Hemodynamic Disorders Review Questions with complete Solutions Rated A+
A 60-year-old man with a history of multiple myocardial infarcts is hospitalized for shortness of breath.
Physical exami- nation reveals marked jugular distension, hepatomegaly, ascites, and pitting edema. A
chest X-ray reveals cardiomegaly. The patient subsequently dies of cardiorespiratory failure.
Examination of the lungs at autopsy would most likely dis- close which of the following pathologic
changes?
(A) Diffuse alveolar damage with hyaline membranes
(B) Intra-alveolar purulent exudate
(C) Lymphocytic interstitial pneumonitis
(D) Pulmonary arteriopathy with plexiform lesions
(E) Vascular congestion and hemosiderin-laden macrophages - Answers The answer is E: Vascular
congestion and hemosiderin-laden macrophages. Left ventricular failure leads to chronic passive
congestion of the lungs. Blood leaks from the congested pulmo- nary capillaries into the alveoli. Alveolar
macrophages degrade RBCs and accumulate hemosiderin. These hemosiderin-laden macrophages are
called heart failure cells. Diffuse alveolar damage with hyaline membranes (choice A) is a feature of
adult respiratory distress syndrome. Purulent exudate (choice B) is observed in bacterial pneumonia.
Lymphocytic interstitial pneumonitis (choice C) is characteristic of viral pneumonitis. Plexiform lesions
(choice D) are typically seen in patients with pulmonary hypertension.
Diagnosis: Congestive heart failure, pulmonary edema
A 92-year-old woman is brought unconscious to the emergency room from a nursing home. Her blood
pressure is 70/30 mm Hg. She is febrile (38°C/100.5°F) and tachypneic. Laboratory studies demonstrate
a WBC count of 22,000/μL with 92% neutrophils. Urinalysis reveals numerous Gram-negative organisms.
Which of the following most likely accounts for this patient's signs and symptoms?
(A) Anaphylacticshock
(B) Cardiogenic shock
(C) Hypovolemicshock
(D) Neurogenicshock
(E) Septic shock - Answers The answer is E: Septic shock. Septic shock results from a systemic
inflammatory response syndrome that leads to mul- tiple 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. These processes often
progress to multiple organ dysfunction syndrome in crit- ically ill patients. Septicemia with Gram-
negative organisms is the most common cause of septic shock. Anaphylactic shock (choice A) occurs as a
,consequence of a systemic type I hyper- sensitivity reaction. Neurogenic shock (choice D) can follow
acute injury to the brain or spinal cord, which impairs the neural control of vasomotor tone, leading to
generalized vaso- dilation. Cardiogenic shock (choice B) is a feature of advanced heart failure.
Hypovolemic shock (choice C) occurs following blood loss.
Diagnosis: Septic shock
A 21-year-old pregnant woman experiences abruptio placentae at 37 weeks of gestation and develops
severe vaginal bleeding that is difficult to control. Five months later, the patient presents with profound
lethargy, pallor, muscle weakness, failure of lactation, and amenorrhea. Which of the following best
explains the pathogenesis of pituitary insufficiency in this patient?
(A) Abscess
(B) Embolism
(C) Infarction
(D) Passivehyperemia (E) Thrombosis - Answers The answer is C: Infarction.
Hypotension caused by post- partum bleeding can, in rare cases, lead to infarction of the pituitary. The
pituitary is particularly susceptible at this time because its enlargement during pregnancy renders it
vulnerable to a reduction in blood flow. None of the other choices cause clinical features of pan-
hypopituitarism. Diagnosis: Sheehan syndrome, pituitary infarction
A 62-year-old man with a history of hypertension is rushed to the emergency room with severe "tearing
pain" of the anterior chest. His blood pressure is 80/50 mm Hg. Physical examination shows pallor,
diaphoresis, and a murmur of aortic regurgitation. Laboratory studies and ECG show no evidence of
acute myocardial infarction. Four hours later, the patient goes into cardiac arrest. An ECG reveals
electromechanical dissociation. Which of the following best explains the pathogenesis of cardiac
tamponade in this patient?
(A) Disseminated intravascular coagulation
(B) Embolism
(C) Hemorrhage
(D) Passivehyperemia
(E) Thrombosis - Answers The answer is C: Hemorrhage. Pericardial fluid may accu- mulate rapidly,
particularly with hemorrhage caused by a ruptured myocardial infarct, dissecting aortic aneurysm (seen
in this patient), 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 "electromechanical
dissociation" refers to a heart rhythm that should produce a pulse, 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 dissecting aortic aneurysm in most instances can be traced to a weakening of the
aortic media (cystic medial necrosis). Most patients have a history of hypertension. Disseminated
intravascular coagulation (choice A) refers to widespread ischemic changes secondary to microvascular
thrombi. Passive hyperemia (choice D) refers to the engorgement of an organ with venous blood.
Diagnosis: Dissecting aortic aneurysm
A 58-year-old woman is brought to the emergency department 4 hours after vomiting blood and
experiencing bloody stools. The patient was diagnosed with alcoholic cirrhosis 2 years ago. Endoscopy
reveals large esophageal varices, one of which is actively bleeding. Which of the following best explains
the pathogenesis of dilated esophageal veins in this patient?
(A) Decreased intravascular oncotic pressure
(B) Increased capillary permeability
(C) Increased intravascular hydrostatic pressure
(D) Vasoconstriction of arterioles
(E) Vasodilatation of capillaries - Answers The answer is C: Increased intravascular hydrostatic pressure.
This patient with alcoholic cirrhosis has portal hypertension (increased hydrostatic pressure) and
bleeding esophageal varices. Massive hematemesis is a frequent cause of death in patients with
esophageal varices. Decreased intravascular oncotic pressure (choice A) contributes to the development
of ascites in patients with cirrhosis but not to the development of esophageal varices.
Diagnosis: Esophageal varices, hematemesis
A 69-year-old retired man is brought to the emergency department because of the sudden onset of left-
sided chest pain, which is exacerbated upon inspiration. Physical examination reveals dyspnea and
hemoptysis. His temperature is 38°C (101°F), pulse 110 per minute, respirations 35 per minute, and
blood pressure 158/100 mm Hg. A lateral chest wall friction rub is present on auscultation. The left leg is
markedly edematous with a positive Homans' sign. A chest X-ray reveals a left pleural effusion. What is
the most likely cause of this patient's pulmonary condition?
(A) Congestive heart failure
(B) Cor pulmonale
(C) Mitralstenosis
(D) Subacuteendocarditis
(E) Thromboembolism - Answers The answer is E: Thromboembolism. This patient with mild congestive
heart failure developed pulmonary embolism. 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.
A 60-year-old man with a history of multiple myocardial infarcts is hospitalized for shortness of breath.
Physical exami- nation reveals marked jugular distension, hepatomegaly, ascites, and pitting edema. A
chest X-ray reveals cardiomegaly. The patient subsequently dies of cardiorespiratory failure.
Examination of the lungs at autopsy would most likely dis- close which of the following pathologic
changes?
(A) Diffuse alveolar damage with hyaline membranes
(B) Intra-alveolar purulent exudate
(C) Lymphocytic interstitial pneumonitis
(D) Pulmonary arteriopathy with plexiform lesions
(E) Vascular congestion and hemosiderin-laden macrophages - Answers The answer is E: Vascular
congestion and hemosiderin-laden macrophages. Left ventricular failure leads to chronic passive
congestion of the lungs. Blood leaks from the congested pulmo- nary capillaries into the alveoli. Alveolar
macrophages degrade RBCs and accumulate hemosiderin. These hemosiderin-laden macrophages are
called heart failure cells. Diffuse alveolar damage with hyaline membranes (choice A) is a feature of
adult respiratory distress syndrome. Purulent exudate (choice B) is observed in bacterial pneumonia.
Lymphocytic interstitial pneumonitis (choice C) is characteristic of viral pneumonitis. Plexiform lesions
(choice D) are typically seen in patients with pulmonary hypertension.
Diagnosis: Congestive heart failure, pulmonary edema
A 92-year-old woman is brought unconscious to the emergency room from a nursing home. Her blood
pressure is 70/30 mm Hg. She is febrile (38°C/100.5°F) and tachypneic. Laboratory studies demonstrate
a WBC count of 22,000/μL with 92% neutrophils. Urinalysis reveals numerous Gram-negative organisms.
Which of the following most likely accounts for this patient's signs and symptoms?
(A) Anaphylacticshock
(B) Cardiogenic shock
(C) Hypovolemicshock
(D) Neurogenicshock
(E) Septic shock - Answers The answer is E: Septic shock. Septic shock results from a systemic
inflammatory response syndrome that leads to mul- tiple 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. These processes often
progress to multiple organ dysfunction syndrome in crit- ically ill patients. Septicemia with Gram-
negative organisms is the most common cause of septic shock. Anaphylactic shock (choice A) occurs as a
,consequence of a systemic type I hyper- sensitivity reaction. Neurogenic shock (choice D) can follow
acute injury to the brain or spinal cord, which impairs the neural control of vasomotor tone, leading to
generalized vaso- dilation. Cardiogenic shock (choice B) is a feature of advanced heart failure.
Hypovolemic shock (choice C) occurs following blood loss.
Diagnosis: Septic shock
A 21-year-old pregnant woman experiences abruptio placentae at 37 weeks of gestation and develops
severe vaginal bleeding that is difficult to control. Five months later, the patient presents with profound
lethargy, pallor, muscle weakness, failure of lactation, and amenorrhea. Which of the following best
explains the pathogenesis of pituitary insufficiency in this patient?
(A) Abscess
(B) Embolism
(C) Infarction
(D) Passivehyperemia (E) Thrombosis - Answers The answer is C: Infarction.
Hypotension caused by post- partum bleeding can, in rare cases, lead to infarction of the pituitary. The
pituitary is particularly susceptible at this time because its enlargement during pregnancy renders it
vulnerable to a reduction in blood flow. None of the other choices cause clinical features of pan-
hypopituitarism. Diagnosis: Sheehan syndrome, pituitary infarction
A 62-year-old man with a history of hypertension is rushed to the emergency room with severe "tearing
pain" of the anterior chest. His blood pressure is 80/50 mm Hg. Physical examination shows pallor,
diaphoresis, and a murmur of aortic regurgitation. Laboratory studies and ECG show no evidence of
acute myocardial infarction. Four hours later, the patient goes into cardiac arrest. An ECG reveals
electromechanical dissociation. Which of the following best explains the pathogenesis of cardiac
tamponade in this patient?
(A) Disseminated intravascular coagulation
(B) Embolism
(C) Hemorrhage
(D) Passivehyperemia
(E) Thrombosis - Answers The answer is C: Hemorrhage. Pericardial fluid may accu- mulate rapidly,
particularly with hemorrhage caused by a ruptured myocardial infarct, dissecting aortic aneurysm (seen
in this patient), 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 "electromechanical
dissociation" refers to a heart rhythm that should produce a pulse, 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 dissecting aortic aneurysm in most instances can be traced to a weakening of the
aortic media (cystic medial necrosis). Most patients have a history of hypertension. Disseminated
intravascular coagulation (choice A) refers to widespread ischemic changes secondary to microvascular
thrombi. Passive hyperemia (choice D) refers to the engorgement of an organ with venous blood.
Diagnosis: Dissecting aortic aneurysm
A 58-year-old woman is brought to the emergency department 4 hours after vomiting blood and
experiencing bloody stools. The patient was diagnosed with alcoholic cirrhosis 2 years ago. Endoscopy
reveals large esophageal varices, one of which is actively bleeding. Which of the following best explains
the pathogenesis of dilated esophageal veins in this patient?
(A) Decreased intravascular oncotic pressure
(B) Increased capillary permeability
(C) Increased intravascular hydrostatic pressure
(D) Vasoconstriction of arterioles
(E) Vasodilatation of capillaries - Answers The answer is C: Increased intravascular hydrostatic pressure.
This patient with alcoholic cirrhosis has portal hypertension (increased hydrostatic pressure) and
bleeding esophageal varices. Massive hematemesis is a frequent cause of death in patients with
esophageal varices. Decreased intravascular oncotic pressure (choice A) contributes to the development
of ascites in patients with cirrhosis but not to the development of esophageal varices.
Diagnosis: Esophageal varices, hematemesis
A 69-year-old retired man is brought to the emergency department because of the sudden onset of left-
sided chest pain, which is exacerbated upon inspiration. Physical examination reveals dyspnea and
hemoptysis. His temperature is 38°C (101°F), pulse 110 per minute, respirations 35 per minute, and
blood pressure 158/100 mm Hg. A lateral chest wall friction rub is present on auscultation. The left leg is
markedly edematous with a positive Homans' sign. A chest X-ray reveals a left pleural effusion. What is
the most likely cause of this patient's pulmonary condition?
(A) Congestive heart failure
(B) Cor pulmonale
(C) Mitralstenosis
(D) Subacuteendocarditis
(E) Thromboembolism - Answers The answer is E: Thromboembolism. This patient with mild congestive
heart failure developed pulmonary embolism. 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.
