1. A 62-year-old man is brought to the emergency department because of a 3-hour history of progressive difficulty breathing and mild left shoulder pain. His symptoms began after he ran up several flights of stairs. He has poorly controlled hypertension and mild angina pectoris. He has smoked one-half pack of cigarettes daily for 40 years. He appears uncomortable and has labored breathing. Diffuse crackles, ronchi, and scattered wheezing on auscultation of the posterior lung fields. His arterial PO2 is 58 mm Hg. Which of the following is the most likely diagnosis?
A. Cardiac tamponade
D. Pulmonary edema
E. Pulmonary embolism
My answer was C. pneumothorax and that was wrong. I figured that his emphysema destroyed the lung parenchyma, thus increasing his risk of spontaneous pneumothorax (consistent with mild pain and hypoxemia). Although I wasn't happy with that choice because he has crap in his lungs which made me think pulmonary edema, but I figured a 40 year smoker is almost always going to have crap in his lungs. What do you guys think? We never really learned about acute episodes of pulmonary edema from simply walking up stairs in angina pectoris. Does that commonly happen?
2. An investigator is studying the human immune response to tumor antigens in malignancies. Which of the following sets of cancer types and tumor antigens is most likely to produce the highest antibody titer?
Cancer type; Tumor antigen
A. B-cell lymphoma; CD19
B. Breast cancer; HER2/neu
C. Cervical cancer; HPV type 16 E6 protein
D. Melanoma; tyrosinase
E. Prostate cancer; prostatic acid phosphatase
I picked B. Breast cancer; HER2/neu and that was wrong. I didn't even know where to begin on this one. I went with which cancer has a monoclonal antibody treatment, since I figured that means that the cancer was immunogenic enough for labs to create a synthetic drug (perhaps by studying cancer patient's serum antibodies?). Obviously not. What principles are going on here that I am totally missing? Is it something like HPV E6 is a viral component, therefore it's more immunogenic than any cancer that over expresses self-antigen? Is it some principle of which antigen is sitting on the cell membrane thus most accessible to circulating antibodies?
3. A 42-year-old man comes to the physican because of a 4-week history of muscle cramping and pain. Two months ago, he began treatment with simvastatin (80 mg daily) for hypercholesterolemia. After 1 month, marked improvement was noted in his serum LDL-cholesterol concentration, but serum triglyceride concentration remained increased. At that time, gemfibrozil was added to his regimen to decrease his triglyceride concentration. Physical examination today shows no abnormalities. This patient's myalgia is most likely related to which of the following effects of gemfibrozil on simvastatin?
A. Decreased bioavailability
B. Increased absorption
C. Inhibition of cytochrome P450 metabolism
D. Inhibition of hepatic glycosylation
E. Inhibition of hepatic sulfation
I picked D. inhibition of hepatic glycosylation and that was wrong. This question really ticked me off. I asked two professors at my school's pharmacology department and they said they couldn't find a source that could support any of those five answer choices. I mean maybe they didn't search that exhaustively, but it just seems silly that two PhD pharmacologists can't find the answer. What do you guys think? I remember from the Kaplan videos that gemfibrozil inhibits excretion of statins but Raymond never specifies the exact mechanism beyond that it's NOT P450 inhibition. I presume it's by inhibiting glucuronidation? Anyway, that's not an answer choice (on the exam when I saw glycosylation, I read glucuronidation... oops). Is it sulfation?
4. A 52-year-old man comes to the physician because of a 3-month history of epigastric abdominal pain; he also has had an unintentional 6.8-kg (15-lb) weight loss during this period. He has osteoarthritis treated with naproxen as needed. He has immigrated to the UsA from Japan 6 months ago. He eats mostly traditional Japanese food prepared by his wife. He has smoked 2 packs of cigarettes daily for 30 years and drinks three to four glasses of wine daily. He is 170 cm (5 ft 7 in) tall and now weighs 82 kg (180 lb); BMI is 28 kg/m^2. Physical examination shows epigastric tenderness. Upper gastrointestinal endoscopy shows a 4-cm ulcer in the stomach. Examination of a biopsy specimen of the lesion confirms adenocarcinoma. Which of the following is the strongest predisposing risk factor for the patient's condition?
A. Alcohol use
E. Tobacco use
Okay so we have a male Japanese who eats nitrosamines, smokes, drinks, and uses NSAIDS. My answer was C. ethnicity and that was wrong. All I remembered when doing this question was that Japanese have a 3x elevated rate of occurrence of gastric adenocarcinoma vs whites in the US. I know that H. pylori causes most gastric adenocarcinoma, but that's not an answer choice unless I'm totally missing something. So the SECOND most common cause is what? Am I going to feel really dumb because I didn't habitually guess smoking?
Thanks for any feedback!
Last edited by ijn; 03-12-2012 at 07:35 AM.