Chapter 7

Question 1

Left ventricular failure leads to chronic passive congestion of the lungs. Blood leaks from the congested pulmonary capillaries into the alveoli. Alveolar macrophages degrade RBCs and accumulate hemosiderin. Hemosiderin-laden macrophages are called heart failure cells.

Answer 1

congestive heart failure, pulmonary edema

Question 2

Diffuse alveolar damage with hyaline membranes is a feature of what syndrome?

Answer 2

adult respiratory distress syndrome

Question 3

What is purulent exudate a feature of?

Answer 3

bacterial pneumonia

Question 4

interstitial lymphocytes is a characteristic of what?

Answer 4

Viral pneumonitis

Question 5

What is typically seen in patients with pulmonary hypertension?

Answer 5

Plexiform lesions

Question 6

This results from a systemic inflammatory response syndrome that leads to multiple organ dysfunction and hypotension. Clinical features include two or more signs of systemic inflammation (e.g. fever, tachycardia, tachypnea, leukocytosis, or leukopenia) in the setting of a known cause of inflammation. Processes progress to multiple organ dysfunction syndrome in critically ill patients. Gram-negative organisms are the most common cause of this.

Answer 6

Septic shock

Question 7

A consequence of type I hypersensitivity reactions

Answer 7

Anaphylactic shock

Question 8

Follows acute injury to the brain or spinal cord, which impairs the neural control of vasomotor tone, leading to generalized vasodilation.

Answer 8

Neurogenic shock

Question 9

A feature of advanced heart failure. A feature of blood loss.

Answer 9

Cardiogenic and hypovolemic shock

Question 10

Hypotension caused by postpartum bleeding can, in rare cases, lead to this. The pituitary is particularly susceptible at this time because its enlargement during pregnancy renders it vulnerable to a reduction in blood flow.

Answer 10

Sheehan syndrome, pituitary infarction

Question 11

Pericardial fluid may accumulate rapidly, particularly with hemorrhage caused by a ruptured myocardial infarct, this, or trauma. In these circumstances, the pressure in the pericardial cavity exceeds the filling pressure of the heart, a condition termed cardiac tamponade. The term ‘electomechanical dissociation’ refers to a heart rhythm that should produce a beat, but does not. The most common cause of this condition is hypovolemia. The resulting precipitous decline in cardiac output is often fatal. The pathogenesis of this in most cases can be traced to a weakening of the aortic media (cystic medial necrosis). Most patients have a history of hypertension.

Answer 11

Dissecting aortic aneurysm

Question 12

This refers to widespread ischemic changes secondary to microvascular thrombi.

Answer 12

Disseminated intravascular coagulation

Question 13

This is the engorgement of an organ with venous blood

Answer 13

Passive hyperemia

Question 14

Massive hematemesis (vomiting blood) is a frequent cause of death in patients with this. The patient with alcoholic cirrhosis has portal hypertension (increased hydrostatic pressure) and these are bleeding.

Answer 14

Esophageal varices hematemesis

Question 15

Small pulmonary emboli rarely cause infarctions because of the dual blood supply to the lungs and because oxygen can diffuse from the alveoli into lung tissue. Symptoms depend upon the extent of blockage of the pulmonary arterial tree, whether there is already cardiopulmonary disease, and whether pulmonary infarction occurs,

Answer 15

Thromboembolism

Question 16

These originate from adipose tissue in the medulla of fractured long bones. Fat carried by venous blood reaches the lungs, filters 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 this.

Deep venous thrombosis and septic shock unlikely in short time frame.

Answer 16

Fat embolism

Question 17

When emboli arise in the venous circulation and bypasses the lungs by traveling through an incompletely closed foramen ovale, subsequently entering the arterial circulation

Answer 17

Paradoxical embolism

Question 18

Septicemia with Gram-negative organisms is the most common cause of septic shock. The invading bacteria are responsible for the release of endotoxin, a LPS. On entry into the circulation, LPS binds to the surface of monocytes/macrophages. The CD14 recognition complex mediates signalling through activation of nuclear transcription factor-kappa B (NF-kappa B) and upregulates the expression of TNF-alpha. In septic shock, this protein is released in great excess, resulting in effects that are often lethal.

Answer 18

Meningitis, septic shock

Question 19

The heart is the most common source of arterial thromboemboli, which usually arise from mural thrombi or diseased valves. These emboli tend to lodge at points where the vessel lumen narrows abruptly (e.g, at bifurcations or in the area of an atherosclerotic plaque).

Answer 19

Cerebral embolism, stroke

Question 20

Embolism is the passage through the venous or arterial circulations of any material capable of lodging in a blood vessel and, thereby, obstructing its lumen. Intravenous drug abusers who use talc as a carrier for illicit drugs may introduce it into the lung via the bloodstream (i.e. venous embolism)

None of the other choices exhibit birefringence under polarized light.

Answer 20

Pulmonary embolism, talc embolism

Question 21

Amniotic fluid embolism refers to the entry of amniotic fluid containing fetal cells and debris into the maternal circulation through open uterine and cervical veins. It is a rare maternal complication of childbirth, but when it occurs, it is often catastrophic. This disorder usually occurs at the end of labor when the pulmonary emboli are composed of the epithelial constituents (squamae) contained in the amniotic fluid.

Answer 21

Amniotic fluid embolism

Question 22

A thrombotic microangiopathy. Fibrin thrombi form in small blood vessels because of uncontrollable coagulopathy, which consumes fibrin and other coagulation factors. Once coagulation factors are depleted, uncontrollable hemorrhage ensues.

If someone overcomes this, they are at risk for acute respiratory distress syndrome.

Answer 22

DIC

Question 23

A generalized increase in venous pressure, typically from chronic heart failure, results in an increase in the volume of blood in many organs (e.g., liver, spleen, and kidneys). The liver is particularly vulnerable to chronic passive congestion because the hepatic veins empty into the vena cava immediately inferior to the heart.

Answer 23

Congestive heart failure, nutmeg liver

Question 24

In patients with chronic passive congestion of the liver, the central veins of the hepatic lobule become dilated. The increased venous pressure leads to dilation of the sinusoids and pressure atrophy of the centrilobular hepatocytes. Grossly, the cut surface of the chronically congested liver exhibits dark foci of centrilobular congestion surrounded by paler zones of unaffected peripheral portions of the lobules. The result resembles a cross section of a nutmeg. Longstanding passive congestion leads to bridging fibrosis; however, only in the most extreme cases is the fibrosis sufficiently severe to justify the label cardiac cirrhosis.

Answer 24

Chronic passive congestion of the liver

Question 25

A symptom of upper gastrointestinal bleeding. Blood from ruptured esophageal varices or a peptic ulcer is partially digested by hydrochloric acid. Hemoglobin is transformed into a black pigment (hematin), which imparts a typical "coffee-grounds" color to the stool.

Answer 25

Melena

Question 26

Vomiting of blood

Answer 26

Hematemesis

Question 27

Bleeding in to the biliary passagesas a complication of trauma or neoplasia

Answer 27

Hematobilia

Question 28

The passage of bloody stools caused by lower GI hemorrhage

Answer 28

Hematochezia

Question 29

Passage of fatty stools caused by pancreatic disease and malabsorption

Answer 29

Steatorrhea

Question 30

Venous thrombosis is caused by the same factors that predispose to arterial thrombosis, namely endothelial injury, stasis, and a hypercoaguable state.

Answer 30

Deep venous thrombosis

Question 31

Refers to bleeding into the joint cavity. Associated with joint swelling and is a crippling complication of hemophilia. Repeated bleeding may cause deformities and may limit the mobility of the joints.

Answer 31

Hemophilia, hemarthrosis

Question 32

intracranial infusion of blood

Answer 32

Hematocephalus

Question 33

coughing up blood

Answer 33

Hemoptysis

Question 34

May be caused by hemorrhage, fluid 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.

Answer 34

Hypovolemic shock

Question 35

Accumulation of fluid in the peritoneal cavity, protruding belly. Most commonly due to cirrhosis, severe liver disease or neoplasm

Answer 35

Ascites

Question 36

May be confined to a limb or an organ as a result of localized obstruction to venous drainage. Examples include deep venous thrombosis of the leg veins, with resulting edema of the lower extremity, and thrombosis of the hepatic veins (Budd-Chiari syndrome) with secondary chronic passive congestion of the liver.

Answer 36

Passive hyperemia

Question 37

An augmented blood supply of blood to an organ, usually as a physiologic response to an increased functional demand. The most striking active hyperemia occurs in association with inflammation.

Answer 37

Active hyperemia

Question 38

Typically causes infarction

Answer 38

Arterial embolism

Question 39

Extravascular accumulation of blood

Answer 39

Hematoma and hemorrhage

Question 40

A larger superficial hemorrhage in the skin. Following hemorrhage, the initially purple discoloration of the skin turns green and then yellow before resolving. This sequence follows the progressive oxidation of bilirubin released from the hemoglobin of degraded erythrocytes. A "Black eye" is a good example of this.

Answer 40

Ecchymosis

Question 41

pinpoint hemorrhages usually in the skin or conjunctiva. lesion represents the rupture of a capillary or arteriole and occurs in conjunction with vasculitis and coagulopathy. May also be produced by microemboli from infected heart valves (bacterial endocarditis)

Answer 41

petechiae

Question 42

Diffuse superficial hemorrhage in the skin up to 1 cm in diameter

Answer 42

pupura

Question 43

flat red area on skin covered in bumps

Answer 43

maculopapular rash

Question 44

The pressure differential between the intravascular and the interstitial compartments is largely determined by the concentration of plasma proteins, especially albumin. Any condition that lowers plasma albumin levels, whether from albuminuria in nephrotic syndrome or reduced albumin synthesis in chronic liver disease, tends to promote generalized edema.

Answer 44

Decreased intravascular oncotic pressure

Question 45

Increased hematocrit in the patient reflects hemoconcentration caused by dehydration, secondary to diarrhea. This hematologic condition, termed relative polycythemia, is characterized by decreased plasma volume with a normal red cell mass. When patients suffer from burns, vomiting, excessive sweating, or diarrhea, they not only lose fluid but also suffer electrolyte disturbances. Systemic blood pressure falls with continuous dehydration, and declining perfusion eventually leads to death.

Answer 45

Dehydration, relative polycythemia (proportion of RBC increases)

Question 46

Inflammatory redness of the skin

Answer 46

Erythema

Question 47

Embolism of an artery of the artery of the leg leads to sudden pain, absence of pulses, and a cold limb. In some cases, the limb must be amputated.

Answer 47

Arterial thromboembolism

Question 48

Chronic failure of the left ventricle constitutes an impediment to the exit of blood from the lungs and leads to chronic passive congestion of the lungs. The pressure in the alveolar capillaries increases, and the vessels become engorged with blood. Microhemorrhages release erythrocytes into the alveolar spaces, where they are degraded by alveolar macrophages. The released iron, in the form of hemosiderin, remains in the macrophages, which are then labeled "heart failure cells."

Answer 48

Congestive Heart Failure

Question 49

A large pulmonary embolus may lodge at the bifurcation of the main pulmonary artery (saddle embolus), obstructing blood flow to both lungs. With acute obstruction of more than half of the pulmonary arterial tree, the patient experiences severe hypotension and may die within minutes.

Answer 49

Deep venous thrombosis

Question 50

What are examples of causes of arterial embolism?

Answer 50

Bacterial endocarditis, complicated artherosclerotic plaque, paradoxical embolization, right ventricular mural thrombus

Question 51

Secondary to a pronounced decrease in vlood or plasma volume, caused by the loss of fluid from the vascular compartment. Hemorrhage, fluid loss from severe burns, diarrhea, excessive urine formation, perspiration, and traume are major mechanisms of fluid loss that can lead to hypovolemic shock.

Answer 51

Hypovolemic shock

Question 52

In patients with severe aortic artherosclerosis, embolization of artheromatous debris into the renal arteries and vascular tree may cause acute renal failure.

Answer 52

Renal infarct, arterial embolism

Question 53

Patients with this complain of shortness of breath (dyspnea) on exertion and when recumbent (orthopnea). They may be awakened from sleep by episodes of shortness of breath (paroxysmal nocturnal dyspnea). Physical examination usually reveals distended jugular veins.

Answer 53

left sided congestive heart failure

Question 54

Persons with right-sided failure have pitting edema of the lower extremities and an enlarged and tender liver. Patients in congestive heart failure with pulmonary edema have crackling breath sounds (rales) caused by the expansion of fluid-filled alveoli.

Answer 54

right sided congestive heart failure

Question 55

Myocardial infarction is the most common cause of mural thrombi in the left ventricle. These mural thrombi are a common source of arterial thromboemboli. Such emboli may occlude cerebral arteries and cause cerebral infarcts, known as strokes. Atrial fibrillation predisposes to the formation of mural thrombi.

Answer 55

Mural thrombus

Question 56

Once formed, arterial thrombi may undergo 1. lysis, 2. propagation, 3. organization, 4. canalization, 5. embolization. Organization refers to the invasion of connective tissue elements, which causes a thrombus to become firm and appear grayish white. Canalization is the process by which new lumina lined by endothelial cells form within an organized thrombus. Propagation implies an increase in size.

Answer 56

The steps of mural thrombus

Question 57

Cardiac myxoma is the most common primary tumor of the heart. one third of patients with left artial or left ventricular myoma die from tumor embolization to the brain.

Answer 57

Cardiac myxoma

Question 58

Obstruction of lymphatic flow may occur in a number of clinical settings, but is most common because of surgical removal of lymph nodes or tumor obstruction. For example, the lymphatic system may be obstructed after axillary lymph node dissection for breast cancer. Prolonged lymphatic obstruction in the patient's shoulder causes edema, progressive dilation of lymphatic vessels (lymphangiectasia), and overgrowth of fibrous tissue,

Answer 58

Lymphedema

Question 59

Represents an accumulation of lymphedema in the pleural space (chyle - lymph)

Answer 59

Chylothorax

Question 60

This 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 filling reduce cardiac output, resulting in obstructive shock. Such conditions include pulmonary embolism, cardiac tamponade, and rarely atrial myxoma.

Answer 60

Cardiogenic shock

Question 61

In patients with congestive heart failure, venous engorgement of the lungs leads to accumulation of a transudate in the alveoli. Chronic left ventricle failure impedes blood flow out of the lungs and leads to passive pulmonary congestion. As a result, pressure in the alveolar capillaries increase (increased hydrostatic pressure) and these vessels become engorged with blood. Increased pressure forces fluid from the blood into the alveolar spaces, resulting in pulmonary edema, which interferes with gas exchange.

Answer 61

Pulmonary Edema

Question 62

Volvulus is an example of intestinal obstruction in which a segment of gut twists on its mesentery, thereby kinking the bowel and usually interrupting the blood supply. Ischemia leads to infarction and intestinal gangrene.

Answer 62

Infarct

Question 63

Myocardial infarcts are described as transmural (through the entire wall) or subendocardial. A transmural infarct results from complete occlusion of a major extramural coronary artery.

Answer 63

Transmural infarct

Question 64

Reflects prolonged ischemia caused by partially occluding lesions of the coronary arteries when the requirement for oxygen exceeds the supply. Such a situation prevails in disorders such as shock, anoxia, or severe tachycardia.

Answer 64

Subendocardial infarction

Question 65

Coughing up blood

Answer 65

hemoptysis

Question 66

color of infarcts typically seen in the heart, kidneys, and spleen.

Answer 66

pale infarct

Question 67

Results from either arterial or venous occlusion. They are distinguished from the other infarcts by bleeding into the necrotic area from adjacent arteries and veins. These infarcts occur principally in organs with a dual blood supply, such as the small intestine and brain. In the heart, this infarct occurs when the infarcted area is reperfused, as may occur following spontaneous or therapeutically induced lysis of the occluding thrombus. Grossly, these infarcts are sharply circumscribed, firm, and dark red to purple. Over a period of several days, acute inflammatory cells infiltrate the necrotic area from the viable border. The cellular debris is phagocytosed and digested by polumorphonuclear leukocytes and later by macrphages. Granulation tissue eventually forms, to be replaced ultimately by a scar.

Answer 67

red infarct

Question 68

The pathogenesis of RDS of the newborn is intimately linked to a deficiency of surfactant. This material lowers the surface tension of the alveoli at low lung volumes and thereby prevent collapse (atelectasis) of the alveoli during expiration. Atelectasis secondary to surfactant deficiency results in perfused but not ventilated alveoli, a situation that leads to hypoxia and acidosis. Intraventricular cerebral hemorrhage is a major complication of RDS. The periventricular germinal matrix in the newborn brain is particularly vulnerable to hemorrhage because the dilated, thin-walled veins in this area rupture easily. The pathogenesis of this complication is believed to reflect anoxic injury to the periventricular capillaries, venous sludging and thrombosis, and impaired vascular autoregulation. Despite advances in neonatal intensive care, the overall mortality of RDS is about 15%, and 1/3 of infants born before 30 weeks of gestational age die of this order.

Answer 68

Respiratory distress syndrome of the neonate

Question 69

present in the blood, especially in excess

Answer 69

-emia

Question 70

lodging of a blood clot, fat globule, or gas bubble in the bloodstream which can cause blockage. May affect a body part away from the site of embolism

Answer 70

embolism

Question 71

blood clot at the site of origin

Answer 71

thrombus