Pulmonary hypertension — MCQs

10 questions

A 36-year-old man presents to his primary care physician because of shortness of breath. He is an office worker who has a mostly sedentary lifestyle; however, he has noticed that recently he feels tired and short of breath when going on long walks with his wife. He also has had a hacking cough that seems to linger, though he attributes this to an upper respiratory tract infection he had 2 months ago. He has diabetes that is well-controlled on metformin and has smoked 1 pack per day for 20 years. Physical exam reveals a large chested man with wheezing bilaterally and mild swelling in his legs and abdomen. The cause of this patient's abdominal and lower extremity swelling is most likely due to which of the following processes?

A 61-year-old man comes to the physician for shortness of breath and chest discomfort that is becoming progressively worse. He has had increasing problems exerting himself for the past 5 years. He is now unable to walk more than 50 m on level terrain without stopping and mostly rests at home. He has smoked 1–2 packs of cigarettes daily for 40 years. He appears distressed. His pulse is 85/min, blood pressure is 140/80 mm Hg, and respirations are 25/min. Physical examination shows a plethoric face and distended jugular veins. Bilateral wheezing is heard on auscultation of the lungs. There is yellow discoloration of the fingers on the right hand and 2+ lower extremity edema. Which of the following is the most likely cause of this patient's symptoms?

A 42-year-old man comes to the physician because of a 2-month history of fatigue and increased urination. The patient reports that he has been drinking more than usual because he is constantly thirsty. He has avoided driving for the past 8 weeks because of intermittent episodes of blurred vision. He had elevated blood pressure at his previous visit but is otherwise healthy. Because of his busy work schedule, his diet consists primarily of fast food. He does not smoke or drink alcohol. He is 178 cm (5 ft 10 in) tall and weighs 109 kg (240 lb); BMI is 34 kg/m2. His pulse is 75/min and his blood pressure is 148/95 mm Hg. Cardiopulmonary examination shows no abnormalities. Laboratory studies show: Hemoglobin A1c 6.8% Serum Glucose 180 mg/dL Creatinine 1.0 mg/dL Total cholesterol 220 mg/dL HDL cholesterol 50 mg/dL Triglycerides 140 mg/dL Urine Blood negative Glucose 2+ Protein 1+ Ketones negative Which of the following is the most appropriate next step in management?

A 65-year-old man with hypertension and type 2 diabetes mellitus is brought to the emergency department 20 minutes after the onset of severe anterior chest pain and shortness of breath. He has smoked one pack of cigarettes daily for 30 years. He appears distressed. His pulse is 116/min, respirations are 22/min, and blood pressure is 156/88 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. A grade 3/6, high-pitched, blowing, diastolic murmur is heard over the right upper sternal border. Which of the following is the most likely cause of this patient's symptoms?

A 27-year-old woman with a history of a "heart murmur since childhood" presents following a series of syncopal episodes over the past several months. She also complains of worsening fatigue over this time period, and notes that her lips have begun to take on a bluish tinge, for which she has been using a brighter shade of lipstick. You do a careful examination, and detect a right ventricular heave, clubbing of the fingers, and 2+ pitting edema bilaterally to the shins. Despite your patient insisting that every doctor she has ever seen has commented on her murmur, you do not hear one. Transthoracic echocardiography would most likely detect which of the following?

A 57-year-old woman comes to the physician for a routine health maintenance examination. She has well-controlled type 2 diabetes mellitus, for which she takes metformin. She is 163 cm (5 ft 4 in) tall and weighs 84 kg (185 lb); BMI is 31.6 kg/m2. Her blood pressure is 140/92 mm Hg. Physical examination shows central obesity, with a waist circumference of 90 cm. Laboratory studies show: Fasting glucose 94 mg/dl Total cholesterol 200 mg/dL High-density lipoprotein cholesterol 36 mg/dL Triglycerides 170 mg/dL Without treatment, this patient is at greatest risk for which of the following conditions?

A 59-year-old man presents to his primary care provider with the complaint of daytime fatigue. He often has a headache that is worse in the morning and feels tired when he awakes. He perpetually feels fatigued even when he sleeps in. The patient lives alone, drinks 2-3 beers daily, drinks coffee regularly, and has a 10 pack-year smoking history. His temperature is 99.0°F (37.2°C), blood pressure is 180/110 mm Hg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam is notable for a BMI of 39 kg/m^2. The rest of the patient's pulmonary and neurological exams are unremarkable. Which of the following is the best next step in management?

A 65-year-old man presents to the physician for the evaluation of increasing dyspnea and swelling of the lower extremities over the past year. He has no cough. He also complains of frequent awakenings at night and excessive daytime sleepiness. He has no history of a serious illness. He takes no medications other than zolpidem before sleep. He is a 35-pack-year smoker. His blood pressure is 155/95 mm Hg. His BMI is 37 kg/m2. Oropharyngeal examination shows a small orifice and an enlarged tongue and uvula. The soft palate is low-lying. The examination of the nasal cavity shows no septal deviation or polyps. Symmetric pitting edema is seen below the knee, bilaterally. The lungs are clear to auscultation. Echocardiography shows a mildly dilated right ventricle and an elevated systolic pulmonary artery pressure with no abnormalities of the left heart. A ventilation-perfusion scan shows no abnormalities. Which of the following is the most likely cause of this patient’s symptoms?

A 59-year-old man presents to the emergency department with a sudden onset of severe pain (10/10 in severity) between the shoulder blades. He describes the pain as tearing in nature. Medical history is positive for essential hypertension for 11 years. The patient has smoked 10–15 cigarettes daily for the past 30 years. His temperature is 36.6°C (97.8°F), the heart rate is 107/min, and the blood pressure is 179/86 mm Hg in the right arm and 157/72 mm Hg in the left arm. CT scan of the chest shows an intimal flap limited to the descending thoracic aorta. Which of the following best describes the most likely predisposing factor for this condition?

Q10

A 65-year-old man presents to the emergency department for sudden weakness. The patient states that he was at home enjoying his morning coffee when his symptoms began. He says that his left arm suddenly felt very odd and weak thus prompting him to come to the ED. The patient has a past medical history of diabetes, COPD, hypertension, anxiety, alcohol abuse, and PTSD. He recently fell off a horse while horseback riding but claims to not have experienced any significant injuries. He typically drinks 5-7 drinks per day and his last drink was yesterday afternoon. His current medications include insulin, metformin, atorvastatin, lisinopril, albuterol, and fluoxetine. His temperature is 99.5°F (37.5°C), blood pressure is 177/118 mmHg, pulse is 120/min, respirations are 18/min, and oxygen saturation is 93% on room air. On physical exam, you note an elderly man who is mildly confused. Cardiopulmonary exam demonstrates bilateral expiratory wheezes and a systolic murmur along the right upper sternal border that radiates to the carotids. Neurological exam reveals cranial nerves II-XII as grossly intact with finger-nose exam mildly abnormal on the left and heel-shin exam within normal limits. The patient has 5/5 strength in his right arm and 3/5 strength in his left arm. The patient struggles to manipulate objects such as a pen with his left hand. The patient is given a dose of diazepam and started on IV fluids. Which of the following is the most likely diagnosis in this patient?

Pulmonary hypertension US Medical PG Practice Questions and MCQs

Question 1: A 36-year-old man presents to his primary care physician because of shortness of breath. He is an office worker who has a mostly sedentary lifestyle; however, he has noticed that recently he feels tired and short of breath when going on long walks with his wife. He also has had a hacking cough that seems to linger, though he attributes this to an upper respiratory tract infection he had 2 months ago. He has diabetes that is well-controlled on metformin and has smoked 1 pack per day for 20 years. Physical exam reveals a large chested man with wheezing bilaterally and mild swelling in his legs and abdomen. The cause of this patient's abdominal and lower extremity swelling is most likely due to which of the following processes?

A. Excessive protease activity
B. Damage to kidney tubules
C. Hyperplasia of mucous glands
D. Defective protein folding
E. Right ventricular dysfunction secondary to pulmonary hypertension (Correct Answer)

Explanation: ***Right ventricular dysfunction secondary to pulmonary hypertension*** - This patient's long history of smoking, chronic cough, and wheezing suggest significant **chronic obstructive pulmonary disease (COPD)**, which leads to **hypoxemia** and **pulmonary hypertension**. - **Pulmonary hypertension** increases the workload on the **right ventricle**, eventually leading to **right heart failure** (cor pulmonale), characterized by peripheral edema (leg swelling) and ascites (abdominal swelling). *Excessive protease activity* - While excessive protease activity (e.g., elastase) is implicated in the pathogenesis of **emphysema** by destroying alveolar walls, it does not directly cause peripheral edema and ascites. - This process primarily leads to **airflow obstruction** and **gas exchange abnormalities**, which can indirectly contribute to pulmonary hypertension but is not the direct cause of the peripheral edema. *Damage to kidney tubules* - **Acute tubular necrosis** or chronic kidney disease can cause edema due to impaired fluid and electrolyte balance, but the patient's symptoms (dyspnea, wheezing, smoking history) point strongly to a primary pulmonary and cardiac etiology. - While diabetes can cause nephropathy, there is no information to suggest acute kidney injury or chronic kidney disease leading to such severe edema. *Hyperplasia of mucous glands* - **Hyperplasia of mucous glands** in the bronchi is characteristic of **chronic bronchitis**, contributing to the chronic cough and airway obstruction. - This pathology primarily affects airway clearance and airflow, rather than directly causing systemic edema or ascites. *Defective protein folding* - **Defective protein folding**, such as in **alpha-1 antitrypsin deficiency**, can lead to early-onset emphysema and liver disease. - While this could fit with a pulmonary presentation, it is less common than smoking-induced COPD and does not directly explain the edema and ascites caused by right heart failure.

Question 2: A 61-year-old man comes to the physician for shortness of breath and chest discomfort that is becoming progressively worse. He has had increasing problems exerting himself for the past 5 years. He is now unable to walk more than 50 m on level terrain without stopping and mostly rests at home. He has smoked 1–2 packs of cigarettes daily for 40 years. He appears distressed. His pulse is 85/min, blood pressure is 140/80 mm Hg, and respirations are 25/min. Physical examination shows a plethoric face and distended jugular veins. Bilateral wheezing is heard on auscultation of the lungs. There is yellow discoloration of the fingers on the right hand and 2+ lower extremity edema. Which of the following is the most likely cause of this patient's symptoms?

A. Coronary plaque deposits
B. Chronic respiratory acidosis
C. Increased left atrial pressure
D. Elevated pulmonary artery pressure (Correct Answer)
E. Decreased intrathoracic gas volume

Explanation: ***Elevated pulmonary artery pressure*** * The patient's long history of **heavy smoking** and progressive exertional dyspnea, wheezing, plethoric face, distended jugular veins, and lower extremity edema are highly suggestive of **cor pulmonale** due to chronic obstructive pulmonary disease (COPD). * **COPD** leads to chronic hypoxia and vasoconstriction of pulmonary arteries, increasing **pulmonary artery pressure**, which eventually causes right ventricular failure (cor pulmonale) manifested by the systemic venous congestion symptoms. *Coronary plaque deposits* * While **coronary plaque deposits** can lead to chest discomfort, the prominent signs of **right-sided heart failure** (jugular venous distension, lower extremity edema) and chronic respiratory symptoms point away from isolated coronary artery disease as the primary cause. * The patient's wheezing and long smoking history are more indicative of a **respiratory rather than purely cardiac origin** for his dyspnea. *Chronic respiratory acidosis* * **Chronic respiratory acidosis** can occur in severe COPD, but it is a **consequence** of impaired gas exchange, not the primary cause of the patient's presenting symptoms of shortness of breath and chest discomfort with signs of overt heart failure. * While important, acidosis alone does not explain the **physical findings of right heart failure** such as jugular venous distention and peripheral edema. *Increased left atrial pressure* * **Increased left atrial pressure** is characteristic of **left-sided heart failure**, which typically presents with pulmonary edema (rales, pink frothy sputum) and symptoms like orthopnea and paroxysmal nocturnal dyspnea. * This patient's symptoms, particularly the **plethoric face, distended jugular veins, and lower extremity edema**, are classic signs of **right-sided heart failure**, not left-sided heart failure. *Decreased intrathoracic gas volume* * **Decreased intrathoracic gas volume** is usually seen in restrictive lung diseases (e.g., pulmonary fibrosis), not obstructive diseases like COPD, where gas trapping leads to **increased intrathoracic gas volume**. * The patient's wheezing and long smoking history are classic for **obstructive lung disease**, which is associated with air trapping and hyperinflation, rather than decreased lung volumes.

Question 3: A 42-year-old man comes to the physician because of a 2-month history of fatigue and increased urination. The patient reports that he has been drinking more than usual because he is constantly thirsty. He has avoided driving for the past 8 weeks because of intermittent episodes of blurred vision. He had elevated blood pressure at his previous visit but is otherwise healthy. Because of his busy work schedule, his diet consists primarily of fast food. He does not smoke or drink alcohol. He is 178 cm (5 ft 10 in) tall and weighs 109 kg (240 lb); BMI is 34 kg/m2. His pulse is 75/min and his blood pressure is 148/95 mm Hg. Cardiopulmonary examination shows no abnormalities. Laboratory studies show: Hemoglobin A1c 6.8% Serum Glucose 180 mg/dL Creatinine 1.0 mg/dL Total cholesterol 220 mg/dL HDL cholesterol 50 mg/dL Triglycerides 140 mg/dL Urine Blood negative Glucose 2+ Protein 1+ Ketones negative Which of the following is the most appropriate next step in management?

A. Metformin therapy (Correct Answer)
B. Low-carbohydrate diet
C. Aspirin therapy
D. ACE inhibitor therapy
E. Insulin therapy

Explanation: ***Metformin therapy*** - This patient has **newly diagnosed type 2 diabetes mellitus** with classic symptoms (polyuria, polydipsia, blurred vision) and laboratory confirmation (HbA1c 6.8%, glucose 180 mg/dL, glucosuria). - **Metformin is the first-line pharmacologic therapy** for type 2 diabetes according to current guidelines (ADA, AACE) due to its efficacy, safety profile, cardiovascular benefits, and low risk of hypoglycemia. - The patient's creatinine is normal (1.0 mg/dL), so metformin is not contraindicated. - Addressing the **symptomatic hyperglycemia** is the most appropriate next step in management. *ACE inhibitor therapy* - ACE inhibitors are indicated for diabetic patients with **hypertension and albuminuria** to provide renoprotection and slow progression of diabetic nephropathy. - While this patient has both hypertension (148/95 mm Hg) and proteinuria (1+), ACE inhibitor therapy should be initiated **after or concurrent with diabetes management**, not as the sole initial intervention. - The patient needs **glycemic control first** given symptomatic hyperglycemia, though ACE inhibitor would be an appropriate addition to the treatment regimen. *Low-carbohydrate diet* - **Lifestyle modifications** including medical nutrition therapy and exercise are foundational for managing type 2 diabetes and should be recommended. - However, given the patient's **symptomatic hyperglycemia** (HbA1c 6.8%, glucose 180 mg/dL with classic symptoms), lifestyle changes alone are **insufficient as the initial management**. - Pharmacologic therapy with metformin should be initiated immediately alongside lifestyle counseling. *Insulin therapy* - Insulin therapy is indicated for patients with **very high HbA1c** (typically >9-10%), **severe symptoms of hyperglycemia**, evidence of catabolism, or failure of oral agents. - This patient's HbA1c of 6.8% represents **relatively mild hyperglycemia** that is appropriately managed with metformin as first-line therapy. - Insulin is **not indicated** at this stage of disease. *Aspirin therapy* - **Aspirin for primary prevention** in diabetes is controversial; current guidelines suggest shared decision-making for patients at increased cardiovascular risk without high bleeding risk. - While this patient has cardiovascular risk factors (diabetes, hypertension, obesity, dyslipidemia), aspirin would be a **secondary priority** after addressing the acute metabolic derangements. - **Glycemic control takes precedence** over aspirin initiation in newly diagnosed diabetes.

Question 4: A 65-year-old man with hypertension and type 2 diabetes mellitus is brought to the emergency department 20 minutes after the onset of severe anterior chest pain and shortness of breath. He has smoked one pack of cigarettes daily for 30 years. He appears distressed. His pulse is 116/min, respirations are 22/min, and blood pressure is 156/88 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. A grade 3/6, high-pitched, blowing, diastolic murmur is heard over the right upper sternal border. Which of the following is the most likely cause of this patient's symptoms?

A. Rupture of a bulla in the lung
B. Perforation of the esophageal wall
C. Obstruction of the pulmonary arteries
D. Fibrofatty plaque in the aortic wall
E. Tear in the tunica intima (Correct Answer)

Explanation: ***Tear in the tunica intima*** - The sudden onset of **severe anterior chest pain**, hypertension, and a **diastolic murmur** consistent with **aortic insufficiency** points strongly to an **aortic dissection**, which begins with a tear in the tunica intima. - Risk factors like **hypertension**, **smoking**, and **advanced age** increase the likelihood of aortic dissection. *Rupture of a bulla in the lung* - This would typically cause **pneumothorax**, leading to **sharp, pleuritic chest pain** and **dyspnea**, often with diminished breath sounds on the affected side. - A **cardiac murmur** and severe distress in the context of vascular risk factors are not characteristic of a ruptured bulla. *Perforation of the esophageal wall* - Esophageal perforation (Boerhaave syndrome) presents with **severe chest pain**, **vomiting**, and often **subcutaneous emphysema** or **pleural effusion**. - While it causes severe chest pain, the described **diastolic murmur** and absence of vomiting or other specific signs make this less likely. *Obstruction of the pulmonary arteries* - **Pulmonary embolism** (obstruction of pulmonary arteries) typically causes **sudden onset dyspnea**, **pleuritic chest pain**, **tachycardia**, and **hypoxia**, often without a significant cardiac murmur of this nature. - The oxygen saturation of 98% makes a large pulmonary embolism less probable. *Fibrofatty plaque in the aortic wall* - While common in patients with hypertension and smoking history, an **atherosclerotic plaque** in the aortic wall itself rarely causes acute, severe chest pain and a new diastolic murmur unless it leads to an **aortic dissection** or **rupture**. - This option describes a precursor to diseases like aortic dissection but not the acute event itself.

Question 5: A 27-year-old woman with a history of a "heart murmur since childhood" presents following a series of syncopal episodes over the past several months. She also complains of worsening fatigue over this time period, and notes that her lips have begun to take on a bluish tinge, for which she has been using a brighter shade of lipstick. You do a careful examination, and detect a right ventricular heave, clubbing of the fingers, and 2+ pitting edema bilaterally to the shins. Despite your patient insisting that every doctor she has ever seen has commented on her murmur, you do not hear one. Transthoracic echocardiography would most likely detect which of the following?

A. Mitral insufficiency
B. Aortic stenosis
C. Dynamic left ventricular outflow tract obstruction
D. Positive bubble study (Correct Answer)
E. Ventricular aneurysm

Explanation: ***Positive bubble study*** - The patient's symptoms, including **cyanosis** (**bluish tinge to the lips**), **clubbing**, and **right ventricular heave**, suggest **Eisenmenger syndrome**, a late complication of a **left-to-right shunt** that has reversed due to pulmonary hypertension. - A positive bubble study on echocardiography would confirm the presence of a **right-to-left shunt**, characteristic of Eisenmenger syndrome, by showing microbubbles crossing from the right to the left side of the heart. *Mitral insufficiency* - While mitral insufficiency can cause a murmur and heart failure symptoms, it does not typically lead to the **cyanosis** and **clubbing** described. - The absence of a murmur, despite a history of one, points away from a significant current insufficiency. *Aortic stenosis* - Aortic stenosis is characterized by an **ejection systolic murmur** that would likely be heard on examination, contradicting the scenario where no murmur is audible. - It usually presents with a different constellation of symptoms, such as angina, syncope, and heart failure, without the prominent cyanosis or clubbing seen here. *Dynamic left ventricular outflow tract obstruction* - This is characteristic of **hypertrophic obstructive cardiomyopathy (HOCM)**, which can cause exertional syncope. - However, HOCM does not typically lead to **cyanosis**, a **right ventricular heave**, or **clubbing**, which are strong indicators of a right-to-left shunt. *Ventricular aneurysm* - A ventricular aneurysm is a bulging of the ventricular wall, often a complication of a **myocardial infarction**, which is unlikely in a 27-year-old with a history of a "heart murmur since childhood." - It typically presents with symptoms related to heart failure, arrhythmias, or embolism, and would not explain the prominent **cyanosis** and **clubbing**.

Question 6: A 57-year-old woman comes to the physician for a routine health maintenance examination. She has well-controlled type 2 diabetes mellitus, for which she takes metformin. She is 163 cm (5 ft 4 in) tall and weighs 84 kg (185 lb); BMI is 31.6 kg/m2. Her blood pressure is 140/92 mm Hg. Physical examination shows central obesity, with a waist circumference of 90 cm. Laboratory studies show: Fasting glucose 94 mg/dl Total cholesterol 200 mg/dL High-density lipoprotein cholesterol 36 mg/dL Triglycerides 170 mg/dL Without treatment, this patient is at greatest risk for which of the following conditions?

A. Osteoporosis
B. Rheumatoid arthritis
C. Subarachnoid hemorrhage
D. Central sleep apnea
E. Liver cirrhosis (Correct Answer)

Explanation: ***Liver cirrhosis*** * This patient has **metabolic syndrome**, characterized by **central obesity** (waist >88 cm in women), **hypertension** (≥130/85 mm Hg), **low HDL cholesterol** (<50 mg/dL in women), **elevated triglycerides** (≥150 mg/dL), and **type 2 diabetes mellitus**. * Metabolic syndrome is strongly associated with **non-alcoholic fatty liver disease (NAFLD)**, which affects **70-90% of patients** with this condition. * NAFLD can progress to **non-alcoholic steatohepatitis (NASH)**, then to **hepatic fibrosis**, and ultimately **cirrhosis**—making this patient's greatest long-term risk without intervention. * NAFLD is now the **leading cause of chronic liver disease** in developed countries, and the combination of obesity, insulin resistance, and dyslipidemia directly promotes hepatic lipid accumulation and inflammation. *Incorrect: Osteoporosis* * While common in post-menopausal women, **obesity is generally protective against osteoporosis** due to increased weight-bearing stress on bones and higher estrogen levels from adipose tissue aromatization. * No specific risk factors for osteoporosis (e.g., corticosteroid use, smoking, low calcium intake) are present. *Incorrect: Rheumatoid arthritis* * This is an **autoimmune condition** not associated with metabolic syndrome. * The patient has no symptoms of joint pain, morning stiffness, or synovitis that would suggest rheumatoid arthritis. * Metabolic factors do not increase the risk of developing rheumatoid arthritis. *Incorrect: Subarachnoid hemorrhage* * While **hypertension** is a risk factor for hemorrhagic stroke, subarachnoid hemorrhage is more specifically associated with **ruptured aneurysms** or **arteriovenous malformations**. * The patient's moderately elevated blood pressure poses some cardiovascular risk, but this is not the greatest risk compared to the progressive liver disease associated with metabolic syndrome. *Incorrect: Central sleep apnea* * **Central sleep apnea** (cessation of respiratory effort) is primarily associated with **heart failure**, **stroke**, or **opioid use**—not metabolic syndrome. * **Obstructive sleep apnea** (OSA) is what's associated with obesity and metabolic syndrome, but that is not an option here. * While this patient may be at risk for OSA, central sleep apnea is not the primary concern in metabolic syndrome.

Question 7: A 59-year-old man presents to his primary care provider with the complaint of daytime fatigue. He often has a headache that is worse in the morning and feels tired when he awakes. He perpetually feels fatigued even when he sleeps in. The patient lives alone, drinks 2-3 beers daily, drinks coffee regularly, and has a 10 pack-year smoking history. His temperature is 99.0°F (37.2°C), blood pressure is 180/110 mm Hg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam is notable for a BMI of 39 kg/m^2. The rest of the patient's pulmonary and neurological exams are unremarkable. Which of the following is the best next step in management?

A. Caffeine avoidance
B. Screening for depression
C. Alcohol avoidance in the evening
D. CT head
E. Weight loss (Correct Answer)

Explanation: ***Weight Loss*** - The patient's **BMI of 39 kg/m²** indicates **class III obesity**, which is the strongest modifiable risk factor for **obstructive sleep apnea (OSA)**. The clinical presentation—**daytime fatigue**, morning headaches, unrefreshing sleep despite adequate sleep duration, and hypertension—strongly suggests OSA. - While **polysomnography** is the gold standard for confirming OSA, the clinical diagnosis is evident in this case. **Weight loss** is the most important initial therapeutic intervention, as even modest weight reduction (10% of body weight) can significantly improve or resolve OSA in obese patients. - Weight loss reduces upper airway collapse by decreasing fatty tissue deposition around the pharynx and improving lung volumes. This addresses the underlying pathophysiology rather than just treating symptoms. - This intervention also addresses his **hypertension** (180/110 mm Hg), which is commonly associated with and exacerbated by OSA. *Caffeine avoidance* - While excessive caffeine can disrupt sleep architecture, the patient's symptoms—particularly **morning headaches** and **unrefreshing sleep despite sleeping in**—are not characteristic of caffeine-induced insomnia, which typically presents with difficulty initiating sleep. - These symptoms, combined with obesity and hypertension, point strongly to a sleep-related breathing disorder rather than a stimulant effect. *Screening for depression* - Fatigue is indeed a cardinal symptom of major depressive disorder, but the specific pattern here—**morning headaches** (from nocturnal hypercapnia/hypoxemia), **unrefreshing sleep**, and **obesity with hypertension**—is far more consistent with OSA. - Depression screening could be considered if symptoms persist after addressing the sleep disorder, as untreated OSA can contribute to or worsen mood disorders. *Alcohol avoidance in the evening* - **Alcohol consumption** (2-3 beers daily) does worsen OSA by relaxing upper airway dilator muscles and suppressing arousal responses to hypoxemia. Evening alcohol avoidance would be a beneficial **adjunctive measure**. - However, while helpful, this intervention is less impactful than weight loss. The patient's **severe obesity** (BMI 39 kg/m²) is the predominant and most modifiable risk factor, making weight loss the priority intervention that will have the greatest effect on reducing OSA severity. *CT head* - CT head would be indicated if there were focal neurological deficits, papilledema, or features suggesting increased intracranial pressure or structural brain pathology. - This patient's **neurological exam is unremarkable**, and his headaches are characteristic of OSA (worse in the morning due to nocturnal CO₂ retention, improving throughout the day). Imaging is not warranted.

Question 8: A 65-year-old man presents to the physician for the evaluation of increasing dyspnea and swelling of the lower extremities over the past year. He has no cough. He also complains of frequent awakenings at night and excessive daytime sleepiness. He has no history of a serious illness. He takes no medications other than zolpidem before sleep. He is a 35-pack-year smoker. His blood pressure is 155/95 mm Hg. His BMI is 37 kg/m2. Oropharyngeal examination shows a small orifice and an enlarged tongue and uvula. The soft palate is low-lying. The examination of the nasal cavity shows no septal deviation or polyps. Symmetric pitting edema is seen below the knee, bilaterally. The lungs are clear to auscultation. Echocardiography shows a mildly dilated right ventricle and an elevated systolic pulmonary artery pressure with no abnormalities of the left heart. A ventilation-perfusion scan shows no abnormalities. Which of the following is the most likely cause of this patient’s symptoms?

A. Chronic obstructive pulmonary disease
B. Pulmonary thromboembolism
C. Idiopathic pulmonary artery hypertension
D. Obstructive sleep apnea (Correct Answer)
E. Heart failure with a preserved ejection fraction

Explanation: ***Obstructive sleep apnea*** - This patient's symptoms of **dyspnea, lower extremity swelling, frequent nocturnal awakenings, and excessive daytime sleepiness**, in conjunction with **obesity (BMI 37)**, **hypertension**, and specific **oropharyngeal abnormalities** (small orifice, enlarged tongue and uvula, low-lying soft palate), are highly suggestive of **obstructive sleep apnea (OSA)**. - The echocardiographic findings of a **mildly dilated right ventricle** and **elevated systolic pulmonary artery pressure** (cor pulmonale) without left heart abnormalities are a common consequence of chronic hypoxia and hypercapnia associated with severe OSA. *Chronic obstructive pulmonary disease* - While the patient is a 35-pack-year smoker, the absence of a **cough** and **clear lungs to auscultation** make COPD less likely. - A Ventilation-Perfusion scan showing **no abnormalities** further decreases the likelihood of significant parenchymal lung disease often seen in COPD. *Pulmonary thromboembolism* - Although dyspnea is a symptom of pulmonary thromboembolism, the **insidious onset over a year** and the absence of acute symptoms like pleuritic chest pain or hemoptysis make it unlikely. - A **normal ventilation-perfusion scan** effectively rules out significant pulmonary thromboembolism. *Idiopathic pulmonary artery hypertension* - This diagnosis typically presents with **progressive dyspnea** and signs of **right heart failure**, similar to the patient's presentation. - However, the patient's severe **risk factors for OSA (obesity, oropharyngeal features)** provide a more specific and likely underlying cause for the observed pulmonary hypertension, rather than idiopathic. *Heart failure with a preserved ejection fraction* - This condition is characterized by dyspnea and edema with normal or near-normal left ventricular ejection fraction. - However, the echocardiogram specifically states **no abnormalities of the left heart**, which would typically show some signs of diastolic dysfunction in HFpEF. The primary findings point to right heart strain.

Question 9: A 59-year-old man presents to the emergency department with a sudden onset of severe pain (10/10 in severity) between the shoulder blades. He describes the pain as tearing in nature. Medical history is positive for essential hypertension for 11 years. The patient has smoked 10–15 cigarettes daily for the past 30 years. His temperature is 36.6°C (97.8°F), the heart rate is 107/min, and the blood pressure is 179/86 mm Hg in the right arm and 157/72 mm Hg in the left arm. CT scan of the chest shows an intimal flap limited to the descending thoracic aorta. Which of the following best describes the most likely predisposing factor for this condition?

A. Coronary atherosclerosis
B. Aortic coarctation
C. Hypertensive urgency
D. Aortic atherosclerosis
E. Abnormal elastic properties of the aorta (Correct Answer)

Explanation: ***Abnormal elastic properties of the aorta*** - Chronic **hypertension** (11 years) is the #1 risk factor for aortic dissection, causing **cystic medial degeneration** (breakdown of elastic fibers and smooth muscle in the tunica media). - This degenerative process results in **abnormal elastic properties** and weakening of the aortic wall, predisposing to dissection. - The tearing pain, blood pressure differential between arms, and CT findings of intimal flap are classic for **Type B aortic dissection**. - While often associated with connective tissue disorders in younger patients, cystic medial degeneration is also the pathophysiologic result of chronic hypertension in older patients. *Aortic atherosclerosis* - Atherosclerosis primarily affects the **intima** layer, while aortic dissection occurs in the **media** layer. - Though hypertension and smoking contribute to atherosclerosis, this is not the primary predisposing mechanism for dissection. - The underlying pathology is medial degeneration with abnormal elastic properties, not atherosclerotic plaque. *Coronary atherosclerosis* - This affects the coronary arteries supplying the heart, not the aortic wall structure. - Does not explain the anatomical location of dissection or the tearing interscapular pain. - Not a predisposing factor for aortic dissection. *Hypertensive urgency* - This refers to elevated blood pressure without acute end-organ damage. - The patient has **aortic dissection**, which represents acute end-organ damage (hypertensive emergency, not urgency). - While hypertension can precipitate dissection, the underlying **predisposing factor** is the chronic medial wall changes (abnormal elastic properties), not the acute blood pressure elevation itself. *Aortic coarctation* - This is a **congenital** narrowing of the aorta, typically diagnosed in childhood or young adulthood. - Classic finding is upper extremity hypertension with **lower extremity hypotension** (opposite pattern from arm-to-arm differential seen in dissection). - The patient's age, presentation, and 11-year history of essential hypertension make this unlikely.

Question 10: A 65-year-old man presents to the emergency department for sudden weakness. The patient states that he was at home enjoying his morning coffee when his symptoms began. He says that his left arm suddenly felt very odd and weak thus prompting him to come to the ED. The patient has a past medical history of diabetes, COPD, hypertension, anxiety, alcohol abuse, and PTSD. He recently fell off a horse while horseback riding but claims to not have experienced any significant injuries. He typically drinks 5-7 drinks per day and his last drink was yesterday afternoon. His current medications include insulin, metformin, atorvastatin, lisinopril, albuterol, and fluoxetine. His temperature is 99.5°F (37.5°C), blood pressure is 177/118 mmHg, pulse is 120/min, respirations are 18/min, and oxygen saturation is 93% on room air. On physical exam, you note an elderly man who is mildly confused. Cardiopulmonary exam demonstrates bilateral expiratory wheezes and a systolic murmur along the right upper sternal border that radiates to the carotids. Neurological exam reveals cranial nerves II-XII as grossly intact with finger-nose exam mildly abnormal on the left and heel-shin exam within normal limits. The patient has 5/5 strength in his right arm and 3/5 strength in his left arm. The patient struggles to manipulate objects such as a pen with his left hand. The patient is given a dose of diazepam and started on IV fluids. Which of the following is the most likely diagnosis in this patient?

A. Bridging vein tear
B. Cerebellar bleeding
C. Berry aneurysm rupture
D. Hypertensive encephalopathy
E. Lipohyalinosis (Correct Answer)

Explanation: ***Lipohyalinosis*** - This patient's history of **hypertension** and **diabetes** are major risk factors for **lipohyalinosis**, which leads to **lacunar infarcts** and presents with sudden onset **pure motor hemiparesis**, as seen with the left arm weakness. - The elevated blood pressure of 177/118 mmHg further supports a diagnosis involving **cerebral small vessel disease** secondary to chronic hypertension. *Bridging vein tear* - A bridging vein tear would typically lead to a **subdural hematoma**, characterized by a **gradual onset of symptoms** like headache, confusion, and neurological deficits, often following trauma, which is inconsistent with the sudden onset in this case. - While the patient recently fell off a horse, his symptoms are acute and focal, not typical of the delayed presentation often seen with subdural hematomas. *Cerebellar bleeding* - **Cerebellar bleeding** usually presents with symptoms such as **ataxia**, **nystagmus**, vertigo, and vomiting, along with potential truncal instability, which are not the primary symptoms observed here. - While the patient has some mild abnormality on the finger-nose test, the predominant symptom is **pure motor weakness** of the left arm, making a cerebellar bleed less likely. *Berry aneurysm rupture* - A **berry aneurysm rupture** typically causes a **sudden, severe headache** (thunderclap headache), neck stiffness, photophobia, and altered mental status due to subarachnoid hemorrhage, which are not reported by the patient. - The patient's primary complaint is **focal motor weakness** and mild confusion, not the classic diffuse hemorrhagic symptoms of aneurysm rupture. *Hypertensive encephalopathy* - **Hypertensive encephalopathy** presents with a more generalized and rapidly progressive decline in neurological function, including severe headache, altered mental status, seizures, and visual disturbances, usually with **diastolic blood pressure >120 mmHg**. - While the patient's blood pressure is high, the presentation of **focal motor deficit without severe headache** or global neurological decline makes this less likely than a lacunar stroke due to lipohyalinosis.

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free