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  • 1. Pathology Practice Exam 1 – Block 5 (2013)<br />Note: remember Dr. Hill’s histology lectures will be included here!<br />1) A 30-year-old man presents because of a swelling involving the posterior distal portion of his right leg. Physical examination finds a single tumor nodule in his right Achilles tendon that is consistent with a xanthoma. Pertinent medical history is that his father died of a myocardial infarct before the age of 40. Laboratory evaluation finds a serum cholesterol of 392 mg/dL (normal < 200), a LDL cholesterol level of 333 mg/dL (normal range: 60-180), triglycerides 68 mg/dL (normal range: 40-160), and HDL-cholesterol 45 mg/dL (normal > 45). Which of the following is the most likely diagnosis?<br />A) Familial hypercholesterolemia<br />B) Abetalipoproteinemia<br />C) Dysbetalipoproteinemia<br />D) Familial chylomicronemia<br />E) Hypoalphalipoproteinemia<br />2) The disorder described in Question 1 most likely resulted from an abnormality involving the receptor for which one of the following substances?<br />A) Oxidized low-density lipoproteins<br />B) Very low-density lipoproteins<br />C) High-density lipoproteins<br />D) Apolipoprotein B48<br />E) Low-density lipoproteins<br />3) A 37-year-old obese man is diagnosed as having type II diabetes mellitus, which is due in part to insulin resistance. On physical examination, his blood pressure is 185/100 mm Hg. The most common type of secondary dyslipidemia associated with diabetes mellitus is characterized by elevated serum levels of which one of the following substances?<br />A) Triglycerides<br />B) High-density lipoproteins <br />C) Low-density lipoproteins<br />D) All of the above<br />E) None of the above<br />4) A 60-year-old man died secondary to coronary artery disease. At the time of autopsy marked atherosclerotic changes were present within his coronary arteries. Sections from these abnormal areas revealed complicated atherosclerotic plaques with calcification and hemorrhage. Within these plaques there were compact zones such as the fibrous cap, which was composed of new fibrous collagen tissue and a central core with necrotic debris, foam cells and cholesterol clefts. Which one of the following cell types is mostly responsible for the development of foam cells in the atherosclerotic plaques?<br />A) Neutrophil<br />B) T lymphocyte<br />C) B lymphocyte<br />D) Endothelial cell<br />E) Monocyte<br />5) A 51-year-old woman presents with a long history of arterial hypertension, and signs of renal failure. During the workup of her disease, a renal biopsy is performed and reveals the lumens of the small blood vessels to be narrowed by uniform, homogenous, pink deposits within the walls of the vessels. No “onionskinning” or fibrinoid necrosis of blood vessels is seen. What is the best diagnosis?<br />A) Medial calcific sclerosis<br />B) Microscopic polyangiitis<br />C) Hyperplastic arteriolosclerosis<br />D) Hyaline arteriolosclerosis<br />E) Thromboangiitis obliterans<br />6) Three years later the patient described in Question 5 died from chronic renal failure. <br />Examination of the kidneys at autopsy reveals symmetrically shrunken small kidneys, with a uniformly finely granular surface. The microscopic examination found numerous glomeruli with severe global sclerosis/hyalinosis to the degree of complete loss of architecture and total obliteration of Bowman space. Which of the following is the most likely cause of this patient’s kidney gross appearance?<br />A) Benign nephrosclerosis<br />B) Rapidly progressive glomerulonephritis<br />C) Focal segmental glomerulosclerosis<br />D) Minimal change disease<br />E) Goodpasture syndrome<br />10) A 30-year-old male smoker presents with gangrene of his extremities. Which one of the following histologic findings from a biopsy of the blood vessels supplying this area would be most consistent with a diagnosis of thromboangiitis obliterans (Buerger’s disease)?<br />A) Granulomatous inflammation with giant cells<br />B) Fibrinoid necrosis with overlying thrombosis<br />C) Focal aneurysmal dilation<br />D) Fragmentation of neutrophils<br />E) Occlusive thrombosis with microabscesses<br />11) During a routine physical examination, a 60-year-old man is found to have a 5-cm pulsatile mass in his abdomen. Angiography reveals a marked fusiform dilation of his aorta distal to the renal arteries. Which of the following is the most likely cause of this aneurysm?<br />A) Atherosclerosis<br />B) A congenital defect<br />C) Hypertension<br />D) A previous syphilitic infection<br />E) Trauma<br />12) All of the following factors play a crucial role in the pathogenesis of the aortic lesion described in Question 11 except:<br />A) Cystic medial necrosis<br />B) Presence of transmural inflammation <br />C) Degradation of the vascular wall by matrix metalloproteinases<br />D) Apoptosis of vascular smooth muscle cells<br />E) Genetic factors<br />13) Two years later the patient described in Question 11 presents to the emergency room with numbness of his left leg. Temperature and blood pressure are normal. Physical examination shows pallor and a cool left leg with absence of distal pulse An ECG reveals no abnormalities. An arteriogram demonstrates a markedly dilated abdominal aorta and occlusion of the left popliteal artery. The blockage is removed surgically, and the patient recovers. Which of the following is the most likely source of the arterial thromboembolus in this patient?<br />A) Deep venous thrombosis<br />B) Left ventricular mural thrombus<br />C) Nonbacterial endocarditis<br />D) Septic pylephlebitis<br />E) Thrombosis in an aneurysm <br />27) A 74-year-old woman presents with increasing chest pain and occasional syncopal episodes, especially with physical exertion. She has trouble breathing at night and when she lies down. Physical examination reveals a midsystolic ejection murmur with a single second heart sound (S2) because A2 is absent or soft. Pressure studies reveal that the left ventricular pressure during systole is markedly greater than the aortic pressure. Which of the following is the most likely diagnosis?<br />A) Aortic regurgitation<br />B) Aortic stenosis<br />C) Constrictive pericarditis<br />D) Mitral regurgitation<br />E) Mitral stenosis<br />28) Which of the following is the most frequent cause of the cardiac abnormality present in the patient described in Question 27?<br />A) Congenital bicuspid valve<br />B) Infective endocarditis<br />C) Latent syphilis<br />D) Degenerative senile valvular calcification <br />E) Rheumatic fever<br />29) A 45-year-old African American man undergoes renal biopsy for evaluation of chronic renal failure. The patient has a 60-pack-year history of smoking. Physical examination reveals a blood pressure of 210/130 mm Hg. A renal biopsy shows “onionskinning” of tunica intima in small arteries and arterioles and fibrinoid necrosis in arterioles and selective areas of the glomerular tuft. The Congo red stain is negative. Laboratory studies show hemoglobin of 10.2 g/dL (normal range 14-18) and serum cholesterol is 250 mg/dL (normal range < 200). BUN and serum creatinine are 42 and 5.5 mg/dL, respectively (normal range 10-20 and 0.6-1.2 respectively). Which of the following is the most likely cause of renal failure in this patient?<br />A) Amyloid nephropathy<br />B) Chronic pyelonephritis<br />C) Polyarteritis nodosa<br />D) Churg-Strauss syndrome<br />E) Malignant hypertension<br />30) A 40-year-old woman presents with an 8-month history of severe headaches, weakness, and dizziness. Blood pressure is 180/110 mm Hg. An abdominal CT scan reveals a 4-cm mass in the right adrenal gland. The results of laboratory studies include serum potassium of 2.3 mEq/L ( normal range 3.5-5), serum sodium of 155 mEq/L (normal range 136-145), plasma cortisol of 25 μg/dL at 8 AM and 20 μg/dL at 4 PM (normal range 5-23 and 3-13 respectively), and low plasma renin. These clinical and laboratory findings are consistent with which of the following?<br />A) Essential hypertension<br />B) Secondary vascular hypertension<br />C) Secondary renovascular hypertension<br />D) Secondary endocrine hypertension<br />E) Secondary renal parenchymal hypertension<br />31) A 45-year-old woman comes to your clinic with a 4-month history of pain and numbness of distal digits of her both hands with blanching, followed by bluish discoloration upon exposure to cold. She is a nonsmoker. Over the past 6 months, she has noticed progressive difficulty in swallowing solid food. Physical examination reveals smooth and tight skin over the face. The serologic test for anti-Scl-70 (antitopoisomerase) is positive. You suspect she has systemic sclerosis (scleroderma). Painful hands in this patient are best described using which of the following terms?<br />A) Raynaud phenomenon<br />B) Frostbite<br />C) Homans sign<br />D) Intermittent claudication<br />E) Trousseau syndrome<br />32) A heart murmur is noted during the preschool physical examination of a 4-year-old girl. An echocardiogram reveals a defect between the right and left atrium involving the limbus of the foramen ovale. The diagnosis is atrial septal defect. Which of the following is the most frequent atrial septal defect anatomic type?<br />A) Ostium primum defect<br />B) Ostium secundum defect<br />C) Sinus venosus defect<br />D) Coronary sinus defect<br />33) A 5-year-old boy is found to have a harsh, holosystolic murmur is loudest along the lower left sternal border. The child has a history of recurrent pneumonias and respiratory tract infections. His parents deny a history of bluish spells. An echocardiogram reveals a heart defect associated with left atrial and left ventricular hypertrophy. Cardiac catheterization discloses pulmonary hypertension. The patient likely has which of the following congenital heart diseases?<br />A) Coarctation of aorta<br />B) Truncus arteriosus<br />C) Patent ductus arteriosus<br />D) Pulmonic stenosis<br />E) Ventricular septal defect<br />34) An 8 month old girl is brought to the emergency room by her parents, who complain that their daughter is breathing rapidly and not eating. Physical examination reveals tachypnea, pallor, absent femoral pulses, and a murmur heard at the left infraclavicular area and under the left scapula. There is hypertension in the upper extremities and low blood pressure in both legs. A chest x-ray shows notching or scalloping of the ribs. What is the appropriate diagnosis?<br />A) Aortic valve stenosis<br />B) Atrial septal defect<br />C) Coarctation of aorta<br />D) Patent ductus arteriosus<br />E) Tetralogy of Fallot<br />35) A 2-week-old girl is found to have a harsh murmur along the left sternal border. The parents report that the baby gets “bluish’ when she cries or drinks from her bottle. Echocardiogram reveals a congenital heart defect associated with pulmonary stenosis, ventricular septal defect, dextroposition of the aorta, and right ventricular hypertrophy. What is the appropriate diagnosis?<br />A) Atrial septal defect<br />B) Coarctation of aorta,<br />C) Ductus arteriosus<br />D) Tetralogy of Fallot<br />E) Truncus arteriosus<br />36) A 50-year-old man with familial hypercholesterolemia undergoes resection of an abdominal aneurysm. Signs of congestive heart failure develop shortly after surgery. Despite treatment, the patient becomes hypotensive and expires 2 days later. Autopsy reveals marked narrowing of coronary arteries, without thrombosis. Multiple foci of necrosis are found around the inner walls of both ventricles, involving the territories of all three main coronary arteries. Which of the following is the most likely cause of congestive heart failure in this patient?<br />A) Calcific aortic stenosis<br />B) Dilated cardiomyopathy<br />C) Rupture of papillary muscle<br />D) Circumferential myocardial infarction<br />E) Transmural myocardial infarction<br />39) A 59-year-old woman with papillary ovarian adenocarcinoma had a central-vein catheter placed in the right subclavian vein for adjuvant chemotherapy. One day later the patient developed pain at the insertion site, high fever (39°C, 102.2°F), and chills. An abscess at insertion site was found and the catheter was removed. Blood cultures, purulent secretion, and catheter tip were positive for Staphylococcus aureus. Intravenous dicloxacillin was initiated and amikacin was added 1 day later, but fever and positive blood cultures persisted. Echo-Doppler documented thrombosis of brachiocephalic trunk and CT scan showed a thrombus reaching brachiocephalic trunk and superior vena cava. Seven days after beginning with antibiotics, the patient received an initial bolus of 250,000 international units (IU) of streptokinase administered in 1 h followed by an infusion of 40,000 IU per h for 24 h through a peripheral vein. One day after thrombolysis began fever and positive blood cultures disappeared. Full permeability of right brachiocephalic vein and superior vena cava was documented by CT scan. Which of the following is the most likely diagnosis?<br />A) Phlebothrombosis<br />B) Thrombophlebitis<br />C) Trousseau syndrome<br />D) Budd-Chiari syndrome<br />E) Pylephlebitis<br />40) A 7-year-old boy presents with the acute onset of fever, arthralgia in several joints, and a skin rash. Physical examination finds an enlarged heart, several subcutaneous nodules, and a skin rash on his back with a raised, erythematous margin. Laboratory tests find an elevated erythrocyte sedimentation rate and an elevated antistreptolysin O titer. Within the past month, this boy most likely had which one of the following abnormalities?<br />A) Anitschkow cells develop in the lungs<br />B) Aschoff bodies develop in the skin<br />C) β-hemolytic streptococcal infection of the pharynx<br />D) Streptococcus viridans infection of the aorta<br />E) Stenosis of the mitral valve<br />42) A 23-year-old woman develops the sudden onset of congestive heart failure. Her condition rapidly deteriorates and she dies in heart failure. At autopsy, patchy interstitial infiltrates composed mainly of lymphocytes are found, some of which surround individual necrotic cardiomyocytes. Which of the following is the most likely cause of this patient’s heart failure?<br />A) Autoimmune reaction (to group A β-hemolytic streptococci)<br />B) Bacterial myocarditis (due to S. aureus infection)<br />C) Pericardial tamponade (due to rapid accumulation of 500 ml of fluid)<br />D) Hypereosinophilic syndrome (with fibrous thickening of mural endocardium)<br />E) Viral myocarditis (due to coxsackievirus infection)<br />45) Autopsy investigations on a 70-year-old man with a history of peripheral vascular disease reveal an atherosclerotic plaque in the left anterior descending coronary artery, which results in 80% luminal stenosis. This atherosclerotic plaque shows a small central lipid pool, and a thick fibrous cap covered by a smooth endothelial lining without evidence of thrombosis, ulceration or hemorrhage. The remaining coronary vessels are relatively spared. Which of the following clinical syndromes would most likely have resulted from this pathologic lesion?<br />A) Chest pain awakening the patient in the early morning<br />B) Chest pain occurring with progressive frequency and severity<br />C) Chest pain precipitated by exercise and consistently relieved by rest<br />D) Progressive development of congestive heart failure without chest pain<br />E) Prolonged (more than 30 minutes) chest pain not relieved by nitroglycerin<br />46) A 22-year-old man is evaluated for mitral regurgitation due to mitral valve prolapse. Examination reveals a tall, slender young man with disproportionately long extremities. Pupillary dilatation followed by slit lamp examination reveals bilateral lens dislocation. This patient is potentially at increased risk for development of which of the following?<br />A) Progressive left ventricular congestive failure<br />B) Aortic abdominal aneurysm<br />C) Aortic dissection<br />D) Hypertrophic cardiomyopathy<br />E) Constrictive pericarditis<br />48) A 17-year-old high school student dies suddenly while playing basketball. At autopsy his heart revealed a thickened left ventricular wall, asymmetric septal hypertrophy and a small slit-like left ventricular chamber. Histologic sections from the septal myocardium reveal disarray of the myofibers, which are thicker than normal and have hyperchromatic nuclei. Which of the following statements best describes the familial form of the cardiac disease that caused the death of this individual?<br />A) An autosomal dominant disorder associated with an abnormal fibrillin gene<br />B) An autosomal dominant disorder associated with an abnormal β-myosin gene<br />C) An autosomal recessive disorder associated with decreased acid maltase formation<br />D) An X-linked recessive disorder associated with an abnormal dystrophin gene<br />E) An X linked recessive disorder associated with decreased NADPH oxidase formation<br />1) Physical examination of a 70-year-old man shows severe hypertension, an epigastric bruit and diminished amplitude of pedal pulses. Plasma renin activity is increased. Angiogram of the renal artery shows decreased uptake of dye and a small kidney on the left side and normal uptake of the dye and a normal-sized kidney on the right side. Which of the following best describes the pathogenesis of the hypertension?<br />A) Adrenal tumor that produces excess aldosterone<br />B) Adrenal tumor that produces excess catecholamines<br />C) Essential hypertension with bilateral nephrosclerosis<br />D) Unilateral renal artery stenosis caused by atherosclerosis<br />E) Unilateral renal artery stenosis caused by fibromuscular hypoplasia<br />2) A 25-year-old man has fever, fatigue, difficulty breathing and substernal chest pain while walking or at rest. The patient has a history of alcohol abuse. Physical examination shows bibasilar rales, distension of the jugular neck veins, hepatomegaly and dependent pitting edema. A chest radiograph shows generalized cardiac enlargement. Laboratory studies show an increase in cardiac specific troponins. An endomyocardial biopsy reveals a diffuse interstitial infiltrate of lymphocytes and plasma cells and scattered myocyte necrosis. Which of the following is the most likely cause of this patient’s heart disease?<br />A) Congestive cardiomyopathy<br />B) Rheumatic fever<br />C) Coronary artery thrombosis<br />D) Ischemic cardiomyopathy<br />E) Viral myocarditis<br />30) A 10-year-old girl was brought to a pediatrician because of fever, malaise and a sore throat. The pediatrician noted pharyngeal erythema and enlarged, inflamed tonsils. He swabbed her throat tested for group A hemolytic streptococci in his office, sent blood for antistreptolysin O titer and prescribed treatment. Three weeks later the patient is admitted to your hospital with fever and swelling of her elbow and ankle joints. Physical examination reveals temperature 102°F (38.8°C), pulse 110/min, a pericardial friction rub and a murmur suggestive of mitral regurgitation, erythematous rash over the distal extremities that appears as ping rings. Laboratory findings include a throat culture positive for group A β-hemolytic streptococcus, elevated antistreptolysin O titer and elevated erythrocyte sedimentation rate. You treat her for acute rheumatic fever. The patient displays all the major manifestations of acute rheumatic fever except:<br />A) Subcutaneous nodules<br />B) Sydenham chorea<br />C) Both A and B<br />D) Neither A nor B<br />31) Jones criteria for the clinical diagnosis of acute rheumatic fever require evidence of a preceding group A streptococcal infection plus two major manifestations or one major and two minor manifestations. Which of the following signs and/or laboratory findings displayed by the patient described in question (30) is considered a minor manifestation of acute rheumatic fever?<br />A) Fever<br />B) Elevated erythrocyte sedimentation ratio<br />C) Both A and B<br />D) Neither A nor B<br />32) Which of the following is not accurate regarding acute rheumatic fever-associated arthritis?<br />A) It is likely to be immunologic in origin<br />B) Subsides spontaneously leaving no residual disability<br />C) A migratory pattern is classic<br />D) Large joints are predominantly affected<br />E) It commonly predisposes the patient to septic arthritis due to group A streptococci<br />33) What is the usual latent period between the onset of strep throat and acute rheumatic fever?<br />A) 2 days<br />B) 4 days<br />C) 10 days to 6 weeks<br />D) 3 months<br />E) 1 year<br />34) When the patient described in question (30) turned 35, she began to have dyspnea on exertion, which slowly increased in severity as she reached her forties. In the months prior to her hospital admission for this and related symptoms, she had awakened at night feeling short of breath. She had one fainting spell, followed by an episode of temporary loss of vision in one eye. On admission to the hospital after that incident she was very short of breath and had coughed up some blood-tinged sputum. Physical examination and laboratory tests suggested narrowing of the mitral valve orifice. Her chest X-ray showed an enlarged left atrium and pulmonary edema. The most serious complication of acute rheumatic fever (which worsens with each recurrence) is:<br />A) Polyarthritis<br />B) Chorea<br />C) Carditis<br />D) Erythema marginatum<br />E) Subcutaneous nodules<br />35) Which of the components of Aschoff bodies is pathognomonic for the rheumatic fever?<br />A) Central focus of swollen eosinophilic collagen<br />B) Lymphocytes<br />C) Plasma cells<br />D) Anitchkow cells<br />E) Giant multinuclear Aschoff cells<br />36) Which heart valves are most commonly affected in patients with rheumatic heart disease?<br />A) Mitral and tricuspidal<br />B) Mitral and aortic<br />C) Aortic and pulmonary<br />D) Tricuspidal and pulmonary<br />E) Aortic and tricuspidal<br />38) What is the most common type of congenital heart disease in children?<br />A) Atrial septal defect<br />B) Coarctation of aorta<br />C) Ventricular septal defect<br />D) Tetralogy of Fallot<br />E) Transposition of the great arteries<br />39) An 18-year-old man was born with a membranous ventricular septal defect that was never repaired. A chest radiograph now reveals a prominent right heart border. He has increasing dyspnea along with cyanosis. His arterial oxygen saturation is now only 85% (normal 95). Which of the following mechanisms is most likely involved in the pathogenesis of these symptoms?<br />A) Natural closure of the ventricular septal defect<br />B) Infective endocarditis<br />C) Coronary atherosclerosis<br />D) Aortic regurgitation<br />E) Pulmonary hypertension<br />40) All of the following statements are correct concerning the natural history of ventricular septal defect except:<br />A) Left-to-right shunt initially increases pulmonary blood flow (volume overload).<br />B) Small pulmonary arteries respond by vasoconstriction in order to prevent pulmonary edema.<br />C) Prolonged vasoconstriction stimulates the development of obstructive vascular lesions.<br />D) Increased pulmonary vascular resistance and pressure reverses the shunt to right-to-left with increasing cyanosis.<br />E) Surgical closure of the defect is possible at any age since the pulmonary obstructive vascular changes are reversible.<br />41) A portion of the aorta 2 cm long is excised just distal to the left subclavian artery (opposite to the closed ductus arteriosus) in an 18-year-old man. There is luminal narrowing of the aorta in this specimen to 3 mm. Which of the following findings was most likely discovered during his workup prior to surgery?<br />A) Mid-systolic “click” heart murmur<br />B) Positive serologic test for syphilis<br />C) Chest radiograph showing aortic dissection<br />D) Chest radiograph showing rib notching<br />E) Hemoglobin A1C markedly elevated<br />46) A patient has a ventricular septal defect (VSD), an aorta that overrides the VSD, right ventricular outflow obstruction and right ventricular hypertrophy. The most likely diagnosis is:<br />A) Atrioventricular septal defect<br />B) Transposition of the great arteries<br />C) Truncus arteriosus<br />D) Hypoplastic left heart syndrome<br />E) Tetralogy of Fallot<br />47) All of the following are major risks for atherosclerosis except:<br />A) Cigarette smoking<br />B) Hypertension<br />C) Hyperlipidemia<br />D) Type B personality<br />E) Diabetes<br />48) A 25-year-old man presents with shaking chills and profound weakness. On physical examination his temperature is 104° F (40°C) and petechiae are noted in his sclera and gingiva. A murmur is heard in the region of the tricuspid valve. The most likely diagnosis is:<br />A) Acute rheumatic fever<br />B) Infective endocarditis<br />C) Acute pericarditis<br />D) Acute myocardial infarction with cardiogenic shock<br />E) Anaphylactic shock<br />49) What is the most likely predisposing factor of the condition described in question (48)?<br />A) Insect bite<br />B) Hypercholesterolemia<br />C) Group A streptococcal pharyngitis<br />D) Viral infection<br />E) Intravenous drug use<br />50) What laboratory procedures or imaging studies would be helpful in establishing a definitive diagnosis for our patient described in question (48)?<br />A) Antistreptolysin O titer<br />B) Blood culture<br />C) Erythrocyte sedimentation rate<br />D) Troponin level<br />E) Plasma histamine levels<br />4) In patients with rheumatic fever, Aschoff bodies are usually seen in:<br />A) Synovium<br />B) Endocardium<br />C) Myocardium<br />D) Pericradium<br />E) Subcutaneous tissue<br />13) Positive antibody against DNA topoisomerase I (anti-Scl-70) is most closely associated with:<br />A) Systemic sclerosis<br />B) Mixed connective tissue disease<br />C) Sjogren syndrome<br />D) Systemic lupus erythematosus<br />E) Wegener granulomatosis<br />24) Positive antibodies against SS-A (Ro) and SS-B (La) are most closely associated with:<br />A) Systemic sclerosis<br />B) Systemic lupus erythematosus<br />C) Sjogren syndrome<br />D) Wegener granulomatosis<br />E) Mixed connective tissue disease<br />25) Components of a typical atherosclerotic plaque include:<br />A) Smooth muscle cells<br />B) Macrophages<br />C) Necrotic lipid core<br />D) Fibrous cap<br />E) All of the above<br />42) What is the most common location for an atherosclerotic aneurysm?<br />A) Circle of Willis<br />B) Pulmonary artery<br />C) Coronary artery<br />D) Abdominal aorta<br />E) Thoracic aorta<br />44) Characteristics of a congenital bicuspid aortic valve include:<br />A) Causes calcification of the valve to occur at an earlier age<br />B) It is symptomatic from birth<br />C) Both A and B<br />D) Neither A nor B<br />45) A 40-year-old woman with systemic sclerosis develops painful fingers when exposed to cold. The fingers turn white, then blue and red. Which of the following is most likely?<br />A) Takayasu arteritis<br />B) Wegener granulomatosis<br />C) Thromboangiitis obliterans<br />D) Raynaud phenomenon<br />E) Kawasaki disease<br />7. A 44-year-old male was referred for evaluation of severe hypercholesterolemia. He had a history of coronary heart disease among paternal relatives. Patient’s medical history was unremarkable with the exception of hypercholesterolemia diagnosed at age 40 years. His lipid profile was total cholesterol 370 mg/dL (reference level <200), LDL-cholesterol 300 mg/dL (reference range: 60-180), HDL-cholesterol 32 mg/dL (reference level: >45), and triglycerides, 189 mg/dL (reference range: 40-160). Atorvastatin 40 mg/day and lifestyle modifications were started. The LDL-cholesterol was lower than 100 mg/dL in the follow-up measurements. Which of the following is the most likely diagnosis? (thrown out) <br />A) Abetalipoproteinemia<br />B) Hypoalphalipoproteinemia <br />C) Familial chylomicronemia<br />D) Familial hypercholesterolemia<br />E) Dysbetalipoproteinemia<br />8. The disorder described in Question 7 is most likely due to a receptor abnormality involving which one of the following lipoproteins? (thrown out)<br />A) Low-density lipoproteins<br />B) Very low-density lipoproteins<br />C) High-density lipoproteins<br />D) Apolipoprotein B48<br />E) Oxidized low-density lipoproteins<br />9. The disorder described in Question 7 is inherited as a(n): (thrown out)<br />A) Autosomal dominant trait<br />B) Autosomal recessive trait<br />C) X-linked trait<br />D) Mitochondrial trait<br />E) Polygenic trait<br />10. A 32-year-old woman presents with dyspnea on exertion. On further questioning she gives a history of increasing cough over the last week and limitations of her daily activities. She also gives a history of breathlessness at night after going to bed. Her past medical history is significant for a bout of rheumatic fever at age 15. Physical examination shows a woman in distress. There is peripheral and facial cyanosis. There are prominent “a” waves in the jugular venous pulse. Palpation yields a diastolic thrill at the apex in the left lateral position. Ausculation shows the presence of a mid-diastolic murmur best heard in the mitral area. Chest radiograph shows left atrial enlargement. Which of the following is the most likely diagnosis?<br />A) Aortic stenosis<br />B) Aortic insufficiency<br />C) Mitral stenosis<br />D) Mitral insufficiency<br />E) Tricuspid insufficiency<br />24. A 70-year-old man presents to the Emergency Room with a 2 month history of progressive breathlessness on exertion. The patient also gives a history of syncopal attacks, stating that he’s had 4 episodes in the last 3 months, but did not seek medical attention. He denies any chest pain. Past medical history is not significant. His vitals are as follows: heart rate 68 beats/min, blood pressure 130/70 mm Hg and respiratory rate 20/min. On cardiac auscultation, a harsh ejection systolic murmur is audible at the right second intercostals space radiating to the neck. Based on the history and examination, which of the following valvular heart diseases does the patient have?<br />A) Mitral stenosis<br />B) Mitral valve prolapse<br />C) Tricuspid stenosis<br />D) Aortic stenosis<br />E) Pulmonary regurgitation<br /> <br />25. A 19-year-old girl presents with fever, anorexia, and joint pains. She gives a history of previous sore throat. Along with these symptoms she has skin rashes, carditis and neurological features. You suspect acute rheumatic fever. Which of the following is not a major manifestation of Jones criteria for acute rheumatic fever?<br />A) Carditis<br />B) Positive throat culture for Group A beta-hemolytic Streptococci<br />C) Polyarthritis<br />D) Erythema marginatum<br />E) Sydenham chorea<br />27. A 50-year-old man comes to the cardiac unit. You are an intern in the cardiac unit. The senior resident tells you that the patient has calcification of one of the cardiac structures that was abnormal from birth. Calcification is most likely in which of the following structures?<br />A) Foramen ovale<br />B) Aortic valve<br />C) Mitral valve<br />D) Aortic root<br />E) Pulmonary arterial vasculature<br />28. A 40-year-old woman has worsening congestive cardiac failure with symptoms of breathlessness and peripheral edema for several years. She also has increasing difficulty swallowing. She underwent open-heart surgery. The appearance of excised portion of the mitral valve that was replaced with a mechanical prosthesis shows thickened and fused chordae tendineae. She was suffering from which of the following underlying conditions?<br />A) Diabetes mellitus<br />B) Marfan syndrome<br />C) Systemic lupus erythematosus<br />D) Congenital heart disease<br />E) Rheumatic heart disease<br />29. A 60-year-old woman dies due to complications of Parkinson disease. At autopsy it is found that she had an enlarged heart, predominantly the left ventricle and the left atrium. The mitral valve shows thickened and retracted valvular leaflets, resulting in diminished size of the valvular opening. The aortic valve cusps are also thickened with partial fusion of the commissures that resulted in a narrow orifice. Which of the following conditions is most likely to have contributed to the appearance of the heart described in this patient?<br />A) Group A streptococci infections<br />B) Blunt trauma to the chest<br />C) Systemic lupus erythematosus<br />D) Hereditary hemochromatosis<br />E) Cardiac amyloidosis<br />30. A 30-year-old woman dies suddenly. At autopsy, one of her cardiac valves demonstrates attenuation of the chordae tendineae with rupture of one of the leaflets, while the other shows myxomatous change. The cause of death is:<br />A) Rheumatic heart disease<br />B) Infective endocarditis<br />C) Mitral valve prolapse<br />D) Carcinoid heart disease<br />E) Acute myocardial infarction<br />31. A 25-year-old man is severely ill over the past two days with fever and malaise. On admission to the emergency Room, he has heart rate of 110/min, respiratory rate 24/min, blood pressure 80/50 mm Hg and temperature 100°F (37.7°C). A grade IV/VI diastolic murmur is audible. He has small splinter hemorrhages on the nailbeds. His spleen is palpable. The process that is least likely to predispose to this illness would be:<br />A) Prosthetic valve replacement<br />B) IV drug use<br />C) Cardiac amyloidosis<br />D) Rheumatic heart disease<br />E) Ventricular septal defect<br />33. A 47-year-old-man presents to the Emergency Room with a high-grade fever that he has had for a week. Patient has no other significant complaints. Chest X-ray film shows multiple patchy infiltrates in both lungs. Echocardiography and blood cultures suggest a diagnosis of acute bacterial endocarditis limited to the tricuspid valve. Which of the following is the most probable cause for the endocarditis in this patient?<br />A) Intravenous drug abuse<br />B) Rheumatic fever<br />C) Rheumatoid arthritis<br />D) Congenital heart disease<br />E) Systemic lupus erythematosus<br />34. Which of the following is most likely the causative organism in the cardiac disorder of the patient described in Question 33?<br />A) Pseudomonas aeruginosa<br />B) Group A beta-hemolytic streptococci<br />C) Staphylococus aureus<br />D) Enterococci<br />E) Fungi<br />35. A 57-year-old man undergoing a routine examination is found to have a grade III systolic heart murmur. The patient has an enlarged spleen and small petechial hemorrhages on the arms and legs. His past medical history is significant for rheumatic fever and mitral valve regurgitation with a grade I murmur, and it is determined that the patient is currently a candidate for surgical therapy. The patient is admitted and blood cultures are obtained. Blood cultures are most likely positive for which of the following organisms?<br />A) Streptococus pneumoniae<br />B) Pseudomonas aeruginosa<br />C) Staphylococcus aureus<br />D) Viridans streptococci<br />E) Streptococcus pyogenes (group A streptococci)<br />36. A 60-year-old woman presents with over 40 lb weight loss over the past 6 months with painless jaundice. By abdominal CT scan, she is found to have a large mass involving the head of the pancreas along with widespread nodules in the liver. Nodules are seen in the lungs on chest X-ray. The most likely cardiac complication in this patient would be:<br />A) Dilated cardiomyopathy<br />B) Nonbacterial thrombotic endocarditis<br />C) Fibrinous pericarditis<br />D) Acute myocardial infarction<br />E) Endomyocardial fibrosis<br />32. A 45-year-old man has a sudden change in mental status. He is brought to the hospital where a right-sided subarachnoid hemorrhage is detected on CT scan of the head. There is subsequent pressure effect with herniation and death. At autopsy a peripheral right parietal cerebral artery branch shows acute inflammation and necrosis with fusiform aneurismal dilatation with rupture of the arterial wall. This is most likely a complication of: (thrown out)<br />A) Marfan syndrome<br />B) Metastatic adenocarcinoma<br />C) Hemangioma<br />D) Aortic valve infective endocarditis<br />E) Arterial hypertension<br />40. A 5-year-old boy was brought to the Emergency Room by his mother with complaints of becoming bluish on excessive crying. Examination showed a child in moderate distress having difficulty in breathing. There was general cyanosis of the extremities. Palpation revealed a thrill at the left sternal border and parasternal lift. Auscultation was positive for a loud S2 with a grader III/VI pansystolic murmur in the left third and fourth interspaces.Imaging studies revealed the chest X-ray was positive for cardiomegaly with prominence of ventricles and increased pulmonary vasculature. ECG was positive for biventricular hypertrophy, and echo revealed the presence of a large ventricular septal defect. A color flow Doppler showed a right-to-left shunt. What is the pathophysiology of cyanosis of this child?<br />A) Ventricular septal defect with a left-to-right shunt<br />B) Ventricular fibrillation suddenly occurs, leading to lack of cardiac output<br />C) Elevation of left ventricular end-diastolic pressure<br />D) Decreased left ventricular compliance due to myocardial fibrosis<br />E) Pulmonary hypertension leading to elevated right ventricular pressure, ultimately creating a right-to-left shunt.<br />42. A 45-year-old woman comes to your office because she realized a difference in circumference of her calves. There is neither pain nor discoloration of the skin. Upon examination you determine that the circumference of the right calf is 1.5 cm larger. There is some tenderness to palpitation and the skin temperature of the affected calve is slightly higher than the other one. The Homans sign is positive on the right side. Foot pulses are strong and equal on both sides. There is no history of vascular disease. What is the most likely diagnosis?<br />A) Deep venous thrombosis<br />B) Thrombophlebitis<br />C) Baker’s cyst<br />D) Cellulitis<br />E) Lymphedema<br />44. A 58-year-old man has developed deep vein thrombosis with cyanosis during hospitalization for prostatectomy. He exhibits decreased mental status with right hemiplegia. A CT scan of the brain suggests an acute cerebral infarction in the distribution of middle cerebral artery. A chest x-ray reveals cardiac enlargement and prominence of the main pulmonary arteries that suggests pulmonary hypertension. His serum troponin I is <0.4 ng/mL. Which of the following lesions is most likely to be present on echocardiography?<br />A) Coarctation of aorta<br />B) Tetralogy of Fallot<br />C) Ventricular septal defect<br />D) Pulmonic stenosis<br />E) Dextrocardia<br />50. A 35-year-old woman is brought by ambulance to the Emergency Room because she developed sudden sharp, tearing, intractable left chest pain which radiated to her back. While the duty doctor was examining her, he noted a declining level of consciousness and dyspnea. Subsequently she fainted. Her accompanying husband revealed that she had a history of hypertension. On measuring blood pressure in the left arm there was marked hypotension (90/50 mm Hg) while the right arm read 170/80 mm Hg. Aortic regurgitation murmur was present on auscultation, as also were inspiratory crackles at lung bases bilaterally. A CT scan revealed a spiraling intimal flap with true and false lumen. Which of the following is the most likely diagnosis?<br />A) Dissecting aneurysm<br />B) Saccular aneurysm<br />C) Berry aneurysm<br />D) Fusiform aneurysm<br />E) Abdominal aortic aneurysm<br />51. A 70-year-old man presents to the Emergency Room with abdominal pain. He has a history of rheumatoid arthritis with steroid treatment. Patient history reveals that his mother died of ruptured aortic aneurysm. A triple coronary bypass was performed about a year ago without complications. An aortic sonogram is ordered and an aneurysm is discovered. What is the most common location for an aortic aneurysm in this patient?<br />A) Proximal thoracic aorta<br />B) Mid thoracic aorta<br />C) Proximal abdominal aorta<br />D) Mid abdominal aorta<br />E) Distal abdominal aorta<br />53. In 90% of patients diagnosed with arterial hypertension the underlying mechanism of the disease is which of the following diseases?<br />A) Renal hypertension<br />B) Hormonal hypertension<br />C) Nervous hypertension<br />D) Essential hypertension<br />E) Vascular hypertension<br />Histology Questions:<br />26. The dark line indicated by the arrows is the _________.<br />external elastic membrane<br />internal elastic membrane<br />tunica adventicia<br />tunica intima <br />tunica media<br />27. Name the layer indicated by the arrows.<br />endocardium <br />epicardium<br />myocardium<br />29. The arrow indicates the lumen of a(n) ______.<br />arteriole<br />capillary<br />lymphatic vessel<br />venule<br />35. Name the layer indicated by the arrow.<br />tunica adventicia<br />tunica intima<br />tunica media<br />36. Which of the following is responsible for the staining properties of the structures indicated by the arrows?<br />glycogen storage vesicles<br />irregular arrangement of actin and myosin<br />junctional complexes between adjacent cells<br />regular arrangement of actin and myosin<br />37. . The star is located in the lumen of a(n) ________. (both A and D were provided on the answer key. Check the key below this document to confirm)<br />arteriole<br />capillary<br />lymphatic vessel<br />venule<br />39. The bright pink line indicated by the arrows is the _________.<br />external elastic membrane<br />internal elastic membrane<br />tunica adventicia<br />tunica intima <br />tunica media<br />