1. A 60 year old man experiences dysphagia soon after he begins eating and changes in his voice soon after he begins speaking. Examination demonstrates mild weakness of the upper facial muscles. A diagnosis can best be obtained from the results of [1]:

   A. Muscle biopsy
   B. A CT scan of the thorax
   C. Administration of steroids
   D. Administration of edrophonium chloride
   E. Electromyography of the tongue

2. Which of the following immunoglobulins achieves a significant concentration in both the vascular and extra vascular spaces, has a half life of 23 (20-28) days, crosses the placenta, and can activate complement [2] ?

   A. IgA
   B. IgD
   C. IgE
   D. IgG
   E. IgM

3. A 34 year old patient presents with chronic, progressive dysphagia. Barium esophagram demonstrates a dilated atonic esophagus which cannot empty without the aid of gravity. The most likely diagnosis is [3]:

   A. Scleroderma
   B. Polymyositis
   C. Multiple sclerosis
   D. Amyotrophic lateral sclerosis
   E. A tumor of the gastroesophageal junction

4. A 55 year old thin white woman with a history of Stage II breast cancer at age 45 (treated with lumpectomy, radiation, and adjuvant chemotherapy), mild uterine hyperplasia and fibroids, and a strong family history of cardiovascular disease and osteoporosis presents to you for a second opinion after a bone densitometry was <2.5 standard deviations below the mean. She has no symptoms of vertebral or other fractures, and a spinal radiograph shows reduced bone density without fractures. She underwent menopause at the age of 53 and has a fasting total cholesterol level of 250mg/dL, an LDL of 182, HDL 38mg/dL, and fasting triglycerides of 150mg/dL. Which one of the following agents for osteoporosis treatment is best suited to this patient [4] ?

   A. Tamoxifen (Nolvadex®)
   B. Raloxifene (Evista®)
   C. Hormone Replacement Therapy (Standard HRT)
   D. Phytoestrogen + progesterone
   E. Alendronate (Fosamax®)

5. A 25 year old man who undergoes weekly immunotherapy for numerous pollen sensitivity's and recurrent nasal polyposis is stung by a wasp. Large hives and severe wheezing development and treatment is immediately initiated with subcutaneous epinephrine and IV antihistamines and glucocorticoids. What type of hypersensitivity reaction is represented in this setting [5]:

   A. Type 1
   B. Type 2
   C. Type 3
   D. Type 4
   E. Type 5

6. A 75 year old diabetic male recently underwent treatment of a left sided otitis externa with antibiotic drops. Four days later, he returns to the emergency room with a severe left sided headache, purulent drainage from the left year, and a low grade fever. On exam, the canal is swollen, and the drum cannot be seen. There is no mastoid tenderness. The neck is soft and supple. You would recommend [6]:

   A. Antibiotic ear drops with activity against pseudomonas, and placement of a wick
   B. Antibiotic ear drops with activity against pseudomonas, placement of a wickand oral antibiotics
   C. Admission for antibiotics intravenously
   D. Emergent CT scan with contrast, and otolaryngology consultation
   E. Culture of the ear, hydrogen peroxide irrigation, and acetic acid drops

7. A 38 year old woman is being evaluated for malaise and slow weight loss. Her physical exam is normal. A chest radiograph is performed, and multiple pulmonary parenchymal nodules are noted. Bronchoscopy with trans-bronchial biopsy of a nodule is performed. Light microscopy is non-diagnostic. Electron microscopy reveals neural secretory granules. Of the following, the most likely primary is:

   A. Non-Hodgkin's lymphoma
   B. Metastatic medullary carcinoma of the thyroid
   C. Metastatic papillary carcinoma of the thyroid
   D. Metastatic adenocarcinoma of the ovary
   E. Metastatic breast carcinoma

8. Lesions of bullous pemphigoid have which of the following histologic characteristics?

   A. Increased macrophage infiltration
   B. Increased lymphocyte infiltration
   C. Increased plasma cell infiltration
   D. Linear deposits of IgG and complement
   E. Granular deposits of IgA and complement

9. Patients with primary Sjogren syndrome are at risk for [9]:

   A. Hodgkin's disease
   B. Non-Hodgkin's lymphoma
   C. Hashimoto's thyroiditis
   D. Juvenile rheumatoid arthritis
   E. Systemic lupus erythematosis

10. An 83 year old woman is recovering from an exploratory laparotomy for intestinal ischemia. On post operative day No. 4, she's noted to have a fever, trismus, and left parotid gland swelling, tenderness, and erythema. Treatment should include which one of the following antibiotics [10]:

    A. Ampicillin
    B. Penicillin G procaine
    C. Ceftriaxone
    D. Cloxacillin
    E. Ciprofloxacin

Answers

1. D
2. D
3. A
4. B (Tamoxifen has uterine growth stimulatory effects and increases endometrial cancer risk; raloxifene does not.)
5. A
6. D (Mastoiditis may be present, invasive otitis externa and potential for meningitis.)
7. B (Medullary thyroid carcinoma is most likely given the neural secretory granules.)
8. D
9. B
10. D