Heart failure Practice Questions

Q: A 61-year-old female with congestive heart failure and type 2 diabetes is brought to the emergency room by her husband because of an altered mental status. He states he normally helps her be compliant with her medications, but he had been away for several days. On physical exam, her temperature is 37.2 C, BP 85/55, and HR 130. Serum glucose is 500 mg/dL. Which of the following is the first step in the management of this patient?

IV NS. ***IV NS*** - The patient presents with **hypotension (85/55 mmHg)** and **tachycardia (130 bpm)**, indicating significant **volume depletion** despite a history of congestive heart failure. - **Isotonic intravenous fluids (e.g., normal saline)** are crucial in the initial management of **diabetic ketoacidosis (DKA)** or **hyperosmolar hyperglycemic state (HHS)** to restore intravascular volume and improve tissue perfusion. *IV ½ NS* - **Hypotonic solutions** such as IV ½ NS are typically used later in DKA/HHS management, once the patient's **hemodynamic stability** has been achieved and serum sodium levels are stable or elevated. - Administering hypotonic fluids to an already **hypotensive and volume-depleted patient** could worsen hypotension and potentially lead to cerebral edema if not carefully monitored. *IV insulin* - While insulin is essential for correcting hyperglycemia, it is administered **after or concurrently with fluid resuscitation** to avoid worsening hypovolemia as it drives glucose and potassium into cells, potentially causing **hypokalemia** and further **hemoconcentration**. - **Fluid resuscitation** should always precede or be initiated simultaneously with insulin therapy, especially in cases of hemodynamic instability. *Subcutaneous insulin injection* - **Subcutaneous insulin** is not appropriate for initial management in this critically ill patient due to its **slower onset of action** and potentially **erratic absorption** in hypotensive and poorly perfused states. - **Intravenous insulin** is preferred in DKA/HHS for its rapid, titratable effect. *IV D5W* - **Dextrose 5% in water (D5W)** is a hypotonic solution primarily used when **blood glucose levels fall below 250 mg/dL** during DKA/HHS treatment to prevent hypoglycemia. - Administering D5W in a patient with a **serum glucose of 500 mg/dL** would further elevate blood sugar and worsen the hyperosmolar state.

Q: A 65-year-old man with hypertension comes to the physician for a routine health maintenance examination. Current medications include atenolol, lisinopril, and atorvastatin. His pulse is 86/min, respirations are 18/min, and blood pressure is 145/95 mm Hg. Cardiac examination is shown. Which of the following is the most likely cause of this physical examination finding?

Decreased compliance of the left ventricle. ***Decrease in compliance of the left ventricle*** - The patient's **uncontrolled hypertension** for a long time can lead to **left ventricular hypertrophy** and **stiffening** of the heart muscle, resulting in **decreased compliance**. - A decrease in left ventricular compliance can result in a **diastolic dysfunction**, leading to **heart failure with preserved ejection fraction (HFpEF)**. *Myxomatous degeneration of the mitral valve* - This condition is typically associated with **mitral valve prolapse**, which causes a **mid-systolic click** and a **late systolic murmur**. - There is no information in the question about associated findings to suggest mitral valve prolapse, such as valvular disease or specific murmurs. *Inflammation of the pericardium* - **Pericarditis** typically presents with **sharp chest pain** that is relieved by leaning forward and a characteristic **friction rub** on auscultation. - While inflammation can affect cardiac function, it's not the most direct consequence of chronic hypertension in the absence of other symptoms. *Thickening of the mitral valve leaflets* - **Mitral valve leaflet thickening** often results from **rheumatic fever** or age-related calcification, leading to **mitral stenosis** or **regurgitation**. - The patient's history of long-standing hypertension does not directly indicate thickening of the mitral valve leaflets. *Dilation of the aortic root* - Aortic root dilation is associated with conditions like **Marfan syndrome**, **Ehlers-Danlos syndrome**, or uncontrolled hypertension leading to **aortic aneurysm** or **dissection**. - While chronic hypertension can contribute to aortic dilation, this finding isn't directly supported by the current clinical picture suggesting a primary cause for a physical finding.

Q: A 62-year-old woman comes to the physician because of coughing and fatigue during the past 2 years. In the morning, the cough is productive of white phlegm. She becomes short of breath walking up a flight of stairs. She has hypertension and hyperlipidemia. She has recently retired from working as a nurse at a homeless shelter. She has smoked 1 pack of cigarettes daily for 40 years. Current medications include ramipril and fenofibrate. Her temperature is 36.5°C (97.7°F), respirations are 24/min, pulse is 85/min, and blood pressure is 140/90 mm Hg. Scattered wheezing and rhonchi are heard throughout both lung fields. There are no murmurs, rubs, or gallops but heart sounds are distant. Which of the following is the most likely underlying cause of this patient's symptoms?

Progressive obstruction of expiratory airflow. ***Progressive obstruction of expiratory airflow*** - This patient's **40-year smoking history** strongly suggests **Chronic Obstructive Pulmonary Disease (COPD)**, characterized by **progressive airflow limitation** that is not fully reversible. - Symptoms like **chronic cough with white phlegm**, **dyspnea on exertion** (walking up stairs), and **wheezing/rhonchi** are classic findings in COPD, which involves obstruction of expiratory airflow. *Chronic decrease in pulmonary compliance* - **Decreased pulmonary compliance** is characteristic of **restrictive lung diseases**, such as **pulmonary fibrosis**, where the lungs become stiff and difficult to expand. - This patient's symptoms and smoking history are more consistent with an obstructive process, not a restrictive one. *Local accumulation of kinins* - **Kinins** are inflammatory mediators associated with conditions like **angioedema** or **acute inflammation**, causing pain, swelling, and vasodilation. - While inflammation plays a role in COPD, kinin accumulation is not the primary underlying cause of the chronic symptoms described. *Mycobacterial invasion of pulmonary parenchyma* - **Mycobacterial invasion** implies **tuberculosis**, which typically presents with fever, night sweats, weight loss, and a more persistent, often bloody cough. - The patient's chronic, productive cough of white phlegm and lack of systemic symptoms like fever make tuberculosis less likely. *Incremental loss of functional residual capacity* - **Loss of functional residual capacity (FRC)** typically occurs in **restrictive lung diseases** where lung volumes are reduced due to decreased compliance. - In COPD, FRC tends to be **increased** due to **air trapping** and hyperinflation, rather than decreased.

Question 1

A 61-year-old female with congestive heart failure and type 2 diabetes is brought to the emergency room by her husband because of an altered mental status. He states he normally helps her be compliant with her medications, but he had been away for several days. On physical exam, her temperature is 37.2 C, BP 85/55, and HR 130. Serum glucose is 500 mg/dL. Which of the following is the first step in the management of this patient?

Accepted Answer

IV NS

Answer

IV ½ NS

Answer

IV insulin

Answer

Subcutaneous insulin injection

Answer

IV D5W

Question 2

A 65-year-old man with hypertension comes to the physician for a routine health maintenance examination. Current medications include atenolol, lisinopril, and atorvastatin. His pulse is 86/min, respirations are 18/min, and blood pressure is 145/95 mm Hg. Cardiac examination is shown. Which of the following is the most likely cause of this physical examination finding?

Accepted Answer

Decreased compliance of the left ventricle

Answer

Myxomatous degeneration of the mitral valve

Answer

Inflammation of the pericardium

Answer

Thickening of the mitral valve leaflets

Answer

Dilation of the aortic root

Question 3

A 62-year-old woman comes to the physician because of coughing and fatigue during the past 2 years. In the morning, the cough is productive of white phlegm. She becomes short of breath walking up a flight of stairs. She has hypertension and hyperlipidemia. She has recently retired from working as a nurse at a homeless shelter. She has smoked 1 pack of cigarettes daily for 40 years. Current medications include ramipril and fenofibrate. Her temperature is 36.5°C (97.7°F), respirations are 24/min, pulse is 85/min, and blood pressure is 140/90 mm Hg. Scattered wheezing and rhonchi are heard throughout both lung fields. There are no murmurs, rubs, or gallops but heart sounds are distant. Which of the following is the most likely underlying cause of this patient's symptoms?

Accepted Answer

Progressive obstruction of expiratory airflow

Answer

Chronic decrease in pulmonary compliance

Answer

Local accumulation of kinins

Answer

Mycobacterial invasion of pulmonary parenchyma

Answer

Incremental loss of functional residual capacity

Heart failure — MCQs

Heart failure — MCQs

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