Atherosclerosis Thrombosis - Part 1

(D) CORRECT. He has multiple risk factors for atherosclerosis, including his weight, smoking, hypertension, and high total cholesterol with low 'good' HDL cholesterol. His findings suggest coronary artery disease.
(A) Incorrect. Hyperplastic arteriolosclerosis can accompany malignant hypertension, which he does not have.
(C) Incorrect. Medical calcific sclerosis is a benign form of arteriosclerosis that does not often contribute to significant disease. It does not involve coronary arteries.
(F) Incorrect. Plexiform arteriopathy is seen in peripheral pulmonary arteries with pulmonary hypertension.

(B) CORRECT. This is the first sign. It is benign and reversible, but it may be the precursor to more severe plaques.
(C) Incorrect. Calcification is a complication of an atheroma.
(E) Incorrect. Lymphocytes and macrophages play a role in atherogenesis, but their numbers are relatively small.
(F) Incorrect. Ulceration of an atheromatous plaque is an advanced lesion, not an early lesion. Ulceration or fissuring of the plaque increases the likelihood for overlying thrombosis.

(C) CORRECT. The immobilization would predispose to thrombosis of leg veins. This is the most common cause for deep venous thrombosis.
(A) Incorrect. The hypercoagulable state of Trousseau syndrome with an underlying malignancy such as an adenocarcinoma predisposes to venous thrombosis, but her prior healthy condition makes malignancy less likely.
(B) Incorrect. Protein C deficiency is associated with venous thrombosis, but the onset of the disease is typically much earlier in life.
(F) Incorrect. Systemic hypertension increases the risk for atherosclerosis, which increases the risk for thrombosis in the arterial system, such as the coronary arteries or carotid arteries.

(A) CORRECT. This is the most common cause of death in persons with diabetes mellitus, because of the high prevalence of coronary atherosclerosis.
(B) Incorrect. Although renal failure is a common complication of diabetes, it is not the major cause of death.
(C) Incorrect. Cerebrovascular disease in diabetes is common but is not the major cause of death.
(D) Incorrect. This complication may be life-threatening, but it is not frequent.
(E) Incorrect. This complication is usually treated before secondary sepsis becomes life-threatening

C) CORRECT. The very high cholesterol with symptoms of coronary artery disease at such a young age, coupled with the family history, are all consistent with familial hypercholesterolemia. In most persons with hypercholessterolemia from multifactorial causes, including diet and exercise patterns, the cholesterol rarely exceeds 400 mg/dL.
(A) Incorrect. Type II diabetes mellitus is most often a disease of middle aged to older adults.
(B) Incorrect. Malignant hypertension may, on occasion, complicate longstanding hypertension that is associated with development of atherosclerosis, but this is usually a complication seen in middle aged to older adults.
(D) Incorrect. The hypercortisolism of Cushing syndrome tends to promote diabetes mellitus, but the underlying conditions that lead to Cushing syndrome are unlikely to allow a long enough survival to develop severe atherosclerosis.
(E) Incorrect. Morbid obesity is a risk for type II diabetes mellitus, and decades are required to develop complications of atherosclerosis. It is unlikely that the cholesterol would be this high.

(C) CORRECT. She has had a 'stroke' which is most often a consequence of cerebral atherosclerosis or embolic disease from the heart as a consequence of ischemic heart disease from atherosclerosis. LDL brings cholesterol to arterial walls, and when increased LDL is present or when there is hypertension, smoking, and diabetes, there is more degradation of LDL to oxidized LDL which is taken up into arterial walls via scavenger receptors in macrophages to help form atheromas.
(B) Incorrect. Endothelial lipoprotein lipase splits off fatty acids that are then used as a substrate in other metabolic pathways and not in atheroma formation.
(D) Incorrect. Both adipose tissue and muscle are areas where VLDL is transformed to LDL, and this does not directly promote atherogenesis.

(A) CORRECT. The signs point to thrombophlebitis.
(B) Incorrect. Septic emboli produce focal hemorrhage or infarction and are usually arterial.
(C) Incorrect. The peripheral edema that accompanies CHF would be symmetrical.
(D) Incorrect. Cellulitis would produce a warm, swollen, tender appearance from the subcutaneous inflammation.
(E) Incorrect. Infarction is a focal process from arterial occlusion.

(D) CORRECT. Fish oils diminish arachidonic acid metabolites and reduce platelet aggregation.
(F) Incorrect. Trans-fats are partially hydrogenated fats made commercially. Trans-fats tend to increase LDL cholesterol, decrease HDL cholesterol, and increase triglycerides - all of which are bad effects.

(B) CORRECT. A typical ischemic infarction with coagulative necrosis is described.
(A) Incorrect. Caseous necrosis is a mixture of liquefactive and coagulative necrosis, and is typical for inflammation caused by mycobacterial or fungal infections.
(C) Incorrect. Fat necrosis most often occurs in breast (with trauma) and in pancreas (with acute pancreatitis).
(D) Incorrect. Gangrene involves a whole organ or body part. There can be elements of coagulative necrosis ('dry' gangrene) and liquefactive necrosis ('wet' gangrene).
(E) Incorrect. Liquefactive necrosis is most typical for brain infarction and for abscesses with many neutrophils.

(C) CORRECT. The restoration of blood flow is helpful if the existing cell damage is not great, so further damage can be prevented. However, the reperfusion of damaged cells results in generation of oxygen free radicals to produce a reperfusion injury.
(B) Incorrect. The tPA does not produce a chemical injury, but induces thrombolysis to help restore blood flow.
(D) Incorrect. Creatine kinase is released, but synthesis does not (cannot) increase from the injured cells.
(E) Incorrect. The elevation in creatine kinase is indicative of myocardial cell necrosis, not atrophy.

(B) CORRECT. HTN is a risk factor that accelerates atheromatous plaque formation.
(C) Incorrect. In Marfan syndrome, there is cystic medial necrosis of the aorta, but not atherosclerosis.
(D) Incorrect. Thrombophlebitis involves veins. Atherosclerosis does not involve veins.
(E) Incorrect. Various forms of vasculitis may produce vascular occlusion, but do not accelerate atherosclerosis.
(F) Incorrect. Cancer is a debilitating condition likely to result in reversal of atheroma formation. Hypercoagulable states from cancers are most likely to result in venous thrombosis, though arterial thrombi are possible, but not dependent upon prior arterial atheroma formation.
(G) Incorrect. SLE and autoimmune diseases in general are debilitating conditions in which atheromas may diminish in size. The antiphospholipid syndrome that can sometimes occur with SLE can lead to thrombosis, not atheroma formation.

(C) CORRECT. He has 'abdominal angina' from diminished blood flow to the bowel as a consequence of severe atherosclerosis. Persons with diabetes mellitus may have this finding, because all branches of major arteries to the bowel are affected by atherosclerosis.
(B) Incorrect. The liver has a dual blood supply (hepatic arterial plus portal venous circulations) and is difficult to infarct.
(D) Incorrect. Pancreatitis is a disease of the pancreatic acinar parenchyma, not the islets. Even in persons with pancreatitis, diabetes mellitus is a rare outcome.
(E) Incorrect. Nephrosclerosis can lead to renal failure. However, there is typically no pain associated with this process.

(A) CORRECT. The bronchial arterial supply to the lung does not provide enough oxygenation to prevent infarction, but does provide blood to make the infarct hemorrhagic.
(B) Incorrect. A myocardial infarction is predominantly ischemic, though the border may be hemorrhagic.
(C) Incorrect. The liver is hard to infarct because of its dual blood supply, but when infarcts occur, they are usually pale.
(D) Incorrect. Renal infarcts are usually ischemic and pale.
(E) Incorrect. Splenic infarcts are typically pale.
(F) Incorrect. A cerebral arterial aneurysm is most likely to rupture and produce subarachnoid hemorrhage. This hemorrhage may produce vasospasm with cerebral ischemia, which in the brain can produce liquefactive necrosis.

(D) CORRECT. Left ventricular mural thrombi are prone to embolize to the systemic arterial circulation. Such mural thrombi are likely to result from damage to the left ventricle from ischemic heart disease, either acutely with an underlying myocardial infarction, or with a left ventricular aneurysm formed following resolution of a large myocardial infarction.
(B) Incorrect. Left atrial thrombi are prone to embolize to the arterial circulation, but an enlarged left atrium is most likely to result from valvular heart disease, not ischemic heart disease.
(C) Incorrect. The left ventricular thrombi cannot get into the pulmonary circulation without a ventricular septal defect, and the VSD would probably lead to abnormal cardiac function.

(C) CORRECT. Ketonuria is typical for type I diabetes mellitus.
(D) Incorrect. This finding is more typical of type II diabetes mellitus.
(E) Incorrect. The child probably has ketoacidosis.
(F) Incorrect. She is unlikely to have an acute Addison disease which would be characterized by hypotension and hypoglyccemia, and she is unlikely to present at this age with congenital adrenal hyperplasia.

(C) CORRECT. She has a pulmonary thromboembolus. Stasis predisposes to thrombosis, as is evidenced by the danger for thromboembolism in hospitalized patients.
(E) Incorrect. Atherosclerosis is seen in arteries, not veins.
(B) Incorrect. The cirrhotic liver functions poorly, usually causing an increase in prothrombin time. This makes it more difficult to form thrombi.

(A) CORRECT. Immobilization is a major risk for the development of venous thrombosis and subsequent pulmonary embolization.
(C) Incorrect. Chronic alcoholics tend to have a coagulopathy due to their underlying liver disease which predisposes them to bleeding, not thrombosis.
(E) Incorrect. People with Autoimmune diseases generally do not have major problems with thrombosis, though some can develop an antiphospholipid syndrome with thrombosis.

(C) CORRECT. She has claudication from severe peripheral arterial atherosclerosis, most likely from the iliac arteries down. She has risk factors for atherosclerosis.
(A) Incorrect. The result of lymphatic obstruction is lymphedema, with marked swelling from collection of interstitial fluid. Lymphatics normally scavenge the fluid and protein that escapes at the venule and capillary level and returns it to circulation.
(B) Incorrect. Arteriolosclerosis is more typically found in the kidneys and brain, not the extremities.
(D) Incorrect. Medial calcific sclerosis of Monckeberg is not typically a serious problem.
(E) Incorrect. Venous thrombosis should lead to a warm, tender, swollen extremity.

(B) CORRECT. Monckeberg calcific medial sclerosis is a benign, incidental finding most often seen in the elderly. Small arteries in pelvis and extremities are typically involved. The vascular lumen is not compromised.
(E) Incorrect. Dystrophic calcification from tissue damage would probably not be so localized to arteries.
(A) Incorrect. Although calcification may complicate atheromas, this is typically seen in larger vessels.
(C) Incorrect. Metastatic calcification from hypercalcemia would involve other areas in lung, kidney and GI tract first.
(D) Incorrect. Dystrophic calcification following injury from trauma would be localized and would take weeks to form.

(D) CORRECT. The findings suggest hyperplastic arteriolosclerosis, which accompanies malignant hypertension.
(B) Incorrect. Hypercalcemia can be associated with hyperparathyroidism.
(C) Incorrect. Increased cholesterol leads to atherosclerotic vascular changes.
(E) Incorrect. Myocardial injury increases the troponin I.
(G) Incorrect. An increased CRP can be a marker for an increased risk for atherosclerosis with atheroma formation, but not concentric endothelial proliferation.

(A) CORRECT. Out-of-control diabetes over time can be better detected because the glycosylated RBCs will persist for months and the Hgb A1C increased.
(B) Incorrect. The ketones suggest ketoacidosis, but this could have been a recent development.
(C) Incorrect. Hyperosmolar coma is possible, but would be relatively recent in onset.
(D) Incorrect. This would be a likely finding with diabetes mellitus, but would tell you nothing about the course or the degree of control of hyperglycemia.
(E) Incorrect. In type I diabetes mellitus, elevated anti-insulin antibodies are often present, but tell you nothing about the course or the control of the hyperglycemia.

(E) Incorrect. Liquefactive necrosis is most typical for brain infarction and for abscesses with many neutrophils.
(A) Incorrect. The cerebral bridging veins cross the subdural space and rupture of them can produce a subdural hematoma. Cerebral venous thrombosis is far less common than cerebral arterial thrombosis or embolism.
(E) Incorrect. His original myocardial infarction may have been due to coronary thrombosis, but his last event was not, since the troponin I was not elevated.
(C) Incorrect. The superior vena cava may become occluded by thrombus when involved by a neoplasm in the chest. A thromboembolus from a leg vein may pass through the inferior vena cava on the way to the pulmonary arterial tree.

(D) CORRECT. She has marked blood loss with shock. There will be vasoconstriction in skin in response to the hypovolemia. Decreased renal blood flow from shock can lead to acute tubular necrosis. The lack of tissue perfusion with shock leads to increased anaerobic glycolysis and lactic acidosis.
(B) Incorrect. Hyperglycemia is not a feature of blood loss with shock.
(C) Incorrect. She has had blood loss, but the oxygen carrying capacity of the remaining RBCs is not affected, and her ability to oxygenate is not completely lost.
(E) Incorrect. An elevated troponin I suggests myocardial ischemia. With good coronary blood flow in a young person, the myocardium is not seriously affected until the patient is near death.

(E) Incorrect. The elevation in creatine kinase is indicative of myocardial cell necrosis, not atrophy.
(B) Incorrect. The size of the infarct gives no clue as to whether a thrombus was present or not.
(C) Incorrect. The severity of the atherosclerosis does not necessarily predict whether a thrombus will have formed.
(A) Incorrect. Though an increased total serum cholesterol suggests a risk for atherosclerosis and its complications, it does not predict acute events.

(E) CORRECT. The big problem in gestational diabetes is eventual placental malfunction in later pregnancy (third trimester) with potential fetal demise.
(A) Incorrect. The babies of diabetic mothers tend to have macrosomia (increased size).
(B) Incorrect. This patient has gestational diabetes, not type 1 diabetes mellitus.
(C) Incorrect. This unlikely, given that hyperosmolar coma is more typical of older type 2 diabetics.
(D) Incorrect. The rate of fetal malformation is slightly increased in mothers with diabetes mellitus type 1 or 2, but not gestational diabetes.

(D) CORRECT. The hyperglycemia leads to formation of sorbitol in tissues not requiring insulin for glucose uptake, resulting in osmotic cellular injury. This can occur in small vessels, retina, kidney, and nerves. The failure of erection and ejaculation results from diabetic neuropathy.
(A) Incorrect. Atherosclerotic cerebrovascular disease is more frequent with diabetes mellitus, but not findings related to osmotic vascular injury.
(B) Incorrect. The risk for cancer is not increased with diabetes mellitus.
(C) Incorrect. However, the major damage to the heart with diabetes mellitus is done via atherosclerotic coronary artery disease. Atherosclerosis affects muscular arteries by formation of intimal atheromatous plaques which occlude the lumen and lead to ischemic injury.
(E) Incorrect. Pyelonephritis with diabetes is related to diminished neutrophil function with hyperglycemia.