usmle 1,2 qbank

8/13/2019 usmle 1,2 qbank

1/10

A 24-year-old baseball player visits his doctor with complaints of right arm pain. Onquestioning, he states that it has hurt for several weeks but he has been ignoring it,attributing to muscle strain. adiographic e!amination demonstrates an e!pansile,lytic pro!imal right humeral epiphyseal lesion. "ased on the clinical, radiologic, andbiopsy findings, the mass and pro!imal humerus are resected. On gross

e!amination, the mass demonstrates hemorrhagic areas with multiple small spindle-shaped cells. #aboratory tests performed at the same time demonstrate normalserum and calcium levels. $hich of the following is the likely diagnosis%

&A' Aneurysmal bone cyst

&"' "rown tumor

&(' )iant cell tumor

&*' +wing sarcoma

&+' Osteoid osteoma

he correct answer is (.

&A' Aneurysmal bone cysts can be difficult to distinguish, although histology woulddemonstrate multiple blood-filled cysts without spindle-shaped cells.

&"' A brown tumor can also be difficult to differentiate, however, this lesion occursin hyperparathyroidism. here is no evidence for hyperparathyroidism in thispatient.

&(' (O +( he key factor in determining the nature of a bone neoplasm isknowing the patient s age and region of bone involved. )iant cell tumors areepiphyseal lesions that affect the distal femur, pro!imal tibia, distal radius and as, inthis case, the pro!imal humerus. his lesion e!pands the bone, thins the corte!, andhas a lytic appearance. Often these are associated with an e!traosseous soft tissuecomponent. here is low malignant potential, however, local recurrence is frequent.

&*' +wing sarcomas are diaphyseal lesions and typically occur in a younger agegroup &/-20 years'.

&+' Osteoid osteomas are benign tumors that classically present with nighttime painrelieved with aspirin because the tumor secretes prostaglandin +&2'.

Brain Baffler A 45-year-old woman is undergoing chemotherapy for chronic lymphocyticleukemia. She begins to develop progressive neurological impairment, including

weakness of the right leg and double vision. maging demonstrates e!tensive scatteredareas of asymmetric demyelination involving both the cerebrum and cerebellum. "he

patient becomes more unresponsive and succumbs to a secondary unrelated infection. Atautopsy, microscopic e!amination of the brain demonstrates viral inclusion bodies withinoligodendrocytes and bi#arre giant astrocytes. $hich of the following is the most likelydiagnosis%

&A' Acute disseminated encephalomyelitis


2/10

&B' (entral pontine myelinolysis

&(' )ultiple sclerosis

&*' +rogressive multifocal leukoencephalopathy

& ' Subacute sclerosing panencephalitis

"he correct answer is .

&A' An androblastoma is a Sertoli- eydig cell tumor. "hese commonl produce androgens

and cause virili#ation.&B' A Brenner tumor is also uncommon, occurring in the older age group. )ucin-containing cysts are often seen. )icroscopically there is a fibroblastic stroma withadditional nests of cells that resemble transitional epithelium.

&(' A dysgerminoma occurs in the younger population &/0-10 year old'. 2erm cells withfibrous septa are noted microscopically.

&*' ndometrioid carcinomas make up about /35 of malignant ovarian neoplasms. "heyare distinct from, but often occur with, endometriosis. "he tumor has the appearance ofuterine endometrium.

& ' ( (" 6ibrothecomas are relatively uncommon benign ovarian neoplasms,

seen primarily in postmenopausal women. As the name indicates, the tumor is composed primarily of fibroblasts with a few interspersed lipid-rich thecal cells. "hese solid-appearing tumors, which can grow up to /5-70 cm in si#e, are usually unilateral. n 70-408 of cases, such tumors are associated with abdominal ascites in the triad of ovarianneoplasm, ascites, and pleural effusions &)eigs syndrome'. nce the neoplasm isremoved, the ascites and pleural effusion resolves.

espiratory iddle A 47-year-old woman with no significant past medical history isundergoing a routine physical e!amination. She states that she is e!cellent health, does

not drink, does not smoke, and runs twice a week. n further 9uestioning, she mentionsthat the running has become slightly more difficult lately. adiographic analysis revealsthat in the periphery of the left lung, there is a poorly defined mass. A biopsy is

performed, which reveals a large number of mucin-containing cells with minimal atypia. :o other lesions are seen either in the lung or other organs. $hich of the following is themost likely diagnosis%

&A' Adenocarcinoma of the lung


3/10

&B' )etastatic colon cancer

&(' )etastatic ovarian cancer

&*' Small cell carcinoma of the lung

& ' S9uamous cell carcinoma of the lung

The correct answer to the question above is: A.

CORRECT: The findings of a peripheral lung mass containing mucin is highly concerning foradenocarcinoma . The lack of other lesions makes it more likely to be primary to the lungrather than metastatic from elsewhere. Although adenocarcinoma is the most commonlung cancer in the female nonsmoker, it is still has a much higher incidence in smokers(70-80 of people with adenocarcinomas are smokers!. Two distinct types ofadenocarcinoma are the bronchial-deri"ed adenocarcinoma and the bronchioloal"eolarcarcinoma. These neoplasms spread from al"eolus to al"eolus along airways and alongthe pores of #ohn. (A!

Colon cancer can certainly spread to the lungs. $t is, howe"er, an unusual age group and ishighly unlikely to be the only finding at presentation. (%!

Ovarian cancer is more likely to spread to the peritoneal ca"ity rather than the lungs. (&!

Small cell carcinomas are central tumors. These are highly malignant, poorly differentiated,and the cells do not contain mucin. ('!

Squamous cell carcinoma is also deri"ed from the central airways. &haracteristic histologicfindings include intercellular bridges, palisading cells, and keratin pearls.( !

Diagnostic Dilemma A )*-year-old male body builder collapses during a particularly strenuous workout. +is traineraccompanies him to the emergency department and is able to pro"ide information regarding thepatient. +e denies any significant past medical history e cept for a torn biceps tendon yearspre"iously. The trainer, howe"er, appears hesitant when asked about illicit drug use. hysicale amination re"eals a hypotensi"e, tachycardic patient in moderate distress. /adiologice amination re"eals a subcapsular mass within the li"er and a large amount of blood within theabdomen. The patient is taken to the operating room in which a * cm subcapsular solid yellowmass is remo"ed. 1hich of the following is the most likely diagnosis2

(A! 3ocal nodular hyperplasia (%! +epatic adenoma

(&! +epatic cyst

('! +epatic hemangioma


4/10

( ! +epatocellular carcinoma

The correct answer to the question above is: B.

Focal nodular hyperplasia leads to well-circumscribed li"er nodules, classically with a centralscar. The nodule is made up of disorgani4ed li"er parenchyma. $t is important to note thatall components of the li"er parenchyma are present, albeit disorgani4ed. These areusually disco"ered incidentally and are not prone to hemorrhage. (A!

CORRECT: Hepatic adenomas are commonly seen in young female patients taking oralcontracepti"es and in those patients that are taking anabolic steroids. Although these arebenign tumors, they can rarely undergo malignant transformation. The greatest risk,howe"er, is not in terms of their neoplastic acti"ity, but in the risk for subcapsular lesionsto rupture with resultant hemorrhage. This may present with right upper 5uadrant pain,but if se"ere enough, it can lead to hemorrhagic shock (as in this patient!. +istology

re"eals a solid yellow nodule with hepatocytes. 6ther hepatic components (#upffer cells,bile ducts! are not present. (%!

Hepatic cysts are cystic rather than solid, and not a likely source of hemorrhage. (&!

Hepatic hemangiomas are the most common benign hepatic tumor. The si4e and clinicalpresentation is highly "ariable, with the most common being asymptomatic. Theselesions can rupture with significant blood loss howe"er, the histology woulddemonstrated large "ascular channels.('!

Hepatocellular carcinoma usually appears in the cirrhotic patient after many years. Althoughthey may bleed, it is an unlikely diagnosis in this case. ( !

Cardiac conundrum A *-year-old woman with a history of "al"e replacement "isits her dentist for a routine cleaning.Two days later, she de"elops a se"ere fe"er, has small hemorrhages on her fingers, andfunduscopic e"aluation re"eals the presence of retinal hemorrhages. 9he becomes hypotensi"eand is rushed to the emergency department. 1hich of the following is the most diagnosis2

(A! Acute bacterial endocarditis

(%! Acute rheumatic fe"er (&! :ibman-9acks endocarditis

('! ;onbacterial thrombotic endocarditis ( ! 9ubacute bacterial endocarditis


5/10


CORRECT: re"iously damaged heart "al"es or prosthetic "al"es are susceptible toinfection. %acteria seed the "al"es in this case after dental work. The rapid decline of thepatient and the peripheral and retinal hemorrhages re"eal the likely diagnosis as acutebacterial endocarditis . $n mechanical "al"es, if there is infection around the "al"e, it canlead to its possible dislodgement. (A!

Acute rheumatic fever may lead to fe"er. $f the myocardium is affected, conductionabnormalities may result. /epeated bouts affecting the myocardium lead to its scarring.(%!

Libman-Sacks endocarditis presents as sterile "egetations on both sides of the heart "al"es.3e"er and peripheral hemorrhage are not seen. These "egetations are seen in systemiclupus erythematosus.(&!

As the name implies, nonbacterial thrombotic endocarditis is characteri4ed by accumulationof small thrombotic emboli on the heart "al"es. This condition is associated with chronicdiseases such as cancers.('!

1hile a normal heart "al"e is not usually susceptible to the less "irulent organisms that gi"e

rise to subacute bacterial endocarditis , those with a prosthesis are. The importantdistinction is rapidity of the onset of symptoms. ( !

Cardiac conundrum A *-year-old woman with a history of "al"e replacement "isits her dentist for a routine cleaning.Two days later, she de"elops a se"ere fe"er, has small hemorrhages on her fingers, andfunduscopic e"aluation re"eals the presence of retinal hemorrhages. 9he becomes hypotensi"e

and is rushed to the emergency department. 1hich of the following is the most diagnosis2

(A! Acute bacterial endocarditis

(%! Acute rheumatic fe"er

(&! :ibman-9acks endocarditis

('! ;onbacterial thrombotic endocarditis

( ! 9ubacute bacterial endocarditis


CORRECT: re"iously damaged heart "al"es or prosthetic "al"es are susceptible to


6/10

infection. %acteria seed the "al"es in this case after dental work. The rapid decline of thepatient and the peripheral and retinal hemorrhages re"eal the likely diagnosis as acutebacterial endocarditis . $n mechanical "al"es, if there is infection around the "al"e, it canlead to its possible dislodgement.(A!

Acute rheumatic fever may lead to fe"er. $f the myocardium is affected, conductionabnormalities may result. /epeated bouts affecting the myocardium lead to its scarring.

(%!Libman-Sacks endocarditis presents as sterile "egetations on both sides of the heart "al"es.

3e"er and peripheral hemorrhage are not seen. These "egetations are seen in systemiclupus erythematosus.(&!

As the name implies, nonbacterial thrombotic endocarditis is characteri4ed by accumulationof small thrombotic emboli on the heart "al"es. This condition is associated with chronicdiseases such as cancers.('!

1hile a normal heart "al"e is not usually susceptible to the less "irulent organisms that gi"erise to subacute bacterial endocarditis , those with a prosthesis are. The importantdistinction is rapidity of the onset of symptoms. ( !

Renal Riddle A )-year-old girl is brought to the doctor


7/10

Alport syndrome is an @-linked disorder in the alpha- chain of the collagen type $ molecule.This disorder is associated with deafness. (%!

CORRECT: 'eposits of $gA, &), and properdin in the mesangium occurs in $gA nephropathy,also known as !erger disease . %erger disease initially presents in children, mostcommonly, following a respiratory tract infection. $t can, howe"er, occur following urinaryor gastrointestinal tract infections. atients may ha"e a mild nephritic syndrome with

edema and some proteinuria. The proteinuria is not to the le"el seen in nephriticsyndrome. The gross hematuria only lasts a few days but often recurs a few months later.

Although initial serum creatinine can be normal, chronic renal disease can occur in up tohalf of the patients after se"eral decades. (&!

$gA deposits are seen in Henoch-Sch"nlein purpura there are, howe"er, purpuric lesions. ('!

#inimal change disease is the most common cause of nephrotic syndrome in children. $t isnot associated with deposition of $gA.( !

Reproductive Riddle A -year-old woman presents to her doctor with abdominal pain. 9he states that she has had thepain on and off for the last ) months, but lately it is worse. 9he has no significant past medicalhistory and does not take any medication. 9he has been married for B years and has nochildren. +er husband has been her only se ual partner. hysical e amination re"eals adistended, but nontender abdomen. /adiologic e amination demonstrates ascites and multiplesoft tissue masses throughout the peritoneum as well as a primary lesion. The primary lesion isbiopsied and demonstrates cystic spaces lined with tall columnar cells psammoma bodies arealso identified. Additional blood tests for & A and &A C-C are negati"e. &A- is positi"e. 1hichof the following is the most likely primary diagnosis2

(A! &er"ical cancer

(%! &olon cancer

(&! :i"er cancer

('! 6"arian cancer ( ! ancreatic cancer

The correct answer to the question above is: '.

Cervical cancer is associated with infection with particular subtypes of human papilloma "irus(+ !, which is more common in indi"iduals with a greater number of se ual partners.(A!

Anemia in a middle-aged woman should prompt an in"estigation to rule out adenocarcinoma


8/10

of the colon . +owe"er, the patientDs clinical and histologic findings are different.(%!

Hepatocellular carcinoma is associated with abdominal pain if the capsule is in"ol"ed, and isoften associated with ele"ated E-fetoprotein.(&!

CORRECT: The clinical presentation of ovarian cancer can be 5uite nonspecific. atientsoften present, as in this case, with abdominal distension and pain. 6ther symptoms caninclude "aginal bleeding and a change in bowel habits. 3emales in the si th to se"enthdecade of life are most commonly affected. 6ther risk factors include nulliparity and earlymenarche (endometrial cancers ha"e similar risk factors!. Although initially restricted tothe o"ary, o"arian cancer spreads to the peritoneum with multiple soft tissue deposits andascites, termed pseudomy oma peritonei. $t is the spread to the abdominal ca"ity thatcan lead to symptoms and therefore, presentation. The asymptomatic nature of thecancer in its early stages results in late presentation and a poor prognosis. &A- isele"ated in o"arian cancers, and should be used to monitor treatment. $t is not anappro"ed means to screen for o"arian cancer, howe"er. 6"arian cancer has ) maFortypesG serous, mucinous, and endometrioid. This patient has the malignant serous form(serous cystadenocarcinoma!. &haracteristic histologic findings include columnarepithelial cells and concentric calcified structures (psammoma bodies!.('!

ancreatic cancer presents with Faundice secondary to obstruction of the bile duct. ( !

ultis!stem !ster! A *-year-old man presents to the emergency department with e cruciating right lower 5uadrantpain, rebound tenderness, and a fe"er. A &T scan is performed and confirms the clinicallysuspected diagnosis of appendicitis. ;ote is also made of multiple large cysts within the kidneyand li"er. :aboratory tests indicate a leukocytosis, but renal function is normal. The patient wasadopted and is unaware of any family history of kidney problems. The inflamed appendi isremo"ed and once he has reco"ered, the patient is sent for further e"aluation of his kidneyproblems. This e"aluation includes imaging of his brain. 1hat finding would this imaging mostlikely show2

(A! Agenesis of the corpus callosum

(%! %erry aneurysm

(&! 'ownward displacement of the cerebellar tonsils

('! >ultiple areas of demyelination

( ! 9ubependymal giant cell astrocytomas

The correct answer to the question above is: %.

$ndi"iduals with agenesis of the corpus callosum may be asymptomatic or retarded. $t is not,


9/10

howe"er, associated with polycystic kidney disease. (A!

CORRECT: ;ormally, autosomal dominant polycystic kidney disease (pre"iously termedadult! remains unnoticed and asymptomatic until the fourth or fifth decade. &ysts can bepresent earlier, howe"er, before renal function is compromised. 9e"eral geneticmutations ha"e been identified as responsibleG #' (on chromosome B!, #' , and

#'). trarenal findings include cysts in the li"er, increased incidence of mitral "al"e

prolapse, and an increase incidence of berry aneurysms at the circle of 1illis. (%!&hiari type $$ malformations are associated with a plethora of &;9 defects, but not renal

defects.(&!

There is no reason to e pect a demyelination process . ('!

%uberous sclerosis is associated with renal and li"er cysts. A common malignancy is thesubependymal giant cell astrocytoma. ancreatic cysts would also be e pected. ( !


10/10

usmle 1,2 qbank

Documents

Transcript of usmle 1,2 qbank