4 Hemodynamic Disorders, Thromboembolic Disease, and Shock
1 While shaving one morning, a 23-year-old man nicks his lip with a razor. Seconds after the injury, the bleeding stops. Which of the following mechanisms is most likely to reduce blood loss from a small dermal arteriole?
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(E) 2 A 73-year-old man was diagnosed 1 year ago with pancreatic adenocarcinoma. He now sees his physician because of a transient ischemic attack. On auscultation of the chest, a heart murmur is heard. Echocardiography shows a 1-cm nodular lesion on the superior aspect of the anterior mitral valve leaflet. The valve leaflet appears to be intact. The blood culture is negative. Which of the following terms best describes this mitral valve lesion?
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(G) 3 A 21-year-old woman sustains multiple injuries, including fractures of the right femur and tibia and the left humerus, in a motor vehicle collision. She is admitted to the hospital, and the fractures are stabilized surgically. Soon after admission to the hospital, she is in stable condition. She suddenly becomes severely dyspneic, however, 2 days later. Which of the following complications is the most likely cause of this sudden respiratory difficulty?
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4 For the past week, a 61-year-old man has had increasing levels of serum AST and ALT. On physical examination, he has lower leg swelling with grade 2+ pitting edema to the knees and prominent jugular venous distention to the level of the mandible. Based on the gross appearance of the liver, seen in the figure, which of the following underlying conditions is most likely to be present?
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(E) 5 A 55-year-old woman has had discomfort and swelling of the left leg for the past week. On physical examination, the leg is slightly difficult to move, but on palpation, there is no pain. A venogram shows thrombosis of deep left leg veins. Which of the following mechanisms is most likely to cause this condition?
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(E) 6 A 25-year-old woman who has had altered consciousness and slurred speech for the past 24 hours is brought to the emergency department. A head CT scan shows a right temporal hemorrhagic infarction. Cerebral angiography shows a distal right middle cerebral arterial occlusion. Within the past 3 years, she has had an episode of pulmonary embolism. A pregnancy 18 months ago ended in miscarriage. Laboratory studies show a false-positive serologic test for syphilis, normal prothrombin time, elevated partial thromboplastin time, and normal platelet count. Which of the following is the most likely cause of these findings?
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(E) 7 A 66-year-old woman comes to the emergency department 30 minutes after the onset of chest pain that radiates to her neck and left arm. She is diaphoretic and hypotensive; the serum troponin I level is elevated. Thrombolytic therapy is begun. Which of the following drugs is most likely to be administered?
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(E) 8 A 49-year-old man is in stable condition after an infarction of the anterior left ventricular wall. He receives therapy with anti-arrhythmic and pressor agents. He develops severe breathlessness 3 days later, and an echocardiogram shows a markedly decreased ejection fraction. He dies 2 hours later. At autopsy, which of the following microscopic changes is most likely to be present in the lungs?
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(F) 9 A 27-year-old man is on a scuba diving trip to the Caribbean and descends to a depth of 50 m in the Blue Hole off the coast of Belize. After 30 minutes, he has a malfunction in his equipment and quickly returns to the boat on the surface. He soon experiences difficulty breathing, with dyspnea and substernal chest pain, followed by a severe headache and vertigo. About 1 hour later, he develops severe, painful myalgias and arthralgias. These symptoms abate within 24 hours. Which of the following mechanisms is the most likely cause of these symptoms?
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(E) 10 A 39-year-old woman comes to the physician because she has noticed a lump in her breast. Over the past 2 months, the left breast has become slightly enlarged compared with the right breast. On physical examination, the skin overlying the left breast is thickened, reddish orange, and pitted. Mammography shows a 3-cm underlying density, and a fine-needle aspirate of the density indicates carcinoma. Which of the following mechanisms best explains the gross appearance of the left breast?
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(E) 11 A 29-year-old woman has a history of frequent nosebleeds and increased menstrual flow. On physical examination, petechiae and purpura are present on the skin of her extremities. Laboratory studies show normal partial thromboplastin time, prothrombin time, and platelet count, and decreased von Willebrand factor activity. This patient most likely has a derangement in which of the following steps in hemostasis?
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12 A 70-year-old man who was hospitalized 3 weeks ago for a cerebral infarction is ambulating for the first time. Within minutes of returning to his hospital room, he has sudden onset of dyspnea with diaphoresis. He cannot be resuscitated. The gross appearance of the hilum of the left lung at autopsy is shown in the figure. Which of the following risk factors most likely contributed to this finding?
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(E) 13 A 25-year-old woman has had multiple episodes of deep venous thrombosis during the past 10 years and one episode of pulmonary thromboembolism during the past year. Prothrombin time, partial thromboplastin time, platelet count, and platelet function studies all are normal. Which of the following risk factors has most likely contributed to the patient’s condition?
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(E) 14 A 76-year-old woman is hospitalized after falling and fracturing her left femoral trochanter. Two weeks later, the left leg is swollen, particularly below the knee. She experiences pain on movement of the leg; on palpation, there is tenderness. Which of the following complications is most likely to occur after these events?
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(E) 15 A 12-year-old boy has a history of multiple soft tissue hemorrhages and acute upper airway obstruction from hematoma formation in the neck. On physical examination, he has decreased range of motion of the large joints, particularly the knees and ankles. He has no petechiae or purpura of the skin. Laboratory studies show normal prothrombin time, elevated partial thromboplastin time, and normal platelet count, but markedly decreased factor VIII activity. Which of the following mechanisms best describes the development of this disease?
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(F) 16 Within 1 hour after a gunshot wound to the abdomen, a 19-year-old man exhibits tachycardia. His skin is cool and clammy to the touch, and blood pressure is 80/30 mm Hg. Which of the following organ-specific changes is most likely to occur within 2 days after this injury?
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(E) 17 A 56-year-old man with a history of diabetes mellitus goes to the emergency department because he has had left-sided chest pain that radiates to the arm for the past 5 hours. Serial measurements of serum creatine kinase–MB levels show an elevated level 24 hours after the onset of pain. Partial thromboplastin time and prothrombin time are normal. Coronary angiography shows occlusion of the left anterior descending artery. Which of the following mechanisms is the most likely cause of thrombosis in this patient?
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(F) 18 An experiment is conducted in which platelet function is analyzed. A substance is obtained from the dense bodies (delta granules) of normal pooled platelets from healthy blood donors. When this substance is added to platelets obtained from patients with a bleeding disorder, no platelet aggregation occurs. Adding the substance to platelets from a normal control group induces platelet aggregation. Which of the following substances is most likely to produce this effect?
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(G) 19 In an experiment, thrombus formation is studied in areas of vascular damage. After a thrombus forms in an area of vascular injury, the propagation of the thrombus to normal arteries is prevented. Researchers identify a substance that diminishes thrombus propagation by binding to thrombin, converting it from a procoagulant to an anticoagulant that activates protein C. Which of the following substances is most likely to produce this effect?
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