PATHO 370 Week 3 Pathophysiology Examination: Mastery-Level 150-Question Bank with
Integrated Clinical Scenarios, Challenging Distractors, and Comprehensive Explanations – 2026
Updated Edition
Questions 1–150 (With Correct Answers & Explanations)
Section 1: Complex Hemodynamics & Shock Integration (1–30)
1. A patient with septic shock has a cardiac index of 3.8 L/min/m², SVR of 320 dyn·s·cm⁻⁵, and ScvO₂
of 78%. Despite this, lactate is 6 mmol/L. The most likely explanation is:
A) Inadequate fluid resuscitation
B) Microcirculatory shunting with oxygen extraction deficit
C) Hypermetabolism without tissue hypoxia
D) Laboratory error
Correct Answer: B – Normal or high ScvO₂ in sepsis can occur due to microvascular shunting and
impaired oxygen utilization, not adequate oxygenation.
2. A patient with cardiogenic shock on dobutamine and norepinephrine has MAP 65 mmHg, cardiac
index 2.0, and PCWP 22. Dobutamine is increased to 10 mcg/kg/min. Heart rate rises from 100 to
135. The next best step is:
A) Increase dobutamine further
B) Add milrinone
C) Add esmolol for rate control
D) Add vasopressin
Correct Answer: C – Excessive tachycardia increases myocardial oxygen demand and reduces diastolic
filling time; beta-blockade (esmolol) may improve hemodynamics in this setting.
3. A patient with hemorrhagic shock receives 4 L crystalloid and 2 units PRBC. BP improves to
110/70, but then deteriorates to 80/50 over 30 minutes. Repeat hemoglobin is 7.5 g/dL. The most
likely cause is:
A) Ongoing hemorrhage
B) Dilutional coagulopathy
C) Resuscitation-associated vasodilation
D) Myocardial contusion
,Correct Answer: A – Transient improvement followed by deterioration suggests rebleeding;
hemoglobin drop confirms.
4. In a patient with obstructive shock due to massive PE, which finding would paradoxically improve
with fluid administration?
A) Hypotension
B) Right ventricular dilation
C) Cardiac output
D) Central venous pressure
Correct Answer: B – Fluids may worsen RV dilation in massive PE; but in select patients, modest fluids
may increase preload to the failing RV. This question tests nuance: RV dilation worsens, CO may not
improve.
5. A patient with anaphylactic shock receives IM epinephrine. BP improves from 70/40 to 100/60,
then drops again after 15 minutes. The next best step is:
A) Repeat IM epinephrine
B) Start IV epinephrine infusion
C) Give IV diphenhydramine
D) Give IV methylprednisolone
Correct Answer: B – Biphasic anaphylaxis requires continuous IV epinephrine infusion after initial IM
dose.
6. A patient with neurogenic shock from C5 injury has BP 85/50, HR 52, and warm extremities.
Norepinephrine is started. Which additional medication may be required due to loss of sympathetic
tone?
A) Atropine
B) Phenylephrine
C) Vasopressin
D) Dobutamine
Correct Answer: A – Neurogenic shock often causes bradycardia; atropine may be needed if
norepinephrine alone does not increase HR.
7. A patient with septic shock and acute respiratory distress syndrome (ARDS) is on norepinephrine
and vasopressin. MAP is 70, but urine output is 10 mL/hr over 4 hours. Central venous pressure is 14.
The best next step is:
A) Fluid bolus 500 mL
B) Start furosemide
C) Add dobutamine
, D) Start hydrocortisone
Correct Answer: D – Relative adrenal insufficiency is common in septic shock; steroids improve
vasopressor responsiveness and may improve urine output.
8. A patient with Takotsubo cardiomyopathy presents with apical ballooning and LVEF 25%.
Hemodynamics show low cardiac output and PCWP 28. Which finding differentiates this from
anterior STEMI?
A) Elevated troponin
B) Regional wall motion beyond single coronary territory
C) ST elevation
D) Normal coronary arteries on angiography
Correct Answer: D – Takotsubo has normal coronary arteries or non-obstructive CAD; wall motion
involves multiple territories.
9. A patient with cardiogenic shock receives an Impella CP device. The expected hemodynamic
change is:
A) Increased PCWP, decreased MAP
B) Decreased PCWP, increased MAP
C) Increased SVR, decreased CO
D) Decreased SVR, increased HR
Correct Answer: B – Impella unloads LV, reducing PCWP and improving forward flow.
10. A patient with hypovolemic shock from GI bleed has a base deficit of -15. After 4 units PRBC,
base deficit improves to -8. Hemoglobin is 9. The patient is still hypotensive. The most likely
explanation is:
A) Inadequate volume
B) Coagulopathy with ongoing bleed
C) Myocardial depression
D) Transfusion reaction
Correct Answer: B – Persistent shock despite normalization of base deficit suggests ongoing bleeding;
base deficit partially corrected but not resolved.
11. In a patient with septic shock, which hemodynamic parameter best predicts fluid
responsiveness?
A) Central venous pressure
B) Mean arterial pressure
C) Pulse pressure variation >13%
D) Cardiac index
, Correct Answer: C – Dynamic measures (PPV, SVV) are superior to static CVP for predicting fluid
responsiveness in mechanically ventilated patients.
12. A patient with massive PE and obstructive shock receives thrombolytics. Thirty minutes later, BP
improves from 70/40 to 110/70, but then sudden hypotension recurs with new JVD and muffled
heart sounds. The most likely diagnosis is:
A) Recurrent PE
B) Cardiac tamponade from hemorrhagic pericardial effusion
C) Tension pneumothorax
D) Right ventricular free wall rupture
Correct Answer: B – Thrombolytics can cause bleeding; hemopericardium with tamponade presents
with Beck’s triad.
13. A patient with end-stage heart failure on continuous milrinone develops new fever, hypotension,
and leukocytosis. Milrinone is discontinued. The most likely cause of hypotension after stopping
milrinone is:
A) Sepsis
B) Milrinone withdrawal-associated vasoconstriction
C) Adrenal insufficiency
D) Volume depletion
Correct Answer: B – Milrinone withdrawal unmasks rebound vasoconstriction in patients with chronic
afterload reduction.
14. A patient with cardiogenic shock and severe mitral regurgitation from papillary muscle rupture
has a pulmonary artery catheter showing large V waves. The optimal therapy is:
A) High-dose furosemide
B) Intra-aortic balloon pump
C) Dobutamine alone
D) Norepinephrine alone
Correct Answer: B – IABP reduces afterload and regurgitant fraction, stabilizing patients until surgery.
15. A patient with septic shock has a Pv-aCO₂ gradient (venous-arterial CO₂ difference) of 12 mmHg
despite ScvO₂ of 72%. This indicates:
A) Adequate global oxygen delivery
B) Persistent hypoperfusion despite normal ScvO₂
C) Hyperventilation
D) Metabolic alkalosis
Integrated Clinical Scenarios, Challenging Distractors, and Comprehensive Explanations – 2026
Updated Edition
Questions 1–150 (With Correct Answers & Explanations)
Section 1: Complex Hemodynamics & Shock Integration (1–30)
1. A patient with septic shock has a cardiac index of 3.8 L/min/m², SVR of 320 dyn·s·cm⁻⁵, and ScvO₂
of 78%. Despite this, lactate is 6 mmol/L. The most likely explanation is:
A) Inadequate fluid resuscitation
B) Microcirculatory shunting with oxygen extraction deficit
C) Hypermetabolism without tissue hypoxia
D) Laboratory error
Correct Answer: B – Normal or high ScvO₂ in sepsis can occur due to microvascular shunting and
impaired oxygen utilization, not adequate oxygenation.
2. A patient with cardiogenic shock on dobutamine and norepinephrine has MAP 65 mmHg, cardiac
index 2.0, and PCWP 22. Dobutamine is increased to 10 mcg/kg/min. Heart rate rises from 100 to
135. The next best step is:
A) Increase dobutamine further
B) Add milrinone
C) Add esmolol for rate control
D) Add vasopressin
Correct Answer: C – Excessive tachycardia increases myocardial oxygen demand and reduces diastolic
filling time; beta-blockade (esmolol) may improve hemodynamics in this setting.
3. A patient with hemorrhagic shock receives 4 L crystalloid and 2 units PRBC. BP improves to
110/70, but then deteriorates to 80/50 over 30 minutes. Repeat hemoglobin is 7.5 g/dL. The most
likely cause is:
A) Ongoing hemorrhage
B) Dilutional coagulopathy
C) Resuscitation-associated vasodilation
D) Myocardial contusion
,Correct Answer: A – Transient improvement followed by deterioration suggests rebleeding;
hemoglobin drop confirms.
4. In a patient with obstructive shock due to massive PE, which finding would paradoxically improve
with fluid administration?
A) Hypotension
B) Right ventricular dilation
C) Cardiac output
D) Central venous pressure
Correct Answer: B – Fluids may worsen RV dilation in massive PE; but in select patients, modest fluids
may increase preload to the failing RV. This question tests nuance: RV dilation worsens, CO may not
improve.
5. A patient with anaphylactic shock receives IM epinephrine. BP improves from 70/40 to 100/60,
then drops again after 15 minutes. The next best step is:
A) Repeat IM epinephrine
B) Start IV epinephrine infusion
C) Give IV diphenhydramine
D) Give IV methylprednisolone
Correct Answer: B – Biphasic anaphylaxis requires continuous IV epinephrine infusion after initial IM
dose.
6. A patient with neurogenic shock from C5 injury has BP 85/50, HR 52, and warm extremities.
Norepinephrine is started. Which additional medication may be required due to loss of sympathetic
tone?
A) Atropine
B) Phenylephrine
C) Vasopressin
D) Dobutamine
Correct Answer: A – Neurogenic shock often causes bradycardia; atropine may be needed if
norepinephrine alone does not increase HR.
7. A patient with septic shock and acute respiratory distress syndrome (ARDS) is on norepinephrine
and vasopressin. MAP is 70, but urine output is 10 mL/hr over 4 hours. Central venous pressure is 14.
The best next step is:
A) Fluid bolus 500 mL
B) Start furosemide
C) Add dobutamine
, D) Start hydrocortisone
Correct Answer: D – Relative adrenal insufficiency is common in septic shock; steroids improve
vasopressor responsiveness and may improve urine output.
8. A patient with Takotsubo cardiomyopathy presents with apical ballooning and LVEF 25%.
Hemodynamics show low cardiac output and PCWP 28. Which finding differentiates this from
anterior STEMI?
A) Elevated troponin
B) Regional wall motion beyond single coronary territory
C) ST elevation
D) Normal coronary arteries on angiography
Correct Answer: D – Takotsubo has normal coronary arteries or non-obstructive CAD; wall motion
involves multiple territories.
9. A patient with cardiogenic shock receives an Impella CP device. The expected hemodynamic
change is:
A) Increased PCWP, decreased MAP
B) Decreased PCWP, increased MAP
C) Increased SVR, decreased CO
D) Decreased SVR, increased HR
Correct Answer: B – Impella unloads LV, reducing PCWP and improving forward flow.
10. A patient with hypovolemic shock from GI bleed has a base deficit of -15. After 4 units PRBC,
base deficit improves to -8. Hemoglobin is 9. The patient is still hypotensive. The most likely
explanation is:
A) Inadequate volume
B) Coagulopathy with ongoing bleed
C) Myocardial depression
D) Transfusion reaction
Correct Answer: B – Persistent shock despite normalization of base deficit suggests ongoing bleeding;
base deficit partially corrected but not resolved.
11. In a patient with septic shock, which hemodynamic parameter best predicts fluid
responsiveness?
A) Central venous pressure
B) Mean arterial pressure
C) Pulse pressure variation >13%
D) Cardiac index
, Correct Answer: C – Dynamic measures (PPV, SVV) are superior to static CVP for predicting fluid
responsiveness in mechanically ventilated patients.
12. A patient with massive PE and obstructive shock receives thrombolytics. Thirty minutes later, BP
improves from 70/40 to 110/70, but then sudden hypotension recurs with new JVD and muffled
heart sounds. The most likely diagnosis is:
A) Recurrent PE
B) Cardiac tamponade from hemorrhagic pericardial effusion
C) Tension pneumothorax
D) Right ventricular free wall rupture
Correct Answer: B – Thrombolytics can cause bleeding; hemopericardium with tamponade presents
with Beck’s triad.
13. A patient with end-stage heart failure on continuous milrinone develops new fever, hypotension,
and leukocytosis. Milrinone is discontinued. The most likely cause of hypotension after stopping
milrinone is:
A) Sepsis
B) Milrinone withdrawal-associated vasoconstriction
C) Adrenal insufficiency
D) Volume depletion
Correct Answer: B – Milrinone withdrawal unmasks rebound vasoconstriction in patients with chronic
afterload reduction.
14. A patient with cardiogenic shock and severe mitral regurgitation from papillary muscle rupture
has a pulmonary artery catheter showing large V waves. The optimal therapy is:
A) High-dose furosemide
B) Intra-aortic balloon pump
C) Dobutamine alone
D) Norepinephrine alone
Correct Answer: B – IABP reduces afterload and regurgitant fraction, stabilizing patients until surgery.
15. A patient with septic shock has a Pv-aCO₂ gradient (venous-arterial CO₂ difference) of 12 mmHg
despite ScvO₂ of 72%. This indicates:
A) Adequate global oxygen delivery
B) Persistent hypoperfusion despite normal ScvO₂
C) Hyperventilation
D) Metabolic alkalosis
