A 24-year-old man is evaluated due to an episode of syncope.  He was jogging when he felt light-headed and passed out, but he did not sustain a head injury.  The patient has had 2 similar episodes of light-headedness while jogging over the last year, but this was the first time he passed out.  He considers himself in good health and has no other medical conditions.  The patient does not use tobacco, alcohol, or recreational drugs.  His father died suddenly at age 30.  Vital signs are within normal limits.  On physical examination, the patient has a harsh systolic murmur.  The lungs are clear to auscultation.  There is no peripheral edema.  Transthoracic echocardiography shows asymmetric interventricular septal hypertrophy.  This patient’s symptoms are most likely explained by left ventricular outflow obstruction created by which of the following structures?

A 45-year-old man comes to the emergency department because of severe chest pain, diaphoresis, and palpitations.  The patient dies two hours after the onset of his symptoms.  Autopsy reveals 100% occlusion of the left anterior descending artery.  At the time of the patient’s death, light microscopy of the affected myocardium would most likely demonstrate which of the following?

A 53-year-old man comes to the emergency department due to fever and progressive weakness over the last 2 weeks.  Yesterday, he also developed shortness of breath.  The patient emigrated from Eastern Europe 2 years ago and says he was diagnosed with “heart disease” in the distant past, but he does not recall any details.  He does not use tobacco, alcohol, or illicit drugs.  Despite receiving appropriate medical care, the patient expires during hospitalization.  On autopsy, gross examination of his heart shows large, friable masses on the mitral valve with extensive destruction of cuspal tissue.

Item 1 of 2

Which of the following is the most likely predisposing factor for this patient’s presenting condition?

An 18-year-old man suddenly collapses during a high school soccer game.  There was no preceding collision or trauma.  Immediate resuscitation is initiated but he dies before the emergency medical service arrives.  The patient had recently experienced occasional exertion-related chest discomfort and dyspnea.  Otherwise, he had no significant medical history.  He took no medications and did not use tobacco, alcohol, or illicit drugs.  Which of the following is most likely to be seen on autopsy?

Item 2 of 2

The blood cultures obtained from this patient on admission grow Streptococcus species.  Which of the following processes was the most likely initiating step in the pathogenesis of this patient’s condition?

A 65-year-old man dies while hospitalized for severe breathing difficulty.  The patient had several prior episodes of dyspnea and cough requiring hospitalization.  He had a history of hypertension and chronic kidney disease.  The patient smoked a pack of cigarettes daily for 38 years and immigrated to the United States 20 years ago.  Autopsy is performed, and microscopic examination of the lungs reveals alveolar macrophages containing aggregates of golden-brown cytoplasmic granules that turn dark blue with Prussian blue staining.  Which of the following conditions is most likely associated with this patient’s microscopic findings?

A group of forensic pathologists are analyzing tissue samples of adolescents age 13-18 to study the aging process.  Autopsy of a 14-year-old boy who died in a motor vehicle accident shows several minimally raised yellow spots on the inner surface of the abdominal aorta.  The rest of the cardiovascular findings during the autopsy are unremarkable.  He had no known medical problems.  There was no family history of cardiovascular disease or sudden cardiac death.  Which of the following is most likely to be the predominant cell type in these lesions on light microscopy?

A 62-year-old, obese woman is brought to the hospital due to acute-onset chest pain and shortness of breath.  Medical history includes hyperlipidemia, diet-controlled type 2 diabetes mellitus, and peripheral artery disease.  Two years ago, she had an ischemic stroke but had no residual neurologic deficits.  The patient is a current smoker with a 30-pack-year history.  After initial evaluation, she is taken to the cardiac catheterization laboratory where she has a cardiac arrest due to ventricular arrhythmia and cannot be resuscitated.  Autopsy reveals thrombotic occlusion of the left anterior descending artery.  In addition, it shows 95% atherosclerotic narrowing of the proximal right renal artery but no significant stenosis of the left renal artery.  Compared with the right kidney, this patient’s left kidney is more likely to demonstrate which of the following findings?

A 56-year-old man comes to the clinic for a routine checkup.  Medical history includes hypertension, type 2 diabetes mellitus, hyperlipidemia, and mild intermittent asthma.  The patient currently takes no medications and has not seen a physician in 7 years.  He reports feeling well.  Blood pressure is 152/101 mm Hg and pulse is 87/min.  Waist circumference is 110 cm (43 in).  Laboratory results are as follows:

Which of the following vascular beds is most likely to carry the highest atherosclerotic burden in this patient?

A 66-year-old man comes to the office for a routine visit.  He has a history of hypertension and osteoarthritis.  The patient has smoked a pack of cigarettes daily for 40 years and occasionally drinks 1 or 2 glasses of wine but does not use illicit drugs.  Blood pressure is 142/82 mm Hg and pulse is 80/min.  Cardiopulmonary examination is normal.  There is a pulsating, central abdominal mass on physical examination.  Which of the following pathologic conditions is the most likely underlying cause of this patient’s abnormal findings?

A 1-week-old boy is brought to the office for his first primary care visit following an uncomplicated vaginal delivery at 40 weeks gestation.  The boy was born to a 30-year-old woman who took prenatal vitamins throughout the pregnancy.  She was diagnosed with gestational diabetes mellitus at 28 weeks gestation, which was treated with dietary modification and exercise.  The nursery course was uncomplicated, and the boy was discharged at around 30 hours of life following observation of appropriate breastfeeding, voiding, and stooling.  His weight, length, and head circumference are at the 50th percentile.  Physical examination shows a grade II/VI harsh, holosystolic murmur best heard at the left mid to lower sternal border.  Birth records show that no murmur was heard by 2 different health care providers in the newborn nursery.  Which of the following is the most likely diagnosis?

A 10-year-old boy is brought to the physician by his parents due to restlessness and involuntary jerking.  He takes no medications and his vaccinations are up-to-date.  His parents do not recall any recent injuries or illnesses other than a sore throat 3 months ago.  On examination, the patient has rapid, irregular jerking movements involving his face, arms, and legs.  This patient is at greatest risk for developing which of the following conditions?

A 58-year-old man with dyspnea and chronic exertional angina is evaluated for coronary revascularization.  He has a history of hypertension, type 2 diabetes mellitus, and hypercholesterolemia.  His blood pressure is 130/80 mm Hg and pulse is 72/min and regular.  Cardiopulmonary examination is normal with the exception of a fourth heart sound.  Echocardiogram reveals hypokinesia of the anterior wall of the left ventricle and a left ventricular ejection fraction (LVEF) of 35%.  The patient undergoes coronary artery bypass grafting.  Repeat echocardiogram 10 days after the surgery shows that hypokinesia is no longer evident and LVEF has increased to 50%.  Which of the following best explains the changes in the cardiac contractility and wall motion seen in this patient?

An 82-year-old man comes to the office due to progressive dyspnea and fatigue over the last year, which now limit his daily activities.  He has also noticed bilateral swelling of his feet.  The patient has hypertension, which is controlled with amlodipine.  His blood pressure is 122/72 mm Hg and pulse is 55/min.  Physical examination reveals elevated jugular venous pressure with rapid ‘y’ descent and a prominent S4.  Abdominal examination shows moderate ascites.  The patient has 3+ bilateral lower extremity pitting edema.  Echocardiogram reveals left atrial enlargement with marked left ventricular hypertrophy and normal left ventricular ejection fraction.  Complete blood count and basic metabolic panel are within normal limits.  Endomyocardial biopsy findings are shown below.

Which of the following is the most likely diagnosis?

A 54-year-old man comes to the emergency department due to worsening shortness of breath for the last 3 days.  His symptoms initially occurred with exertion but are now present at rest.  The patient could not sleep last night because of a suffocating cough each time he tried to lie down.  He considers himself generally healthy and states, “I’ve never had to see a doctor for any problems.”  Family history is remarkable for asthma and hypertension.  Blood pressure is 162/86 mm Hg, pulse is 92/min, and respirations are 26/min.  An x-ray of the chest is shown in the exhibit.  Which of the following is the most likely diagnosis?

A 42-year-old man comes to the emergency department due to fatigue and exertional dyspnea.  Over the last 2 weeks his symptoms have progressively worsened to the point that he can no longer walk across his living room without becoming short of breath.  He is admitted to the hospital but dies suddenly despite aggressive treatment.  An autopsy is performed, and a cross-section of his heart is shown in the image below.

This patient’s symptoms were most likely caused by which of the following mechanisms?

A 42-year-old woman comes to the emergency department for evaluation of chest pain.  She was moving furniture in her summer house 2 days ago when she experienced sharp pain in the left side of the sternum that quickly subsided.  Since then, the patient has had episodic pain with deep inspiration or trunk movement.  She has no fever or cough.  The patient has a history of hypertension.  Her father died of myocardial infarction at age 67.  She does not use tobacco or illicit drugs.  Blood pressure is 146/85 mm Hg in the right arm and 142/80 mm Hg in the left arm, pulse is 86/min, and respirations are 12/min.  She has localized tenderness to palpation at the left sternal border.  Lungs are clear to auscultation, and cardiac examination reveals normal heart sounds without gallops or murmurs.  The abdomen is soft and nontender.  There is no peripheral edema.  Which of the following is the most likely cause of this patient’s symptoms?

A 56-year-old man is admitted to a tertiary care center after being involved in a high-speed motor vehicle accident.  The patient was thrown from his vehicle and suffered severe head trauma along with multiple fractures involving his ribs and extremities.  Despite aggressive treatment, he dies the following day from massive cerebral edema and brainstem herniation.  Autopsy shows the following heart findings:

Left atrium: enlarged

Left ventricular myocardial mass: increased

Left ventricular wall thickness: increased

The structural changes observed in this patient’s heart are most likely associated with which of the following conditions?

A 44-year-old man is evaluated in the clinic for occasional chest discomfort that is not consistently related to exertion.  The patient’s past medical history is significant for hypertension and hyperlipidemia.  His grandfather experienced a myocardial infarction at age 50.  Coronary CT angiography reveals several nonobstructive atherosclerotic plaques in the coronary arteries.  One plaque in the proximal left anterior descending artery appears extensive, has a large hypodense core, and occupies 40% of the lumen.  No intervention is performed.  One year later, the patient comes to the emergency department with acute severe chest pain and is found to have thrombotic occlusion of the proximal left anterior descending artery.  High intraplaque activity of which of the following enzymes most likely resulted in this patient’s myocardial infarction?

A 65-year-old man is admitted to the hospital with an acute ST-segment elevation myocardial infarction.  The patient undergoes coronary angiography with stent placement in the left circumflex artery, and he is started on therapy with a beta blocker and antiplatelet agents.  On day 3 of hospitalization he experiences chest pain.  The pain, described as sharp and radiating to his neck and shoulders, is exacerbated by coughing and swallowing.  He has no shortness of breath, lightheadedness, or abdominal pain.  Temperature is 37.5 C (99.5 F), blood pressure is 130/80 mm Hg, pulse is 90/min and regular, and respirations are 20/min.  The lungs are clear on auscultation.  There is no peripheral edema.  Which of the following is the most likely cause of this patient’s chest pain?

A 64-year-old man dies suddenly while playing tennis.  In the preceding months, the patient experienced fatigue and some exertional dyspnea.  Autopsy reveals rupture of an unsuspected ascending aortic aneurysm.  Heart examination shows a septal thickness of 1.1 cm (normal: ≤1.1), a posterior wall thickness of 1.1 cm (normal: ≤1.1), and an internal left ventricular diameter of 6.8 cm (normal: 3.5-5.9).  No focal myocardial scarring is seen.  Which of the following is the most likely cause of the cardiac findings seen in this individual?

A 38-year-old woman suddenly collapses at home after experiencing severe chest pain and dies before reaching a hospital.  Postmortem examination reveals an occluding thrombus overlying a ruptured atherosclerotic plaque on the left anterior descending artery.  The patient is also found to have thickened mitral valve leaflets with multiple small vegetations on both valvular surfaces and fibrinoid necrosis of arterioles.  Other findings include glomerular capillary basement membrane thickening with wire-loop changes.  This patient was most likely suffering from which of the following conditions?

A 69-year-old man comes to the clinic due to a squeezing pressure in his midline chest and neck that occurs when walking.  He has a history of hypertension and type 2 diabetes mellitus.  The patient is an ex-smoker with a 20-pack-year history.  Coronary angiography shows extensive atherosclerosis and near-total occlusion of the left anterior descending artery.  Further testing shows normal resting left ventricular ejection fraction with no regional wall motion abnormalities.  The absence of myocardial necrosis and scarring despite vessel occlusion in this patient can be best explained by which of the following features of the occluding plaque?

In experiments, transient myocardial ischemia causes myocardial cells to increase in size.  This effect is due in part to which of the following?

A 56-year-old man comes to the emergency department with acute, severe chest pain.  His electrocardiogram is within normal limits.  Contrast-enhanced computed tomography of his chest is shown below.

Which of the following is the single most important risk factor for this patient’s current condition?

A 42-year-old man is brought to the emergency department 1 hour after the onset of severe headache, nausea, vomiting, and confusion.  The patient has primary hypertension and chronic kidney disease; he has been prescribed 2 antihypertensive agents but has been noncompliant with therapy recently.  Temperature is 36.8 C (98.2 F), blood pressure is 240/150 mm Hg, heart rate is 90/min, and respirations are 20/min.  Ophthalmologic examination shows bilateral papilledema.  The lungs are clear to auscultation.  Cardiac examination reveals an S4 and no murmurs.  Laboratory results are as follows:

Which of the following pathologic findings in the kidney is most correlated with this patient’s acute condition?

An 80-year-old man is brought to the hospital due to increasing chest pain.  Over the past 6 weeks, he has had dry cough, dysphagia, and a change in voice quality.  The patient has a long history of hypertension.  He is an ex-smoker with a 35-pack-year history.  On physical examination, the patient appears anxious, pale, and diaphoretic.  Blood pressure is 80/60 mm Hg, pulse is 120/min, and respirations are 20/min.  While being evaluated in the emergency department, he develops cardiac arrest with pulseless electrical activity and cannot be resuscitated.  Autopsy is most likely to show which of the following findings?

A 24-year-old woman comes to the physician with a 3-week history of progressive fatigue.  Physical examination shows lesions involving the nail beds, as seen in the photograph below.

Further evaluation would most likely reveal additional abnormalities during which part of the physical examination?

A 4-year-old boy is brought in by his parents for evaluation of a fever that has persisted for the past 5 days.  He has also been more irritable than usual and had 2 or 3 episodes of vomiting.  The patient has no prior medical problems and takes no medications.  He has received all recommended vaccinations.  He traveled to China last year to visit his grandparents and cousins but has not traveled outside of the country this year.  Temperature is 38.9 C (102 F).  Physical examination shows bilateral conjunctival injection with no exudates.  His tongue is bright red and lips are cracked.  Nonpitting edema is present on his hands and feet.  Which of the following complications is this patient at greatest risk for developing?

A 34-year-old woman comes to the emergency department because of sharp chest pain that radiates to the left shoulder.  The pain increases with inspiration and is partially relieved by sitting up and leaning forward.  Review of her outpatient medical records shows that she was seen for a facial rash 6 months ago.  She is also being evaluated for proteinuria that was identified during her last clinic appointment.  Which of the following is the most likely cause of this patient’s chest pain?

A 38-year-old woman comes to the office due to worsening shortness of breath over the past 4 weeks.  She has no chest pain or lightheadedness but has noticed some ankle puffiness.  The patient can hardly do chores without having to stop to catch her breath.  Medical history is unremarkable.  She delivered a healthy child 2 months ago without complications.  The patient is a lifetime nonsmoker and does not use alcohol.  She has no family history of early heart disease or sudden cardiac death.  Blood pressure is 96/60 mm Hg and pulse is 92/min and regular.  The apical impulse is palpated along the anterior axillary line, and S3 is heard at the apex.  There are no heart murmurs.  Which of the following best describes the left ventricular changes in this patient?

A 45-year-old woman comes to the office due to 3 days of progressive pain in the right upper quadrant, nausea, and vomiting.  In the preceding year, the patient has had fatigue, weight loss, joint pain, and intermittent abdominal pain.  Laboratory studies show increased blood urea nitrogen and serum creatinine.  Right-upper quadrant ultrasound shows no evidence of gallstones, but an inflamed gallbladder is present.  The patient undergoes cholecystectomy, and subsequent biopsy of the submucosal gallbladder vessels is shown in the exhibit (2 images).  Which of the following is the most likely diagnosis?

A 67-year-old man is admitted to the hospital due to acute right-sided weakness.  Medical history includes hypertension, hyperlipidemia, and coronary artery disease, for which the patient underwent placement of 2 stents in the left anterior descending artery.  He also has intermittent claudication that limits exercise capacity.  The patient’s antihypertensive regimen includes chlorthalidone, amlodipine, and lisinopril, which he takes as prescribed.  He is an ex-smoker with a 35-pack-year history.  Blood pressure is 180/110 mm Hg and pulse is 80/min.  Serum creatinine is 1.6 mg/dL.  CT scan of the head reveals hemorrhage of the left basal ganglia, and renal ultrasound shows that the right kidney is 7 cm long and the left kidney is 11 cm long.  Which of the following mechanisms most likely explains the renal morphology in this patient?