WEB PATH – AKL

CELLULAR INJURY

Question 1

A 48-year-old male with a history of chronic alcoholism who is continuing

to perform adequately on the job will most often have which of the
following findings in liver:

A Cholestasis

B Fatty change

C Hemochromatosis

D Hypertrophy of smooth endoplasmic reticulum

E Coagulative necrosis

(B) CORRECT. The toxic effects of the alcohol culminate in lipid

accumulation within hepatocytes.

(A) Incorrect. Bile stasis may occur in the late stages of cirrhosis, or may be
a function of biliary tract obstruction or liver cell injury.

(D) Incorrect. This is the result of chronic barbiturate ingestion.

(E) Incorrect. Liver infarction is rare because of the dual blood supply, and
it does not occur with alcoholism.
Question 2

A 53-year-old male who is developing an acute myocardial infarction from

coronary occlusion has an irreversible injury to the myocardium when:

A Glycogen is depleted

B Cytoplasmic sodium increases

C Nuclei undergo karyorrhexis

D Intracellular pH diminishes

E Blebs form on cell membranes

(C) CORRECT. Chromatin clumping is reversible, but dissolution of the

entire nucleus is not.

Question 3

While in a home improvement center warehouse buying paint, a 35-year-old

male hears "Look out below!" and is then struck on the leg by a falling
pallet rack. The yellow-brown color of the bruise to his thigh a couple of
weeks after injury is due to accumulation of:

A Lipofuscin

B Bilirubin

C Melanin

D Hemosiderin

E Glycogen

(D) CORRECT. The iron in the heme pigment from the red blood cells in
the hemorrhage is incorporated into hemosiderin granules.
Question 4

After years of breathing dirty city air, your lungs have accumulated:

A Anthracotic pigment

B Lipofuscin

C Melanin

D Hemosiderin

E Biliverdin

(A) CORRECT. The dirt is collected by macrophages and transferred into

lymphatics. It looks bad but does not compromise lung function.

Question 5

Even after thrombolytic therapy to restore coronary blood flow early in the
course of a myocardial infarction, a reperfusion injury occurs because of:

A Cytoskeletal intermediate filament loss

B A decreased intracellular pH from anaerobic glycolysis

C An increase in toxic oxygen radicals

D Mitochondrial swelling

E Nuclear chromatin clumping and decreased protein synthesis

(C) CORRECT. Such toxic oxygen radicals are released from neutrophils
when blood flow is restored following ischemia.
Question 6

The best microscopic evidence for remote hemorrhage in the joint space of a
hemophiliac would be the presence of:

A Lipofuscin

B Russell bodies

C Neutrophils

D Cholesterol crystals

E Anthracotic pigment

(D) CORRECT. The lipid from the red cell membranes is broken down and
cholesterol crystals form.

Question 7

The presence of squamous epithelium in the lower trachea of a 42-year-old

female with a history of smoking is called:

A Dysplasia

B Aplasia

C Anaplasia

D Hyperplasia

E Metaplasia

(D) CORRECT. The lipid from the red cell membranes is broken down and
cholesterol crystals form.
Question 8

A 59-year-old female had a cerebral infarction. Months later, a computed

tomographic (CT) scan shows a cystic area in her cerebral cortex. The CT
finding is a lesion that is the consequence of resolution from:

A Liquefactive necrosis

B Atrophy

C Coagulative necrosis

D Caseous necrosis

E Apoptosis

(A) CORRECT. The brain undergoes liquefactive necrosis with infarction.

As it resolves, a cystic area forms in the region of infarction.

Question 9

Features of hypoxic cell injury include all of the following EXCEPT:

A Cell swelling

B Lack of ATP generation

C Mitochondrial calcium deposition

D Lactic acidosis

E Apoptosis

(E) CORRECT. Single cell necrosis is not a feature of hypoxia.

Question 10

The light brown perinuclear pigment seen on H&E staining of the cardiac
muscle fibers in the heart of an 80 year old male is:

A Hemosiderin resulting from iron overload

B Lipochrome from "wear and tear"

C Glycogen resulting from a storage disease

D Cholesterol as a consequence of atherosclerosis

E Calcium deposition following necrosis

Question 11

An immunohistochemical stain that microscopically identifies the presence

of intermediate filaments within cells is useful because:

A Cytoskeletal alterations are seen with impending cell death

B A neoplasm can be determined to be a carcinoma

C Contractile properties of the cells can be determined

D A history of chronic alcoholism can be confirmed

E The degree of metaplasia or dysplasia can be assessed

(B) CORRECT. Carcinomas contain cytokeratins while sarcomas contain

vimentin.
Question 12

A 20-year-old female who was 165 cm tall and weighed 55 kg had

Goodpasture's syndrome which progressed to chronic renal failure with
hypertension. At autopsy, her heart weighed 540 gm primarily because of:

A Myocardial hypertrophy

B Fatty infiltration

C Myocardial hyperplasia

D Fatty degeneration

E Edema

(A) CORRECT. The pressure load of hypertension led to myocardial fiber

hypertrophy and a heart twice normal size.

Question 13

Cellular injury through generation of free radicals is LEAST typical for:

A Pulmonary diffuse alveolar damage from oxygen toxicity

B Acute purulent inflammation

C Accumulation of lipochrome pigment in myocardium with aging

D Radiation therapy for breast carcinoma

E Acute myocardial infarction

(E) CORRECT. The major mechanism for cell damage with acute infarction
is ischemia with lack of oxygen. Reperfusion of infarcted tissue, however,
may lead to free radical injury.
Question 14

In which of the following situations is epithelial metaplasia most likely to

have occurred:

A Tanning of the skin following sunlight exposure

B Lactation following pregnancy

C Vitamin A deficiency

D Acute myocardial infarction

E Urinary obstruction from an enlarged prostate

(C) CORRECT. Vitamin A is necessary to maintain epithelia, and squamous

metaplasia of the respiratory tract may occur if there is a deficiency.

Question 15 ***

Cellular apoptosis plays a significant role in the histopathologic appearance

of:

A Viral hepatitis

B Brown atrophy of the heart

C Renal transplant rejection

D Chronic alcoholic liver disease

E Barbiturate overdose

(A) CORRECT. Viral infection leads to individual hepatocyte necrosis.

Question 16

The appearance of gangrenous necrosis in the big toe necessitating

amputation is most typical for a patient with:

A Complications of diabetes mellitus

B Monckeberg's arteriosclerosis

C Blunt force trauma

D Complications of AIDS

E Type III hypersensitivity reaction

(A) CORRECT. The occlusive peripheral atherosclerotic vascular disease is

typical for diabetes mellitus.

(C) Incorrrect. Such focal gangrenous necrosis is not typical for trauma.

(E) Incorrect. A type III reaction could produce focal vasculitis, but would
not typically result in infarction of a large area or body part.

Question 17

Hypertrophy is best illustrated by:

A The uterine myometrium in pregnancy

B The female breast at puberty

C The liver following partial resection

D The ovary following menopause

E The cervix with chronic inflammation

(A) CORRECT. This accounts for the marked increase in size of the uterus.
Following pregnancy, the uterus returns to its normal size.
Question 18

Of the following cells and tissues in the body, the LEAST sensitive to the
effects of radiation are:

A Ovarian follicles

B Small intestinal epithelium

C Erythropoietic cells of bone marrow

D Spermatogonia of testicular tubules

E Neurons of cerebral cortex

(E) CORRECT. These cells do not actively divide or proliferate.

Question 19

Karyorrhexis refers to:

A Disintegration of the cell cytoplasm

B Cell membrane lysis

C Disintegration of the cell nucleus

D Mitochondrial swelling and lysis

E Oxygen toxicity
Question 20

A 40-year-old schizophrenic male drank a pint of Geritol (containing

vitamins with iron) each day for 20 years. His liver would most likely show:

A Severe fatty change

B Coagulative necrosis

C Hemochromatosis

D Anthracosis

E Sphingolipidosis

(C) CORRECT. The excessive iron intake would lead to a buildup of iron
stores in reticuloendothelial tissues.

Question 21

Which of the following tissues is most likely to withstand hypoxia with the
least damage in a patient with loss of blood pressure and resultant shock:

A Skeletal muscle

B Small intestinal epithelium

C Retina

D Myocardium

E Hippocampus
Question 22

Focal fat necrosis is most often associated with which of the following
clinical conditions:

A Fibrinous pericarditis

B Chronic salpingitis

C Acute pancreatitis

D Hepatitis

E Acute gastritis

(C) CORRECT. The enzymes released from the pancreas damage the
surrounding fat and form soaps -- localized soft tan to yellow areas of fat
necrosis.

Question 23

The spleen at autopsy on sectioning shows a tan to white, wedge-shaped

lesion with base on the capsule. This most likely represents the result of:

A Coagulative necrosis

B Abscess formation

C Metaplasia

D Caseous necrosis

E Liquefactive necrosis

(A) CORRECT. The description is that of a typical infarct.

Question 24

A 3500 gm liver from a 35-year-old female has a yellow, greasy cut surface.
This appearance most likely resulted from:

A Galactosemia

B Iron accumulation

C Mycobacterium tuberculosis infection

D Alcoholism

E Hypoxia

(D) CORRECT. The marked fatty change of the liver is a typical sequel of
alcoholism.

Question 25

In which of the following patients would calcification be least harmful:

A A 55-year-old male undergoing coronary artery angioplasty

B Nephrocalcinosis in a 60-year-old female with hyperparathyroidism

C Aortic valvular calcification in a 70-year-old male

D Alveolar wall calcification in a 41-year-old female with breast cancer

metastatic to bone

E Aortic arch calcification in a 62-year-old male

(E) CORRECT. Such calcification would not have major consequences

because the function of the aorta in carrying blood would not be seriously
compromised.

(C) Incorrect. The valvular calcification could lead to stenosis.

 (A) Incorrect. The calcification of the coronary arteries would make
angioplasty difficult and complicated.

Question 26

A below-the-knee amputation specimen from a 55-year-old male with

diabetes mellitus shows extensive black discoloration of skin and soft tissue
of the foot. This process is best characterized as:

A Neoplasia

B Gangrenous necrosis

C A coagulation disorder

D Hemosiderosis

E Caseation

(B) CORRECT. Gangrene is a typical complication of diabetes mellitus with

peripheral vascular disease.

Question 27

A 35-year-old who eats a lot of pizza and gets very little exercise will
develop:

A Fatty metamorphosis of liver

B Hyperplasia of steatocytes

C Fatty degeneration of myocardium

D Hypertrophy of steatocytes

E Metaplasia of muscle to adipose tissue

(D) CORRECT. The fat cells increase in size with obesity in adults.
Question 28

Characteristics of cellular injury from free radicals include all of the

following statements EXCEPT:

A Glutathione peroxidase is one enzyme that helps to defend cells

against them

B Catalases in peroxisomes decompose them

C DNA is not damaged by them

D They can be generated in tissues subjected to radiation therapy

E Vitamin E provides an antioxidant effect against them

Question 29

The marked enlargement of the uterus that occurs with pregnancy is

accompanied by histopathologic evidence for an increase in:

A Myometrial cell numbers

B Nuclear anaplasia

C Cellular DNA content

D Myometrial cell size

E Fibroblasts and collagen

(D) CORRECT. The marked increase in size of the uterus is due to

increased cytoplasm as the cells enlarge (hypertrophy).
Question 30

Following infarction of the anterior pituitary, the adrenal glands are found to
weigh only 2.2 grams each (normal 4 to 6 grams). This alteration of the
adrenals is primarily due to:

A Metaplasia of the cortex

B Lipid depletion of the cortex

C Atrophy of the medulla

D Atrophy of the cortex

E Adrenal infarction

(D) CORRECT. The loss of ACTH leads to cortical atrophy with decreased
glucocorticoid and mineralocorticoid production.

(C) Incorrect. ACTH from the pituitary does not affect the adrenal medulla.
Hormones from the medulla include norepinephrine and epinephrine.

Question 31

Thin (actin), thick (myosin), or intermediate filaments within cell cytoplasm

contribute to all of the following cellular findings EXCEPT:

A Mallory bodies in liver

B Neutrophil phagocytosis

C Neurofibrillary tangles in neurons

D Russell bodies in plasma cells

E Respiratory epithelial ciliary function

(D) CORRECT. Russell bodies are accumulations of immunoglobulins.

(B) Incorrect. Leukocyte chemotaxis and phagocytosis depend upon

cytoskeletal elements. In the Chediak Higashi syndrome, defective
microtubules impair phagocytosis.
Question 32

In which of the following cases will the greatest degree of permanent

damage result:

A Tuberculosis infection with solitary caseating granuloma of lung

B A 50-year-old male surviving a myocardial infarction

C Human papillomavirus infection with cervical dysplasia

D Adult revived after being at the bottom of a swimming pool for 10

minutes

E Multiple transfusions of red blood cells for chronic anemia

Question 33

Which of the following cellular changes represents the best evidence for
irreversible cellular injury:

A Epithelial dysplasia

B Cytoplasmic fatty metamorphosis

C Nuclear pyknosis

D Atrophy

E Anaerobic glycolysis

(C) CORRECT. Nuclear chromatin clumping is reversible, but nuclear

pyknosis is not.
Question 34

A 73-year-old male suffers a "stroke" with loss of blood supply to cerebral

cortex in the distribution of the middle cerebral artery. The most likely
consequence of this is:

A Infarction with liquefactive necrosis

B Pale infarction with coagulative necrosis

C Predominant loss of glial cells

D Recovery of damaged neurons if the vascular supply is reestablished

E Wet gangrene with secondary bacterial infection

(A) CORRECT. Liquefactive necrosis typifies brain infarction.

Question 35

A 30-year-old woman is claiming in a civil lawsuit that her husband abused

her. A workup by her physician revealed a breast mass that on biopsy
showed fat necrosis. This biopsy result is most consistent with:

A Physiologic atrophy

B Probable trauma to the breast

C Lactation

D Radiation injury

E Hypoxic injury

(B) CORRECT. Fat necrosis is seen with trauma to the breast, a fact of
which her lawyer will make good use.
Question 36

As a physician, you should be concerned about a surgical pathology report

that describes "metaplasia" in a biopsy because:

A This change indicates irreversible tissue damage

B It may be due to an irritant that can be avoided

C The patient will probably develop cancer

D The etiology is probably a viral infection that can be treated

E The patient will probably develop a dysplasia

(B) CORRECT. The irritant effect leads to replacement of the normal

epithelium with another (such as squamous epithelium replacing respiratory
epithelium).

Question 37

A below-the-knee amputation for gangrenous necrosis was most likely to be

performed on which of the following patients:

A A 30-year-old female with protein S deficiency

B A 55-year-old male with type I diabetes mellitus

C A 25-year-old female with systemic lupus erythematosus

D A 15-year-old male hours after a motorcycle accident

E A 61-year-old male with congestive heart failure

(B) CORRECT. Diabetics often have poor peripheral circulation from

accelerated atherosclerosis, as well as poor wound healing.

(C) Incorrect. SLE may be associated with a vasculitis, which can produce
very localized tissue necrosis, but not extensive gangrenous areas.
(A) Incorrect. Protein S deficiency would be associated with risk for venous
thrombosis, which is unlikely to produce gangrenous necrosis.

Question 38

All of the following findings represent changes seen within cells that
represent potentially reversible cellular injury EXCEPT:

A Fatty change in hepatocytes

B Neuronal cell swelling

C Skeletal muscle fiber anaerobic glycolysis

D Renal tubular cell nuclear pyknosis

E Kupffer cell iron deposition

(D) CORRECT. Loss of the cell nucleus is an irreversible change.

(B) Incorrect. Cell swelling without loss of cell membranes is reversible.

Question 39

A 55 year old male has sudden onset of chest pain and a myocardial
infarction is suspected. Which of the following laboratory tests is most
useful in this situation:

A Total serum cholesterol with HDL cholesterol

B Creatine phosphokinase (CPK)

C Serum triglyceride

D Serum amylase

E Sedimentation rate
 (B) CORRECT. The CPK will be elevated with myocardial injury. The
CPK-MB isoenzyme fraction is specific for cardiac muscle.

Question 40

Physical examination on a 42 year old female reveals scleral icterus. Which

of the following underlying conditions is most likely to contribute to this
finding:

A Hypercholesterolemia

B Thrombocytopenia

C Metastatic carcinoma

D Hepatitis

E Diabetes mellitus

(D) CORRECT. Hepatitis, most often an infectious viral hepatitis, leads to

liver cell dysfunction with increasing serum bilirubin that produces
jaundice.

The conjunctiva of the eye are one of the first tissues to change color as
bilirubin levels rise in jaundice. ... The term "icterus" itself is sometimes
incorrectly used to refer to jaundice that is noted in the sclera of the eyes; its
more common and more correct meaning is entirely synonymous with
jaundice, however.

What causes icterus?

Hemolysis causes a type of anemia called hemolytic anemia, which is
different from blood loss anemia that is a result of external hemorrhage from
an injury. 2) Liverdisease. Any disease or condition that damages or
destroys liver cells can cause icterus. 3) Obstruction of the bile duct
Question 41

A 56 year old female has smoked 2 packs of cigarettes per day for the past
35 years. She has a chronic cough, but recently has noted sputum streaked
with blood. Bronchoscopy with biopsy is performed. The biopsy reveals
bronchial epithelium with squamous metaplasia. This most strongly suggests
that:

A This is a physiologic process of aging

B This process is irreversible, even if she stops smoking

C She has metastases to lung from a primary somwhere else

D She has an increased risk for pulmonary infection

E A pulmonary thromboembolus caused pulmonary infarction

(D) CORRECT. The loss of normal functioning respiratory epithelium

means that the normal barrier to infection has been weakened.
(E) Incorrect. Pulmonary infarctions are not accompanied by squamous
metaplasia.
Question 42

Increased lipochrome (lipofuscin) within the myocardial fibers of a 90 year

old female results from which of the following cellular mechanisms:

A Nuclear pyknosis

B Myocardial fiber hypertrophy

C Coagulative necrosis

D Autophagocytosis

E Anaerobic glycolysis

(D) CORRECT. The lipochrome represents the residual debris of organelles

and appears with increased frequency with aging, particularly in heart and
liver.

Question 43

Liquefactive necrosis is most likely to play a role in development of which

of the following pathologic lesions:

A Acute renal infarction

B Acute viral hepatitis

C Pneumocystis carinii pneumonia

D Remote cerebral infarction

E Brown atrophy of the heart

(D) CORRECT. The brain undergoes liquefactive necrosis with severe

ischemic injury. This can resolve to a cystic area representing a remote (old)
infarction.
Question 44

The best example of dystrophic calcification is seen in a(an):

A 55 year old female with metastases from breast carcinoma and

hypercalcemia

B Healing granuloma in a 41 year old male with pulmonary tuberculosis

C Gangrenous lower extremity in a 50 year old female with diabetes

mellitus

D 62 year old female with a recent cerebral infarction

E Abscess of the left fallopian tube in a 19 year old female with

Neisseria gonorrheae infection

(B) CORRECT. Dystrophic calcification occurs in damaged tissues;

granulomas typically heal by deposition of calcium, which often appears on
chest x-rays in the upper lobes with tuberculosis.

(A) Incorrect. Hypercalcemia may lead to metastatic, not dystrophic,

calcification on the basis of the high serum calcium level.

(E) Incorrect. Abscesses from bacterial agents typically resolve with

granulation tissue and fibrosis, but not calcium deposition.
Question 45

The appearance of fat necrosis is most often seen in which of the following
settings:

A A 31 year old male has an acute abdomen with marked abdominal

pain and an elevated serum amylase

B A 66-year-old female with chronic alcoholism has an elevated serum

AST

C A 23 year old female with a decreased total serum complement has a

history of systemic lupus erythematosus

D A 70 year old female with adenocarcinoma of the colon and

metastases to liver has an elevated LDH

E A 49 year old male with sudden onset of chest pain has an elevated
serum creatine kinase

(A) CORRECT. The amylase suggests that the abdominal pain is from
pancreatitis. Pancreas undergoes fat necrosis with injury.

(B) Incorrect. The liver in alcholism may demonstrate fatty change,

cirrhosis, or acute alcoholic hepatitis.

(D) Incorrect. The metastases of the adenocarcinoma, as well as the primary,

may undergo necrosis, but not fat necrosis.

(E) Incorrect. This setting suggests an acute myocardial infarction with

coagulative necrosis.
Questions 46 and 47: Click on the checkbox first, then the lettered item.

(46) Which of the following is an example of dystrophic calcification:

(47) Which of the following is an example of metastatic calcification:

A Healing M. tuberculosis granuloma

B Fatty metamorphosis of liver

C Parathyroid adenoma with hyperparathyroidism

D Viral hepatitis with apoptosis

E Coronary atherosclerosis

(A) Match on 46. Calcium is deposited in and around the granuloma as a

reaction to injury with necrosis.

(C) Match with 47. The high calcium levels with hyperparathyroidism lead
to calcium deposition, even in normal tissues.
Questions 48 and 49: Click on the checkbox first, then the lettered item:

(48) Compensatory hyperplasia.

(49) Physiologic hypertrophy.

A Breast late in pregnancy

B Weightlifter's skeletal muscle

C Liver after partial hepatectomy

D Postmenopausal uterus

E Bronchial mucosa of a smoker

Question 50 and 51: Click on the checkbox first, then the lettered item:

(50) A 45-year-old male has been drinking a quart of vodka a day for
the past 25 years.

(51) A 25-year-old female with a seizure disorder has been taking

phenobarbital.

A Giant mitochondria in hepatocytes

B Increased hepatocyte lipofuscin

C Hypertrophy of hepatic smooth endoplasmic reticulum

D Apoptosis of hepatocytes

E Fatty infiltration of myocardium

(A) Match on 50. Enlarged mitochondria can be a feature of liver with

chronic alcoholism.

(C) Match with 51. Barbiturates induce hypertrophy of SER so that the drug
is more quickly metabolized.
Question 52

Several months following an acute myocardial infarction in a 48 year old

male physician, he is found to have evidence for a left ventricular aneurysm
with decreased cardiac output and congestive heart failure (CHF). He is
stable and does not have chest pain. Which of the following findings is
LEAST likely to be found at the time he presents with CHF:

A Elevated serum creatine kinase

B Collagenous scar tissue in the myocardium

C Chronic passive congestion of the liver

D Organizing mural thrombus in left ventricle

E Recanalization of a coronary artery thrombosis

(A) CORRECT. Elevations in CK enzymes are going to be seen acutely

with infarction (within the first few days).

(B) Incorrect. A remote infarct of several months age consists mainly of a

collagenous scar, and the complications depend upon the size.
Question 53

A 53 year old male suffers a cardiac arrest and his wife calls 911. The
paramedics arrive a few minutes later and begin resuscitative measures. A
regular heart rate is established after about 40 minutes of resuscitative
efforts as he is being transported to the hospital. A thrombolytic agent is
administered, but the following process occurs in the myocardium at that
time:

A Apoptosis

B Free radical injury

C Heterophagocytosis

D Squamous metaplasia

E Accumulation of cytokeratins

(B) CORRECT. The ischemia during the cardiac arrest followed by

reperfusion established following successful resuscitation will generate
activated oxygen species to produce free radical injury.
WEB PATH – AKL
THROMBOSIS
Question 1

A 56-year-old Caucasian male with hypertension (blood pressure 155/95

mm Hg) smokes 2 packs of cigarettes per day and has an HDL cholesterol
that is greater than normal. Which of the following factors in his case is
NOT associated with an increased risk for his developing atherosclerosis:

A Hypertension

B Male sex

C His age

D Increased HDL cholesterol

E Smoking

(D) CORRECT. HDL cholesterol is the 'good' cholesterol that protects

against atherosclerosis.

(B) Incorrect. Males have a greater risk for atherosclerosis than females.
Question 2

Etiologies for the development of venous thrombosis in the saphenous vein

of an adult woman would likely include any of the following conditions
EXCEPT:

A Pancreatic adenocarcinoma with Trousseau's syndrome

B Protein C deficiency

C Femoral fracture

D Pregnancy

E Chronic alcoholism

(E) CORRECT. The liver disease of chronic alcoholism predisposes to

coagulopathy with hemorrhage, not thrombosis.

(A) Incorrect. The hypercoagulable state of Trousseau's syndrome

predisposes to venous thrombosis.

The Trousseau sign of malignancy or Trousseau's syndrome is a medical

sign involving episodes of vessel inflammation due to blood clot
(thrombophlebitis) which are recurrent or appearing in different locations over
time (thrombophlebitis migrans or migratory thrombophlebitis).
Question 3

Which of the following findings is LEAST likely to occur as a result of

severe atherosclerosis in a 63 year old male who has had insulin dependent
diabetes mellitus for two decades:

A Abdominal aortic aneurysm

B Hepatic infarction

C Cerebral infarction

D Gangrene of big toe

E Chronic renal failure

(B) CORRECT. The liver has a dual blood supply (hepatic arterial plus
portal venous circulations) and is difficult to infarct.

Question 4

Which of the following statements is LEAST likely to be correct in a patient

with normal cardiac function:

A A systemic artery embolus may rarely result from thrombosis in a

peripheral vein.

B A systemic artery embolus may result from a left atrial mural

thrombus.

C Pulmonary embolism may result from a left ventricular mural

thrombus.

D A systemic artery embolus may result from a left ventricular mural

thrombus.

E Pulmonary embolism may result from thrombosis in a peripheral

vein.
Question 5

A hemorrhagic infarct will most typically be present in which of the

following situations:

A Lung with pulmonary thromboembolism

B Heart with coronary thrombosis

C Liver with hypovolemic shock

D Kidney with septic embolus

E Spleen with embolized mural thrombus

(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.
 Question 6

A middle-aged patient should be advised that, of the following dietary

components, the one most likely to reduce the risk for atherosclerosis is:

A 40% of total caloric intake as fat

B Saturated fat

C Cholesterol

D Fish oil

E Triglyceride

(D) CORRECT. Fish oils diminish arachidonic acid metabolites and reduce
platelet aggregation.

Question 7

Of the following findings or conditions, the one that is the most important
factor favoring venous thrombosis is:

A Increased white blood cell count

B Cirrhosis of the liver

C Altered flow with stasis

D Increased platelet count

E Atherosclerosis

(C) CORRECT. Stasis predisposes to thrombosis, as is evidenced by the

danger for thromboembolism in hospitalized patients.
Question 8

Lipoprotein transport and metabolism in the body can be characterized by

all of the following findings EXCEPT:

A Chylomicrons are synthesized in the liver.

B Endothelial cells contain lipoprotein lipase.

C Arterial walls contain cells with LDL receptors.

D VLDL transformation to LDL occurs in adipose tissue.

E Cholesterol is needed for the formation of red blood cell membranes.

(A) CORRECT. Chylomicrons are formed by complexing lipids absorbed

from the small intestine to transport apoproteins. They then travel to the
liver.
 Question 9

The first visible gross evidence for the formation of an atheroma in an artery
such as the aorta is:

A Thrombosis

B A fatty streak

C Calcification

D Hemorrhage

E Arterial narrowing

(B) CORRECT. This is the first sign. It is benign and reversible, but it may
be the precursor to more severe plaques.

(A) Incorrect. Thrombosis is a complication of an atheroma.

Atheroma - degeneration of the walls of the arteries caused by accumulated

fatty deposits and scar tissue, and leading to restriction of the circulation and
a risk of thrombosis.
 the fatty material which forms deposits in the arteries.

Coronary heart disease (CHD) is usually caused by a build-up of fatty

deposits (atheroma) on the walls of the arteries around the heart
(coronary arteries). The build-up of atheroma makes the arteries narrower,
restricting the flow of blood to theheart muscle. This process is
called atherosclerosis.
Question 10

A 63-year-old obese male has had poorly controlled non-insulin dependent

diabetes mellitus for the past 25 years. He is most likely to die from:

A Myocardial infarction

B Renal failure

C Stroke

D Hyperosmolar coma

E Gangrene

(A) CORRECT. This is the most common cause of death, because of the
high incidence of coronary atherosclerosis.
Question 11

The proliferative (hyperplastic) type of arteriolosclerosis:

A Is seen most frequently in the small vessels of the liver

B Occurs most commonly in the elderly

C Is associated with progressive hypertension (diastolic >110 mm Hg)

D Often accompanies an acute myocardial infarction

E May result from hereditary hypercholesterolemia

(C) CORRECT. The presence of significant hypertension leads to

concentric, laminated thickening of the arterioles with lumenal narrowing.

(A) Incorrect. It is most often seen in the kidney.

(D) Incorrect. Atherosclerosis is the lesion in coronary arteries that most

often accompanies an acute infarction.
Question 12

A 10-year-old child has a history of polydipsia and polyuria for several

months. Despite an increased appetite, she appears cachectic and is losing
weight. Which of the following laboratory findings would you most strongly
suspect in this setting:

A Increased blood insulin

B Decreased blood glucagon

C Ketonuria

D Markedly increased serum osmolality

E Decreased plasma hydrogen ion (alkalosis)

(C) CORRECT. Ketonuria is typical for type I diabetes mellitus.

Question 13

A 75-year-old female is noted to have calcification of hypogastric arteries

on an abdominal radiograph performed following abdominal trauma. What
is the probable lesion which accounts for this calcification:

A Ulcerative atherosclerosis

B Monckeberg's sclerosis

C Metastatic calcification

D Trauma

E Dystrophic calcification

(B) CORRECT. Monckeberg's sclerosis is a benign, incidental finding in the

elderly. Small arteries in pelvis and extremities are often involved.

(C) Incorrect. Metastatic calcification from hypercalcemia would involve

other areas in lung, kidney and GI tract first.

(E) Incorrect. Dystrophic calcification from tissue damage would probably

not be so localized to arteries.
Question 14

A 55-year-old woman has been treated in the hospital for pneumonia for 3
weeks. She is examined one morning and found to have a swollen right leg.
It is tender to palpation posteriorly but is not warm. This condition is most
likely the result of:

A Venous thrombosis

B Septic emboli

C Congestive heart failure

D Cellulitis

E Infarction

(A) CORRECT. The signs point to thrombophlebitis.

(B) Incorrect. Septic emboli produce focal hemorrhage or infarction and are
usually arterial.
(D) Incorrect. Cellulitis would produce a warm, swollen, tender appearance
from the subcutaneous inflammation.
Question 15

A 29 year old female is involved in a motor vehicle accident that results in

several severe lacerations, along with blunt abdominal trauma, with massive
loss of blood. Which of the following consequences is LEAST likely in this
situation:

A Cool, pallid skin from vasoconstriction

B Guaiac positive stool from gastrointestinal mucosal necrosis

C Decreased urine output from acute tubular necrosis

D Dyspnea from lung infarction

E Lactic acidosis from persistent oxygen deficit

(D) CORRECT. Pulmonary infarction is a possible consequence of a

pulmonary embolus, not shock.

(B) Incorrect. Ischemic enterocolitis with hemorrhage can be a consequence

of shock.

What does a positive occult blood test indicate?

For the guaiac-based FOBT, a positive test result indicates that
abnormal bleedingis occurring somewhere in the digestive tract. This blood
loss could be due to ulcers, diverticulosis, polyps, inflammatory bowel
disease, hemorrhoids, blood swallowed due to bleeding gums or nosebleeds,
or benign or cancerous
Question 16

Of the following persons, the one who is at LEAST risk for venous
thrombosis is:

A A 34-year-old female taking oral contraceptives

B A 62-year-old male with adenocarcinoma of the pancreas

C A 41-year-old male with a deficiency of Von Willebrand's factor

D An 82-year-old female following surgery for a broken hip

E A 20-year-old in the third trimester of pregnancy

(C) CORRECT. A deficiency of VWF leads to bleeding, not thrombosis.

A venous thrombus (PL thrombi) is a blood clot (thrombus) that forms

within a vein. Thrombosis is a term for a blood clot occurring inside a blood
vessel. A common type of venous thrombosis is a deep vein
thrombosis (DVT), which is a blood clot in the deep veinsof the leg.
Question 17

The best evidence for the presence of a coronary arterial thrombus as the
etiology for an acute myocardial infarction in a 52 year old female is:

A Elevation of lactate dehydrogenase (LDH) in serum

B Increased size of the infarction

C Severe coronary atherosclerosis by angiography

D Response to thrombolytic therapy

E A history of diabetes mellitus

(D) CORRECT. The purpose of thrombolytic therapy is to lyse the

thrombus and restore blood flow.

(A) Incorrect. This enzyme will increase following the infarction whether a
thrombus was present or not.

Question 18

An infarction:

A Typically occurs most often from venous thrombosis

B Is less common in liver than in spleen

C Usually involves an entire organ

D Follows bronchial artery occlusion

E Is intermediate (subacute) when serum enzymes remain elevated

(B) CORRECT. The liver has a dual blood supply and is hard to infarct.
(A) Incorrect. Over 99% of infarctions occur following arterial thrombosis.
Question 19

Which of the following events is LEAST likely to occur:

A Severe drop in blood pressure with a loss of 1200 cc of blood into

pleural cavity

B Evidence of organization of an acute myocardial infarction 3 weeks

following coronary thrombosis

C Embolization of a femoral vein thrombus to the right pulmonary

artery

D Acute infarction of the liver with celiac arterial occlusion

E Mural thrombosis of the left ventricle following acute myocardial

infarction

(D) CORRECT. The liver is hard to infarct because of the dual blood
supply. Also, emboli entering the celiac axis tend to be directed out of the
splenic artery.

(B) Incorrect. Organization is well underway after 3 weeks, with extensive

collagen deposition.

(C) Incorrect. The venous thrombus can travel up the vena cava, through the
right heart, and out into the main pulmonary arteries.
Question 20

A 25-year-old primagravida is in the first trimester of pregnancy. During

prenatal visits, she has fasting serum glucose levels of 145 and 152 mg/dl.
Which of the following problems is most likely to occur:

A Intrauterine fetal growth retardation

B Infant with glucose intolerance following birth

C Hyperosmolar coma

D Chromosomal anomalies

E Placental insufficiency in late pregnancy

(E) CORRECT. The big problem in gestational diabetes is eventual

placental malfunction in later pregnancy with potential fetal loss.
Question 21

Though a 54-year-old diabetic male always has blood glucose levels below
110 mg/dl on clinic visits, he has had a number of urinary tract infections
and a non-healing ulcer on his big toe. This situation could be explained by
which of the following laboratory findings:

A An elevated hemoglobin A1C level

B Increased urine ketones

C Markedly elevated serum osmolarity

D Decreased plasma insulin level

E Elevated titer of anti-insulin antibodies

(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.

Question 22

A 36-year-old male with familial hypercholesterolemia and a serum total

cholesterol of 540 mg/dL has the greatest risk for death from:

A Hyaline arteriolosclerosis

B Superior mesenteric artery thrombosis

C Ruptured aortic aneurysm

D Monckeberg's medial calcific sclerosis

E Hyperplastic arteriolosclerosis

(C) CORRECT. One of the complications of advanced atherosclerosis is

aneurysm formation. A large aortic aneurysm can rupture.
Question 23

Increased sorbitol resulting in osmotic cellular injury in a patient with

diabetes mellitus is LEAST likely to be manifested as:

A Decreased visual acuity

B Congestive heart failure

C Decreased gastrointestinal motility

D Dilated bladder

E Impotence

(B) CORRECT. The major damage to the heart with diabetes mellitus is
done via atherosclerotic coronary artery disease.

Question 24

Which of the following complications is LEAST likely to occur in a 49-

year-old female who has atherosclerosis who has severe generalized
atherosclerosis:

A Sudden death

B Gangrene of the right big toe

C Pulmonary artery atherosclerosis

D Remote (healed) myocardial infarction

E Retinopathy with blindness

(C) CORRECT. Pulmonary atherosclerosis occurs most often with

pulmonary hypertension and usually develops independently from systemic
arterial atherosclerosis.
 (A) Incorrect. Sudden deaths can occur with coronary thrombosis.

(B) Incorrect. She may have severe peripheral vascular disease, particularly
if she has diabetes mellitus as the cause for her advanced coronary artery
disease

(E) Incorrect. She may have diabetes mellitus as the cause for her
atherosclerotic complications, and diabetic retinopathy is another
complication.

Question 25

An aorta that demonstrated a mild degree of atherosclerosis with only lipid

streaks and just a few atheromatous plaques would be most consistent with
which of the following histories from patients in the U.S.:

A A 62-year-old male with familial hypercholesterolemia

B A 48-year-old male who exercises regularly

C A 45-year-old female with nodular glomerulosclerosis

D A 10-year-old child killed in a motor vehicle accident

E A 56-year-old male with angina

(B) CORRECT. This is not bad for his age and for living in the U.S. with
lots of atherogenic food around.

(A) Incorrect. Persons with familial hypercholesterolemia would be

expected to have an advanced degree of atherosclerosis, even at a young
age.

(C) Incorrect. Nodular glomerulosclerosis is typical for advanced diabetes

mellitus, in which the degree of atherosclerosis would also be more
advanced.
Question 26

The gross finding at autopsy of a saddle pulmonary embolus is most likely

to be present in a patient:

A Several weeks following placement of a hip prosthesis

B With marked thrombocytopenia

C Who has a history of chronic alcoholism

D Infected with the human immunodeficiency virus

E With a positive antinuclear antibody test

(A) CORRECT. Immobilization is a major risk for the development of

venous thrombosis and subsequent pulmonary embolization.

Saddle pulmonary embolism (PE) is a form of largepulmonary thrombo-

embolism that straddles the mainpulmonary arterial trunk at its bifurcation.
Its incidence among patients diagnosed with PE was found to be
approximately 2.6%.

Pulmonary embolism occurs when a clump of material, most often a blood

clot, gets wedged into an artery in your lungs. These blood clots most
commonly come from the deep veins of your legs. This condition is known as
deep vein thrombosis (DVT).

(B) Incorrect. Thrombocytopenia leads to bleeding, not to thrombosis.

(C) Incorrect. Chronic alcoholics tend to have a coagulopathy due to their

underlying liver disease which predisposes them to bleeding, not
thrombosis.
Question 27

A renal arteriole demonstrating hyperplastic arteriolosclerosis is most likely

to be found in which of the following patients:

A A 54-year-old male with chronic renal failure and amyloidosis

B A 29-year-old female with proteinuria and lupus nephritis

C A 44-year-old female with marked hypertension and scleroderma

D A 49-year-old male with acute cellular allograft rejection

E A 19-year-old female with graft versus host disease

(C) CORRECT. Hyperplastic arteriolosclerosis is typically seen with severe

hypertension, which can occur with progressive systemic sclerosis
(scleroderma).

(A) Incorrect. Amyloid deposits can be seen in small arteries and glomeruli
in the kidney, but do not produce a hyperplastic arteriolosclerosis.

(B) Incorrect. Lupus nephritis may be accompanied by a vasculitis, but not

usually hyperplastic arteriolosclerosis.

Hyperplastic arteriolosclerosis is a type of arteriolosclerosis involving a

narrowed lumen.[1]
The term "onion-skin" is sometimes used to describe this form of blood vessel[2] with
thickened concentric smooth muscle cell layer and thickened, duplicated basement
membrane. In malignant hypertension these hyperplastic changes are often accompanied
by fibrinoid necrosis of the arterial intima and media. These changes are most prominent
in the kidney and can lead to ischemia and acute kidney failure.
It can be caused by malignant hypertension

Scleroderma is a group of autoimmune diseases that may result in changes

to the skin, blood vessels, muscles, and internal organs. The disease can be
either
Question 28

The appearance of coronary artery thrombosis in a 49 year old male with

sudden onset of chest pain is LEAST likely to be associated with:

A A long history of diabetes mellitus

B Hypercholesterolemia

C Acute myocardial infarction

D Recurrent pneumonia

E A history of smoking

(D) CORRECT. Recurrent infections are not a risk for atherosclerosis.

Question 29

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.
The immediate cause of death is:

A Squamous cell carcinoma of lung

B Tuberculosis

C Pulmonary embolism

D Pneumonia with pneumococcus

E Congestive heart failure

Question 30

The gross appearance an aorta with severe ulcerative atherosclerosis is

associated with each of the following additional findings EXCEPT:

A Mural thrombosis

B Diabetes mellitus, type I

C Hypercholesterolemia

D Neoplasia

E Aneurysm formation

(D) CORRECT. Neoplasia does not lead to atherosclerosis. The cachexia

that follows from malignant neoplasms often leads to a reversal of
atherosclerosis.

The condition typically occurs in an area of the aorta that has plaque buildup
due toatherosclerosis. The buildup of plaque causes that area of the aorta
to weaken. The risk of developing atherosclerosis, and consequently a
penetrating aorticulcer, is increased by: ... Heart disease.

Atherosclerosis begins with damage to the endothelium. It's caused by

high blood pressure, smoking, or high cholesterol. That damage leads to
the formation of plaque. When bad cholesterol, or LDL, crosses
the damaged endothelium, the cholesterol enters the wall of the artery.
Question 31

The microscopic finding of an insulitis of the islets of Langerhans suggests

that:

A The patient is over the age of 50

B The patient is pregnant

C There is a risk for ketoacidosis at a later date

D The patient will become obese

E There is peripheral resistance of cells to insulin

(C) CORRECT. An insulitis is seen with type I diabetes mellitus. Actually,

it is rare to see it because by the time the patients present with overt diabetes
mellitus, the islets are long gone.

(D) Incorrect. Obesity is typically associated with type II diabetes mellitus.

(E) Incorrect. Peripheral insulin resistance is typically associated with type

II diabetes mellitus.
Question 32

Severe coronary atherosclerosis leads to an acute myocardial infarction in a

55 year old female. Which of the following factors is LEAST likely to have
contributed to this:

A Endothelial injury occurred in the first 3 cm of the coronary artery

from turbulent flow

B Platelets were adherent to a damaged intima following appearance of

a lipid streak

C Disruption of an intimal plaque led to thrombus formation in the left

anterior descending artery

D Macrophages released growth factors that led to smooth muscle

migration and proliferation

E A reduced amount of low density lipoproteins with LDL cholesterol

were present in the blood

(E) CORRECT. Increased LDL is a risk for atherosclerosis. There are LDL
receptors in arteries.

(B) Incorrect. The earliest atherosclerotic lesion is the lipid streak, and this
can progress with additional endothelial injury with platelet adherence.

(C) Incorrect. Plaque disruption is suggested as one reason that thrombus

formation occurs in a coronary artery.
Question 33

A 45 year old male feels some crushing chest pain along with numbness in
his left arm after shoveling 15 cm of snow off his driveway. An hour 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 Total white blood cell count

B Glucose

C Platelet count

D Creatine kinase

E Amylase

(D) CORRECT. Elevations in CK enzymes are going to be seen acutely

with myocardial infarction beginning within hours and remaining for days.

Question 34

A 68 year old woman has survived multiple episodes of pulmonary

thromboembolism in the past three months. Which of the following
conditions is most likely to be related to this situation:

A She has micronodular cirrhosis of the liver

B She has adenocarcinoma of the pancreas

C Her platelet count is decreased

D She has familial hypercholesterolemia

E She has mitral valve endocarditis

(B) CORRECT. The recurrent episodes suggest a hypercoagulable state, and

carcinomas can do this (Trousseau's syndrome).

(A) Incorrect. Liver disease leads to a coagulopathy marked by a tendency

to bleeding, not thrombosis.
Question 35

Which of the following statements is LEAST likely to be true regarding the

64 year old male who has occlusive coronary artery atherosclerosis with
thrombosis:

A The total serum cholesterol is 250 mg/dl

B He has type I diabetes mellitus

C He died suddenly

D There is a long history of chronic alcoholism

E He has type II diabetes mellitus

(D) CORRECT. Chronic alcoholics tend to have less atherosclerosis than

patients who do not drink.

(A) Incorrect. An elevated total serum cholesterol, particularly if the HDL

component is low, is a risk factor for atherosclerosis.

Question 36

Minimal coronary atherosclerosis with a few scattered lipid plaques is

LEAST likely to become more advanced in patients with:

A A transplanted heart

B Type I diabetes mellitus

C A 2 pack per day smoking habit

D Acquired immunodeficiency syndrome

E Familial hypercholesterolemia

(D) CORRECT. AIDS and other severe chronic illnesses tend to reverse any
atherosclerosis that is present.
Question 37

Pulmonary thromboembolism is LEAST likely to occur in which of the

following patients:

A 42 year old female who has been taking oral contraceptives for
several years

B 75 year old female who is diagnosed with adenocarcinoma of the

head of the pancreas

C 47 year old male with a long history of alcoholic liver disease

D 15 year old female with protein C deficiency

E 85 year old female hospitalized for hip fracture

(C) CORRECT. The liver disease tends to diminish the ability to clot, as is
measured in the laboratory by the protime.

(D) Incorrect. Inherited deficiencies of protein C, protein S, and

antithrombin III are associated with an increased risk for thrombosis,
particularly at a young age.

A pulmonary embolism is a sudden blockage in a lungartery. The cause is

usually a blood clot in the leg called a deep vein thrombosis that breaks
loose and travels through the bloodstream to the lung. Pulmonary
embolism is a serious condition that can cause. Permanent damage to the
affected lung
Question 38

Malignant hypertension in a 44 year old African-American male with a

blood pressure of 275/150 mm Hg is most closely associated with which of
the following pathologic lesions:

A Hyperplastic arteriolosclerosis with fibrinoid necrosis

B Nodular glomerulosclerosis and renal hyaline arteriolosclerosis

C Monckeberg's medical calcific arterial sclerosis

D Severe occlusive coronary artery atherosclerosis with recent

thrombosis

E Thrombophlebitis with pelvic vein thrombosis

(A) CORRECT. Hyperplastic arteriolosclerosis is seen in the setting of

malignant hypertension, and renal failure is common.

Question 39

A serum glucose of 1083 mg/dl (normal 70 - 110 mg/dl) is most suggestive

of which of the following conditions in a 65 year old female:

A Insulin overdose

B Hyperosmolar coma

C Hyperlipidemia

D Ketoacidosis

E Overeating

(B) CORRECT. This is an extremely elevated serum glucose that would

increase the serum osmolality markedly.
 (C) Incorrect. Hyperlipidemia can be due to either an increased serum
cholesterol or serum triglyceride.

(D) Incorrect. Diabetics with ketoacidosis may have a serum glucose around
500 to 600 mg/dl, but generally not over 1000 mg/dl.

Question 40

The cellular injury that accompanies diabetes mellitus from glycosylation

end products and from sorbitol accumulation within cells may lead to all of
the following conditions EXCEPT:

A Chronic renal failure

B Impotence

C Hemosiderosis

D Cataracts

E Retinopathy

(C) CORRECT. The accumulation of iron is not a consequence of diabetes,

but of deranged iron metabolism.
Question 41

Sudden death in a 45 year old male with coronary thrombosis is best

predicted by which of the following laboratory findings that was present the
year before:

A Elevated sedimentation rate

B Increased total serum cholesterol

C Elevated serum alkaline phosphatase

D Decreased serum alpha-1-antitrypsin

E Thrombocytopenia

(B) CORRECT. The greater the increase in total cholesterol (as well as a
decrease in HDL cholesterol) the more likely ischemic heart disease is.

A common complication that can occur after deep vein thrombosis is known
as postphlebitic syndrome, also called postthrombotic syndrome. Damage to
yourveins from the blood clot reduces blood flow in the affected areas, which
can cause: Persistent swelling of your legs (edema) Leg pain.

(C) Incorrect. Alk phos is increased with bone and liver diseases.

(D) Incorrect. This is seen with alpha-1-antitrypsin deficiency, which can

lead to pulmonary emphysema and cirrhosis of the liver.
Question 42

Which of the following laboratory testing strategies for diagnosis and

management of diabetes mellitus in a 20 year old male who has been taking
insulin injections for 5 years is INCORRECT:

A A urinalysis for detection and semiquantitation of ketones will help to

diagnose a problem resulting from lack of insulin

B The use of hemoglobin A1c will help to determine how well this
patient has complied with dosage of insulin and diet

C A glucose tolerance test will demonstrate glucose intolerance by a

failure of blood glucose to return to the normal range in 2 hours

D If he is not taking his insulin, then his fasting blood glucose is likely
to be greater than 140 mg/dl

E An overdose of insulin by injection can be detected by an increase in

the serum C-peptide

(E) CORRECT. When insulin is released from the islets of Langerhans, then
C-peptide is also produced, but when insulin is injected, no C-peptide is
produced.
Questions 43 and 44: Click on the checkbox first, then the lettered item:

(43) A 45-year-old female with a left lower lobe pulmonary infarction.

(44) Seen in the kidney of a 57-year-old male with hypertension.

A Hyaline arteriolosclerosis

B Monckeberg's medial calcific sclerosis

C Complex calcified coronary atherosclerosis

D Arterial mural thrombosis

E Thromboembolus

(E) Match on 43 (E) A pulmonary infarction is due to a thromboembolus

that arose in a vein (usually legs or pelvic region) and travelled to the lungs.

(A) Match with 44 (A) This is the type of vascular change that is typical
with hypertension and/or diabetes mellitus.

(D) No match. An arterial mural thrombus can become an embolus in the

systemic arterial circulation and produce an infarct (but not in lung, which is
supplied by the pulmonary circulation).
Questions 45 and 46: Click on the checkbox first, then the lettered item:

(45) Infant of a diabetic mother just after delivery.

(46) A 70-year-old woman with type II diabetes mellitus is found

comatose. She had not been eating or drinking much for days.

A Decreased hemoglobin A1C

B Markedly increased serum osmolality

C Inflammation of islets of Langerhans

D Blood glucose of 20 mg/dl

E Ketoacidosis

(D) Match on 45 . Infants of diabetic mothers are at risk for hypoglycemia

following delivery, because they have islet hypertrophy and hyperplasia.

(B) Match with 46. She has hyperosmolar coma with a markedly elevated
serum glucose.

(C) No match. An 'islitis' that precedes type I diabetes probably occurs in

children and is hardly ever observed, because the diabetes is treated.

(E) No match. Ketoacidosis is typical for type I diabetes in which there is an

absolute insulin lack.
Questions 47 and 48: Click on the checkbox first, then the lettered item:

(47) Transports exogenous (dietary) triglyceride from the intestine.

(48) Enhances formation of fatty streaks in the aorta.

A Apoprotein (apolipoprotein)

B Chylomicron

C Lipoprotein lipase

D Oxidized low density lipoprotein

E High density lipoprotein

(B) Match on 47. Chylomicrons formed in intestinal epithelial cells contain

apoproteins, triglyceride and cholesterol.

(D) Match with 48. Such LDL is injurious to endothelium and is more
avidly taken up by macrophages and smooth muscle, thus promoting
atherogenesis in vessels.

(E) No match. HDL is 'good' because it transports cholesterol back to the

liver.

(A) No match. There are a number of apoproteins involved in transport of

lipids in the blood.
Questions 49 and 50: Click on the checkbox first, then the lettered item:

(49) These cells do not require insulin for glucose uptake.

(50) These cells transform very low density lipoproteins (VLDL) into
low density lipoproteins (LDL).

A Cardiac muscle cells

B Fibroblasts

C Steatocytes

D Neurons

E Smooth muscle cells.

(D) Match on 49. Neurons do not require insulin for glucose uptake.

(C) Match with 50. Fat cells require insulin for glucose uptake. Steatocytes
also are part of the endogenous pathway of lipoprotein transport and convert
VLDL to LDL.
Question 51

During hospitalization, a 40 year old female 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 Acute inflammation

B Rupture

C Embolization

D Organization

E Propagation

(D) CORRECT. Thrombi will organize over time, with much of the clot
eventually removed and the vascular lumen restored.

Thrombophlebitis is a phlebitis (inflammation of a vein) related to a

thrombus (blood clot). When it occurs repeatedly in different locations, it is
known asthrombophlebitis migrans, (migratingthrombophlebitis)

What is the cause of thrombophlebitis?

A blood clot causes thrombophlebitis. Inactivity, such as
being bedridden after trauma or surgery, is a major cause of blood clots.
You can also develop a blood clot if you sit still for too long, such as during a
plane ride or a car ride
Question 52

A 52 year old male has an ulcerated area on the sole of his foot that has not
healed for several months. He is overweight and continues 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 Antithrombin III

B Cortisol

C Creatine kinase

D Glucose

E Carcinoembryonic antigen

(D) CORRECT. The history suggests diabetes mellitus, most likely type II,
and persistent hyperglycemia would confirm the diagnosis.
WEB PATH – AKL

INFLAMATORY RESP – 1/2

Question 1

The right lower quadrant abdominal pain associated with acute

inflammation in acute appendicitis is predominantly the result of the
formation of which two mediators:

A Complement C3b and IgG

B Interleukin-1 and tumor necrosis factor

C Histamine and serotonin

D Prostaglandin and bradykinin

E Leukotriene and HPETE

(D) CORRECT. Aspirin, by inhibiting the cyclooxygenase pathway, can

decrease prostaglandin synthesis.
Question 2

Which of the following cell types would be most characteristic of the

inflammatory response accompanying a leaking silicone breast implant:

A Mast cell

B Eosinophil

C Giant cell

D Neutrophil

E Plasma cell

Question 3

The most critical factor in determining whether the skin will regenerate
following a burn injury is the presence of:

A Good cardiac output

B Skin appendages

C Underlying connective tissue

D Minimal edema and erythema

E Granulation tissue
Question 4

The destruction of Streptococcus pneumoniae organisms would be most

effectively accomplished through generation of which of the following
substances by polymorphonuclear leukocytes:

A Platelet activating factor

B Prostaglandins

C Kallikrein

D Leukotriene

E Hydrogen peroxide

Question 5

The clinical course of a patient with fever and chills of 3 days' duration
along with a pharyngitis and accompanying pharyngeal purulent exudate is
most typical for:

A Granulomatous inflammation

B Acute inflammation

C Abscess formation

D Resolution of inflammation

E Chronic inflammation

Question 6

The collagen deposition that accompanies silicosis in a 56 year old male

with multiple pulmonary nodules on chest radiograph is a function of:

A Neutrophilic infiltration with release of leukotrienes

B Foreign body giant cell formation

C Plasma cell production of immunoglobulin

D Histamine release by mast cells

E Release of growth factors by macrophages

Question 7

Premature labor in a 20-year-old female with acute chorioamnionitis is

mediated most by the effects from which of the following:

A Immunoglobulin

B Prostaglandin

C Complement

D Fibrinogen

E Lymphokines

Question 8

Any of the following may be either an etiology or an outcome of venous

thrombosis of the lower extremities EXCEPT:

A Sudden death

B A protein C or S deficiency

C Thrombocytopenia

D A femoral intravenous catheter

E Resolution without sequelae

Question 9

The most important cell in the development of a granuloma is a:

A Macrophage

B Fibroblast

C Neutrophil

D Mast cell

E Platelet

Question 10

Of the following chemical mediators, which plays the greatest role in

chemotaxis of neutrophils:

A Histamine

B Prostaglandin

C Hageman factor

D Bradykinin

E Complement C5a

Question 11

Which of the following contributes LEAST to fluid exudation from the

intravascular compartment with acute inflammation:

A Endothelial cell contraction

B Increased capillary hydrostatic pressure

C Arteriolar dilation

D Histamine release

E Increased capillary colloid osmotic pressure

Question 12

Neutrophils form part of an alveolar exudate in an acute bronchopneumonia

as a result of the actions of all of the following factors EXCEPT:

A Complement C5a

B Bradykinin

C Soluble bacterial products

D Tumor necrosis factor

E Leukotriene B4

Question 13

Acetylsalicylic acid (aspirin) has its greatest effect in diminishing the acute
inflammatory process of:

A Neutrophil chemotaxis by leukotriene B4

B Fever resulting from interleukin-1 release

C Prostaglandin-mediated vasodilation

D Pain resulting from bradykinin generation

E Anticoagulation by Hageman factor inhibition

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Question 14

The mononuclear phagocyte system includes all of the following cells

EXCEPT:

A Kupffer cells in liver

B Tissue macrophages

C Lymph node sinus histiocytes

D Thymic epithelial cells

E Alveolar type II pneumonocytes

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Question 15

Transformation of tissue macrophages to epithelioid cells is most likely to

occur as an inflammatory response to:

A Mycobacterium leprae

B Pseudomonas aeruginosa

C Cytomegalovirus

D Giardia lamblia

E Antigen-antibody complexes

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Question 16

A lesion which appears mainly as a loss of an epithelial surface in a

localized area is most typical for which of the following pathologic
processes:

A Abscess

B Serositis

C Granuloma

D Gangrene

E Ulcer

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Question 17

Following blunt force abdominal trauma to the driver of a 1992 GMC

Syclone GT pickup truck, the body's response to injury may result in any of
the following cells entering the G1 cell cycle from the G0 phase EXCEPT:

A Smooth muscle

B Endothelium

C Skeletal muscle

D Fibroblast

E Hepatocyte

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Question 18

Which of the following findings results from the action of a product of the
cyclooxygenase pathway:

A Leukotriene-induced neutrophil aggregation

B Complement-induced hemolysis

C Histamine-induced laryngeal edema

D Endotoxin-induced disseminated intravascular coagulation

E Prostaglandin-mediated abortion

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Question 19
The appearance of fibrin with numerous neutrophils on the pericardial
surface is most characteristic for:

A Bacterial infection

B Systemic lupus erythematosus

C Metastatic carcinoma

D Acute myocardial infarction

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Question 20

A 55 year old male has had a history of coronary artery disease and has
suffered a myocardial infarction in the past. He now presentw with crushing
substernal chest pain. Which of the following laboratory tests is most
specific for diagnosis of an acute myocardial infarction:

A Increased white blood cell count

B Elevated sedimentation rate

C Decreased serum complement

D Increased serum creatinine kinase

E Decreased platelet count

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Question 21

The appearance of red, swollen nasal mucosa from allergy to ragweed

pollen has been mediated by:

A Complement C3b

B Platelet activating factor (PAF)

C Tumor necrosis factor (TNF)

D Histamine

E Immunoglobulin G

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Question 22

Blocking of the cyclooxygenase pathway by aspirin would best help acutely

to alleviate:

A Thrombosis

B Pain

C Liquefactive necrosis

D Fibrinolysis

E Scar formation
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Question 23

Which of the following persons has the LEAST risk for thrombosis:

A A 30-year-old male with antithrombin III deficiency

B A 60-year-old female in hospital following hip fracture

C A 40-year-old female taking oral contraceptives

D A 70-year-old male with a large, dilated left atrium

E A 50-year-old male with iron deficiency anemia

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Question 24

Inflammation with fibrinous exudate is more serious than serous

inflammation because:

A Complete resolution cannot occur when fibrin is present.

B Organization with scar tissue formation is more likely to occur.

C Infectious agents are probably present.

D Fluid collections alone are never a serious complication.

E An underlying autoimmune disease is probably present.

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Question 25

Opsonins that aid in recognition and attachment of leukocytes to bacteria

include all of the following features EXCEPT:

A They may be derived from the C3b fragment of serum complement.

B The leukocytes have an Fc receptor.

C Binding of opsonins triggers engulfment.

D Leukocyte adhesion molecules are needed.

E Immunoglobulin G plays a role.

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Question 26

Which statement regarding macrophages is INCORRECT:

A Macrophages survive much longer than neutrophils.

B Kupffer cells in the liver can function like macrophages.

C Cytokines may be elaborated by macrophages.

D Growth factors may be released by macrophages.

E Macrophages are derived from T-lymphocytes.

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Question 27

Lymphatics perform all of the following functions EXCEPT:

A Carry lymphocytes from lymph nodes into tissues

B Drain off excess tissue fluid

C Aid in resolution of inflammation

D Serve as a route for dissemination of infection

E Connect to lymph nodes

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Question 28

Angiogenesis is most important in:

A Granuloma formation with Mycobacterium tuberculosis infection

B Abscess formation with Staphylococcus aureus infection

C Chronic active viral hepatitis with Hepatitis B virus

D Healing of acute myocardial infarction

E Ulceration of the gastric mucosal epithelium

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Chronic active viral hepatitis characterized by SINGLE CELL or

PIECEMAL NECROSIS … Without extensive granulation tissue formation.

Ulcer has acute and chronic inflammation as it forms. Granulation tissue

would become more prominent with healing of the ulcer.

Question 29

A pleural effusion is tapped in a 55-year-old male. Upon examination of the

fluid obtained, which of the following is most characteristic of a transudate:

A Cloudy appearance
B High protein content

C A few lymphocytes

D The presence of fibrin

E Larger size of the effusion

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Question 30

Of the following substances, the one that functions intracellularly in cells

involved in wound healing is:

A Fibronectin

B Laminin

C Tyrosine kinase
D Hyaluronic acid

E Collagen

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Question 31

Following laparotomy with a midline abdominal incision, nearly all of the

tensile strength to be obtained in wound healing in skin is achieved within:

A One week

B One month

C Three months

D Six months

E One year
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Question 32

Which of the following substances, on contact with injured vascular

basement membrane, activates both the coagulation sequence and the kinin
system:

A Thromboxane

B Plasmin

C Platelet activating factor

D Hageman factor

E Histamine

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Question 33

Fish oil may have a beneficial effect in the diet from inhibition of the
deleterious effects of platelet aggregation through:

A Decreased formation of arachidonic acid metabolites

B Inhibition of complement activation by the alternative pathway

C Decreased cytokine production

D Inhibition of histamine release by mast cells

E Diminished production of platelet activating factor by leukocytes

Question 34

Wound healing will be delayed the least by:

A Infection

B Poor tissue perfusion

C Sutures

D Corticosteroids

E Hypoalbuminemia

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Question 35

A 24 year old primagravida has some cramping pain followed by passage of

some fluid along with a foul-smelling discharge late in the second trimester
of pregnancy. The fetus is stillborn several days later. Examination of the
placenta demonstrates extensive neutrophilic infiltrates in the fetal
membranes. Which of the following organisms is most likely to be
responsible for these findings:

A Mycobacterium tuberculosis

B Herpes simplex virus

C Escherichia coli

D Treponema pallidum

E Toxoplasma gondii

(C) CORRECT. This is an acute chorioamnionitis, and bacterial infections

that precede or follow premature rupture of membranes are most often to
blame.

Question 36

Which of the following is a direct consequence of macrophage activation:

A Release of tumor necrosis factor and interleukin-1

B Secretion of gamma interferon to activate T-lymphocytes

C Release of Hageman factor to activate the kinin system

D Aggregation of macrophages into the center of an abscess

E A decrease in macrophage cell size

(B) Incorrect. It is the other way around. Gamma interferon from T-cells
activates macrophages.
(D) Incorrect. The center of an abscess typically contains neutrophils.
Macrophages help organize and heal the abscess from the periphery.
Question 37

Which of the following cells would be LEAST typical of the inflammatory

response forming a granuloma with Cryptococcus neoformans infection of
the lung:

A Fibroblast

B Eosinophil

C Macrophage

D Plasma cell

E Lymphocyte

(B) CORRECT. Eosinophils are more typical for allergic and parasitic
inflammatory responses.

Question 38

Upon arrival at Sydney's Kingsford Smith airport following the flight from
Los Angeles, a 52-year-old passenger cannot put her shoes on. This is
because:

A Activation of Hageman factor has led to bradykinin production.

B A lot of drinks were served in the first class section.

C She didn't take any aspirin.

D A cellulitis developed in her legs.

E Venous hydrostatic pressure was increased.

E) CORRECT. The longest non-stop flight in the world has its drawbacks.
Extracellular fluid builds up when hydrostatic pressure is increased over a
long time.

Question 39

Which statement is INCORRECT:

A A subcutaneous furuncle is filled with neutrophils, and

Staphylococcus aureus is cultured

B A gastric ulcer results when surface epithelial excavation follows

sloughing of inflammatory necrotic tissue

C Leukocytosis results initially from accelerated bone marrow release

of cells under the influence of cytokines

D Serous inflammation is marked by fluid collection with a high protein

and cell content

E Fibrinous inflammation may resolve with scarring from ingrowth of

fibroblasts

(D) CORRECT. Serous inflammation is accompanied by fluid with little

protein or cells.
(A) Incorrect. This is a localized collection of pus -- an abscess.
(C) Incorrect. Such a leukocytosis can be accompanied by release of bands -
- a so called 'left shift'

Question 40

The rebound tenderness in the right lower quadrant of the abdomen in a 20-
year-old woman on physical examination suggests:

A Generation of bradykinin with acute inflammation

B Gamma interferon release by T-lymphocytes

C Histamine release by mast cells in an allergic reaction

D Macrophage activation with chronic inflammation

E Complement activation by the alternate pathway

(A) CORRECT. One of the mediators of pain with an acute inflammatory

reaction is bradykinin.
WEB PATH – AKL

INFLAMATORY RESP – 2/2

Question 41

Which of the following patients is most likely to develop anasarca:

A A 25-year-old woman in the first trimester of pregnancy

B A 20-year-old male who suffers head trauma in a football game

C A 48-year-old male with thrombophlebitis of the legs

D A 62-year-old male with severe congestive heart failure

E A 43-year-old woman following right radical mastectomy

(D) CORRECT. The heart failure would be most likely to result in anasarca
-- edema of the entire body.

What is the cause of Anasarca?

It is usually caused by liver failure (cirrhosis of the liver), renal
failure/disease, right-sided heart failure, as well as severe
malnutrition/protein deficiency. The increase in salt and water retention
caused by low cardiac output can also result in anasarca as a long
term maladaptive response.
Question 41

Which of the following patients is most likely to develop anasarca:

A A 25-year-old woman in the first trimester of pregnancy

B A 20-year-old male who suffers head trauma in a football game

C A 48-year-old male with thrombophlebitis of the legs

D A 62-year-old male with severe congestive heart failure

E A 43-year-old woman following right radical mastectomy

Question 42

A neutrophilic exudate is present at the site of an infection. Which of the

following sets of organisms and mediators was most likely present to
produce this exudate:

A M. tuberculosis, interleukin-1
B Hemophilus influenzae, complement C5a

C Aspergillus fumigatus, prostaglandin

D Cytomegalovirus, tumor necrosis factor

E Steptococcus pyogenes, Hageman factor

(B) CORRECT. Neutrophilic exudates are typical for bacterial infections,

and C5a is a neutrophilic chemotactic factor.

Question 43

Which of the following pathologic findings is LEAST likely to occur as a

result of cytokine release from macrophages:

A Silicotic nodules in the lung

B Lupus nephritis

C Splenic miliary granulomas

D Heart transplant rejection

E Hypertrophic scar

(B) CORRECT. Lupus nephritis is primarily a result of immune complex

deposition and complement activation.

(A) Incorrect. Ingestion of silica by macrophages results in activation with

cytokine release, including fibroblast growth factor and interleukin.

(C) Incorrect. Granuloma formation with type IV hypersensitivity results

from macrophage participation.

(D) Incorrect. One type of rejection employs a type IV hypersensitivity

reaction in which macrophages play a role.
 (E) Incorrect. Macrophages participate in wound healing, including
elaboration of cytokines that promote collagenization.

Question 44

The appearance of granulomas with Langhans giant cells in the lung from a
54 year old male with fever, night sweats, weight loss, and cough for several
months suggests that infection with which of the following is the probable
diagnosis:

A Influenza A virus

B Mycobacterium tuberculosis

C Streptococcus pneumoniae

D Cytomegalovirus

E Pneumocystis carinii

(B) CORRECT. Tuberculosis produces a granulomatous inflammatory

reaction.
(A) Incorrect. Influenza A, as well as many other viral infections, produce
lymphocytic interstitial infiltrates in the lung.

(C) Incorrect. Bacterial pneumonias have patchy areas of consolidation with

neutrophilic infiltrates. The time course is usually over a period of days.

(D) Incorrect. CMV pneumonias are seen in immunocompromised patients

and produce interstitial inflammation.

(E) Incorrect. Pneumocystis pneumonia appears in immunocompromised

patients and the foamy alveolar exudates produce extensive consolidation.
Question 45

An embolus to the middle cerebral artery of a 69 year old female results in a

large recent infarction of a portion of the left cerebral hemisphere and is
unable to move the right side of her body. In order to reduce the ischemia
and prevent additional loss of neurologic function, a protocol is instituted
that utilizes:

A Aspirin to decrease platelet aggregation

B Interleukin-1 to increase macrophage function

C Fibroblast growth factor to increase angiogenesis

D Nitric oxide to increase vasodilation

E Fibrinogen to promote coagulation

(D) CORRECT. There is evidence that nitric oxide can decrease ischemic
damage by promoting vasodilation.
(A) Incorrect. The thrombus has already occurred. The effects of aspirin on
platelets have usefulness in patients with recurrent myocardial infarction to
help prevent coronary thrombosis.

(B) Incorrect. Macrophages will be useful mainly in the resolution of the

infarct.
Question 46

For about a day, a 20 year old male has noted increasing abdominal pain.
Physical examination reveals that this pain is mainly in the right lower
quadrant, and there is rebound tenderness. Which of the following is the best
laboratory finding to help you make a decision regarding further
management of this patient:

A Total serum complement level

B Sedimentation rate

C WBC count with differential

D TB skin test

E Creatine phosphokinase (CK)

(C) CORRECT. The findings suggest acute appendicitis, and an elevted

WBC count with a left shift will be most supportive of this diagnosis.

(D) Incorrect. His findings do not suggest granulomatous disease with

tuberculosis, which most often involves the lung.
(A) Incorrect. Measuring complement levels is most useful for chronic
immunologic diseases such as systemic lupus erythematosus
Question 47

Thoracentesis with removal of 1 liter of clear yellow fluid from the left
pleural cavity is most indicative of:

A An effusion that is a transudate in a patient with congestive heart

failure

B A serosanguineous effusion in a patient with pulmonary tuberculosis

C A purulent exudate in a patient with Staphylococcus aureus

pneumonia

D A fibrinous exudate in a patient with vasculitis

E Remote hemothorax with trauma

(A) CORRECT. The clear fluid suggests there are few cells and little
protein, typical of a transudate.

(B) Incorrect. A serosanguineous effusion has blood in it and is pink to red

in color.

(C) Incorrect. Purulent exudates are cloudy and yellow.

(D) Incorrect. Fibrinous exudates create precipitates of shaggy fibrin, and

the fluid is usually cloudy because of the increased protein.

(E) Incorrect. Hemothorax refers to blood in the pleural cavity.

Question 48

A fetus is 39 weeks (term gestation) and the mother notes the absence of
fetal movement for a day. Ultrasound confirms fetal demise. The baby is
stillborn. The placenta is examined and shows only mild acute
chorioamnionitis. Culture reveals group B streptococcus. Which of the
following factors, inhibited by the streptococcal organisms, is most
important in promoting chemotaxis to elicit an inflammatory response:

A Bradykinin

B Hageman factor

C Complement C5a

D Thromboxane

E Gamma interferon

(C) CORRECT. There should be a pronounced neutrophilic response with a

bacterial infection, with C5a as the major chemotactic agent for neutrophils,
but Group B strep inhibits this.

Question 49

Wound healing is characterized by all of the following statements EXCEPT:

A Corticosteroids impede wound healing

B Previous scar tissue does not heal well when reinjured

C Elastic fibers are not usually regenerated with wound healing

D Re-epithelialization of a surgical wound generally occurs within a

week

E Hypertrophic scars ("keloids") are the typical result of primary union

(E) CORRECT. Hypertrophic scars are abnormal and disfiguring. The

purpose of primary union is to produce as small a scar as possible.
Question 50

While turning in your exam papers, you suffer a small paper cut to the distal
right index finger. The bleeding stops in a few minutes primarily because of:

A Plasminogen activation by tissue factors

B Neutrophil margination, adherence, and emigration

C Arteriolar vasoconstriction

D Organization of a thrombus

E Platelet adherence, release, and aggregation

(E) CORRECT. Platelets are mainly responsible for hemostasis in small

vessels, which is the principle behind the laboratory test known as the
'bleeding time'.

Question 51

A previously healthly 47 year old woman dies suddenly after an illness

lasting only a couple of days. The high power microscopic section from lung
demonstrates extensive neutrophilic alveolar exudates. What is the most
likely etiology for this disease:

A Influenza A virus

B Mycobacterium tuberculosis

C Streptococcus pneumoniae

D Cytomegalovirus

E Pneumocystis carinii
 (C) CORRECT. Bacterial infections of the lung are known to produce
exudates containing PMN's. Pneumococcus is a very common etiology for
pneumonia.

(E) Incorrect. PCP is seen in immunocompromised patients and produces a

relatively acellular foamy alveolar exudate.

Question 52

A 45 year old male has had gradual enlargement of the right parotid gland
for several months. A calculus (stone) is found in the salivary gland duct.
The best diagnosis, based upon the appearance of extensive mononuclear
cell infiltrates in the gland, is:

A Gummatous necrosis

B Cryptococcus neoformans infection

C Chronic sialadenitis

D Acute infarction with coagulative necrosis

E Gangrene

(C) CORRECT. The chronic obstruction has led to inflammation. Mostly

round cells (lymphocytes) are present, so this is chronic inflammation of the
salivary gland.

Chronic sclerosing sialadenitis is a chronic inflammatory condition affecting

the salivary gland. Relatively rare in occurrence, this condition is benign, but
presents as hard, indurated and enlarged masses that are clinically
indistinguishable from salivary gland neoplasms or tumors.
Question 53

Vasodilation mediated by which of the following compounds would be

useful to prevent additional ischemic tissue damage:

A Thromboxane

B Complement C3b

C Nitric oxide

D Tumor necrosis factor

E Phospholipase

(C) CORRECT. Endothelial cells contain nitric oxide synthetase which can
be used to generate nitric oxide and produce vasodilation.

Question 54

Your 50 year old patient has difficulty breathing and physical examination
reveals decreased, distant breath sounds on the left. A chest radiograph
demonstrates a marked fluid collection in the left pleural cavity. A
thoracentesis reveals that the fluid is serosanguinous Which of the following
etiologies is most likely to accompany these findings:

A Viral pneumonia

B Lung carcinoma

C Congestive heart failure

D Hypoalbuminemia

E Chronic renal failure

(B) CORRECT. Local hemorrhagic exudates may suggest a neoplasm has

spread to a body cavity. Neoplasms tend to infiltrate, with necrosis and
hemorrhage.
(C) Incorrect. CHF tends to produce transudates.

(D) Incorrect. The decreased intravascular oncotic pressure with decreased

serum albumin tends to produce transudates.

(E) Incorrect. Chronic renal failure tends to produce edema and transudates.

Serosanguineous means containing or relating to both blood and the liquid

part of blood (serum). It usually refers to fluids collected from or leaving the
body. For example, fluid leaving a wound that is serosanguineous is yellowish
with small amounts of blood

Clear Drainage: serous drainage is clear and may be slightly yellow or

colorless in appearance. ... Serous exudate, or discharge, is normal from a
wound in the early stages of healing, typically in the first 48 to 72 hours after
the incision is

Question 55

Platelets:

A Release ADP and calcium to promote platelet aggregation and

coagulation

B Are normally found in an inactive state attached to intact endothelium

C Help to form arterial thrombi, but not venous thrombi

D Generate prostacyclin to promote vasodilation

E Are measured functionally by the protime and partial thromboplastin

time

(A) CORRECT. The granules release products that promote platelet

attraction, release, and aggregation, as well as promote the coagulation
mechanism
Question 56

A red blood cell becomes irreversibly injured and ceases to function when:

A It no longer has a nucleus

B It travels through an atherosclerotic artery

C Complement C5-9 attaches to the cell membrane

D Oxidative metabolism is no longer possible

E Hyperglycemia is present

(C) CORRECT. This is the Òmembrane attack complexÓ and leads to cell
lysis when attached to the RBC. This is the mechanism for immune induced
hemolysis.

Questions 57 and 58: Click on the checkbox first, then the lettered item:

(57) A paracentesis yields 600 cc of clear, yellow fluid from the

peritoneal cavity.

(58) The left upper and lower lung lobes are stuck together with a
shaggy, soft pink to tan material.

A Hemorrhagic effusion

B Empyema

C Serous effusion

D Resolution of inflammation

E Fibrinous exudate

(C) Match on 57. A simple serous effusion is just fluid collection with few
cells and protein, so it is clear.
(E) Match with 58. Fibrin has this gross appearance.
(A) No match. A hemorrhagic effusion would be red in color.
Questions 59 and 60: Click on the checkbox first, then the lettered item:

(59) Enhances phagocytosis of bacteria by neutrophils.

(60) Mediator for pain of inflammation that is relieved by aspirin.

A Histamine

B Interleukin-1

C Complement C3b

D Prostaglandin

E Lysozyme

(C) Match on 59. This is an opsonin.

(D) Match with 60. Prostaglandin is a product of the cyclo-oxygenase
pathway that is blocked by aspirin.
Question 61 and 62: Click on the checkbox first, then the lettered item:

(61) A G0 cell is recruited into the G1 phase of the cell cycle.

(62) A cell remains as a permanent, non-dividing cell.

A Endothelial cell

B Cardiac muscle cell

C Jejunal columnar epithelial cell

D Testicular germ cell

E Hematopoietic stem cell

(A) Match on 61. Connective tissue cells, including endothelium, are

quiescent until stimulated during injury and repair to enter the cell cycle

(B) Match with 62. It would be nice if cardiac muscle could regenerate
following injury, but it is replaced by scar tissue.
Questions 63 and 64: Click on the checkbox first, then the lettered item:

(63) These cells are seen in large numbers in a subacute (intermediate)

ischemic infarct.

(64) These cells release histamine.

A Foreign body giant cells

B Neutrophils

C Fibroblasts

D Mast cells

E Langhans giant cells

(C) Match on 63. Fibroblasts are part of the healing process and appear with
granulation tissue formation.

(D) Match with 64. Histamine is a powerful vasodilator.

(A) No match. Foreign body giant cells are seen in places with foreign
bodies (aspirated food, sutures, implants, wood splinters, ruptured cysts,
etc).

(E) No match. Langhans giant cells are usually seen in association with
granulomatous inflammation such as with infection by Mycobacteria.
Questions 65 and 66: Click on the checkbox first, then the lettered item:

(65) A child with the onset of renal failure from nephrotic syndrome
who is feeling tired, but is still up and around, is noted to have this finding
on physical examination.

(66) This complication is seen several months following left radical

mastectomy for breast carcinoma in 57 year old female.

A Anasarca

B Ascites

C Periorbital edema

D Lymphedema

E Presacral edema

(C) Match on 65. This is the one place on a child where the skin and soft
tissue is a bit looser to allow you to see edema.

(D) Match with 66. The radical surgery disrupted the lymphatic drainage
from the left arm.

(B) No match. Ascites is a fluid collection in the peritoneal cavity.

(A) No match. Anasarca is edema involving most of the body.
Question 67

A 51 year old supermarket employee works in the check-out line. She stands
up for nearly the entire shift. She notices that her feet are slightly swollen at
the end of each day, but by morning the swelling has gone away. The most
likely cause for this phenomenon is:

A Lymphatic obstruction

B Increased hydrostatic pressure

C Decreased oncotic pressure

D Acute inflammation

E Thrombophlebitis

(B) CORRECT. Standing up creates increased hydrostatic pressure,

particularly in the lower extremities. There are valves in the veins to help
aid return of blood flow, but these work less efficiently with aging.
Decreased muscle tone and some degree of congestive heart failure don't
help either.
(A) Incorrect. Obstruction of lymphatics is most typical for neoplasms, post-
operative states, and rare chronic infectious processes.

(E) Incorrect. Persons who are mobile generally do not develop

thrombophlebitis. Thrombophlebitis develops over days.

(C) Incorrect. Hypoalbuminemia from liver disease or from proteinuria, for

example, leads to decreased oncotic pressure.

Thrombophlebitis is a phlebitis (inflammation of a vein) related to a

thrombus (blood clot). When it occurs repeatedly in different locations, it is
known asthrombophlebitis migrans, (migratingthrombophlebitis)

A blood clot causes thrombophlebitis. Inactivity, such as

being bedridden after trauma or surgery, is a major cause of blood clots.
You can also develop a blood clot if you sit still for too long, such as during a
plane ride or a car ride.
Question 68

The pain and tenderness along with the red discoloration of the skin seen in
a 29 year old male who was at the beach all day and who now is in the early
stage of sunburn is most likely to be mediated by:

A Complement C3b

B Bradykinin

C Interleukin-1

D C-reactive protein

E ICAM-1

(B) CORRECT. There is vasodilation to produce the erythema, along with

the pain, as a consequence of generation of bradykinin.

(C) Incorrect. IL-1 mediates the appearance of fever, among other functions.

(D) Incorrect. CRP is one of the 'acute phase reactants' that can be measured
in serum that non-specifically indicates the presence of an acute
inflammatory process.

(E) Incorrect. ICAM-1 is an adhesion molecule that functions in leukocyte

adherence.
Question 69

Prior to performing surgery to replace an arthritic hip joint with a prosthesis,

a 67 year old female has a test called a bleeding time performed. This test is
based upon:

A Plasminogen activation by tissue factors

B Neutrophil margination, adherence, and emigration

C Arteriolar vasoconstriction

D Organization of a thrombus

E Platelet adherence, release, and aggregation

(E) CORRECT. Hemostasis following injury to small vessels is mainly

brought about by the actions of platelets. The bleeding time measures
platelet function and may help to determine if the patient is at risk for
excessive bleeding during surgery.