INTEGRATED BASIC SCIENCES PreTest® Self-Assessment and Review pot

INTEGRATED
BASIC SCIENCES
PreTest®
Self-Assessment
and Review


NOTICE
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INTEGRATED
BASIC SCIENCES
PreTest®

Self-Assessment
and Review
EDITOR

Earl J. Brown, MD
Associate Professor
Department of Pathology
East Tennessee State University
Johnson City, Tennessee

McGRAW-HILL
Health Professions Division
New York St. Louis San Francisco Auckland Bogotá Caracas Lisbon
London Madrid Mexico City Milan Montreal New Delhi
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DOI: 10.1036/0071435581


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CONTENTS

Introduction
Acknowledgments
CHAPTER 1

CHAPTER 2

CHAPTER 3

CHAPTER 4

CHAPTER 5

HEMATOLOGY
Questions
Answers, Explanations, and
References
CARDIOVASCULAR
Questions
Answers, Explanations, and
References

vii
ix
1
1

29

73
74

102

RESPIRATORY
Questions
Answers, Explanations, and
References

151

HEAD AND NECK
Questions
Answers, Explanations, and
References

219

GASTROINTESTINAL
Questions
Answers, Explanations, and
References

279

152

177

220

242

280

305

v

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vi

CHAPTER 6

CHAPTER 7

CHAPTER 8

CONTENTS

GU/BREAST
Questions
Answers, Explanations, and
References

353

ENDOCRINE
Questions
Answers, Explanations, and
References

437

MUSCULOSKELETAL
AND NEUROPATHOLOGY
Questions
Answers, Explanations, and

References

Bibliography

354

385

438

461

497
498

528

577


INTRODUCTION

One of the current trends in medical education is to integrate material between the basic science courses of the first two years of medical school
and to integrate material between the basic science courses and the clinical departments. Medical students often feel submerged by the flood of
information during medical school and attempts to integrate this material
are often met with much frustration. The basic premise for this book is to
help in the integration of material between the basic science courses of
medical school. The questions in this book are grouped in sets of three
questions around a clinical scenario. The organization of each of these
three question sets is as follows: the first question in each group covers

anatomy illustrated by the clinical scenario [either gross anatomy, microscopic anatomy (histology), or developmental anatomy (embryology)];
the second question in each group covers the normal functioning that is illustrated by the clinical scenario (either biochemistry, physiology, or immunology), and the third question of each set covers the abnormal functions involving the clinical case (namely pathology, pharmacology, or
microbiology).
The questions in each PreTest® Self-Assessment and Review book parallel the format and degree of difficulty of the questions found in the United
States Medical Licensing Examinations (USMLE). Each question is accompanied by an answer, a paragraph explanation, and a specific page
reference to an appropriate textbook or journal article. A bibliography
listing sources can be found following the last chapter of this text. An effective way to use this PreTest® is to read a clinical scenario and answer
the set of three questions that are associated with that clinical case. You
should allow yourself about one minute to answer each question in the
set. As you proceed, indicate your answer beside each question. By following this suggestion, you approximate the time limits imposed by the
Step. After you finish going through the questions in each set, spend as
much time as you need verifying your answers and carefully reading the
explanations provided. Pay special attention to the explanations for the
questions you answered incorrectly — but read every explanation. The authors of this material have designed the explanations to reinforce and supplement the information tested by the questions. If you feel you need
vii

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viii

INTRODUCTION

further information about the material covered, consult and study the references indicated. This book is directed primarily toward medical students, especially second year medical students as they prepare for the
USMLE Step 1. Since the book will integrate material from many of the
basic science medical courses, it will also benefit first and second year
medical students as they study for individual courses during the first two
years of medical school. It will especially be beneficial if they use it to integrate these courses. Additionally, since the questions will all be based
on patient histories, this book will also be beneficial to students during
their third and fourth years to review basic science course material and integrate this into their clinical experience. It will also be beneficial for

these students as they study for the USMLE Step 2.
Earl Brown, MD


ACKNOWLEDGMENTS

I would like to express my appreciation and gratitude to my colleagues in
the Department of Pathology for their support and help over the past
decade that I have been director of the sophomore pathology course at the
Quillen College of Medicine. I would like to especially thank Dr. Philip
S. Coogan, the chairman of our department, who has supported my efforts
over the years and has enabled me to progress as a teacher. I would especially like to express my deep felt thanks to all the many students who
over the years have inspired me with their spirit, their common sense, and
their enthusiasm. They have showed me time and time again different and
better ways to explain concepts and integrate basic science material. They
have taught me much. Finally, I would like to thank my family, my wife
Janet and my two children Kevin and Heather, who have supported me
through many late-night and weekend typing sessions.

ix

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CHAPTER 1

HEMATOLOGY

I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
XI.
XII.
XIII.
XIV.
XV.
XVI.
XVII.
XVIII.

megaloblastic anemia
iron-deficiency anemia
hereditary spherocytosis
methemoglobin
sickle cell anemia
porphyria (PCT)
aplastic anemia
chronic myeloid leukemia
acute myeloid leukemia
acute lymphoid leukemia
severe combined immune deficiency

syndrome
multiple myeloma
infectious mononucleosis
lymphoma (B cell)
immune thrombocytopenia purpura
myelofibrosis
von Willebrand disease
hemophilia A

1

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Case Study I

MEGALOBLASTIC ANEMIA
Integrated Basic Science Content Review
ANATOMY/HISTOLOGY/EMBRYOLOGY

Normal RBC Maturation
BIOCHEMISTRY/PHYSIOLOGY/IMMUNOLOGY

Biochemical Reactions Involving B12
PATHOLOGY/PHARMACOLOGY/MICROBIOLOGY

Schilling Test

I. A 44-year-old woman presents with fatigue, weakness, a sore
tongue, and numbness and tingling (paresthesias) of her arms

and legs.
Physical examination reveals a slightly enlarged spleen and a smooth,
beefy-red tongue. Neurologic examination reveals a decreased sense
of vibration and position in both her arms and legs. The complete
blood count (CBC) reveals decreased numbers of erythrocytes, leukocytes, and platelets (pancytopenia) along with an increase in the mean
cell volume (MCV) of the erythrocytes. Examination of the peripheral
smear reveals numerous enlarged, oval-shaped erythrocytes (macroovalocytes), and many of the neutrophils have more than five lobes
(hypersegmented neutrophils). Histologic examination of a smear
made from a bone marrow aspiration reveals asynchrony in red blood
cell (RBC) precursors between the maturation of the nuclei and their
cytoplasm. Additional workup discovers achlorhydria and chronic atrophic gastritis.
1. Which one of the following sequences correctly describes the normal
maturation sequence of RBC precursors between the proerythroblast
stage and bone marrow reticulocytes?
1 ϭ basophilic erythroblast
2 ϭ orthochromatophilic erythroblast
3 ϭ polychromatophilic erythroblast
2


CHAPTER 1 HEMATOLOGY
(A) 1 : 2 : 3
(B) 1 : 3 : 2
(C) 2 : 3 : 1

3

(D) 3 : 1 : 2
(E) 3 : 2 : 1

2. Vitamin B12 normally participates directly in which one of the following biochemical reactions?
(A)
(B)
(C)
(D)
(E)

propionyl coenzyme A (CoA) : methylmalonyl CoA
methylmalonyl CoA : succinyl CoA
succinyl CoA 2 : fumarate
malonyl CoA 2 : palmitate
dUMP 2 : dTMP

3. Which of the following tests would most likely indicate the etiology
of this patient’s signs and symptoms?
(A) acid hemolysis test
(B) Coombs’ test
(C) metabisulfite test

(D) osmotic fragility test
(E) Schilling test

Case Study II

IRON-DEFICIENCY
ANEMIA
Integrated Basic Science Content Review
ANATOMY/HISTOLOGY/EMBRYOLOGY

Normal RBC Histologic Appearance

BIOCHEMISTRY/PHYSIOLOGY/IMMUNOLOGY

Iron Gastrointestinal Absorption
PATHOLOGY/PHARMACOLOGY/MICROBIOLOGY

Bone Marrow Findings


4

INTEGRATED BASIC SCIENCES

II. A 37-year-old woman presents with fatigue, lethargy, and muscle
weakness.
Physical examination reveals pallor of her skin, a smooth tongue, and
a concave shape (“spoon-nails”) of her fingernails. Her heart rate is
increased (tachycardia), and her respiratory rate is slightly increased.
Examination of her peripheral smear reveals her RBCs to be small and
pale (microcytic and hypochromic) and different shapes (poikilocytosis). Laboratory evaluation reveals a hemoglobin concentration of
10.4 g/dL, and her red cell indexes reveal a mean cell volume of 71
␮m3 and a mean cell hemoglobin (MCH) of 21.5 g/dL. Additional
tests reveal the serum iron, serum ferritin, and the transferrin saturation to be decreased, but the total iron-binding capacity (TIBC) is
increased.
4. Which one of the following statements is INCORRECT concerning
the normal histologic appearance of RBCs in the peripheral blood?
(A)
(B)
(C)
(D)
(E)

They are anucleate cells as they lack a nucleus.
They are round biconcave disks.
They contain abundant hemoglobin and lack cell organelles.
They contain multiple, finely granular, basophilic cytoplasmic granules.
They have a central pallor that is about one-third the diameter of the cell.

5. Most of the dietary iron is absorbed in the
(A)
(B)
(C)
(D)
(E)

stomach
upper part of the small intestines
lower part of the small intestines
upper part of the colon
lower part of the colon

6. Examination of the bone marrow of this individual is most likely to
reveal
(A)
(B)
(C)
(D)
(E)

absent iron stores
iron trapped within macrophages

megaloblastic erythroid maturation
numerous ring sideroblasts
red cell aplasia


CHAPTER 1 HEMATOLOGY

5

Case Study III

HEREDITARY
SPHEROCYTOSIS
Integrated Basic Science Content Review
ANATOMY/HISTOLOGY/EMBRYOLOGY

RBC Membrane
BIOCHEMISTRY/PHYSIOLOGY/IMMUNOLOGY

RBC Lysis
PATHOLOGY/PHARMACOLOGY/MICROBIOLOGY

Diagnosis

III. A 24-year-old man presents with signs and symptoms of mild
anemia.
Physical examination shows a mildly enlarged spleen. Laboratory
examination reveals normal liver serum enzyme levels, and the direct
antiglobulin test is negative. Examination of his peripheral blood
reveals that most of the erythrocytes are small, spherical, and lack the

central pallor. Reticulocytes are increased in number. The RBC
indices reveal a mean cell hemoglobin concentration (MCHC) of 37%
and an MCH of 28 pg.
7. The spherical erythrocytes (spherocytes) in this individual’s peripheral
blood may be the result of an abnormality involving the RBC membrane. Which one of the following proteins is a peripheral protein of
the normal RBC membrane?
(A) amyloid
(B) dystrophin
(C) fibrillin

(D) protein 3
(E) spectrin


6

INTEGRATED BASIC SCIENCES

8. The abnormal spherical shape of these erythrocytes would most likely
result in
(A) decreased ability to transport bicarbonate ions
(B) decreased ability to transport chloride ions
(C) increased red cell capacity to expand when placed in a hypotonic salt solution
(D) increased red cell lysis when placed in a hypotonic salt solution
(E) resistance to Plasmodium falciparum infection

9. What is the most likely diagnosis for this individual?
(A)
(B)
(C)

(D)
(E)

hereditary pyropoikilocytosis
hereditary spherocytosis
paroxysmal cold hemoglobinuria
paroxysmal nocturnal hemoglobinuria
pyruvate kinase deficiency

Case Study IV

METHEMOGLOBIN
Integrated Basic Science Content Review
ANATOMY/HISTOLOGY/EMBRYOLOGY

Hemoglobin
BIOCHEMISTRY/PHYSIOLOGY/IMMUNOLOGY

Hemoglobin–Oxygen Dissociation Curve
PATHOLOGY/PHARMACOLOGY/MICROBIOLOGY

Cause of Abnormality (Brown Color)

IV. A 5-year-old boy is being evaluated for generalized cyanosis.
Physical examination reveals his lungs to be clear, and his heart is
found to be within normal limits. No cardiac murmurs are heard, and


CHAPTER 1 HEMATOLOGY

7

no cardiopulmonary abnormalities are found. Laboratory examination
reveals his CBC, electrolytes, blood urea nitrogen (BUN), and creatinine to be within normal limits. Blood gases reveal a normal oxygen
tension (PaCO2) and a low arterial oxygen saturation (SaO2). There is
no increase in SaO2 with oxygen therapy. It was noted when the blood
was drawn to be sent to the hospital laboratory that it had an unusual
chocolate-brown color, and when the blood was exposed to the air it
remained an abnormal brown color.
10. Which one of the following substances is most responsible for producing the normal red color of blood?
(A) albumin
(B) haptoglobin
(C) hemoglobin

(D) immunoglobulin
(E) myoglobin

11. All of the following will cause the hemoglobin – oxygen dissociation
curve to shift to the right and increase the P50 of hemoglobin
EXCEPT
(A)
(B)
(C)
(D)
(E)

an abnormal hemoglobin with decreased oxygen affinity
decreased concentration of 2,3-bisphosphoglycerate
decreased pH
increased PCO2

increased temperature

12. Which one of the following is most likely responsible for the brown
color of this individual’s blood?
(A)
(B)
(C)
(D)
(E)

an abnormal hemoglobin with decreased oxygen affinity
an abnormal hemoglobin with increased oxygen affinity
carbon monoxide
oxidized hemoglobin
reduced hemoglobin


8

INTEGRATED BASIC SCIENCES

Case Study V

SICKLE CELL ANEMIA
Integrated Basic Science Content Review
ANATOMY/HISTOLOGY/EMBRYOLOGY

Normal Hemoglobin Types in Adults
BIOCHEMISTRY/PHYSIOLOGY/IMMUNOLOGY

Classification of Amino Acids
PATHOLOGY/PHARMACOLOGY/MICROBIOLOGY

RBC Inclusions

V. An 18-year-old man with a history of recurrent episodes of severe
abdominal pain is being followed for a chronic, nonhealing ulcer of
his lower leg.
Examination of his peripheral blood reveals abnormal-shaped erythrocytes and occasional Howell-Jolly bodies. Hemoglobin electrophoresis reveals 88% hemoglobin S, 8% hemoglobin A2, and 4%
hemoglobin F.
13. In comparison to this individual, which one of the following combinations of hemoglobin percentages is most consistent with the hemoglobin electrophoresis pattern from a normal adult?
HEMOGLOBIN A

(A)
(B)
(C)
(D)
(E)

HEMOGLOBIN A2

HEMOGLOBIN F

HEMOGLOBIN S

3%
4%
55%
50%
97%

95%
60%
5%
46%
2%

2%
6%
5%
4%
1%

0%
30%
35%
0%
0%


CHAPTER 1 HEMATOLOGY

9

14. Which one of the following amino acids has a nonpolar side chain and
is most likely to participate in hydrophobic interactions?
(A) arginine
(B) asparagine
(C) glutamic acid

(D) glutamine
(E) valine

15. Howell-Jolly bodies are composed of
(A) aggregates of ␤-globin chains
(B) aggregates of iron
(C) denatured hemoglobin

(D) remnants of nuclear chromatin
(E) remnants of RNA

Case Study VI

PORPHYRIA (PCT)
Integrated Basic Science Content Review
ANATOMY/HISTOLOGY/EMBRYOLOGY

Sites for Synthesis of Heme
BIOCHEMISTRY/PHYSIOLOGY/IMMUNOLOGY

Rate-Limiting Step in Heme Synthesis
PATHOLOGY/PHARMACOLOGY/MICROBIOLOGY

Diagnosis

VI. A 29-year-old man seeks medical advice because of a chronic,
recurrent rash on sun-exposed areas of his face and arms.
Obtaining his medical history, you discover that he has always been
sensitive to the light. He states that his face will break out in a rash if
he stays in the sun too long. He also states that his urine turns dark

with time and that in public rest rooms it has a strange red tint. He


10

INTEGRATED BASIC SCIENCES

notes that sometimes alcohol ingestion will make these episodes
worse. Physical examination reveals multiple fluid-filled vesicles and
bullae on his face, forearms, and dorsa of his hands, along with a
diffuse distribution of lanugo-type hair over most of his body. No
neurologic abnormalities are found. Laboratory examination reveals
elevated urine levels of uroporphyrin, but no increased levels of
aminolevulinic acid or porphobilinogen. Fecal porphyrin is normal.
16. The major sites for the synthesis of heme are the
(A) bone marrow and kidney
(B) bone marrow and liver
(C) liver and kidney

(D) spleen and bone marrow
(E) spleen and kidney

17. Which one of the following biochemical steps is the rate-limiting step
in the biosynthesis of heme?
(A) four molecules of porphobilinogen condense to form uroporphyrinogen
III
(B) iron is inserted into protoporphyrin
(C) succinyl CoA combines with glycine to form ␦-aminolevulinic acid
(D) two molecules of ␦-aminolevulinic acid condense to form porphobilinogen
(E) uroporphyrinogen III is converted into coproporphyrinogen III

18. What is the best diagnosis for this individual?
(A) acute intermittent porphyria
(B) glucose-6-phosphate deficiency
(C) lead poisoning

(D) porphyria cutanea tarda
(E) sideroblastic anemia


CHAPTER 1 HEMATOLOGY

11

Case Study VII

APLASTIC ANEMIA
Integrated Basic Science Content Review
ANATOMY/HISTOLOGY/EMBRYOLOGY

Normal Bone Marrow Findings
BIOCHEMISTRY/PHYSIOLOGY/IMMUNOLOGY

Interleukin 3
PATHOLOGY/PHARMACOLOGY/MICROBIOLOGY

Diagnosis

VII. A 35-year-old woman with a history of hepatitis C infection
presents with pallor, fever, epistaxis, and multiple hemorrhages

on her skin.
Physical examination reveals pallor of the skin and conjunctiva, and
multiple petechial hemorrhages on her skin. Her liver and spleen are
not enlarged, and there is no significant lymphadenopathy. The results
of her physical examination are otherwise unremarkable. A complete
CBC reveals a normocytic normochromic anemia, thrombocytopenia,
and neutropenia (pancytopenia). The corrected reticulocyte count is
Ͻ 2%, and polychromasia was not noted. The serum blood urea nitrogen and creatinine are within normal limits. A Coombs’ test is negative. A bone marrow biopsy is performed and histologic examination
reveals a fat-to-cell ratio of more than 10 to 1. A few scattered groups
of cells are found consisting mainly of histologically unremarkable
lymphocytes and plasma cells. No granulomas, fibrosis, or metastatic
malignant cells are found.


12

INTEGRATED BASIC SCIENCES

19. All of the following findings found in a bone marrow specimen from
the posterior iliac crest of a 40-year-old woman are within normal
limits EXCEPT
(A)
(B)
(C)
(D)
(E)

1% plasma cells
10% lymphocytes
a fat to cell ratio of 4 to 1

a myeloid to erythroid ratio of 3 to 1
two megakaryocytes per low-power field

20. Which one of the following substances is a factor that causes the
proliferation of granulocytes, monocytes, erythrocytes, and megakaryocytes?
(A) erythropoietin
(B) G-CSF
(C) GM-CSF

(D) interleukin 3
(E) M-CSF

21. What is the best diagnosis for this individual?
(A)
(B)
(C)
(D)
(E)

aplastic anemia
megaloblastic anemia
microangiopathic hemolytic anemia
myelophthisic anemia
pure red cell aplasia

Case Study VIII

CHRONIC MYELOID
LEUKEMIA
Integrated Basic Science Content Review

ANATOMY/HISTOLOGY/EMBRYOLOGY

Alkaline Phosphatase
BIOCHEMISTRY/PHYSIOLOGY/IMMUNOLOGY

Function of c-abl
PATHOLOGY/PHARMACOLOGY/MICROBIOLOGY

Diagnosis


CHAPTER 1 HEMATOLOGY

13

VIII. A 42-year-old man presents with left-sided abdominal pain,
increasing fatigue, and a low-grade fever.
Physical examination reveals pallor of the skin and a markedly
enlarged spleen. A CBC reveals the white blood cell (WBC) count to
be increased to 68,000 cells/␮L, due mainly to increased numbers of
neutrophils, bands, and metamyelocytes. Basophils and eosinophils
are slightly increased in number. Other laboratory tests reveal a low
leukocyte alkaline phosphatase (LAP score) and increased serum
levels of vitamin B12. Examination of a bone marrow biopsy
specimen reveals marked hypercellularity ( Ͼ 95% cells) due to a
diffuse proliferation of myeloid precursors. A differential count of
these cells reveals all of the neutrophil precursors to be increased
except myeloblasts. A karyotype from the bone marrow reveals the
presence of a chromosomal translocation 22 to 9 (Philadelphia chromosome).
22. Which one of the following cells is a phagocytic leukocyte that contains alkaline phosphatase, collagenase, lactoferrin, and lysozyme

within its specific cytoplasmic granules?
(A) basophil
(B) eosinophil
(C) lymphocyte

(D) monocyte
(E) neutrophil

23. The product of the oncogene c-abl, which is located on chromosome
9 and is translocated in the Philadelphia chromosome, is a
(A) cell surface receptor
(B) growth factor
(C) GTP-binding protein

(D) nuclear regulatory protein
(E) tyrosine kinase

24. What is the best diagnosis for this individual?
(A) adult T cell leukemia/lymphoma
(B) chronic lymphocytic leukemia
(C) chronic myelocytic leukemia

(D) hairy cell leukemia
(E) mycosis fungoides


14

INTEGRATED BASIC SCIENCES

Case Study IX

ACUTE MYELOID
LEUKEMIA
Integrated Basic Science Content Review
ANATOMY/HISTOLOGY/EMBRYOLOGY

Normal Myeloid Maturation
BIOCHEMISTRY/PHYSIOLOGY/IMMUNOLOGY

Myeloperoxidase
PATHOLOGY/PHARMACOLOGY/MICROBIOLOGY

Chemotherapy

IX. A 32-year-old woman presents with fever, weakness, and widespread bleeding.
Physical examination reveals marked pallor of the skin along with
multiple purpuric patches. Examination of the peripheral smear reveals a normocytic anemia, thrombocytopenia, and a marked leukocytosis with frequent immature cells that have granular-appearing cytoplasm. Coagulation studies reveal prolonged prothrombin and partial
thromboplastin times. A bone marrow biopsy is performed and reveals
that 45% of the bone marrow cells are blasts, the majority of
which stain positively with myeloperoxidase. Promyelocytes are also
increased in number, and a rare Auer rod is found.
25. Which one of the following combinations of histologic characteristics
correctly describes promyelocytes?