NAME:__________________________ 50 points List your neighbors: --> --> --> --> --> --> UNIVERSITY OF HEALTH SCIENCES PATHOLOGY EXAM VI 1994-1995 INSTRUCTIONS As usual, if you have a question, don't phonate. It has been both a privilege and a pleasure to instruct you, the primary care physicians of tomorrow, about the basics of disease. From now on, learning is up to you. We wish you happiness and good health in the years to come. [The first 15 items were GRIPE bank questions.] MATCHING: Use each item once. A. alanine aminotransferase ("SGPT"; "ALT") B. alkaline phosphatase C. alpha-fetoprotein D. aspartate aminotransferase ("SGOT"; "AST") E. lactate dehydrogenase (LDH) 16. Enzyme fairly specific for liver cell injury [A] 17. Enzyme that becomes elevated in liver, heart, or skeletal muscle injury, but which doesn't present useful isoenzymes [D] 18. Enzyme with a fifth isoenzyme indicating liver or skeletal muscle injury [E] 19. Enzyme elevated when osteoblasts are busy, a baby is soon to be born, or bile flow is obstructed [B] 20. Tumor marker for hepatocellular carcinoma [C] MATCHING. Use each item once. A. Factitious hyperthyroidism (taking exogenous thyroid) B. Graves' disease C. Hashimoto's thyroiditis D. Pituitary adenoma with secondary hypopituitarism E. Pregnancy 21. T4, T3RU, TSH, increased uptake of radio-iodine on scan, serum positive for anti-TSH receptor autoantibodies, serum cholesterol likely to be low [B] 22. T4, T3RU, TSH, abnormally low uptake of radio-iodine on scan, no anti-TSH receptor autoantibodies, serum cholesterol likely to be low [A] 23. T4, T3RU, TSH, serum positive for anti-microsomal and/or anti- thyroglobulin autoantibodies, serum cholesterol likely to be high [C] 24. T4, T3RU, TSH, no autoantibodies, serum cholesterol likely to be high, other evidence of endocrine disturbance likely [D] 25. T4, T3RU, normal TSH, mild anemia likely [E] MATCHING. Use each item once. A. anemia of chronic disease B. autoimmune hemolytic anemia from "Aldomet" C. iron deficiency from a slowly-bleeding ulcer D. pernicious anemia, classic type E. thalassemia minor, beta type 26.  lifelong MCV, serum iron studies not helpful, basophilic stippling, slightly increased percentage of hemoglobin A2 [E] 27.  MCV, normal or deceased reticulocyte count, positive Schilling tests [D] 28.  MCV,  serum iron, -N total iron binding capacity,  serum albumin,  serum ferritin, normal reticulocyte count, evidence of ongoing, widespread macrophage activation [A] 29.  MCV,  serum iron,  total iron binding capacity, zero serum ferritin, maybe pencil cells [C] 30. normal or slightly  MCV, positive Coombs' test, slightly elevated unconjugated bilirubin, increased reticulocyte count [B] MATCHING. Use each item once. A. C-peptide B. ferritin C. gamma-glutamyl transpeptidase D. hemoglobin A1c E. porphobilinogen 31. check the urine for this if you suspect acute intermittent porphyria [E] 32. elevated in insulinoma and tolbutamide abuse; diminished in insulin abuse and type I diabetes [A] 33. lone elevation is a good sign of recent alcohol abuse [C] 34. markedly elevated in true, developed hemochromatosis [B] 35. non-enzymatic glycosylation product with levels that increase when diabetes is out of control [D] MATCHING. Use each item once. A. activated partial thromboplastin time B. bleeding time C. clot retraction D. prothrombin time E. urea solubility 36. factor I, platelet count, and for Glanzmann's [C] 37. factor XIII [E] 38. quality and quantity of platelets [B] 39. quality and quantity of I, II, V, VII, X [D] 40. quality and quantity of I, II, V, VIII, IX, X, XI, XII [A] 41. Which is LEAST IMPORTANT in deciding on the workup and management of a patient with a sore throat? A. Does this patient have a cough? B. Does this patient have a fever over 100 degrees? C. Is there anterior cervical lymphadenopathy? D. Is this patient over 18 years old? * E. What is the white cell count in the blood? 42. Which is LEAST HELPFUL if you suspect a pulmonary embolus? A. blood gases B. chest x-ray C. electrocardiogram D. pulmonary angiogram * E. serum lactate dehydrogenase, with isoenzymes 43. Which is the BEST test to get when you want to screen for general digestive-tract malabsorption? A. beta-carotene level B. d-xylose test * C. fecal fat D. lactose tolerance test (oral) E. small bowel biopsy 44. Which is NOT a good reason to perform a lumbar puncture? * A. confirm diagnosis of glioblastoma made on MRI scan B. suspected bacterial meningitis C. suspected ruptured berry aneurysm D. suspected multiple sclerosis E. suspected viral meningitis 45. Which is the WORST idea if you think your patient has idiopathic postprandial syndrome? A. check for Addison's disease * B. do a 5-hour oral glucose tolerance test C. get a serum glucose while symptoms are occurring D. get a serum insulin while symptoms are occurring E. get a serum insulin while symptoms are occurring 46. About how soon after conception does the standard blood test for pregnancy turn positive? A. 1 hour B. 1 day * C. 1 week D. 2 weeks E. 4 weeks, i.e., 2 weeks after the first missed period 47. You've just discovered that somebody's got 2+ proteinuria. History and physical exam are entirely unremarkable. The urine is otherwise normal. Which is the BEST thing to do NEXT? A. bone marrow biopsy, to rule out plasma cell myeloma B. do a 24 hour urine collection C. do a urine protein electrophoresis * D. see if the proteinuria goes away while she's lying down E. proceed directly to renal biopsy 48. How will you diagnose Cushing's syndrome? A. ACTH stimulation test * B. 24-hour urine free cortisol or overnight dexamethasone suppression test C. overnight urine for metanephrine and creatinine D. spot serum cortisol and serum ACTH E. urine potassium, serum potassium, and plasma renin 49. Which is NOT a reason to perform bacterial cultures and stool- for-ova-and-parasites on somebody with diarrhea? A. it's lasted a month B. the patient is a food handler in your cafeteria * C. the stool smells really horrible and floats D. there's blood in the stool E. there's a bunch of neutrophils in the stool 50. What's the "RDW", reported on your complete blood counts? A. a measure of how big the red cells are * B. a measure of how different the red cell sizes are ("red-cell distribution width") C. an estimate of the reticulocyte count ("reticulocytes, Dobbins-Watson technique") D. an estimate of immaturity (derivation from immature reserve marrow pool) of neutrophils ("reserve derivation of white-cells") E. the percentage of nucleated red cells (relative DNA weighting) BONUS ITEMS: A. Anti-cardiolipin ("lupus anticoagulant") B. Anti-centromere C. Anti-teichoic acid D. C1-esterase inhibitor E. Nitroblue tetrazolium 51. "Chronic granulomatous disease" in which patients cannot kill staphylococci with their neutrophils [E] 52. "CREST", a common scleroderma variant [B] 53. Hereditary angioedema test [D] 54. Mysterious cause of abortion, hyper-clotting, false-positive syphilis test [A] 55. Staph infections, part of the arcana of "Infectious Disease" [C] 56. A 43 year old pathologist took out-of-date tetracycline and gave himself transaminasitis. Nothing else is wrong. If he were to get a liver biopsy, what would you see? A. centrilobular necrosis B. cholestasis C. granulomas D. macrovesicular steatosis * E. microvesicular steatosis Questions 57-59 relate to the following scenario: "Sig Ape", a popular men's college fraternity, has engaged you, a distinguished primary care physician, to oversee a national campaign to identify those unfortunate brothers on all campuses who have contracted pinworms. A Scotch Tape test has a sensitivity of 80%, and a specificity of 99%. There are 100,000 Sig Apes, and the incidence of pinworms among them is 90%. No, I don't care to see your work, but you may use the space at the bottom of the page if you wish. 57. What is the predictive value of a positive result? Just the right answer, please. [99.8%, credit for anything from 99-99.999] 58. What is the predictive value of a negative result? Just the right answer, please. [33.5%, credit for anything from 30-35%] 59. What is the diagnostic accuracy? Just the right answer, please. [72%, credit for anything from 70-75%] 60. Why are these people smiling? [Who knows? +1 for any correct answer] _______________________________________________________________________ Workspace for 57-59: