MCQ Book Questions

Q60482. A 20-year-old woman presents with a 4-week history of dry mouth, fatigue, fever, and yellow sclerae. Physical examina- tion shows mild jaundice and hepatomegaly. Serum total bili- rubin is 3.3 mg/dL. Serologic markers for viral hepatitis are negative. The anti–mitochondrial antibody test is negative. A liver biopsy discloses parenchymal and periportal infl am- matory cell infi ltrates composed primarily of lymphocytes and plasma cells. The patient’s signs and symptoms abate follow- ing 2 months of treatment with steroids. Which of the follow- ing is the most likely diagnosis?

Q60483. A 52-year-old recent immigrant from Vietnam complains of abdominal swelling, weight loss, and upper abdominal pain of 3 weeks in duration. His past medical history includes malaria and infection with the liver fl uke Clonorchis sinensis. The liver is hard to palpation. An abdominal CT scan shows a hypoat- tenuated mass with lobulated margins in the liver. A biopsy discloses well-differentiated neoplastic glands embedded in a dense fi brous stroma. Which of the following is the most likely diagnosis?

Q60484. A 58-year-old man with longstanding alcoholic cirrhosis presents with abdominal pain, fever, and an episode of hematemesis. Physical examination reveals jaundice and a markedly distended abdomen. The patient is disoriented and has a coarse fl apping tremor of the hands. Labora- tory studies reveal modestly elevated serum levels of AST and ALT (96 and 92 U/L, respectively) and a high serum level of alkaline phosphatase (320 U/L). Prothrombin time is prolonged (20 seconds). The WBC count is 18,000/μL. Shortly after admission, the patient develops coma, adult respiratory distress syndrome, and renal failure (oliguria and elevated serum levels of BUN and creatinine), lead- ing to death within 3 days. Histologic examination of the patient’s kidney at autopsy would most likely show which of the following?

Q60485. A liver biopsy in the patient described in Question 14 would defi nitely show which of the following pathologic changes?

Q60486. A 49-year-old woman presents with a 1-month history of yellow discoloration of her eyes, abdominal pain, malaise, weight loss, and low-grade fever (38.4°C, 101°F). Physical examina- tion shows a distended abdomen with right upper quadrant tenderness and a palpable liver 2 cm below the right costal margin. Laboratory studies reveal decreased serum albumin (2.6 g/dL), elevated serum AST (225 U/L) and ALT (150 U/L), and increased alkaline phosphatase (210 U/L). The prothrom- bin time is prolonged (15 seconds). A moderate leukocytosis (13,500/μL, 80% neutrophils) is observed. A liver biopsy is shown in the image. These pathologic fi ndings are most com- monly associated with which of the following liver diseases?

Q60487. A 36-year-old woman presents with a 6-month history of progressive generalized itching, weight loss, fatigue, and yel- low sclerae. She denies use of oral contraceptives or any other medication. Physical examination reveals mild jaundice and ste- atorrhea. Blood studies show a high cholesterol level of 350 mg/ dL, elevated serum alkaline phosphatase (240 U/L), and normal levels of AST and ALT. An intravenous cholangiogram shows no evidence of obstruction. An antimitochondrial antibody test is positive; antinuclear antibodies are not present. Which of the following skin manifestations is expected in this patient?

Q60488. For the patient described in Question 21, a liver biopsy would most likely show which of the following pathologic fi ndings?

Q60489. A 25-year-old woman complains of sudden onset of acute abdominal pain. Physical examination shows abdominal distention. Her temperature is 37°C (98.6°F), respirations 22 per minute, heart rate 110 per minute, and blood pressure 70/50 mm Hg. A tap of the abdomen returns blood. A CT scan reveals a solitary 20-cm mass of the liver. A surgically resected portion of the liver is shown in the image. This patient’s tumor was most likely associated with chronic exposure to which of the following?

Q60490. A 28-year-old woman presents with a 4-day history of abdominal pain and increasing abdominal girth. She does not drink alcoholic beverages, but smokes a pack of cigarettes a day. Except for oral contraceptives, she takes no medications. Physical examination shows hepatomegaly, ascites, and mild jaundice. A liver biopsy is obtained (shown in the image). Which of the following is the most likely diagnosis?

Q60491. A 47-year-old woman presents with a 3-month history of vague upper abdominal pain after fatty meals, some abdomi- nal distension, and frequent indigestion. Physical examination shows an obese woman (BMI = 30 kg/m2) with right upper quadrant tenderness. An ultrasound examination discloses multiple echogenic objects in the gallbladder. The opened gallbladder is shown in the image. Which of the following metabolic changes is most likely associated with the formation of gallstones in this patient?

Q60492. A 60-year-old man has a 6-month history of abdominal swelling. On a daily basis, he smokes two packs of cigarettes, drinks fi ve cups of coffee, and reports that he consumes 2 six- packs of beer. Physical examination shows a distended abdo- men with a palpable liver 2 cm below the costal margin. A liver biopsy is shown in the image. If this patient becomes absti- nent, his liver will most likely do which of the following?

Q60493. A 54-year-old man presents with a 9-month history of pro- gressive skin pigmentation. He passes large amounts of urine and is always thirsty. His father died of liver cancer. Physical examination reveals a dark skin color and an enlarged liver. Laboratory studies show normal serum levels of corticotropin. A glucose tolerance test indicates chemical diabetes. A liver biopsy stained with Prussian blue is shown in the image. If untreated, which of the following conditions is most likely to develop in this patient?

Q60494. A 66-year-old man presents with a 2-week history of abdomi- nal bloating, weight loss, and pain in the right upper quad- rant. The patient had a serious motor vehicle accident 16 years ago, in which he required transfusion of 10 U of whole blood. On physical examination, he exhibits massive distension of the abdomen. The liver is hard on palpation and occupies the entire right side of the abdomen. Laboratory studies show a low serum albumin (2.2 g/dL) and a markedly elevated serum alpha-fetoprotein. An abdominal ultrasound examination reveals ascites. The patient expires 6 months later. The liver at autopsy is shown in the image. Which of the following is the most common cause of this disease worldwide?

Q60495. A 60-year-old woman presents with several years of abdomi- nal pain radiating to her back and a 5-day history of yellow skin and sclerae. She has lost 15 lb during the past several months, and her stools have become lighter in color. On phys- ical examination, the patient is cachectic and jaundiced. The liver edge descends 1 cm below the right costal margin and is nontender. Her right calf is tender and erythematous. Serum AST and ALT are at the upper limits of normal, but alkaline phosphatase is increased to 430 U/L. A CT scan shows a mass in the head of the pancreas. What is the most likely cause of jaundice in this patient?

Q60496. For the patient described in Question 26, which of the following is a common complication?

Q60497. A 68-year-old man complains of vague abdominal pain, inter- mittent fever, and a 20-lb (9-kg) weight loss over the past 6 months. For the past 12 years, he has suffered from chronic hepatitis B. On physical examination, the patient shows diffuse abdominal tenderness, hepatomegaly, and mild jaundice. A CT scan of the abdomen reveals a diffusely nodular liver, with a dominant mass measuring 3 cm in diameter. A needle biopsy is shown in the image. Which of the following serum markers is useful for monitoring the progression of disease in this patient?

Q60498. A 30-year-old man presents with a 3-week history of fatigue, occasional fever, yellow skin and sclerae, tenderness below the right costal margin, and dark urine. Physical examination reveals jaundice and mild hepatomegaly. Laboratory studies show elevated serum levels of bilirubin, decreased albumin, and prolonged prothrombin time. Serologic tests disclose anti- bodies to hepatitis C virus. Which of the following tests is the most accurate method for assessing the extent of liver disease in this patient?

Q60499. A previously healthy, 24-year-old woman presents with a 1-week history of intermittent fever, lethargy, and yellow skin and sclerae. Physical examination shows jaundice. Laboratory studies reveal decreased serum albumin (2.2 g/dL), extremely high levels of AST and ALT (1,200 and 1,800 U/L, respec- tively), and elevated alkaline phosphatase (300 U/L). Her ceruloplasmin level is normal. She is admitted to the hospi- tal. Her condition progressively deteriorates, and she develops hepatic encephalopathy and hepatorenal syndrome. Which of the following is the most likely diagnosis?

Q60500. A 36-year-old, alcoholic woman presents with a 1-week history of yellow skin and sclerae. She has suffered persistent head- aches. Her vital signs are normal. Physical examination reveals jaundice. Laboratory studies disclose markedly elevated levels of AST and ALT (956 and 1,400 U/L, respectively). A few days later, she develops hepatic encephalopathy and renal failure. A liver biopsy shows prominent centrilobular necrosis. Which of the following is the most likely diagnosis?

Q60501. A 30-year-old man from Mexico presents with a 3-week history of constant pain in his upper right quadrant and epigastrium and persistent cough. The patient also reports a recent history of nausea, vomiting, and bloody diarrhea. Physical examina- tion shows hepatomegaly and tenderness over the right upper quadrant. A liver biopsy displays fi broblastic proliferation and trophozoites (shown in the image). Which of the following is the most likely diagnosis?