同济大学：《病理学》课程教学资源（试卷习题，含答案）Thrombosis I-II, Hemodynamics, Atherosclerosis

Week 3 Quiz 1 Thrombosis I-IL.Hemodynamics.Atherosclerosis 1.A 25-year-old female medical student is found to be anemic on a routine physical.She reports heavy menstrual bleeding throughout her life.She has also experienced frequent epistaxis(nose bleeds)and a "funny rash"on her legs whenever she takes aspirin.Her aPTT was also found to be mildly prolonged.Which diagnosis is most likely? A Factor vIll deficiency R Glanzma ann thrombasthenia C Live D.Th ombin defici E.VonWil ebrand Ans:E Von Willebrand disease results in both a platelet defect (prolonged bleeding time and micro- hemorrhages)AND a coagulation defect (prolonged PTT).Factor VIll deficiency (type A hemophilia)is X-linked (therefore more common in males)and would likely present with macro- hemorrhages,hemarthroses.and a prolonged PTT,but not a rash or menorrhagia.Glan-mann thrombasthenia is a platelet disorder due to defective plug formation (decreased Gpllb/Illa)that would not prolong the PTT.Liver failure would reduce the production of clotting factors,but this diagnosis is unlikely given only mild coagulation and platelet disturbances.Thrombin (factor lla)would present with prolonged PT,not PTT. 2.While shaving one morning L a 23-vear-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 vein? ization C Plat activation Ans:C The first barrier to further bleeding is the formation ofa platelet plug.This structure is very fragile,but gets reinforced by cross-linking with fibrinogen which is transformed to fibrin. Fibrin cross-linking is critical to reinforcing the platelet plug.but alone is not sufficient to stop bleeding.Neutrophil chemotaxis will clear bacteria introduced into the wound,but these cells do not stop bleeding.Protein C activation promotes anticoagulation,serving as a check on the coagulation cascade,which is the opposite of the desired effect for this patient.Vasodilation occurs in the setting of injury and inflammation,but this does not reduce blood loss

Week 3 Quiz 1 Thrombosis I-II, Hemodynamics, Atherosclerosis 1. A 25-year-old female medical student is found to be anemic on a routine physical. She reports heavy menstrual bleeding throughout her life. She has also experienced frequent epistaxis (nose bleeds) and a "funny rash" on her legs whenever she takes aspirin. Her aPTT was also found to be mildly prolonged. Which diagnosis is most likely? A. Factor VIII deficiency B. Glanzmann thrombasthenia C. Liver failure D. Thrombin deficiency E. VonWillebrand disease Ans: E Von Willebrand disease results in both a platelet defect (prolonged bleeding time and micro￾hemorrhages) AND a coagulation defect (prolonged PTT). Factor VIII deficiency (type A hemophilia) is X-linked (therefore more common in males) and would likely present with macro￾hemorrhages, hemarthroses, and a prolonged PTT, but not a rash or menorrhagia. Glanzmann thrombasthenia is a platelet disorder due to defective plug formation (decreased GpIIb/IIIa) that would not prolong the PTT. Liver failure would reduce the production of clotting factors, but this diagnosis is unlikely given only mild coagulation and platelet disturbances. Thrombin (factor IIa) would present with prolonged PT, not PTT. 2. 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 vein? A. Fibrin polymerization B. Neutrophil chemotaxis C. Platelet aggregation D. Protein C activation E. Vasodilation Ans: C The first barrier to further bleeding is the formation of a platelet plug. This structure is very fragile, but gets reinforced by cross-linking with fibrinogen which is transformed to fibrin. Fibrin cross-linking is critical to reinforcing the platelet plug, but alone is not sufficient to stop bleeding. Neutrophil chemotaxis will clear bacteria introduced into the wound, but these cells do not stop bleeding. Protein C activation promotes anticoagulation, serving as a check on the coagulation cascade, which is the opposite of the desired effect for this patient. Vasodilation occurs in the setting of injury and inflammation, but this does not reduce blood loss

3.An 80-year-old female falls down the steps leading to the entrance of the house of a relativ who is hosting a family reunion.She is hospitalized for surgery to replace a broken hip.She is then moved to a nursing home,but she is unable to ambulate until about a month later.She gets up to bathe with assistance and she experiences the sudden onset of severe dyspnea(shortness of breath)and goes into cardiac arrest,from which she cannot be resuscitated.Which of the following is most likely to be the immediate cause of death found at autopsy? A.Acute bronchopneumonia B.Acute renal failure C.Complications of alcohol abuse D.Congestive heart failure E.Pulmonary embolism Ans:E sis and this w man probably suffered a the le would e rena due to ischemic r toxic insult,i e088e den dea There is no indt on here of alco abuse,bu f she were an alco holic,trauma or liver failure would be more likely to cause ded th.Congestive heart failure would have a gradual or at least sub-acute onset.Sudden death could result from an arrhythmia but in the absence ofevidence indicating cardiac disease,this choice is less likely. 4.A 20-year-old man incurs blunt trauma to his upper outer arm.On physical examination,there is a 2 x 3 cm contusion.The initial soft tissue bleeding stops in a few minutes,the size of the bruise does not increase and the soft tissue bleeding resolves.Which of the following chemical mediators is most important in this episode of hemostasis? A Factor VIll B leukotriene C Plasmin D.Prost vclin ndir Ans:C mediators listed.on plasminogen plays arole in.is ihtly boud o us an important part of the platelet plug.Later.w s fibrin as part of the healing process.Factor VIll is part of the coagulation cascade,and in its absence. the coagulation cascade is dysfunctional.Leukotriene,prostacyclin and prostaglandin are involved in inflammation.not hemostasis. 5.When evaluating patients with bleeding disorders,the most important information is gained from the

3. An 80-year-old female falls down the steps leading to the entrance of the house of a relative who is hosting a family reunion. She is hospitalized for surgery to replace a broken hip. She is then moved to a nursing home, but she is unable to ambulate until about a month later. She gets up to bathe with assistance and she experiences the sudden onset of severe dyspnea (shortness of breath) and goes into cardiac arrest, from which she cannot be resuscitated. Which of the following is most likely to be the immediate cause of death found at autopsy? A. Acute bronchopneumonia B. Acute renal failure C. Complications of alcohol abuse D. Congestive heart failure E. Pulmonary embolism Ans: E Prolonged immobilization predisposes to venous stasis and this woman probably suffered a saddle embolus from a deep vein in the legs that killed her suddenly. Acute bronchopneumonia would not cause sudden death. Acute renal failure, due to ischemia or toxic insult, is a common complication in hospitalized patients, but there is no supporting evidence to suggest this diagnosis and it would not cause sudden death. There is no indication here of alcohol abuse, but if she were an alcoholic, trauma or liver failure would be more likely to cause death. Congestive heart failure would have a gradual or at least sub-acute onset. Sudden death could result from an arrhythmia but in the absence of evidence indicating cardiac disease, this choice is less likely. 4. A 20-year-old man incurs blunt trauma to his upper outer arm. On physical examination, there is a 2 x 3 cm contusion. The initial soft tissue bleeding stops in a few minutes, the size of the bruise does not increase and the soft tissue bleeding resolves. Which of the following chemical mediators is most important in this episode of hemostasis? A. Factor VIII B. Leukotriene C. Plasminogen D. Prostacyclin E. Prostaglandin Ans: C Of all the mediators listed, only plasminogen plays a role in clot formation. It is tightly bound to fibrin and thus an important part of the platelet plug. Later, when activated, it degrades fibrin as part of the healing process. Factor VIII is part of the coagulation cascade, and in its absence, the coagulation cascade is dysfunctional. Leukotriene, prostacyclin and prostaglandin are involved in inflammation, not hemostasis. 5. When evaluating patients with bleeding disorders, the most important information is gained from the

A.Clotting time B.History C.Platelet count D.Partial thromboplastin time E Prothrombin time Ans:B Many bleeding disorders are hereditary,thus a detailed family history can usually identify the etiology.If you were able to select onl ne of these laboro uld miss the di nlatelet dis med with detailed his to use only one test.but we'll leave that guesswor House chinician might be 6.A 12 year-old boy presents with a history of easy bruising and recurrent bleeding into his kne joints.He required a blood transfusion following extraction of a tooth when he was 9-years-old Laboratory results show a partial thromboplastin time(PTT)of 108 seconds with a control of 32 seconds,normal prothrombin time(PT)and normal bleeding time.The patient has which of the following deficiencies? A.Factor II B.Factor VII C.Factor VIII D.Factor XII E.Von Willebrand factor Ans:C Normal bleeding time rules ors Vill.IX.XI defect.Prolonged st be eficie with a famil 20 sfusion is clas sic jo A.O ency (pro-tnror ong both the ncy would prolong the xII defic s a very tosomal rec sive disord r that would reatly prolong more in deficiency):it d es not lead to exce eeding. deficiency woula present with evidence of a platelet disorder as well,namely a prolonged bleeding time:PTT may be normal or prolonged

A. Clotting time B. History C. Platelet count D. Partial thromboplastin time E. Prothrombin time Ans: B Many bleeding disorders are hereditary, thus a detailed family history can usually identify the etiology. If you were able to select only one of these laboratory tests, chances are you would miss the diagnosis, especially in setting of mixed platelet and coagulation disorders. Armed with a detailed history, an experienced clinician might be able to use only one test, but we’ll leave that guesswork to House. 6. A 12 year-old boy presents with a history of easy bruising and recurrent bleeding into his knee joints. He required a blood transfusion following extraction of a tooth when he was 9- years-old. Laboratory results show a partial thromboplastin time (PTT) of 108 seconds with a control of 32 seconds, normal prothrombin time (PT) and normal bleeding time. The patient has which of the following deficiencies? A. Factor II B. Factor VII C. Factor VIII D. Factor XII E. Von Willebrand factor Ans: C Normal bleeding time rules out platelet disorders, so this is a pure coagulation defect. Prolonged PTT and normal PT indicate that one of factors VIII, IX, XI, or XII must be deficient. A male with a family history and bleeding requiring a transfusion is classic for hemophilia A, or deficiency of Factor VIII (X-linked). Factor II deficiency (pro-thrombin) would prolong both the PTT and PT. Factor VII deficiency would prolong the PT. Factor XII deficiency is a very rare, autosomal recessive disorder that would greatly prolong PTT (even more than Factor VIII deficiency); it does not lead to excessive bleeding. Von Willebrand factor deficiency would present with evidence of a platelet disorder as well, namely a prolonged bleeding time; PTT may be normal or prolonged

7.Approximately 30-60 minutes after being bitten by a"bug",a 16 year-old ma n noticed a localized swelling and erythema in the affected area.These changes are caused by which of the following physiologic responses? A.Altered plasma oncotic pressure B.Increased arterial hydrostatic pressure C.Increased vascular permeability D.Lymphatic obstruction E.Venous obstruction Ans:C The inflammatory response induces vasodilation causing extravasation of fluids (swelling)and erythema due to the increased local blood flow.Altered plasma oncouic ressure ased drostatic rily ma anc ob mnune response to 8.A 61-year-old man has had lower leg swelling and pitting edema to the knees with prominen jugular venous distension to the level of the mand ible.He also complains of dyspnea(shortness of breath)after walking from his bedroom to his kitchen.Based on the appearance of the liver seen here.which of the following underlying conditions is likely to be present? A.Chronic renal failure B.Common bile duct obstruction

7. Approximately 30-60 minutes after being bitten by a "bug", a 16 year-old man noticed a localized swelling and erythema in the affected area. These changes are caused by which of the following physiologic responses? A. Altered plasma oncotic pressure B. Increased arterial hydrostatic pressure C. Increased vascular permeability D. Lymphatic obstruction E. Venous obstruction Ans: C The inflammatory response induces vasodilation causing extravasation of fluids (swelling) and erythema due to the increased local blood flow. Altered plasma oncotic pressure, increased arterial hydrostatic pressure, lymphatic obstruction and venous obstruction would all cause edema, but not necessarily marked erythema. Moreover, these situations are not directly correlated to the immune response to injury. 8. A 61-year-old man has had lower leg swelling and pitting edema to the knees with prominent jugular venous distension to the level of the mandible. He also complains of dyspnea (shortness of breath) after walking from his bedroom to his kitchen. Based on the appearance of the liver seen here, which of the following underlying conditions is likely to be present? A. Chronic renal failure B. Common bile duct obstruction

C.Congestive heart failure D.Portal vein thrombosis E.Thrombocytopenia Ans:C This gentleman probably has left-sided heart failure (causing pulmonary congestion)that has mic edema.increased JVP.and hepatic co rainst the vellow fthe cells in the lobular nal und.Co bile du and pal ored sto bu it does no n signific ould ca hepatic portal hyp lension ccurs most comm h cirrho patient's dyspnea. Increased hepatic congestion can lead to congestion in the splenic vein and ubsequent thrombocytopenia 9.A 61-year-old man had a myocardial infarction(MI)one year ago,which was the first major illness of his life.He smokes a pack of cigarettes a day and has done so for the past 40 years.His father died of an MI at age 55.His cholesterol level is elevated.He is employed as a urologic surgeon in private practice.Which of the following strategies would be most effective in this patient's management? A.Aggressive reduction of serum cholesterol to 250 mg/dl B.Genetic manipulation C.Hire a junior partner for his urologic surgery practice. D.Rest by increasing sedentary activity. E.Stop smoking and start a regular exercise program Ans:E 0s2Cew”口 stero dbetes.Chole han 100 patients with significant ng cess ion and starting a regular exercise hat patlents shoud o ae c choice n dcy s exdcny me opposte o 10.A 50-year-old man has a two-year history of angina pectoris that occurs when he exercises His blood pressure and pulse are normal.Coronary angiography shows 75%narrowing of the left anterior descending artery.Which of the following cell types was the initial target in the development of this lesion? A.Endothelial cells B.Fibroblasts C.Lymphocytes

C. Congestive heart failure D. Portal vein thrombosis E. Thrombocytopenia Ans: C This gentleman probably has left-sided heart failure (causing pulmonary congestion) that has progressed to right sided heart failure (systemic edema, increased JVP, and hepatic congestion). The image shows “nutmeg liver” in which the distended central veins stand out as dark red foci against the yellow of the cells in the lobular periphery. Hepatorenal syndrome causes renal failure due to hypo-perfusion in the setting of cirrhosis, but not the other way around. Common bile duct obstruction would cause jaundice, abdominal pain, dark urine, and pale-colored stools, but it does not explain significant edema and dyspnea. Portal vein thrombosis would cause pre￾hepatic portal hypertension and occurs most commonly with cirrhosis. This does not explain the patient’s dyspnea. Increased hepatic congestion can lead to congestion in the splenic vein and subsequent thrombocytopenia. 9. A 61-year-old man had a myocardial infarction (MI) one year ago, which was the first major illness of his life. He smokes a pack of cigarettes a day and has done so for the past 40 years. His father died of an MI at age 55. His cholesterol level is elevated. He is employed as a urologic surgeon in private practice. Which of the following strategies would be most effective in this patient’s management? A. Aggressive reduction of serum cholesterol to 250 mg/dl B. Genetic manipulation C. Hire a junior partner for his urologic surgery practice. D. Rest by increasing sedentary activity. E. Stop smoking and start a regular exercise program. Ans: E Coronary heart disease risk is substantially reduced within two years of quitting smoking. Exercise will increase cardiac health as well as improve control of blood pressure, weight, cholesterol, and diabetes. Cholesterol should be less than 100mg/dL for patients with significant cardiac risk. Hiring a junior partner might reduce his stress, but smoking cessation and starting a regular exercise program is the single best choice. Sedentary activity is exactly the opposite of what patients should do after a heart attack. 10. A 50-year-old man has a two-year history of angina pectoris that occurs when he exercises. His blood pressure and pulse are normal. Coronary angiography shows 75% narrowing of the left anterior descending artery. Which of the following cell types was the initial target in the development of this lesion? A. Endothelial cells B. Fibroblasts C. Lymphocytes

D.Platelets E.Smooth muscle cells Ans:A The general sequence of atherosclerotic plaques is this:endothelial injury at lesion prone sites (low sheer stress,fluctuating flow)>macrophages adhere to injured endothelial and bring lipids foamy macrophages reduce growth factors to promote smooth muscle cell proliferation and inflammation mural thrombi stimulate PDGF>smooth muscle proliferation an matrix deposition formation of fibro-inflammatory lipid plaque with central necrotic core:Platelets and lymphocytes do not play a role in plaque formation. 11.A 59-year-old man has experienced chest pain at rest for over one year.He develops crushing chest pain,collapses and dies due to arrhythmia.The figure above shows a cross section of his left anterior descending artery.Which of the following laboratory findings has a causal relationship to this lesion? A.Absent C-reactive protein B.Inherited deficiency in VEGF C.Low HDL cholesterol D Low total se n cholesterol E.Positive VDRL Ans:C Elevated HDL is associated with decreased risk of coronary artery disease,thus low HDL is likely in this patient.CRP has been associated with cardiovascular disease but it is non-specific

D. Platelets E. Smooth muscle cells Ans: A The general sequence of atherosclerotic plaques is this: endothelial injury at lesion prone sites (low sheer stress, fluctuating flow)  macrophages adhere to injured endothelial and bring lipids  foamy macrophages reduce growth factors to promote smooth muscle cell proliferation and inflammation  mural thrombi stimulate PDGF  smooth muscle proliferation an matrix deposition  formation of fibro-inflammatory lipid plaque with central necrotic core; Platelets and lymphocytes do not play a role in plaque formation. 11. A 59-year-old man has experienced chest pain at rest for over one year. He develops crushing chest pain, collapses and dies due to arrhythmia. The figure above shows a cross section of his left anterior descending artery. Which of the following laboratory findings has a causal relationship to this lesion? A. Absent C-reactive protein B. Inherited deficiency in VEGF C. Low HDL cholesterol D. Low total serum cholesterol E. Positive VDRL Ans: C Elevated HDL is associated with decreased risk of coronary artery disease, thus low HDL is likely in this patient. CRP has been associated with cardiovascular disease but it is non-specific

Anti-neoplastic drugs that block VEGF have cardiac toxicity.but inherited deficiency of VEGF exists only in a few case reports of hereditary lymphedema or mouse models demonstrating embryonic cardiovascular failure.The total cholesterol to HDL ratio is a better predictor of coronary artery disease than serum cholesterol alone.A positive VRDL would indicate syphilis or one of the many false positive conditions (HIV.SLE,malaria,Lyme disease). 12.A 12-year-old boy died of complications of acute lymphocytic leukemia.An autor sy was Are debris covered byacapof smooth musce cells A d c lation and hemorrhag cells and macrophages Ep调本d Ans:E The photograph shows a fatty streak,a flat lesion in the intima that contains accumulations of lipid.These are common even in voung children.subsequent stages of atherosclerotic plaque formation are represented by features such as a core of lipid debris covered by a cap of smooth muscle cells:cholesterol clefts surrounded by smooth muscle cells and macrophages;a lipid core,granulation tissue and hemorrhage and foam cells (macrophages),areas of necrosis and calcification

Anti-neoplastic drugs that block VEGF have cardiac toxicity, but inherited deficiency of VEGF exists only in a few case reports of hereditary lymphedema or mouse models demonstrating embryonic cardiovascular failure. The total cholesterol to HDL ratio is a better predictor of coronary artery disease than serum cholesterol alone. A positive VRDL would indicate syphilis or one of the many false positive conditions (HIV, SLE, malaria, Lyme disease). 12. A 12-year-old boy died of complications of acute lymphocytic leukemia. An autopsy was performed and his aorta is shown above. Histologic examination of the area marked by the arrow is most likely to show which of the following features? A. A core of lipid debris covered by a cap of smooth muscle cells B. A lipid core, granulation tissue and hemorrhage C. Cholesterol clefts surrounded by smooth muscle cells and macrophages. D. Foam cells (macrophages), areas of necrosis and calcification. E. Lipid filled myointimal cells Ans: E The photograph shows a fatty streak, a flat lesion in the intima that contains accumulations of lipid. These are common even in young children. Subsequent stages of atherosclerotic plaque formation are represented by features such as a core of lipid debris covered by a cap of smooth muscle cells; cholesterol clefts surrounded by smooth muscle cells and macrophages; a lipid core, granulation tissue and hemorrhage and foam cells (macrophages), areas of necrosis and calcification