PATHO 370 Week 3 Pathophysiology: Advanced Mastery-Level 150-Question Bank with Integrated
Hemodynamics, Shock Differentiation, Complex ACS, Heart Failure Nuances, and Arrhythmia
Mechanisms – 2026 Edition
Questions 1–150 (With Correct Answers & Explanations)
Section 1: Hemodynamic Differentiation & Mixed Shock States (1–30)
1. A patient with cirrhosis and septic shock has a cardiac index of 4.5 L/min/m², SVR of 250
dyn·s·cm⁻⁵, and a CVP of 18 mmHg. The patient remains hypotensive despite norepinephrine. The
most likely contributing factor is:
A) Adrenal insufficiency
B) Hyperdynamic cirrhosis with splanchnic vasodilation
C) Cardiogenic component from cirrhotic cardiomyopathy
D) Occult bleeding
Correct Answer: C – Cirrhotic cardiomyopathy (blunted contractile reserve) can coexist with
hyperdynamic circulation, limiting response to vasopressors.
2. A patient with massive PE and obstructive shock has a right ventricular systolic pressure of 70
mmHg and a cardiac index of 1.6 L/min/m². Thrombolytics are given. After 2 hours, RVSP is 55
mmHg and CI is 2.0. The patient then develops new hypotension with a distended abdomen. The
most likely diagnosis is:
A) Recurrent PE
B) Retroperitoneal hemorrhage from thrombolytics
C) Abdominal compartment syndrome
D) Mesenteric ischemia
Correct Answer: B – Thrombolytics increase bleeding risk; retroperitoneal hematoma presents with
hypotension and abdominal distension without overt external bleeding.
3. A patient with cardiogenic shock on VA-ECMO has a left ventricular (LV) distention on
echocardiogram. The next best intervention to unload the LV is:
A) Increase ECMO flow
B) Add an Impella or percutaneous LV vent
C) Increase norepinephrine
D) Decrease ECMO flow
,Correct Answer: B – VA-ECMO increases afterload, causing LV distention; LV venting (Impella, IABP, or
surgical vent) is required.
4. A patient with septic shock has a rising lactate from 2 to 6 mmol/L over 4 hours despite MAP >65
on norepinephrine and adequate fluid resuscitation. ScvO₂ is 70%. The most likely mechanism is:
A) Overt sepsis with increased oxygen consumption
B) Microcirculatory dysfunction with normal global oxygen delivery
C) Type B lactic acidosis from liver failure
D) Thiamine deficiency
Correct Answer: B – Normal ScvO₂ with rising lactate suggests microvascular shunting and impaired
oxygen utilization (cytopathic hypoxia).
5. A patient with hemorrhagic shock from a ruptured abdominal aortic aneurysm receives 10 units
PRBC, 10 units plasma, and 2 units platelets. After repair, the patient becomes hypotensive with a
temperature of 34°C, INR >4, and fibrinogen <50 mg/dL. The most likely diagnosis is:
A) Hemorrhagic shock recurrence
B) Trauma-induced coagulopathy with hypothermia
C) Heparin-induced thrombocytopenia
D) Disseminated intravascular coagulation (DIC)
Correct Answer: B – Lethal triad: hypothermia, acidosis, coagulopathy from massive transfusion.
6. A patient with anaphylactic shock receives IM epinephrine, then IV epinephrine infusion. BP
improves to 110/70, but then the patient develops pulmonary edema with oxygen desaturation. The
most likely cause is:
A) Anaphylaxis-induced cardiomyopathy
B) Negative pressure pulmonary edema from upper airway obstruction
C) Fluid overload
D) Epinephrine-induced pulmonary hypertension
Correct Answer: B – Upper airway edema during anaphylaxis can cause inspiratory obstruction,
generating negative intrathoracic pressure and noncardiogenic pulmonary edema.
7. A patient with neurogenic shock from a high cervical SCI has BP 85/50, HR 45, and warm
extremities. Norepinephrine is started. BP increases to 110/70, but HR remains 45. The patient
develops pulmonary artery catheter data showing CI 1.8 L/min/m². The next best step is:
A) Increase norepinephrine
B) Start dobutamine
C) Start atropine
D) Start vasopressin
,Correct Answer: C – Bradycardia limits cardiac output; atropine increases HR, improving CO.
8. A patient with obstructive shock from cardiac tamponade undergoes pericardiocentesis. Removal
of 300 mL bloody fluid improves BP from 70/40 to 120/80. Ten minutes later, BP drops to 90/60. The
next best step is:
A) Repeat pericardiocentesis
B) CT angiography for aortic dissection
C) Fluid bolus
D) Increase norepinephrine
Correct Answer: B – Bloody effusion after pericardiocentesis that reaccumulates suggests aortic
dissection or myocardial rupture.
9. A patient with mixed cardiogenic and septic shock has a PAC showing: CI 1.8, PCWP 24, SVR 800.
Which combination of vasoactive agents is most appropriate?
A) Norepinephrine + dobutamine
B) Phenylephrine + milrinone
C) Vasopressin alone
D) Epinephrine alone
Correct Answer: A – Norepinephrine for vasodilation (low SVR) and dobutamine for low CI.
10. A patient with septic shock and severe ARDS is on norepinephrine and prone positioning. The
patient becomes more hypotensive after turning prone. The most likely explanation is:
A) Increased intra-abdominal pressure from prone position
B) Reduced preload from compression of inferior vena cava
C) Vasovagal response
D) Pulmonary embolism
Correct Answer: B – Prone positioning can compress abdominal vessels, reducing venous return.
11. A patient with hypovolemic shock from pancreatitis has a calcium of 6.0 mg/dL and albumin of
2.0 g/dL. The corrected calcium is:
A) 6.0
B) 7.0
C) 8.0
D) 9.0
Correct Answer: C – Corrected Ca = measured Ca + 0.8 × (4 – albumin). Albumin 2 → 4 – 2 = 2 → 0.8
× 2 = 1.6 → 6.0 + 1.6 = 7.6 (closest 8.0).
, 12. A patient with septic shock has an ionized calcium of 0.9 mmol/L (low) despite normal total
calcium. The next best step is:
A) IV calcium gluconate
B) IV magnesium
C) No treatment
D) IV phosphate
Correct Answer: A – Ionized hypocalcemia impairs myocardial contractility and vasopressor response.
13. A patient with cardiogenic shock on dobutamine and norepinephrine has a lactate of 8 mmol/L.
Dobutamine is increased from 5 to 10 mcg/kg/min. Heart rate increases from 100 to 140. Lactate
increases to 10. The next best step is:
A) Increase dobutamine further
B) Add esmolol to lower heart rate
C) Add milrinone
D) Start IABP
Correct Answer: B – Excessive tachycardia increases myocardial oxygen demand and reduces diastolic
filling, worsening ischemia and lactate.
14. A patient with septic shock and acute liver failure has a lactate of 12 mmol/L. Norepinephrine is
at 50 mcg/min. The patient is anuric. Which vasopressor is relatively contraindicated due to lack of
hepatic metabolism?
A) Norepinephrine
B) Vasopressin
C) Epinephrine
D) Dopamine
Correct Answer: B – Vasopressin is metabolized in the liver; levels may accumulate unpredictably.
15. A patient with obstructive shock from massive PE has a right ventricular (RV) to left ventricular
(LV) ratio of 1.2 on echocardiogram. After thrombolytics, the ratio decreases to 0.9. The patient then
develops new hypotension and a new holosystolic murmur at left sternal border. This suggests:
A) Ventricular septal rupture
B) Tricuspid regurgitation from papillary muscle ischemia
C) Mitral regurgitation
D) Aortic stenosis
Correct Answer: B – RV dilation and ischemia can cause tricuspid papillary muscle dysfunction and TR.
16. A patient with cardiogenic shock receives an Impella CP. The device output is 3.5 L/min. The
patient’s native cardiac output is 1.5 L/min. Total systemic flow is 5.0 L/min. The aortic valve remains
Hemodynamics, Shock Differentiation, Complex ACS, Heart Failure Nuances, and Arrhythmia
Mechanisms – 2026 Edition
Questions 1–150 (With Correct Answers & Explanations)
Section 1: Hemodynamic Differentiation & Mixed Shock States (1–30)
1. A patient with cirrhosis and septic shock has a cardiac index of 4.5 L/min/m², SVR of 250
dyn·s·cm⁻⁵, and a CVP of 18 mmHg. The patient remains hypotensive despite norepinephrine. The
most likely contributing factor is:
A) Adrenal insufficiency
B) Hyperdynamic cirrhosis with splanchnic vasodilation
C) Cardiogenic component from cirrhotic cardiomyopathy
D) Occult bleeding
Correct Answer: C – Cirrhotic cardiomyopathy (blunted contractile reserve) can coexist with
hyperdynamic circulation, limiting response to vasopressors.
2. A patient with massive PE and obstructive shock has a right ventricular systolic pressure of 70
mmHg and a cardiac index of 1.6 L/min/m². Thrombolytics are given. After 2 hours, RVSP is 55
mmHg and CI is 2.0. The patient then develops new hypotension with a distended abdomen. The
most likely diagnosis is:
A) Recurrent PE
B) Retroperitoneal hemorrhage from thrombolytics
C) Abdominal compartment syndrome
D) Mesenteric ischemia
Correct Answer: B – Thrombolytics increase bleeding risk; retroperitoneal hematoma presents with
hypotension and abdominal distension without overt external bleeding.
3. A patient with cardiogenic shock on VA-ECMO has a left ventricular (LV) distention on
echocardiogram. The next best intervention to unload the LV is:
A) Increase ECMO flow
B) Add an Impella or percutaneous LV vent
C) Increase norepinephrine
D) Decrease ECMO flow
,Correct Answer: B – VA-ECMO increases afterload, causing LV distention; LV venting (Impella, IABP, or
surgical vent) is required.
4. A patient with septic shock has a rising lactate from 2 to 6 mmol/L over 4 hours despite MAP >65
on norepinephrine and adequate fluid resuscitation. ScvO₂ is 70%. The most likely mechanism is:
A) Overt sepsis with increased oxygen consumption
B) Microcirculatory dysfunction with normal global oxygen delivery
C) Type B lactic acidosis from liver failure
D) Thiamine deficiency
Correct Answer: B – Normal ScvO₂ with rising lactate suggests microvascular shunting and impaired
oxygen utilization (cytopathic hypoxia).
5. A patient with hemorrhagic shock from a ruptured abdominal aortic aneurysm receives 10 units
PRBC, 10 units plasma, and 2 units platelets. After repair, the patient becomes hypotensive with a
temperature of 34°C, INR >4, and fibrinogen <50 mg/dL. The most likely diagnosis is:
A) Hemorrhagic shock recurrence
B) Trauma-induced coagulopathy with hypothermia
C) Heparin-induced thrombocytopenia
D) Disseminated intravascular coagulation (DIC)
Correct Answer: B – Lethal triad: hypothermia, acidosis, coagulopathy from massive transfusion.
6. A patient with anaphylactic shock receives IM epinephrine, then IV epinephrine infusion. BP
improves to 110/70, but then the patient develops pulmonary edema with oxygen desaturation. The
most likely cause is:
A) Anaphylaxis-induced cardiomyopathy
B) Negative pressure pulmonary edema from upper airway obstruction
C) Fluid overload
D) Epinephrine-induced pulmonary hypertension
Correct Answer: B – Upper airway edema during anaphylaxis can cause inspiratory obstruction,
generating negative intrathoracic pressure and noncardiogenic pulmonary edema.
7. A patient with neurogenic shock from a high cervical SCI has BP 85/50, HR 45, and warm
extremities. Norepinephrine is started. BP increases to 110/70, but HR remains 45. The patient
develops pulmonary artery catheter data showing CI 1.8 L/min/m². The next best step is:
A) Increase norepinephrine
B) Start dobutamine
C) Start atropine
D) Start vasopressin
,Correct Answer: C – Bradycardia limits cardiac output; atropine increases HR, improving CO.
8. A patient with obstructive shock from cardiac tamponade undergoes pericardiocentesis. Removal
of 300 mL bloody fluid improves BP from 70/40 to 120/80. Ten minutes later, BP drops to 90/60. The
next best step is:
A) Repeat pericardiocentesis
B) CT angiography for aortic dissection
C) Fluid bolus
D) Increase norepinephrine
Correct Answer: B – Bloody effusion after pericardiocentesis that reaccumulates suggests aortic
dissection or myocardial rupture.
9. A patient with mixed cardiogenic and septic shock has a PAC showing: CI 1.8, PCWP 24, SVR 800.
Which combination of vasoactive agents is most appropriate?
A) Norepinephrine + dobutamine
B) Phenylephrine + milrinone
C) Vasopressin alone
D) Epinephrine alone
Correct Answer: A – Norepinephrine for vasodilation (low SVR) and dobutamine for low CI.
10. A patient with septic shock and severe ARDS is on norepinephrine and prone positioning. The
patient becomes more hypotensive after turning prone. The most likely explanation is:
A) Increased intra-abdominal pressure from prone position
B) Reduced preload from compression of inferior vena cava
C) Vasovagal response
D) Pulmonary embolism
Correct Answer: B – Prone positioning can compress abdominal vessels, reducing venous return.
11. A patient with hypovolemic shock from pancreatitis has a calcium of 6.0 mg/dL and albumin of
2.0 g/dL. The corrected calcium is:
A) 6.0
B) 7.0
C) 8.0
D) 9.0
Correct Answer: C – Corrected Ca = measured Ca + 0.8 × (4 – albumin). Albumin 2 → 4 – 2 = 2 → 0.8
× 2 = 1.6 → 6.0 + 1.6 = 7.6 (closest 8.0).
, 12. A patient with septic shock has an ionized calcium of 0.9 mmol/L (low) despite normal total
calcium. The next best step is:
A) IV calcium gluconate
B) IV magnesium
C) No treatment
D) IV phosphate
Correct Answer: A – Ionized hypocalcemia impairs myocardial contractility and vasopressor response.
13. A patient with cardiogenic shock on dobutamine and norepinephrine has a lactate of 8 mmol/L.
Dobutamine is increased from 5 to 10 mcg/kg/min. Heart rate increases from 100 to 140. Lactate
increases to 10. The next best step is:
A) Increase dobutamine further
B) Add esmolol to lower heart rate
C) Add milrinone
D) Start IABP
Correct Answer: B – Excessive tachycardia increases myocardial oxygen demand and reduces diastolic
filling, worsening ischemia and lactate.
14. A patient with septic shock and acute liver failure has a lactate of 12 mmol/L. Norepinephrine is
at 50 mcg/min. The patient is anuric. Which vasopressor is relatively contraindicated due to lack of
hepatic metabolism?
A) Norepinephrine
B) Vasopressin
C) Epinephrine
D) Dopamine
Correct Answer: B – Vasopressin is metabolized in the liver; levels may accumulate unpredictably.
15. A patient with obstructive shock from massive PE has a right ventricular (RV) to left ventricular
(LV) ratio of 1.2 on echocardiogram. After thrombolytics, the ratio decreases to 0.9. The patient then
develops new hypotension and a new holosystolic murmur at left sternal border. This suggests:
A) Ventricular septal rupture
B) Tricuspid regurgitation from papillary muscle ischemia
C) Mitral regurgitation
D) Aortic stenosis
Correct Answer: B – RV dilation and ischemia can cause tricuspid papillary muscle dysfunction and TR.
16. A patient with cardiogenic shock receives an Impella CP. The device output is 3.5 L/min. The
patient’s native cardiac output is 1.5 L/min. Total systemic flow is 5.0 L/min. The aortic valve remains
