a = new Array(274);
var f = "<FONT FACE=ARIAL SIZE=2>"
a[0] = ""
a[1] = f + "(A) Incorrect. Hyperplastic arteriolosclerosis can accompany malignant hypertension, which he does not have."
a[2] = f + "(B) Incorrect. Lymphedema is not related to the risk factors that he has, which are factors affecting muscular arteries."
a[3] = f + "(C) Incorrect. Medical calcific sclerosis is a benign form of arteriosclerosis that does not often contribute to significant disease. It does not involve coronary arteries."
a[4] = f + "(D) CORRECT. He has multiple risk factors for atherosclerosis, including his weight, smoking, hypertension, and high total cholesterol with low 'good' HDL cholesterol. His findings suggest coronary artery disease."
a[5] = f + "(E) Incorrect. He does have an increased risk for thrombosis, but atherosclerosis is the worst risk, and his symptoms suggest coronary artery disease."
a[5.1] = f + "(F) Incorrect. Plexiform arteriopathy is seen in peripheral pulmonary arteries with pulmonary hypertension."
a[6] = f + "(A) Incorrect. The hypercoagulable state of Trousseau syndrome with an underlying malignancy such as an adenocarcinoma predisposes to venous thrombosis, but her prior healthy condition makes malignancy less likely."
a[7] = f + "(B) Incorrect. Protein C deficiency is associated with venous thrombosis, but the onset of the disease is typically much earlier in life."
a[8] = f + "(C) CORRECT. The immobilization would predispose to thrombosis of leg veins. This is the most common cause for deep venous thrombosis."
a[9] = f + "(D) Incorrect. The enlarged uterus obstructing venous return would predispose to thrombosis. However, her age is not in the childbearing years, and prior pregnancies do not significantly increase the risk for thrombosis."
a[10] = f + "(E) Incorrect. The liver disease of chronic alcoholism predisposes to coagulopathy with hemorrhage, not thrombosis."
a[10.1] = f + "(F) Incorrect. Systemic hypertension increases the risk for atherosclerosis, which increases the risk for thrombosis in the arterial system, such as the coronary arteries or carotid arteries."
a[11] = f + "(A) Incorrect. Atherosclerotic aneurysms of the abdominal aorta can occur with the advanced atherosclerosis of diabetes mellitus, but there can be a pulsatile mass, and rupture is a medical emergency."
a[12] = f + "(B) Incorrect. The liver has a dual blood supply (hepatic arterial plus portal venous circulations) and is difficult to infarct."
a[13] = f + "(C) CORRECT. He has 'abdominal angina' from diminished blood flow to the bowel as a consequence of severe atherosclerosis. Persons with diabetes mellitus may have this finding, because all branches of major arteries to the bowel are affected by atherosclerosis."
a[14] = f + "(D) Incorrect. Pancreatitis is a disease of the pancreatic acinar parenchyma, not the islets. Even in persons with pancreatitis, diabetes mellitus is a rare outcome."
a[15] = f + "(E) Incorrect. Nephrosclerosis can lead to renal failure. However, there is typically no pain associated with this process."
a[16] = f + "(A) Incorrect. This is the infamous 'paradoxical embolus' through a patent foramen ovale, and it rarely occurs."
a[17] = f + "(B) Incorrect. Left atrial thrombi are prone to embolize to the arterial circulation, but an enlarged left atrium is most likely to result from valvular heart disease, not ischemic heart disease."
a[18] = f + "(C) Incorrect. The left ventricular thrombi cannot get into the pulmonary circulation without a ventricular septal defect, and the VSD would probably lead to abnormal cardiac function."
a[19] = f + "(D) CORRECT. Left ventricular mural thrombi are prone to embolize to the systemic arterial circulation. Such mural thrombi are likely to result from damage to the left ventricle from ischemic heart disease, either acutely with an underlying myocardial infarction, or with a left ventricular aneurysm formed following resolution of a large myocardial infarction."
a[20] = f + "(E) Incorrect. Peripheral veins, particularly the large leg veins, are usually the source for pulmonary emboli."
a[21] = f + "(A) CORRECT. The bronchial arterial supply to the lung does not provide enough oxygenation to prevent infarction, but does provide blood to make the infarct hemorrhagic."
a[22] = f + "(B) Incorrect. A myocardial infarction is predominantly ischemic, though the border may be hemorrhagic."
a[23] = f + "(C) Incorrect. The liver is hard to infarct because of its dual blood supply, but when infarcts occur, they are usually pale."
a[24] = f + "(D) Incorrect. Renal infarcts are usually ischemic and pale."
a[25] = f + "(E) Incorrect. Splenic infarcts are typically pale."
a[25.1] = f + "(F) Incorrect. A cerebral arterial aneurysm is most likely to rupture and produce subarachnoid hemorrhage. This hemorrhage may produce vasospasm with cerebral ischemia, which in the brain can produce liquefactive necrosis."
a[26] = f + "(A) Incorrect. This is far too much fat. No more than 30% of the diet should consist of fat."
a[27] = f + "(B) Incorrect. Saturated fats are worse than unsaturated fats."
a[28] = f + "(C) Incorrect. Increased dietary cholesterol is not good."
a[29] = f + "(D) CORRECT. Fish oils diminish arachidonic acid metabolites and reduce platelet aggregation."
a[30] = f + "(E) Incorrect. Animal fats tend to be saturated fats."
a[30.1] = f + "(F) Incorrect. Trans-fats are partially hydrogenated fats made commercially. Trans-fats tend to increase LDL cholesterol, decrease HDL cholesterol, and increase triglycerides - all of which are bad effects."
a[31] = f + "(A) Incorrect. An increased WBC count suggests inflammation, or may represent cell death with infarction following thrombosis."
a[32] = f + "(B) Incorrect. The cirrhotic liver functions poorly, usually causing an increase in prothrombin time. This makes it more difficult to form thrombi."
a[33] = f + "(C) CORRECT. She has a pulmonary thromboembolus. Stasis predisposes to thrombosis, as is evidenced by the danger for thromboembolism in hospitalized patients."
a[34] = f + "(D) Incorrect. Only infrequently does an increased number of platelets lead to increased thrombosis."
a[35] = f + "(E) Incorrect. Atherosclerosis is seen in arteries, not veins."
a[36] = f + "(A) Incorrect. Chylomicrons are formed by complexing lipids absorbed from the small intestine to transport apoproteins. They then travel to the liver. They do not directly produce atheromatous plaques."
a[37] = f + "(B) Incorrect. Endothelial lipoprotein lipase splits off fatty acids that are then used as a substrate in other metabolic pathways and not in atheroma formation."
a[38] = f + "(C) CORRECT. She has had a 'stroke' which is most often a consequence of cerebral atherosclerosis or embolic disease from the heart as a consequence of ischemic heart disease from atherosclerosis. LDL brings cholesterol to arterial walls, and when increased LDL is present or when there is hypertension, smoking, and diabetes, there is more degradation of LDL to oxidized LDL which is taken up into arterial walls via scavenger receptors in macrophages to help form atheromas."
a[39] = f + "(D) Incorrect. Both adipose tissue and muscle are areas where VLDL is transformed to LDL, and this does not directly promote atherogenesis."
a[40] = f + "(E) Incorrect. HDL cholesterol helps to transport lipid away from arterial walls to the liver, thus protecting against atheroma formation."
a[41] = f + "(A) Incorrect. Thrombosis is a complication of an atheroma."
a[42] = f + "(B) CORRECT. This is the first sign. It is benign and reversible, but it may be the precursor to more severe plaques."
a[43] = f + "(C) Incorrect. Calcification is a complication of an atheroma."
a[44] = f + "(D) Incorrect. Hemorrhage is a complication of an atheroma."
a[45] = f + "(E) Incorrect. Lymphocytes and macrophages play a role in atherogenesis, but their numbers are relatively small."
a[45.1] = f + "(F) Incorrect. Ulceration of an atheromatous plaque is an advanced lesion, not an early lesion. Ulceration or fissuring of the plaque increases the likelihood for overlying thrombosis."
a[46] = f + "(A) CORRECT. This is the most common cause of death in persons with diabetes mellitus, because of the high prevalence of coronary atherosclerosis."
a[47] = f + "(B) Incorrect. Although renal failure is a common complication of diabetes, it is not the major cause of death."
a[48] = f + "(C) Incorrect. Cerebrovascular disease in diabetes is common but is not the major cause of death."
a[49] = f + "(D) Incorrect. This complication may be life-threatening, but it is not frequent."
a[50] = f + "(E) Incorrect. This complication is usually treated before secondary sepsis becomes life-threatening."
a[51] = f + "(A) Incorrect. An elevated blood ammonia is indicative of increasing hepatic failure."
a[52] = f + "(B) Incorrect. Hypercalcemia can be associated with hyperparathyroidism."
a[53] = f + "(C) Incorrect. Increased cholesterol leads to atherosclerotic vascular changes."
a[54] = f + "(D) CORRECT. The findings suggest hyperplastic arteriolosclerosis, which accompanies malignant hypertension."
a[55] = f + "(E) Incorrect. Myocardial injury increases the troponin I."
a[55.1] = f + "(F) Incorrect. An elevated triglyceride increases the risk for atherosclerosis with atheroma formation, but not concentric endothelial proliferation."
a[55.2] = f + "(G) Incorrect. An increased CRP can be a marker for an increased risk for atherosclerosis with atheroma formation, but not concentric endothelial proliferation."
a[56] = f + "(A) Incorrect. The insulin is probably decreased."
a[57] = f + "(B) Incorrect. The glucagon is probably increased."
a[58] = f + "(C) CORRECT. Ketonuria is typical for type I diabetes mellitus."
a[59] = f + "(D) Incorrect. This finding is more typical of type II diabetes mellitus."
a[60] = f + "(E) Incorrect. The child probably has ketoacidosis."
a[60.1] = f + "(F) Incorrect. She is unlikely to have an acute Addison disease which would be characterized by hypotension and hypoglyccemia, and she is unlikely to present at this age with congenital adrenal hyperplasia."
a[61] = f + "(A) Incorrect. Although calcification may complicate atheromas, this is typically seen in larger vessels."
a[62] = f + "(B) CORRECT. Monckeberg calcific medial sclerosis is a benign, incidental finding most often seen in the elderly. Small arteries in pelvis and extremities are typically involved. The vascular lumen is not compromised."
a[63] = f + "(C) Incorrect. Metastatic calcification from hypercalcemia would involve other areas in lung, kidney and GI tract first."
a[64] = f + "(D) Incorrect. Dystrophic calcification following injury from trauma would be localized and would take weeks to form."
a[65] = f + "(E) Incorrect. Dystrophic calcification from tissue damage would probably not be so localized to arteries."
a[66] = f + "(A) CORRECT. The signs point to thrombophlebitis."
a[67] = f + "(B) Incorrect. Septic emboli produce focal hemorrhage or infarction and are usually arterial."
a[68] = f + "(C) Incorrect. The peripheral edema that accompanies CHF would be symmetrical."
a[69] = f + "(D) Incorrect. Cellulitis would produce a warm, swollen, tender appearance from the subcutaneous inflammation."
a[70] = f + "(E) Incorrect. Infarction is a focal process from arterial occlusion."
a[71] = f + "(A) Incorrect. She has signs of marked blood loss, so her hematocrit should be low--probably in the 20's or lower."
a[72] = f + "(B) Incorrect. Hyperglycemia is not a feature of blood loss with shock."
a[73] = f + "(C) Incorrect. She has had blood loss, but the oxygen carrying capacity of the remaining RBCs is not affected, and her ability to oxygenate is not completely lost."
a[74] = f + "(D) CORRECT. She has marked blood loss with shock. There will be vasoconstriction in skin in response to the hypovolemia. Decreased renal blood flow from shock can lead to acute tubular necrosis. The lack of tissue perfusion with shock leads to increased anaerobic glycolysis and lactic acidosis."
a[75] = f + "(E) Incorrect. An elevated troponin I suggests myocardial ischemia. With good coronary blood flow in a young person, the myocardium is not seriously affected until the patient is near death."
a[76] = f + "(A) Incorrect. The elevation in creatine kinase is indicative of myocardial cell necrosis, not regeneration."
a[77] = f + "(B) Incorrect. The tPA does not produce a chemical injury, but induces thrombolysis to help restore blood flow."
a[78] = f + "(C) CORRECT. The restoration of blood flow is helpful if the existing cell damage is not great, so further damage can be prevented. However, the reperfusion of damaged cells results in generation of oxygen free radicals to produce a reperfusion injury."
a[79] = f + "(D) Incorrect. Creatine kinase is released, but synthesis does not (cannot) increase from the injured cells."
a[80] = f + "(E) Incorrect. The elevation in creatine kinase is indicative of myocardial cell necrosis, not atrophy."
a[81] = f + "(A) Incorrect. Though an increased total serum cholesterol suggests a risk for atherosclerosis and its complications, it does not predict acute events."
a[82] = f + "(B) Incorrect. The size of the infarct gives no clue as to whether a thrombus was present or not."
a[83] = f + "(C) Incorrect. The severity of the atherosclerosis does not necessarily predict whether a thrombus will have formed."
a[84] = f + "(D) CORRECT. The purpose of thrombolytic therapy is to lyse the thrombus and restore blood flow."
a[85] = f + "(E) Incorrect. Atherosclerosis is accelerated and complications are more likely with diabetes mellitus, but this does not indicate that a thrombus is present."
a[86] = f + "(A) Incorrect. Caseous necrosis is a mixture of liquefactive and coagulative necrosis, and is typical for inflammation caused by mycobacterial or fungal infections."
a[87] = f + "(B) CORRECT. A typical ischemic infarction with coagulative necrosis is described."
a[88] = f + "(C) Incorrect. Fat necrosis most often occurs in breast (with trauma) and in pancreas (with acute pancreatitis)."
a[89] = f + "(D) Incorrect. Gangrene involves a whole organ or body part. There can be elements of coagulative necrosis ('dry' gangrene) and liquefactive necrosis ('wet' gangrene)."
a[90] = f + "(E) Incorrect. Liquefactive necrosis is most typical for brain infarction and for abscesses with many neutrophils."
a[91] = f + "(A) Incorrect. The cerebral bridging veins cross the subdural space and rupture of them can produce a subdural hematoma. Cerebral venous thrombosis is far less common than cerebral arterial thrombosis or embolism."
a[92] = f + "(B) Incorrect. Vertebral artery thrombi are rare and may be the result of local trauma."
a[93] = f + "(C) Incorrect. The superior vena cava may become occluded by thrombus when involved by a neoplasm in the chest. A thromboembolus from a leg vein may pass through the inferior vena cava on the way to the pulmonary arterial tree."
a[94] = f + "(D) CORRECT. Mural thrombi can form over the damaged area of ventricular wall following myocardial infarction. Portions of the mural thrombus can break off and embolize via the systemic arterial circulation to places such as the cerebral circulation."
a[95] = f + "(E) Incorrect. His original myocardial infarction may have been due to coronary thrombosis, but his last event was not, since the troponin I was not elevated."
a[95.1] = f + "(F) Incorrect. A thrombus in the saphenous vein may become a thromboembolus that travels to the lungs. The only way such a thromboembolus may reach the arterial circulation is through a patent foramen ovale--a rare event."
a[96] = f + "(A) Incorrect. The babies of diabetic mothers tend to have macrosomia (increased size)."
a[97] = f + "(B) Incorrect. This patient has gestational diabetes, not type 1 diabetes mellitus."
a[98] = f + "(C) Incorrect. This unlikely, given that hyperosmolar coma is more typical of older type 2 diabetics."
a[99] = f + "(D) Incorrect. The rate of fetal malformation is slightly increased in mothers with diabetes mellitus type 1 or 2, but not gestational diabetes."
a[100] = f + "(E) CORRECT. The big problem in gestational diabetes is eventual placental malfunction in later pregnancy (third trimester) with potential fetal demise."
a[101] = f + "(A) CORRECT. Out-of-control diabetes over time can be better detected because the glycosylated RBCs will persist for months and the Hgb A1C increased."
a[102] = f + "(B) Incorrect. The ketones suggest ketoacidosis, but this could have been a recent development."
a[103] = f + "(C) Incorrect. Hyperosmolar coma is possible, but would be relatively recent in onset."
a[104] = f + "(D) Incorrect. This would be a likely finding with diabetes mellitus, but would tell you nothing about the course or the degree of control of hyperglycemia."
a[105] = f + "(E) Incorrect. In type I diabetes mellitus, elevated anti-insulin antibodies are often present, but tell you nothing about the course or the control of the hyperglycemia."
a[106] = f + "(A) Incorrect. Type II diabetes mellitus is most often a disease of middle aged to older adults."
a[107] = f + "(B) Incorrect. Malignant hypertension may, on occasion, complicate longstanding hypertension that is associated with development of atherosclerosis, but this is usually a complication seen in middle aged to older adults."
a[108] = f + "(C) CORRECT. The very high cholesterol with symptoms of coronary artery disease at such a young age, coupled with the family history, are all consistent with familial hypercholesterolemia. In most persons with hypercholessterolemia from multifactorial causes, including diet and exercise patterns, the cholesterol rarely exceeds 400 mg/dL."
a[109] = f + "(D) Incorrect. The hypercortisolism of Cushing syndrome tends to promote diabetes mellitus, but the underlying conditions that lead to Cushing syndrome are unlikely to allow a long enough survival to develop severe atherosclerosis."
a[110] = f + "(E) Incorrect. Morbid obesity is a risk for type II diabetes mellitus, and decades are required to develop complications of atherosclerosis. It is unlikely that the cholesterol would be this high."
a[111] = f + "(A) Incorrect. Atherosclerotic cerebrovascular disease is more frequent with diabetes mellitus, but not findings related to osmotic vascular injury."
a[112] = f + "(B) Incorrect. The risk for cancer is not increased with diabetes mellitus."
a[113] = f + "(C) Incorrect. However, the major damage to the heart with diabetes mellitus is done via atherosclerotic coronary artery disease. Atherosclerosis affects muscular arteries by formation of intimal atheromatous plaques which occlude the lumen and lead to ischemic injury."
a[114] = f + "(D) CORRECT. The hyperglycemia leads to formation of sorbitol in tissues not requiring insulin for glucose uptake, resulting in osmotic cellular injury. This can occur in small vessels, retina, kidney, and nerves. The failure of erection and ejaculation results from diabetic neuropathy."
a[115] = f + "(E) Incorrect. Pyelonephritis with diabetes is related to diminished neutrophil function with hyperglycemia."
a[116] = f + "(A) Incorrect. The result of lymphatic obstruction is lymphedema, with marked swelling from collection of interstitial fluid. Lymphatics normally scavenge the fluid and protein that escapes at the venule and capillary level and returns it to circulation."
a[117] = f + "(B) Incorrect. Arteriolosclerosis is more typically found in the kidneys and brain, not the extremities."
a[118] = f + "(C) CORRECT. She has claudication from severe peripheral arterial atherosclerosis, most likely from the iliac arteries down. She has risk factors for atherosclerosis."
a[119] = f + "(D) Incorrect. Medial calcific sclerosis of Monckeberg is not typically a serious problem."
a[120] = f + "(E) Incorrect. Venous thrombosis should lead to a warm, tender, swollen extremity."
a[121] = f + "(A) Incorrect. Hypercalcemia is not a risk factor for advanced atherosclerosis."
a[122] = f + "(B) CORRECT. Hypertension is a risk factor that accelerates atheromatous plaque formation."
a[123] = f + "(C) Incorrect. In Marfan syndrome, there is cystic medial necrosis of the aorta, but not atherosclerosis."
a[124] = f + "(D) Incorrect. Thrombophlebitis involves veins. Atherosclerosis does not involve veins."
a[125] = f + "(E) Incorrect. Various forms of vasculitis may produce vascular occlusion, but do not accelerate atherosclerosis."
a[125.1] = f + "(F) Incorrect. Cancer is a debilitating condition likely to result in reversal of atheroma formation. Hypercoagulable states from cancers are most likely to result in venous thrombosis, though arterial thrombi are possible, but not dependent upon prior arterial atheroma formation."
a[125.2] = f + "(G) Incorrect. SLE and autoimmune diseases in general are debilitating conditions in which atheromas may diminish in size. The antiphospholipid syndrome that can sometimes occur with SLE can lead to thrombosis, not atheroma formation."
a[126] = f + "(A) CORRECT. Immobilization is a major risk for the development of venous thrombosis and subsequent pulmonary embolization."
a[127] = f + "(B) Incorrect. Thrombocytopenia leads to bleeding, not to thrombosis."
a[128] = f + "(C) Incorrect. Chronic alcoholics tend to have a coagulopathy due to their underlying liver disease which predisposes them to bleeding, not thrombosis."
a[129] = f + "(D) Incorrect. Some AIDS patients get an acquired protein S deficiency that predisposes to thrombosis, but this is not common."
a[130] = f + "(E) Incorrect. Persons with autoimmune diseases generally do not have major problems with thrombosis, though some can develop an antiphospholipid syndrome with thrombosis."
a[131] = f + "(A) Incorrect. Amyloid deposits can be seen in small arteries and glomeruli in the kidney, but do not produce a hyperplastic arteriolosclerosis."
a[132] = f + "(B) Incorrect. Lupus nephritis may be accompanied by a vasculitis, but not hyperplastic arteriolosclerosis."
a[133] = f + "(C) CORRECT. Hyperplastic arteriolosclerosis is typically seen with severe hypertension, which can occur with progressive systemic sclerosis (scleroderma)."
a[134] = f + "(D) Incorrect. There are no prominent vascular changes with rheumatoid arthritis."
a[135] = f + "(E) Incorrect. Cryoglobulinemic vasculitis may complicate some cases of hepatitis B or C infection. In general viral infections do not involve the vasculature."
a[135.1] = f + "(F) Incorrect. Diabetes mellitus leads to accelerated atherosclerosis of medium to large arteries. There may also be hyaline arteriolosclerosis, but not hyperplastic arteriolosclerosis."
a[136] = f + "(A) Incorrect. Diabetes mellitus is a disease marked by hyperglycemia that leads to early and advanced atherosclerosis with peripheral vascular disease."
a[137] = f + "(B) Incorrect. Patients with hypercholesterolemia are at increased risk for accelerated atherosclerosis and peripheral vascular disease."
a[138] = f + "(C) Incorrect. Poor tissue perfusion leads to increased anaerobic glycolysis and lactic acidosis."
a[139] = f + "(D) CORRECT. The platelets are responsible for dealing with small leaks in vessels. Thrombocytopenia is marked by petechiae and purpura. She does not have evidence for peripheral vascular disease, since her circulation is good. Venous thrombosis should lead to swelling and tenderness."
a[140] = f + "(E) Incorrect. She has no evidence for liver disease, which would reduce prothrombin production. The pattern of her bleeding fits best with lack of platelets, not coagulation factors."
a[140.1] = f + "(F) Incorrect. The amount of bleeding into soft tissues is unlikely to lower the hematocrit significantly. Bone marrow injuries that lead to reduced platelet production, however, may also lead to anemia. With anemia, tissue appear pale."
a[141] = f + "(A) Incorrect. Older persons are at risk for cancer, but this course suggests immobilization leading to pulmonary thromboembolism."
a[142] = f + "(B) Incorrect. Signs and symptoms of an infectious disease were not present."
a[143] = f + "(C) CORRECT. Immobilization following fracture, particularly in the elderly, is a significant risk for development of deep venous thrombosis, followed by pulmonary embolism."
a[144] = f + "(D) Incorrect. The elderly are at risk for pneumonia when in hospital, but the course is marked by signs and symptoms of an infection."
a[145] = f + "(E) Incorrect. CHF is a possibility in the elderly, but in the setting given is unlikely to be the cause of the sudden death."
a[146] = f + "(A) Incorrect. Marked dehydration or free water loss could lead to this degree of hypernatremia. Many persons with essential hypertension may have increased retention of sodium, but it is not marked by significant hypernatremia."
a[147] = f + "(B) Incorrect. Anti-cardiolipin antibody is seen with the antiphospholipid syndrome, which is a cause for thrombosis. It is unlikely that the selective renal artery occlusion represents a hypercoagulable state."
a[148] = f + "(C) Incorrect. An elevated prothrombin time predisposes to bleeding."
a[149] = f + "(D) CORRECT. She has renal artery stenosis that is reducing renal blood flow on the right and simulating the JG cells to secrete renin to try and raise blood pressure to increase renal blood flow."
a[150] = f + "(E) Incorrect. The decreased perfusion of the right kidney occurs over a long period of time, without a significant rise in lactate that would accompany more global hypoperfusion."
a[151] = f + "(A) Incorrect. An insulitis is typical for type I diabetes mellitus; there is no increased risk for neoplasia."
a[152] = f + "(B) Incorrect. The insulitis involves just the endocrine portion of the pancreas, not the exocrine portion, so there is no loss of pancreatic enzymes for digestion."
a[153] = f + "(C) CORRECT. An insulitis is seen with type I diabetes mellitus. Actually, it is rare to see it because by the time the patients present with overt diabetes mellitus, the islets are long gone."
a[154] = f + "(D) Incorrect. Obesity is typically associated with type II diabetes mellitus; with type I diabetes mellitus, there is a catabolic state with weight loss."
a[155] = f + "(E) Incorrect. The lymphocytes in the islets are part of an autoimmune phenomenon, not an infectious process."
a[156] = f + "(A) Incorrect. Leukotrienes are generated by the lipo-oxygenase pathway of arachidonic acid metabolism and can cause some vasoconstriction."
a[157] = f + "(B) Incorrect. Prostaglandins promote vasodilation."
a[158] = f + "(C) Incorrect. Prostacyclin release causes vasodilation and inhibits platelet aggregation, the opposite of what is needed for hemostasis."
a[159] = f + "(D) Incorrect. Activation of plasminogen leads to clot lysis."
a[160] = f + "(E) CORRECT. Thromboxane is released by platelets to promote formation of a stable 'secondary plug' to achieve hemostasis."
a[161] = f + "(A) Incorrect. An elevation in WBC count is not a specific indicator for myocardial infarction."
a[162] = f + "(B) Incorrect. Though he may have diabetes mellitus as an underlying cause for the atherosclerosis leading to myocardial infarction, serum glucose will not help to diagnose the infarction."
a[163] = f + "(C) Incorrect. Platelet counts are of no value in diagnosing infarctions, even though platelets play a role in formation of thrombi that can lead to infarction."
a[164] = f + "(D) CORRECT. Elevations in CK enzymes are going to be seen acutely with myocardial infarction beginning within hours and remaining for days."
a[165] = f + "(E) Incorrect. Amylase is increased with pancreatitis, which is not related to cardiovascular disease."
a[166] = f + "(A) Incorrect. Liver disease leads to a coagulopathy marked by a tendency to bleeding, not thrombosis."
a[167] = f + "(B) CORRECT. The recurrent episodes suggest a hypercoagulable state, and carcinomas can do this (Trousseau syndrome)."
a[168] = f + "(C) Incorrect. A decreased platelet count is a risk for hemorrhage, not thrombosis."
a[169] = f + "(D) Incorrect. Hypercholesterolemia could accelerate atherosclerosis and thrombosis, but in arteries, not veins."
a[170] = f + "(E) Incorrect. An endocarditis could lead to to embolization, but into the systemic circulation from the mitral valve."
a[170.1] = f + "(F) Incorrect. Diabetes mellitus increases the risk for atherosclerosis, but atherosclerosis does not involve veins."
a[171] = f + "(A) Incorrect. The factor V Leiden mutation is a risk for a hypercoagulable state with venous thrombosis, typically manifested at a young age."
a[172] = f + "(B) Incorrect. Factor VIII deficiency is one cause for hemophilia with risk for bleeding into soft tissues, manifested early in life."
a[173] = f + "(C) Incorrect. An increased CEA can be seen with some malignancies, such as adenocarcinoma of the colon. In this case, the mass is an aortic aneurysm caused by atherosclerosis."
a[174] = f + "(D) CORRECT. An elevated plasma homocysteine is a risk for atherosclerosis as well as thrombosis. Her findings point to an abdominal aortic aneurysm which ruptured. Such aneurysms are invariably the result of atherosclerosis."
a[175] = f + "(E) Incorrect. HDL is the 'good' cholesterol that tends to protect against atherosclerosis."
a[176] = f + "(A) Incorrect. Coagulopathies with thrombosis may be due to a congenital anticoagulant factor deficiency, but thrombotic events are usually sudden."
a[177] = f + "(B) Incorrect. Septic thrombosis and mycotic aneurysms may be the result of septicemia, but this is an acute illness."
a[178] = f + "(C) Incorrect. Oxygen saturation is typically dependent more upon pulmonary function and is not related to focal events, as in the lower extremities."
a[179] = f + "(D) CORRECT. This is peripheral arterial vascular disease from severe atherosclerosis, which is promoted by diabetes mellitus. The absence of pulses defines this as an arterial process, as does the claudication (pain with exercise). Thrombophlebitis is a venous process and leads to swelling and pain in the leg, but not loss of pulses.."
a[180] = f + "(E) Incorrect. Calcium levels have little to do with vascular problems in general (except for the rare condition in persons with renal failure called calciphylaxis)."
a[181] = f + "(A) Incorrect. The serum sodium may give an indication of the degree of hydration, not tissue perfusion."
a[182] = f + "(B) Incorrect. Poor perfusion leading to myocardial infarction would increase the creatine kinase."
a[183] = f + "(C) CORRECT. Under conditions of poor tissue perfusion, there will be more anaerobic glycolysis and more acidosis. The blood lactate rises in this condition."
a[184] = f + "(D) Incorrect. The hematocrit suggests the ability of the blood to carry oxygen and prevent ischemia, but does not predict whether there is poor perfusion with ischemia."
a[185] = f + "(E) Incorrect. The sed rate gives an indication of the presence of inflammation, a consequence of an ischemic event."
a[186] = f + "(A) CORRECT. Hyperplastic arteriolosclerosis is seen in the setting of malignant hypertension, and renal failure is common."
a[187] = f + "(B) Incorrect. These are complications typically seen in association with diabetes mellitus."
a[188] = f + "(C) Incorrect. This is a histologic curiosity with no major clinical importance."
a[189] = f + "(D) Incorrect. Hypertension is a risk for coronary artery disease, but malignant hypertension is not specifically linked to coronary thrombosis."
a[190] = f + "(E) Incorrect. Venous thrombosis is most often a result of stasis from immobilization."
a[191] = f + "(A) Incorrect. An overdose of insulin would lead to hypoglycemia."
a[192] = f + "(B) CORRECT. This is an extremely elevated serum glucose that would increase the serum osmolality markedly."
a[193] = f + "(C) Incorrect. Hyperlipidemia can be due to either an increased serum cholesterol or serum triglyceride."
a[194] = f + "(D) Incorrect. Diabetics with ketoacidosis may have a serum glucose around 500 to 600 mg/dl, but generally not over 1000 mg/dl."
a[195] = f + "(E) Incorrect. You can't get an extremely high serum glucose just from oral intake alone."
a[196] = f + "(A) Incorrect. A variety of conditions occur with diabetes mellitus, including nodular glomerulosclerosis and pyelonephritis, can lead to renal failure."
a[197] = f + "(B) Incorrect. The neuropathy that occurs with diabetes mellitus can affect penile erection in men."
a[198] = f + "(C) CORRECT. Stroke from cerebral atherosclerosis or from embolization of mural thrombi from a heart involved with ischemic injury as a consequence of atherosclerosis...."
a[199] = f + "(D) Incorrect. Cataracts involving the crystalline lens of the eye are seen more frequently in diabetics."
a[200] = f + "(E) Incorrect. Blindness from diabetic retinopathy is a frequent long term complication of diabetes mellitus."
a[201] = f + "(A) Incorrect. The accumulation of sorbitol in tissues not requiring insulin for glucose uptake is a feature of diabetes mellitus with hyperglycemia."
a[202] = f + "(B) CORRECT. He has hypercholesterolemia with more of the 'bad' LDL cholesterol that can become oxidized and taken up by modified arterial wall LDL receptors. The lipid collects in macrophages and becomes a lipid lesion--the precursor to more serious atheromatous plaques."
a[203] = f + "(C) Incorrect. Neutrophilic inflammation can be the result of infection and is unusual in arteries. It is not related to atherosclerosis."
a[204] = f + "(D) Incorrect. Mutations can result in neoplastic transformation, but atherosclerosis is not a neoplastic process."
a[205] = f + "(E) Incorrect. The process of atherogenesis proceeds slowly, without significant inflammation and activation of complement."
a[206] = f + "(A) Incorrect. This is a cause for hypercoagulability, usually manifesting at an early age, with a risk mainly for venous thrombosis, not atherosclerosis."
a[207] = f + "(B) Incorrect. Malignancies can be associated with a hypercoagulable state with thrombosis, but not manifestations of atherosclerosis. In fact, persons with malignancies typically have a regression of atherosclerotic lesions."
a[208] = f + "(C) Incorrect. Trauma can cause hemorrhage, not atherosclerosis. The 'trauma' to arterial endothelium that promotes atherosclerosis is from altered blood flow at a microscopic level, not external trauma."
a[209] = f + "(D) Incorrect. Vasculitis does not typically lead to findings in a distribution associated with atherosclerosis. Some forms of vasculitis favor thrombosis, others occlusion."
a[210] = f + "(E) CORRECT. He has findings associated with atherosclerosis, including coronary and aortic disease at least, with congestive heart failure and evidence for an aortic aneurysm. Diabetes mellitus causes advanced atherosclerosis. There is a genetic component, with a family history often present, particularly for type II diabetes mellitus."
a[211] = f + "(A) Incorrect. This is the type of vascular change that is typical with hypertension and/or diabetes mellitus."
a[212] = f + "(B) Incorrect. Monckeberg sclerosis is not generally associated with any complications."
a[213] = f + "(C) Incorrect. This would lead to ischemia and/or infarction of the myocardium."
a[214] = f + "(D) Incorrect. An arterial mural thrombus can become an embolus in the systemic arterial circulation and produce an infarct (but not in lung, which is supplied by the pulmonary circulation)."
a[215] = f + "(E) CORRECT. A pulmonary infarction is due to a thromboembolus that arose in a vein (usually legs or pelvic region) and travelled to the lungs. Immobilization with vascular stasis predisposes to phlebothrombosis to form thrombi that can then dislodge and become thromboemboli."
a[216] = f + "(A) Incorrect. The hemoglobin A1C is typically increased in diabetics with poor control."
a[217] = f + "(B) Incorrect. Hyperosmolar coma with a markedly elevated serum glucose is a feature of type II diabetes mellitus in adults."
a[218] = f + "(C) Incorrect. An 'islitis' that precedes type I diabetes probably occurs in children and is hardly ever observed, because the diabetes is treated."
a[219] = f + "(D) CORRECT. Infants of diabetic mothers are at risk for hypoglycemia following delivery, because they have islet hypertrophy and hyperplasia, and the increased islet production of insulin carries into the immediate postpartum period."
a[220] = f + "(E) Incorrect. Ketoacidosis is typical for type I diabetes in which there is an absolute insulin lack."
a[221] = f + "(A) Incorrect. There are a number of apoproteins involved in transport of lipids in the blood."
a[222] = f + "(B) CORRECT. Chylomicrons formed in intestinal epithelial cells contain apoproteins, triglyceride and cholesterol."
a[223] = f + "(C) Incorrect. Lipoprotein lipase in endothelium hydrolyzes chylomicrons, liberating fatty acids for use by fat and muscle. The cholesterol-rich chylomicron remnants go to the liver."
a[224] = f + "(D) Incorrect. Such LDL is injurious to endothelium and is more avidly taken up by macrophages and smooth muscle, thus promoting atherogenesis in vessels."
a[225] = f + "(E) Incorrect. HDL is 'good' because it transports cholesterol back to the liver."
a[226] = f + "(A) Incorrect. Cardiac muscle cells require insulin for glucose uptake."
a[227] = f + "(B) Incorrect. Fibroblasts require insulin for glucose uptake."
a[228] = f + "(C) Incorrect. Fat cells require insulin for glucose uptake. Steatocytes also are part of the endogenous pathway of lipoprotein transport and convert VLDL to LDL."
a[229] = f + "(D) CORRECT. Neurons do not require insulin for glucose uptake. The excess glucose diffusing into the cells is shunted into the sorbitol pathway and can lead to osmotic injury, resulting in neuropathy."
a[230] = f + "(E) Incorrect. Smooth muscle requires insulin for glucose"
a[231] = f + "(A) Incorrect. Some inflammation, possibly acute, may have been present at the time of the original episode of thrombophlebitis."
a[232] = f + "(B) Incorrect. Thrombophlebitis is a process best known for thrombus formation, and rupture of a vein wall would be an extreme rarity."
a[233] = f + "(C) Incorrect. After she is mobile again and months pass, any thrombus capable of embolizing is long gone."
a[234] = f + "(D) CORRECT. Thrombi will organize over time, with much of the clot eventually removed and the vascular lumen restored."
a[235] = f + "(E) Incorrect. Propagation of a thrombus is most likely to occur at the time it originally forms, or soon thereafter."
a[236] = f + "(A) Incorrect. ATIII may be diminished in some cases of recurrent thrombosis."
a[237] = f + "(B) Incorrect. Cortisol may be decreased with adrenal failure. Increased cortisol with Cushing syndrome may result in weight gain, but signs of severe peripheral atherosclerosis are lacking"
a[238] = f + "(C) Incorrect. CK is a good indicator for injury to muscle, and cardiac ischemia or infarction in particular, which may be a consequence of his underlying disease."
a[239] = f + "(D) CORRECT. The history suggests diabetes mellitus, most likely type II, and persistent hyperglycemia would confirm the diagnosis."
a[240] = f + "(E) Incorrect. CEA can be a marker for some malignancies."
a[241] = f + "(A) CORRECT. Hyaline arteriolosclerosis is a feature of long-standing hypertension and is part of benign nephrosclerosis which may go on for many years with no complications. The small arterioles are thickened."
a[242] = f + "(B) Incorrect. Medial calcific sclerosis is a form of arteriolosclerosis without significant complications. The vascular lumen is not significantly compromised by the medial calcification."
a[243] = f + "(C) Incorrect. Coronary artery disease is caused by atherosclerosis that can be accelerated by hypertension. Atheromatous plaques occur in medium to large sized arteries and can be complicated by calcification of the plaques."
a[244] = f + "(D) Incorrect. Mural thrombosis typically occurs in the aorta and its branches when there is severe atherosclerosis."
a[245] = f + "(E) Incorrect. Hyperplastic arteriolosclerosis is usually seen in the kidneys when there is severe hypertension."
a[246] = f + "(A) Incorrect. Persons with diabetes mellitus that is not well controlled will have an elevated Hgb A1C. This is a better long-term indicator of control than random glucose measurements."
a[247] = f + "(B) CORRECT. There is insulin production in type II diabetes mellitus, but not enough to prevent hyperglycemia, either from abnormal secretion patterns or from peripheral resistance. When dehydration occurs, the glucose can rise significantly."
a[248] = f + "(C) Incorrect. She is unlikely to have decreased tissue perfusion, as her blood pressure is still fairly good."
a[249] = f + "(D) Incorrect. Profound hypoglycemia is a complication of too much self-administration of insulin in a person with diabetes mellitus."
a[250] = f + "(E) Incorrect. Ketoacidosis is a complication of type I diabetes mellitus, in which there is an absolute lack of insulin production."
a[251] = f + "(A) CORRECT. There are circulating antibodies that bind plasma proteins with an affinity for phospholipid surfaces, and this can cause thrombosis and in women stillbirth. This syndrome is most often acquired in adulthood, either from an underlying disease or as an idiopathic condition. The two subsets of this syndrome, as defined by laboratory testing, are: lupus anticoagulant (which may or may not be seen with SLE), and anti-cardiolipin antibody."
a[252] = f + "(B) Incorrect. This is the most common inherited form of hypercoagulability. The mutation, which leads to activated protein C resistance, is present in 5% of Caucasians but is rare in persons of African and Asian ancestry. Heterozygotes have a mild risk for thrombosis, but the rare homozygotes have a marked risk. A point mutation leads to impaired inactivation of factor V by activated protein C. Recurrent venous thrombosis can occur, starting even in young persons, and in women stillbirth."
a[253] = f + "(C) Incorrect. Neoplastic cells may elaborate a factor, such as a thromboplastin-like substance, that can increase the risk for thrombosis. This is one form of paraneoplastic syndrome, with the name Trousseau syndrome. There can be venous (more likely) or arterial thrombosis."
a[254] = f + "(D) Incorrect. This condition is as common as factor V Leiden mutation. There may be genetic and environmental factors causing it. Oral contraceptive use increases factor VIII levels. The result is deep venous thrombosis."
a[255] = f + "(E) Incorrect. This condition is an autosomal dominant disorder and leads to recurrent venous thrombosis, even starting in young persons. Thrombosis is often spontaneous, without other precipitating events."
a[256] = f + "(A) Incorrect. Hemophilia A is an X-linked disorder that almost always affect males. There is no coagulopathy. Instead, there is bleeding, typically into soft tissues such as joints."
a[257] = f + "(B) Incorrect. Von Willebrand disease is a condition in which a particular blood coagulation factor (von Willebrand factor) is reduced, and the features resemble thrombocytopenia. Other coagulation factors are not reduced."
a[258] = f + "(C) CORRECT. She has a coagulopathy in which there is consumption of coagulation factors leading to hemorrhage. Conditions such as sepsis, severe trauma, neoplasia, and obstetric complications can set off the coagulation system in a generalized fashion, resulting in DIC."
a[259] = f + "(D) Incorrect. The antiphospholipid syndrome can have thrombosis as well as bleeding, but there is a circulating antibody present. There does not tend to be a consumptive coagulopathy."
a[260] = f + "(E) Incorrect. Severe liver disease can lead to bleeding because the liver makes many coagulation factors. However, a consumptive coagulopathy affecting even platelets is unlikely."