Deck 28: Pulmonary Vascular Disease

Question 1

Which of the following conditions predispose a patient to venous thromboembolic disease?
1) Carcinoma
2) COPD
3) Trauma
4) Thrombocytosis

A)1, 2, and 3 only
B)1 and 4 only
C)2 only
D)1, 3, and 4 only

Answer 1

D

Question 2

What treatment is initiated in patients suspected of pulmonary emboli, and continued until pulmonary emboli is ruled out?

A) Antiarrhythmia
B) Anticoagulation
C) Corticosteroids
D) Diuretics

Answer 2

B
Explanation: Unless there is a contraindication to anticoagulation of the patient (e.g., recent bleeding, head trauma, etc.), anticoagulation is often begun when the diagnosis of pulmonary embolism is first suspected and continued until pulmonary embolism is ruled out by tests.

Question 3

Which of the following findings on a chest radiograph are consistent with pulmonary embolism?
1) Diffuse hyperinflation
2) Elevation of the diaphragm
3) Enlargement of the heart shadow
4) Pleural effusion

A)2, 3, and 4 only
B)1 and 2 only
C)3 and 4 only
D)1, 2, and 3 only

Answer 3

A

Question 4

Which of the following are the main components of Virchow's triad?
1) Hypercoagulable states
2) Vessel wall abnormalities
3) Fibrinogen abnormalities
4) Venous stasis

A)1, 3, and 4 only
B)1, 2, and 3 only
C)1, 2, and 4 only
D)2, 3, and 4 only

Question 5

What percentage of the pulmonary vascular bed must be occluded by emboli before pulmonary hypertension occurs?

A) 25%
B) 33%
C) 50%
D) 75%

Question 6

What is the main hemodynamic consequence of pulmonary emboli?

A) Increased pulmonary vascular resistance
B) Increased systemic vascular resistance
C) Pulmonary instability
D) Pulmonary vasodilation

Question 7

What percentage of patients with pulmonary embolism have pulmonary infarction as a complication?

A) Less than 10%
B) Approximately 25%
C) Approximately 40%
D) Approximately 65%

Question 8

What is the most frequent symptom found in patients with confirmed pulmonary emboli?

A) Cough
B) Dyspnea
C) Leg swelling
D) Pleuritic pain

Question 9

Which of the following physical examination findings are consistent with the diagnosis of pulmonary embolism?
1) Congestive heart failure
2) Inspiratory crackles on auscultation
3) Loud P₂
4) Tachypnea

A)2, 3, and 4 only
B)1 and 4 only
C)3 only
D)2 and 4 only

Question 10

Death from massive pulmonary embolism is the result of:

A) cardiovascular collapse.
B) respiratory failure.
C) renal complications.
D) massive blood loss.

Question 11

Which of the following pathophysiologic changes in the lung is not typically associated with pulmonary embolism?

A) Bronchoconstriction
B) Decreased ciliary mobility
C) Increased dead space ventilation
D) Reduced surfactant production

Question 12

Where do most pulmonary emboli originate?

A) Deep veins of the arms
B) Deep veins of the legs
C) Thrombi from the right side of the heart
D) Veins of the thorax

Question 13

Approximately what percentage of patients who die from pulmonary embolism are not suspected before death?

A) 5%
B) 20%
C) 40%
D) 70%

Question 14

What are the two most common findings on the electrocardiogram (ECG) in the patient with pulmonary embolism?

A) Bradycardia and elevated ST segment
B) Inverted T waves and depressed ST segment
C) Large P waves and inverted T waves
D) Tachycardia and depressed ST segment

Question 15

Which of the following conditions contribute to the development of hypoxemia in a patient with pulmonary emboli?
1) Cardiogenic shock
2) Destruction of lung parenchyma
3) Intrapulmonary shunt
4) Mismatch

A)1, 2, and 3 only
B)1 and 4 only
C)2 only
D)1, 3, and 4 only

Question 16

What is the critical value for mean pulmonary arterial pressure, above which the right ventricle fails and death may ensue?

A) 30 mm Hg
B) 40 mm Hg
C) 50 mm Hg
D) 60 mm Hg

Question 17

Where in the lung is pulmonary embolism most frequently observed?

A) Right lower lobe
B) Lingula
C) Left lower lobe
D) Right middle lobe

Question 18

Most pulmonary infarctions associated with thromboembolic obstruction occur in which part of the lung?

A) Right lung
B) Lung bases
C) Lung apexes
D) Left lung

Question 19

Which of the following risk factors are associated with an increase in the incidence of pulmonary embolism?
1) Advanced age
2) Immobilization
3) Multiple injuries from trauma
4) Positive smoking history

A)2 and 3 only
B)1, 2, and 3 only
C)4 only
D)2, 3, and 4 only

Question 20

Approximately what percentage of patients with pulmonary embolism have a normal ECG?

A) 10% to 15%
B) 25% to 30%
C) 40% to 60%
D) 70% to 75%

Question 21

Which of the following arterial blood gas findings is seen in most patients with pulmonary embolism?

A) Hypercapnia
B) Hypoxemia
C) Low pH
D) Normal SaO₂

Question 22

Pulmonary artery hypertension (PAH) is not typically associated with which of the following conditions?

A) Amyotrophic lateral sclerosis
B) Cirrhosis of the liver
C) Congenital heart disease
D) Human immunodeficiency virus infection

Question 23

What is the initial event in the pathogenesis of idiopathic pulmonary artery hypertension (IPAH)?

A) Insult to the pulmonary endothelium
B) Elevated level of serotonin
C) Monoclonal proliferation of endothelial cells
D) Vascular remodeling

Question 24

In patients suspected of having pulmonary emboli in which noninvasive studies do not give a definite diagnosis, what diagnostic procedure is the test of choice?

A) CT
B) MRI
C) Pulmonary angiography
D) scan

Question 25

How does impedance plethysmography determine the presence or absence of deep vein thrombosis?

A) Notes resistance to electrical current associated with blood flow.
B) Radioactive isotopes target clots and show "hot" on gamma cameras.
C) Uses ultrasonic waves to delineate the presence of clot or clots.
D) Uses radiographic technique to spot the clots.

Question 26

A patient with pulmonary emboli has severe hypoxemia, acute right-sided heart failure, and shock. What treatment should be given at this time?

A) Acetylcholine esterase
B) Heparin
C) Streptokinase
D) Warfarin

Question 27

Which of the following medications should be used in the hospital for prophylactic deep venous thrombosis therapy?

A) Acetylcholine esterase
B) Albuterol
C) Aspirin
D) Heparin

Question 28

Which of the following is true regarding the use of CT with contrast for diagnosing pulmonary embolism (PE)?

A) Limited due to availability of CT equipment
B) Most sensitive of the diagnostic techniques
C) Can only identify the medium to large PE
D) High risk of mortality limits its use

Question 29

What is the fastest way to achieve therapeutic levels of heparin in the treatment of acute deep venous thrombi?

A) Continuous drip system
B) Follow established nomogram
C) Large bolus at 10 µg/kg
D) IV injections while tracking blood levels

Question 30

A D-dimer test is performed in a patient in whom a pulmonary embolism is suspected. The value comes back at 379 mg/L. What does this suggest?

A) Almost completely establishes the presence of pulmonary embolism.
B) Almost completely rules out pulmonary embolism.
C) Establishes roughly a 50/50 chance of pulmonary embolism.
D) Is indeterminate but highly suggestive of pulmonary embolism.

Question 31

Which of the following medications would be standard therapy to treat acute deep venous thrombi?

A) Acetylcholine esterase
B) Heparin
C) Streptokinase
D) Warfarin

Question 32

What is the most commonly used oral anticoagulant?

A) Acetylcholine esterase
B) Heparin
C) Streptokinase
D) Warfarin

Question 33

At rest, what level does the mean pulmonary artery pressure need to reach before it is considered pulmonary hypertension?

A) Greater than 10 mm Hg
B) Greater than 15 mm Hg
C) Greater than 20 mm Hg
D) Greater than 25 mm Hg

Question 34

Which of the diagnostic tests for pulmonary embolism is likely the safest and the most consistently accurate?

A) Impedance plethysmography
B) MRI
C) Pulmonary angiogram
D) Helical CTA

Question 35

Why is the D-dimer test not routinely performed on hospital inpatients suspected of having pulmonary emboli?

A) A high D-dimer only suggests the presence of comorbidities.
B) A low D-dimer is associated with immunodepression.
C) It loses sensitivity if numerous blood tests have been performed.
D) The cost is prohibitive.

Question 36

On average, how long does the diagnosis of idiopathic pulmonary artery hypertension (IPAH) follow the onset of the disease?

A) 6 months
B) 1 year
C) 18 months
D) 2 years

Question 37

What are the two most common symptoms associated with primary pulmonary hypertension?

A) Dry cough and dyspnea
B) Dyspnea and angina
C) Hemoptysis and dyspnea
D) Syncope and chest pain

Question 38

Prophylactic deep venous thrombosis (DVT) therapy would be most important in which of the following patient groups?

A) General surgery patients
B) General ward patients
C) ICU patients
D) Patients with hip replacements

Question 39

What drugs are classified as a prostanoid?
1) Epoprostenol
2) Iloprost
3) Treprostinil
4) Sildenafil

A)1, 2, and 3 only
B)3 and 4 only
C)1 and 4 only
D)2 only

Question 40

What drug would be the treatment of choice for pulmonary emboli?

A) Heparin
B) Streptokinase
C) Urokinase
D) Warfarin

Question 41

What is the most common pulmonary function abnormality found in patients with idiopathic pulmonary artery hypertension (IPAH)?

A) Reduced diffusing capacity of the lungs (DLCO)
B) Reduced forced vital capacity (FVC)
C) Reduced forced expiratory flow (FEF_{25% to 75%})
D) Reduced lung compliance (CL)

Question 42

Why are calcium-channel blockers not used in all patients with idiopathic pulmonary artery hypertension?

A) It causes severe side effects.
B) Many of these patients have systemic hypotension.
C) Only a small percentage of IPAH patients respond.
D) There is a high incidence of anaphylaxis.

Question 43

Which of the following physical examination findings are found in patients with primary pulmonary hypertension?
1) Cyanosis
2) Diastolic heart murmur
3) Digital clubbing
4) Loud second heart sound (P₂)

A)2 and 4 only
B)1 and 3 only
C)1, 2, and 4 only
D)2, 3, and 4 only

Question 44

In what type of IPAH patient is lung transplantation indicated?

A) All pulmonary artery hypertension patients with clinically significant disease
B) Patients not responding to vasodilators with significant cardiac dysfunction
C) Patients with class II, class III, or class IV disease
D) Patients with refractory hypoxemia

Question 45

What is the most important noninvasive diagnostic test for evaluation of a patient with idiopathic pulmonary artery hypertension (IPAH)?

A) Posteroanterior chest radiograph
B) Physical examination
C) Pulmonary function testing
D) scan

Question 46

What ECG finding is most often associated with right-sided heart failure and pulmonary hypertension?

A) Elevated ST segment
B) Inverted P wave in lead I
C) Prolonged PR interval
D) Right-axis deviation

Question 47

What is the 5-year survival rate for patients with untreated idiopathic pulmonary artery hypertension (IPAH)?

A) 33%
B) 44%
C) 55%
D) 66%

Question 48

What type of drug is Bosentan?

A) Corticosteroid
B) Endothelin antagonists
C) Phosphodiesterase inhibitors
D) Prostanoids

Question 49

What ECG findings are typically seen in patients with idiopathic pulmonary artery hypertension?
1) Frequent premature ventricular complexes
2) Right-axis deviation
3) Right ventricular hypertrophy
4) Left bundle-branch block

A)1, 2, and 4 only
B)2 and 3 only
C)4 only
D)2, 3, and 4 only

Question 50

Most hospitalized patients who are immobile need prophylaxis for venous thromboembolism.

Question 51

Which of the following radiographic findings is not typical for patients with primary pulmonary hypertension?

A) Enlargement of the pulmonary artery
B) Enlargement of the right ventricle
C) Narrowing of the peripheral arteries
D) Pleural effusion

Question 52

The presence of previous chronic obstructive pulmonary disease (COPD) reduces the diagnostic usefulness of scans in acute pulmonary embolism.

Question 53

What is the most important factor contributing to the onset of pulmonary hypertension in the patient with COPD?

A) Alveolar hypoxia
B) Compression of pulmonary vasculature
C) Left ventricular failure
D) Loss of vascular surface

Question 54

What therapy has been proven to improve survival in patients with COPD and pulmonary hypertension?

A) Bronchodilators
B) Oral vasodilators
C) Oxygen
D) Prostanoids

Question 55

Why is the use of oxygen to maintain oxygen saturations greater than 90% particularly important in the management of idiopathic pulmonary artery hypertension?

A) These patients have a low cardiopulmonary reserve.
B) Low alveolar oxygen causes vasoconstriction.
C) Many patients have central cyanosis.
D) These patients are especially susceptible to tissue hypoxia.

Question 56

What IV infusion has been found to improve exercise capacity, hemodynamic variables, and survival in patients with severe IPAH?

A) Bosentan
B) Epoprostenol
C) Methylprednisolone
D) Sildenafil

Question 57

Unless there are contraindications, what treatment is given universally to all patients with idiopathic pulmonary artery hypertension (IPAH)?

A) Oral anticoagulation
B) Oxygen
C) Steroids
D) Vasodilators