Pulmonary Vascular Disease
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USMLE Step 2 CK › Pulmonary Vascular Disease
A 50-year-old woman with prior DVT has suspected CTEPH based on V/Q mismatch and elevated PASP on echo. Meds: none. Exam: loud P2, RV heave. She asks what therapy offers potential cure rather than symptom control.
Which of the following is the most appropriate next step in management?
Give IV thrombolysis because chronic defects respond best to lysis
Start azithromycin to treat presumed chronic infectious dyspnea
Prescribe diuretics alone as definitive long-term management strategy
Stop physical activity to prevent worsening pulmonary pressures
Refer for evaluation for pulmonary thromboendarterectomy if operable
Explanation
This question tests USMLE Step 2 CK skills in understanding Pulmonary Vascular Disease and its management. Pulmonary Vascular Disease includes conditions like pulmonary embolism and hypertension, requiring specific diagnostic and management strategies. In this scenario, the vignette provides clinical clues such as prior DVT and V/Q mismatches suggesting CTEPH, which suggest potential for surgical cure. Choice A is correct because it aligns with the guideline to refer for PTE evaluation in operable CTEPH. Choice B is incorrect because it fails to address the thromboembolic cause, often leading to infectious misdiagnosis. Teaching strategies include emphasizing the importance of recognizing key clinical signs of pulmonary vascular disorders and applying evidence-based management protocols. Encourage practice with differential diagnosis and appropriate test selection.
A 65-year-old woman has sudden dyspnea and pleuritic chest pain shortly after a long flight. PMH: osteoarthritis. Meds: naproxen. Vitals: HR 118, BP 132/78, RR 26, SpO2 89% room air. Exam: clear lungs, tachycardia, mild unilateral calf tenderness. Labs: D-dimer elevated. CTPA demonstrates a lobar PE with mild right ventricular enlargement; troponin is slightly elevated. She remains normotensive.
Which of the following is the most appropriate next step in management?
Treat empirically with antibiotics for atypical pneumonia coverage
Withhold anticoagulation and repeat CTPA in 24 hours
Administer thrombolysis immediately because RV strain is present
Start therapeutic anticoagulation and monitor for clinical deterioration
Start beta-blocker therapy to reduce right ventricular oxygen demand
Explanation
This question tests USMLE Step 2 CK skills in understanding Pulmonary Vascular Disease and its management. Pulmonary Vascular Disease includes conditions like pulmonary embolism and hypertension, requiring specific diagnostic and management strategies. In this scenario, the vignette provides clinical clues such as post-flight dyspnea and lobar PE with mild RV enlargement, which suggest intermediate-risk pulmonary embolism. Choice B is correct because it aligns with the guideline to anticoagulate and monitor stable patients based on clinical stability. Choice A is incorrect because it fails to address the absence of shock, often leading to overtreatment with thrombolysis. Teaching strategies include emphasizing the importance of recognizing key clinical signs of pulmonary vascular disorders and applying evidence-based management protocols. Encourage practice with differential diagnosis and appropriate test selection.
A 65-year-old woman has sudden dyspnea after a long flight. D-dimer is elevated. CTPA shows PE. PMH: prior GI bleed 2 weeks ago requiring transfusion. Meds: pantoprazole. She is stable but high bleeding risk.
Which of the following is the most appropriate next step in management?
Administer thrombolysis to avoid need for anticoagulation altogether
Place an IVC filter because anticoagulation is temporarily contraindicated
Provide reassurance and discharge with outpatient follow-up only
Treat with antibiotics because PE often mimics pneumonia symptoms
Start full-dose anticoagulation immediately despite recent major bleeding
Explanation
This question tests USMLE Step 2 CK skills in understanding Pulmonary Vascular Disease and its management. Pulmonary Vascular Disease includes conditions like pulmonary embolism and hypertension, requiring specific diagnostic and management strategies. In this scenario, the vignette provides clinical clues such as post-flight PE with recent GI bleed, which suggest high bleeding risk. Choice A is correct because it aligns with the guideline to place IVC filter when anticoagulation is contraindicated. Choice B is incorrect because it fails to address bleeding risk, often leading to avoidance of necessary prevention. Teaching strategies include emphasizing the importance of recognizing key clinical signs of pulmonary vascular disorders and applying evidence-based management protocols. Encourage practice with differential diagnosis and appropriate test selection.
A 45-year-old man has 10 months of progressive exertional dyspnea and fatigue. He has untreated obstructive sleep apnea and loud snoring; he has not used CPAP. PMH: obesity. Meds: none. Vitals: BP 134/82, HR 96, RR 18, SpO2 93% on room air. Exam: accentuated P2, parasternal heave, mild bilateral ankle edema; lungs are clear. Labs: BNP mildly elevated; CBC normal. ECG: right axis deviation. CXR: prominent central pulmonary arteries. Transthoracic echocardiogram shows estimated pulmonary artery systolic pressure 62 mm Hg with right ventricular hypertrophy and normal left ventricular systolic function.
Which diagnostic test should be ordered next?
Exercise treadmill test to assess for occult coronary ischemia
Cardiac MRI to quantify right ventricular ejection fraction
CT pulmonary angiography to exclude acute pulmonary embolism
Right heart catheterization to confirm pressures and hemodynamics
D-dimer testing to evaluate for chronic thromboembolic disease
Explanation
This question tests USMLE Step 2 CK skills in understanding Pulmonary Vascular Disease and its management. Pulmonary Vascular Disease includes conditions like pulmonary embolism and hypertension, requiring specific diagnostic and management strategies. In this scenario, the vignette provides clinical clues such as progressive dyspnea and elevated pulmonary artery pressure on echo, which suggest pulmonary hypertension likely from OSA. Choice A is correct because it aligns with the guideline to confirm pulmonary hypertension diagnosis via right heart catheterization based on echocardiographic suspicion. Choice B is incorrect because it fails to address the chronic nature, often leading to overlooking underlying causes. Teaching strategies include emphasizing the importance of recognizing key clinical signs of pulmonary vascular disorders and applying evidence-based management protocols. Encourage practice with differential diagnosis and appropriate test selection.
A 50-year-old woman reports 2 years of worsening exercise intolerance and dyspnea. She had a proximal DVT 3 years ago and stopped anticoagulation after 3 months. PMH: DVT. Meds: none. Vitals: BP 122/76, HR 92, RR 18, SpO2 94% on room air. Exam: loud P2, right ventricular heave, mild hepatomegaly, no wheezes. ECG: right axis deviation. Echocardiogram shows right ventricular enlargement with elevated estimated pulmonary artery systolic pressure. Ventilation-perfusion scan demonstrates multiple segmental perfusion defects with preserved ventilation.
What is the most likely diagnosis?
Idiopathic pulmonary arterial hypertension due to vasoconstriction
COPD-related cor pulmonale from chronic hypoxic vasoconstriction
Acute pulmonary embolism causing sudden right ventricular strain
Left-sided heart failure causing postcapillary pulmonary hypertension
Chronic thromboembolic pulmonary hypertension from organized thrombi
Explanation
This question tests USMLE Step 2 CK skills in understanding Pulmonary Vascular Disease and its management. Pulmonary Vascular Disease includes conditions like pulmonary embolism and hypertension, requiring specific diagnostic and management strategies. In this scenario, the vignette provides clinical clues such as prior DVT and mismatched V/Q defects, which suggest chronic thromboembolic pulmonary hypertension. Choice B is correct because it aligns with the guideline to diagnose CTEPH based on history and imaging mismatches. Choice A is incorrect because it fails to address the thromboembolic history, often leading to misattribution to idiopathic causes. Teaching strategies include emphasizing the importance of recognizing key clinical signs of pulmonary vascular disorders and applying evidence-based management protocols. Encourage practice with differential diagnosis and appropriate test selection.