Right heart failure — MCQs

A 41-year-old man comes to the emergency department because of fatigue, worsening abdominal discomfort, and progressive swelling of his legs for 3 months. The swelling is worse in the evenings. His only medication is ibuprofen for occasional joint pain. The patient does not smoke and drinks 2–3 beers each weekend. His temperature is 36°C (96.8°F), pulse is 88/min, respirations are 18/min, and blood pressure is 130/80 mm Hg. Pulmonary examination shows no abnormalities. Abdominal examination shows a mildly distended abdomen with shifting dullness. The liver is palpated 2–3 cm below the right costal margin. When pressure is applied to the right upper quadrant, the patient's jugular veins become visibly distended for 15 seconds. The 2nd and 3rd metacarpophalangeal joints of both hands are tender to palpation. There is 2+ edema in the lower extremities. Which of the following is the most likely underlying cause of this patient's edema?

A 38-year-old woman comes to the physician because of an 8-week history of shortness of breath and dull chest pain. She has a history of antiphospholipid syndrome. Physical examination shows jugular venous distention. Right heart catheterization shows a mean pulmonary arterial pressure of 30 mm Hg and a pulmonary capillary wedge pressure of 10 mm Hg. Further evaluation is most likely to show which of the following?

Six days after undergoing a left hemicolectomy for colorectal carcinoma, a 59-year-old man collapses in the hospital hallway and is unconscious for 30 seconds. Afterwards, he complains of shortness of breath and chest pain with deep inhalation. He has hypertension and hyperlipidemia. He smoked one pack of cigarettes daily for 35 years but quit prior to admission to the hospital. He does not drink alcohol. He is in distress and appears ill. His temperature is 36.5°C (97.7°F), blood pressure is 80/50 mm Hg, and pulse is 135/min and weak. Oxygen saturation is 88% on room air. Physical examination shows elevated jugular venous distention. Cardiac examination shows a regular, rapid heart rate and a holosystolic murmur that increases during inspiration. His abdomen is soft and mildly tender to palpation around the surgical site. Examination of his extremities shows pitting edema of the left leg. His skin is cold and clammy. Further examination is most likely to reveal which of the following findings?

A 70-year-old female with a history of congestive heart failure presents to the emergency room with dyspnea. She reports progressive difficulty breathing which began when she ran out of her furosemide and lisinopril prescriptions 1-2 weeks ago. She states the dyspnea is worse at night and when lying down. She denies any fever, cough, or GI symptoms. Her medication list reveals she is also taking digoxin. Physical exam is significant for normal vital signs, crackles at both lung bases and 2+ pitting edema of both legs. The resident orders the medical student to place the head of the patient's bed at 30 degrees. Additionally, he writes orders for the patient to be given furosemide, morphine, nitrates, and oxygen. Which of the following should be checked before starting this medication regimen?

A 56-year-old man comes to the physician for a 5-month history of progressive bilateral ankle swelling and shortness of breath on exertion. He can no longer walk up the stairs to his bedroom without taking a break. He also constantly feels tired during the day. His wife reports that he snores at night and that he sometimes chokes in his sleep. The patient has smoked 1 pack of cigarettes daily for 25 years. He has a history of hypertension treated with enalapril. His pulse is 72/min, respirations are 16/min, and blood pressure is 145/95 mmHg. There is jugular venous distention. The lungs are clear to auscultation bilaterally. The extremities are warm and well perfused. There is 2+ lower extremity edema bilaterally. ECG shows right axis deviation. Which of the following is the most likely cause of this patient's condition?

A 70-year-old Caucasian male visits your office regularly for treatment of New York Heart association class IV congestive heart failure. Which of the following medications would you add to this man's drug regimen in order to improve his overall survival?

A 64-year-old male with a history of coronary artery disease, hypertension, hyperlipidemia, and type II diabetes presents to his primary care physician with increasing shortness of breath and ankle swelling over the past month. Which of the following findings is more likely to be seen in left-sided heart failure and less likely to be seen in right-sided heart failure?

A 74-year-old woman comes to the physician for a follow-up examination. Eight months ago, she underwent an emergency cardiac catheterization with stenting for myocardial infarction. At the time of discharge, her heart configuration was normal, end-diastolic volume was 300 mL and ejection fraction was 51%. For the past 8 weeks she has noticed increasing shortness of breath while playing with her 2-year-old grandson. She feels otherwise well. She has arterial hypertension, coronary artery disease, and hypercholesterolemia. She admits to rarely taking her medication as she usually feels well and has no symptoms. Her temperature is 37.3°C (99.1°F), pulse is 93/min, and blood pressure is 142/93 mm Hg. Examination shows no abnormalities. A complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range. ECG shows broad, deep Q waves and T-wave inversion. Echocardiography shows left ventricular dilation and an end-diastolic volume of 370 mL; Ejection fraction is 40%. Which of the following is most likely to have prevented this patient's worsening of ventricular function?

A 78-year-old man presents to the clinic complaining of shortness of breath at rest and with exertion. He also complains of difficulty breathing while lying down. He also is concerned because he startles from sleep and feels like he is choking. These symptoms have been bothering him for the last several weeks and they are getting worse. He has been afebrile with no known sick contacts. 6 months ago, he had an acute myocardial infarction from which he recovered and until recently had felt well. He has a history of hyperlipidemia for which he takes atorvastatin. His temperature is 37.0°C (98.6°F), the pulse is 85/min, the respiratory rate is 14/min, and the blood pressure is 110/75 mm Hg. On physical examination, his heart has a regular rate and rhythm. He has bilateral crackles in both lungs. An echocardiogram is performed and shows a left ventricular ejection fraction of 33%. What medication should be started?

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?