COMBANK - GI/Pulmonary: Questions With In-
Depth Solutions
A 47-year-old female comes into the emergency department with a
chief complaint of epigastric distress. The pain is most severe after
eating dinner and persists over night. Past surgical history includes
gastric bypass surgery. She does not take any medications. Physical
exam shows a palpable nontender mass in the right upper quadrant.
Ultrasound in the right upper quadrant is significant for a structure
with a biconvex curvilinear echogenic appearance with acoustic
shadowing Correct Answer - Intramural calcification of the
gallbladder (porcelain gallbladder)
- result of chronic cholecystitis (It is possible to have chronic
cholecystitis without prior symptomatic attacks, as in this patient)
On ultrasound, a porcelain gallbladder may present in three
different ways.
Type I - Hyperechoic semilunar appearance with posterior acoustic
shadowing
Type II - Biconvex curvilinear echogenic appearance with acoustic
shadowing (this patient)
Type III- Irregular clumps of echoes with posterior acoustic
shadowing
Pathology could present in two separate ways. There can be
calcification broadly within the muscularis, which can appear as a
large plaque area on radiologic scans, or multiple punctate
calcifications can be present in the glandular spaces of the mucosa,
seen as granular calcification on radiographs.
A 50-year-old man with a history of hypertension and rheumatoid
arthritis presents with dyspnea. His dyspnea began 12 months ago
,and has gradually worsened. Auscultation of the lungs reveals fine
inspiratory crackles at both bases. Correct Answer - Interstitial
lung disease (ILD) due to rheumatoid arthritis
- The fundamental pathophysiological abnormality in ILD is a
reduction in compliance
- When compliance is decreased, the lung has greater inward elastic
recoil, and FRC decreases.
- When lung compliance is reduced in ILD, the inspiratory muscles
can't inflate the lungs to as great a volume, and TLC is reduced.
- Since TLC is significantly reduced, and RV is usually minimally
affected, the vital capacity is reduced.
BCL2 Correct Answer - Follicular lymphoma seen in older
adults with generalized lymphadenopathy. t(14;18) forms a BCL2-
IgH fusion gene. Lymph node biopsy includes two cells: 1)
centrocytes (small cells with irregular nuclear contours and scant
cytoplasm) and 2) centroblasts (larger cells with open nuclear
chromatin, several nucleoli, and modest amounts of cytoplasm).
BCL6 Correct Answer - Diffuse large B-cell lymphoma most
common in adults. Rapidly growing mass. Over-expression of BCL6,
which is due to t(3;Var)(q27;Var). The lymph node biopsy would
show large cell size.
C-MYC Correct Answer - Burkitt lymphoma; adolescents or
young adults with extranodal masses. Associated with Epstein-Barr
virus. t(8;14) involving c-MYC and Ig loci. LN biopsy: "starry sky"
pattern.
Cyclin D1 Correct Answer - Mantle cell lymphoma; older males
with disseminated disease. t(11;14), cyclin D1-IgH fusion gene.
Biopsy: homogenous population of small lymphocytes with irregular
deeply clefted nuclear contours
,A 65-year old male with a history of chronic hepatitis B presents
with worsening ascites. On laboratory examination, the patient has a
serum ALT of 75 U/L and AST of 80 U/L. His hepatitis B virus (HBV)
DNA measures 10,000 copies/mL. An abdominal CT is performed
revealing a hepatic lesion with poorly defined margins. His serum
alpha-fetoprotein is elevated at 68 µg/L. Liver biopsy confirms the
diagnosis of hepatocellular carcinoma. Which of the following best
describes the mechanism by which HBV leads to development of
cancer? Correct Answer - Viral integration into host genome -
HBV can cause HCC in the absence of cirrhosis by integrating into
the DNA of hepatocytes and acting as a mutagen; increased
chromosomal instability and interference of DNA repair and
apoptosis; uncontrolled cellular proliferation and malignant
transformation
A 53-year-old male presents to his primary care physician's office
with abdominal discomfort. The patient says that his pain is located
in the epigastrium and is exacerbated by eating. The patient has a
past medical history significant for hypertension, hyperlipidemia,
and asthma. A test for fecal occult blood is positive. An upper
endoscopy and colonoscopy are performed and the patient is
diagnosed with peptic ulcer disease. Which of the following ulcer
locations is least commonly associated with malignancy? Correct
Answer - Duodenum - Duodenal carcinoma typically arises
sporadically, without an ulcerative precursor lesion.
A 42-year-old female comes into the emergency department with a
chief complaint of upper abdominal pain. She has symptoms of
nausea, vomiting, and anorexia. The patient has a past medical
history of gallstones. She does not smoke or drink alcohol. Vital
signs are temperature of 38.0°C, pulse of 107 beats/minute, blood
pressure of 85/62 mm Hg, and body mass index (BMI) of 39 kg/m2.
On physical examination, she has an ecchymotic discoloration over
the flanks. Alkaline phosphatase and serum amylase are both
, elevated. What other complications are associated with this
patient's disease? Correct Answer - ARDS - This patient is
suffering from acute pancreatitis secondary to gallstone disease
(Remember the 4 F's = fat, female, forty, fertile). Gallstone induced
obstruction is also suggested by the elevated levels of alkaline
phosphatase. Her elevated amylase level is consistent with
pancreatitis. Other complications of acute pancreatitis include
pseudocyst formation, abscess formation, hypocalcemia, and acute
renal failure
A 65-year-old man walks into outpatient clinic with a chief
complaint of bright red bleeding from his rectum that started two
days ago. He notes mild bloating but denies nausea, vomiting,
abdominal pain, fever, chills, and chest pain. His temperature is
36ºC, heart rate is 100/min, blood pressure is 95/69 mmHg, and
respiratory rate is 19/min. Physical exam shows an abdomen that is
soft, nondistended, and nontender without rebound or guarding. CT
scan of the abdomen and pelvis shows small outpouchings of the
colon but no increased soft tissue density in the pericolic fat or
bowel wall thickening. Hemoglobin is 7.5 g/dL. What is the most
likely etiology of this patient's problem? Correct Answer -
Diverticulum herniation against the vasa recta causes eccentric
intimal thickening and thinning of the media, predisposing to
rupture of the lumen. Clinically, this presents as painless rectal
bleeding.
A 50-year-old male comes to the physicians office complaining of a
loss of appetite and chest tightness for the past 4 months. He noted
that his clothes have been a loose-fitting and his wife has noticed
that he appears much thinner. He is a non-smoker and drinks beer
socially on the weekends. Recreationally he would go kayaking on
the weekends but has been unable to these past 4 weeks. His
temperature is 37.4 C, respirations are 14/min, pulse is 88/min and
regular, blood pressure is 129/88 mm HG. An EKG is shows non-
Depth Solutions
A 47-year-old female comes into the emergency department with a
chief complaint of epigastric distress. The pain is most severe after
eating dinner and persists over night. Past surgical history includes
gastric bypass surgery. She does not take any medications. Physical
exam shows a palpable nontender mass in the right upper quadrant.
Ultrasound in the right upper quadrant is significant for a structure
with a biconvex curvilinear echogenic appearance with acoustic
shadowing Correct Answer - Intramural calcification of the
gallbladder (porcelain gallbladder)
- result of chronic cholecystitis (It is possible to have chronic
cholecystitis without prior symptomatic attacks, as in this patient)
On ultrasound, a porcelain gallbladder may present in three
different ways.
Type I - Hyperechoic semilunar appearance with posterior acoustic
shadowing
Type II - Biconvex curvilinear echogenic appearance with acoustic
shadowing (this patient)
Type III- Irregular clumps of echoes with posterior acoustic
shadowing
Pathology could present in two separate ways. There can be
calcification broadly within the muscularis, which can appear as a
large plaque area on radiologic scans, or multiple punctate
calcifications can be present in the glandular spaces of the mucosa,
seen as granular calcification on radiographs.
A 50-year-old man with a history of hypertension and rheumatoid
arthritis presents with dyspnea. His dyspnea began 12 months ago
,and has gradually worsened. Auscultation of the lungs reveals fine
inspiratory crackles at both bases. Correct Answer - Interstitial
lung disease (ILD) due to rheumatoid arthritis
- The fundamental pathophysiological abnormality in ILD is a
reduction in compliance
- When compliance is decreased, the lung has greater inward elastic
recoil, and FRC decreases.
- When lung compliance is reduced in ILD, the inspiratory muscles
can't inflate the lungs to as great a volume, and TLC is reduced.
- Since TLC is significantly reduced, and RV is usually minimally
affected, the vital capacity is reduced.
BCL2 Correct Answer - Follicular lymphoma seen in older
adults with generalized lymphadenopathy. t(14;18) forms a BCL2-
IgH fusion gene. Lymph node biopsy includes two cells: 1)
centrocytes (small cells with irregular nuclear contours and scant
cytoplasm) and 2) centroblasts (larger cells with open nuclear
chromatin, several nucleoli, and modest amounts of cytoplasm).
BCL6 Correct Answer - Diffuse large B-cell lymphoma most
common in adults. Rapidly growing mass. Over-expression of BCL6,
which is due to t(3;Var)(q27;Var). The lymph node biopsy would
show large cell size.
C-MYC Correct Answer - Burkitt lymphoma; adolescents or
young adults with extranodal masses. Associated with Epstein-Barr
virus. t(8;14) involving c-MYC and Ig loci. LN biopsy: "starry sky"
pattern.
Cyclin D1 Correct Answer - Mantle cell lymphoma; older males
with disseminated disease. t(11;14), cyclin D1-IgH fusion gene.
Biopsy: homogenous population of small lymphocytes with irregular
deeply clefted nuclear contours
,A 65-year old male with a history of chronic hepatitis B presents
with worsening ascites. On laboratory examination, the patient has a
serum ALT of 75 U/L and AST of 80 U/L. His hepatitis B virus (HBV)
DNA measures 10,000 copies/mL. An abdominal CT is performed
revealing a hepatic lesion with poorly defined margins. His serum
alpha-fetoprotein is elevated at 68 µg/L. Liver biopsy confirms the
diagnosis of hepatocellular carcinoma. Which of the following best
describes the mechanism by which HBV leads to development of
cancer? Correct Answer - Viral integration into host genome -
HBV can cause HCC in the absence of cirrhosis by integrating into
the DNA of hepatocytes and acting as a mutagen; increased
chromosomal instability and interference of DNA repair and
apoptosis; uncontrolled cellular proliferation and malignant
transformation
A 53-year-old male presents to his primary care physician's office
with abdominal discomfort. The patient says that his pain is located
in the epigastrium and is exacerbated by eating. The patient has a
past medical history significant for hypertension, hyperlipidemia,
and asthma. A test for fecal occult blood is positive. An upper
endoscopy and colonoscopy are performed and the patient is
diagnosed with peptic ulcer disease. Which of the following ulcer
locations is least commonly associated with malignancy? Correct
Answer - Duodenum - Duodenal carcinoma typically arises
sporadically, without an ulcerative precursor lesion.
A 42-year-old female comes into the emergency department with a
chief complaint of upper abdominal pain. She has symptoms of
nausea, vomiting, and anorexia. The patient has a past medical
history of gallstones. She does not smoke or drink alcohol. Vital
signs are temperature of 38.0°C, pulse of 107 beats/minute, blood
pressure of 85/62 mm Hg, and body mass index (BMI) of 39 kg/m2.
On physical examination, she has an ecchymotic discoloration over
the flanks. Alkaline phosphatase and serum amylase are both
, elevated. What other complications are associated with this
patient's disease? Correct Answer - ARDS - This patient is
suffering from acute pancreatitis secondary to gallstone disease
(Remember the 4 F's = fat, female, forty, fertile). Gallstone induced
obstruction is also suggested by the elevated levels of alkaline
phosphatase. Her elevated amylase level is consistent with
pancreatitis. Other complications of acute pancreatitis include
pseudocyst formation, abscess formation, hypocalcemia, and acute
renal failure
A 65-year-old man walks into outpatient clinic with a chief
complaint of bright red bleeding from his rectum that started two
days ago. He notes mild bloating but denies nausea, vomiting,
abdominal pain, fever, chills, and chest pain. His temperature is
36ºC, heart rate is 100/min, blood pressure is 95/69 mmHg, and
respiratory rate is 19/min. Physical exam shows an abdomen that is
soft, nondistended, and nontender without rebound or guarding. CT
scan of the abdomen and pelvis shows small outpouchings of the
colon but no increased soft tissue density in the pericolic fat or
bowel wall thickening. Hemoglobin is 7.5 g/dL. What is the most
likely etiology of this patient's problem? Correct Answer -
Diverticulum herniation against the vasa recta causes eccentric
intimal thickening and thinning of the media, predisposing to
rupture of the lumen. Clinically, this presents as painless rectal
bleeding.
A 50-year-old male comes to the physicians office complaining of a
loss of appetite and chest tightness for the past 4 months. He noted
that his clothes have been a loose-fitting and his wife has noticed
that he appears much thinner. He is a non-smoker and drinks beer
socially on the weekends. Recreationally he would go kayaking on
the weekends but has been unable to these past 4 weeks. His
temperature is 37.4 C, respirations are 14/min, pulse is 88/min and
regular, blood pressure is 129/88 mm HG. An EKG is shows non-
