SOAL INTERNET USMLE

Question 1

A 41-year-old man has a history of drinking 1 to 2 liters of whisky per day

for the past 20 years. He has had numerous episodes of nausea and
vomiting in the past 5 years. He now experiences a bout of prolonged
vomiting, followed by massive hematemesis. On physical examination his
vital signs are: T 36.9°C, P 110/min, RR 26/min, and BP 80/40 mm Hg lying
down. His heart has a regular rate and rhythm with no murmurs and his lungs
are clear to auscultation. There is no abdominal tenderness or distension and
bowel sounds are present. His stool is negative for occult blood. Which of the
following is the most likely diagnosis?

A   Hiatal hernia ->

B   Esophageal laceration -> This is Mallory-Weiss syndrome. The lacerations are

induced by the forceful, prolonged vomiting and can extend to submucosal veins that bleed
profusely. Esophageal variceal bleeding should also be suspected with such a history, because
hepatic cirrhosis is likely to be present. The acute nature of the process means blood has not
yet passed through the bowel to the rectum.

C   Esophageal pulsion diverticulum -> Diverticula of the esophagus do not often

bleed.

D   Barrett esophagus -> Barrett mucosa is associated with gastric acid reflux with
inflammation and possible ulceration, but any bleeding is not usually massive.

E   Esophageal squamous cell carcinoma -> Ulceration of the mucosa occurs with
carcinoma, but massive bleeding is not common.

F   Esophageal stricture -> Strictures of the esophagus result from scarring, typically
with reflux, or with scleroderma. It is a chronic process without massive hemorrhage.

Question 2

A 50-year-old man has had persistent nausea for 5 years with occasional
vomiting. On physical examination there are no abnormal findings. He
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undergoes upper GI endoscopy, and a small area of gastric fundal mucosa

has loss of rugal folds. Biopsies are taken and microscopically reveal well-
differentiated adenocarcinoma confined to the mucosa. An upper GI
endoscopy performed 5 years previously showed a pattern of gastritis and
microscopically there was chronic inflammation with the presence of. Which
of the following is the most likely risk factor for his neoplasm?

A   Inherited APC gene mutation -> Early gastric carcinoma (EGC) is not associated
with APC gene mutations.

B   Helicobacter pylori infection -> H. pylori infection can lead to chronic gastritis that

promotes development of adenocarcinoma. The prognosis with early gastric carcinoma (EGC)
is good, compared with other gastric cancers.

C   Chronic alcohol abuse -> Alcohol is more likely to produce acute changes.

D   Use of non-steroidal anti-inflammatory drugs -> NSAIDS are more likely to

produce acute changes, including ulceration and perforation.

E   Vitamin B12 deficiency -> Although atrophic gastritis leading to B12 deficiency is a
risk for carcinoma, in this case there was no evidence for atrophy.

Question 3

A 58-year-old man has had increasing difficulty swallowing for the past 6
months and has lost 5 kg. No abnormal physical examination findings are
noted. Upper GI endoscopy reveals a nearly circumferential mass with
overlying ulceration in the mid esophageal region. Biopsy of the mass
reveals pink polygonal cells with marked hyperchromatism and
pleomorphism. Which of the following is the most likely risk factor for
development of his disease?

A   Iron deficiency -> Iron deficiency anemia may be accompanied in rare instances by
development of an esophageal web (Plummer-Vinson syndrome), and there is a small risk for
esophageal cancer with these webs. Overall, this is an uncommon risk for esophageal cancer.
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B   Helicobacter pylori infection ->  H. pylori infection is associated with gastritis and

peptic ulcer disease. The risk for subsequent gastric adenocarcinoma is increased.

C   Chronic alcohol abuse -> Chronic alcoholism and tobacco use are two of the most
important risk factors for squamous cell carcinoma of the esophagus in the U.S., specifically
related to squamous cell carcinomas of the mid-esophagus, as in this man. Zinc and
molybdenum are trace elements in the diet whose absence increases the risk for carcinoma of
the esophagus. Food contaminated with Aspergillus also carries a risk, as does food containing
nitrosamines.

D   High fruit diet -> This is not a risk factor for squamous cell carcinoma of the
esophagus. Eat your vegetables, too (but don't pickle them).

E   Zenker diverticulum -> Esophageal diverticula are not risk factors for squamous cell
carcinoma of the esophagus.

Question 4

A 31-year-old man with a stab wound to the abdomen is taken to surgery.

While repairing the small intestine, the surgeon notices the presence of a 1
cm circumscribed submucosal mass in the ileum. The lesion is resected
and on gross examination has a firm, yellow-tan cut surface.
Microscopically, the mass is composed of nests of cells with uniform small
round nuclei and cytoplasm with small purple granules. The cytoplasm is
positive with antibody to chromogranin on immunohistochemical staining.
Which of the following pathologic findings is most likely to accompany this
man's lesion?

A   Liver metastases ->  A carcinoid tumor of this small size is likely to be benign and
unlikely to metastasize. However, carcinoids can never be completely trusted on gross and
microscopic characteristics, regardless of size.

B   Another similar lesion -> This lesion is a carcinoid tumor, and these neoplasms can
be multiple, even when biologically benign. Small carcinoids typically act in a benign fashion.
Most of them do not secrete hormones causing clinical symptoms, but some do. They are often
incidental findings.
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C   Multiple gastric ulcerations -> Carcinoid tumors are neuroendocrine lesions that
can potentially secrete a variety of neuropeptides, including gastrin, but most carcinoids are
non-functional.

D   Pancreatic adenocarcinoma -> Such a small incidental circumscribed mass is

unlikely to be a metastasis, and he is quite young to have pancreatic adenocarcinoma.

E   Inflammatory bowel disease -> Mass lesions are not typical for Crohn disease or
infections of the small bowel. There is a slight increase in risk for adenocarcinoma with Crohn
disease.

F   Tropheryma whippelii infection -> Whipple disease produces a diffuse infiltrate of

macrophages containing the organisms. It is quite rare.

Question 5

A 38-year-old man has had upper abdominal pain for 3 months. For the
past week he has had nausea. On physical examination a stool sample is
positive for occult blood. An upper GI endoscopy reveals no esophageal
lesions, but there is a solitary 2 cm diameter shallow, sharply demarcated
ulceration of the stomach. Which of the following is most characteristic for
this lesion?

A   Antral location -> The gastric antrum is the typical location for a benign peptic ulcer.
The small size and sharp margins are characteristics for a benign ulcer, but all gastric
ulcerations require biopsy because malignancies have many different appearances.

B   Potential for metastases -> The size and shape suggest that this ulceration is
benign.

C   Increased gastric acid production. -> There is usually some acid in patients with
peptic ulceration, but not absence of acid.
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D   No need for biopsy -> The size is not a reliable clue that it is benign. ALL gastric
ulcers seen on endoscopy should be biopsied.

E   Accompanying pancreatic gastrinoma -> The Zollinger-Ellison syndrome, which

is a rare cause for gastric ulceration, is typically accompanied by the presence of multiple
gastric and duodenal ulcerations.

Question 6

A 15-year-old boy from Ghana has the acute onset of right upper quadrant
abdominal pain. Abdominal ultrasound reveals a dilated gallbladder with
thickened wall and filled with calculi. A laparoscopic cholecystectomy is
performed. The gallbladder is opened to reveal ten multifaceted 0.5 to 1 cm
diameter dark, greenish-black gallstones. Which of the following underlying
conditions does this boy most likely have?

A   Sickle cell anemia -> Darkly pigmented gallstones usually contain bilirubin.
Hyperbilirubinemia is a consequence of hemolysis. Patients with sickle cell anemia have chronic
hemolysis.

B   Crohn disease -> Yellow to green 'mixed' stones of mainly cholesterol are more likely
to form when there is are decreased bile acids from decreased enterohepatic circulation with
Crohn disease.

C   Hypercholesterolemia -> Yellow to green stones of mainly cholesterol would be

formed in conditions of increased cholesterol.

D   Hyperparathyroidism -> Hypercalcemia leads to gallstone formation with increased

calcium combined with cholesterol to produce yellow-white stones.

E   Primary biliary cholangitis -> PBC produces an increase in serum cholesterol with
cholelithiasis in about 15% of cases, mainly cholesterol stones that are yellow to green.
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F   Schistosomiasis -> Schistosomiasis with S. mansoni or S. japonicum leads to

hepatic portal fibrosis and portal hypertension.

Question 7

A 35-year-old healthy woman develops sudden severe abdominal pain. On

physical examination she is afebrile. On palpation the pain is centered in the
mid-epigastric region, though there is marked diffuse tenderness in all
quadrants. Bowel sounds are absent. No masses are palpable. Laboratory
studies show her serum lipase is 610 U/L. Which of the following laboratory
test findings is most likely to indicate the risk factor for this woman's
illness?

A   Hypercholesterolemia -> Hypercholesterolemia is not a risk for pancreatitis.

However, hypertriglyceridemia is a cause for pancreatitis, though the triglyceride level must be
quite high--probably over 500 mg/dL.

B   Positive urea breath test -> Helicobacter pylori organisms in the gastric mucus
produce urease which will break down urea to ammonia and to CO2. The patient drinks a
measured quantity of a urea-containing solution with radiolabeled carbon. If organisms are
present they metabolize the urea and release the radiolabeled carbon which is detected in
exhaled air. However, H. pylori infection is not a cause for pancreatitis.

C   Hypercalcemia -> Hypercalcemia is a less common cause for acute pancreatitis,

though it can be found in persons with primary hyperparathyroidism. Once the pancreatitis has
started, the formation of the chalky soap deposits of fat necrosis may draw off calcium to
produce hypocalcemia.

D   Elevated sweat chloride -> Florid acute pancreatitis is not a typical complication of
cystic fibrosis. The acinar pancreas, however, atrophies over time, with fatty replacement, but it
does not typically become markedly acutely inflamed. A 34 year old with cystic fibrosis is
typically not healthy, but has chronic lung disease.

E   Positive serology for HBsAg -> Viral hepatitis is not a risk for pancreatitis.
However, some cases of pancreatitis are caused by other viruses.
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Question 8

After a summertime camping trip in the Green mountains of Vermont, a 29-

year-old man has developed a mild watery diarrhea for the past week.
While on the trip he drank water from the mountain streams. A physical
examination reveals no abdominal pain or masses. He is afebrile. Bowel
sounds are present. His stool is negative for occult blood. The diarrhea
abates in 3 weeks. His two children are similarly affected. Which of the
following infectious agents most likely caused his disease?

A   Rotavirus -> Rotavirus infection is usually seen in children under age 6. In very young
children and infants the fluid loss from the diarrbea can be life-threatening.

B   Shigella flexneri -> Shigellosis is a more severe disease, often producing dysentery
with bloody stools. Shigella is not likely to be found up in the mountains, but in food/water with
fecal contamination.

C   Vibrio cholerae -> ibrio cholerae is the cause for cholera, which produces a profuse,
watery diarrhea that is life-threatening.

D   Giardia duodenalis - Giardiasis is typically a non-life threatening nuisance in

immunocompetent persons. The organisms are found in contaminated water, particularly in
areas such as apparently pristine, remote, mountains not considered to be a risk for infectious
diseases. He had not read his Sierra Club guide in regard to treatment of drinking water while
camping.

E   Entamoeba histolytica -> Amebiasis is more common in developing nations. There

can be findings mimicking inflammatory bowel disease and some mucosal ulceration may be
present.

F   Cryptosporidium parvum -> Cryptosporidiosis is more likely to occur in

immunocompromised patients. It can produce a self-limited diarrhea in immunocompetent
persons, and occurs in outbreaks. It is not frequently encountered in the natural environment.
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G   Salmonella enterica -> Salmonellosis (non-typhi) can produce a self-limited

diarrheal illness with cramping abdominal pain. It is often acquired via contaminated poultry
products.

H   Norovirus -> Noroviruses are a common cause for epidemic, food-borne diarrheal
illness.

Question 9

A 45-year-old man has had vague abdominal pain and nausea for the past
3 years. This pain is unrelieved by antacid medications. He has no difficulty
swallowing and no heartburn following meals. On physical examination there
are no abnormal findings. Upper GI endoscopy reveals antral mucosal
erythema, but no ulcerations or masses. Biopsies are taken, and
microscopically there is a chronic non-specific gastritis. Which of the following
conditions is most likely to be present in this man?

A   Zollinger-Ellison syndrome -> The secretion of large amounts of gastrin with a

neoplasm such as a gastrinoma would lead to multiple ulcerations. This syndrome is rare.

B   Pernicious anemia -> This condition is the result of an atrophic gastritis with loss of
the parietal cells that secrete the intrinsic factor that complexes with vitamin B12 for absorption.

C   Helicobacter pylori infection -> H. pylori infection is often seen in association with

chronic gastritis and with peptic ulcer disease.

D   Adenocarcinoma -> Adenocarcinomas are mass lesions, or they can present as

ulcerations. There is a long-term risk for development of adenocarcinoma with H.
pylori infection.

E   Crohn disease -> rohn disease involving stomach is quite uncommon. The
inflammation with Crohn disease is transmural.
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F   Mixed connective tissue disease -> Autoimmune diseases in general do not often
involve the stomach. There is a form of autoimmune gastritis that can lead to gastric mucosal
atrophy and pernicious anemia.

Question 10

A 25-year-old man has noted cramping abdominal pain for the past week
associated with fever and low-volume diarrhea. On physical examination,
there is right lower quadrant tenderness. Bowel sounds are present. His
stool is positive for occult blood. A colonoscopy reveals mucosal edema
and ulceration in the ascending colon, but the transverse and descending
portions of the colon are not affected. Laboratory studies show serum anti-
Saccharomyces cerevisiae antibodies. Which of the following microscopic
findings is most likely to be present in biopsies from his colon?

A   Crypt abscesses -> This is a more typical finding of ulcerative colitis, which would
involve the rectum first and extend upward in a continuous fashion.

B   Entameba histolytica organisms -> Amebiasis may produce a similar clinical

picture, but is usually not so localized.

C   Adenocarcinoma -> Adenocarcinomas are mass lesions. They are uncommon at

this age (but do occur in younger persons).

D   Band-like mucosal fibrosis -> Fibrosis is more characteristic of collagenous colitis

seen in persons over age 30 (mostly women) and associated with autoimmune diseases.

E   Non-caseating granulomas -> This history is most typical for Crohn disease, which
is a form of inflammatory bowel disease that tends to involve the bowel in a segmental pattern.

F   Necrotizing vasculitis -> Vasculitis involving the colon is uncommon. A necrotizing

vasculitis can be caused by ANCA-associated granulomatous vasculitis, which often involves
multiple organs, but most often pulmonary and/or renal disease preceed the onset of
manifestations elsewhere.
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Question 11

A 32-year-old woman has a 10 year history of intermittent, bloody diarrhea.

She has no other major medical problems. On physical examination there are
no lesions palpable on digital rectal examination, but a stool sample is
positive for occult blood. Colonoscopy reveals a friable, erythematous mucosa
with focal ulceration that extends from the rectum to the mid-transverse
colon. Biopsies are taken and all reveal mucosal acute and chronic
inflammation with crypt distortion, occasional crypt abscesses, and superficial
mucosal ulceration. This patient is at greatest risk for development of which of
the following conditions?

A   Acute pancreatitis

B   Diverticulitis

C   Sclerosing cholangitis -> This patient has ulcerative colitis (UC). One of the
extraintestinal manifestations of this form of inflammatory bowel disease is hepatic sclerosing
cholangitis, which can still occur even after the colon is removed.

D   Appendicitis

E   Perirectal fistula

F   Non-Hodgkin lymphoma

Question 13

A 72-year-old woman notes increasing jaundice and nausea for the past
month. On physical examination she is afebrile, but scleral icterus is
present. There is no abdominal pain on palpation. She has active bowel
sounds. A stool sample is negative for occult blood. Laboratory findings
include total protein 6.1 g/dL, albumin 3.3 g/dL, alkaline phosphatase 210 U/L,
AST 49 U/L, ALT 40 U/L, total bilirubin 7.2 mg/dL, and direct bilirubin 6.3
mg/dL. Her serum lipase is 50 U/L. Which of the following conditions is she
most likely to have?
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A   Pancreatic adenocarcinoma -> Adenocarcinoma of the head of pancreas

produces extrahepatic biliary obstruction with an elevation predominantly of the direct bilirubin
along with an elevation in alkaline phosphatase. This results in the classic finding of 'painless
jaundice'. There is no significant inflammatory component.

B   Cystic fibrosis -> Cystic fibrosis leads to atrophy of pancreatic acinar tissue, but
without biliary tract obstruction.

C   Chronic active hepatitis -> Hepatitis would increase the transaminases (AST and
ALT) markedly.

D   Primary biliary cholangitis -> The AMA would be positive in most cases of PBC.

E   Chronic persistent hepatitis -> The transaminases would continue to be elevated,

though not as high as with acute hepatitis.

F   Autoimmune hemolytic anemia -> Hemolysis should result in an elevated indirect

bilirubin, without liver enzyme elevation. In older persons an autoimmune hemolytic anemia is
often of the 'cold' variety with an underlying hematologic malignancy such as a lymphoma.