1.

A 48-year-old man with a history of chronic alcoholism who is continuing to perform adequately on the job will most likely have which of the following microscopic findings in his liver? A Cholestasis B Coagulative necrosis C Fatty change CORRECT ANSWER D Hemochromatosis E Hypertrophy of smooth endoplasmic reticulum -------------------------------------------------------------------------------Additional Information Given the history of chronic alcoholism, the most likely finding is certainly fatty change or steatosis. This is found in 100% of alcoholics who are currently drinking.

2. The appearance of granulomas with Langhans giant cells on biopsy of the lung from a 54-year-old man with fever, night sweats, weight loss, and cough for several months suggests that infection with which of the following infectious agents has occurred? A Cytomegalovirus B Influenza A virus C Mycobacterium tuberculosis CORRECT ANSWER D Staphylococcus aureus E Streptococcus pneumoniae -------------------------------------------------------------------------------Additional Information Infectious granulomas are found with tuberculosis and certain fungal infections. They do not occur with viruses (choices A or B) or with common extracellular bacteria (choices D or E). 3. A 50-year-old woman with low back pain was found to have several discrete lytic lesions in the lumbar vertebrae and pelvis. She has an elevated serum alkaline phosphatase and serum calcium, but serum protein and peripheral blood smears are normal. Aspiration biopsy of a pelvic lesion is most likely to show A metastatic carcinoma CORRECT ANSWER B multiple myeloma C osteogenic sarcoma D osteoporosis E rhabdomyosarcoma

-------------------------------------------------------------------------------Additional Information Most carcinomas that metastasize to bones cause lytic lesions. This destruction of bone releases calcium and can produce hypercalcemia. The resulting increased metabolic activity of the bone causes increased release of alkaline phosphatase. Multiple myeloma is characterized by the presence of multiple tumours of plasma cells within bone marrow. These plasma cells secrete large amounts of immunoglobulin; therefore one would not expect normal serum proteins as found in this patient. The sarcomas would be very uncommon in a woman of this age. Osteoporosis has a more uniform reduction in bone density rather than the focal lytic lesions seen here. Also the alkaline phosphatase level would not be increased.

4. A 55-year-old man has sudden onset of chest pain and a myocardial infarction is suspected. Which of the following laboratory tests on the patient's serum is most useful in this situation? A Amylase B Sedimentation rate C Total cholesterol with HDL cholesterol D Troponin I CORRECT ANSWER E Triglyceride -------------------------------------------------------------------------------Additional Information Of these choices, the only marker of myocardial damage is troponon I. Increased amylase is a non-specific marker for pancreatic injury. The sed rate is non-specific and is usually increased in inflammation but also in many other conditions. Cholesterol and triglyceride give no information on myocardial necrosis.

5. A 53-year-old man has experienced severe chest pain for the past couple of hours. A coronary angiogram reveals occlusion of the left anterior descending artery. An irreversible injury to myocardial fibers will have occurred when A blebs form on cell membranes B cytoplasmic sodium increases C glycogen stores are depleted D intracellular pH diminishes E nuclei undergo karyorrhexis CORRECT ANSWER -------------------------------------------------------------------------------Additional Information The only irreversible change here is the karyorrhexis of nuclei. All of the other choices are reversible if the agent causing the cell injury is removed.

6. A 57-year-old diabetic man who has an ulceration on his left foot develops a focus of acute inflammation within the soft tissues. There is pain, swelling, and redness. Of the following mediators, which plays the greatest role in chemotaxis of neutrophils to this site? A Bradykinin B Complement C5a CORRECT ANSWER C Hageman factor D Histamine E Prostaglandin -------------------------------------------------------------------------------Additional Information The main roles of bradykinin are in producing vasodilation, increased vascular permeability, and pain. Hageman factor is an initiating factor for the plasma-derived mediators but is not necessary for this activity. Histamine is a preformed mediator that produces early vasodilation and increased vascular permeability but not chemotaxis. Prostaglandins have many roles in inflammation but are not chemotactic. Chemotaxis can be produced by a number of endogenous mediators including C5a, LTB4, and IL8. There are also important exogenous chemotactic agents derived from bacteria.

7. A 50-year-old woman presents with a pleural effusion. She has no occupational exposure to asbestos but has a 60 pack/year smoking history. Bloody pleural fluid is aspirated, and cytology shows highly unusual-appearing cells resembling epithelial cells. Of the following, the most likely diagnosis is A carcinoma CORRECT ANSWER B congestive heart failure C mesothelioma D pulmonary infarction E tuberculosis -------------------------------------------------------------------------------Additional Information The smoking history and the "unusual-appearing" (i.e., probably pleomorphic) cells make carcinoma highly likely. A person in heart failure is more likely to produce a clear, acellular transudate. Mesothelioma is a very rare tumor having a very strong association with asbestos exposure. Pulmonary infarction and tuberculosis could produce a bloody pleural fluid but would not explain the presence of the unusual cells.

8. A 56-year-old Caucasian man with untreated hypertension (blood pressure 155/95 mm Hg) smokes 2 packs of cigarettes per day and has an HDL cholesterol that is 66 mg/dL. Which of the following factors in his case is NOT associated with an increased risk for his developing complications of atherosclerosis? A Age B HDL cholesterol CORRECT ANSWER C Hypertension D Male sex E Smoking -------------------------------------------------------------------------------Additional Information High levels of HDL are protective against atherosclerosis. All of the other factors mentioned here increase risk.

9. While performing a pneumonectomy for squamous cell carcinoma of the right lung of a 58-year-old man, the thoracic surgeon notes that the hilar lymph nodes are small, 0.5 to 1.0 cm in size, and jet black in color throughout. You would describe these lymph nodes as having A accumulation of melanin B anthracotic pigmentation CORRECT ANSWER C hemosiderosis D lipochrome deposition E metastatic carcinoma -------------------------------------------------------------------------------Additional Information The most common cause of black discoloration of the hilar lymph nodes is the accumulation of inhaled anthracotic pigment. Metastatic melanoma could also produce black lymph nodes but is much less common and would most likely produce additional clinical findings. The other three conditions listed here do not produce black discoloration.

10. The clinical course of a 15-year-old boy with fever and chills of 3 days' duration along with pharyngitis and accompanying pharyngeal purulent exudate is most typical for A abscess formation B acute inflammation CORRECT ANSWER C chronic inflammation D granulomatous inflammation

E resolution of inflammation -------------------------------------------------------------------------------Additional Information The acute course and the purulent exudate (i.e., PMNs) indicate a typical acute inflammatory response. There is nothing in the information given to suggest abscess formation. Choices C and D are chronic responses inconsistent with a three day clinical course. This is still an active inflammatory response that is not yet resolving (choice E).

11. A 36-year-old woman noticed a lump in her left breast one month ago. The mass is hard and seems to be attached to the chest wall. Several 2-3 cm lumps are present in the left axilla. At the time of biopsy, the surgeon discovers a 4 cm hard, poorly defined mass in the breast. The most likely diagnosis is A carcinoma CORRECT ANSWER B dyplasia C hamartoma D hyperplasia E metaplasia -------------------------------------------------------------------------------Additional Information All of these findings point to a breast carcinoma that has metastasized to the axillary lymph nodes. Dysplasia is a premalignant change that would not produce metastases. Hamartoma is a focus of histologically normal tissues derived from the organ in which it is found. Hyperplasia is increased cell number that is usually a normal physiological response to increased demand. Metaplasia is the replacement of one normal tissue by another.

12. A 29-year-old woman sustains a closed femoral fracture as a result of a car accident. She is also 4 weeks pregnant. Which of the following is the most likely complication to occur within the first two days after the accident? A Acute pulmonary embolism B Air embolism C Amniotic fluid embolism D Chronic pulmonary embolism E Fat embolism CORRECT ANSWER -------------------------------------------------------------------------------Additional Information Fractures to long bones containing fatty marrow can release fat into the circulation. However, fewer than 10% of patients have clinical manifestations. For those who do, the symptoms develop 1 to 3 days after the injury. Usually there is a

hemorrhagic rash and the sudden onset of dyspnea, tachypnea, and tachycardia. The small fat globules can pass through the lungs and get into the systemic circulation and cause CNS effects such as irritability and restlessness which can progress to delirium or coma. In these severe cases the fatality rate can approach 10%.

13. A 40-year-old schizophrenic man drank a pint of Geritol (a liquid marketed to older adults that contained vitamins with iron) each day for 20 years. His liver would most likely show A anthracosis B coagulative necrosis C hemochromatosis CORRECT ANSWER D severe fatty change E sphingolipidosis -------------------------------------------------------------------------------Additional Information The long term accumulation of iron in the body results in tissue damage due to a number of mechanisms including free radical formation. It can be either primary (genetic) due to an inherited defect in the control of intestinal iron absorption or secondary (as in this case). Early diagnosis is essential to prevent the serious consequences of the resulting tissue damage - particularly to the liver and pancreas.

14. Thoracentesis (drainage of fluid from the pleural cavity) is performed on a 45-year-old man who has had a fever and cough for several days, and now has more difficulty breathing. A right pleural effusion is seen by chest radiograph. The fluid obtained has a cloudy appearance with a cell count showing 5,500 leukocytes/uL, 98% of which are neutrophils. The best description of the pleural process is A chronic inflammation B fibrinous inflammation C granulomatous inflammation D purulent inflammation CORRECT ANSWER E serous inflammation -------------------------------------------------------------------------------Additional Information Both chronic and granulomatous inflammation are marked by the presence of mononuclear cells. Fibrinous indicates the presence of fibrin, and serous refers to a clear, relatively cell-free (serum-like) exudate. The fluid described above contains many PMNs which is referred to as purulent.

15. You have developed a new laboratory test for a general cancer marker. It has a sensitivity of 100% and a specificity of 99%. In the population that you are studying, the prevalence of cancer is 0.5%. The first subject that you test gives a positive result. What are the chances that this result is a true positive? A 0.5% B 1% C 10% D 33% CORRECT ANSWER E 50% F 67% G 99% H 100% -------------------------------------------------------------------------------Additional Information Let us take a population of 100,000. Since the prevalence of cancer is 0.5% in this population, there will be 500 expected cancer patients. The test has a sensitivity of 100% so all 500 will give a positive test result (TP =100%, FN = 0%). Individuals without cancer equals 99,500 (100,000 minus 500). Since the specificity is 99%, 98,505 of these will give a negative test result (TN = 99% of 99,500)and 995 give a positive test result (FP = 1% of 99,500). There are 500 true positive test results and 995 false positive test results for a total of 1,495 positive test results. The chances of a test result being a true positive therefore are 500/1,495 = 0.33 = 33%.

16. A 55-year-old woman has been treated in the hospital for pneumonia for 3 weeks. She is examined one morning and found to have a swollen right leg. It is tender to palpation posteriorly but is not warm. This condition is most likely the result of A cellulitis B congestive heart failure C infarction D septic emboli E venous thrombosis CORRECT ANSWER -------------------------------------------------------------------------------Additional Information This is a case of venous thrombosis due to prolonged inactivity. Cellulitis is a spreading infection that should be warm to the touch. Heart failure would produce a systemic edema not swelling of one leg. There is no evidence for infarction or septic emboli.

17. A below-the-knee amputation specimen received in surgical pathology from a 55-year-old man with diabetes mellitus shows extensive black discoloration of skin and soft tissue of the foot. This process is best characterized as A caseation B coagulation disorder C gangrenous necrosis CORRECT ANSWER D hemosiderosis E neoplasia -------------------------------------------------------------------------------Additional Information This is a very classic case of dry gangrene of an extremity in a diabetic.

18. A 40-year-old woman has a chronic cough with fever and weight loss. A chest radiograph reveals multiple nodules, some of which demonstrate cavitation in the upper lobes. A sputum sample reveals acid fast bacilli. The most important cells in the development of her lung lesions are A fibroblasts B macrophages CORRECT ANSWER C mast cells D neutrophils E platelets -------------------------------------------------------------------------------Additional Information The clinical, radiographic, and microscopic findings point to tuberculosis. The lung lesions would, therefore, be granulomas in which the most important cell is the macrophage.

19. A rubbery spherical mass removed from the uterus of a 35-year-old woman is most likely to be A adenocarcinoma of the uterus B leiomyoma CORRECT ANSWER C leiomyosarcoma D metastatic carcinoma

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Additional Information A rubbery, spherical mass in the uterus describes a leiomyoma. A and C would be more infiltrative lesions probably occurring in an older woman. Metastases to the uterus are uncommon and do not fit the gross description.

20. During hospitalization, a 40-year-old woman develops thrombophlebitis in a femoral vein. She recovers and is discharged. She returns to her job as an electrician. A couple of months later, which of the following terms would best describe the process seen in the affected femoral vein after recovery from her thrombophlebitis? A Acute inflammation B Embolization C Organization CORRECT ANSWER D Propagation E Rupture -------------------------------------------------------------------------------Additional Information Two months later the acute inflammation, embolization, and propagation could no longer be seen. Rupture in not expected in a case such as this. However, the thrombus does become organized when it is not promptly lysed (which is the other possibility not listed above).

21. A 71-year-old man has a very firm prostate gland by digital rectal exam, and his prostate specific antigen is elevated at 16 ng/mL. These findings are consistent with A carcinoma of the urethra B chronic prostatitis C metastatic prostate carcinoma CORRECT ANSWER D nodular hyperplasia of the prostate E prostatic calculi -------------------------------------------------------------------------------Additional Information A patient with a very firm prostate and a PSA this high has a very great possibilty of having advanced prostatic carcinoma. PSA levels can be increased in other conditions but very rarely to this extent. Thus, the other choices listed here become considerably less likely.

22. The pain and tenderness along with the red discoloration of the skin seen in a 29-year-old man who was at the beach all day and who is now in the early stage of sunburn is most likely to be mediated by

A bradykinin CORRECT ANSWER B C-reactive protein C complement C3b D ICAM-1 E interleukin-1 -------------------------------------------------------------------------------Additional Information In addition to causing vasodilation and increased vascular permeability, bradykinin is one of the main mediators that cause pain.

23. A 30-year-old woman is claiming in a civil lawsuit that her husband abused her. A workup by her physician revealed a breast mass that on biopsy showed microscopic evidence for fat necrosis. This biopsy result is most consistent with A hypoxic injury B lactation C physiologic atrophy D probable trauma to the breast CORRECT ANSWER E radiation injury

-------------------------------------------------------------------------------Additional Information Non-enzymatic fat necrosis typically is the result of trauma to adipose tissue.

24. The collagen deposition that accompanies silicosis (fibrosing disease resulting from inhalation of silica dust) in a 56year-old man with increasing dyspnea, no cough, no fever, and multiple pulmonary nodules on chest radiograph is primarily a function of A foreign body giant cell formation B histamine release by mast cells C neutrophilic infiltration with release of leukotrienes D plasma cell production of immunoglobulin E release of growth factor by macrophages CORRECT ANSWER

-------------------------------------------------------------------------------Additional Information Fibroblasts are activated to produce collagen by fibroblast-activating factors released by macrophages and other cells.

25. A 58-year-old woman complained of pain and fullness in the right upper quadrant of her abdomen. A liver scan demonstrated several filling defects in the right hepatic lobe. Which of the following is the most likely diagnosis? A Angiosarcoma B Bile duct adenoma C Hepatocellular carcinoma D Metastatic carcinoma CORRECT ANSWER -------------------------------------------------------------------------------Additional Information Bile duct adenoma cannot explain the presence of several lesions in the liver. Of the three malignancies listed here, metastatic carcinoma is by far the most common.

26. A 75-year-old chronically ill man with a long history of alcoholism suddenly develops dyspnea. A lung scan reveals a large segmental perfusion defect in the right lower lobe with normal ventilation. Of the following, what is the most likely factor that could have initiated a sequence of events culminating in his dyspnea? A Anemia due to chronic illness B Cirrhosis of the liver due to alcoholism C Pulmonary artery obstruction due to atherosclerosis D Venous stasis due to inactivity CORRECT ANSWER -------------------------------------------------------------------------------Additional Information D) The sudden dyspnea and the the focal decrease in perfusion point to a pulmonary embolism. Given the man's age and chronic illness, a likely sequence of events is: inactivity - producing venous stasis - leading to thrombophlebosis - and then thromboembolism. Anemia (choice A) could produce a gradually evolving dyspnea but not decreased perfusion. Cirrhosis of the liver (choice B) could produce portal hypertension but this does not relate to the patient's condition. The pulmonary arteries are at a lower pressure than the systemic arteries so they do not develop arteriosclerosis unless there is chronic pulmonary hypertension. Therefore choice C is unlikely.

27. While working in his garden, a 52-year-old man develops a severe substernal pain. This persists for the next two hours and radiates to his neck and jaw. Despite his protests, his wife calls 911 and he is transported to the emergency room six

hours after the onset of his pain. Of the following laboratory tests run on his serum, the one that would be most likely to yield a useful result is A bilirubin B glucose C lactate dehydrogenase D lipase E troponin I CORRECT ANSWER -------------------------------------------------------------------------------Additional Information This patient manifested the classical pain of an acute myocardial infarction. The damaged and necrotic myocardial fibers leak enzymes and other proteins which appear in the serum and serve as convenient markers of the tissue injury. Troponin I levels start to rise about 4-8 hours after a myocardial infarction and peak at 14-36 hours. Lactate dehydrogenase (choice C) is also released by damaged myocardial fibers but does not begin to increase until about 8-12 hours after infarction. This patient was admitted at 6 hours after the onset of his pain so troponin I is more likely to yield a useful result. Bilirubin (choice A), glucose (choice B), and lipase (choice D) levels do not increase following a myocardial infarct.

28. A 67-year-old man is involved in a traffic accident and suffers a broken leg. An x-ray reveals a comminuted fracture of the right femur and a pattern of calcification of the femoral artery. This latter finding is best characterized as the result of A dystrophic calcification B metastatic calcification C Monckeberg sclerosis CORRECT ANSWER D trauma from the accident -------------------------------------------------------------------------------Additional Information Mnckeberg (medial calcific) sclerosis is a degenerative aging change of medium-sized muscular arteries of the lower and upper extremities, and the genital tract. Calcium is deposited in the media of these vessels often as transverse rings, giving a "railroad track" appearance by x-ray. These changes usually do not have any clinical significance and are usually an incidental finding on x-ray. Dystrophic calcification (choice A) is the deposition of calcium in areas of necrosis or tissue injury and in some neoplasms. Serum calcium levels are normal. Mnckeberg sclerosis is an example of dystrophic calcification but is a more specific diagnosis in this case and is therefore the best answer. Metastatic calcification (choice B) occurs in patients with hypercalcemia and results in deposition of calcium in otherwise normal tissues - typically lung, kidney, arteries and stomach. The broken leg (choice D) could result in fat emboli being released into the circulation but would not result in the x-ray findings described here.

29. A 64-year-old nonsmoking woman presents with shortness of breath and malaise. Chest x-ray reveals numerous, approximately round, 1-3 cm densities throughout both lung fields. What is the most likely diagnosis? A Bronchogenic adenocarcinoma B Bronchogenic undifferentiated small cell carcinoma C Bronchogenic squamous cell crcinoma D Metastatic carcinoma from the breast CORRECT ANSWER E Metastatic carcinoma from the cervix F Metastatic carcinoma from the liver -------------------------------------------------------------------------------Additional Information Given that this woman does not smoke and that there are multiple lesions, metastatic disease becomes much more likely. Of the choices for metastases, by far the most common primary site in a woman is breast.

30. A 24-year-old black woman has noticed a slowly growing firm nodule near the site of a recent earpiercing. Excision and microscopic examination of the nodule reveals it to be composed of densely collagenized fibrous tissue. The most probable diagnosis is A dermoid cyst B hamartoma C keloid CORRECT ANSWER D malignant melanoma E teratoma -------------------------------------------------------------------------------Additional Information The described lesion is a keloid. Keloids are an example of excessive scar formation due to a relative abundance of collagen matrix ground substance which is laid down in a disorganized manner. Keloids most frequently occur in blacks and may recur after excision. A dermoid cyst (choice A) is a mature teratoma of the ovary. Excessive collagenization is not evident with this tumor. A hamartoma (choice B) is a collection of several different types of adult tissue in an abnormal organization. The lung is the most frequent site. A malignant melanoma (choice D) would show malignant pigmented cells by microscopy, not dense fibrous tissue. A teratoma (choice E) is a neoplasm derived from germ cells and usually displays several types of partially mature tissue. They usually occur in the ovary, testicles, or mediastinum.

31. An 85-year-old man is hospitalized following a confirmed myocardial infarct. However, he develops intractable cardiogenic shock and dies on the third day. An autopsy is performed and a very hemorrhagic, wedge-shaped area is found in one of his organs. Microscopic examination shows this to be an area of coagulative necrosis. The lesion was most likely found in the

A brain due to thromboembolus in the left cerebral artery B heart due to thrombus superimposed on coronary atherosclerosis C kidney due to embolized mural thrombosis D liver due to cardiogenic shock E lung due to embolized deep vein thrombosis CORRECT ANSWER

-------------------------------------------------------------------------------Additional Information This is a patient who is inactive due to the combined effects of his age, myocardial infarct, and hospitalization. Such a patient is at risk for deep vein thrombosis and thromboembolism. In a patient with heart failure this will most likely produce an infarct of the lung since the bronchial artery circulation is compromised. Microscopically this will appear as an area of coagulative necrosis and grossly as a hemorrhagic, wedge-shaped area. An infarct of the brain (choice A) would be an area of liquefactive necrosis, not coagulative. An infarct of the heart (choice B) is irregular and pale (not wedge-shaped and hemorrhagic). An infarct of the kidney (choice C) is most likely to be pale and wedge-shaped. The liver (choice D) is an unusual site for infarction because of its dual circulation.

32. A 35-year-old woman noted a lump in her breast which seemed to be enlarging. The breast was biopsied primarily to exclude A carcinoma CORRECT ANSWER B fat necrosis C fibroadenoma D fibrocystic change E mastitis -------------------------------------------------------------------------------Additional Information The major concern in a patient such as this is breast carcinoma. Fibroadenoma is a very common benign breast tumor and the other three conditions listed are non-neoplastic.

33. A 73-year-old man with congestive heart failure undergoes a thoracentesis, which yields about 200 mL of strawcolored watery fluid. A laboratory study of the fluid reveals: Specific gravity: 1.010; Total protein: 0.4 g/dL; Cell count: very rare mesothelial cell present; Fat stain: negative. These pleural fluid findings are indicative of a(n) A anasarca B empyema

C erysipelas D exudate E hemothorax F transudate CORRECT ANSWER -------------------------------------------------------------------------------Additional Information Transudates are an ultrafiltrate of plasma that enter the extracellular space by either increased hydrostatic pressure, decreased colloid oncotic pressure, or lymphatic obstruction. Transudates typically have a specific gravity below 1.012, less than 1.5 g/dL of protein, minimal fibrin, and few or no cells. Clinically, transudates are seen with heart failure, cirrhosis, kwashiorkor, and nephrotic syndrome. Anasarca (choice A) is a massive edema involving the entire body. An empyema (choice B) is a collection of pus within the thoracic cavity with many neutrophils. Erysipelas (choice C) is a spreading inflammation often due to streptococcal infections. An exudate (choice D) is an extracellular fluid accumulation that has a specific gravity above 1.020, more than 3 g/dL protein, a high content of fibrin, and many cells. Most exudates are inflammatory in nature but may also be found in malignancies. Hemothorax (choice E) is a collection of blood within the thoracic spaces. An analysis would reveal many erythrocytes and a total protein of more than 3 g/dL.

34. A 76-year-old woman suffers a massive myocardial infarct and dies in cardiogenic shock 16 hours after its onset. Microscopic examination of her infarcted myocardium would be expected to demonstrate A abundant neutrophils and monocytes B coagulative necrosis without many neutrophils CORRECT ANSWER C fibrosis and collagen deposition D monocytes and neovascularization E plasma cells and caseous necrosis -------------------------------------------------------------------------------Additional Information A 16-hour-old ischemic infarct of the myocardium should demonstrate coagulative necrosis without much of an inflammatory response. Abundant neutrophils and monocytes (choice A) typically are seen about two to four days after an infarction. Fibrosis and collagen deposition (choice C) are late healing phenomena that do not begin until at least one week after the infarct has occurred. Monocytic infiltration and neovascularization (choice D) usually occur about three to six days after an infarction. Plasma cells and caseous necrosis (choice E) are not seen with ischemic myocardial damage. This pattern occurs with the granulomatous inflammation of tuberculosis.

35. A 47-year-old man has had a cough for the past week which produces yellowish sputum. He is found to have a total WBC count of 16,300/uL with a differential count of 75% segmented neutrophils, 11% band (immature) neutrophils, 9% lymphocytes, 4% monocytes, and 1% eosinophils. His temperature is 100F and chest x-ray reveals a lesion in the right lower lobe which has a central cavity and an air-fluid level. The most likely diagnosis is

A bronchogenic carcinoma B lobar pneumonia C pulmonary abscess CORRECT ANSWER D pulmonary tuberculosis E viral pneumonia -------------------------------------------------------------------------------Additional Information The productive cough and leukocytosis with a high percentage of neutrophils and bands indicates that this is a bacterial infection and, of the choices given, is most likely an abscess. The air-fluid level in the cavity indicating a liquifying process also supports this diagnosis. Bronchogenic carcinoma (choice A) can obstruct an airway and produce infection but there is no evidence presented here to support this. Lobar pneumonia (choice B) fills the affected lobe with exudate but does not typically result in necrosis or abscess formation. Pulmonary tuberculosis (choice D) can produce a cavitary lesion, typically at the apices, but also is marked by a mononuclear response. Viral pneumonia (choice E) produces a mononuclear response rather than a neutrophilic response. The cough is usually non-productive because the inflammation involves the interstitium and air spaces are usually clear.

36. Following a long and difficult labor, a 28-year-old woman gives birth to a healthy baby boy. Shortly thereafter, she develops severe dyspnea, cyanosis, and hypotensive shock. She becomes comatose and dies later that morning. These clinical manifestations are best explained by the development in this woman of A bilateral adrenal necrosis B disseminated intravascular coagulation CORRECT ANSWER C gestational diabetes D pulmonary thromboembolism E Rh incompatibility -------------------------------------------------------------------------------Additional Information This clinical picture following immediately after a difficult delivery makes amniotic fluid embolism a likely event in this woman. The amniotic fluid contains thromboplastic substances that initiate disseminated intravascular coagulation. Bilateral adrenal necrosis (Waterhouse-Friderichsen syndrome) (choice A) is typically associated with meningococcemia. This can also cause shock and disseminated intravascular coagulation but there is no evidence for meningococcal infection in this patient. In gestational diabetes (choice C) high levels of glucose can cross the placenta and result in fetal hypersecretion of insulin. This in turn can produce fetal macrosomia increasing the possibility of birth trauma, caesarian section, prematurity, and neonatal hypoglycemia. However, the mother of such an infant would not have the findings described in the above case. Pulmonary thromboembolism (choice D) can occur in association with pregnancy and could cause dyspnea and cyanosis but does not fit the rest of the clinical presentation. Rh incompatibility (choice E) can cause unconjugated hyperbilirubinemia and edema in the fetus but does not affect the mother.

37. A 51-year-old alcoholic man comes to the emergency room complaining of severe mid-epigastric pain and persistent vomiting. An x-ray of the pancreas displays numerous scattered abnormal small areas of calcification. The most likely histologic finding would be A fat necrosis CORRECT ANSWER B lipofuscin pigmentation C liquefaction necrosis D melanin pigmentation E viral inclusion bodies -------------------------------------------------------------------------------Additional Information Fat necrosis is commonly associated with dystrophic calcific deposits. Acute pancreatitis allows digestive enzymes to leak out of damaged acinar cells. Liberated lipases act on the adjacent fat to precipitate calcific deposits which may be visualized by radiographic means. Lipofuscin (choice B) is a noncalcific degradation pigment that is not radiopaque. Liquefaction necrosis (choice C) is a form of cell death which is usually seen only in ischemic necrosis of the brain and with abscesses. Calcification is not part of the process. Melanin (choice D) is a black pigment made by melanocytes that cannot be visualized radiographically. Viral infections (choice E) are rare in the pancreas and would not explain the clinical findings.

38. A hysterectomy specimen of a 40-year-old woman shows multiple, discrete, sharply circumscribed, firm, gray-white masses ranging from 5 mm to 8 cm in size. What is the most likely diagnosis? A endometrial adenocarcinoma B leiomyomas CORRECT ANSWER C metastatic carcinoma D sarcomas of the uterus E tuberculous granulomas -------------------------------------------------------------------------------Additional Information A discrete, sharply circumscribed mass in the uterus is much more likely to be a benign (e.g.,leiomyoma) rather than a malignant (e.g., endometrial adenocarcinoma, metastatic carcinoma, or sarcoma) tumor. Tuberculous granulomas would probably be caseous and therefore soft rather than firm.

39. A 40-year-old black woman was admitted to County Hospital complaining of shortness of breath over the past 18 months, ankle edema for 9 months, ascites for 3 months, and a marked increase in these symptoms for the past two weeks. Chest x-ray showed focal lesions throughout both lung fields associated with some pleural thickening. Her condition deteriorated, and she died two days later. An autopsy examination revealed that her disease process involved most of her

major organs. Microscopic examination of the lesions revealed focal collections of macrophages, giant cells, and lymphocytes without any evidence of necrosis. The most likely diagnosis is A chronic abscesses B metastatic lung carcinoma C multiple infarcts D sarcoidosis CORRECT ANSWER E widespread tuberculosis -------------------------------------------------------------------------------Additional Information The description is that of non-caseating granulomas. Given that similar lesions were found throughout her other organs, the most likely diagnosis is sarcoidosis. Chronic abscesses (choice A) by definition are necrotic and are neutrophilic, not mononuclear. Metastatic lung carcinoma (choice B) could have widespread involvement of the organs but would demonstrate malignant cells, not granulomas. It would be unusual for infarcts (choice C) to involve so many organs. Also the microscopic description is not appropriate for infarcts which should demonstrate coagulative necrosis. Tuberculosis (choice E) is an infectious granulomatous disease but the granulomas usually have central caseous necrosis.

40. A 58-year-old white man has a five-year history of progressively worsening heart failure. An autopsy limited to the heart reveals extensive replacement of the myocardium by an acellular eosinophilic material. This material is most likely to be A amyloid CORRECT ANSWER B calcium salt deposition C cholesterol D myocyte fibrinoid necrosis E post-infarctive scars -------------------------------------------------------------------------------Additional Information Amyloid is an acellular material that is eosinophilic. After Congo red staining there is apple-green dichroism when examined under polarized light microscopy. Calcium salts (choice B) tend to be deeply basophilic, not eosinophilic, with routine stains. Cholesterol deposits (choice C) tend to dissolve out of tissues with routine processing agents leaving only empty outlines of where the crystals once were present. Myocyte fibrinoid necrosis (choice D) and post-infarctive scars (choice E) would be moderately cellular and eosinophilic. Congo-red dichroism is not evident in either.