KAPLAN FNP MICRO VIRTUAL
SIMULATION EXAM Clinical Case Scenario
Questions – Answers with Rationales
Case 1 – A 62-year-old male with hypertension and 40-pack-year smoking history
presents with 3 months of progressive exertional dyspnea, orthopnea (2 pillows),
bilateral edema. BP 148/92, HR 96, RR 22, SpO2 93%. Exam: JVD, S3 gallop,
bibasilar crackles. CXR: cardiomegaly, bilateral pleural effusions. BNP 1,200
pg/mL.
1. What is the most likely diagnosis?
A) COPD exacerbation
B) Acute decompensated heart failure
C) Community-acquired pneumonia
D) Pulmonary embolism
Answer: B – Acute decompensated heart failure
Rationale: S3 gallop, orthopnea, elevated BNP (>400), and cardiomegaly are
classic for heart failure. COPD would show hyperinflation, not S3. PE would have
acute dyspnea, not progressive orthopnea.
2. Which medication class is contraindicated in this acute setting?
A) Loop diuretics
B) IV nitroglycerin
C) Beta-blockers (metoprolol)
D) Morphine
Answer: C – Beta-blockers
Rationale: Beta-blockers have negative inotropic effects; starting or increasing
them during acute decompensated HF can worsen shock. They are used in chronic
stable HF.
Case 2 – A 55-year-old woman presents with acute onset of sharp, pleuritic chest
pain and dyspnea after a long flight. She has a history of DVT. HR 110, RR 24, BP
130/80, O2 sat 91%. No calf swelling.
,3. What is the most appropriate initial diagnostic test?
A) D-dimer
B) CTA chest
C) Chest X-ray
D) Venous duplex ultrasound of legs
Answer: B – CTA chest
Rationale: High suspicion for PE (recent travel, prior DVT, hypoxia) warrants
CTA chest as the definitive test. D-dimer is for low-to-moderate pretest probability.
4. If CTA confirms bilateral segmental pulmonary emboli, which anticoagulation
is first-line?
A) Aspirin 325 mg daily
B) Warfarin alone
C) Apixaban (DOAC)
D) Unfractionated heparin IV
Answer: C – Apixaban (DOAC)
Rationale: For non-massive PE, DOACs (apixaban, rivaroxaban) are first-line due
to fixed dosing, no monitoring, and lower bleeding risk than warfarin.
Case 3 – A 68-year-old man with COPD (FEV1 45%) presents with increased
dyspnea, purulent sputum, and fever. CXR shows no infiltrate. He is not hypoxic.
5. What is the appropriate antibiotic?
A) No antibiotics
B) Doxycycline 100 mg BID for 5 days
C) Levofloxacin 750 mg daily
D) Amoxicillin-clavulanate 875 mg BID
Answer: B – Doxycycline
Rationale: AECOPD with increased sputum purulence warrants antibiotics.
Doxycycline covers typical pathogens (H. flu, M. catarrhalis, pneumococcus) with
low resistance.
Case 4 – A 72-year-old with HFrEF (LVEF 30%) on carvedilol, lisinopril,
furosemide, spironolactone remains NYHA III. QRS 160 ms with LBBB.
, 6. Which therapy reduces mortality?
A) Digoxin
B) Cardiac resynchronization therapy (CRT)
C) Ivabradine
D) Hydralazine/isosorbide dinitrate
Answer: B – Cardiac resynchronization therapy (CRT)
*Rationale: CRT (biventricular pacing) is indicated for HFrEF ≤35%, LBBB, QRS
≥150 ms, NYHA II-IV. It reduces mortality and hospitalizations.*
Case 5 – A 45-year-old woman presents with acute onset of severe, tearing chest
pain radiating to the back. BP 150/90 in right arm, 100/60 in left arm.
7. What is the most likely diagnosis?
A) Myocardial infarction
B) Pulmonary embolism
C) Aortic dissection
D) Pericarditis
Answer: C – Aortic dissection
Rationale: Tearing pain, unequal blood pressures, and radiation to back are
classic for aortic dissection. Immediate CTA chest is needed.
Case 6 – A 30-year-old woman with asthma uses albuterol daily. She wakes up at
night with cough once weekly. She has normal lung function.
8. What is the next step in management?
A) Increase albuterol to 4 puffs q4h
B) Add low-dose inhaled corticosteroid (ICS)
C) Add oral montelukast
D) Switch to long-acting beta-agonist alone
Answer: B – Add low-dose inhaled corticosteroid (ICS)
Rationale: Daily rescue inhaler use and nocturnal symptoms indicate persistent
asthma requiring controller therapy (ICS). LABA alone is dangerous.
Case 7 – A 58-year-old with hypertension presents with sudden onset of left-sided
weakness and facial droop. Last known well 45 minutes ago. NIHSS 14. Non-
contrast CT normal.
SIMULATION EXAM Clinical Case Scenario
Questions – Answers with Rationales
Case 1 – A 62-year-old male with hypertension and 40-pack-year smoking history
presents with 3 months of progressive exertional dyspnea, orthopnea (2 pillows),
bilateral edema. BP 148/92, HR 96, RR 22, SpO2 93%. Exam: JVD, S3 gallop,
bibasilar crackles. CXR: cardiomegaly, bilateral pleural effusions. BNP 1,200
pg/mL.
1. What is the most likely diagnosis?
A) COPD exacerbation
B) Acute decompensated heart failure
C) Community-acquired pneumonia
D) Pulmonary embolism
Answer: B – Acute decompensated heart failure
Rationale: S3 gallop, orthopnea, elevated BNP (>400), and cardiomegaly are
classic for heart failure. COPD would show hyperinflation, not S3. PE would have
acute dyspnea, not progressive orthopnea.
2. Which medication class is contraindicated in this acute setting?
A) Loop diuretics
B) IV nitroglycerin
C) Beta-blockers (metoprolol)
D) Morphine
Answer: C – Beta-blockers
Rationale: Beta-blockers have negative inotropic effects; starting or increasing
them during acute decompensated HF can worsen shock. They are used in chronic
stable HF.
Case 2 – A 55-year-old woman presents with acute onset of sharp, pleuritic chest
pain and dyspnea after a long flight. She has a history of DVT. HR 110, RR 24, BP
130/80, O2 sat 91%. No calf swelling.
,3. What is the most appropriate initial diagnostic test?
A) D-dimer
B) CTA chest
C) Chest X-ray
D) Venous duplex ultrasound of legs
Answer: B – CTA chest
Rationale: High suspicion for PE (recent travel, prior DVT, hypoxia) warrants
CTA chest as the definitive test. D-dimer is for low-to-moderate pretest probability.
4. If CTA confirms bilateral segmental pulmonary emboli, which anticoagulation
is first-line?
A) Aspirin 325 mg daily
B) Warfarin alone
C) Apixaban (DOAC)
D) Unfractionated heparin IV
Answer: C – Apixaban (DOAC)
Rationale: For non-massive PE, DOACs (apixaban, rivaroxaban) are first-line due
to fixed dosing, no monitoring, and lower bleeding risk than warfarin.
Case 3 – A 68-year-old man with COPD (FEV1 45%) presents with increased
dyspnea, purulent sputum, and fever. CXR shows no infiltrate. He is not hypoxic.
5. What is the appropriate antibiotic?
A) No antibiotics
B) Doxycycline 100 mg BID for 5 days
C) Levofloxacin 750 mg daily
D) Amoxicillin-clavulanate 875 mg BID
Answer: B – Doxycycline
Rationale: AECOPD with increased sputum purulence warrants antibiotics.
Doxycycline covers typical pathogens (H. flu, M. catarrhalis, pneumococcus) with
low resistance.
Case 4 – A 72-year-old with HFrEF (LVEF 30%) on carvedilol, lisinopril,
furosemide, spironolactone remains NYHA III. QRS 160 ms with LBBB.
, 6. Which therapy reduces mortality?
A) Digoxin
B) Cardiac resynchronization therapy (CRT)
C) Ivabradine
D) Hydralazine/isosorbide dinitrate
Answer: B – Cardiac resynchronization therapy (CRT)
*Rationale: CRT (biventricular pacing) is indicated for HFrEF ≤35%, LBBB, QRS
≥150 ms, NYHA II-IV. It reduces mortality and hospitalizations.*
Case 5 – A 45-year-old woman presents with acute onset of severe, tearing chest
pain radiating to the back. BP 150/90 in right arm, 100/60 in left arm.
7. What is the most likely diagnosis?
A) Myocardial infarction
B) Pulmonary embolism
C) Aortic dissection
D) Pericarditis
Answer: C – Aortic dissection
Rationale: Tearing pain, unequal blood pressures, and radiation to back are
classic for aortic dissection. Immediate CTA chest is needed.
Case 6 – A 30-year-old woman with asthma uses albuterol daily. She wakes up at
night with cough once weekly. She has normal lung function.
8. What is the next step in management?
A) Increase albuterol to 4 puffs q4h
B) Add low-dose inhaled corticosteroid (ICS)
C) Add oral montelukast
D) Switch to long-acting beta-agonist alone
Answer: B – Add low-dose inhaled corticosteroid (ICS)
Rationale: Daily rescue inhaler use and nocturnal symptoms indicate persistent
asthma requiring controller therapy (ICS). LABA alone is dangerous.
Case 7 – A 58-year-old with hypertension presents with sudden onset of left-sided
weakness and facial droop. Last known well 45 minutes ago. NIHSS 14. Non-
contrast CT normal.
