11 Blood Vessels
1 The development of atheromatous plaque formation with subsequent complications is observed in an experiment. Atherosclerotic plaques are shown to change slowly but constantly in ways that can promote clinical events, including acute coronary syndromes. In some cases, changes occurred that were not significantly associated with acute coronary syndromes. Which of the following plaque alterations is most likely to have such an association?
(A) 
(B) 
(C) 
(D) 
(E) 2 A 60-year-old woman has reported increasing fatigue over the past year. Laboratory studies show a serum creatinine level of 4.7 mg/dL and urea nitrogen level of 44 mg/dL. An abdominal ultrasound scan shows that her kidneys are symmetrically smaller than normal. The high-magnification microscopic appearance of the kidneys is shown in the figure. These findings are most likely to indicate which of the following underlying conditions?
(A) 
(B) 
(C) 
(D) 
(E) 3 A 55-year-old woman visits her physician for a routine health maintenance examination. On physical examination, her temperature is 36.8°C, pulse is 70/min, respirations are 14/min, and blood pressure is 160/105 mm Hg. Her lungs are clear on auscultation, and her heart rate is regular. She feels fine and has had no major medical illnesses or surgical procedures during her lifetime. An abdominal ultrasound scan shows that the left kidney is smaller than the right kidney. A renal angiogram shows a focal stenosis of the left renal artery. Which of the following laboratory findings is most likely to be present in this patient?
(A) 
(B) 
(C) 
(D) 
(E) 
(F) 
(G) 4 A 7-year-old child has had abdominal pain and dark urine for 10 days. Physical examination shows purpuric skin lesions on the trunk and extremities. Urinalysis shows hematuria and proteinuria. Serologic test results are negative for P-ANCAs and C-ANCAs. A skin biopsy specimen shows necrotizing vasculitis of small dermal vessels. A renal biopsy specimen shows immune complex deposition in glomeruli, with some IgA-rich immune complexes. Which of the following is the most likely diagnosis?
(A) 
(B) 
(C) 
(D) 
(E) 
(F) 5 A 30-year-old woman has had coldness and numbness in her arms and decreased vision in the right eye for the past 5 months. On physical examination, she is afebrile. Her blood pressure is 100/70 mm Hg. Radial pulses are not palpable, but femoral pulses are strong. She has decreased sensation and cyanosis in her arms, but no warmth or swelling. A chest radiograph shows a prominent border on the right side of the heart and prominence of the pulmonary arteries. Laboratory studies show serum glucose, 74 mg/dL; creatinine, 1 mg/dL; total serum cholesterol, 165 mg/dL; and negative ANA test result. Her condition remains stable for the next year. Which of the following is the most likely diagnosis?
(A) 
(B) 
(C) 
(D) 
(E) 
(F) 6 A 61-year-old man had a myocardial infarction 1 year ago, which was the first major illness in his life. He now wants to prevent another myocardial infarction and is advised to begin a program of exercise and to change his diet. A reduction in the level of which of the following serum laboratory findings 1 year later would best indicate the success of this diet and exercise regimen?
(A) 
(B) 
(C) 
(D) 
(E) 7 A 23-year-old man experiences sudden onset of severe, sharp chest pain. On physical examination, his temperature is 36.9°C, and his lungs are clear on auscultation. A chest radiograph shows a widened mediastinum. Transesophageal echocardiography shows a dilated aortic root and arch, with a tear in the aortic intima 2 cm distal to the great vessels. The representative microscopic appearance of the aorta with elastic stain is shown in the figure. Which of the following is the most likely cause of these findings?
(A) 
(B) 
(C) 
(D) 
(E) 
(F) 8 A 40-year-old man with a history of diabetes mellitus has had worsening abdominal pain for the past week. On physical examination, his vital signs are temperature, 36.9°C; pulse, 77/min; respirations, 16/min; and blood pressure, 140/90 mm Hg. An abdominal CT scan shows the findings in the figure. Laboratory studies show his hemoglobin A1C is 10.5%. Which of the following is the most likely underlying disease process in this patient?
(A) 
(B) 
(C) 
(D) 
(E) 
9 A 10-year-old boy is brought to the physician for a routine health maintenance examination. The physician notes a 2-cm spongy, dull red, circumscribed lesion on the upper outer left arm. The parents state that this lesion has been present since infancy. The lesion is excised, and its microscopic appearance is shown in the figure. Which of the following is the most likely diagnosis?
(A) 
(B) 
(C) 
(D) 
(E) 10 A pharmaceutical company is developing an antiatherosclerosis agent. An experiment investigates mechanisms of action of several potential drugs to determine their efficacy in reducing atheroma formation. Which of the following mechanisms of action is likely to have the most effective antiatherosclerotic effect?
(A) 
(B) 
(C) 
(D) 
(E) 
(F) 
(G) 11 A 73-year-old man who has had progressive dementia for the past 6 years dies of bronchopneumonia. Autopsy shows that the thoracic aorta has a dilated root and arch, giving the intimal surface a “tree-bark” appearance. Microscopic examination of the aorta shows an obliterative endarteritis of the vasa vasorum. Which of the following laboratory findings is most likely to be recorded in this patient’s medical history?
(A) 
(B) 
(C) 
(D) 
(E) 12 For the past 3 weeks, a 70-year-old woman has been bedridden while recuperating from a bout of viral pneumonia complicated by bacterial pneumonia. Physical examination now shows some swelling and tenderness of the right leg, which worsens when she raises or moves the leg. Which of the following terms best describes the condition involving the patient’s right leg?
(A) 
(B) 
(C) 
(D) 
(E) 13 A 49-year-old man is feeling well when he visits his physician for a routine health maintenance examination for the first time in 20 years. On physical examination, his vital signs are temperature, 37°C; pulse, 73/min; respirations, 14/min; and blood pressure, 155/95 mm Hg. He has had no serious medical problems and takes no medications. Which of the following is most likely to be the primary factor in this patient’s hypertension?
(A) 
(B) 
(C) 
(D) 
(E) 14 A 50-year-old man has a 2-year history of angina pectoris that occurs during exercise. On physical examination, his blood pressure is 135/75 mm Hg, and his heart rate is 79/min and slightly irregular. Coronary angiography shows a fixed 75% narrowing of the anterior descending branch of the left coronary artery. Which of the following types of cells is the initial target in the pathogenesis of this arterial lesion?
(A) 
(B) 
(C) 
(D) 
(E) 15 A study of atheroma formation leading to atherosclerotic complications evaluates potential risk factors for relevance in a population. Three factors are found to play a significant role in the causation of atherosclerosis: smoking, hypertension, and hypercholesterolemia. These factors are analyzed for their relationship to experimental models for atherogenesis. Which of the following events is the most important direct biologic consequence of these factors?
(A) 
(B) 
(C) 
(D) 
(E) 16 A 55-year-old woman has noted the increasing prominence of unsightly dilated superficial veins over both lower legs for the past 5 years. Physical examination shows temperature of 37°C, pulse of 70/min, respirations of 14/min, and blood pressure of 125/85 mm Hg. There is no pain, swelling, or tenderness in either lower leg. Which of the following complications is most likely to occur as a consequence of this condition?
(A) 
(B) 
(C) 
(D) 
(E) 17 A 35-year-old man is known to have been HIV-positive for the past 10 years. Physical examination shows several skin lesions with the appearance shown in the figure. These lesions have been slowly increasing for the past year. Which of the following infectious agents is most likely to play a role in the development of these skin lesions?
(A) 
(B) 
(C) 
(D) 
(E) 18 A 50-year-old man complains of a chronic cough that has persisted for the past 18 months. Physical examination shows nasopharyngeal ulcers, and the lungs have diffuse crackles bilaterally on auscultation. Laboratory studies include a serum urea nitrogen level of 75 mg/dL and a creatinine concentration of 6.7 mg/dL. Urinalysis shows 50 RBCs per high-power field and RBC casts. His serologic titer for C-ANCA is elevated. A chest radiograph shows multiple, small, bilateral pulmonary nodules. A nasal biopsy specimen shows mucosal and submucosal necrosis and necrotizing granulomatous inflammation. A transbronchial lung biopsy specimen shows a vasculitis involving the small peripheral pulmonary arteries and arterioles. Granulomatous inflammation is seen within and adjacent to small arterioles. Which of the following is the most likely diagnosis?
(A) 
(B) 
(C) 
(D) 
(E) 
(F) 
(G) 
(H) 19 While cleaning debris out of the gate in an irrigation canal, a 50-year-old man cuts his right index finger on a sharp metal shard. The cut stops bleeding within 3 minutes, but 6 hours later he notes increasing pain in the right arm and goes to his physician. On physical examination, his temperature is 38°C. Red streaks extend from the right hand to the upper arm, and the arm is swollen and tender when palpated. Multiple tender lumps are noted in the right axilla. A blood culture grows group A hemolytic streptococci. Which of the following terms best describes the process that is occurring in this patient’s right arm?
(A) 
(B) 
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(D) 
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(F) 
(G) 20 An experiment studies early atheromas. Lipid streaks on arterial walls are examined microscopically and biochemically to determine their cellular and chemical constituents and the factors promoting their formation. Early lesions show increased attachment of monocytes to endothelium. The monocytes migrate subendothelially and become macrophages; these macrophages transform themselves into foam cells. Which of the following is most likely to produce these effects?
(A) 
(B) 
(C) 
(D) 
(E) 
(F) 
21 A 12-year-old boy died of complications of acute lymphocytic leukemia. The gross appearance of the aorta at autopsy is shown in the figure. Histologic examination of the linear pale marking is most likely to show which of the following features?
(A) 
(B) 
(C) 
(D) 
(E) 
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