EXO PANCREAS

1 A 1-month-old infant is brought to the physician by her parents. She has had repeated bouts of bilious vomiting over the past month and
cannot be fed adequately. She is in the 10th percentile for weight and the 50th percentile for length. An upper GI series discloses marked
narrowing of the midportion of the duodenum. What is the most likely cause of this infant’s GI obstruction?
(A) Annular pancreas
(B) Duodenal polyp
(C) Islet cell adenoma
(D) Pancreatic pseudocyst
(E) Pyloric stenosis

2 A 42-year-old obese woman (BMI = 32 kg/m2) presents with severe abdominal pain that radiates to the back. There is no history of
alcohol or drug abuse. The blood pressure is 90/45 mm Hg, respirations are 32 per minute, and pulse is 100 per minute. Physical
examination shows abdominal tenderness, guarding, and rigidity. An X-ray fi lm of the chest shows a left pleural effusion. Laboratory
studies reveal elevated serum amylase (850 U/L) and lipase (675 U/L), and hypocalcemia (7.8 mg/dL). Which of the following is the most
likely diagnosis?
(A) Acute cholecystitis
(B) Acute pancreatitis
(C) Alcoholic hepatitis
(D) Chronic calcifying pancreatitis
(E) Dissecting aortic aneurysm

3 Which of the following is most likely associated with the pathogenesis of the condition of the patient described in Question 2?
(A) Carcinoid syndrome
(B) Cholelithiasis
(C) Insulinoma
(D) Pancreatic adenocarcinoma
(E) Portal hypertension

4 A 60-year-old alcoholic man presents with a 6-month history of recurrent epigastric pain, progressive weight loss, and foulsmelling
diarrhea. The abdominal pain is now almost constant and intractable. An X-ray fi lm of the abdomen reveals multiple areas of calcifi cation
in the mid-abdomen. Which of the following is the most likely diagnosis?
(A) Carcinoid syndrome
(B) Chronic pancreatitis
(C) Crohn disease
(D) Insulinoma
(E) Miliary tuberculosis

5 Which of the following fi ndings is most likely to be encountered in the patient described in Question 4?
(A) Achlorhydria
(B) Hypoglycemia
(C) Melena
(D) Pernicious anemia
(E) Steatorrhea

6 A 50-year-old woman complains of persistent abdominal pain, anorexia, and abdominal distention. Her past medical history is signifi
cant for a previous hospitalization for acute pancreatitis. Physical examination shows jaundice and a nonpulsatile abdominal mass.
Laboratory studies reveal normal serum levels of bilirubin, AST, and ALT. A CT scan of the abdomen shows a fl uid-fi lled cavity in the head
of the pancreas. What is the most likely diagnosis?
(A) Acute hemorrhagic pancreatitis
(B) Insulinoma
(C) Pancreatic cystadenoma
(D) Pancreatic islet cell tumor
(E) Pancreatic pseudocyst
7 The surgical specimen is shown in the image for the patient described in Question 6. In addition to blood and necrotic debris, which of
the following best describes the contents of this cystic lesion?
(A) Bile
(B) Chylous fl uid
(C) Lymph
(D) Mucopolysaccharides
(E) Pancreatic enzymes
8 A 60-year-old man presents with a 3-week history of weight loss, vague abdominal pain, and progressive yellowing of his skin and
sclerae. He also reports the recent onset of intermittent pain in the upper and lower extremities. Laboratory studies show a serum
bilirubin level of 15 mg/dL, mostly in the conjugated form. A CT scan of the abdomen reveals a mass in the head of the pancreas. The
patient develops sudden shortness of breath and is diagnosed with pulmonary thromboembolism. Which of the following is the most
likely cause of thromboembolism in this patient?
(A) Adenocarcinoma of the ampulla of Vater
(B) Gastrinoma of the pancreas
(C) Insulinoma of the pancreas
(D) Pancreatic adenocarcinoma
(E) Pancreatic pseudocyst

9 Despite best efforts at treatment, the patient described in Question 8 subsequently dies. The gross appearance of the pancreas and liver
at autopsy is shown in the image. This patient’s tumor most likely arose from which of the following types of cells?
(A) Acinar cells
(B) Alpha cells
(C) Beta cells
(D) Delta cells
(E) Ductal cells

10 A 65-year-old woman presents with a 5-week history of yellow skin and sclera, anorexia, and epigastric pain. Her past medical history is
signifi cant for insulin-dependent diabetes mellitus. She smoked one pack of cigarettes a day for the past 20 years. Physical examination
reveals jaundice and a palpable gallbladder. Laboratory studies show a serum bilirubin level of 10 mg/dL, mostly in the conjugated form,
and an elevated alkaline phosphatase (260 U/L). A CT scan of the abdomen discloses a mass in the head of the pancreas and multiple
nodules in the liver measuring up to 3 cm. Which of the following is the most likely cause of jaundice in this patient?
(A) Cholelithiasis
(B) Cirrhosis
(C) Extrahepatic biliary obstruction
(D) Hemolysis
(E) Intrahepatic cholestasis

11 Which of the following is the most important risk factor for the neoplasm arising in the patient described in Question 10?
(A) Alcohol abuse
(B) Cholelithiasis
(C) Cigarette smoking
(D) Diabetes mellitus type 1
(E) High-fat diet

12 A 47-year-old man suffers from long-standing peptic ulcer disease, which is largely unresponsive to pharmacologic therapy. Endoscopic
examination reveals multiple, nonhealed ulcerations of the duodenum and jejunum. Which of the following is the most likely diagnosis?
(A) Carcinoid syndrome
(B) Insulinoma
(C) Pancreatic adenocarcinoma
(D) Verner-Morrison syndrome
(E) Zollinger-Ellison syndrome

13 A 35-year-old woman presents with 6-month history of skin rash and fatigue. Physical examination shows pallor and a necrotizing
erythematous skin rash of her lower body. Laboratory studies reveal mild anemia and fasting blood glucose of 160 mg/dL. A CT scan of the
abdomen demonstrates a 2-cm mass in the pancreas. Which of the following is the most likely diagnosis?
(A) Carcinoid tumor
(B) Gastrinoma
(C) Glucagonoma
(D) Insulinoma
(E) Pancreatic polypeptide-secreting tumor
14 A 40-year-old woman comes to the physician with a 6-week history of episodic hunger and fainting spells. She is currently seeing a
psychiatrist because she is irritable and quarreling with her family. Laboratory studies show a serum glucose concentration of 35 mg/dL. A
CT scan of the abdomen demonstrates a 1.5-cm mass in the pancreas. The gross appearance of the bisected tumor is shown in the image.
What is the most likely diagnosis?
(A) Adenocarcinoma
(B) Gastrinoma
(C) Glucagonoma
(D) Insulinoma
(E) Somatostatinoma

15 A 36-year-old woman complains of a 4-week history of unremitting watery diarrhea. She reports that she is always thirsty and drinks
continuously. Laboratory studies show achlorhydria, hypokalemia, and mild acidosis. A CT scan of the abdomen demonstrates a 1.5-cm
pancreatic mass. Which of the following is the most likely diagnosis?
(A) Carcinoid tumor
(B) Gastrinoma
(C) Pancreatic polypeptide-secreting tumor
(D) Somatostatinoma
(E) VIPoma

16 A 45-year-old woman complains of right upper quadrant abdominal pain, weight loss, dry mouth, increased urine production, and foul-
smelling fatty stools. She has a recent history of mild diabetes mellitus. Abdominal ultrasound examination reveals gallstones and a
solitary 1.5-cm mass in the pancreas. Which of the following hormones would most likely be elevated in the blood of this patient?
(A) Calcitonin
(B) Gastrin
(C) Insulin
(D) Somatostatin
(E) Vasoactive intestinal polypeptide

17 A 35-year-old man complains of severe acute periumbilical pain that radiates to his back and nausea. The patient recently had a heart
transplant for idiopathic cardiomyopathy and is taking azathioprine for immunosuppression. Physical examination reveals bruising of both
fl anks. Blood pressure is 120/70 mm Hg, pulse rate 100 per minute, and temperature 37.8°C (100°F). Laboratory studies show elevated
serum levels of amylase (950 U/L) and lipase (780 U/L), normal levels of serum calcium, and a normal serum lipid profi le. The patient
expires, and the pancreas is examined at autopsy (shown in the image). Which of the following is the most likely underlying cause of these
pathologic fi ndings?
(A) Acute ischemia
(B) Drug-induced pancreatitis
(C) Graft-versus-host reaction
(D) Hypercalcemia
(E) Hyperlipidemia

18 A 63-year-old woman presents with a 6-month history of recurrent epigastric pain and nausea. Abdominal ultrasound reveals a 13-mm
hypoechoic lesion in the tail of the pancreas. Physical examination shows fl ushing of the face, periorbital edema, and hypotension (blood
pressure = 90/50 mm Hg). Laboratory studies disclose normal serum levels of gastrin, amylase, insulin, and vasoactive intestinal
polypeptide. Urinalysis demonstrates elevated levels of metanephrines (10 mg per 24 hours). Which of the following is the most likely
diagnosis?
(A) Adenocarcinoma of pancreas
(B) Glucagonoma
(C) Insulinoma
(D) Pancreatic carcinoid
(E) Somatostatinoma

19 A 65-year-old man with a history of acromegaly complains of recurrent epigastric pain and dark-colored tarry stools. Laboratory studies
reveal moderate hypercalcemia, hyperlipidemia, and elevated serum levels of PTH and gastrin. Serum glucose is within normal limits.
Abdominal ultrasound shows a mass in the tail of the pancreas. Which of the following is the most likely diagnosis?
(A) Glucagonoma
(B) Insulinoma
(C) Multiple endocrine neoplasia type 1
(D) Multiple endocrine neoplasia type 2
(E) Pancreatic carcinoid
1 A 24-year-old, G2, P1001, woman has a screening ultrasound that shows polyhydramnios at 17 weeks’ gestation. She gives birth at term
to a boy who on examination has no abnormal findings. Since birth, he has often vomited after feedings. An infant radiograph with
contrast enhancement shows the findings in the figure. Laboratory studies show sodium, 130 mmol/L; potassium, 3.4 mmol/L; chloride,
85 mmol/L; CO2, 32 mmol/L; glucose, 65 mg/dL; and amylase, 15 U5/L. What is the most likely diagnosis?
A Acute pancreatitis
B Annular pancreas
C Chronic pancreatitis
D Islet cell adenoma
E Pancreatic adenocarcinoma
F Pyloric stenosis

2 A 16-year-old boy incurs a gunshot wound to the abdomen in a drive-by shooting. At exploratory laparotomy, the surgeon finds a
perforated portion of jejunum. She resects this portion and palpates a mass in the jejunal submucosa. Sectioning of this lesion reveals that
it is a 1.5-cm diameter circumscribed, solid, tan mass. The mass is sent for frozen section. What is the pathologist most likely to see under
her microscope?
A Adenocarcinoma
B Adrenal medulla
C Gastric mucosa
D Non-Hodgkin lymphoma
E Pancreatic acini

3 A 33-year-old woman with Hodgkin lymphoma of cervical lymph nodes has an abdominal CT scan for staging. The scan reveals a solitary
4-cm cyst in the body of the pancreas. A fine-needle aspirate is performed and yields clear serous fluid that microscopically has low cuboidal
cells with no atypia. What is this cyst most likely to be?
A Adenocarcinoma
B A component of autosomal dominant polycystic kidney disease
C Congenital malformation
D Cystadenoma, serous
E Pseudocyst

4 A clinical study of patients with acute abdomen is performed. Those patients with elevated serum lipase are identified. A decrease in
which of the following analytes is most likely to predict a worse prognosis?
A Albumin
B Bilirubin
C Calcium
D Fibrinogen
E Haptoglobin

5 A 35-year-old man has a 1-year history of bouts of dull abdominal pain. Over the next 5 years he also develops steatorrhea and mild
glucose intolerance. He does not develop jaundice. An abdominal CT scan shows specks of calcification in the midabdomen, particularly
near the duodenum. One of his sisters has a similar clinical picture, but both parents are unaffected. Loss of inhibition of which of the
following is the most likely cause for the disease seen in these persons?
A Amylase
B Complement
C Lipase
D Transforming growth factor beta (TGF-β)
E Trypsin

6 A 52-year-old man has had severe abdominal pain for the past 2 days. Physical examination shows boardlike rigidity of the abdominal
muscles, making further examination difficult. There is no observable abdominal distention. The representative gross appearance of the
disease process is shown in the figure. Which of the following is the mechanism most likely to produce this appearance?
A CFTR gene mutation
B Coxsackievirus B infection
C Dysregulation of trypsinogen inactivation
D Marked hypertriglyceridemia
E Vasculitis with acute ischemia
F Blunt force trauma to the abdomen
7 An 11-year-old boy has experienced multiple bouts of severe abdominal pain for the past 6 years, but no other medical problems. His
father and grandfather have been similarly affected. On examination during the last episode, bowel sounds were absent, and he exhibited
marked diffuse abdominal pain with abdominal wall rigidity. A radiograph of the abdomen showed dilated loops of bowel with air-fluid
levels. Laboratory studies showed serum amylase of 3320 U/L. This boy is most likely to have an inherited mutation involving which of the
following genes?
A CFTR
B KRAS
C PRSS1
D SMAD4
E SPINK1

8 A 38-year-old woman with a long history of gallbladder disease has a sudden onset of severe midabdominal pain. On physical examination,
she has marked abdominal tenderness, particularly in the upper abdomen, and bowel sounds are reduced. An abdominal radiograph shows
no free air, but there is marked soft tissue edema. Abdominal CT scan shows decreased attenuation with fluid density involving the pancreas.
She is given intravenous fluids and nasogastric suction and recovers gradually. Which of the following serum laboratory tests is most useful
for diagnosis of her disease process?
A Alanine aminotransferase
B Ammonia
C Bicarbonate
D Bilirubin
E Glucose
F Amylase

9 A 63-year-old man who had worsening congestive heart failure with cardiac dysrhythmias for the past year of his life died of pneumonia.
At autopsy, his pancreas is grossly small and densely fibrotic. Microscopic examination shows extensive atrophy of the acini with residual
chronic inflammation, fibrosis, and inspissated protein plugs in small, obstructed pancreatic ducts. Some of the protein plugs show
calcification. The islets of Langerhans appear normal. The heart weighs 500 g, and all four chambers are dilated. Which of the following
conditions is most likely to account for his findings?
A αl-Antitrypsin deficiency
B Blunt trauma to the abdomen
C Cholelithiasis
D Chronic alcoholism
E Cystic fibrosis
F Hypercholesterolemia

10 A 39-year-old man has had numerous bouts of pneumonia caused by Pseudomonas aeruginosa and Burkholderia cepacia for the past 35
years. He now has diarrhea of mild-to-moderate volume. On physical examination, he has decreased breath sounds and dullness to
percussion in both lungs. His stool guaiac test is negative. Laboratory studies show the ΔF508 mutation. His quantitative stool fat is 7.5
g/day. Which of the following pathologic findings is most likely to be present in the pancreas of this patient?
A Acute inflammation
B Acinar atrophy
C Adenocarcinoma
D Amyloidosis
E Pseudocyst

11 A 36-year-old woman with a history of pulmonary infections since childhood has had chronic abdominal pain for 4 years, along with a 6-
kg weight loss. On physical examination her BMI is 18. There is pitting edema on the lower leg. Laboratory studies show serum albumin 3
g/dL, total protein 5.2 g/ dL, and glucose 155 mg/dL. Abdominal CT imaging shows calcifications in the upper abdomen, posterior to the
stomach. No mass lesion is noted. She is most likely to have a mutation involving which of the following genes?
A CFTR
B KRAS
C PRSS1
D SPINK1
E VHL
12 A 65-year-old woman has had upper abdominal pain for the past month. On examination, the pain is localized to the epigastric region
on palpation. Abdominal CT scan shows a well-circumscribed, 8-cm mass in the tail of the pancreas that has many small fluid-filled areas. At
laparotomy, the mass is removed and on microscopic examination shows glycogen-rich, low cuboidal cells surrounding spaces filled with
clear fluid. There is no recurrence of the lesion. What is the most likely diagnosis?
A Adenocarcinoma
B Autosomal dominant polycystic kidney disease
C Chronic pancreatitis
D Cystic fibrosis
E Pseudocyst
F Serous cystadenoma

13 A 46-year-old woman has severe abdominal pain for 2 days. On physical examination she has marked epigastric pain, and bowel sounds
are reduced. Laboratory studies show an elevated serum lipase. With supportive care, her acute condition subsides within 7 days. Which of
the following complications is most likely to occur in this patient?
A Gastric ulceration
B Hemoperitoneum
C Hyperosmolar coma
D Ketoacidosis
E Pseudocyst formation
F Small bowel infarction

14 A 58-year-old woman has experienced abdominal discomfort for the past year. On physical examination, she has midepigastric
tenderness on palpation. Laboratory studies show a normal serum lipase. The figure shows her abdominal CT scan. The lesion is excised,
and on microscopic examination has cells that show cytologic and architectural atypia, but no invasion of surrounding pancreatic
parenchyma. What is the most likely diagnosis?
A Adenocarcinoma
B Autosomal dominant polycystic kidney disease
C Mucinous cystic neoplasm
D Cystic fibrosis
E Islet cell tumor, nonfunctional
F Pseudocyst

15 A 79-year-old woman belongs to a religious sect that follows the dictum “if it sounds like fun, you shouldn’t do it,” and has in so (not)
doing avoided many risk factors for disease and remained healthy. For the past 7 months, she has had vague abdominal pain, however, and
yesterday she experienced acute chest pain with dyspnea. Chest and abdomen CT scans show a pulmonary embolus. Her abdominal CT scan
is shown in the figure. Laboratory studies show elevation in CEA and CA19-9. A mutation involving which of the following genes is most
likely implicated in development of this mass?
A APC
B BRCA2
C CFTR
D KRAS
E PRSS1
F SPINK1

16 A 73-year-old woman has noticed a 10-kg weight loss in the past 3 months. She is becoming increasingly icteric and has constant vague
epigastric pain, nausea, and episodes of bloating and diarrhea. On physical examination, she is afebrile. There is mild tenderness to palpation
in the upper abdomen, but bowel sounds are present. Her stool is negative for occult blood. Laboratory findings include a total serum
bilirubin concentration of 11.6 mg/dL and a direct bilirubin level of 10.5 mg/dL. Which of the following conditions involving the pancreas is
most likely to be present?
A Adenocarcinoma
B Chronic pancreatitis
C Cystic fibrosis
D Islet cell adenoma
E Pseudocyst
17 A 68-year-old man notes dull but constant abdominal pain accompanied by nausea with vomiting for the past 8 months. On physical
examination he has tenderness to palpation of the upper abdomen. Abdominal CT imaging shows a 2-cm circumscribed mass in the body
of the pancreas. Pancreatectomy is performed and microscopic examination of this mass shows tall, columnar, mucinous epithelial cells
lining papillary excrescences within the main pancreatic duct. There is minimal atypia and no invasion. What is the most likely future course
for this man?
A Additional gastrointestinal neoplasms
B Complete remission
C Development of extraabdominal malignancies
D Local recurrence
E Pseudocyst formation

18 An 80-year-old man has increasing jaundice with abdominal pain for the past 2 weeks. He has lost 4 kg over the past 5 months. On
physical examination there is tenderness with palpable gallbladder in the right upper quadrant. An abdominal CT scan shows gallbladder
and common bile duct dilation, along with a 3-cm mass in the head of the pancreas. Which of the following lesions is the most likely precursor
to this mass?
A Colonic neuroendocrine carcinoma
B Duodenal adenocarcinoma
C Neuroendocrine tumor
D Pancreatic intraepithelial neoplasia
E Serous cystadenoma
ENDO PANCREAS

1 A 14-year-old boy presents for a presummer camp physical examination. Routine urinalysis discloses 3+ glucosuria. He admits to thirst
and frequent urination, accompanied by a 4-kg (9-lb) weight loss over the past few months. His parents note that he had a fl u-like illness
5 months ago. His blood glucose is 220 mg/dL. Which of the following best explains the pathogenesis of hyperglycemia in this patient?
(A) Excess dietary glucose
(B) Increased peripheral insulin uptake
(C) Irregular insulin secretion
(D) Islet cell destruction
(E) Peripheral insulin resistance

2 A 10-year-old boy with a recent onset of diabetes mellitus dies following an automobile accident. Histologic examination of the child’s
pancreas at autopsy is shown in the image. Injury to pancreatic islet cells in this patient was most likely mediated by which of the
following mechanisms of disease?
(A) Antibody-mediated islet cell destruction
(B) Cell-mediated immunity
(C) Direct viral cytopathic effects
(D) Hypovolemic shock
(E) Phagocytosis by activated macrophages

3 A 55-year-old obese woman (body mass index = 33 kg/m2) complains of declining visual acuity. Funduscopic examination shows
peripheral retinal microaneurysms. Urinalysis reveals 3+ proteinuria and 3+ glucosuria. Serum albumin is 3 g/dL, and serum cholesterol is
350 mg/dL. These clinicopathologic findings are best explained by which of the following mechanisms of disease?
(A) Anti-insulin antibodies
(B) Increased peripheral insulin uptake
(C) Irregular insulin secretion
(D) Peripheral insulin resistance
(E) Secretion of insulin-like proteins

4 A 61-year-old man presents with a 5-year history of pain in both legs during exercise. He has been treated for diabetes for 8 years. His
fasting blood glucose is 280 mg/dL. Which of the following best explains the pathogenesis of leg pain in this patient?
(A) Atherosclerosis
(B) Malignant hypertension
(C) Microaneurysms
(D) Peripheral neuropathy
(E) Vasculitis

5 A 60-year-old man with diabetes mellitus complains of deep burning pain and sensitivity to touch over his hands and fingers. Nerve
conduction studies show slow transmission of impulses and diminished muscle stretch refl exes in the ankles and knees. Sensations to
vibrations and light touch are also markedly diminished. The development of polyneuropathy in this patient correlates best with which of
the following conditions?
(A) Anti-insulin antibody titer
(B) Hyperglycemia
(C) Insulin defi ciency
(D) Intermittent hypoglycemia
(E) Ketoacidosis

6 A 56-year-old man with a 14-year history of diabetes mellitus presents with poor vision, peripheral vascular disease, and mild
proteinuria. Which of the following is the best monitor of the control of blood sugar levels in this patient?
(A) Glycosylated hemoglobin
(B) Islet cell autoantibody
(C) Serum myoinositol
(D) Serum sorbitol
7 A 65-year-old obese man (body mass index = 32 kg/m2) presents with a 2-year history of diffi culty walking. Physical examination reveals
chronic ulcers in the lower extremities. Funduscopic examination reveals proliferative retinopathy. Which of the following best describes
the pathogenesis of chronic ulcers on the legs of this patient?
(A) Abnormal glycosylation of hemoglobin
(B) Inadequate leukocytic response to infection
(C) Low concentrations of insulin in tissues
(D) Microvascular disease
(E) Varicose veins

8 Thickening of small vessel basement membranes in the patient described in Question 7 is most likely related to abnormalities in which
of the following cellular and biochemical processes?
(A) Amyloidosis
(B) Collagenous fi brosis
(C) Glycosylation
(D) Immunoglobulin deposition
(E) Insudation of fi brin

9 A 58-year-old man with a long-standing history of type 2 diabetes mellitus suffers a massive hemorrhagic stroke and expires.
Examination of the pancreas shows hyalinization of many islets of Langerhans. Which of the following characterizes the material within
the islets of Langerhans?
(A) Amyloid
(B) Collagen type IV
(C) Fibrin
(D) Fibronectin
(E) Proteoglycan

10 A 50-year-old man with diabetes mellitus develops swelling in his lower extremities. Urinalysis shows 3+ proteinuria and 3+ glucosuria.
Serum albumin is 3 g/dL and serum cholesterol is 350 mg/ dL. A kidney biopsy is shown in the image. Which of the following glomerular
changes is evident in this biopsy specimen?
(A) Amyloidosis
(B) Deposition of basement membrane–like material
(C) Endothelial cell hyperplasia
(D) Fibrinoid necrosis
(E) Mesangial hyperplasia

11 A 75-year-old woman with well-controlled diabetes complains of poor eyesight. A grayish-white opacifi cation of the lens is
found during a comprehensive eye examination. Which of the following metabolic pathways is most likely involved in this lens
abnormality?
(A) Aldose reductase pathway
(B) Amino acid degradation cycle
(C) Citric acid cycle
(D) Oxidative phosphorylation
(E) Pentose-phosphate shunt

12 A 40-year-old diabetic woman complains of fl ank pain and fever. Her temperature is 38.7°C (103°F), respirations are 25 per minute,
and blood pressure is 150/90 mm Hg. Urinalysis reveals pyuria with WBC casts. Which of the following features of diabetes is the most
important contributing factor in the development of fl ank pain and fever in this patient?
(A) Anti-insulin antibodies
(B) Glycosylation of hemoglobin
(C) Hyperglycemia
(D) Peripheral insulin resistance
(E) Sorbitol accumulation

13 A 32-year-old woman with diabetes mellitus delivers a child after 38 weeks of gestation. Which of the following is the most likely
abnormality that might be encountered in this child at birth?
(A) Cataracts
(B) Hyperbilirubinemia
(C) Hypoglycemia
(D) Low birth weight
(E) Mental retardation
14 An obese woman (body mass index [BMI] = 32 kg/m2) presents for a routine physical examination. In reviewing your patient’s health
status, you mention that obesity is associated with an increased incidence of which of the following diseases?
(A) Cardiomyopathy
(B) Cervical carcinoma
(C) Chronic obstructive pulmonary disease
(D) Degenerative joint disease
(E) Diabetes mellitus type 1

34 A 27-year-old man has controlled his diabetes mellitus for the past 10 years with insulin injections. This morning, his roommate is
unable to awaken him. The man is unconscious when brought to the emergency department. On physical examination, his temperature is
37° C, pulse is 91/min, respirations are 30/min, and blood pressure is 90/65 mm Hg. Laboratory findings include a high plasma level of
insulin and a lack of detectable C peptide. Urinalysis shows no blood, protein, or glucose, but 4+ ketonuria. Which of the following
conditions is most likely to be present?
A Acute myocardial infarction
B Bacteremia
C Hepatic failure
D Hyperosmolar syndrome
E Hypoglycemic coma
F Ketoacidosis

35 Blood relatives of individuals diagnosed with type 1 or type 2 diabetes mellitus are studied for 10 years. Laboratory testing for glucose
and insulin levels and autoantibody formation is performed on a periodic basis. The HLA types of the subjects are determined. A cohort of
the subjects who are 8 to 22 years old has no overt clinical illnesses and no hyperglycemia; however, autoantibodies to glutamic acid
decarboxylase are present. Many subjects in this cohort have the HLA-DR3 and HLA-DR4 alleles. Which of the following pancreatic
abnormalities is most likely to be found in this cohort of study subjects?
A Acinar acute inflammation and necrosis
B Acinar fibrosis and fatty replacement
C Islet amyloid deposition
D Islet hyperplasia
E Insulitis
F Normal islets in a fibrous stroma

36 A 23-year-old woman has a routine health status examination. Her body mass index is 22. Laboratory studies show fasting plasma
glucose is 130 mg/dL. Urinalysis shows mild glucosuria, but no ketonuria or proteinuria. She has no detectable insulin autoantibodies. Her
father was similarly affected at age 20 years. She is most likely to have a mutation in a gene encoding for which of the following?
A Glucagon
B Glucokinase
C GLUT4
D Insulin
E MHC DR

37 A 13-year-old girl collapses while playing basketball. On arrival at the emergency department, she is obtunded. On physical
examination, she is hypotensive and tachycardic with deep, rapid, labored respirations. Laboratory studies show serum Na+, 151 mmol/L;
K+, 4.6 mmol/L; Cl–, 98 mmol/L; CO2, 7 mmol/L; and glucose, 521 mg/dL. Urinalysis shows 4+ glucosuria and 4+ ketonuria levels, but no
protein, blood, or nitrite. Which pathologic abnormality is most likely to be present in her pancreas at the time of her collapse?
A Loss of islet beta cells
B Acute inflammation of islets
C Amyloid replacement of islet beta cells
D Chronic inflammation of islets
E Hyperplasia of alpha cells
F Pancreatic neuroendocrine tumo
38 A study of patients more than 25 years of age with body mass index above 30, dyslipidemia, hypertension, and fasting glucose averaging
115 mg/dL is performed. They have adipose tissue abnormalities including increased nonesterified fatty acid release, altered adipokines
with decreased adiponectin, greater proinflammatory cytokine release, and diminished peroxisome proliferator-activated receptor gamma
(PPARγ) function. Which of the following is the best initial therapeutic intervention for these patients?
A Adrenalectomy
B Caloric restriction
C Insulin injection
D l-Thyroxine
E Liposuction

39 An infant is born following premature delivery. Multiple external congenital anomalies are noted. The infant exhibits a seizure soon after
birth. The blood glucose is 19 mg/dL. Which of the following maternal diseases is the most likely cause for the observed findings in this
infant?
A Cystic fibrosis
B Diabetes mellitus, type 2
C Gestational diabetes
D Maturity onset diabetes of the young
E Pancreatic neuroendocrine tumor

40 A clinical study is conducted in patients diagnosed with either type 1 or type 2 diabetes mellitus. Persons with either type develop
complications of accelerated and advanced atherosclerosis. All untreated patients have an elevated hemoglobin A1c. Which of the following
features common to patients with either type 1 or type 2 diabetes mellitus is most likely to be found by this study?
A Association with certain MHC class II alleles
B High concordance rate in monozygotic twins
C Marked resistance to the action of insulin
D Nonenzymatic glycosylation of proteins
E Presence of islet cell antibodies

41 A 50-year-old man with fasting blood glucose >140 mg/dL on two occasions is put on a restricted caloric diet and started on a glucagon-
like peptide-1 (GLP-1) receptor agonist. Which of the following laboratory studies is most likely to afford the best method of monitoring
disease control in this man?
A Cholesterol, total
B Fasting plasma glucose
C Glycosylated hemoglobin
D Microalbuminuria
E Random plasma glucose
F Serum fructosamine

42 A 50-year-old man has had a nonhealing ulcer on the bottom of his foot for 2 months. On examination, the 2-cm ulcer overlies the right
first metatarsal head. There is reduced sensation to pinprick in his feet. His visual acuity is reduced bilaterally. Laboratory studies show
serum creatinine is 2.9 mg/dL. Which of the following laboratory test findings is he most likely to have?
A Glucosuria
B Hypoalbuminemia
C Hypokalemia
D Leukopenia
E Steatorrhea
F Uricosuria

43 A 52-year-old man has been concerned about a gradual weight gain over the past 30 years. He is 174 cm (5 feet 7 inches) tall and weighs
91 kg (body mass index 30). He is taking no medications. On physical examination, he has decreased sensation to pinprick and light touch
over the lower extremities. Patellar reflexes are reduced. Motor strength seems to be normal in all extremities. Laboratory studies show
blood glucose of 169 mg/dL, creatinine of 1.9 mg/dL, total cholesterol of 220 mg/dL, HDL cholesterol of 27 mg/dL, and triglycerides of 261
mg/dL. A chest radiograph shows mild cardiomegaly. Five years later, he has claudication in the lower extremities when he exercises. Based
on these findings, which of the following complications is most likely to occur in this man?
A Gangrene
B Hypoglycemic coma
C Ketoacidosis
D Mucormycosis
E Pancreatitis
F Systemic amyloidosis
44 A 45-year-old woman has had angina pectoris, polyuria, and polydipsia for the past 5 years. On physical examination, she has a body
mass index of 32. Laboratory studies show her hemoglobin A1c is 10%. Urinalysis shows proteinuria, but no ketonuria. The representative
microscopic appearance of her kidneys is shown in the figure. Which of the following is the most likely mechanism leading to the disease
causing her findings?
A Chronic pancreatitis
B Glucokinase gene mutation
C Insulin resistance
D Systemic amyloidosis
E T-cell mediated B-cell destruction

45 A 50-year-old man has a 35-year history of diabetes mellitus. During this time, he has had hemoglobin A1c values between 7% and 10%.
He now has problems with sexual function, including difficulty attaining an erection. He also is plagued by mild but recurrent low-volume
diarrhea and difficulty with urination. He has delayed gastric emptying. These problems are most likely to originate from which of the fol-
lowing mechanisms of cellular injury?
A Cross-linking of extracellular matrix proteins
B Production of vascular endothelial growth factor
C Abnormal transforming growth factor-beta signaling
D Increased endothelial procoagulant activity
E Nonenzymatic glycosylation
F Polyol-induced susceptibility to oxidative stress

46 A 74-year-old woman is admitted to the hospital in an obtunded condition. Her temperature is 37° C, pulse is 95/ min, respirations are
22/min, and blood pressure is 90/60 mm Hg. She appears dehydrated and has poor skin turgor. Her serum glucose level is 872 mg/dL.
Urinalysis shows 4+ glucosuria, but no ketones, protein, or blood. Which of the following factors is most important in the pathogenesis of
this patient’s condition?
A Autoimmune insulitis
B Glucokinase gene mutation
C HLA-DR3/HLA-DR4 genotype
D Peripheral insulin resistance
E Virus-induced injury to beta cells in islets

47 A 40-year-old woman has experienced chest pain on exertion for the past 2 months. A month ago, she had pneumonia with
Streptococcus pneumoniae cultured from her sputum. On physical examination, she has a body mass index of 35. A random blood glucose
value is 132 mg/dL. The next day, a fasting blood glucose is 120 mg/dL, followed by a value of 122 mg/ dL on the following day. She is given
an oral glucose tolerance test, and her blood glucose is 240 mg/dL 2 hours after receiving the standard 75-g glucose dose. On the basis of
these findings, she is prescribed an oral thiazolidinedione (TZD) drug. After 2 months of therapy, her fasting blood glucose is 90 mg/ dL. The
beneficial effect of TZD in this patient is most likely related to which of the following processes?
A Activation of PPARγ nuclear receptor in adipocytes
B Decreased production of insulin autoantibodies
C Greater density of insulin receptors in adipocytes
D Increased half-life of circulating plasma insulin
E Reduced secretion of glucagon by a cell in islets of Langerhans
F Regeneration of beta cells in islets of Langerhans

48 A family is followed longitudinally for two generations. Four of eight children develop hyperglycemia by age 18 years. They are found to
have serum islet autoantibodies. They have similar MHC I and MHC II loci. Treatment with insulin injections normalizes their Hgb A1c levels.
Which of the following is the most likely mechanism leading to their disease?
A Chloride ion channel abnormality
B Chromosome 21 trisomy
C Glucokinase gene mutation
D Peripheral insulin resistance
E Loss of T-cell tolerance
49 A 33-year-old woman has had several “fainting spells” over the past 6 months. Each time, she has a prodrome of lightheadedness
followed by a brief loss of consciousness. After each episode, she awakens and on examination has no loss of motor or sensory function.
Physical examination after the current episode shows that she is afebrile, with a pulse of 72/min, respirations of 17/min, and blood pressure
of 120/80 mm Hg. Imaging studies reveal a 0.5-cm lesion in the head of the pancreas. The microscopic appearance of this lesion is shown in
the figure. Which of the following pancreatic disorders is most likely to be present in this patient?
A Acute necrotizing pancreatitis
B Adenocarcinoma
C Cystic fibrosis
D Neuroendocrine tumor
E Pseudocyst

50 A 43-year-old man from Stockholm, Sweden, has had low-volume watery diarrhea for the past 3 months. He now has midepigastric pain.
Over-the-counter antacid medications do not relieve the pain. On physical examination, he is afebrile; on palpation, there is no abdominal
tenderness and no masses. An upper gastrointestinal endoscopy shows multiple 0.5- to 1.1-cm, shallow, sharply demarcated ulcerations in
the first and second portions of the duodenum. He is given omeprazole. Three months later, repeat endoscopy shows that the ulcerations
are still present. Which of the following analytes is most likely to be increased in his in serum or plasma?
A Gastrin
B Glucagon
C Insulin
D Somatostatin
E Vasoactive intestinal polypeptide (VIP)