. A urinalysis confirms the presence of blood, but no proteinuria or glucosuria. A urine culture is negative. A cystoscopy is performed, and a 3 cm exophytic mass is seen in the dome of the bladder. A biopsy of this mass is performed and microscopic examination reveals fibrovascular cores covered by a thick layer of transitional cells. Which of the following risk factors is most likely to have led to development of this lesion? A. Diabetes mellitus B. Recurrent urinary tract infection C. Therapy with methicillin D. Cigarette smoking E. Tuberous sclerosis F. Use of NSAIDS 121. A 53-year-old woman has noted fever and right-sided flank pain for the past 3 days. On physical examination her temperature is 38.4°C and there is right costovertebral angle tenderness. A urinalysis reveals sp. gr. 1.010, pH 7.5, no glucose, no protein, no ketones, and 1+ blood. Many WBCs and WBC casts are seen on urine microscopic examination. An abdominal radiograph reveals a radiopaque calculus that forms a cast of a dilated right renal collecting system. A urine culture grows Proteus vulgaris. Which of the following crystals is most likely to be seen in large numbers on microscopic urinalysis in this woman? A. Calcium oxalate B. Cystine C. Calcium phosphate dihydrate D. Uric acid E. Magnesium ammonium phosphate 122. A 60-year-old man was diagnosed last year with adenocarcinoma of the lung, and he underwent right lower lobectomy. For the past 3 weeks he has had increasing malaise. On physical examination he has pitting edema to his knees and presacral edema. Abdominal and chest CT scans show scattered hepatic mass lesions and hilar lymphadenopathy. A urinalysis reveals 4+ proteinuria, and his 24 hour urine protein is 2.7 gm. His serum urea nitrogen is 55 mg/dL with creatinine of 6.1 mg/dL. A renal biopsy is performed, and there is focal  deposition of IgG and C3 with a granular pattern. Which of the following forms of glomerular disease is he most likely to have? A. Membranous nephropathy B. Rapidly progressive glomerulonephritis C. Nodular glomerulosclerosis D. Chronic glomerulonephritis E. Dense deposit disease 123. A clinical study is performed with subjects born with congenital urinary tract anomalies. Their records are reviewed to assess the development of long term complications. One group of subjects is found to have an increased risk for both infection and development of a carcinoma. Which of the following congenital urinary tract anomalies is most likely to carry this risk? A. Unilateral renal agenesis B. Bladder exstrophy C. Bilateral ureteral duplication D. Horseshoe kidney E. Medullary sponge kidney 124. A 57-year-old man has had dysuria for the past week. Over the past 2 days he has experienced shaking chills. On physical examination his temperature is 39.3°C. A urinalysis shows sp gr 1.016, pH 6, 1+ glucose, 1+ blood, no ketones, and no protein. Urine microscopic examination shows numerous WBCs and WBC casts. His serum creatinine is 1.5 mg/dL and glucose 155 mg/dL with hemoglobin A1C 8.7%. A renal ultrasound scan shows a 0.3 cm free floating echodense object in the left renal pelvis. Which of the following complications has this man most likely developed? A. Acute tubular necrosis B. Aspergillus fungus ball C. Cystine-containing calculus D. Hematoma formation E. Papillary necrosis F. Renal cell carcinoma G. Urothelial carcinoma 125. A 48-year-old woman has had increasing malaise for the past 6 months. On physical examination there are no abnormal findings except for diminished sensation to pinprick and light touch in her lower legs and feet. She is afebrile and normotensive. Laboratory studies show serum creatinine 4.5 mg/dL, urea nitrogen 42 mg/dL, glucose 130 mg/dL, and hemoglobin A1C 7.9%. A urinalysis shows 1+ glucose, 1+ protein, no blood, and no ketones. Urine microscopic examination shows 1 RBC/hpf and 1 WBC/hpf. Which of the following pathologic abnormalities is she most likely to have in her kidneys?  A. Acute pyelonephritis B. Acute tubular necrosis C. Chronic glomerulonephritis D. Hydronephrosis E. Hyperplastic arteriolosclerosis F. Membranous nephropathy G. Nodular glomerulosclerosis H. Polycystic change 126. A 25-year-old G3 P2 woman has felt no fetal movement by 18 weeks gestation. Fetal ultrasound scan reveals the lack of amniotic fluid, making imaging difficult, but bilaterally asymmetrically enlarged fetal kidneys are seen. No fetal bladder can be visualized. The fetal heart appears to have four chambers, and the feet have marked varus deformities. At the time of birth at 36 weeks gestation, the neonate has severe respiratory difficulty. Which of the following is the most likely diagnosis? A. Bilateral Wilms tumor B. Autosomal dominant polycystic kidney disease C. Urethral atresia D. Congenital infection E. Multicystic renal dysplasia 127. A 49-year-old woman has been hospitalized for the past 10 days for treatment of bronchopneumonia. She has developed chills and fever over the past 2 days. On physical examination her temperature is 38.8°C and she has a diffuse erythematous skin rash. Laboratory studies show serum creatinine 2.2 mg/dL and glucose 73 mg/dL. A peripheral blood smear reveals eosinophilia. On urinalysis she has 2+ proteinuria but no blood, glucose, or ketones. Which of the following is the most likely diagnosis? A. Post-streptococcal glomerulonephritis B. Drug-induced interstitial nephritis C. IgA nephropathy D. Acute tubular necrosis E. Acute serum sickness 128. A clinical study is performed with subjects diagnosed with hypertension who underwent an extensive workup to determine possible treatable causes for their hypertension. It is observed that some causes for hypertension are surgically correctable, while other causes are amenable to pharmacologic therapy. Laboratory findings in the subjects are analyzed. Which of the following laboratory test findings is most likely to be present in subjects with hypertension treated by drugs, rather than by surgery? A. Hyperaldosteronemia B. Hyperreninemia  C. Increased catecholamines D. Hypercalcemia E. Autoantibodies 129. A 30-year-old man has had increasing malaise with fever, abdominal pain, and weight loss of 3 kg over the past 3 weeks. On physical examination his blood pressure is 165/110 mm Hg. He has a stool positive for occult blood. A urinalysis reveals hematuria but no proteinuria or glucosuria. He has no serum anti-neutrophil cytoplasmic autoantibodies and his antinuclear antibody test is negative. Aneurysmal arterial dilations and occlusions are seen in the medium sized renal and mesenteric arteries with angiography. He improves with corticosteroid therapy. Which of the following is the most likely diagnosis? A. Benign nephrosclerosis B. Fibromuscular dysplasia C. Nodular glomerulosclerosis D. Classic polyarteritis nodosa E. Systemic lupus erythematosus F. Thrombotic microangiopathy G. ANCA-associated granulomatous vasculitis 130. A young, sexually active man has a two day history of burning pain with urination. Physical examination reveals no penile lesions. A urinalysis reveals no blood, glucose, protein, or ketones, but the leukocyte esterase is positive. Urine microscopic examination shows 50 WBCs/hpf. A culture of penile secretions is negative for Neisseria gonorrheae. Which of the following infectious agents is most likely to cause his disease? A. Human papillomavirus B. Hemophilus ducreyi C. Chlamydia trachomatis D. Treponema pallidum E. Herpes simplex virus 131. A 59-year-old man has experienced lower back pain for 4 months. On physical examination there are no abnormal findings. A urinalysis shows microscopic hematuria, but no proteinuria or glucosuria. An abdominal CT scan reveals a 6 cm solid mass in the upper pole of the right kidney. A right nephrectomy is performed, and the grossly variegated mass is seen microscopically to be composed of nests of cells with clear cytoplasm. Which of the following laboratory test findings likely to be associated with this lesion? A. Hypercalcemia B. Increased catecholamines C. Positive serology for hepatitis B surface antigen D. Hyponatremia E. Hyperaldosteronemia 132. A 30-year-old man has noted puffiness around his eyes and swelling of his feet for the past 2 weeks. On physical examination his blood pressure is 155/95 mm Hg. Urine microscopic examination reveals oval fat bodies. Which of the following conditions is he most likely to have? A. Ascending pyelonephritis B. Nephritic syndrome C. Nephrotic syndrome D. Obstructive uropathy E. Renal infarction F. Papillary necrosis 133. An 18-year-old primigravida has noted minimal fetal movement during pregnancy. She gives birth at 30 weeks gestation to a 2000 gm girl infant with Apgar scores of 4 and 5 at 1 and 5 minutes. The baby dies from respiratory distress within an hour of birth. At autopsy, the kidneys are markedly enlarged bilaterally. Microscopically, the renal parenchyma is replaced by numerous small radially arranged cysts. These findings are most likely to be seen in association with which of the following pathologic conditions? A. Alobar holoprosencephaly B. Hepatic cysts and hepatic fibrosis C. Concomitant presence of an imperforate anus D. Lack of ureteral development E. Papilloma of the bladder 134. A 55-year-old man is found down and unconscious. On physical examination he is afebrile. After catheterization, he passes a small amount of dark urine. The urine dipstick test for blood is positive but no red blood cells are seen on microscopic examination of the urine sediment. Which of the following is the most likely diagnosis? A. Post-streptococcal glomerulonephritis B. Renal papillary necrosis C. Ureteral lithiasis D. Rhabdomyolysis E. Renal infarction 135. A 5-year-old child has been noted by his mother to be lethargic for 2 weeks. On physical examination he has periorbital edema. He is afebrile. Dipstick urinalysis reveals no glucose, ketones, or blood, but he has 4+ proteinuria present. Microscopic urinalysis reveals no casts, but oval fat bodies are seen. He is treated with corticosteroid therapy and his condition improves. Which of the following renal electron micrographic findings is most characteristic for this child's disease?  A. Fusion of podocyte foot processes B. Subepithelial electron dense deposits C. Duplication of glomerular capillary basement membranes D. Irregular thickening of the glomerular basement membranes E. Mesangial cell proliferation 136. A 70-year-old man has noted passing darker urine for the past week. On physical examination he has vital signs with T 37.1°C, P 73/minute, RR 16/minute, and BP 130/80 mm Hg. Laboratory studies include urinalysis with sp gr 1.015, pH 7, 2+ blood, no glucose, no protein, and no ketones. Urine microscopic examination shows 10 to 15 RBC/hpf and no WBCs, casts, or crystals. Cystoscopy is performed and no lesions are noted. Intravenous urography shows a 2 cm filling defect in the left renal pelvis. Which of the following laboratory test findings is most likely to be present in this man? A. Elevated hemoglobin and hematocrit B. Hemoglobin S on electrophoresis C. Increased urine calcium D. Positive serology for antinuclear antibody E. Atypical cells with urine cytology 137. An 11-year-old girl has increasing lethargy and has passed dark-coloured urine for the past week. She had a sore throat two weeks ago. On physical examination she is afebrile with blood pressure 140/90 mm Hg. Laboratory studies show her serum creatinine is 2.8 mg/dL and urea nitrogen 24 mg/dL. Urinalysis shows 2+ blood, 2+ protein, no glucose, and no ketones. Microscopic urinalysis shows dysmorphic RBC's. A renal biopsy is performed and on microscopic examination shows glomerular hypercellularity, with PMNs present. Electron microscopy shows subepithelial electron dense 'humps'. Which of the following laboratory test findings is most likely to be present in this girl? A. Elevated serum glucose B. Antibody to double stranded DNA C. Antiglomerular basement membrane antibody D. Positive C3 nephritogenic factor E. Elevated antistreptolysin O titer 138. An otherwise healthy 44-year-old man with no prior medical history has had increasing back pain and right hip pain for the past decade. The pain is worse at the end of the day. On physical examination he has bony enlargement of the distal interphalangeal joints. A radiograph of the spine reveals the presence of prominent osteophytes involving the vertebral bodies. There is sclerosis with narrowing of the joint space at the right acetabulum seen on a radiograph of the pelvis. Which of the following diseases is he most likely to have? A. Gout B. Rheumatoid arthritis C. Osteoarthritis D. Osteomyelitis E. Lyme disease F. Pseudogout 139. An 80-year-old woman has had no major medical problems, but she has never been physically active for most of her life. One day she falls out of bed and immediately notes a sharp pain in her left hip. She is subsequently unable to ambulate without severe pain. Radiographs show not only a fracture of the left femoral head, but also a compressed fracture of T10. Which of the following conditions is she most likely to have? A. Vitamin D deficiency B. Acute osteomyelitis C. Osteogenesis imperfecta D. Osteoporosis E. Polyostotic fibrous dysplasia F. Metastatic breast carcinoma 140. A 51-year-old man has noted constant, dull right hip pain for the past 3 months. On physical examination he has diminished range of motion of the right hip. A radiograph reveals a 10 x 13 cm mass involving the right ischium of the pelvis. The mass has irregular borders and there are extensive areas of bony destruction along with some scattered calcifications. The lesion is resected, and grossly the mass has a bluish-white cut surface. Which of the following is the most likely diagnosis? A. Osteosarcoma B. Enchondroma C. Osteoblastoma D. Chondrosarcoma E. Paget sarcoma 141. A 62-year-old man has had back pain for 4 months. No abnormal findings are noted on physical examination. Laboratory findings include WBC count of 3700/microliter, hemoglobin 10.3 g/dL, hematocrit 31.1%, MCV 85 fL, and platelet count 110,000/microliter. His total serum protein is 9.5 gm/dl with an albumin of 4.1 gm/dl. A chest radiograph shows no abnormalities of heart or lung fields, but there are several lucencies noted in the vertebral bodies. A sternal bone marrow aspirate is performed and yields a dark red jelly-like material in the syringe. Which of the following cell types is most likely to be numerous on microscopic examination of this aspirate? A. Giant cells B. Fibroblasts C. Osteoblasts D. Metastatic renal carcinoma cells E. Plasma cells 142. A 58-year-old man has the sudden onset of severe pain in his left great toe. There is no history of trauma. On examination there is edema with erythema and pain on movement of the left 1st metatarsophalangeal joint, but there is no overlying skin ulceration. A joint aspirate is performed and on microscopic examination reveals numerous neutrophils and needle-shaped crystals. Over the next 3 weeks, he has two more similar episodes. On physical examination between these attacks, there is minimal loss of joint mobility. Which of the following laboratory test findings is most characteristic for his underlying disease process? A. Hyperglycemia B. Positive antinuclear antibody C. Hyperuricemia D. Hypercalcemia E. High rheumatoid factor titer 143. An 11-year-old boy has pain in his left leg that has persisted for 3 weeks. On physical examination his temperature is 37.9°C. A radiograph of the leg reveals a mass in the diaphyseal region of the left femur with overlying cortical erosion and soft tissue extension. A bone biopsy is performed and the lesion on microscopic examination shows numerous small round blue cells. Karyotypic analysis of these cells shows t(11;22). Which of the following neoplasms is he most likely to have? A. Ewing sarcoma B. Medulloblastoma C. Neuroblastoma D. Chondroblastoma E. Osteoblastoma 144. A 14-year-old West African man has a history of multiple episodes of sudden onset of severe abdominal pain and back pain lasting for hours. Each time this happens, his peripheral blood smear demonstrates numerous sickled erythrocytes. A hemoglobin electrophoresis shows 94% Hgb S, 5% Hgb F, and 1% Hgb A2. He now has a painful right hip that is tender to palpation. A radiograph reveals irregular bony destruction of the femoral head. Which of the following infectious agents is most likely responsible for his findings? A. Yersinia pestis B. Clostridium perfringens C. Salmonella enterica D. Group B Streptococcus E. Candida albicans 145. A 69-year-old man has noted increasing back and leg pain for 3 years. He has greater difficulty hearing on the left. On physical examination he has decreased range of motion at the hips. Radiographs reveal bony sclerosis of the sacroiliac, lower vertebral, and uppe