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An elevated serum value of which of the following laboratory tests would be most useful for diagnosis of this patient on admission to the hospital Which of the following underlying conditions is most likely to be present in this patient DiGeorge syndrome Down syndrome Familial hypercholesterolemia Hereditary hemochromatosis Marfan syndrome 28 A 72-year-old man with poorly controlled diabetes mellitus has worsening exercise tolerance for 5 years treatment xanthelasma buy persantine online now. On physical examination he has bilateral pulmonary rales and pitting edema of his legs. Echocardiography shows decreased left ventricular ejection fraction (25%) with diminished wall motion. On physical examination, her temperature is 37° C, pulse is 77/min, respirations are 20/min, and blood pressure is 140/90 mm Hg. Echocardiography shows no valvular abnormalities, but there is decreased left ventricular wall motion and an ejection fraction of 32%. Which of the following pharmacologic agents is most likely to be beneficial in the treatment of this patient Amiodarone Alteplase Glyburide Nitroglycerin Propranolol Simvastatin 30 A 50-year-old man has sudden onset of severe substernal chest pain that radiates to the neck. On physical examination, he is afebrile, but has tachycardia, hyperventilation, and hypotension. Emergent coronary angiography shows a thrombotic occlusion of the left circumflex artery and areas of 50% to 70% narrowing in the proximal circumflex and anterior descending arteries. Which of the following complications of this disease is most likely to occur within 1 hour of these events Myocardial rupture Pericarditis Valvular insufficiency Ventricular fibrillation Thromboembolism 32 A 59-year-old man has experienced chronic fatigue for the past 18 months. A chest radiograph shows bilateral pulmonary edema and a prominent left heart border. Laboratory studies show serum glucose, 74 mg/dL; total cholesterol, 189 mg/dL; total protein, 7. Chronic alcoholism Diabetes mellitus Hemochromatosis Pneumoconiosis Systemic hypertension 31 A study of persons receiving emergent medical services is conducted. It is observed that 5% of persons with sudden cardiac arrest who receive cardiopulmonary resuscitation survive. Which of the following is the most likely mechanism for cardiac arrest in these survivors Arrhythmia Infarction Inflammation Valve failure Ventricular rupture 33 A 56-year-old man has worsening cough and orthopnea for the past 2 years. On physical examination, he has dullness to percussion at both lung bases and diffuse crackles in the upper lung fields. Echocardiography shows marked left ventricular hypertrophy and severe aortic stenosis. On physical examination, she is now afebrile with pulse of 68/min, respirations of 15/min, and blood pressure of 130/85 mm Hg. On auscultation, the lungs are clear, the heart rate is irregular, and there is a midsystolic click. Carcinoid heart disease Hyperparathyroidism Infective endocarditis Mitral annular calcification Rheumatic heart disease Senile calcific stenosis the Heart 169 36 A 65-year-old healthy woman has a check of her health status and the only finding is a midsystolic click on auscultation of the heart. Destructive vegetations Dystrophic calcification Fibrinoid necrosis Myxomatous degeneration Rheumatic fibrosis 37 A 35-year-old woman has had palpitations, fatigue, and worsening chest pain during the past year. Auscultation of the chest indicates a midsystolic click with late systolic murmur. A review of systems indicates that the patient has one or two anxiety attacks per month. Aortic valvular vegetations Mitral valve prolapse Patent ductus arteriosus Pulmonic stenosis Tricuspid valve regurgitation 38 An 11-year-old boy had a sore throat, no cough, tonsillar exudates, and 38. On auscultation, a diastolic mitral murmur is audible, and there are diffuse rales over both lungs. Over the next 2 days he has several episodes of atrial fibrillation accompanied by signs of acute left ventricular failure. An echocardiogram shows small vegetations at the closure line of the mitral and aortic valves. An endomyocardial biopsy shows focal interstitial aggregates of mononuclear cells enclosing areas of fibrinoid necrosis. An external examination by the medical examiner showed splinter hemorrhages under the fingernails and no signs of trauma. Which of the following laboratory findings is most likely to provide evidence for the cause of his disease She manifests choreiform movements and begins to complain of pain in her knees and hips, particularly with movement. An abnormality detected by which of the following serum laboratory findings is most characteristic of the disease affecting this girl Antistreptolysin O antibody titer Antinuclear antibody titer Creatinine level Rapid plasma reagin test Troponin I level 42 A 22-year-old previously healthy man undergoes a tooth extraction, and 4 days later he develops a fever. In which of the following locations is the congenital anomaly in this man most likely found Ascending aorta Atrial appendage Chordae tendineae Cusps of valves Muscular septum 43 A 26-year-old woman has had a fever for 5 days. There are splinter hemorrhages under the fingernails and tender hemorrhagic nodules on the palms and soles. After surgery, he is stable, and an echocardiogram shows no abnormal valvular or ventricular function. Which of the following pharmacologic agents should he receive regularly after this surgical procedure Aspirin Ciprofloxacin Cyclosporine Digoxin Propranolol Warfarin 45 A 71-year-old woman has had a 10-kg weight loss accompanied by severe nausea and vomiting of blood for the past 8 months. Biopsy specimens obtained by upper gastrointestinal endoscopy show adenocarcinoma of the stomach. Calcific aortic valvular stenosis Constrictive pericarditis Epicardial metastatic carcinoma Left ventricular mural thrombosis Nonbacterial thrombotic endocarditis 49 A 44-year-old, previously healthy man has experienced worsening exercise tolerance accompanied by marked shortness of breath for the past 6 months. An echocardiogram shows four-chamber cardiac enlargement and mitral and tricuspid valvular regurgitation, with an ejection fraction of 30%. A coronary angiogram shows less than 10% narrowing of the major coronary arteries. Amyloidosis Hypercholesterolemia Familial cardiomyopathy Rheumatic heart disease Trypanosoma cruzi infection 46 A 41-year-old woman has had increasing dyspnea for the past week. A chest radiograph shows large bilateral pleural effusions and a normal heart size. Which of the following cardiac lesions is most likely to be present in this patient Calcific aortic stenosis Hemorrhagic pericarditis Nonbacterial thrombotic endocarditis Libman-Sacks endocarditis Mural thrombosis Rheumatic verrucous endocarditis 50 A 56-year-old man has experienced increased fatigue and decreased exercise tolerance for the past 2 years. On physical examination, his temperature is 37° C, pulse is 75/min, respirations are 17/min, and blood pressure is 115/75 mm Hg.
Some of the substances for which special stains are commonly used in a surgical pathology laboratory are amyloid medicine 5325 buy 100 mg persantine overnight delivery, carbohydrates, lipids, proteins, nucleic acids, connective tissue, microorganisms, neural tissues, pigments, minerals; these stains are listed in Table 2. Congo red with polarising light Toluidine blue Amyloid Amyloid Congo red Toluidine blue Green-birefringence: amyloid Orthochromatic blue: amyloid B. Oil red O Reticular fibres Fats (unfixed cryostat) Fats (unfixed cryostat) Fats (unfixed cryostat) Oil red O Mineral oils: red Unsaturated fats, phospholipids: pink Unsaturated fats: blue black Unsaturated lipids: brown black Saturated lipids: unstained 13. Currently, enzyme histochemistry has limited diagnostic applications and not so popular, partly due to requirement of fresh tissues and complex technique, and partly due to relative lack of specificity of reaction in many cases, and hence have been largely superseded by immunohistochemical procedures and molecular pathology techniques. The usual type of microscope used in clinical laboratories is called light microscope. The compound microscope can be monocular having single eyepiece or binocular which has two eyepieces. Multi-headed microscopes are used as an aid to teaching and for demonstration purposes. The microorganisms are illuminated by an oblique ray of light which does not pass through the microorganism. The condenser is blackened in the centre and light passes through its periphery illuminating the living microorganism on a glass slide. A variety of filters are used between the source of light and objective: first, heat absorbing filter; second, red-light stop filter; and third exciter filter to allow the passage of light of only the desired wavelength. On passing through the specimen, light of both exciting and fluorescence wavelength collects. Dark-ground condenser is used in fluorescence microscope so that no direct light falls into the object and instead gives dark contrast background to the fluorescence. There are two types of fluorescence techniques both of which are performed on cryostat sections of fresh unfixed tissue: direct and indirect. In the direct technique, first introduced by Coons (1941) who did the original work on immunofluorescence, antibody against antigen is directly conjugated with the fluorochrome and then examined under fluorescence microscope. In the indirect technique, also called sandwich technique, there is interaction between tissue antigen and specific antibody, followed by a step of washing and then addition of fluorochrome for completion of reaction. In renal diseases for detection of deposits of immunoglobulins, complement and fibrin in various types of glomerular diseases by frozen section as discussed in Chapter 22. In skin diseases to detect deposits of immunoglobulin by frozen section, particularly at the dermo-epidermal junction and in upper dermis. Two discs made up of prism are placed in the path of light, one below the object known as polariser and another placed in the body tube which is known as analyser. This is done by using specific antibody against the antigenic molecule forming antigen-antibody complex at the specific antigenic site which is made visible by employing a fluorochrome which has the property to absorb radiation in the form of ultraviolet light so as to be within the visible spectrum of light in microscopic examination. Fluorescence microscopy is based on the principle that the exciting radiation from ultraviolet light of shorter wavelength (360 nm) or blue light (wavelength 400 nm) causes fluorescence of certain substances and thereafter re-emits light of a longer wavelength. Secondary fluorescence is more commonly employed and is the production of fluorescence on addition of dyes or chemicals called fluorochromes. Mercury vapour and xenon gas lamps are used as source of light for fluorescence microscopy. In renal pathology in conjunction with light microscopy and immunofluorescence (Chapter 22). Following fixation, the tissue is post-fixed in buffered solution of osmium tetroxide to enhance the contrast. First, semithin sections are cut at a thickness of 1 m and stained with methylene blue or toluidine blue. Semithin sections guide in making the differential diagnosis and in selecting the area to be viewed in ultrathin sections. For ultrastructural examination, ultrathin sections are cut by use of diamond knife. In order to increase electron density, thin sections may be stained by immersing the grid in solution of lead citrate and urinyl acetate. Need for fluorescent microscope was obviated by subsequent development of horseradish peroxidase enzymatic labelling technique with some colorogenic system instead of fluorochrome so that the frozen section with labelled antibody could be visualised by light microscopy. Subsequently, immunoperoxidase technique employing labelled antibody method to formalin-fixed paraffin sections was developed which is now widely used. Generally, a panel of antibodies is preferable over a single test to avoid errors. The technique is used to detect the status and localisation of particular antigen in the cells (membrane, cytoplasm or nucleus) by use of specific antibodies which are then visualised by chromogen as brown colour. This then helps in determining cell lineage specifically, or is used to confirm a specific infection. A panel of antibodies is chosen to resolve such diagnostic problem cases; the selection of antibodies being made is based on clinical history, morphologic features, and results of other relevant investigations. Analysis of tumours by these methods is a significant improvement in management over the conventional prognostic considerations by clinical staging and histologic grading. The specific receptors for these growth regulating hormones are located on respective tumour cells. Tumours expressing high level of receptor positivity would respond favourably to removal of the endogenous source of such hormones (oophorectomy in oestrogen-positive breast cancer and orchiectomy in androgen-positive prostatic carcinoma), or hormonal therapy is administered to lower their levels: oestrogen therapy in prostatic cancer and androgen therapy in breast cancer. Thus, the sex of the offspring is determined by paternal chromosomal contribution i. Karyotyping Karyotype is defined as the sequence of chromosomal alignment on the basis of size, centromeric location and banding pattern. Determination of karyotype of an individual is an important tool in cytogenetic analysis. The dividing cells are then arrested in metaphase by the addition of colchicine or colcemid, both of which are inhibitory to microtubule formation. When stained, chromosomes have the property of forming alternating dark and light bands.
Distribution of the primary colorectal cancer reveals that about 60% of the cases occur in the rectum symptoms 4 days after conception cheapest persantine, followed in descending order, by sigmoid and descending colon (25%), caecum and ileocaecal valve (10%); ascending colon, hepatic and splenic flexures (5%); and quite uncommonly in the transverse colon. B, Left-sided growth-napkin-ring configuration with spread of growth into the bowel wall. The remaining 5% tumours include uncommon microscopic patterns like undifferentiated carcinoma, signet-ring cell carcinoma, and adenosquamous carcinomas seen in more distal colon near the anus. The histologic grades indicating the degree of differentiation are: well-differentiated, moderatelydifferentiated and poorly-differentiated. Spread via lymphatics occurs rather commonly and involves, firstly the regional lymph nodes in the vicinity of the tumour, and then into other groups of lymph nodes like preaortic, internal iliac and the sacral lymph nodes. Blood spread of large bowel cancer occurs relatively late and involves the liver, lungs, brain, bones and ovary. The prognosis of colorectal cancer depends upon a few variables: i) Extent of the bowel involvement ii) Presence or absence of metastases iii) Histologic grade of the tumour iv) Location of the tumour the most important prognostic factor in colorectal cancer is, however, the stage of the disease at the time of diagnosis. Other Colorectal Malignant Tumours Aside from colorectal carcinoma, other malignant tumours which are encountered sometimes in the large bowel are leiomyosarcoma (page 737) and malignant lymphoma (page 559). Amongst the benign tumours of the anal canal, multiple viral warts called as condyloma acuminata are the only tumours of note. Other structures topographically related to peritoneum are retroperitoneum, omentum, mesentery and umbilicus. These structures are involved in a variety of pathologic states but a few important conditions included below are inflammation (peritonitis), tumour-like lesions (idiopathic retroperitoneal fibrosis and mesenteric cysts) and tumours (primary and metastatic). Chemical peritonitis can be caused by the following: Bile extravasated due to trauma or diseases of the gallbladder. Chemical peritonitis is localised or generalised sterile inflammation of the peritoneum. It may be generalised or may get localised by omentum such as in appendiceal abscess following acute appendicitis. Though idiopathic, the etiologic role of ergot derivative drugs and autoimmune reaction has been suggested. On the basis of their possible origin, they are of various types: Chylous cyst is a thin-walled cyst arising from lymph vessels and lined by endothelium. Mesothelioma is an example of primary peritoneal tumour (benign and malignant) and is similar in morphology as in pleural cavity (page 505). Metastatic peritoneal tumours are quite common and may occur from dissemination from any intra-abdominal malignancy. The liver is the largest organ in the body weighing 1400-1600 gm in the males and 1200-1400 gm in the females. There are 2 main anatomical lobes-right and left, the right being about six times the size of the left lobe. The liver has a double blood supply-the portal vein brings the venous blood from the intestines and spleen, and the hepatic artery coming from the coeliac axis supplies arterial blood to the liver. The hexagonal or pyramidal structure with central vein and peripheral 4 to 5 portal triads is termed the classical lobule. The venous drainage from the liver is into the right and left hepatic veins which enter the inferior vena cava. Lymphatics and the nerve fibres accompany the hepatic artery into their branchings and terminate around the porta hepatis. The hepatic parenchyma is composed of numerous hexagonal or pyramidal classical lobules, each with a diameter of 0. Each classical lobule has a central tributary from the hepatic vein and at the periphery are 4 to 5 portal tracts or triads containing branches of bile duct, portal vein and hepatic artery. Cords of hepatocytes and blood-containing sinusoids radiate from the central vein to the peripheral portal triads. The functioning lobule or liver acinus as described by Rappaport has a portal triad in the centre and is surrounded at the periphery by portions of several classical lobules. Thus it is not uncommon to find liver cells containing more than one nuclei and having polyploidy up to octoploidy. A hepatocyte has 3 surfaces: one facing the sinusoid and the space of Disse, the second facing the canaliculus, and the third facing neighbouring hepatocytes. These canaliculi join at the periphery of the lobule to drain eventually into terminal bile ducts or ductules (canal of Hering) which are lined by cuboidal epithelium. Thus a battery of liver function tests are employed for accurate diagnosis, to assess the severity of damage, to judge prognosis and to evaluate therapy. Water-soluble conjugated bilirubin gives direct van den Bergh reaction with diazo reagent within one minute, whereas alcohol-soluble unconjugated bilirubin is determined by indirect van den Bergh reaction. The serum of normal adults contains less than 1 mg/ dl of total bilirubin, out of which less than 0. Its excretion depends upon the level of conjugated bilirubin in plasma that is not proteinbound and is therefore available for glomerular filtration. Bilirubinuria appears in patients of hepatitis before the patient becomes jaundiced. An increase in urobilinogen in the urine is found in hepatocellular dysfunctions such as in alcoholic liver disease, cirrhosis and malignancy of the liver. The primary bile acids (cholic acid and cheno-deoxycholic acid) are formed from cholesterol in the hepatocytes. To understand the mechanisms underlying biliary pathology, it is important to understand normal bilirubin metabolism (page 596). Amino acid and protein metabolism: i) Serum proteins (total, A/G ratio, protein electrophoresis) ii) Immunoglobulins iii) Clotting factors iv) v) 2. Serum ammonia Aminoaciduria Hypoalbuminaemia in hepatocellular diseases; hyperglobulinaemia in cirrhosis and chronic active hepatitis Nonspecific alterations in IgA, IgG and IgM Prothrombin time and partial thromboplastin time prolonged in patients with hepatocellular disease Increased in acute fulminant hepatitis, cirrhosis, hepatic encephalopathy In fulminant hepatitis Increased in cholestasis, decreased in acute and chronic diffuse liver disease and in malnutrition Decreased in hepatic necrosis Lipid and lipoprotein metabolism: Blood lipids (total serum cholesterol, triglycerides and lipoprotein fractions) 3.