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Download DemoVendor: USMLE
Certifications: USMLE Certifications
Exam Code: USMLE-STEP-1
Exam Name: United States Medical Licensing Step 1
Updated: Apr 14, 2024
Q&As: 847
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A 17-year-old boy presented to his orthopedist complaining of progressive knee pain for 3 months. Physical examination revealed a swollen, warm, and tender right knee. Serum alkaline phosphatase levels were increased. Right knee x-ray revealed a lytic lesion in the metaphyseal area of the knee extending into the proximal diaphysis, and elevation of the periosteum with new bone production. Microscopically, biopsy demonstrated haphazard osteoid formation, pleomorphic cells with hyperchromatic nuclei, and tumor giant cells. Based on this information, what is the most likely diagnosis?
A. chondrosarcoma
B. Ewing sarcoma
C. giant cell tumor
D. malignant fibrous histiocytoma
E. osteosarcoma
Correct Answer: E
Section: Pathology and Path physiology In a 17-year-old boy, the anatomical location and the x-ray findings are very typical of osteosarcoma. In this case, the tumor has broken through the cortex, elevated the periosteum with reactive periosteal bone formation (the characteristic triangular shadow seen on x-ray is known radiographically as Codman triangle). The microscopic findings of pleomorphic cells with hyperchromatic nuclei, tumor giant cells, and bone formation confirm the diagnosis. Chondrosarcomas (choice A) most typically occur in the age range of 4060 with the most common locations being the pelvic girdle, ribs, shoulder girdle, and to a lesser extent the long bones, vertebrae, and sternum. Microscopically, the lower grade tumors will show chondroid differentiation, whereas a grade 3 tumor may appear as a spindle cell tumor with little chondroid differentiation. Ewing sarcomas (choice B) occur in children and young adults and usually originate in long bones, ribs, pelvis, and vertebrae. Microscopically one sees small, uniform, oval to round cells with hyperchromatic nuclei and little cytoplasm, which may appear clear due to glycogen abundance. Giant cell tumors (choice C) usually occur in the age range of 2040 most commonly originating in distal femur, proximal tibia, distal radius, and proximal humerus, but virtually any bone may be affected. These are usually benign tumors that can, however, be locally aggressive; roughly 410% do metastasize and these must be considered as malignant. Not surprisingly, the microscopic appearance is marked by the presence of many giant cells that have an osteoclast-like, syncytial appearance. Malignant fibrous histiocytomas (choice D) are fibroblastic, collagen-producing bone tumors that may also arise from soft tissues; indeed, they are the most common type of soft tissue sarcoma. They occur more frequently in the middle-aged and elderly but have been reported at all ages. Microscopically, lesions reveal spindle cells arranged in a whorled pattern with variable amounts of collagen deposition; also present may be large, plump cells (resembling histiocytes), tumor giant cells, many mitoses, and a chronic inflammatory infiltrate.
Which of the following acts as a folate antagonist in the treatment of malaria?
A. amodiaquine
B. chloroquine
C. mefloquine
D. proguanil
E. quinine
Correct Answer: D
Section: Pharmacology Proguanil is a prodrug that is converted to cycloguanil, an inhibitor of malarial dihydrofolate reductase. Amodiaquine (choice A) and chloroquine (choice C) are similar and probably interfere with metabolism of heme in the vacuoles of the parasite. Mefloquine (choice C) and quinine (choice E) have unknown mechanisms of action but are not folate antagonists.
Which of the following agents is associated with numerous drug-drug interactions because of its inhibition of hepatic cytochrome P450 activity?
A. atracurium
B. cromolyn
C. ketoconazole
D. Phenobarbital
E. rifampin
Correct Answer: C
Section: Pharmacology Ketoconazole is a potent inhibitor of cytochrome P450 isozymes; its antifungal action is the result of inhibition of fungal P450. Atracurium (choice A) is used to produce skeletal muscle relaxation during surgery. Atracurium is eliminated by a spontaneous chemical reaction and by plasma cholinesterases, and is not a substrate or inhibitor of cytochrome P450. Cromolyn sodium (choice B) is not a substrate or inhibitor of cytochrome P450. The extremely small amounts of this drug that are absorbed are excreted unchanged in the urine and bile. Phenobarbital (choice D) is eliminated by cytochrome P450 metabolism, and is an inducer of drug metabolism activity. Rifampin (choice E) similarly produces many drug interactions because of its ability to induce (rather than inhibit) cytochrome P450 activity.
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