UNIVERSITY OF HEALTH SCIENCES PATHOLOGY EXAM IV 1994-1995 INSTRUCTIONS For the multiple-choice items, including the pictures, fill in your answers on the answer sheet provided. For the completion items, put your answers on the exam sheet. Use ink if you have it. Your instructor will only review possible grading errors if there is no evidence of erasure. We have tried to write a fair test, but there will surely be problems with certain items. If you have a question, raise you hand and we'll talk about it QUIETLY (don't phonate!) during the exam. O COME, DESIRE OF NATIONS, BIND IN ONE THE HEARTS OF HUMANKIND, BID THOU OUR SAD DIVISIONS CEASE AND BE FOR US THE PRINCE OF PEACE. -- Advent Hymn, C. 900 ("O Come Emmanuel") [The first 35 items came from the GRIPE bank.] 36. "Dental plaque", the cause most caries and periodontal disease, is composed primarily of A. bacteria (living and dead) B. lipid C. nucleic acid * D. polysaccharide E. protein 37. What's the eponym for a spreading cellulitis of the floor of the mouth and the nearby tissues, which can compromise the airway? A. Beh€et's * B. Ludwig's C. Vincent's D. Von Ebner's E. Warthin's 38. Which is the antibiotic you'd rather not give a pregnant woman or a child, for fear of staining the teeth? A. cephalosporo-something-or-other B. erythromycin C. gentamicin * D. tetracycline E. penicillin 39. What do you call it when the esophago-gastric sphincter won't relax to let dinner into your stomach? * A. achalasia B. globus C. Schatzki's ring D. stenosis E. tenesmus 40. Which is the most common in humans? A. congenital pyloric stenosis B. diaphragmatic hernia C. rolling hiatus hernia * D. sliding hiatus hernia E. trichobezoar 41. Which is NOT known to be a risk factor for squamous cell carcinoma of the esophagus? A. alcohol abuse B. American trypanosomiasis * C. Barrett's esophagus D. cigaret smoking E. old scarring from drinking lye 42. Which is NOT reasonably well-established as a risk factor for gastric adenocarcinoma? * A. diet high in animal fat B. diet high in smoked food C. lack of green vegetables in the diet D. pernicious anemia E. previous ulcer surgery 43. Sister Mary Joseph's node is stomach cancer metastatic to the * A. belly button B. celiac lymph node chain C. left supraclavicular / jugular lymph node D. ovarian surface E. para-pancreatic lymph nodes 44. Which is LEAST LIKELY to complicate a Meckel's diverticulum? A. acute abdomen simulating appendicitis * B. carcinoma C. bleeding ulcer D. painful ulcer E. volvulus 45. 0157:H8 is: * A. a dangerous strain of E. coli bacteria B. an antigen used to immunostain for hemolytic-uremic syndrome C. an antigen which is one of the salmonella virulence factors D. an experimental antibiotic for tough shigella infections E. Dr. Del Campo's license plate number 46. You're doing the autopsy on a homeless person, without identification, found dead in the snow. You note ulcers of the bowel, and find the lymphoid follicles packed with macrophages loaded with red cells. What probably killed him? A. Crohn's disease B. infectious mononucleosis * C. typhoid D. ulcerative colitis, perhaps with backwash ileitis E. Whipple's disease MATCHING!! Use each item no more than once. A. chicken fat B. current jelly C. pea soup D. peanut butter and jelly E. rice water 47. The stool in cholera [E] 48. The stool in shigellosis or inflammatory bowel disease [B] 49. The stool in typhoid [C] 50. Which is NOT a currently-discussed complication of cow's milk ingestion? A. allergic-type eczema (skin rash) B. autoimmune diabetes C. delayed-hypersensitivity, T-cell-mediated enteritis * D. immune-complex glomerular disease E. iron-deficiency when cow's milk is the basis of the diet 51. The pathologist says, "Small intestinal biopsy, consistent with celiac sprue." What did she see? A. "Casper the Ghost"-faced organisms on the brush border B. lipid-laden absorptive enterocytes * C. no villi, deep glands D. non-caseating granulomas E. PAS-positive bacilli in macrophages 52. You, the generalist, then instruct the celiac sprue patient, who lives in Kansas City, to: A. avoid cow's milk and refined sugar * B. scrupulously avoid wheat, barley, and rye C. take folic acid supplements and antibiotics D. take immune-suppressive drugs E. take tetracycline for a year to kill the bacteria 53. Like most rural generalists, you're doing your own proctoscopies. Thus, you're very familiar with those trivial little white things that look like rice grains on the colonic mucosa. They're: A. diverticulum openings * B. hyperplastic polyps C. juvenile polyps ("juvenile" means "little" here) D. tubular adenomas E. villous adenomas 54. What's the notable risk factor for squamous cell carcinoma of the anus? A. hemorrhoids * B. HPV infection from anal intercourse C. low-fiber diet D. pinworms E. sun exposure MATCHING!! Use each item exactly once. A. Hepatitis A B. Hepatitis B C. Hepatitis C D. Hepatitis D E. Hepatitis E 55. Calcivirus, not much found in the U.S., which is good [E] 56. "The Dane Particle", carried by 200,000,000 humans [B] 57. Most of the old "non-A, non-B" post-transfusion cases [C] 58. Requires co-infection with Hepatitis B [D] 59. Vaccine became available in 1994; stay tuned [A] 60. The pathologist reported your liver biopsy as "cirrhosis", but your patient (a gym rat) died next year with an essentially normal liver, with the biopsy leading into an area of: A. an old anabolic-steroid related adenoma B. cavernous hemangioma * C. focal nodular hyperplasia D. localized Caroli change E. normal liver, the cirrhosis self-cured as it's prone to do 61. Lysolecithin is currently accused of causing all EXCEPT: * A. bonding Helicobacter to the cells of pyloric epithelium B. inflaming the gallbladder in acute cholecystitis C. washing backwards up the pancreatic duct and causing pancreatitis D. washing backwards through the pylorus and contributing to stomach problems 62. I'm jaundiced and can feel my gallbladder through my skinny abdominal wall. That gallbladder is poking out two inches below my ribcage. I bet I've got: A. cancer of the gallbladder * B. cancer of the pancreas C. common bile duct stone D. cystic duct stone E. Klatskin cancer at the juncture of the hepatic ducts 63. Evidence of past or present hepatitis E infection is MOST prevalent in A. Caribbean B. Far East * C. Middle East D. sub-Saharan Africa E. U.S. inner cities 64. How does a pancreatic pseudocyst differ from a true cyst? * A. no epithelial lining B. not an abnormal finding, really C. not fluid-filled D. not truly closed, but communicates with the pancreatic duct E. it is a true cyst, somebody is just playing mind games 65. A current experimental procedure involves the diagnosis of cancer of the pancreas based on the finding, in the pancreatic fluid, of: A. a viruses B. Hšrthle cells C. molybdenum * D. oncogenic ras by PCR E. phosphofructokinase 66. What gene bears the mutation in maturity-onset diabetes of the young? A. fibroblast growth-factor 3 B. glucose oxidase * C. glucokinase D. glycogen synthetase E. transketolase 67. Which is LEAST LIKELY to give you a diffuse proliferative glomerulonephritis pattern? * A. anti-GBM disease B. lupus C. post-streptococcal disease D. severe sepsis E. staphylococcal infection on a prosthetic heart valve 68. Immune complexes containing mostly IgA tend to be laid down A. as subendothelial "wire loops" B. as coarse epithelial granules C. as "dense deposits" within the GBM D. as fine subepithelial granules * E. in the mesangium 69. Fibrosis around the collecting ducts makes you suspect the patient is being treated with A. anti-diuretic hormone B. gold for rheumatoid arthritis * C. lithium for mood disorder D. non-steroidal anti-inflammatory agents E. none of the above, this is "mechanical bull" lesion 70. ONE KODACHROME. "Number 5" is a(n): A. basement membrane B. capillary lumen C. epithelial cell nucleus D. endothelial cell nucleus * E. mesangial cell nucleus 71. THREE KODACHROMES. What's the glomerular disease? A. cryoglobulins B. diabetes C. diffuse proliferative glomerulonephritis, maybe post-strep D. IgA nephropathy * E. membranous glomerulopathy 72. ONE KODACHROME. Islet of Langerhans in the center, exocrine pancreas around it. What's wrong? A. adenocarcinoma, possibly of endocrine origin B. cystic fibrosis C. old alcoholic disease D. type I diabetes * E. type II diabetes 73. THREE KODACHROMES. What's wrong with this appendix? A. acute appendicitis * B. carcinoid C. mucinous adenocarcinoma D. mucocele E. nothing 74. ONE KODACHROME. The principal risk factor for this gallbladder cancer is A. aflatoxin exposure * B. gallstones C. hemolytic anemia D. hepatitis B or C viruses E. previous surgery 75. THREE KODACHROMES. Salivary gland. What's the diagnosis? A. adenoid cystic carcinoma B. mucoepidermoid carcinoma C. pleomorphic adenoma D. salivary gland calculus * E. Warthin's papillary cystadenoma lymphomatosum 76. TWO KODACHROMES. Kidney. What's the diagnosis? * A. acute pyelonephritis B. acute tubular necrosis C. lead poisoning D. papillary necrosis E. Sj”gren's or something like it 77. ONE KODACHROME. This linear fluorescence pattern tells me it's: * A. Goodpasture's disease B. lupus C. membranous glomerulopathy D. post-streptococcal glomerulonephritis or the like E. Wegener's 78. TWO KODACHROMES. Pancreas. What is the diagnosis? A. acute pancreatitis B. adenocarcinoma C. cystic fibrosis * D. hemochromatosis E. pseudocyst 79. THREE KODACHROMES. Salivary gland mass. What's the diagnosis? A. adenoid cystic carcinoma B. mucoepidermoid carcinoma * C. pleomorphic adenoma D. salivary gland calculus E. Warthin's papillary cystadenoma lymphomatosum 80. TWO KODACHROMES. H&E and PAS stain of glomeruli. What's the diagnosis? A. diffuse proliferative glomerulonephritis * B. diabetes C. end-stage kidney, cannot tell anything more D. lupus, most likely E. membranous glomerulonephritis 81. TWO KODACHROMES. Gross and trichrome stain of stomach. What's your best diagnosis? A. adenocarcinoma B. Crohn's regional enteritis C. malignant lymphoma * D. M‚n‚trier's disease E. ulcer, probably Helicobacter-related 82. ONE KODACHROME. Viral hepatitis. The arrow points to a(n): A. area of piecemeal necrosis B. bile lake * C. Councilman body D. lymphocyte, probably a T-killer cell E. neutrophil 83. THREE KODACHROMES. What probably did this to the dude's liver? * A. alcohol B. acetaminophen overdose C. hepatitis B or C D. Reye's E. viral hepatitis, could have been A, B, C, D, E or whatever 84. TWO KODACHROMES. Photomicrographs of a renal mass. What sort? A. angiomyolipoma B. cystic dysplasia with cartilage C. oncocytoma (Hšrthle cell tumor) D. renal cell carcinoma * E. Wilms' tumor 85. ONE KODACHROME. Kidney. What's the diagnosis? A. autosomal dominant polycystic kidney disease B. autosomal recessive polycystic kidney disease C. cystic dysplasia * D. hydronephrosis E. simple cyst 86. ONE KODACHROME. Glomerulus. What's wrong? A. benign essential hypertension B. diffuse proliferative glomerulonephritis C. diabetes * D. malignant hypertension E. none of these; nothing unusual about this glomerulus 87. TWO KODACHROMES. Liver. What is the diagnosis? * A. autosomal dominant polycystic kidney disease B. Dubin-Johnson C. macronodular cirrhosis D. micronodular cirrhosis E. none of these; nothing unusual about this liver 88. TWO KODACHROMES. Esophagus. What's the diagnosis? A. Barrett's esophagus B. candida infestation * C. carcinoma D. cytomegalovirus E. reflux changes 89. THREE KODACHROMES. Colon. What's the diagnosis? A. Crohn's regional enteritis B. diverticulosis (poor orientation by the pathologist) C. Hirschsprung's disease D. pseudomembranous colitis * E. ulcerative colitis 90. FOUR KODACHROMES. Liver. The gross and microscopic photos both show: A. acute hepatitis, viral or drug B. chronic active hepatitis C. macronodular cirrhosis D. micronodular cirrhosis * E. hepatocellular carcinoma 91. ONE KODACHROME. Liver. What is the diagnosis? * A. Budd-Chiari B. echinococcus C. fish tapeworm D. pork or beef tapeworm E. schistosomiasis 92. FOUR KODACHROMES. Colon. What is the diagnosis? A. Crohn's regional enteritis B. diverticulosis (poor orientation by the pathologist) C. Hirschsprung's disease * D. pseudomembranous colitis E. ulcerative colitis 93. ONE KODACHROME. Colon. What is the diagnosis? A. Crohn's regional enteritis * B. diverticulosis C. Hirschsprung's disease D. pseudomembranous colitis E. ulcerative colitis 94. FOUR KODACHROMES. Photomicrographs of pancreas. This is not cystic fibrosis. What is the diagnosis? A. acute hemorrhagic pancreatitis B. adenocarcinoma * C. "chronic pancreatitis" from alcohol abuse D. primary diabetes, type I E. primary diabetes, type II 95. FIVE KODACHROMES. Kidney. What's the diagnosis? A. diabetic glomerular disease * B. focal-segmental glomerulosclerosis C. hypertensive renal disease D. membranous glomerulonephritis E. Wegener's or something like it 96. ONE KODACHROME. Liver. What's the diagnosis? A. acute hepatitis, viral or drug B. chronic active hepatitis with piecemeal necrosis * C. hemolysis or myelofibrosis (extramedullary erythropoiesis) D. malignant lymphoma E. there is nothing unusual here 97. ONE KODACHROME. Gross photo of small intestine. This is: A. carcinoid B. carcinoma * C. Crohn's regional enteritis D. intussusception E. Meckel's diverticulum 98. TWO KODACHROMES. Two photomicrographs of A. gastric intestinal metaplasia without cancer B. gastric ulcer C. Helicobacter with no ulcer * D. stomach carcinoma E. stomach lymphoma 99. TWO KODACHROMES. This mass in the kidney is a(n): A. angiomyolipoma B. hydronephrosis * C. renal cell carcinoma D. renal cyst E. Wilms tumor 100. ONE KODACHROME. These pale-yellow gallstones are made mostly of A. calcium bilirubinate B. chenodeoxycholic acid * C. cholesterol D. uric acid E. struvite (magnesium ammonium phosphate) BONUS ITEMS: 101. The newly-touted serum tumor marker CA-19-9 supposedly indicates cancer of what organ? [pancreas] 102. Briefly explain why deferoxamine is administered to patients with thalassemia major? [remove iron] 103. What country has a horrible epidemic of cancer of the esophagus, variably blamed on fungi, vitamin deficiency, nitrosamines,and trace-metal deficiencies? [Red China] 104. Zollinger-Ellison syndrome results when a tumor produces what hormone? [gastrin] 105. Earlier this year, new evidence linked both gastric B-cell lymphoma and M‚n‚trier's hypertrophic gastritis to what etiology? [Helicobacter] 106. What is Whipple's triad? [I'll take anything about CNS signs in hypoglycemia] 107. What's the intestinal syndrome caused by overgrowth of Clostridium difficile in patients on antibiotics? [pseudomembranous enterocolitis] 108. Non-caseating granulomas are often, but not always, seen in what intestinal disease of unknown etiology? [Crohn's] 109. You can diagnose Osler-Weber-Rendu telangiectasia before that GI bleeder even opens his mouth, by noticing what? [telangiectasias on the lips] 110. What's the fancy medical name for a white "canker sore" in your mouth around exam time? It really hurts when you drink orange juice. [aphthous stomatitis; I need "aphth" or something close] 111. What is a cryoglobulin? [marginally-soluble plasma protein] 112. What is Alport's disease? Be at least semi-specific. [genetic problem with GBM collagen synthesis] 113. All classic African hepatocellular carcinomas bear a particular mutation in p53 which is known to be caused by what carcinogen? [aflatoxin / moldy food / aspergillus] 114. What's the latest thinking about why patients with cancer of the exocrine pancreas have insulin-resistant diabetes as a paraneoplastic syndrome? [amylin / IAPP production by the cancer] 115. What's the name of the hamartoma-type renal mass that's so common in patients with tuberous sclerosis? [angiomyolipoma] 116. Give the chemical name and/or the chemical structure of endothelial-derived relaxation factor? [nitric oxide / NO] 117. "Dialysis dementia", seen in patients treated in the original hemodialysis programs, featured histopathology similar to Alzheimer's disease, now attributed to accumulation of what chemical element? [aluminum] 118. Dietary protein restriction, angiotensin-converting enzyme inhibitors, and calcium channel blockers are all being used in serious renal disease from many different etiologies, and for the same reason. Why? [seem to prevent hyperfiltration lesions/ sclerosis/] [progressive renal deterioration] 119. You have just been appointed Surgeon General of the United States. Mention something you would do. Be at least semi- serious. [For one thing, you've been hired to urge people and] [government to apply the findings of hard science] [to promote better health. Focus on this, and do not] [allow yourself to be drawn into public discussions about] [controversial social problems, no matter how enlightened] [you may actually be, and how foolish your detractors,] [and even if the discussion relates to public health.] [+1 for any hard science-based proposal, zero for] [being controversial; the latter isn't the S.G.'s job.] 120. Why is this man smiling. [Since he's not a politician, he's free to describe,] [and even burlesque and lampoon, the world as it really is.] [+1 for any reasonable answer.]