PATHOLOGY CHAPTER 4 -
HEMODYNAMIC DISORDERS,
THROMBOEMBOLIC DISEASE, AND
SHOCK EXAM QUESTIONS WITH
CORRECT ANSWERS
1. 32 A 23-year-old woman with an uncomplicated pregnancy develops sudden
dyspnea with cyanosis and hypotension during routine vaginal delivery of a term infant.
She has a generalized seizure and becomes comatose. Her condition does not improve
over the next 2 days. Which of the following findings is most likely to be present in the
peripheral pulmonary arteries? □ (A) Aggregates of red blood cells □ (B) Amniotic fluid □
(C) Fat globules □ (D) Gas bubbles □ (E) Thromboemboli - Answer-32 (B) Amniotic fluid
: Amniotic fluid embolism rarely occurs in pregnancy, but it has a high mortality rate.
The fluid reaches torn uterine veins through ruptured fetal membranes.
Aggregates of red blood cells are seen in passive congestion.
Fat globules are seen in fat embolism, usually after severe trauma.
Gas bubbles in vessels from air embolism can be a rare event in some obstetric
procedures, but it is an unlikely event in natural deliveries.
Peripheral pulmonary thromboemboli are most likely to produce chronic pulmonary
hypertension and develop over weeks to months.
1. 33 A 7-year-old boy has had increasing lethargy for a week. On physical examination
he has periorbital edema and pitting edema at the ankles, but is normotensive and
afebrile. Laboratory studies show marked albuminuria. He is given a thiazide diuretic
and his urine output increases and his edema resolves. Which of the following changes
in his blood most likely potentiated his edema? □ (A) Decreased aldosterone □ (B)
Decreased antidiuretic hormone □ (C) Decreased renin □ (D) Increased albumin □ (E)
Increased cortisol □ (F) Increased sodium - Answer-33 (F) Increased sodium: This child
has nephrotic syndrome with loss of albumin into the urine and hypoalbuminemia that
decreases plasma oncotic pressure, leading to movement of intravascular water into the
extravascular compartment to produce edema. In response, hypovolemia with renal
hypoperfusion induces increased production of renin, angiotensin, and aldosterone,
which promote sodium and water retention, further exacerbating his edema. Thiazide
diuretics increase renal excretion of sodium. Hypovolemia would increase antidiuretic
hormone output.
,Though corticosteroids are used to treat nephrotic syndrome caused by minimal change
disease, the effect is probably to diminish abnormal T-cell function that is driving the
glomerular damage.
Cortisol leads to sodium retention, but not in response to hypovolemia.
34 A 55-year-old man has had episodes of prolonged epistaxis in the past 6 months. On
examination he has occult blood detected in his stool. Coagulation studies show that his
prothrombin time is elevated, but his partial thromboplastin time, platelet count, and
platelet function are all normal. When his plasma is mixed with an equal amount of
normal plasma, the prothrombin time corrects to normal. Which of the following
underlying diseases is most likely to be associated with his findings? □ (A) Nonalcoholic
steatohepatitis □ (B) Hemophilia A □ (C) Antiphospholipid syndrome □ (D) Factor V
Leiden mutation □ (E) Sepsis with Escherichia coli □ (F) Von Willebrand disease -
Answer-34 (A) Nonalcoholic steatohepatitis: His elevated prothrombin time that corrects
with normal plasma points to coagulation factor deficiency, and factors II, VII, IX, and X
are synthesized in the liver and affect this "extrinsic" pathway. They are vitamin K
dependent and are therefore affected by coumadin therapy. His hepatic steatosis
diminishes liver function.
Hemophilia A results from loss of factor VIII function and affects just the partial
thromboplastin time.
Antiphospholipid syndrome has an inhibitory effect upon in vitro coagulation tests and
does not correct with addition of normal plasma.
The factor V Leiden mutation leads to difficulty inactivating factor V by the action of
protein C, thus causing thrombosis, not bleeding.
Gram negative sepsis releases lipopolysaccharide that activates coagulation on a wide
scale, consuming coagulation factors and platelets, so both the prothrombin time and
partial thromboplastin time are elevated while the platelet count is decreased, typical for
disseminated intravascular coagulopathy.
The lack of vonWillebrand factor leads to impaired platelet function.
While shaving one morning, a 23-year-old man nicks his lip with a razor. Seconds after
the injury, the bleeding stops. Which of the following mechanisms is most likely to
reduce blood loss from a small dermal arteriole? □ (A) Protein C activation □ (B)
Vasoconstriction □ (C) Platelet aggregation □ (D) Neutrophil chemotaxis □ (E) Fibrin
polymerization - Answer-1 (B) Vasoconstriction :The initial response to injury is
arteriolar vasoconstriction, but this is transient, and the coagulation mechanism must be
initiated to maintain hemostasis.
Protein C is involved in anticoagulation to counteract clotting.
,Platelet aggregation occurs with release of factors such as ADP, but this takes several
minutes.
Neutrophils are not essential to hemostasis.
Fibrin polymerization is part of secondary hemostasis after the vascular injury is initially
closed.
1. 2 A 73-year-old man was diagnosed 1 year ago with pancreatic adenocarcinoma. He
now sees his physician because of a transient ischemic attack. On auscultation of the
chest, a heart murmur is heard. Echocardiography shows a 1-cm nodular lesion on the
superior aspect of the anterior mitral valve leaflet. The valve leaflet appears to be intact.
The blood culture is negative. Which of the following terms best describes this mitral
valve lesion? □ (A) Adenocarcinoma □ (B) Atheroma □ (C) Chronic passive congestion
□ (D) Mural thrombus □ (E) Petechial hemorrhage □ (F) Phlebothrombosis □ (G)
Vegetation - Answer-2 (G) Vegetation: A thrombotic mass that forms on a cardiac valve
(or, less commonly, on the cardiac mural endocardium) is known as a vegetation. Such
vegetations may produce thromboemboli. Vegetations on the right-sided heart valves
may embolize to the lungs; vegetations on the left embolize systemically to organs such
as the brain, spleen, and kidney. A so-called paradoxical embolus occurs when a right-
sided cardiac thrombus crosses a patent foramen ovale and enters the systemic arterial
circulation. Patients with cancer may have a hypercoagulable state (e.g., Trousseau
syndrome, with malignant neoplasms) that favors the development of arterial and
venous thromboses. An adenocarcinoma is a malignant neoplasm that arises from
glandular epithelium, forming a mass lesion; endocardial metastases are quite rare.
Atheromas form in arteries and do not typically involve the cardiac valves.
Chronic passive congestion refers to capillary, sinusoidal, or venous stasis of blood
within an organ such as the lungs or liver.
Mural thrombi are thrombi that form on the surfaces of the heart or large arteries. The
term typically is reserved for large thrombi in a cardiac chamber or dilated aorta or large
aortic branch; it is not used to describe thrombotic lesions on cardiac valves.
A petechial hemorrhage is a grossly pinpoint hemorrhage.
Phlebothrombosis occurs when stasis in large veins promotes thrombosis formation.
1. 3 A 21-year-old woman sustains multiple injuries, including fractures of the right
femur and tibia and the left humerus, in a motor vehicle collision. She is admitted to the
hospital, and the fractures are stabilized surgically. Soon after admission to the hospital,
she is in stable condition. She suddenly becomes severely dyspneic, however, 2 days
later. Which of the following complications is the most likely cause of this sudden
respiratory difficulty? □ (A) Right hemothorax □ (B) Pulmonary edema □ (C) Fat
embolism □ (D) Cardiac tamponade □ (E) Pulmonary infarction - Answer-3 (C) Fat
, embolism : The mechanism for fat embolism is unknown, in particular, why onset of
symptoms is delayed 1 to 3 days after the initial injury (or 1 week for cerebral
symptoms). The cumulative effect of many small fat globules filling peripheral
pulmonary arteries is the same as one large pulmonary thromboembolus.
Hemothorax and cardiac tamponade would be immediate complications after traumatic
injury, not delayed events.
Pulmonary edema severe enough to cause dyspnea would be unlikely to occur in
hospitalized patients because fluid status is closely monitored.
Pulmonary infarction may cause dyspnea, but pulmonary thromboembolus from deep
venous thrombosis is typically a complication of a longer hospitalization.
1. 4 For the past week, a 61-year-old man has had increasing levels of serum AST and
ALT. On physical examination, he has lower leg swelling with grade 2+ pitting edema to
the knees and prominent jugular venous distention to the level of the mandible. Based
on the gross appearance of the liver, seen in the figure, which of the following
underlying conditions is most likely to be present? □ (A) Thrombocytopenia □ (B) Portal
vein thrombosis □ (C) Chronic renal failure □ (D) Common bile duct obstruction □ (E)
Congestive heart failure - Answer-4 (E) Congestive heart failure : The figure shows a
so-called nutmeg liver caused by chronic passive congestion. The elevated enzyme
levels suggest that the process is so severe that hepatic centrilobular necrosis also has
occurred. The physical findings suggest right-sided heart failure.
The regular pattern of red lobular discoloration seen in the figure is unlikely to occur in
hemorrhage from thrombocytopenia, characterized by petechiae and ecchymoses.
A portal vein thrombus would diminish blood flow to the liver, but it would not be likely to
cause necrosis because of that organ's dual blood supply.
Hepatic congestion is not directly related to renal failure, and hepatorenal syndrome has
no characteristic gross appearance.
Biliary tract obstruction would produce bile stasis (cholestasis) with icterus. (***technical
term for jaundice.***)
1. A 55-year-old woman has had discomfort and swelling of the left leg for the past
week. On physical examination, the leg is slightly difficult to move, but on palpation,
there is no pain. A venogram shows thrombosis of deep left leg veins. Which of the
following mechanisms is most likely to cause this condition? □ (A) Turbulent blood flow
□ (B) Nitric oxide release □ (C) Ingestion of aspirin □ (D) Hypercalcemia □ (E)
Immobilization - Answer-5 (E) Immobilization: The most important and the most
common cause of venous thrombosis is vascular stasis, which often occurs with
immobilization.
Turbulent blood flow may promote thrombosis, but this risk factor is more common in
fast-flowing arterial circulation.
Nitric oxide is a vasodilator and an inhibitor of platelet aggregation.
Aspirin inhibits platelet function and limits thrombosis.
Calcium is a cofactor in the coagulation pathway, but an increase in calcium has
minimal effect on the coagulation process.
HEMODYNAMIC DISORDERS,
THROMBOEMBOLIC DISEASE, AND
SHOCK EXAM QUESTIONS WITH
CORRECT ANSWERS
1. 32 A 23-year-old woman with an uncomplicated pregnancy develops sudden
dyspnea with cyanosis and hypotension during routine vaginal delivery of a term infant.
She has a generalized seizure and becomes comatose. Her condition does not improve
over the next 2 days. Which of the following findings is most likely to be present in the
peripheral pulmonary arteries? □ (A) Aggregates of red blood cells □ (B) Amniotic fluid □
(C) Fat globules □ (D) Gas bubbles □ (E) Thromboemboli - Answer-32 (B) Amniotic fluid
: Amniotic fluid embolism rarely occurs in pregnancy, but it has a high mortality rate.
The fluid reaches torn uterine veins through ruptured fetal membranes.
Aggregates of red blood cells are seen in passive congestion.
Fat globules are seen in fat embolism, usually after severe trauma.
Gas bubbles in vessels from air embolism can be a rare event in some obstetric
procedures, but it is an unlikely event in natural deliveries.
Peripheral pulmonary thromboemboli are most likely to produce chronic pulmonary
hypertension and develop over weeks to months.
1. 33 A 7-year-old boy has had increasing lethargy for a week. On physical examination
he has periorbital edema and pitting edema at the ankles, but is normotensive and
afebrile. Laboratory studies show marked albuminuria. He is given a thiazide diuretic
and his urine output increases and his edema resolves. Which of the following changes
in his blood most likely potentiated his edema? □ (A) Decreased aldosterone □ (B)
Decreased antidiuretic hormone □ (C) Decreased renin □ (D) Increased albumin □ (E)
Increased cortisol □ (F) Increased sodium - Answer-33 (F) Increased sodium: This child
has nephrotic syndrome with loss of albumin into the urine and hypoalbuminemia that
decreases plasma oncotic pressure, leading to movement of intravascular water into the
extravascular compartment to produce edema. In response, hypovolemia with renal
hypoperfusion induces increased production of renin, angiotensin, and aldosterone,
which promote sodium and water retention, further exacerbating his edema. Thiazide
diuretics increase renal excretion of sodium. Hypovolemia would increase antidiuretic
hormone output.
,Though corticosteroids are used to treat nephrotic syndrome caused by minimal change
disease, the effect is probably to diminish abnormal T-cell function that is driving the
glomerular damage.
Cortisol leads to sodium retention, but not in response to hypovolemia.
34 A 55-year-old man has had episodes of prolonged epistaxis in the past 6 months. On
examination he has occult blood detected in his stool. Coagulation studies show that his
prothrombin time is elevated, but his partial thromboplastin time, platelet count, and
platelet function are all normal. When his plasma is mixed with an equal amount of
normal plasma, the prothrombin time corrects to normal. Which of the following
underlying diseases is most likely to be associated with his findings? □ (A) Nonalcoholic
steatohepatitis □ (B) Hemophilia A □ (C) Antiphospholipid syndrome □ (D) Factor V
Leiden mutation □ (E) Sepsis with Escherichia coli □ (F) Von Willebrand disease -
Answer-34 (A) Nonalcoholic steatohepatitis: His elevated prothrombin time that corrects
with normal plasma points to coagulation factor deficiency, and factors II, VII, IX, and X
are synthesized in the liver and affect this "extrinsic" pathway. They are vitamin K
dependent and are therefore affected by coumadin therapy. His hepatic steatosis
diminishes liver function.
Hemophilia A results from loss of factor VIII function and affects just the partial
thromboplastin time.
Antiphospholipid syndrome has an inhibitory effect upon in vitro coagulation tests and
does not correct with addition of normal plasma.
The factor V Leiden mutation leads to difficulty inactivating factor V by the action of
protein C, thus causing thrombosis, not bleeding.
Gram negative sepsis releases lipopolysaccharide that activates coagulation on a wide
scale, consuming coagulation factors and platelets, so both the prothrombin time and
partial thromboplastin time are elevated while the platelet count is decreased, typical for
disseminated intravascular coagulopathy.
The lack of vonWillebrand factor leads to impaired platelet function.
While shaving one morning, a 23-year-old man nicks his lip with a razor. Seconds after
the injury, the bleeding stops. Which of the following mechanisms is most likely to
reduce blood loss from a small dermal arteriole? □ (A) Protein C activation □ (B)
Vasoconstriction □ (C) Platelet aggregation □ (D) Neutrophil chemotaxis □ (E) Fibrin
polymerization - Answer-1 (B) Vasoconstriction :The initial response to injury is
arteriolar vasoconstriction, but this is transient, and the coagulation mechanism must be
initiated to maintain hemostasis.
Protein C is involved in anticoagulation to counteract clotting.
,Platelet aggregation occurs with release of factors such as ADP, but this takes several
minutes.
Neutrophils are not essential to hemostasis.
Fibrin polymerization is part of secondary hemostasis after the vascular injury is initially
closed.
1. 2 A 73-year-old man was diagnosed 1 year ago with pancreatic adenocarcinoma. He
now sees his physician because of a transient ischemic attack. On auscultation of the
chest, a heart murmur is heard. Echocardiography shows a 1-cm nodular lesion on the
superior aspect of the anterior mitral valve leaflet. The valve leaflet appears to be intact.
The blood culture is negative. Which of the following terms best describes this mitral
valve lesion? □ (A) Adenocarcinoma □ (B) Atheroma □ (C) Chronic passive congestion
□ (D) Mural thrombus □ (E) Petechial hemorrhage □ (F) Phlebothrombosis □ (G)
Vegetation - Answer-2 (G) Vegetation: A thrombotic mass that forms on a cardiac valve
(or, less commonly, on the cardiac mural endocardium) is known as a vegetation. Such
vegetations may produce thromboemboli. Vegetations on the right-sided heart valves
may embolize to the lungs; vegetations on the left embolize systemically to organs such
as the brain, spleen, and kidney. A so-called paradoxical embolus occurs when a right-
sided cardiac thrombus crosses a patent foramen ovale and enters the systemic arterial
circulation. Patients with cancer may have a hypercoagulable state (e.g., Trousseau
syndrome, with malignant neoplasms) that favors the development of arterial and
venous thromboses. An adenocarcinoma is a malignant neoplasm that arises from
glandular epithelium, forming a mass lesion; endocardial metastases are quite rare.
Atheromas form in arteries and do not typically involve the cardiac valves.
Chronic passive congestion refers to capillary, sinusoidal, or venous stasis of blood
within an organ such as the lungs or liver.
Mural thrombi are thrombi that form on the surfaces of the heart or large arteries. The
term typically is reserved for large thrombi in a cardiac chamber or dilated aorta or large
aortic branch; it is not used to describe thrombotic lesions on cardiac valves.
A petechial hemorrhage is a grossly pinpoint hemorrhage.
Phlebothrombosis occurs when stasis in large veins promotes thrombosis formation.
1. 3 A 21-year-old woman sustains multiple injuries, including fractures of the right
femur and tibia and the left humerus, in a motor vehicle collision. She is admitted to the
hospital, and the fractures are stabilized surgically. Soon after admission to the hospital,
she is in stable condition. She suddenly becomes severely dyspneic, however, 2 days
later. Which of the following complications is the most likely cause of this sudden
respiratory difficulty? □ (A) Right hemothorax □ (B) Pulmonary edema □ (C) Fat
embolism □ (D) Cardiac tamponade □ (E) Pulmonary infarction - Answer-3 (C) Fat
, embolism : The mechanism for fat embolism is unknown, in particular, why onset of
symptoms is delayed 1 to 3 days after the initial injury (or 1 week for cerebral
symptoms). The cumulative effect of many small fat globules filling peripheral
pulmonary arteries is the same as one large pulmonary thromboembolus.
Hemothorax and cardiac tamponade would be immediate complications after traumatic
injury, not delayed events.
Pulmonary edema severe enough to cause dyspnea would be unlikely to occur in
hospitalized patients because fluid status is closely monitored.
Pulmonary infarction may cause dyspnea, but pulmonary thromboembolus from deep
venous thrombosis is typically a complication of a longer hospitalization.
1. 4 For the past week, a 61-year-old man has had increasing levels of serum AST and
ALT. On physical examination, he has lower leg swelling with grade 2+ pitting edema to
the knees and prominent jugular venous distention to the level of the mandible. Based
on the gross appearance of the liver, seen in the figure, which of the following
underlying conditions is most likely to be present? □ (A) Thrombocytopenia □ (B) Portal
vein thrombosis □ (C) Chronic renal failure □ (D) Common bile duct obstruction □ (E)
Congestive heart failure - Answer-4 (E) Congestive heart failure : The figure shows a
so-called nutmeg liver caused by chronic passive congestion. The elevated enzyme
levels suggest that the process is so severe that hepatic centrilobular necrosis also has
occurred. The physical findings suggest right-sided heart failure.
The regular pattern of red lobular discoloration seen in the figure is unlikely to occur in
hemorrhage from thrombocytopenia, characterized by petechiae and ecchymoses.
A portal vein thrombus would diminish blood flow to the liver, but it would not be likely to
cause necrosis because of that organ's dual blood supply.
Hepatic congestion is not directly related to renal failure, and hepatorenal syndrome has
no characteristic gross appearance.
Biliary tract obstruction would produce bile stasis (cholestasis) with icterus. (***technical
term for jaundice.***)
1. A 55-year-old woman has had discomfort and swelling of the left leg for the past
week. On physical examination, the leg is slightly difficult to move, but on palpation,
there is no pain. A venogram shows thrombosis of deep left leg veins. Which of the
following mechanisms is most likely to cause this condition? □ (A) Turbulent blood flow
□ (B) Nitric oxide release □ (C) Ingestion of aspirin □ (D) Hypercalcemia □ (E)
Immobilization - Answer-5 (E) Immobilization: The most important and the most
common cause of venous thrombosis is vascular stasis, which often occurs with
immobilization.
Turbulent blood flow may promote thrombosis, but this risk factor is more common in
fast-flowing arterial circulation.
Nitric oxide is a vasodilator and an inhibitor of platelet aggregation.
Aspirin inhibits platelet function and limits thrombosis.
Calcium is a cofactor in the coagulation pathway, but an increase in calcium has
minimal effect on the coagulation process.
