Question 226
A 43-year-old male is brought to the emergency room by his family members who said that he has been complaining of a bad headache for two days and then today began to act confused. If the pathologic change illustrated below is characteristic of his disease process, of the following, what feature might be identified upon physical examination?
A. Jugular venous distention
B. A new crescendo-decrescendo systolic murmur
C. Pulsus alternans
D. Retinal hemorrhages
E. Pedal petechiae
Answer for Question 226
Answer: D (Retinal hemorrhages)
Explanation: The pathologic change is hyperplastic arteriolosclerosis (onion-skinning of the arteriole at the black arrow), which is associated with malignant hypertension. Individuals with severe hypertension can present with headache and confusion. Physical examination can reveal retinal hemorrhages. Pulsus alternans and jugular venous distention would be found in patients with congestive heart failure. Petechiae of the feet are not characteristic of malignant hypertension.
Question 227
A 51-year-old male presents to the emergency room. He says that 30 minutes ago, he started to have a severe pressure in his chest that also involves his left and right arm, and that he feels nauseous. He has no significant past medical history, but has smoked 2 packs of cigarettes per day since he was 17 years old. Other than a heart rate of 105 beats per minute, his physical examination is unremarkable. A blood draw for troponin I is ordered immediately upon his arrival to the emergency room and found to be within a normal range. His EKG has no changes. Given that the pathologic change illustrated in the image is the cause of his symptoms, which of the following most likely explains the normal troponin I concentration during laboratory testing?
A. Specimen mix-up
B. Factious low concentration due to hypercholesterolemia
C. Insufficient time since onset of symptoms
D. Competing serologic factor
E. Angina-like non-cardiac chest pain
Answer for Question 227
Answer: C (Insufficient time since onset of symptoms).
Explanation: The image illustrates an acute plaque change, with apparent hemorrhage into the plaque (black arrow) and a near occlusive intraluminal thrombus (purple arrow). Although troponin I will rise rapidly after an infarct, 30 minutes is most likely not sufficient, and a few hours is required; hence, the utility of serial troponin I measurements in individuals with suspected anginal pain. Since the thrombus is not completely occlusive, it is also possible that this individual was only having unstable angina, and would not have an elevation in troponin I; however, this possibility was not a choice listed, and given the choices, the best answer is that there was insufficient time between the onset of symptoms and the time of the blood draw to have allowed for an elevation in troponin I to occur.
Question 228
A 53-year-old male is walking with his wife on the sidewalk near their house when he starts to complain of a pressure in his chest. They turn around to return to the house and when they reach the door he collapses. Other than treated hypertension, he has no other past medical history. His brother sustained a myocardial infarct at the age of 49 years. Of the following, laboratory testing prior to his death may have revealed which abnormality that is a risk factor for his condition illustrated in the image?
A. Elevated HDL
B. Reduced LDL
C. Hypochloremia
D. Hyperhomocysteinemia
E. Hyperkalemia
Answer for Question 228
Answer: D (Hyperhomocysteinemia)
Explanation: Hyperhomocysteinemia is a risk factor for atherosclerosis (which involves the coronary artery and is located by the arrow), although the mechanism is not well understood. Low concentrations of HDL and elevated concentrations of LDL are risk factors for atherosclerosis. Electrolyte abnormalities are not identified as a direct risk factor for atherosclerosis.
Question 229
A 71-year-old male who has no significant past medical history and has not seen a physician in 30 years presents to the emergency room with complaints of a pressure-like pain in his chest after minor exertion. If the pathologic condition illustrated in the image below is the cause of his symptoms, of the following, what is the most likely mechanism for its development?
A. Recurrent Streptococcal infections
B. Hypercholesterolemia
C. Cigarette smoking
D. Metastatic calcification
E. Dystrophic calcification
Examination of the heart would most likely reveal which of the following additional pathologic changes?
A. Right ventricular hypertrophy
B. Left ventricular hypertrophy
C. Metastatic parathyroid carcinoma
D. Myxomatous change of mitral valve
E. Granulomatous inflammation
Answer for Question 229
Answer: E (Dystrophic calcification) and B (Left ventricular hypertrophy)
Explanation: The patient has aortic stenosis due to dystrophic calcification of a tricuspid aortic valve (nodules of calcium at blue arrows). With chronic rheumatic aortic valvulitis, the commissures should be fused, which they are not (yellow arrow). Aortic stenosis leads to left ventricular hypertrophy, which is the source of the patient’s chest pain–the amount of blood that enters the coronary arteries after passing through the stenotic valve is insufficient to oxygenate the heart muscle, and angina occurs with exertion.
Question 230
A 62-year-old male with a past history of hypertension for 15 years, treated with medication, and with a 60-pack-year smoking history tells his wife who he is bowling with him that he suddenly developed abdominal pain. He says he is going to go to the car to take a break and tells her to finish her game. Thirty minutes later, she finds him unresponsive in the car, dead. An autopsy is performed, which identifies a hemoperitoneum and the pathologic condition that is the cause is illustrated in the image. Of the following choices, which is the most likely etiology of his condition?
A. Syphilis infection
B. Bicuspid aortic valve
C. Matrix metalloproteinase imbalance
D. Glycogen storage disorder
E. Past episode of abdominal trauma
Answer for Question 230
Answer: C (Matrix metalloproteinase imbalance)
Explanation: The individual has a ruptured abdominal aortic aneurysm (at the black arrow is thrombus exuding through the rupture site–the green arrow indicates the location of the renal arteries; the blue line and blue arrow indicates the extent of the aneurysm). An imbalance of matrix metalloproteinases contributes to the development of wall weakness and aneurysm formation. Syphilitic aortitis and aneurysms associated with a bicuspid aortic valve involve the thoracic aorta and vasculitis is another cause of thoracic aortic aneurysms. Remote trauma could be a very rare cause of an abdominal aortic aneurysm. A glycogen storage disorder is not normally associated with an abdominal aortic aneurysms.
