Atherosclerosis Thrombosis - Part 2

(C) CORRECT. Immobilization following fracture, particularly in the elderly, is a significant risk for development of deep venous thrombosis, followed by pulmonary embolism.
(D) Incorrect. The elderly are at risk for pneumonia when in hospital, but the course is marked by signs and symptoms of an infection.
(E) Incorrect. CHF is a possibility in the elderly, but in the setting given is unlikely to be the cause of the sudden death.

(D) CORRECT. Elevations in CK enzymes are going to be seen acutely with myocardial infarction beginning within hours and remaining for days.
(A) Incorrect. An elevation in WBC count is not a specific indicator for myocardial infarction.
(B) Incorrect. Though he may have diabetes mellitus as an underlying cause for the atherosclerosis leading to myocardial infarction, serum glucose will not help to diagnose the infarction.
(C) Incorrect. Platelet counts are of no value in diagnosing infarctions, even though platelets play a role in formation of thrombi that can lead to infarction.
(E) Incorrect. Amylase is increased with pancreatitis, which is not related to cardiovascular disease.

(B) CORRECT. He has hypercholesterolemia with more of the 'bad' LDL cholesterol that can become oxidized and taken up by modified arterial wall LDL receptors. The lipid collects in macrophages and becomes a lipid lesion--the precursor to more serious atheromatous plaques.
(A) Incorrect. The accumulation of sorbitol in tissues not requiring insulin for glucose uptake is a feature of diabetes mellitus with hyperglycemia.
(C) Incorrect. Neutrophilic inflammation can be the result of infection and is unusual in arteries. It is not related to atherosclerosis.
(D) Incorrect. Mutations can result in neoplastic transformation, but atherosclerosis is not a neoplastic process.
(E) Incorrect. The process of atherogenesis proceeds slowly, without significant inflammation and activation of complement.

(C) CORRECT. She has a coagulopathy in which there is consumption of coagulation factors leading to hemorrhage. Conditions such as sepsis, severe trauma, neoplasia, and obstetric complications can set off the coagulation system in a generalized fashion, resulting in DIC.
(A) Incorrect. Hemophilia A is an X-linked disorder that almost always affect males. There is no coagulopathy. Instead, there is bleeding, typically into soft tissues such as joints.
(B) Incorrect. Von Willebrand disease is a condition in which a particular blood coagulation factor (von Willebrand factor) is reduced, and the features resemble thrombocytopenia. Other coagulation factors are not reduced.
(D) Incorrect. The antiphospholipid syndrome can have thrombosis as well as bleeding, but there is a circulating antibody present. There does not tend to be a consumptive coagulopathy.
(E) Incorrect. Severe liver disease can lead to bleeding because the liver makes many coagulation factors. However, a consumptive coagulopathy affecting even platelets is unlikely.

(D) CORRECT. The history suggests diabetes mellitus, most likely type II, and persistent hyperglycemia would confirm the diagnosis.
(B) Incorrect. Cortisol may be decreased with adrenal failure. Increased cortisol with Cushing syndrome may result in weight gain, but signs of severe peripheral atherosclerosis are lacking
(A) Incorrect. ATIII may be diminished in some cases of recurrent thrombosis.

(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.
(A) Incorrect. An insulitis is typical for type I diabetes mellitus; there is no increased risk for neoplasia.
(B) Incorrect. The insulitis involves just the endocrine portion of the pancreas, not the exocrine portion, so there is no loss of pancreatic enzymes for digestion.
(D) Incorrect. Obesity is typically associated with type II diabetes mellitus; with type I diabetes mellitus, there is a catabolic state with weight loss.
(E) Incorrect. The lymphocytes in the islets are part of an autoimmune phenomenon, not an infectious process.

(B) CORRECT. Chylomicrons formed in intestinal epithelial cells contain apoproteins, triglyceride and cholesterol.
(A) Incorrect. There are a number of apoproteins involved in transport of lipids in the blood.
(C) Incorrect. Lipoprotein lipase in endothelium hydrolyzes chylomicrons, liberating fatty acids for use by fat and muscle. The cholesterol-rich chylomicron remnants go to the liver.
(D) Incorrect. Such LDL is injurious to endothelium and is more avidly taken up by macrophages and smooth muscle, thus promoting atherogenesis in vessels.
(E) Incorrect. HDL is 'good' because it transports cholesterol back to the liver.

(D) CORRECT. She has renal artery stenosis that is reducing renal blood flow on the right and simulating the JG cells to secrete renin to try and raise blood pressure to increase renal blood flow.
(A) Incorrect. Marked dehydration or free water loss could lead to this degree of hypernatremia. Many persons with essential hypertension may have increased retention of sodium, but it is not marked by significant hypernatremia.
(B) Incorrect. Anti-cardiolipin antibody is seen with the antiphospholipid syndrome, which is a cause for thrombosis. It is unlikely that the selective renal artery occlusion represents a hypercoagulable state.
(C) Incorrect. An elevated prothrombin time predisposes to bleeding.
(E) Incorrect. The decreased perfusion of the right kidney occurs over a long period of time, without a significant rise in lactate that would accompany more global hypoperfusion.

(A) CORRECT. Hyperplastic arteriolosclerosis is seen in the setting of malignant hypertension, and renal failure is common.
(B) Incorrect. These are complications typically seen in association with diabetes mellitus.
(C) Incorrect. This is a histologic curiosity with no major clinical importance.
(D) Incorrect. Hypertension is a risk for coronary artery disease, but malignant hypertension is not specifically linked to coronary thrombosis.
(E) Incorrect. Venous thrombosis is most often a result of stasis from immobilization.

(D) CORRECT. An elevated plasma homocysteine is a risk for atherosclerosis as well as thrombosis. Her findings point to an abdominal aortic aneurysm which ruptured. Such aneurysms are invariably the result of atherosclerosis.
(A) Incorrect. The factor V Leiden mutation is a risk for a hypercoagulable state with venous thrombosis, typically manifested at a young age.
(B) Incorrect. Factor VIII deficiency is one cause for hemophilia with risk for bleeding into soft tissues, manifested early in life.
(C) Incorrect. An increased CEA can be seen with some malignancies, such as adenocarcinoma of the colon. In this case, the mass is an aortic aneurysm caused by atherosclerosis.

(E) CORRECT. A pulmonary infarction is due to a thromboembolus that arose in a vein (usually legs or pelvic region) and travelled to the lungs. Immobilization with vascular stasis predisposes to phlebothrombosis to form thrombi that can then dislodge and become thromboemboli.
(D) Incorrect. 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).
(C) Incorrect. This would lead to ischemia and/or infarction of the myocardium.
(A) Incorrect. This is the type of vascular change that is typical with hypertension and/or diabetes mellitus.
(B) Incorrect. Monckeberg sclerosis is not generally associated with any complications

(A) CORRECT. Hyaline arteriolosclerosis is a feature of long-standing hypertension and is part of benign nephrosclerosis which may go on for many years with no complications. The small arterioles are thickened.
(E) Incorrect. Hyperplastic arteriolosclerosis is usually seen in the kidneys when there is severe hypertension.
(C) Incorrect. Coronary artery disease is caused by atherosclerosis that can be accelerated by hypertension. Atheromatous plaques occur in medium to large sized arteries and can be complicated by calcification of the plaques.
(D) Incorrect. Mural thrombosis typically occurs in the aorta and its branches when there is severe atherosclerosis.
(B) Incorrect. Medial calcific sclerosis is a form of arteriolosclerosis without significant complications. The vascular lumen is not significantly compromised by the medial calcification.

(E) CORRECT. Thromboxane is released by platelets to promote formation of a stable 'secondary plug' to achieve hemostasis.
(A) Incorrect. Leukotrienes are generated by the lipo-oxygenase pathway of arachidonic acid metabolism and can cause some vasoconstriction.
(B) Incorrect. Prostaglandins promote vasodilation.
(C) Incorrect. Prostacyclin release causes vasodilation and inhibits platelet aggregation, the opposite of what is needed for hemostasis.
(D) Incorrect. Activation of plasminogen leads to clot lysis.

(D) CORRECT. The platelets are responsible for dealing with small leaks in vessels. Thrombocytopenia is marked by petechiae and purpura. She does not have evidence for peripheral vascular disease, since her circulation is good. Venous thrombosis should lead to swelling and tenderness.
(E) Incorrect. She has no evidence for liver disease, which would reduce prothrombin production. The pattern of her bleeding fits best with lack of platelets, not coagulation factors.
(A) Incorrect. Diabetes mellitus is a disease marked by hyperglycemia that leads to early and advanced atherosclerosis with peripheral vascular disease.
(C) Incorrect. Poor tissue perfusion leads to increased anaerobic glycolysis and lactic acidosis.
(B) Incorrect. Patients with hypercholesterolemia are at increased risk for accelerated atherosclerosis and peripheral vascular disease.

(D) CORRECT. Thrombi will organize over time, with much of the clot eventually removed and the vascular lumen restored.
(A) Incorrect. Some inflammation, possibly acute, may have been present at the time of the original episode of thrombophlebitis.
(B) Incorrect. Thrombophlebitis is a process best known for thrombus formation, and rupture of a vein wall would be an extreme rarity.
(C) Incorrect. After she is mobile again and months pass, any thrombus capable of embolizing is long gone.
(E) Incorrect. Propagation of a thrombus is most likely to occur at the time it originally forms, or soon thereafter.

(E) CORRECT. He has findings associated with atherosclerosis, including coronary and aortic disease at least, with congestive heart failure and evidence for an aortic aneurysm. Diabetes mellitus causes advanced atherosclerosis. There is a genetic component, with a family history often present, particularly for type II diabetes mellitus.
(A) Incorrect. This is a cause for hypercoagulability, usually manifesting at an early age, with a risk mainly for venous thrombosis, not atherosclerosis.
(B) Incorrect. Malignancies can be associated with a hypercoagulable state with thrombosis, but not manifestations of atherosclerosis. In fact, persons with malignancies typically have a regression of atherosclerotic lesions.
(D) Incorrect. Vasculitis does not typically lead to findings in a distribution associated with atherosclerosis. Some forms of vasculitis favor thrombosis, others occlusion.

(A) CORRECT. There are circulating antibodies that bind plasma proteins with an affinity for phospholipid surfaces, and this can cause thrombosis and in women stillbirth. This syndrome is most often acquired in adulthood, either from an underlying disease or as an idiopathic condition. The two subsets of this syndrome, as defined by laboratory testing, are: lupus anticoagulant (which may or may not be seen with SLE), and anti-cardiolipin antibody.
(B) Incorrect. This is the most common inherited form of hypercoagulability. The mutation, which leads to activated protein C resistance, is present in 5% of Caucasians but is rare in persons of African and Asian ancestry. Heterozygotes have a mild risk for thrombosis, but the rare homozygotes have a marked risk. A point mutation leads to impaired inactivation of factor V by activated protein C. Recurrent venous thrombosis can occur, starting even in young persons, and in women stillbirth.
(C) Incorrect. Neoplastic cells may elaborate a factor, such as a thromboplastin-like substance, that can increase the risk for thrombosis. This is one form of paraneoplastic syndrome, with the name Trousseau syndrome. There can be venous (more likely) or arterial thrombosis.
(D) Incorrect. This condition is as common as factor V Leiden mutation. There may be genetic and environmental factors causing it. Oral contraceptive use increases factor VIII levels. The result is deep venous thrombosis.
(E) Incorrect. This condition is an autosomal dominant disorder and leads to recurrent venous thrombosis, even starting in young persons. Thrombosis is often spontaneous, without other precipitating events.

D) CORRECT. Neurons do not require insulin for glucose uptake. The excess glucose diffusing into the cells is shunted into the sorbitol pathway and can lead to osmotic injury, resulting in neuropathy.
(A) Incorrect. Cardiac muscle cells require insulin for glucose uptake.
(B) Incorrect. Fibroblasts require insulin for glucose uptake.
(C) Incorrect. Fat cells require insulin for glucose uptake. Steatocytes also are part of the endogenous pathway of lipoprotein transport and convert VLDL to LDL.
(E) Incorrect. Smooth muscle requires insulin for glucose

(D) CORRECT. This is peripheral arterial vascular disease from severe atherosclerosis, which is promoted by diabetes mellitus. The absence of pulses defines this as an arterial process, as does the claudication (pain with exercise). Thrombophlebitis is a venous process and leads to swelling and pain in the leg, but not loss of pulses..
(A) Incorrect. Coagulopathies with thrombosis may be due to a congenital anticoagulant factor deficiency, but thrombotic events are usually sudden.
(B) Incorrect. Septic thrombosis and mycotic aneurysms may be the result of septicemia, but this is an acute illness.
(C) Incorrect. Oxygen saturation is typically dependent more upon pulmonary function and is not related to focal events, as in the lower extremities.
(E) Incorrect. Calcium levels have little to do with vascular problems in general (except for the rare condition in persons with renal failure called calciphylaxis).

(C) CORRECT. Stroke from cerebral atherosclerosis or from embolization of mural thrombi from a heart involved with ischemic injury as a consequence of atherosclerosis....
(A) Incorrect. A variety of conditions occur with diabetes mellitus, including nodular glomerulosclerosis and pyelonephritis, can lead to renal failure.
(B) Incorrect. The neuropathy that occurs with diabetes mellitus can affect penile erection in men.
(D) Incorrect. Cataracts involving the crystalline lens of the eye are seen more frequently in diabetics.
(E) Incorrect. Blindness from diabetic retinopathy is a frequent long term complication of diabetes mellitus.

(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 hyperplastic arteriolosclerosis.
(D) Incorrect. There are no prominent vascular changes with rheumatoid arthritis.
(E) Incorrect. Cryoglobulinemic vasculitis may complicate some cases of hepatitis B or C infection. In general viral infections do not involve the vasculature.
(F) Incorrect. Diabetes mellitus leads to accelerated atherosclerosis of medium to large arteries. There may also be hyaline arteriolosclerosis, but not hyperplastic arteriolosclerosis.

(B) CORRECT. This is an extremely elevated serum glucose that would increase the serum osmolality markedly.
(A) Incorrect. An overdose of insulin would lead to hypoglycemia.
(D) Incorrect. Diabetics with ketoacidosis may have a serum glucose around 500 to 600 mg/dl, but generally not over 1000 mg/dl.

(C) CORRECT. Under conditions of poor tissue perfusion, there will be more anaerobic glycolysis and more acidosis. The blood lactate rises in this condition.
(A) Incorrect. The serum sodium may give an indication of the degree of hydration, not tissue perfusion.

(B) Incorrect. Poor perfusion leading to myocardial infarction would increase the creatine kinase.
(D) Incorrect. The hematocrit suggests the ability of the blood to carry oxygen and prevent ischemia, but does not predict whether there is poor perfusion with ischemia.
(E) Incorrect. The sed rate gives an indication of the presence of inflammation, a consequence of an ischemic event.

(B) CORRECT. The recurrent episodes suggest a hypercoagulable state, and carcinomas can do this (Trousseau syndrome).
(A) Incorrect. Liver disease leads to a coagulopathy marked by a tendency to bleeding, not thrombosis.
(D) Incorrect. Hypercholesterolemia could accelerate atherosclerosis and thrombosis, but in arteries, not veins.
(E) Incorrect. An endocarditis could lead to to embolization, but into the systemic circulation from the mitral valve.
(F) Incorrect. Diabetes mellitus increases the risk for atherosclerosis, but atherosclerosis does not involve veins.

(D) CORRECT. Infants of diabetic mothers are at risk for hypoglycemia following delivery, because they have islet hypertrophy and hyperplasia, and the increased islet production of insulin carries into the immediate postpartum period.
(A) Incorrect. The hemoglobin A1C is typically increased in diabetics with poor control.
(B) Incorrect. Monckeberg sclerosis is not generally associated with any complications.
(C) Incorrect. An 'islitis' that precedes type I diabetes probably occurs in children and is hardly ever observed, because the diabetes is treated.
(E) Incorrect. Ketoacidosis is typical for type I diabetes in which there is an absolute insulin lack.

(B) CORRECT. There is insulin production in type II diabetes mellitus, but not enough to prevent hyperglycemia, either from abnormal secretion patterns or from peripheral resistance. When dehydration occurs, the glucose can rise significantly.
(E) Incorrect. Ketoacidosis is a complication of type I diabetes mellitus, in which there is an absolute lack of insulin production.
(A) Incorrect. Persons with diabetes mellitus that is not well controlled will have an elevated Hgb A1C. This is a better long-term indicator of control than random glucose measurements.
(C) Incorrect. She is unlikely to have decreased tissue perfusion, as her blood pressure is still fairly good.
(D) Incorrect. Profound hypoglycemia is a complication of too much self-administration of insulin in a person with diabetes mellitus.