29 - CVS pathology mcqs - 6 to 10

Question 6
A 72-year-old woman has had no major illnesses throughout her life. She has had 3 syncopal episodes over the past 2 weeks. Over the past 2 days she has developed shortness of breath and a cough with production of frothy white sputum. On physical examination she is afebrile. Her blood pressure is 135/90 mm Hg. She has no peripheral edema. A chest radiograph reveals a prominent left heart border in the region of the left ventricle, but the other chambers do not appear to be prominent. There is marked pulmonary edema. Laboratory studies show a total serum cholesterol of 170 mg/dL. Which of the following is the most likely diagnosis?
A Acute rheumatic fever
B Mitral valve stenosis
C Atherosclerotic aortic aneurysm
D Calcific aortic stenosis
E Infective endocarditis
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(D) CORRECT. Senile calcific aortic stenosis is a condition in which there is gradual calcification of a an aortic valve with three cusps. The condition is seen in the elderly and is idiopathic. Aortic valvular stenosis may not manifest itself clinically until there is narrowing of the outflow orifice to less than 1 square centimeter. Aortic valve disease can remain silent and then suddenly result in symptoms.
(A) Incorrect. This is most common in children who have not been adequately treated for a strep throat, a pharyngitis with group A beta hemolytic streptococcus. There may be a myocarditis with rheumatic fever as well.
(B) Incorrect. Mitral valve disease tends to be symptomatic early and then become slowly progressive over years.
(C) Incorrect. An atherosclerotic aneurysm of the aorta is typically located below the renal arteries and can cause abdominal pain when it enlarges.
(E) Incorrect. This is associated with signs of infection, such as fever, murmur, and splenomegaly. Sometimes splinter hemorrhages in nail beds can be seen.
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Question 7
A 17-year-old girl is brought to the physician because she remains short in stature for her age. She has not shown any changes of puberty. On physical examination her vital signs include T 37 C, RR 18/minute, P 75/minute, and BP 165/85 mm Hg. She has a continuous murmur heard over both the front of the chest as well as her back. Her lower extremities are cool with poor capillary filling. She has a webbed neck. A chest radiograph reveals a prominent left heart border, no edema or effusions, and rib notching. Which of the following cardiovascular abnormalities is she most likely to have?
A Shortening and thickening of chordae tendineae of the mitral valve
B Constriction of the aorta past the ductus arteriosus
C Supravalvular narrowing in the aortic root
D Lack of development of the spiral septum and partial absence of conus musculature
E Single large atrioventricular valve
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(B) CORRECT. She has coarctation of the aorta, and the constriction is postductal, allowing prolonged survival. Her physical characteristics also suggest Turner syndrome (monosomy X).
(A) Incorrect. These findings are found with chronic rheumatic valvulitis that is typically seen in adults years after episode(s) of rheumatic fever.
(C) Incorrect. Some forms of aortic stenosis can have supravalvular narrowing.
(D) Incorrect. When the spiral septum does not develop properly, a truncus arteriosus can result, with mixing of right and left heart blood, leading to cyanosis.
(E) Incorrect. A single AV valve would not lead to selective hypertension in upper extremities. Endocardial cushion defects can be seen with trisomy 21.
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Question 8
A 65-year-old man has sudden onset of severe abdominal pain. Physical examination reveals his temperature is 37 C, heart rate 110/minute, respirations 25/minute, and blood pressure 145/100 mmHg. He has diminished pulses in the lower extremities. There is a pulsatile abdominal mass. His serum creatine kinase is not elevated. He has had fasting blood glucose measurements in the range of 140 to 180 mg/dL for over 20 years. Which of the following conditions is he most likely to have?
A Superior mesenteric artery thrombosis
B Atherosclerotic aortic aneurysm
C Polyarteritis nodosa
D Septic embolization
E Monckeberg's medial calcific sclerosis
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(B) CORRECT. The aorta involved with an atherosclerotic aneurysm is markedly enlarged and filled with thrombus. Risk factors for atherosclerosis include both diabetes mellitus and hypertension. Atherosclerotic aortic aneurysms are typically located in the abdominal portion below the renal arteries.
(A) Incorrect. Abdominal pain could be caused from mesenteric artery thrombosis from bowel infarction, but there should be no pulsatile mass.
(C) Incorrect. Arteritides do not cause significant arterial enlargement, and polyarteritis does not affect the aorta.
(D) Incorrect. Septic embolization could produce a mycotic aneurysm, but this would be rare in the abdominal aorta.
(E) Incorrect. Medial calcific sclerosis involves small muscular arteries and is an incidental finding.
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Question 9
A 49-year-old woman had atrial fibrillation that was poorly controlled, even with amiodarone therapy. She suffered a "stroke" and died. At autopsy, her 600 gm heart is noted to have a mitral valve with partial fusion of the leaflets along with thickening and shortening of the chordae tendineae. There is an enlarged left atrium filled with mural thrombus. Which of the following underlying causes of death is she most likely to have?
A Systemic lupus erythematosus
B Coronary atherosclerosis
C Marantic endocarditis
D Rheumatic fever
E Amyloidosis
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(D) CORRECT. This can lead to rheumatic mitral stenosis with left atrial enlargement.
(A) Incorrect. SLE can produce a serous pericarditis with an effusion. In a few cases SLE can produce a Libman-Sacks endocarditis, but valvular scarring does not regularly occur.
(B) Incorrect. There may be some degree of cardiac enlargement, including the left atrium, with the heart failure produced by ischemic heart disease, including myocardial infarction, but it is not marked, and valves are not scarred or stenotic as a consequence.
(C) Incorrect. Small valvular vegetations of non-bacterial thrombotic endocarditis are unlikely to produce enough mitral valvular deformity to produce stenosis that dilates the left atrium.
(E) Incorrect. Amyloid can be found in endocardium and myocardium, but it is best known as a cause for an infiltrative cardiomyopathy.
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Question 10
A 23-year-old woman has had worsening malaise along with a malar skin rash persisting for 3 weeks. On physical examination, she has an audible friction rub on auscultation of the chest, along with a faint systolic murmur. An echocardiogram reveals small vegetations on the mitral valve and adjacent ventricular endocardium. Laboratory studies show a positive antinuclear antibody test, with a titer of 1:2048. Which of the following is the most likely diagnosis?
A Polyarteritis nodosa
B Progressive systemic sclerosis
C Systemic lupus erythematosus
D Wegener's granulomatosis
E Adenocarcinoma of the pancreas
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(C) CORRECT. Patients with systemic lupus erythematosus can develop Libman-Sacks endocarditis, but the vegetations are never large and they rarely embolize, so the endocarditis is not clinically significant in most cases. She probably has a fibrinous pericarditis as a result of uremia from renal failure.
(A) Incorrect. Libman-Sacks endocarditis is associated with systemic lupus erythematosus.
(B) Incorrect. Scleroderma is not typically associated with an endocarditis.
(D) Incorrect. Wegener's granulomatosis with vasculitis uncommonly involves the heart and does not involve the endocardium or pericardium.
(E) Incorrect. This is related to nonbacterial thrombotic (marantic) endocarditis, which can result from a hypercoagulable state that is a paraneoplastic syndrome (Trousseau syndrome).
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