A 56-year-old has not received any medical care nor seen a physician for years. He reports reduced exercise tolerance over the past 5 years. On occasion in the past year he has noted chest pain after ascending a flight of stairs. He smokes 2 packs of cigarettes per day. He is found to have a blood pressure of 155/95 mm Hg. His body mass index is 30. Laboratory findings include a total serum cholesterol of 245 mg/dL with an HDL cholesterol that is 22 mg/dL. Which of the following vascular abnormalities is most likely to be his most serious health risk?
A 55-year-old previously healthy woman is hospitalized for pneumonia. On the 10th hospital day she is found to have swelling and tenderness of her right leg, which apparently has developed over the past 48 hours. Raising the leg elicits pain. An ultrasound examination reveals findings suggestive of femoral vein thrombosis. Which of the following conditions is most likely to have contributed the most to the appearance of these findings?
A 63-year-old man has had insulin dependent diabetes mellitus for over two decades. The degree of control of his disease is characterized by the laboratory finding of a hemoglobin A1C of 10.1%. He has noted episodes of abdominal pain following meals. These episodes have worsened over the past year. On physical examination, there are no masses and no organomegaly of the abdomen, and he has no tenderness to palpation. Which of the following pathologic findings is most likely to be present in this man?
Mesenteric artery occlusion
A 62-year-old man has experienced substernal chest pain upon exertion with increasing frequency over the past 6 months. An electrocardiogram shows features consistent with ischemic heart disease. He has a total serum cholesterol of 262 mg/dL. By angiography, there is 75% narrowing of the left anterior descending artery. Which of the following vascular complications is most likely to occur in this patient?
A systemic artery embolus from a left ventricular mural thrombus.
On sectioning of an organ from a 60-year-old man at the time of autopsy, a focal, wedge-shaped area that is firm is accompanied by extensive hemorrhage, giving it a red appearance. The lesion has a base on the surface of the organ. In which of the following situations will this lesion most likely occur?
Lung with pulmonary thromboembolism
A 44-year-old woman has a family history of heart disease. Her father and mother both developed congestive heart failure and myocardial infarction as a result of extensive coronary atherosclerosis. A dietary modification to include consumption of which of the following is most likely to reduce her risk for ischemic heart disease?
An 81-year-old woman has the sudden onset of dyspnea and palpitations with chest pain. A pulmonary ventilation-perfusion scan is performed and indicates a high probability for a perfusion defect involving right segmental pulmonary arterial branch. Of the following findings or conditions, which is the most important factor favoring development of these findings?
Altered blood flow with stasis
A 66-year-old woman has the sudden loss of movement on part of the left side of her body. She has smoked a pack of cigarettes a day for the past 45 years. She has vital signs including T 37.1 C, P 80/minute, RR 16/minute, and BP 160/100 mm Hg. A cerebral angiogram reveals occlusion of a branch of her middle cerebral artery. Laboratory findings include a hemoglobin A1C of 9%. Which of the following components of blood lipids is most important in contributing to her disease?
An autopsy study reveals that evidence for atheroma formation can begin even in children. The gross appearances of the aortas are recorded and compared with microscopic findings of atheroma formation. Which of the following is most likely to be the first visible gross evidence for the formation of an atheroma?
A 63-year-old man has had increasing exercise intolerance for the past 5 years so that he now becomes short of breath upon climbing a single flight of stairs. Laboratory studies have shown fasting blood glucose measurements from 145 to 210 mg/dL for the past 25 years, but he has not sought medical treatment. If he dies suddenly, which of the following is most likely to be the immediate cause of death?
A 45-year-old man dies suddenly and unexpectedly. The immediate cause of death is found to be a hemorrhage in the right basal ganglia region. On microscopic examination his renal artery branches have concentric endothelial cell proliferation which markedly narrows the lumen, resulting in focal ischemia and hemorrhage of the renal parenchyma. An elevation in which of the following substances in his blood is most likely to be associated with these findings?
A 10-year-old previously healthy child has been noted by her parents to be constantly thirsty. She is consuming large amounts of soft drinks. She is urinating often. Her diet and exercise patterns have not changed, except for an increased appetite, yet she appears cachectic and has lost 7 kg over the past 4 months. On physical examination there are no abnormal findings, other than peripheral muscle wasting and weakness. Which of the following laboratory findings would you most strongly suspect is present in this girl?
A 73-year-old woman who exercises regularly falls down the stairs and injures her right hip. A radiograph is taken of the pelvis. There is no fracture but the radiograph reveals calcification of the small muscular arteries lateral to her uterus. What is the probable vascular lesion which accounts for this calcification?
Calcific medial sclerosis
A 55-year-old woman has been treated in the hospital for pancreatitis for the past three weeks. She is examined one morning on rounds and found to have a swollen right leg. It is tender to palpation posteriorly but is not warm. This condition is most likely to be the result of which of the following vascular complications?
A 29-year-old woman is involved in a motor vehicle accident that results in severe lacerations to her lower extremities, along with blunt abdominal trauma. In the emergency room she is noted to have cool, pallid skin. She has vital signs showing T 36.9 C, P 103/minute, RR 18/minute, and BP 70/30 mm Hg. She has decreased urine output. Which of the following laboratory findings on a blood sample from this patient is most likely to be present?
Lactic acid of 4.8 mmol/L
A 61-year-old man has the sudden onset of severe chest pain. Vital signs include T 37 C, P 101/minute, RR 20/minute, and BP 80/40 mm Hg. An electrocardiogram demonstrates changes that are consistent with myocardial ischemia involving the left lateral ventricular free wall. He is given thrombolytic therapy with tissue plasminogen activator (tPA). However his serum creatinine kinase is found to be 450 U/L 3 hours after this therapy. Which of the following cellular events has most likely occurred?
A 52-year-old woman has experienced marked substernal, crushing chest pain for the past 6 hours. Her vital signs show T 36.9 C, P 80/minute, RR 16/minute, and BP 100/60 mm Hg. Laboratory studies include a serum creatine kinase MB fraction of 10 microgm/L as well as a serum troponin I of 4.5 ng/mL. Which of the following findings is the best evidence for the presence of a coronary arterial thrombus as the etiology for her chest pain?
Response to thrombolytic therapy
In an experiment, a glass bead is embolized to a branch of the renal artery. A day later there is a focal area in which the renal parenchymal cells in the distribution of the occluded artery show karyolysis and karyorrhexis. The outlines of the cells are still visible, but the nuclei have lost basophilic staining and the cytoplasm is eosinophilic but pale. Which of the following types of cellular necrosis is most likely present?
A 52-year-old man has the sudden onset of chest pain. He is found to have a serum troponin I of 5 ng/mL. A year later he has reduced exercise tolerance. An echocardiogram reveals an akinetic segment of left ventricle, and he has reduced cardiac output, with an ejection fraction of 25%. He then experiences a transient ischemic attack (TIA). His serum troponin I is now <0.5 ng/mL. Thrombus formation involving which of the following locations is most likely to have put him at greatest risk for the TIA?
A 25-year-old previously healthy primigravida is in the first trimester of pregnancy. During two successive prenatal visits, she has fasting serum glucose levels of 127 and 131 mg/dL. Prior to this pregnancy, her fasting serum glucose was 80 mg/dL. A hemoglobin A1C level is 8.1% at the last visit, at 18 weeks gestation. She feels well and has no major health problems. Which of the following problems is most likely to become apparent in the latter part of her pregnancy?
A 54-year-old man with diabetes mellitus has had 3 urinary tract infections during the past year. He now sees the physician for an ulceration on his right big toe which has not healed in 2 months. Laboratory studies on each of his doctor visits over the past year show blood glucose levels below 110 mg/dl. This situation could be best explained by which of the following laboratory findings?
Elevated hemoglobin A1C level
A 25-year-old man experiences chest pain on exercise when he attempts to climb three flights of stairs. This pain is relieved by sublingual nitroglycerin. He is 178 cm tall and weighs 101 kg. Laboratory studies show a total serum cholesterol of 550 mg/dL with an HDL cholesterol component of 25 mg/dL. He is worried about these findings because his brother died of a myocardial infarction at age 34. Which of the following conditions is this man most likely to have?
In a clinical study of patients with diabetes mellitus, a group of patients is found who had blood glucose measurements ranging from 140 to 180 mg/dL for at least 10 years. Rectal biopsies from these patients now show that there is a form of osmotic cellular injury present in arterioles. This form of injury is most likely to be manifested by which of the following complications?
A 49-year-old woman has experienced marked pain in her lower extremities on ambulation more than 300 meters for the past 5 months. On physical examination, her lower extremities are cool and pale, without swelling or erythema. No dorsalis pedis or posterior tibial pulses are palpable. Her body mass index is 32. She is a smoker. Which of the following abnormalities of the vasculature is most likely to account for these findings?
An autopsy study is conducted involving the gross appearance of the aorta of adults ranging in age from 60 to 90. In some of these patients, the aorta demonstrates atheromatous plaques covering from 70 to 95% of the intimal surface area, mainly in the abdominal portion, with ulceration and calcification. Which of the following contributing causes of death are these patients most likely to have?
A 59-year-old woman has the sudden onset of severe dyspnea and goes into cardiac arrest, from which she cannot be resuscitated. At autopsy, she has the gross finding of a saddle pulmonary embolus. This event is most likely to be present as a consequence of which of the following?
Placement of a hip prosthesis
At autopsy, the kidneys of a 44-year-old woman who died suddenly are found to be of normal size. Their surfaces appear finely granular. There are small hemorrhages noted. The cortices appear pale. Microscopically, many small renal arteries and arterioles demonstrate concentric intimal thickening with marked luminal narrowing. These findings are most likely to be present as a result of which of the following underlying diseases?
A 35-year-old previously healthy woman notes that she has bruises form on her arms and legs with just minor trauma. Physical examination reveals areas of purpura from 1 to 3 cm in size over her trunk and extremities, but no swelling, warmth, or erythema. Peripheral pulses are all palpable and full. Her blood pressure is 110/70 mm Hg. An ultrasound examination of her lower extremities with Doppler flow measurement reveals no evidence for thrombosis. Laboratory findings include serum urea nitrogen of 20 mg/dL, LDH 300 U/L, total protein 6.9 g/dL, albumin 5.3 g/dL, alkaline phosphatase 50 U/L, AST 40 U/L, and ALT 20 U/L. Which of the following additional laboratory findings is most likely to be present in this patient?
Grandma falls down the steps leading to the entrance of the house of a relative hosting a family reunion, who is heard to remark, "I've been meaning to get that loose step fixed." Grandma is hospitalized for surgery to replace the broken hip she sustains and is then moved to a nursing home, but she is unable to ambulate until about a month later, when she dies suddenly. Which of the following is most likely to be the immediate cause of death found at autopsy?
A 53-year-old woman is found on a routine physical examination to have vital signs with T 36.9 C, P 77/minute, R 15/minute, and BP 165/110 mm Hg. There are no other significant findings. She has an abdominal ultrasound examination that shows the right kidney to be atrophic. Angiography reveals markedly reduced blood flow to the right renal artery from an occlusion at the orifice in the abdominal aorta. Which of the following laboratory findings is she most likely to have?
Plasma renin activity of 4.8 ng/mL/hr supine
A study of pathologic findings in the islets of Langerhans is performed. It is observed that insulitis may occur in the islets. The inflammatory infiltrate is predominantly composed of T lymphocytes. Which of the following is most likely to occur as a consequence of insulitis?
A 20-year-old man incurs blunt trauma to his upper outer arm. On physical examination, there is a 2 x 3 cm contusion. The initial soft tissue bleeding stops in a few minutes and the size of the bruise does not increase. Which of the following chemical mediators is most important in this episode of hemostasis?
A 45-year-old man feels some crushing chest pain along with numbness in his left arm after shoveling 15 cm of snow off his driveway. Three hours later he collapses and is taken to the emergency room. Which of the following laboratory tests run on a blood specimen is most useful in this situation?
A 68-year-old woman has survived multiple episodes of pulmonary thromboembolism during the past three months. Which of the following is the most likely underlying condition leading to this patient's recurrent pulmonary thromboembolism?
Adenocarcinoma of the pancreas
A 77-year-old woman has experienced abdominal pain for the past month. On physical examination, she has a pulsatile lower abdominal mass. An abdominal CT scan reveals an abdominal aorta dilated to 7 cm in diameter, with calcification of the aortic wall. While awaiting surgery, she has an episode of severe abdominal pain and a repeat CT scan shows marked retroperitoneal hemorrhage. Which of the following laboratory test findings is she most likely to have?
A 70-year-old man has noted coldness and numbness of his lower left leg, increasing over the past 4 months. He also experiences pain in this extremity when he tries walking more than the distance of half a city block. On physical examination, his dorsalis pedis, posterior tibial, and popliteal artery pulses are not palpable. Which of the following laboratory test findings is he most likely to have?
A 72-year-old man suffered a myocardial infarction involving half the left ventricular free wall 3 months ago. He now has increasing dyspnea and orthopnea. On echocardiography his ejection fraction is 29%. On examination he has poor capillary filling in hands and feet. A chest x-ray shows pulmonary edema. Which of the following laboratory test analytes is most likely to be increased in this man at this point in time?
A 44-year-old African-American man has had elevated blood pressure for years which has not been treated. He now has severe headaches. On physical examination his blood pressure is 275/150 mm Hg. Laboratory studies show Hgb 13.8 g/dL, serum glucose 76 mg/dL, and creatinine 3.5 mg/dL. These findings are most likely to be associated with which of the following pathologic lesions involving his kidneys?
A 60-year-old woman has become increasingly obtunded over the past day. She was found by her daughter in a stuporous condition and brought to the emergency department. On physical examination, she has poor skin turgor. She is afebrile. Her vital signs reveal a blood pressure of 90/40 mm Hg, respirations 15 and shallow, pulse 95, and temperature 36 C. Laboratory studies show a hemoglobin A1C of 10%. Her serum electrolytes show sodium 144 mmol/L, potassium 5 mmol/L, chloride 95 mmol/L, CO2 22 mmol/L, and glucose 940 mg/dL. Which of the following is the most likely diagnosis?
A study is performed involving persons who have a history of diabetes mellitus type 1 or type 2. These patients are found to have cellular injury that results from glycosylation end products and from sorbitol accumulation within cells. The same patients are also shown to have ischemic tissue damage from accelerated and advanced atherosclerosis. Which of the following complications is most likely to result from atherosclerosis in these patients?
A 30-year-old man goes to his physician for a routine health checkup. On physical examination there are no abnormal findings. Laboratory test findings include serum glucose 80 mg/dL, hemoglobin A1C 4%, total cholesterol 240 mg/dL, LDL cholesterol 180 mg/dL, and HDL cholesterol 20 mg/dL. Through which of the following mechanisms is endothelial vascular injury in this patient most likely to occur?
Insudation of lipid in foam cells
A 65-year-old man has had increasing lower leg swelling along with reduced exercise tolerance for the past 5 years. He sometimes has chest pain on exertion. He has not experienced dyspnea. He has experienced 4 episodes of transient ischemic attacks in the past year. He has experienced abdominal pain in the past 2 months. Vital signs show T 36.9 C, P 82/min, RR 15/min, and BP 130/85 mm Hg. He has pitting edema to the knees bilaterally. The lower extremities have palpable pulses, no tenderness, and no erythema. An abdominal CT scan shows dilation of the abdominal aorta to 5 cm, filled with mural thrombus. Other family members have had similar problems. Which of the following underlying conditions is most likely to produce these findings:
A 45-year-old woman who has been bedridden for several weeks has the onset of left sided chest pain along with dyspnea. She has some tenderness in her left leg, which has a slightly greater circumference in the thigh than the right. A ventilation/perfusion scan shows evidence for a left lower lobe perfusion defect. Which of the following vascular diseases is most likely to cause these findings:
A 27-year-old woman had a hemoglobin A1C of 7.9% noted during a prenatal visit. She gives birth to a 4350 gm baby at 37 weeks gestation. Just after the delivery, the baby becomes irritable and displays seizure activity. Which of the following laboratory findings is most likely to be found in the baby:
Blood glucose of 20 mg/dl
Which of the following chemical components of the blood is mainly responsible for transporting exogenous (dietary) triglyceride from the intestine following a meal.
Some cells demonstrate glucose uptake regardless of the plasma insulin level. In a person who has had persistent hyperglycemia for years, cellular injury can occur. Which of the following cell types is most likely to show injury from hyperglycemia:
During hospitalization, a 40-year-old woman develops thrombophlebitis. She recovers and is discharged. She returns to her job as an electrician. A couple of months later, which of the following terms would best describe the process seen in a femoral vein after recovery from her thrombophlebitis:
A 52-year-old man has an ulcerated area on the sole of his foot that has not healed for 2 months. He is 180 cm tall, weighs 126 kg, and has continued to gain weight gradually. He has not had any major illnesses. His blood pressure is normal. Which of the following laboratory tests performed on serum from a blood sample would be most useful in elucidating the underlying cause for his problem:
A 57-year-old man has had blood pressure measurements in the range of 160/95 to 180/110 mm Hg for many years. He has taken no medications. A renal scan reveals kidneys of normal size for age. These findings with benign nephrosclerosis are most likely to occur with which of the following vascular changes:
A 70-year-old woman with a history of type II diabetes mellitus is found comatose at her home. There are no external signs of trauma. When seen a week ago she was depressed, but in no apparent distress. She had not been ingesting much food or drinking much water for several days. Vital signs show T 35.8 C, P 85, R 16, and BP 100/65 mm Hg. Which of the following laboratory test findings is most likely to be present:
Markedly increased serum osmolality
A 20-year-old woman was diagnosed last year with pulmonary thromboembolism. In her 6th month of her first pregnancy, she delivered a stillborn baby. Laboratory testing revealed the presence of a normal prothrombin time, normal partial thromboplastin time, platelet count of 250,000/microliter, and presence of lupus anticoagulant. These findings are most characteristic for which of the following hypercoagulable states:
A 52-year-old woman has a history of urinary tract infections. Recently, one of these episodes was complicated by acute pyelonephritis involving her kidneys. She became septic, and a blood culture grew Escherichia coli. She developed severe hypotension. She had purpuric areas on her skin. A stool for occult blood was positive. She had a prothrombin time of 50 sec (control 12), partial thromboplastin time of 100 sec (control 25), platelet count of 20,000/microliter, and D-dimer of 4 microgm/mL. These findings are most characteristic for which of the following conditions: