CHAPTER

Hemodynamic Disorders 4
PBD9 Chapter 4: Hemodynamic Disorders

PBD8 Chapter 4: Hemodynamic Disorders, Thromboembolic Disease, and Shock

BP9 Chapter 3: Hemodynamic Disorders, Thromboembolism, and Shock

BP8 Chapter 4: Hemodynamic Disorders, Thrombosis, and Shock

1 A 45-year-old woman who works while standing for 3 A 37-year-old woman has noticed a lump in her left
long periods notices at the end of her 8-hour shift that her breast over the past 2 months. On physical examination, the
lower legs and feet are swollen, although there was no swell- skin overlying the left breast is thickened, reddish orange,
ing at the beginning of the day. There is no pain or erythema and pitted. Mammography shows a 3-cm underlying density.
associated with this swelling. She is otherwise healthy and A fine-needle aspirate of the density is performed and on mi-
takes no medications; laboratory testing reveals normal liver croscopic examination shows carcinoma. Which of the follow-
and renal function. Which of the following mechanisms best ing mechanisms best explains the gross appearance of the skin
explains this phenomenon? of her left breast?
A Excessive free water intake A Chronic inflammation
B Hypoalbuminemia B Chronic passive congestion
C Increased hydrostatic pressure C Ischemic necrosis
D Lymphatic obstruction D Lymphatic obstruction
E Secondary aldosteronism E Venous thrombosis

2 A 56-year-old woman diagnosed with cancer in her left 4 A 7-year-old boy has had increasing lethargy for a week.
breast underwent a mastectomy with axillary lymph node On physical examination, he has periorbital edema and pit-
dissection. Postoperatively, she develops marked swelling of ting edema at the ankles, but is normotensive and afebrile.
the left arm that has persisted for 6 months. Now on physical Laboratory studies show marked albuminuria. He is given a
examination, her temperature is 36.9° C. Her left arm is not thiazide diuretic and his urine output increases and his edema
tender or erythematous, and it is not painful with movement resolves. Which of the following changes most likely potenti-
or to touch, but it is enlarged with a doughy consistency. ated his edema?
Which of the following is the most likely mechanism for these A Decreased aldosterone
findings? B Decreased renin
A Cellulitis C Increased albumin
B Congestive heart failure D Increased cortisol
C Decreased plasma oncotic pressure E Decreased antidiuretic hormone
D Lymphedema F Increased salt retention
E Sodium and water retention
F Phlebothrombosis

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32 UNIT I General Pathology

7 A 58-year-old man with pulmonary emphysema has a

10-year history of congestive heart failure. On physical exami-
nation, he has lower leg swelling with grade 2 pitting edema
to the knees and prominent jugular venous distention to the
level of the mandible. His serum levels of AST and ALT are
increased. The representative gross appearance of his liver is
shown in the figure. Which of the following underlying condi-
5 A 94-year-old woman has dyspnea and an increasing tions is most likely to be present in this man?
cough with frothy sputum production for the past month. She A Chronic renal failure
is afebrile. A chest radiograph shows the findings in the figure. B Common bile duct obstruction
Which of the following is the most likely mechanism for C Congestive heart failure
development of her pulmonary infiltrates? D Portal vein thrombosis
A Decreased sodium intake E Thrombocytopenia
B Hypoalbuminemia
C Increased hydrostatic pressure 8 An 85-year-old man falls in the bathtub and strikes the
D Inflammation back of his head. Over the next 24 hours, he becomes increas-
E Pulmonary venous obstruction ingly somnolent. A head CT scan shows an accumulation of
fluid beneath the dura, compressing the left cerebral hemi-
6 A 50-year-old man suffers an infarction of the anterior sphere. Which of the following terms best describes this col-
left ventricular wall. He receives therapy with anti-arrhythmic lection of fluid?
and pressor agents. He is in stable condition until he develops A Congestion
severe breathlessness 3 days later. An echocardiogram shows B Ecchymosis
a markedly decreased ejection fraction. Representative chest C Hematoma
radiographic findings are shown in the figure above. Which of D Petechiae
the following microscopic changes is most likely to be present E Purpura
in his lungs?
A Alveolar neutrophilic exudate
B Alveolar transudate
C Alveolar wall fibrosis
D Pleural fibrosis
E Pleural space neutrophilic exudate
F Pleural space transudate

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 CHAPTER 4 Hemodynamic Disorders 33

12 In an experiment, thrombus formation is studied in ar-

eas of vascular damage. The propagation of a thrombus in an
area of vascular injury to adjacent normal arteries is prevent-
ed. Which of the following substances diminishes thrombus
propagation by activating protein C?
A Calcium
B Fibrin
C Platelet factor 4
D Prothrombin
E Thrombomodulin
F Tumor necrosis factor (TNF)

13 A 26-year-old woman has a history of frequent nose-

bleeds and increased menstrual blood flow. On physical exam-
ination, petechiae and purpura are present on the skin of her
extremities. Laboratory studies show normal partial thrombo-
plastin time (PTT), prothrombin time (PT), and platelet count,
but decreased von Willebrand factor activity. This patient
most likely has a derangement in which of the following steps
in hemostasis?
A Fibrin polymerization
B Platelet adhesion
C Platelet aggregation
D Prothrombin generation
E Prothrombin inhibition
F Vasoconstriction
9 An autopsy study is performed to correlate patterns of
hemorrhage with underlying causes. Patients with the gross 14 A 59-year-old woman with a history of diabetes mellitus
appearance of hemorrhage shown in the figure had minimal had a myocardial infarction 3 months ago. Her BMI is 35. She
blood volume loss, but an appearance similar to this in many is now taking a low dose of aspirin to reduce the risk for recur-
other organs. Which of the following terms best describes this rent arterial thrombosis. On which of the following steps in
pattern? hemostasis does aspirin have its greatest effect?
A Congestion A Adhesion of platelets to collagen
B Ecchymosis B Aggregation of platelets
C Hematoma C Production of tissue factor
D Petechiae D Synthesis of von Willebrand factor
E Purpura E Synthesis of antithrombin III

10 A superficial puncture wound from a needlestick injury 15 In an experiment, platelet function is analyzed. A sub-
leads to a small amount of bleeding in a healthy person. Sec- stance is obtained from the dense body granules of normal
onds after this injury occurs, the bleeding stops. Which of the pooled platelets from healthy blood donors. When this sub-
following mechanisms is most likely to stop small arteriolar stance is added to platelets obtained from patients with a
blood loss from this injury? bleeding disorder, no platelet aggregation occurs. Adding the
A Fibrin polymerization substance to platelets from a normal control group induces
B Neutrophil chemotaxis platelet aggregation. Which of the following substances is
C Platelet aggregation most likely to produce these effects?
D Protein C activation A Adenosine diphosphate
E Vasoconstriction B Antithrombin III
C Fibronectin
11 A 15-year-old girl incurs a cut to the sole of her foot D Fibrinogen
after stepping on a piece of broken glass. On examination, a E Plasminogen
superficial 0.5-cm laceration ceases to bleed within 5 minutes F Thromboxane A2
after application of local pressure. Which of the following
substances is released by endothelium and is most likely to
counteract platelet aggregation near this site of injury?
A Glycoprotein IIb/IIIa
B Platelet-activating factor
C Prostacyclin
D Tissue-type plasminogen activator
E Thrombomodulin
F Thromboxane

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16 A 12-year-old boy has a 10-year history of multiple soft 20 A 21-year-old woman has had multiple episodes of deep
tissue hemorrhages and acute upper airway obstruction from venous thrombosis during the past 10 years and one episode
hematoma formation in the neck. On physical examination, he of pulmonary thromboembolism during the past year. Labora-
has decreased range of motion of the large joints, particularly tory tests show that her prothrombin time (PT), partial throm-
the knees and ankles. He has no petechiae or purpura of the boplastin time (PTT), platelet count, and platelet function
skin. Laboratory studies show normal prothrombin time, el- studies all are normal. Which of the following risk factors is
evated partial thromboplastin time (PTT), and normal platelet the most common cause for such a coagulopathy?
count, but markedly decreased factor VIII activity. Which of A Antithrombin III deficiency
the following mechanisms best describes the development of B Factor V mutation
his disease? C Hyperhomocysteinemia
A Decrease in production of thrombin D Mutation in protein C
B Decrease in membrane phospholipid E Occult malignancy
C Failure of platelet aggregation F Oral contraceptive use
D Failure of fibrin polymerization G Smoking cigarettes
E Inability to neutralize antithrombin III
F Inability of platelets to release thromboxane A2 21 A 23-year-old woman has had altered consciousness and
slurred speech for the past 24 hours. A head CT scan shows a
17 A 58-year-old man has had episodes of prolonged epi- right temporal hemorrhagic infarction. Cerebral angiography
staxis in the past 6 months. On examination he has occult shows a distal right middle cerebral arterial occlusion. Within
blood detected in his stool. Coagulation studies show that his the past 3 years, she has had an episode of pulmonary embo-
prothrombin time is elevated, but his partial thromboplastin lism. A pregnancy 18 months ago ended in miscarriage. Labo-
time (PTT), platelet count, and platelet function are all normal. ratory studies show a false-positive serologic test for syphilis,
When his plasma is mixed with an equal amount of normal normal prothrombin time (PT), elevated partial thromboplas-
plasma, the prothrombin time corrects to normal. Which of the tin time (PTT), and normal platelet count. Which of the follow-
following underlying diseases is most likely to be associated ing is the most likely cause of these findings?
with these findings? A Antiphospholipid antibody
A Antiphospholipid syndrome B Disseminated intravascular coagulation
B Factor V Leiden mutation C Factor V mutation
C Hemophilia A D Hypercholesterolemia
D Scurvy E Von Willebrand disease
E Sepsis with Escherichia coli
F Vitamin K deficiency

18 A 66-year-old woman has the sudden onset of chest pain

that radiates to her neck and left arm. On examination 30 min-
utes later, she is diaphoretic and hypotensive. Her serum tro-
ponin I level is elevated. Which of the following drugs is most
likely to be administered emergently as thrombolytic therapy
for this woman?
A Acetylsalicylic acid (aspirin)
B Low-molecular-weight heparin
C Nitric oxide
D Tissue plasminogen activator
E Vitamin K

19 A 60-year-old woman with a history of diabetes mellitus

has had left-sided chest pain radiating to the arm for the past 5
hours. Serial measurements of serum creatine kinase–MB lev- 22 A 71-year-old man with a history of diabetes mellitus
els show an elevated level 24 hours after the onset of pain. Par- died of an acute myocardial infarction. At autopsy, the aorta,
tial thromboplastin time (PTT) and prothrombin time (PT) are opened longitudinally and with the superior aspect of the
normal. Coronary angiography shows occlusion of the left an- kidneys below the forceps, appeared as shown in the figure.
terior descending artery. Which of the following mechanisms Which of the following complications associated with this aor-
is the most likely cause of thrombosis in this patient? tic disease would most likely have been present during his life?
A Antibody inhibitor to coagulation A Edema of the left leg
B Damage to endothelium B Gangrene of the foot
C Decreased antithrombin III level C Pulmonary thromboembolism
D Decreased tissue plasminogen activator D Renal infarction
E Mutation in factor V gene E Thrombocytopenia
F Stasis of blood flow

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 CHAPTER 4 Hemodynamic Disorders 35

23 A 55-year-old woman following major abdominal sur-

gery has had discomfort and swelling of her left leg for the
past week. On physical examination, the leg is slightly diffi-
cult to move, and on palpation there is tenderness. A Doppler
sonogram shows thrombosis of deep left leg veins. Which of
the following mechanisms is most likely to contribute to her
condition?
A Hypercalcemia
B Immobilization
C Ingestion of aspirin
D Nitric oxide release
E Turbulent blood flow

24 A 75-year-old man is hospitalized after falling and frac-

turing his left femoral trochanter. Two weeks later, the left leg
is swollen, particularly below the knee. He experiences pain
on movement of the leg; on palpation, there is swelling and 26 A 59-year-old woman with hyperlipidemia has had
tenderness. Which of the following complications is most like- anginal pain for the past 24 hours. Laboratory findings show
ly to occur in this man? no increase in serum troponin I or creatine kinase–MB. She is
A Disseminated intravascular coagulation in stable condition 2 weeks later and has no chest pain, but
B Fat embolism syndrome a small artery in the epicardium has undergone the changes
C Gangrenous necrosis of the foot seen in the figure. Which of the following terms best describes
D Hematoma of the thigh this finding in this epicardial artery?
E Pulmonary thromboembolism A Air embolus
B Cholesterol embolization
C Chronic passive congestion
D Fat embolism syndrome
E Mural thrombosis
F Organization with occlusion
G Phlebothrombosis

27 A 77-year-old woman has a brief fainting episode. She

was diagnosed 1 year ago with pancreatic adenocarcinoma.
On auscultation of her chest, a heart murmur is heard. Echo-
cardiography shows a 1-cm nodular lesion on the superior as-
pect of an intact anterior mitral valve leaflet. A blood culture
is negative. Which of the following terms best describes this
mitral valve lesion?
A Atheroma
B Chronic passive congestion
C Mural thrombus
D Myxoma
25 A 65-year-old woman sustained fractures of the right fe- E Phlebothrombosis
mur, pelvis, and left humerus in a motor vehicle collision. The F Vegetation
fractures were stabilized, and the patient’s recovery was un-
eventful. During a physical examination 3 weeks later, while
still in the hospital, she has swelling and warmth in the left
leg, and there is local pain and tenderness in the left thigh.
Which of the following processes, as shown in the figure, is
most likely occurring in her left femoral vein?
A Atherosclerosis
B Chronic passive congestion
C Inflammation
D Mural thrombosis
E Phlebothrombosis
F Vegetation

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31 A 31-year-old man is on a scuba diving trip and de-

scends to a depth of 50 m in the Blue Hole off the coast of Be-
lize. After 30 minutes, he has a malfunction in his equipment
and quickly returns to the boat on the surface. He develops
difficulty breathing within 5 minutes, with dyspnea and sub-
sternal chest pain, followed by a severe headache and vertigo.
An hour later, he develops severe, painful myalgias and ar-
thralgias. These symptoms abate within 24 hours. Which of
the following occluding his arterioles is the most likely cause
of his findings?
A Fat globules
B Fibrin clots
C Nitrogen gas bubbles
D Platelet thrombi
E Ruptured atheromatous plaque

28 A 70-year-old man was hospitalized 3 weeks ago for a

cerebral infarction. He is now is ambulating for the first time.
Within minutes of returning to his hospital room, he has sud-
den onset of dyspnea with diaphoresis. He cannot be resus-
citated. The gross appearance of the hilum of the left lung at
autopsy is shown in the figure. Which of the following risk
factors most likely contributed to this finding?
A Antiphospholipid antibody
B Bronchopneumonia
C Factor V mutation
D Leg vein thrombosis
E Pulmonary arterial atherosclerosis

29 A 32-year-old man is involved in a vehicular accident

and sustains fractures of the right femur and tibia and the left
humerus. The fractures are stabilized surgically. He is in stable
condition for 2 days, but then suddenly becomes severely dys-
pneic. Which of the following complications from his injuries
is the most likely cause of his sudden respiratory difficulty?
A Cardiac tamponade
B Fat embolism
C Pulmonary edema
D Pulmonary infarction
E Right hemothorax 32 A 53-year-old man with congestive heart failure devel-
ops pulmonary Streptococcus pneumoniae infection after a bout
30 A 22-year-old woman with an uncomplicated pregnan- of influenza. After recuperating for 2 weeks, he notes pleuritic
cy develops sudden dyspnea with cyanosis and hypotension chest pain. The pain is caused by the development of the lesion
intrapartum during routine vaginal delivery of a term infant. shown in the figure. Which of the following events has most
She has a generalized seizure and becomes comatose. Her con- likely occurred in this man?
dition does not improve over the next 2 days. Which of the fol- A Acute pulmonary congestion
lowing findings is most likely to be present in her peripheral B Chronic pulmonary congestion
pulmonary arteries? C Pulmonary edema
A Aggregates of platelets D Pulmonary infarction
B Amniotic fluid E Pulmonary venous thrombosis
C Fat globules
D Gas bubbles
E Thromboemboli
 CHAPTER 4 Hemodynamic Disorders 37

35 An 80-year-old woman with dysuria for 1 week now

has a fever. On examination, her temperature is 37.9° C, pulse
103/min, and blood pressure 80/40 mm Hg. She has right
flank pain. A urinalysis shows numerous WBCs. Her plasma
lactate is increased. Urine culture and blood culture grow
Escherichia coli. Which of the following is most likely to con-
tribute to her cardiovascular collapse by triggering Toll-like
cell receptors?
A Complement C3b
B Lipopolysaccharide
C Nitric oxide
D Platelet-activating factor
E Toxic shock syndrome toxin-1

36 A 63-year-old woman has had a fever and felt faint for

the past 2 days. On physical examination, her temperature is
38.4° C, pulse is 101/min, respirations are 17/min, and blood
pressure is 85/40 mm Hg. She has marked peripheral vaso-
dilation. The serum lactic acid level is 6.8 mg/dL. Which of
the following laboratory findings is most likely related to the
cause of her clinical condition?
A Blood culture positive for Citrobacter
B Decreased hematocrit
C Elevated serum creatine kinase
D Increased blood urea nitrogen
E Reduced PO2 on blood gas measurement

37 A 20-year-old man develops palpitations within 1 hour

33 A 44-year-old man with dilated cardiomyopathy and after a gunshot wound to the abdomen. On examination his
heart failure develops left atrial mural thrombosis. He develops heart rate is 112/minute and blood pressure 80/30 mm Hg.
the complication shown in the figure, manifested by hematuria. His skin is cool and clammy to the touch. Which of the fol-
Which of the following is the best term for this complication? lowing organ-specific changes is most likely to occur within
A Abscess 2 days after this injury?
B Ischemic infarct A Acute hepatic infarction
C Liquefactive necrosis B Cerebral basal ganglia hemorrhage
D Multiorgan failure C Gangrenous necrosis of the lower legs
E Venous thrombosis D Pulmonary diffuse alveolar damage
E Renal passive congestion
34 A 28-year-old woman with a 15-year history of recur-
rent thrombosis from a prothrombin gene mutation develops 38 A 30-year-old man is cutting wood alone in the forest
septicemia after a urinary tract infection with Pseudomonas and incurs a deep cut to his leg from his chain saw. He loses a
aeruginosa. She develops multiple infarcts and organ failure large amount of blood. He is not found until the next day. A
over the next 2 weeks. Which of the following organs is most marked increase in which of the following blood analytes is
likely to be spared from the effects of ischemic injury in this most likely to indicate that he has reached an irreversible stage
woman? of shock?
A Brain A Antidiuretic hormone
B Heart B Bicarbonate
C Kidney C Catecholamines
D Liver D Lactate dehydrogenase
E Spleen E Prothrombin