Chapter 7: Hemodynamic Disorders

Question 1

A 60-year-old man with a history of multiple myocardial
infarcts is hospitalized for shortness of breath. Physical examination
reveals marked jugular distension, hepatomegaly,
ascites, and pitting edema. A chest X-ray reveals cardiomegaly.
The patient subsequently dies of cardiorespiratory failure.
Examination of the lungs at autopsy would most likely disclose
which of the following pathologic changes?

Answer 1

1. Vascular congestion and hemosiderin-laden

macrophages.

Question 2

A 92-year-old woman is brought unconscious to the emergency
room from a nursing home. Her blood pressure is 70/30 mm
Hg. She is febrile (38°C/100.5°F) and tachypneic. Laboratory
studies demonstrate a WBC count of 22,000/μL with 92%
neutrophils. Urinalysis reveals numerous Gram-negative
organisms. Which of the following most likely accounts for
this patient’s signs and symptoms?

Answer 2

2. Septic shock.

Question 3

A 21-year-old pregnant woman experiences abruptio placentae
at 37 weeks of gestation and develops severe vaginal bleeding
that is diffi cult to control. Five months later, the patient
presents with profound lethargy, pallor, muscle weakness,
failure of lactation, and amenorrhea. Which of the following
best explains the pathogenesis of pituitary insuffi ciency in this
patient?

Answer 3

3. Infarction.

Question 4

A 62-year-old man with a history of hypertension is rushed
to the emergency room with severe “tearing pain” of the
anterior chest. His blood pressure is 80/50 mm Hg. Physical examination shows pallor, diaphoresis, and a murmur of aortic
regurgitation. Laboratory studies and ECG show no evidence
of acute myocardial infarction. Four hours later, the patient
goes into cardiac arrest. An ECG reveals electromechanical
dissociation. Which of the following best explains the
pathogenesis of cardiac tamponade in this patient?

Answer 4

4. Hemorrhage.

Question 5

A 58-year-old woman is brought to the emergency department
4 hours after vomiting blood and experiencing bloody stools.
The patient was diagnosed with alcoholic cirrhosis 2 years
ago. Endoscopy reveals large esophageal varices, one of which
is actively bleeding. Which of the following best explains the
pathogenesis of dilated esophageal veins in this patient?

Answer 5

5. Increased intravascular hydrostatic pressure.

Question 6

A 69-year-old retired man is brought to the emergency
department because of the sudden onset of left-sided chest
pain, which is exacerbated upon inspiration. Physical
examination reveals dyspnea and hemoptysis. His temperature
is 38°C (101°F), pulse 110 per minute, respirations 35 per
minute, and blood pressure 158/100 mm Hg. A lateral chest
wall friction rub is present on auscultation. The left leg is
markedly edematous with a positive Homans’ sign. A chest
X-ray reveals a left pleural effusion. What is the most likely
cause of this patient’s pulmonary condition?

Answer 6

6. Thromboembolism.

Question 7

A 22-year-old construction worker falls 30 ft and fractures
several bones, including his femoral shafts. Six hours later,
the patient develops shortness of breath and cyanosis. Which
of the following hemodynamic disorders best explains the
pathogenesis of shock in this patient?

Answer 7

7. Fat embolism.

Fat emboli originate from
adipose tissue in the medulla of fractured long bones. Fat
carried by venous blood reaches the lungs, fi lters through
the pulmonary circulation, enters arterial blood, and is
disseminated throughout the body. The occlusion of cerebral
capillaries is accompanied by petechial hemorrhages in the
brain and is the most important complication of fat embolism.

Question 8

A 20-year-old woman presents to the emergency room complaining
of having had a severe headache for 4 hours. Physical
examination reveals numerous small red spots on the extremities
and a stiff neck. Her temperature is 38.7°C (103°F).
Lumbar puncture returns purulent fl uid, with segmented
neutrophils and Gram-negative organisms resembling meningococci.
A few hours later, the patient goes into shock and
becomes comatose. Severe endothelial injury in this patient is
primarily mediated by which of the following proteins?

Answer 8

8. Tumor necrosis factor-a (TNF-a).

Question 9

A 69-year-old man is brought to the emergency room
complaining of visual diffi culty and weakness. On physical
examination, the patient is aphasic with a right-sided
hemiplegia. Retinal hemorrhages are seen bilaterally. You
suspect that a thromboembolus coursed to the left middle
cerebral artery and smaller emboli traveled to the retinal
arteries. Which of the following anatomic sites is the most
likely source for these emboli in this patient?

Answer 9

9. Heart

Question 10

The body of a 28-year-old homeless man is brought to the
coroner’s offi ce. Histologic examination of the lungs under
polarized light is shown. Which of the following is the most
likely cause of the birefringence observed in this pulmonary
lesion?

Answer 10

10. Intravenous drug use.

Question 11

A 25-year-old woman delivers a healthy baby at 39 weeks of
gestation. Six hours later, the mother develops severe shortness
of breath and appears cyanotic. Despite resuscitation, she
dies 2 hours later. A section of lung at autopsy is shown in the
image. These pathologic fi ndings are associated with which of
the following mechanisms of disease?

Answer 11

11. Amniotic fluid embolism.

Question 12

If the patient described in Question 11 had survived the acute
episode of cyanosis and shock, she would have been at risk for
developing which of the following life-threatening complications?

Answer 12

12. Disseminated intravascular coagulation

DIC

Question 13

A 68-year-old man with ischemic heart disease and a history
of smoking complains of increasing shortness of breath. On
physical examination, the patient has swollen legs, an enlarged
liver, and fl uid in the pleural spaces (bubbly rales are heard on
oscultation). Which of the following hemodynamic disorders
explains the pathogenesis of hepatomegaly in this patient?

Answer 13

13. Chronic passive congestion

Question 14

The patient described in Question 13 suffers a massive heart
attack and expires. Microscopic examination of the liver at
autopsy would most likely reveal which of the following histopathologic
changes?

Answer 14

14. Sinusoids dilated with blood.

Question 15

A 33-year-old woman presents with black stools. Laboratory
studies demonstrate a hypochromic, microcytic anemia.
Upper GI endoscopy reveals a duodenal ulcer. Which of the
following best describes the stools in this patient with peptic

Answer 15

15. Melena

Question 16

A 53-year-old man is hospitalized after injuring his neck in
an automobile accident. He is placed in cervical traction. One
week later, the patient develops painful swelling and erythema
of his left calf. Doppler imaging discloses deep venous thrombosis.
Which of the following is the most likely cause for the
development of thrombosis in this patient

Answer 16

16. Stasis

Question 17

A 23-year-old man with hemophilia is recently wheelchair

bound. Which of the following best accounts for this development?

Answer 17

17. Hemarthrosis

Question 18

A 50-year-old fi re fi ghter emerges from a burning house with
third-degree burns over 70% of his body. The patient expires
24 hours later. Which of the following was the most likely
cause of death?

Answer 18

18. Hypovolemic shock.

Hypovolemic shock
may be caused by hemorrhage, fl uid loss from severe burns,
diarrhea, excessive urine formation, perspiration, or trauma.
In the case of burns or trauma, direct damage to the microcirculation
increases vascular permeability. Persons with
third-degree burns weep large amounts of plasma. The other
choices are unlikely causes of death in an acute burn victim.

Question 19

A 23-year-old woman complains of a recent onset of yellowing
of her skin and increasing abdominal girth. Physical examination
reveals jaundice and ascites. Ultrasound examination of
her abdomen demonstrates thrombosis of the hepatic veins.
A liver biopsy discloses severe sinusoidal dilation within the
centrilobular regions. This pathologic fi nding is caused by
which of the following hemodynamic disorders?

Answer 19

19. Passive hyperemia

Question 20

A 42-year-old woman undergoes a face lift. Two days later, she
presents for follow-up care with confl uent bluish hemorrhages
in the skin around her eyes (“black eyes”). Which of the following
best describes this pattern of superfi cial skin hemorrhage?

Answer 20

20. Ecchymosis

Question 21

A 19-year-old woman complains of swelling of her eyelids,
abdomen, and ankles. At bedtime, there are depressions in her
legs at the location of the elastic in her socks. A chest X-ray
shows bilateral pleural effusions. Urine protein electrophoresis
demonstrates 4+ proteinuria. A percutaneous needle biopsy of
the kidney establishes the diagnosis of minimal change nephrotic
syndrome. Soft tissue edema in this patient is most likely
caused by which of the following mechanisms of disease?

Answer 21

21. Decreased intravascular oncotic pressure.

Question 22

A 50-year-old alcoholic is rushed to the hospital with bleeding
esophageal varices and expires. At autopsy, the patient’s
protruding abdomen is found to contain a large volume of
serous fl uid. What is the appropriate term used to describe
this fl uid?

Answer 22

22. Ascites.

Question 23

A 1-year-old girl is brought to the emergency room by her parents
who report she has had a fever and diarrhea for 3 days. Her temperature
is 38°C (101°F). The CBC shows a normal WBC count
and increased hematocrit (48 g/dL). Which of the following is the
most likely cause of increased hematocrit in this patient?

Answer 23

23. Dehydration.

Question 24

A 40-year-old man with a history of bacterial endocarditis
notices numerous pinpoint hemorrhages around the orbit of his
eyes (shown in the image; see arrows). What is the appropriate
term used to describe this form of superfi cial hemorrhage?

Answer 24

24. Petechia.

Question 25

A 67-year-old man presents with sudden left leg pain, absence
of pulses, and a cold limb. His past medical history is signifi -
cant for coronary artery disease and a small aortic aneurysm.
Which of the following is most likely responsible for development
of a cold limb in this patient?

Answer 25

25. Arterial thromboembolism.

Question 26

A 78-year-old woman dies in her sleep. A Prussian blue stain of
the lungs at autopsy is shown in the image. Which of the following
is the most likely cause of these histopathologic findings?

Answer 26

26. Congestive heart failure

Question 27

A 60-year-old man who is recovering from surgery to correct
an abdominal aneurysm suddenly develops acute chest pain
and dies. A thromboembolus at the bifurcation of the left and
right pulmonary arteries is noted at autopsy (shown in the
image). Which of the following is the most likely cause of this
patient’s pulmonary embolus?

Answer 27

27. Deep venous thrombosis.

Question 28

A 20-year-old man is brought to the emergency room after
rupturing his spleen in a motorcycle accident. His blood pressure
on admission is 80/60 mm Hg. Analysis of arterial blood
gasses demonstrates metabolic acidosis. This patient is most
likely suffering from which of the following conditions?

Answer 28

28. Hypovolemic shock.

Question 29

A 72-year-old man is dead on arrival after collapsing at home.
Renal cortical infarcts are noted at autopsy. A section through
the arcuate artery is shown. Which of the following is the most
likely source of the atheroembolus occluding this artery?

Answer 29

29. Abdominal aorta.

Question 30

A 72-year-old woman complains of shortness of breath on
exertion. She states that she also becomes short of breath
at night unless she uses three pillows (orthopnea). Physical
examination reveals mild obesity, bilateral pitting leg edema,
an enlarged liver and spleen, and fi ne crackling sounds on
inspiration (rales). A chest X-ray shows cardiomegaly. What is
the most likely cause of orthopnea in this patient?

Answer 30

30. Pulmonary edema.

Question 31

A 63-year-old man suffers a massive stroke and expires. At
autopsy, the pathologist fi nds a laminated thrombus adherent
to the wall of the left ventricle (shown in the image).
Which of the following is the most likely cause of this autopsy
fi nding?

Answer 31

31. Myocardial infarction.

Question 32

Histologic examination of the heart in the patient described in
Question 31 shows extensive growth of fi broblasts and deposition
of collagen in the mural thrombus. Which of the following
terms describes this outcome of thrombosis?

Answer 32

32. Organization

Question 33

A 50-year-old woman presents with fatigue and shortness of
breath. Physical examination shows evidence of pulmonary
edema, enlargement of the left atrium, and calcifi cation of the
mitral valve. A CT scan demonstrates a large obstructing mass
in the left atrium. Before open heart surgery can be performed
to remove the tumor, the patient suffers a stroke and expires.
Which of the following hemodynamic disorders best explains
the pathogenesis of stroke in this patient?

Answer 33

33. Arterial embolism.

Question 34

A 50-year-old woman appears at your offi ce. She was subjected
to radical mastectomy and axillary node dissection
for breast cancer a year ago. She now notices that her arm
becomes swollen by the end of the day. What is the appropriate
name for this fl uid accumulation?

Answer 34

34. Lymphedema

Question 35

A 68-year-old man develops sudden, severe substernal chest
pain. Laboratory studies and ECG confi rm an acute myocardial
infarct. Despite vigorous therapy, the patient cannot maintain
his blood pressure and expires 24 hours later. A cross section of the left ventricle is examined at autopsy (shown in
the image). The arrows point to a soft, yellow area of necrosis.
Which of the following was the most likely cause of death?

Answer 35

35. Cardiogenic shock. Cardiogenic shock is
    caused by myocardial pump failure. This condition usually
    arises as a result of a large myocardial infarction, but myocarditis
    may also be responsible. Conditions that prevent
    left or right heart fi lling reduce cardiac output, resulting in
    obstructive shock. Such conditions include pulmonary embolism,
    cardiac tamponade, and (rarely) atrial myxoma. The
    other choices do not refl ect a loss of cardiac output secondary

Question 36

An 80-year-old woman with a history of hypertension is
rushed to the emergency room complaining of chest pain of
1-hour duration. Physical examination discloses bilateral pitting
leg edema, hepatosplenomegaly, and rales at the bases of
both lungs. The patient is apprehensive and sweating. The
patient loses consciousness and dies of a cardiac arrhythmia.
Microscopic examination of the lungs at autopsy is shown.
Which of the following hemodynamic processes best explains
this pathologic fi nding?

Answer 36

36. Increased intravascular hydrostatic pressure.

Question 37

A 9-month-old infant is brought to the emergency room with
a 3-hour history of intense abdominal pain and bloody diarrhea.
Physical examination reveals a tender abdomen without
ascites. The child dies 24 hours later, and torsion (volvulus)
of the small bowel is discovered at autopsy. The small bowel
appears dilated and hemorrhagic (shown in the image). Which
of the following best describes these pathologic fi ndings?

Answer 37

37. Infarct

Question 38

An autopsy of a 70-year-old woman reveals a subendocardial,
circumferential infarct of the left ventricle. This type of infarct
is most commonly associated with which of the following?

Answer 38

38. Hypotensive shock.

Question 39

A 76-year-old woman is brought to the emergency department
because of the sudden onset of two episodes of hemoptysis
and left-sided chest pain, which is exacerbated upon inspiration.
Her temperature is 38°C (101°F), pulse 110 per minute,
respirations 35 per minute, and blood pressure 158/100 mm
Hg. The patient is admitted, but suffers a massive stroke and
expires 48 hours later. Autopsy reveals a pulmonary infarct
in upper segments of the lower lobe (shown in the image).
Which of the following best explains the color of this patient’s
pulmonary infarct?

Answer 39

39. Hemorrhage from bronchial arteries

Question 40

A 22-year-old woman delivers a baby at 29 weeks of gestation.
Shortly after birth, the neonate becomes short of breath. The
neonate is placed on a ventilator, but dies of respiratory insuffi
ciency. The brain at autopsy is shown. Which of the following
mechanisms of disease best explains this complication of
respiratory distress syndrome (RDS) of the neonate?

Answer 40

40. Anoxic injury.