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A child ingests 50 tablets in a bottle that she found on a table
in the house. Two hours later, the child becomes progressively
obtunded and then lapses into a coma. The child is taken to a
local hospital, where supportive care is given. The child exhibits
D Acetylsalicylic acid
tachypnea and tachycardia, but is afebrile. Laboratory studies
with blood gas analysis show metabolic acidosis. Which of the
(D) CORRECT. Aspirin ingestion can lead to metabolic acidosis.
following substances did this child most likely ingest?
The tachypnea is a physiologic compensation with respiratory
A Sodium hypochlorite
alkalosis.
B Lead arsenate
C Methyl alcohol
D Acetylsalicylic acid
E Mercuric chloride
A 17-year-old driver was involved in a motor vehicle accident. He
was thrown from the vehicle and sustained extensive blunt trauma
with multiple fractures of the left tibia and fibula, left femur, and
A Multiple cerebral white matter petechiae
right humerus. He was in stable condition until three days after
admission, when he suddenly became comatose and died. Autop-
(A) CORRECT. He has fat embolism syndrome. This is a compli-
sy is most likely to reveal which of the following gross pathologic
cation of multiple long bone fractures. It is uncommon but unpredi-
findings?
catable in occurrence. Extensive blunt force trauma to soft tissues
A Multiple cerebral white matter petechiae
and burn injuries may also cause fat embolism. The lungs may
B Large thromboembolus in the pulmonic trunk
also be involved, leading to marked dyspnea.
C Hematoma in the epidural space
D 500 cc of blood in the pericardial cavity
E Air in the left pleural space with marked atelectasis
A 20-year-old man is combative when police arrive at a house
from which the neighbors heard screaming and breaking of glass
for the past hour. He suddenly collapses. He is taken to the
hospital, requiring resuscitation with defibrillation en route to try
C Cocaine
and establish a normal cardiac rhythm. On physical examination
his vital signs show temperature 40°C, respirations 36/minute,
(C) CORRECT. Cocaine overdoses are associated with a state
heart rate 110/minute, and blood pressure 175/90 mm Hg. His
of 'excited delirium' which can be accompanied by hyperthermia.
pupils are dilated. He dies within an hour. Autopsy reveals no signs
Cocaine is powerful vasoconstrictor and has a variety of vascular
of major trauma. Which of the following drugs of abuse is most
effects. Many complications come from the cardiac complications
likely to produce these findings?
that include arterial vasoconstriction with ischemic myocardial
A Ethanol
injury and arrhythmias.
B Heroin
C Cocaine
D Methamphetamine
E Marijuana
A 70-year-old man with a medical history of coronary athero-
sclerosis and congestive heart failure is beaten about the head
and robbed. He is unconscious when admitted to the hospital.
During his hospital course over the next two weeks he develops A Blunt head trauma
bronchopneumonia, sepsis and renal failure. He dies four days
later. Which of the following conditions is the most likely underlying (A) CORRECT. No matter what the course of the patient and no
cause of death for this man? matter how long it takes, the underlying cause of death is still the
A Blunt head trauma disease or event that started the chain of events leading to death.
B Bronchopneumonia The manner of death in this case is homicide.
C Coronary atherosclerosis
D Renal failure
E Sepsis

A 30-year-old woman has been the victim of physical abuse by her

spouse on multiple occasions, including punching her in the face
and abdomen. After the most recent incident, she claims that he B Incised wound
attacked her with a knife. Which of the following types of injuries
are you most likely to find on physical examination of this woman (B) CORRECT. The sharp edge of a knife produces an incision
which suggests that her spouse attacked her with a knife? with clean edges (just as a surgical scalpel blade is used to make
A Contusion a surgical incision).
B Incised wound
C Abrasion

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D Laceration
E Puncture
On a trip to the Caribbean, a 29-year-old man takes a scuba diving
course. He goes on a wreck dive to a depth of 50 meters (170
feet). His diving partner signals to him that it is time to ascend, but
he continues to explore the wreck, noticing some time later than
E Nitrogen bubble formation
he is running low on air. He panics and ascends to the surface
quickly. Within 2 hours he then develops a headache, tightness
(E) CORRECT. He has the 'bends' from too rapid decompression.
in his chest, and difficulty breathing. He experiences generalized
Under greater pressure (10 meters = 1 atmosphere) more gas
pain in all extremities. Which of the following injuries is the most
becomes dissolved in the body. When the pressure diminishes too
likely cause for his findings?
quickly, the nitrogen bubbles form in blood and tissues to produce
A Disseminated intravascular coagulopathy
the various symptoms.
B Hypothermia
C Free radical cellular injury
D Apoptosis
E Nitrogen bubble formation
A medical resident puts down the immediate cause of death
as 'Prematurity' followed by the underlying cause of death as
'Hyaline membrane disease' on a death certificate form. Which of
C The listed order is not correct
the following statements regarding this death certificate is most
appropriate?
(C) CORRECT. The resident has the immediate and underlying
A The case should be investigated by the medical examiner
causes of death listed backwards. This destroys the resident's
B A fetal death certificate should be used
credibility unless an amended death certificate is issued.
C The listed order is not correct
D This is a finding with sudden infant death syndrome
E A congenital infection was present
A 66-year old man has an episode of hemoptysis. A chest x-ray
shows a 5 cm mass in the left lung. Fine needle aspiration is
performed and cells from the mass are examined microscopically, A Radon
revealing a non-small cell carcinoma. The man is a non-smoker.
Environmental exposure to which of the following agents is most (A) CORRECT. Exposure to radon gas is considered the second
likely to be a risk factor for development of this man's lung cancer? most common cause for lung cancer--a distant second to smoking.
A Radon Radon gas seeps up from the ground and is trapped in dwellings,
B Silica where it is inspired and may lead to mutational events that underlie
C Mold neoplasia.
D Coal dust
E Ozone
A 4-year-old child lives with a family in a housing project with
very old homes with deteriorating floors, flaking paint, and leaking C Lead
roofs. The child has complained of abdominal pain and headache
for the past day. Which of the following substances has this child (C) CORRECT. Older houses may have lead-based paint, and
most likely ingested? the flaking paint chips have a sweet taste attracting ingestion by
A Arsenic children. Acute lead poisoning is marked by lead colic (abdominal
B Ethanol pain) along with mental deterioration (encephalopathy). Chronic
C Lead lead poisoning more common in adults can lead to anemia and
D Nicotine peripheral neuropathy.
E Organochlorine
A 9-year-old girl is brought to the emergency department by
her aunt. On physical examination there are multiple contusions
of varying ages on the head, torso, arms, and thighs. A chest
C Child abuse
radiograph reveals a healing 6th rib fracture on the left. Her weight
is slightly under that expected for age. The child appears listless.
(C) CORRECT. Any time you see contusions of varying ages in
Which of the following conditions is the most likely diagnosis?
multiple body regions, whether in an adult or a child, suspect pos-
A Down syndrome
sible abuse and see if the explanation makes sense. Rib fractures
B Scurvy
are unlikely to result from normal play by children.
C Child abuse
D Meningococcemia
E Fall down the stairs

A 68-year-old woman is having minor elective eye surgery per-

formed at a free-standing surgi-center. About 5 to 10 patients
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undergo various procedures each morning. She is next in line
for surgery and has just been given pre-operative medications.
Five minutes later, the nurse comes into the room where she is
lying and discovers that she is not breathing. A crash cart and
defibrillator for advanced cardiac life support are not available,
so the nurse and doctor use mouth-to-mouth resuscitation and D This is a therapeutic misadventure
external chest compressions, but to no avail. At autopsy, the
patient is found to have about 30% coronary atherosclerosis with (D) CORRECT. This is an 'oops' which should not have happened.
20% narrowing, a 300 gm heart, mild pulmonary emphysema, Clearly, there was not close enough monitoring of the patient or
and minimal hepatic steatosis. A toxicology screen is negative for adequate facilities to deal with a potential complication of this
drugs of abuse and yields only traces of the medications used nature. You don't expect to have the complication of death with
prior to surgery. Which of the following statements regarding this such minor surgery, and if the patient were unstable, then this
death is most accurate? elective surgery should not have been performed.
A The manner of death is undetermined
B A myocardial infarction is the immediate cause of death
C The prior medical history needs to be obtained
D This is a therapeutic misadventure
E The underlying cause of death is chronic alcoholism
A 70-year-old man died suddenly and unexpectedly within 6 hours
of admission to the hospital for a high fever that has been present
for only 4 hours. At autopsy, there are no significant external
findings on examination of the body. However, on opening the
cranial cavity, the external surface of the markedly edematous C Immediate cause of death is 'meningitis'
brain shows an extensive yellow-tan exudate obscuring the sulci.
Which of the following statements on this man's death certificate (C) CORRECT. The description fits best with an acute bacterial
is most appropriate? meningitis. Such patients can succumb quickly from cerebral ede-
A Underlying cause of death is 'head trauma' ma that leads to herniation.
B Manner of death is 'accident'
C Immediate cause of death is 'meningitis'
D Underlying cause of death is 'pulmonary tuberculosis'
E Intervening cause of death is 'stroke'
A 50-year-old man has had increasing dyspnea for 12 years, but
no chronic cough. On physical examination he is afebrile. A chest A Inorganic dusts
radiograph reveals diffuse interstitial fibrosis involving both lungs.
These findings are most likely produced by which of the following (A) CORRECT. These inorganic dusts, typically silicates con-
environmental exposures? taining silica, are trapped in the lungs and then ingested by
A Inorganic dusts macrophages. The macrophages then release cytokines that re-
B Nitrous oxides sult in fibrogenesis. The length and extent of exposure determine
C Organic inhaled particles the degree of pulmonary fibrosis and the severity of the resulting
D Cigarette smoke pulmonary restrictive disease.
E Radon gas
A 21-year-old man is brought to the emergency department after
he becomes delirious following ingestion of a street drug. He first
exhibited a state of euphoria. On examination his vital signs show A Amphetamines
temperature 39°C, respirations 32/minute, heart rate 110/minute,
and blood pressure 150/100 mm Hg. His teeth are in poor repair. (A) CORRECT. CNS toxicity of methamphetamine may be the
A drugs of abuse screen is most likely to detect which of the result of both hyperthermia as well as direct effects upon individual
following classes of substances? cells. A dose-related increase in body temperature occurs with
A Amphetamines acute ingestion of methamphetamine. Methamphetamine use can
B Barbiturates cause tooth decay that mainly affects the facial (outward) smooth
C Benzodiazepines and interproximal regions of teeth. The xerostomia patients expe-
D Cannabinoids rience may promote consumption of soft drinks with sugar.
E Opiates
F Phencyclidine

A single, round, 9 mm penetrating wound on the forehead extends

into the cranial cavity of a 31-year-old man examined at autopsy
by the medical examiner. On the skin surface surrounding this
B Intermediate range gunshot wound
wound is a 6 cm diameter area with grey-black stippling. Which of
the following mechanisms of injury is most likely to produce these
findings?
A Patterned blunt force injury
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B Intermediate range gunshot wound
C Stab wound from an ice pick
(B) CORRECT. The stippling from gunpowder is typical for an
D Contact range gunshot wound
intermediate range (not contact and not long range).
E Long range shotgun wound
F Invasive fungal infection
A 72-year-old woman was found dead in the bathtub in her home.
She had been visited by her daughter 4 hours earlier and she
appeared to be in good health. At autopsy, her brain grossly
shows subarachnoid hemorrhage along with bilateral contusions
E Fall
inferiorly on frontal lobes. Which of the following accidental injuries
is most likely to be the underlying cause of death?
(E) CORRECT. She probably had a fall backwards to produce a
A Drowning
contrecoup injury pattern.
B Electrocution
C Strangulation
D Heat stroke
E Fall
A 46-year-old man has had increased sputum production and a
chronic cough for the past 5 months. On physical examination
there are expiratory wheezes heard over the right lung anteriorly. A
chest x-ray demonstrates a 6 cm right perihilar mass. Laboratory E Cigarette smoking
studies include a sputum cytology, with the report that 'Atypical
cells are present suggestive of squamous cell carcinoma.' Which (E) CORRECT. Cigarette smoke contains carcinogens. Relatives
of the following risk factors is most likely to be associated with and friends of smokers may be affected by 'passive smoking' that
these findings? also increases their risk for lung cancer, and is a major reason to
A Exposure to silica dust ban smoking in enclosed public places. Squamous cell and small
B Exposure to bird dust cell lung carcinomas are almost all related to smoking.
C congenital cystic fibrosis
D Acquired immunodeficiency syndrome
E Cigarette smoking
A couple returns home from a social event to find that their infant
son is dead. The babysitter who was caring for the infant stated
that she called emergency medical technicians after she checked
on the infant and found him not breathing, and they could not
D Retinal hemorrhages
revive the baby. The babysitter states that the child had been well
an hour prior to this event. Which of the following findings in the
(D) CORRECT. The retinal hemorrhages strongly suggest the
body of the deceased infant documented by the medical examiner
'shaken baby' syndrome. The findings in this case more strongly
would most strongly suggest a non-natural mode of death?
suggest sudden infant death syndrome (SIDS) that is technically
A Jaundice
a natural mode of death for which no one is at fault.
B Blue-purple contusion on forehead
C Cyanosis
D Retinal hemorrhages
E Pulmonary edema
A study is performed using autopsy findings from medical exam-
iner cases of persons who were homeless and who were injection
D Infection
drug users. Toxicologic data is analyzed from these cases. For
those persons who were found to have detectable opiates (as
(D) CORRECT. Infection with HIV and viral hepatitis, as well
heroin) in liver tissue, which of the following conditions is the most
as bacteria producing endocarditis and meningitis, represents a
likely immediate cause of death?
significant and serious risk to persons using drugs intravenously.
A Overdosage
Needle exchange programs are designed to reduce the risk for
B Nephropathy
infection. Persons who become virally infected serve as a reservoir
C Bone marrow failure
of infection in a population.
D Infection
E Pneumoconiosis
A 67-year-old man with a 60 pack year history of smoking was
diagnosed with glioblastoma (high grade glioma) last year. He was
seen by his physician a week ago and was in stable condition. E The underlying cause of death is 'Glioblastoma'
He died suddenly at home last night. The physician must certify
the death of this patient. Which of the following statements on the (E) CORRECT. In fact, all you would have to do is put only the one
death certificate would be most appropriate to make? word on the first line of the death certificate.
A The immediate cause of death is 'Cardiac arrest'
B The mode of death is 'Accident'
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C The time interval for the immediate cause of death is 7 days
D 'Smoking' should be listed under 'Other Conditions'
E The underlying cause of death is 'Glioblastoma'
Police officers respond to reports that an unclothed young man is
running through the back yards of homes in a suburban neigh-
borhood, climbing over fences and hedges and thrashing through
swimming pools. The officers spot him on top of a utility pole.
D Phencyclidine
Toxicologic analysis of the man's blood is most likely to show
which of the following substances?
(D) CORRECT. The more bizarre the history, the more likely that
A Methaqualone
PCP (a schizophrenomimetic drug) is involved.
B Benzodiazepine
C Cocaine
D Phencyclidine
E Ethanol
Multiple deaths result from a shooting incident in a classroom at
a high school. One of the suspects was reportedly seen earlier in
the same classroom on the day of the shooting. What finding on
the victims by the medical examiner is most suggestive that the
D There is gunpowder stippling (tattooing) on the skin
assailant was in the same room, close to the victims as they were
shot?
(D) CORRECT. The presence of the powder stippling is consistent
A The size of the entrance wound matches the caliber of the bullet
with an intermediate range from inches to feet away. The assailant
fired
would have to be close for this to occur.
B An exit wound is present
C An entrance wound is present on the anterior aspect of the torso
D There is gunpowder stippling (tattooing) on the skin
E The exit wound is larger in size than the entrance wound
The 16-year-old driver of a motor vehicle hit a fixed object at
a speed of 60 km/hr in a vehicular accident and dies at the
scene. This driver's automobile had no functioning airbag and she
was not wearing any restraints. She incurs blunt trauma to the E Aortic laceration
abdomen. Which of the following injuries is the most probable
immediate serious consequence of this accident? (E) CORRECT. The deceleration injury can produce tearing of
A Skin abrasions the aorta, which is extremely serious, because a large amount of
B Abdominal wall contusions blood can be lost into the chest in a short period of time.
C Colonic rupture
D Rib fractures
E Aortic laceration
A 64-year-old woman falls down some stairs at work. She suffers
a right hip fracture for which she is hospitalized. She undergoes
surgery for placement of a hip prosthesis. She is recuperating
from the surgery when she suddenly develops dyspnea and
C The mode (manner) of death is accident
expires in only a few minutes despite resuscitative measures.
Autopsy reveals a saddle pulmonary embolus. A 1 cm infiltrating
(C) CORRECT. The chain of events started with the fall; techni-
ductal carcinoma is found in the right breast, but there are no
cally, this is an industrial accident because the injury occurred
metastases. Which of the following statements regarding death
at work. Remember that the underlying cause of death is the
certification is most accurate in this patient?
condition that started the chain of events leading to death, no
A The immediate cause of death is cardiopulmonary arrest
matter how long that took.
B This is a therapeutic misadventure
C The mode (manner) of death is accident
D Breast carcinoma is a contributing cause of death
E Pulmonary embolism is the underlying cause of death
A 25-year-old woman is brought to the emergency room in an
obtunded condition. She is afebrile. Laboratory studies show a
serum sodium of 140 mmol/L, potassium 3.8 mmol/L, chloride 106 A Acetaminophen
mmol/L, CO2 25 mmol/L, glucose 58 mg/dL, creatinine 1.1 mg/dL,
AST 2150 U/L, ALT 2876 U/L, lipase 33 U/L, and calcium 9.0 (A) CORRECT. The liver enzymes are markedly elevated and
mg/dL. She dies a day later. The microscopic appearance of her there is extensive hepatocellular necrosis microscopically, typical
liver at autopsy demonstrates extensive necrosis of hepatocytes. for acetaminophen toxicity. N-acetylcysteine can be administered
Ingestion of which of the following substances is the most likely to increase glutathione to counter the toxic metabolites.
cause for these findings?
A Acetaminophen
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B Ethanol
C Lead
D Methanol
E Vitamin A
A 26-year-old healthy man visiting Arches National Park in south-
ern Utah leaves the campground heading for double 'O' arch some
8 km distant in 40 degree Celsius heat, ignoring the warning
sign about carrying plenty of water. He collapses and is brought
back to the park headquarters. Which of the following findings D Dyspnea with wheezing
on examination by the emergency medical services technician is
most likely to suggest that he has a condition unrelated to the (D) CORRECT. Respiratory difficulty with dyspnea is an unlikely
hike? direct consequence of hyperthermia. Wheezing would suggest
A Cardiac arrhythmias bronchoconstriction, as with acute asthma.
B Shock from hypovolemia
C Peripheral vasodilation
D Dyspnea with wheezing
E Muscle cramps
A 31-year-old man is working on the ungrounded electrical wiring
in his house. He has not flipped the circuit breaker switch to the D Cardiac arrhythmia
'off' position. He accidentally touches the bare black wire of a 110
volt 20 ampere circuit. Which of the following is most likely to be (D) CORRECT. The electrical current interferes with the cardiac
the major life-threatening problem associated with this event? conduction system, particularly if the path the current takes is
A Thermal burns across the chest. Modern wiring includes a 'ground fault inter-
B Pulmonary edema ruptor' designed to reduce the risk for electrical shock past the
C Hyperthermia electrical outlet. However, working with the black (or red) 'hot' wire
D Cardiac arrhythmia directly requires precaution.
E Vascular thrombosis
A saddle-bronc rider in a rodeo was first crushed into the gate,
then thrown from the horse, then stepped on and kicked by the
horse, then dropped from the stretcher by the paramedics carrying
him out of the arena. He sustained right femoral and left humeral
D Fat embolism
fractures. Two days later he developed respiratory difficulty. Which
of the following is the most likely immediate cause for his respira-
(D) CORRECT. Trauma with long bone fractures can lead to fat
tory difficulty?
embolism. Respiratory difficulties typically occur 1 to 3 days fol-
A Vasculitis
lowing the initial injury.
B Pulmonary thromboembolism
C Aspiration of gastric contents
D Fat embolism
E Pulmonary contusion
A 13-year-old girl is playing soccer and runs into the post at the
goal mouth, striking her left thigh. The coach runs out to determine
the extent of the injury and he notes that there is intact skin with no E Contusion
bleeding at the site of injury. There is initially some swelling, and
by the end of the day a red-purple color is present beneath the (E) CORRECT. Contusions are quite common injuries. The blunt
skin. Which of the following terms best describes her leg injury? force injury does not break the skin, but disrupts small blood
A Laceration vessels in the soft tissues beneath the epidermis, with leakage
B Puncture of red blood cells from the capillaries into the surrounding soft
C Abrasion tissues.
D Incised wound
E Contusion
An 11-month-old infant is left unattended in a motor vehicle for 2
hours in an unshaded parking lot in summer with the doors shut C Hyperthermia
and the windows of the vehicle rolled up. This infant is at greatest
risk for the development of which of the following complications? (C) CORRECT. Children, older persons, and pets left unattended
A Asphyxia in autos are at risk for hyperthermia (because they can't open the
B Sudden infant death syndrome windows or get out in response to rising temperatures). Consid-
C Hyperthermia erable heat will build up in a closed space inside the auto, even if
D Hypoglycemia the outside temperature is not high.
E Retinopathy

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A 74-year-old man has been under the care of his physician for
9 years. He suffered an acute myocardial infarction 2 years ago
and has since had poor exercise tolerance. His only abnormal
laboratory test finding is a fasting blood glucose of 162 mg/dL
two weeks ago. In the past his fasting blood glucose has ranged
A The underlying cause of death is diabetes mellitus
from 140 to 180 mg/dL. The physician is called one evening by his
wife, who states that he is being taken to the emergency room,
(A) CORRECT. Remember to list the underlying cause of death,
but he dies before the physician arrives. Which of the following
which is the disease that led to the chain of events culminating
statements is most appropriate regarding death certification in this
in death. With the history that you know, then you have enough
case?
information to establish a natural cause of death from diabetes
A The underlying cause of death is diabetes mellitus
mellitus.
B This sudden and unexpected death is under the jurisdiction of
the medical examiner
C A contributing cause of death is acute myocardial infarction
D The immediate cause of death is cardiac arrest
E The mortuary is responsible for filling out the death certificate
On a cool Fall day, April 29, 1996, a man walked into the Ar-
row Cafe in Port Arthur and began shooting with a .223 caliber
semiautomatic rifle at all persons in and around the cafe. Many
victims were shot as they were running away to exit the building.
The assailant continued to fire at passers-by from the building and
C Small 0.6 to 0.7 cm round skin defects
from stolen automobiles. In the late afternoon, when he was finally
apprehended, 35 people were dead. Which of the following types
(C) CORRECT. The victims were at a distance and exhibited
of wounds did the medical examiner find on most of the victims:
distant, or indeterminate, range gunshot entrance wounds.
A Large 4 cm round 'cookie cutter' wounds with wad marks
B Star-shaped 1 to 2 cm lacerations with soot
C Small 0.6 to 0.7 cm round skin defects
D 5 cm area of powder stippling around 1/2 inch skin defects
E Irregular 1 to 3 cm long lacerations
A 55-year-old man has a history of diabetes mellitus, type II.
He has the sudden onset of severe chest pain and is admit-
ted to the hospital. Vital signs reveal temperature 36.9°C, pulse
88/minute, respirations 23/minute, and blood pressure 155/110
mm Hg. A chest radiograph reveals widening of the mediastinum.
An angiogram reveals a tear of the proximal aorta. He is taken to C Aortic dissection
surgery, and a hemopericardium is evacuated, but then he dies
during the operative procedure. Which of the following is the most (C) CORRECT. Aortic dissections arise in persons who have
appropriate as the immediate cause of death given on the death atherosclerosis and hypertension. The blood can dissect into the
certificate of this man? pericardial cavity, into the pleural cavities, or around great vessels.
A Cardiopulmonary arrest
B Diabetes mellitus
C Aortic dissection
D Hypertension
E Therapeutic misadventure
A group of neo-nazis sets fire to the house of an immigrant family.
Firemen find the bodies of three children trapped inside. Though
the coroner cannot find burn injuries to the skin of the children,
E Inhalation injury
he is able to prove that the deaths were due to the fire by finding
which of the following?
(E) CORRECT. Persons trapped in enclosed spaces during a fire
A Staphylococcus aureus in the blood
often succumb to inhalation of the gases and smoke and not from
B Cerebral fat emboli
the heat of the flames.
C Anasarca
D Conjunctival petechiae
E Inhalation injury

The body of a 17-year-old adolescent male is found near a

dumpster behind the high school he attends. External examination
reveals a single 9 mm circular wound on the right temple, with
C Suicide
small surrounding lacerations and an abrasion ring. Sooting is
found on his right hand. Autopsy reveals that he has widespread
malignant lymphoma. The bullet is recovered beneath the scalp
on the left side of his head. Which manner of death is most likely
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for this situation?
A Accident
B Homicide C) CORRECT. The findings suggest that the victim fired the
C Suicide weapon, and the external wound is consistent with contact range.
D Natural
E Undetermined
The body of a 13-year-old girl is found in her bed at home by
Sheriff's deputies, who were called to the scene by a neighbor
after he heard screaming sounds. Physical examination of the
body reveals no external signs of trauma and no other abnor-
D Smothering with a pillow
malities. A complete autopsy reveals no internal trauma or other
abnormalities. Which of the following mechanisms of injury best
(D) CORRECT. There are few, if any, physical findings with smoth-
explains these findings?
ering, particularly in an infant or child or very old adult who cannot
A Manual strangulation
fight back.
B Carbon monoxide poisoning
C Forcible rape
D Smothering with a pillow
E Striking the head with a baseball bat
A study is performed analyzing patterns of injury. One type of
injury, typically made with a blunt object, can be seen on physical
examination and can be dated by the color change that takes
place over time. Which of the following terms is most likely to D Contusion
describe this injury?
A Laceration (D) CORRECT. The contusion changes color as the blood ex-
B Abrasion travasated into the tissues is broken down and resorbed.
C Puncture
D Contusion
E Incised wound
A 20-year-old man has joined a group of hikers ascending a
mountain peak 8000 meters in height. Beginning at the 5000
meter level, he develops a worsening headache and increas-
ing respiratory distress. He decides to press on. He spends a
sleepless night while camped at 6000 meters. The next day, he
becomes disoriented and cannot stay on the trail. While being B Cerebral edema
attended by other members of the climbing party, he suddenly
loses consciousness. Which of the following pathologic changes (B) CORRECT. He has altitude sickness. He should have de-
is most likely to be present in this man? scended to a lower elevation at the first sign of trouble.
A Bronchopneumonia
B Cerebral edema
C Arterial air embolus
D Subdural hematoma
E Coronary artery thrombosis
G Poisoning
In a study of vital statistics for the U.S., the causes for non-natural
deaths are enumerated. Which of the following causes is most
(G) CORRECT. Poisonings account for over 42,000 deaths per
likely to account for the most deaths per year in the U.S.?
year, and over three-fourths of these are accidental. Overall,
A Acts of terrorism
accidents are the fifth leading cause of death in the U.S., with
B Alcohol use
over 100,000 deaths per year. The world is unsafe more from
C Drowning
unintended human actions than from intentional actions such as
D Falls in the home
wars. The list of chemicals in use and/or potentially released into
E Fires in the home
the environment grows by over a hundred each year. The average
F Hit by vehicles
home contains many drugs and chemicals that may not be safely
G Poisoning
stored.
A 74-year-old man suffers extensive thermal burn injuries in a
natural gas explosion and fire while lighting the furnace in the
E Thickness of the burn
basement of his house. He has 40% total body surface area burns.
Which of the following factors is most likely to determine whether
(E) CORRECT. A partial thickness burn leaves the lower epidermis
skin grafting will be required?
or skin adnexal structures intact, from which re-epithelialization
A His age
may occur without grafting. A full thickness burn leaves no epi-
B Extent of body surface area burned
C Inhalation injury
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 WEBPATH Environmental Pathology
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D Presence of infection dermal regenerative capacity, and skin grafting to that area is
E Thickness of the burn necessary.
The 'employee of the year' is rewarded with a close-in parking
space, but this space is very icy in winter, and she falls getting
out of her car. She scrapes her arm on the pavement. She goes to
the employee clinic, where the physician's assistant observes only
A Abrasion
a superficial epidermal injury in which the skin is not completely
broken. Which of the following terms is most appropriate for the
(A) CORRECT. Abrasions are quite common injuries. There is a
arm injury to this woman?
scraping of the epidermis. Sometimes the pattern of the abrasion
A Abrasion
can indicate how it occurred.
B Laceration
C Puncture
D Incised wound
E Contusion
While driving a formula one grand prix racing car in pursuit of the
world driving championship at a race, the driver loses control and B Accident
crashes. He dies moments later. What is the mode (manner) of
death in this case? (B) CORRECT. This is an obvious accident, because the result
A Natural was not intended. Though a great deal has been done to make
B Accident the sport safer, a human occupying a high speed projectile is an
C Homicide inherently unsafe situation. One can argue about the engineering
D Suicide and maintenance, but the result was still unintended.
E Undetermined
In an Agatha Christie mystery, the plot centers around a homicide
that is made to look like a suicide. Though the famous detective
Hercule Poirot eventually solves this mystery, the mode of death
should have been obvious by inspection of the deceased's body,
because he was alleged to have put the gun to his head and fired.
Which of the following clue(s) is most likely to suggest homicide
as the manner of death?
A The entrance wound on the left temple showed irregular lacer- C The victim had no sooting of his hand, nor gunshot residue in
ations the entrance wound
B Though the victim was from the south of England, he was
wearing argyle socks
C The victim had no sooting of his hand, nor gunshot residue in
the entrance wound
D No exit wound could be found anywhere on the victim's body
E The only weapon at the scene was a .38 caliber revolver, and a
single bullet had been fired
What type of object would you expect to have been found at the
scene of the death of a woman with the following description of a
wound by the medical examiner: 'The incised wound of the neck
is gaping and exposes the larynx and cervical vertebral column.
E Knife
It measures 5 1/2 inches in length and is found at the level of the
superior border of the larynx':
(E) CORRECT. Incised wounds are typically made by a sharp
A Rifle
object such as a knife. This describes the fatal injury.
B Faulty electrical device
C Shovel
D Large brick
E Knife

Which of the following cases should be referred to the medical

examiner to investigate and certify the death?
A A 58-year-old man with a history of atherosclerotic heart dis-
C A 22-year-old man dies suddenly and unexpectedly while play-
ease dies following coronary bypass surgery.
ing a high school football game.
B A 75-year-old woman with Alzheimer disease dies from bron-
chopneumonia in a nursing home.
(C) CORRECT. Such sudden and unexpected deaths need to be
C A 22-year-old man dies suddenly and unexpectedly while play-
investigated to rule out a non-natural manner of death.
ing a high school football game.
D A 47-year-old man infected with HIV dies from Pneumocystis
jiroveci pneumonia.

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 WEBPATH Environmental Pathology
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E A 63-year-old woman dies from pulmonary thromboembolism
following cholecystectomy.
A 95-year-old woman falls to the ground after tripping on the car-
pet in her house. She strikes the back of her head on the floor. She
becomes more irritable, with headache and decreasing mentation B Subdural hematoma
over the next 3 weeks. Which of the following complications of her
injury is she most likely to have developed? (B) CORRECT. The cerebral atrophy in older adults exposes the
A Intraventricular hemorrhage bridging veins beneath the dura to injury from trauma, with tearing
B Subdural hematoma and hematoma formation. A subdural bleed can form and organize
C Infection with Mucor over a long period of time.
D Vertebral artery laceration
E Epidural hemorrhage
Which of the following items listed as the immediate cause of
death on a death certificate is NOT acceptable? A Cardiorespiratory arrest.
A Cardiorespiratory arrest.
B Bronchopneumonia. (A) CORRECT. NEVER put this term on the first line, as it is
C Acute myocardial infarction. meaningless for the purposes of certifying the death. A disease
D Hyaline membrane disease. condition should be listed.
E Pneumocystis jiroveci pneumonia.
A baby is born at term and is of normal birth weight, with Apgar
scores of 9 and 10 at 1 and 5 minutes. Baby and mother are sent
home on the second day following delivery. The baby does fine
and is gaining weight and developing normally and is 4 months
D Sudden infant death syndrome
old. However, one night the mother checks on the baby and finds
the infant prone on the bed and not breathing. Paramedics are
(D) CORRECT. SIDS is sudden, and there are no anatomic find-
called, but the infant cannot be resuscitated. Which of the following
ings. Of course, suffocation could be made to look like SIDS, so
is the most probable explanation for these findings?
it would be necessary to interview persons present at the time of
A Group B streptococcal infection
death.
B congenital heart disease
C Ascorbic acid deficiency
D Sudden infant death syndrome
E congenital galactosemia
A 19-year-old man is taken to the emergency room after his moth-
er finds him comatose on the floor of his room at home following a
night of partying with his friends at a local club. Pertinent laborato-
ry findings from a blood specimen taken postmortem include ALT
B Chronic ethanol ingestion
of 830 U/L and AST of 1053 U/L, along with a significant amount
of acetaminophen. Which of the following pre-existing conditions
(B) CORRECT. Chronic ethanolism depletes glutathione and in-
in the deceased is most likely to have contributed to this injury
duces cytochrome p450, which increases the potential for tox-
pattern?
ic liver injury from acetaminophen ingestion, via production of
A Diabetes mellitus
N-acetyl-p-benzoquinone imine (NAPQI).
B Chronic ethanol ingestion
C Cigarette smoking
D Blunt force trauma
E Major depressive disorder
A 66-year-old man dies suddenly and unexpectedly. He is found
in his home by a neighbor after the man was not seen for over a
day. Police find no evidence of foul play. At autopsy, there are no B Carbon monoxide
signs of physical injury. The skin of his hands displays cherry red
lividity. Which of the following toxins is most likely to be found in (B) CORRECT. Carbon monoxide binds to hemoglobin over 200
this man? times more avidly than oxygen, so even small amounts in the
A Arsenic environment can lead to fatal poisoning. A blood sample must
B Carbon monoxide be taken to determine the CO level. Poorly vented or unvented
C Lead heating devices within the home are most often the cause.
D Methyl salicylate
E Organophosphate

An elderly man is found dead in his bed at home after paramedics

are called by his neighbor, who noticed that the man was out D Organophosphate
working in his garden as he usually did, but collapsed. When
paramedics arrive, the man is noted to have marked salivation
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 WEBPATH Environmental Pathology
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with lacrimation. His pupils are pinpoint. He is incontinent of urine.
On the way to the hospital he vomits. Which of the following
(D) CORRECT. Organophosphate poisoning can be very subtle,
environmental exposures best explains these findings?
with findings of 'SLUDGE' standing for salivation, lacrimation,
A Insect sting
urinary incontinence, defecation, gastrointestinal changes, eme-
B Asbestos
sis, and miosis. Organophosphates inhibit acetylcholinesterase to
C Ozone
produce the cholinergic findings.
D Organophosphate
E Lead
A 27-year-old G2P1 woman is in the 39th week of gestation. A
screening ultrasound at 19 weeks revealed no abnormalities. She
goes into labor and 6 hours later has a routine vaginal delivery of
a term male. An intact placenta is delivered 5 minutes later. The
infant's Apgar scores are 8 and 9 and 1 and 5 minutes. However, D Amniotic fluid embolism
within 10 minutes following delivery, she develops severe dysp-
nea and cyanosis, followed by seizures and coma. Which of the (D) CORRECT. This is a rare, but serious, complication seen in
following is the most likely explanation for this series of events? term births. The amniotic fluid gains access to uterine veins at the
A Disseminated intravascular coagulation time of delivery and is conducted to the lungs.
B Metastatic choriocarcinoma
C Cerebral infarction
D Amniotic fluid embolism
E Pulmonary infarction
During an air raid, a bomb strikes a large office building composed
of concrete blocks. Several civilians are killed immediately. By
B Blunt force trauma
which of the following mechanisms did the victims most likely die
from this event?
(B) CORRECT. 'Precision bombing' is an oxymoron which, when
A Asphyxiation
combined with a chronic inability of most politicians to think things
B Blunt force trauma
through, leads to disasters. Blast injuries, like many physical force
C Cardiopulmonary arrest
injuries, produce extensive contusions with multiple organ injuries.
D Extensive burns
E Myocardial infarction
A 26-year-old woman is brought to the emergency room of a local
hospital by her neighbor. She has 3 to 4 cm long linear incised C My husband attacked me with a knife
wounds to the palms of the hands and to the ventral aspect of her
wrists. Which of the following explanations offered by the woman (C) CORRECT. These wounds are very suggestive of 'defensive'
for the appearance of these injuries are you most likely to believe? wounds by the victim of an assailant with a sharp weapon such
A The dog bit me as a knife that produces incised wounds. Victims of abuse may
B I fell down a flight of stairs fabricate excuses for fear of retaliation by the abuser. The physi-
C My husband attacked me with a knife cian should recognize signs suggesting abuse and initiate a plan
D I was cleaning grass out of the lawn mower to protect the abused person.
E I was pulling arrows from my son's archery target
A 3-month-old infant is found dead by his mother late one evening.
She had put him in bed on his stomach only an hour before, and E No abnormalities
he had shown no signs of distress. The baby had been doing
well prior to that time, feeding well and gaining weight normally. (E) CORRECT. The events suggest sudden infant death syndrome
The baby's term birth had followed an uncomplicated pregnancy. (SIDS). The exact cause is not known, and there are no significant
Which of the following is the medical examiner most likely to find gross or microscopic autopsy findings, though in many cases there
at autopsy of this infant? is a history of a recent respiratory infection. One theory holds that
A Hyaline membrane disease infants developing SIDS have abnormalities of serotonergic neural
B Cerebral cytomegalovirus pathways involving arousal centers in the medulla oblongata of the
C Tetralogy of Fallot brain stem. A respiratory tract stressor may put vulnerable infants
D Adrenal neuroblastoma at risk.
E No abnormalities
A 79-year-old woman is found unconscious in the bedroom by
firemen who respond to a report of a house fire by her neighbor.
She is taken to a local hospital. She is found to have partial thick- C The absence of an inhalation injury
ness burns involving her head and neck and full thickness burns
involving most of her torso and upper extremities. Bronchoscopy (C) CORRECT. Older persons are at greater risk for morbidity
reveals no erythema or ulceration of the trachea mucosa. Which and mortality from burns. The extent of her burns is great, and
of the following features described here suggests the best prog- the presence of burns on her head and neck is more ominous.
nosis?
A The extent of partial thickness burns involving just her head and
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 WEBPATH Environmental Pathology
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neck
B The absence of burns involving her lower extremities
However, she does not have an inhalation injury as determined at
C The absence of an inhalation injury
bronchoscopy.
D Her age
E The extent of full thickness burns involving her torso and arms
A 4-year-old previously healthy child ingests a 100 ml bottle con-
taining a clear liquid he found under the kitchen sink at home. The
child is observed to develop central nervous system depression
over the next 6 hours. Acidosis is documented on admission to
E Methanol
the hospital. Three weeks later, it is noted that the child's visual
acuity is markedly decreased. Which of the following chemical
(E) CORRECT. Methanol is metabolized by the same enzymatic
substances was most likely present in the liquid ingested by this
pathway as ethanol, but the toxic metabolites formaldehyde and
child?
acetaldehyde are produced which damage the CNS and the reti-
A Cyanide
na.
B Mercuric chloride
C Ethanol
D Organophosphate
E Methanol
A 41-year-old man has been a regular user of oxycodone (oxy-
contin) for the past 5 years. He purchases the drug from persons in
his community who supply 'street drugs' illegally. He suddenly de-
B Fentanyl
velops severe respiratory depression. In the emergency depart-
ment, he is given naloxone and recovers. Which of the following
(B) CORRECT. Fentanyl is a powerful synthetic opioid that is
drugs was most likely contaminating the street drug represented
cheap to produce and is often placed into street drugs sold as
to him as oxycontin?
heroin or oxycontin. Opioids are respiratory depressants. The
A Cocaine
naloxone is an opioid antagonist which acts by binding to opioid
B Fentanyl
receptors so as to reverse and block the effects of opioids.
C Methamphetamine
D Oxazepam
E Phenobarbital
A 43-year-old homeless man is found on a bench in a city park. He
is obtunded. External examination reveals swelling of his hands
with pale, cool skin. His vital signs include temperature 31°C,
respirations 12/minute, heart rate 70/minute, and blood pressure E Ethanol
80/50 mm Hg. Which of the following drugs was most likely in-
gested by this man? (E) CORRECT. Ethanol ingestion is common and can diminish
A Acetaminophen mentation to the point of poor judgement and failure to seek
B Acetylsalicylic acid shelter. The features of moderate hypothermia are present here.
C Amphetamine
D Cocaine
E Ethanol
A coal-fired power plant for generation of electricity is built near
a city. This power plant has no environmental controls to reduce
emission of pollutants. Which of the following is the most likely C Intellectual disability in children
long-term health risk observed in an epidemiologic study of this
city 10 years later? (C) CORRECT. Coal combustion can generate methylmercury
A Anemia at all ages which gets into water and into the food chain via fish, which can
B Chronic kidney injury in adults be ingested by humans. The developing brain in utero is highly
C Intellectual disability in children sensitive to toxicity by methylmercury.
D Precocious puberty in children
E Skin cancers in adults

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