, Question 1
A patient presents with sudden-onset tearing chest pain radiating to the back, a
20 mmHg interarm blood pressure differential, and a widened mediastinum on
chest radiograph. Which intervention is the immediate priority?
A. Initiate a continuous heparin infusion.
B. Administer IV esmolol and nitroprusside to reduce aortic wall stress.
C. Administer a bolus of normal saline to maintain preload.
D. Obtain an immediate D-dimer and initiate alteplase.
Correct Answer: B - Administer IV esmolol and nitroprusside to
reduce aortic wall stress.
RATIONALE
The presentation is classic for acute aortic dissection. Immediate
management focuses on reducing aortic wall stress via heart rate and
blood pressure control, typically with a beta-blocker (esmolol) first,
then a vasodilator (nitroprusside). Anticoagulation and thrombolytics
are contraindicated as they increase bleeding risk and mortality.
Question 2
A patient with severe sepsis and suspected septic shock is receiving
norepinephrine at 0.1 mcg/kg/min. Mean arterial pressure remains 58 mmHg
despite adequate fluid resuscitation. Which vasopressor addition is most
appropriate?
A. Dopamine infusion at 10 mcg/kg/min
B. Vasopressin infusion at 0.03 units/min
C. Phenylephrine infusion at 100 mcg/min
D. Epinephrine infusion at 0.5 mcg/kg/min
Correct Answer: B - Vasopressin infusion at 0.03 units/min
Page 2
, RATIONALE
The Surviving Sepsis Campaign recommends adding vasopressin (up
to 0.03 units/min) to norepinephrine to achieve target MAP or reduce
norepinephrine requirements. Vasopressin acts on V1 receptors and is
effective in catecholamine-resistant shock. Dopamine is associated
with more arrhythmias and is not first-line.
Question 3
A patient with a known history of heart failure presents with acute dyspnea,
orthopnea, and pink frothy sputum. Vital signs: BP 180/100, HR 120, RR 32,
SpO2 85% on room air. Which initial pharmacologic therapy is most
appropriate?
A. IV furosemide 40 mg and nitroglycerin infusion
B. IV metoprolol 5 mg and morphine sulfate 4 mg
C. IV diltiazem 20 mg and fluid bolus of 500 mL normal saline
D. IV dopamine infusion at 5 mcg/kg/min and oxygen
Correct Answer: A - IV furosemide 40 mg and nitroglycerin
infusion
RATIONALE
This is acute decompensated heart failure with pulmonary edema and
hypertensive urgency. First-line therapy includes IV loop diuretics
(furosemide) to reduce volume overload and vasodilators
(nitroglycerin) to reduce preload and afterload. Beta-blockers are
contraindicated in acute decompensation due to negative inotropic
effects.
Question 4
A patient is admitted with severe metabolic acidosis (pH 7.10, HCO3 8 mEq/L,
PaCO2 25 mmHg). Which calculation best determines the appropriateness of
respiratory compensation?
A. Anion gap = Na - (Cl + HCO3)
Page 3
, B. Winter's formula: Expected PaCO2 = (1.5 × HCO3) + 8 ± 2
C. Delta-delta = (Measured anion gap - Normal anion gap) / (Normal
HCO3 - Measured HCO3)
D. Osmolal gap = Measured osmolality - Calculated osmolality
Correct Answer: B - Winter's formula: Expected PaCO2 = (1.5 ×
HCO3) + 8 ± 2
RATIONALE
Winter's formula is used to calculate the expected PaCO2 for a given
serum bicarbonate to assess if respiratory compensation is appropriate.
In this case, expected PaCO2 = (1.5 × 8) + 8 ± 2 = 20 ± 2 mmHg. The
measured PaCO2 of 25 mmHg is higher than expected, indicating
inadequate respiratory compensation and a concurrent respiratory
acidosis.
Question 5
A patient with a tension pneumothorax undergoes needle decompression.
Which finding best confirms successful decompression?
A. Immediate improvement in oxygen saturation and hemodynamics
B. Audible hiss of air upon needle insertion
C. Chest radiograph showing lung re-expansion
D. Decreased resistance when advancing the needle
Correct Answer: A - Immediate improvement in oxygen
saturation and hemodynamics
RATIONALE
The definitive confirmation of successful needle decompression for
tension pneumothorax is immediate clinical improvement, including
improved oxygenation and hemodynamic stabilization (e.g., increased
blood pressure, decreased heart rate). While an audible hiss may
occur, it is not always present and does not confirm resolution of the
tension physiology.
Page 4
A patient presents with sudden-onset tearing chest pain radiating to the back, a
20 mmHg interarm blood pressure differential, and a widened mediastinum on
chest radiograph. Which intervention is the immediate priority?
A. Initiate a continuous heparin infusion.
B. Administer IV esmolol and nitroprusside to reduce aortic wall stress.
C. Administer a bolus of normal saline to maintain preload.
D. Obtain an immediate D-dimer and initiate alteplase.
Correct Answer: B - Administer IV esmolol and nitroprusside to
reduce aortic wall stress.
RATIONALE
The presentation is classic for acute aortic dissection. Immediate
management focuses on reducing aortic wall stress via heart rate and
blood pressure control, typically with a beta-blocker (esmolol) first,
then a vasodilator (nitroprusside). Anticoagulation and thrombolytics
are contraindicated as they increase bleeding risk and mortality.
Question 2
A patient with severe sepsis and suspected septic shock is receiving
norepinephrine at 0.1 mcg/kg/min. Mean arterial pressure remains 58 mmHg
despite adequate fluid resuscitation. Which vasopressor addition is most
appropriate?
A. Dopamine infusion at 10 mcg/kg/min
B. Vasopressin infusion at 0.03 units/min
C. Phenylephrine infusion at 100 mcg/min
D. Epinephrine infusion at 0.5 mcg/kg/min
Correct Answer: B - Vasopressin infusion at 0.03 units/min
Page 2
, RATIONALE
The Surviving Sepsis Campaign recommends adding vasopressin (up
to 0.03 units/min) to norepinephrine to achieve target MAP or reduce
norepinephrine requirements. Vasopressin acts on V1 receptors and is
effective in catecholamine-resistant shock. Dopamine is associated
with more arrhythmias and is not first-line.
Question 3
A patient with a known history of heart failure presents with acute dyspnea,
orthopnea, and pink frothy sputum. Vital signs: BP 180/100, HR 120, RR 32,
SpO2 85% on room air. Which initial pharmacologic therapy is most
appropriate?
A. IV furosemide 40 mg and nitroglycerin infusion
B. IV metoprolol 5 mg and morphine sulfate 4 mg
C. IV diltiazem 20 mg and fluid bolus of 500 mL normal saline
D. IV dopamine infusion at 5 mcg/kg/min and oxygen
Correct Answer: A - IV furosemide 40 mg and nitroglycerin
infusion
RATIONALE
This is acute decompensated heart failure with pulmonary edema and
hypertensive urgency. First-line therapy includes IV loop diuretics
(furosemide) to reduce volume overload and vasodilators
(nitroglycerin) to reduce preload and afterload. Beta-blockers are
contraindicated in acute decompensation due to negative inotropic
effects.
Question 4
A patient is admitted with severe metabolic acidosis (pH 7.10, HCO3 8 mEq/L,
PaCO2 25 mmHg). Which calculation best determines the appropriateness of
respiratory compensation?
A. Anion gap = Na - (Cl + HCO3)
Page 3
, B. Winter's formula: Expected PaCO2 = (1.5 × HCO3) + 8 ± 2
C. Delta-delta = (Measured anion gap - Normal anion gap) / (Normal
HCO3 - Measured HCO3)
D. Osmolal gap = Measured osmolality - Calculated osmolality
Correct Answer: B - Winter's formula: Expected PaCO2 = (1.5 ×
HCO3) + 8 ± 2
RATIONALE
Winter's formula is used to calculate the expected PaCO2 for a given
serum bicarbonate to assess if respiratory compensation is appropriate.
In this case, expected PaCO2 = (1.5 × 8) + 8 ± 2 = 20 ± 2 mmHg. The
measured PaCO2 of 25 mmHg is higher than expected, indicating
inadequate respiratory compensation and a concurrent respiratory
acidosis.
Question 5
A patient with a tension pneumothorax undergoes needle decompression.
Which finding best confirms successful decompression?
A. Immediate improvement in oxygen saturation and hemodynamics
B. Audible hiss of air upon needle insertion
C. Chest radiograph showing lung re-expansion
D. Decreased resistance when advancing the needle
Correct Answer: A - Immediate improvement in oxygen
saturation and hemodynamics
RATIONALE
The definitive confirmation of successful needle decompression for
tension pneumothorax is immediate clinical improvement, including
improved oxygenation and hemodynamic stabilization (e.g., increased
blood pressure, decreased heart rate). While an audible hiss may
occur, it is not always present and does not confirm resolution of the
tension physiology.
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