Practice questions Shock
Practice questions
Shock
© Jun Wang, MD, PhD
1. Use this case for the next 7 questions. A 56-year-old man presented with fever, chills and lower abdominal pain for 2 days. He has a history of hypertension, type 2 diabetes, and hyperlipidemia. He drinks beer occasionally but does not drink other alcohol beverage. He does not smoke cigarette. On physical examination, he appears to have acute stress and confused. He has a temperature of 39.6°C, blood pressure of 75/50 mm Hg, a heart rate of 125 beats per minute and respiratory rate of 25/min. His skin is warm and dry with focal cyanosis. His heart and breath sounds are normal. The abdomen was diffusely tense and distended. His CBC reveals a hemoglobin of 13.5 g/dl (normal 14-18 g/dl), white cell count of 27.5 x 109/L (normal 5-11 x 109/L), platelet count 54 x 109/L (normal 150-450 x 109/L). His white cells show left shift, but no blast is seen. He has a PT of 21 second (normal 8.8-12.7 second), aPTT of 90 second (normal 23-29 second), and a fibrinogen of 65 mg/dl (normal 180-350 mg/dL). An abdomen CT examination reveals extraluminal gas and suspected extraluminal feces. His blood pressure is 80/50 mm Hg 3 hours after initiation of fluid resuscitation. What additional test is likely confirmative for the diagnosis?
A. Blood culture
B. Chest X-Ray
C. Echocardiography
D. EKG
E. Flow cytometry of peripheral blood
F. Urine sodium concentration
2. A 56-year-old man presented with fever, chills and lower abdominal pain for 2 days. He has a history of hypertension, type 2 diabetes, and hyperlipidemia. He drinks beer occasionally but does not drink other alcohol beverage. He does not smoke cigarette. On physical examination, he appears to have acute stress and confused. He has a temperature of 39.6°C, blood pressure of 75/50 mm Hg, a heart rate of 125 beats per minute and respiratory rate of 25/min. His skin is warm and dry with focal cyanosis. His heart and breath sounds are normal. The abdomen was diffusely tense and distended. His CBC reveals a hemoglobin of 13.5 g/dl (normal 14-18 g/dl), white cell count of 27.5 x 109/L (normal 5-11 x 109/L), platelet count 54 x 109/L (normal 150-450 x 109/L). His white cells show left shift, but no blast is seen. He has a PT of 21 second (normal 8.8-12.7 second), aPTT of 90 second (normal 23-29 second), and a fibrinogen of 65 mg/dl (normal 180-350 mg/dL). An abdomen CT examination reveals extraluminal gas and suspected extraluminal feces. His blood pressure is 80/50 mm Hg 3 hours after initiation of fluid resuscitation. What is most likely causing his prolonged aPTT?
A. Coagulation factor inhibitors
B. Congenital factor VIII deficiency
C. Internal hemorrhage
D. Over-activation of coagulation components
E. Platelet dysfunction
3. A 56-year-old man presented with fever, chills and lower abdominal pain for 2 days. He has a history of hypertension, type 2 diabetes, and hyperlipidemia. He drinks beer occasionally but does not drink other alcohol beverage. He does not smoke cigarette. On physical examination, he appears to have acute stress and confused. He has a temperature of 39.6°C, blood pressure of 75/50 mm Hg, a heart rate of 125 beats per minute and respiratory rate of 25/min. His skin is warm and dry with focal cyanosis. His heart and breath sounds are normal. The abdomen was diffusely tense and distended. His CBC reveals a hemoglobin of 13.5 g/dl (normal 14-18 g/dl), white cell count of 27.5 x 109/L (normal 5-11 x 109/L), platelet count 54 x 109/L (normal 150-450 x 109/L). His white cells show left shift, but no blast is seen. He has a PT of 21 second (normal 8.8-12.7 second), aPTT of 90 second (normal 23-29 second), and a fibrinogen of 65 mg/dl (normal 180-350 mg/dL). An abdomen CT examination reveals extraluminal gas and suspected extraluminal feces. His blood pressure is 80/50 mm Hg 3 hours after initiation of fluid resuscitation. What is most likely causing his low blood pressure?
A. Abnormal vessel dilation
B. Arrythmias
C. Internal hemorrhage
D. Obstruction of major branches of aorta
E. Ventricular dysfunction
4. A 56-year-old man presented with fever, chills and lower abdominal pain for 2 days. He has a history of hypertension, type 2 diabetes, and hyperlipidemia. He drinks beer occasionally but does not drink other alcohol beverage. He does not smoke cigarette. On physical examination, he appears to have acute stress and confused. He has a temperature of 39.6°C, blood pressure of 75/50 mm Hg, a heart rate of 125 beats per minute and respiratory rate of 25/min. His skin is warm and dry with focal cyanosis. His heart and breath sounds are normal. The abdomen was diffusely tense and distended. His CBC reveals a hemoglobin of 13.5 g/dl (normal 14-18 g/dl), white cell count of 27.5 x 109/L (normal 5-11 x 109/L), platelet count 54 x 109/L (normal 150-450 x 109/L). His white cells show left shift, but no blast is seen. He has a PT of 21 second (normal 8.8-12.7 second), aPTT of 90 second (normal 23-29 second), and a fibrinogen of 65 mg/dl (normal 180-350 mg/dL). An abdomen CT examination reveals extraluminal gas and suspected extraluminal feces. His blood pressure is 80/50 mm Hg 3 hours after initiation of fluid resuscitation. What major pathological process is likely causing his presentations?
A. Abnormal cytokine activities
B. Cardiac tumor associated conductive system disorders
C. Congenital vascular malformations
D. Primary immunodeficiency
E. Reduced cardiac output
5. A 56-year-old man presented with fever, chills and lower abdominal pain for 2 days. He has a history of hypertension, type 2 diabetes, and hyperlipidemia. He drinks beer occasionally but does not drink other alcohol beverage. He does not smoke cigarette. On physical examination, he appears to have acute stress and confused. He has a temperature of 39.6°C, blood pressure of 75/50 mm Hg, a heart rate of 125 beats per minute and respiratory rate of 25/min. His skin is warm and dry with focal cyanosis. His heart and breath sounds are normal. The abdomen was diffusely tense and distended. His CBC reveals a hemoglobin of 13.5 g/dl (normal 14-18 g/dl), white cell count of 27.5 x 109/L (normal 5-11 x 109/L), platelet count 54 x 109/L (normal 150-450 x 109/L). His white cells show left shift, but no blast is seen. He has a PT of 21 second (normal 8.8-12.7 second), aPTT of 90 second (normal 23-29 second), and a fibrinogen of 65 mg/dl (normal 180-350 mg/dL). An abdomen CT examination reveals extraluminal gas and suspected extraluminal feces. His blood pressure is 80/50 mm Hg 3 hours after initiation of fluid resuscitation. What is likely the diagnosis?
A. Anaphylactic shock
B. Cardiogenic shock
C. Hypovolemic shock
D. Obstructive shock
E. Septic shock
6. A 56-year-old man presented with fever, chills and lower abdominal pain for 2 days. He has a history of hypertension, type 2 diabetes, and hyperlipidemia. He drinks beer occasionally but does not drink other alcohol beverage. He does not smoke cigarette. On physical examination, he appears to have acute stress and confused. He has a temperature of 39.6°C, blood pressure of 75/50 mm Hg, a heart rate of 125 beats per minute and respiratory rate of 25/min. His skin is warm and dry with focal cyanosis. His heart and breath sounds are normal. The abdomen was diffusely tense and distended. His CBC reveals a hemoglobin of 13.5 g/dl (normal 14-18 g/dl), white cell count of 27.5 x 109/L (normal 5-11 x 109/L), platelet count 54 x 109/L (normal 150-450 x 109/L). His white cells show left shift, but no blast is seen. He has a PT of 21 second (normal 8.8-12.7 second), aPTT of 90 second (normal 23-29 second), and a fibrinogen of 65 mg/dl (normal 180-350 mg/dL). An abdomen CT examination reveals extraluminal gas and suspected extraluminal feces. His blood pressure is 80/50 mm Hg 3 hours after initiation of fluid resuscitation. What is likely causing his presentations?
A. Allergic reaction
B. Congenital heart disease
C. Internal hemorrhage
D. Primary immunodeficiency
E. Ruptured internal organ
7. A 56-year-old man presented with fever, chills and lower abdominal pain for 2 days. He has a history of hypertension, type 2 diabetes, and hyperlipidemia. He drinks beer occasionally but does not drink other alcohol beverage. He does not smoke cigarette. On physical examination, he appears to have acute stress and confused. He has a temperature of 39.6°C, blood pressure of 75/50 mm Hg, a heart rate of 125 beats per minute and respiratory rate of 25/min. His skin is warm and dry with focal cyanosis. His heart and breath sounds are normal. The abdomen was diffusely tense and distended. His CBC reveals a hemoglobin of 13.5 g/dl (normal 14-18 g/dl), white cell count of 27.5 x 109/L (normal 5-11 x 109/L), platelet count 54 x 109/L (normal 150-450 x 109/L). His white cells show left shift, but no blast is seen. He has a PT of 21 second (normal 8.8-12.7 second), aPTT of 90 second (normal 23-29 second), and a fibrinogen of 65 mg/dl (normal 180-350 mg/dL). An abdomen CT examination reveals extraluminal gas and suspected extraluminal feces. His blood pressure is 80/50 mm Hg 3 hours after initiation of fluid resuscitation. What additional lab test result is likely to be elevated?
A. Arterial oxygen
B. Blood pH
C. Factor VIII
D. Serum lactate
E. Urine sodium concentration
8. Use this case for the next 3 questions. A 29-year-old man presents with high-grade fever with chills and vomiting for 7 days, and purple skin rash over the abdomen and trunk for the last 2 days. His medical and family histories are unremarkable. On physical examination, his appears to be acutely ill with focal cyanosis at lips. He has a temperature of 38.8 °C, a pulse rate of 120/min and systolic BP of 70 mm Hg. Neurological examination reveals positive Kernig and Brudzinski signs. Reddish to brownish rashes and petechia were seen over the whole of the body, but it was predominantly over the abdomen and trunk. His CBC reveals a hemoglobin of 14.5 g/dl (normal 14-18 g/dl), white cell count of 15.5 x 109/L (normal 5-11 x 109/L), platelet count 104 x 109/L (normal 150-450 x 109/L). His white cells has left shift, but no blast is seen. His blood chemistry tests were within normal ranges, except for a sodium of 130 mmol/L (136–145 mmol/L), and a glucose of 55 mg/dL (70–100 mg/dL). He has a PT of 28 second (normal 8.8-12.7 second) and aPTT of 130 second (normal 23-29 second). What additional lab test result is likely to be elevated?
A. ACTH
B. Aldosterone
C. Fibrinogen
D. Glucocorticoid
E. Insulin
9. A 29-year-old man presents with high-grade fever with chills and vomiting for 7 days, and purple skin rash over the abdomen and trunk for the last 2 days. His medical and family histories are unremarkable. On physical examination, his appears to be acutely ill with focal cyanosis at lips. He has a temperature of 38.8 °C, a pulse rate of 120/min and systolic BP of 70 mm Hg. Neurological examination reveals positive Kernig and Brudzinski signs. Reddish to brownish rashes and petechia were seen over the whole of the body, but it was predominantly over the abdomen and trunk. His CBC reveals a hemoglobin of 14.5 g/dl (normal 14-18 g/dl), white cell count of 15.5 x 109/L (normal 5-11 x 109/L), platelet count 104 x 109/L (normal 150-450 x 109/L). His white cells has left shift, but no blast is seen. His blood chemistry tests were within normal ranges, except for a sodium of 130 mmol/L (136–145 mmol/L), and a glucose of 55 mg/dL (70–100 mg/dL). He has a PT of 28 second (normal 8.8-12.7 second) and aPTT of 130 second (normal 23-29 second). What additional exam is likely to confirm the diagnosis?
A. Abdominal CT
B. Blood flow cytometry
C. Bone marrow biopsy
D. Echocardiography
E. Right heart catheterization
10. A 29-year-old man presents with high-grade fever with chills and vomiting for 7 days, and purple skin rash over the abdomen and trunk for the last 2 days. His medical and family histories are unremarkable. On physical examination, his appears to be acutely ill with focal cyanosis at lips. He has a temperature of 38.8 °C, a pulse rate of 120/min and systolic BP of 70 mm Hg. Neurological examination reveals positive Kernig and Brudzinski signs. Reddish to brownish rashes and petechia were seen over the whole of the body, but it was predominantly over the abdomen and trunk. His CBC reveals a hemoglobin of 14.5 g/dl (normal 14-18 g/dl), white cell count of 15.5 x 109/L (normal 5-11 x 109/L), platelet count 104 x 109/L (normal 150-450 x 109/L). His white cells has left shift, but no blast is seen. His blood chemistry tests were within normal ranges, except for a sodium of 130 mmol/L (136–145 mmol/L), and a glucose of 55 mg/dL (70–100 mg/dL). He has a PT of 28 second (normal 8.8-12.7 second) and aPTT of 130 second (normal 23-29 second). What is likely the diagnosis?
A. Acute myelocytic leukemia
B. Insulinoma
C. Pulmonary embolism
D. Vitamin K deficiency
E. Waterhouse–Friderichsen Syndrome
11. Use this case for the next 4 questions. A 9-year-old girl presents with shortness of breath and being dizzy for 2 hours. She was playing in the yard and was stung by a bug. Initially she had localized pain and swelling but shortly she felt dizzy, and shortness of breath developed. Her past medical history is unremarkable. She had a temperature of 37.6°C, blood pressure of 70/45 mm Hg (90/60 mm Hg minimal), a heart rate of 125 beats per minute (normal 70-110 bpm) and respiratory rate of 35/min. Mild respiratory distress is noted. She appears drowsy and pale. Her heart sounds are normal. Mild wheezing is noted in both lung fields. The sting site at her left lower leg appears to be slightly swollen with erythematous changes. What additional test is likely to confirm the diagnosis?
A. Blood culture
B. Chest X-Ray
C. Echocardiography
D. EKG
E. Plasma tryptase
F. Urine sodium concentration
12. A 9-year-old girl presents with shortness of breath and being dizzy for 2 hours. She was playing in the yard and was stung by a bug. Initially she had localized pain and swelling but shortly she felt dizzy, and shortness of breath developed. Her past medical history is unremarkable. She had a temperature of 37.6°C, blood pressure of 70/45 mm Hg (90/60 mm Hg minimal), a heart rate of 125 beats per minute (normal 70-110 bpm) and respiratory rate of 35/min. Mild respiratory distress is noted. She appears drowsy and pale. Her heart sounds are normal. Mild wheezing is noted in both lung fields. The sting site at her left lower leg appears to be slightly swollen with erythematous changes. What treatment would most likely improve her condition?
A. Anti-histamine
B. Broad spectrum antibiotics
C. Intravenous fluid
D. Pericardial drainage
E. Restoration of coronary circulation
13. A 9-year-old girl presents with shortness of breath and being dizzy for 2 hours. She was playing in the yard and was stung by a bug. Initially she had localized pain and swelling but shortly she felt dizzy, and shortness of breath developed. Her past medical history is unremarkable. She had a temperature of 37.6°C, blood pressure of 70/45 mm Hg (90/60 mm Hg minimal), a heart rate of 125 beats per minute (normal 70-110 bpm) and respiratory rate of 35/min. Mild respiratory distress is noted. She appears drowsy and pale. Her heart sounds are normal. Mild wheezing is noted in both lung fields. The sting site at her left lower leg appears to be slightly swollen with erythematous changes. What is the most likely underlying cause of her presentations?
A. Activation of basophils
B. Bacterial endotoxin
C. Diffuse endothelial damage
D. Massive hemorrhage
E. Pericardial tamponade
14. A 9-year-old girl presents with shortness of breath and being dizzy for 2 hours. She was playing in the yard and was stung by a bug. Initially she had localized pain and swelling but shortly she felt dizzy, and shortness of breath developed. Her past medical history is unremarkable. She had a temperature of 37.6°C, blood pressure of 70/45 mm Hg (90/60 mm Hg minimal), a heart rate of 125 beats per minute (normal 70-110 bpm) and respiratory rate of 35/min. Mild respiratory distress is noted. She appears drowsy and pale. Her heart sounds are normal. Mild wheezing is noted in both lung fields. The sting site at her left lower leg appears to be slightly swollen with erythematous changes. What is most likely the diagnosis?
A. Anaphylactic shock
B. Cardiogenic shock
C. Hypovolemic shock
D. Sepsis
E. Tension pneumothorax
15. Use this case for the next 4 questions. A 79-year-old woman presents with nausea, vomiting and chest discomfort and shortness of breath for 2 hours. She has a long history of atrial fibrillation and is currently being treated with warfarin. Her past history is otherwise unremarkable. She is afebrile with a heart rate of 130 beats per minute, and a blood pressure of 70/45 mmHg. Her oxygen saturation was 90% on 4 l/min via nasal cannula. She is in respiratory distress with a respiratory rate of 30 per minute. No petechia nor edematous changes are noted on her skin. Auscultation of the chest reveals diffuse bilateral crackles. The cardiac examination revealed an irregular rhythm without murmurs. Electrocardiogram demonstrated ST elevations in leads I and aVL and ST depressions in leads II, III, aVF, V5, and V6. What exam is likely to confirm the diagnosis?
A. Blood culture
B. Chest X-ray
C. Coronary angiography
D. Plasma tryptase
E. Urine sodium concentration
16. A 79-year-old woman presents with nausea, vomiting and chest discomfort and shortness of breath for 2 hours. She has a long history of atrial fibrillation and is currently being treated with warfarin. Her past history is otherwise unremarkable. She is afebrile with a heart rate of 130 beats per minute, and a blood pressure of 70/45 mmHg. Her oxygen saturation was 90% on 4 l/min via nasal cannula. She is in respiratory distress with a respiratory rate of 30 per minute. No petechia nor edematous changes are noted on her skin. Auscultation of the chest reveals diffuse bilateral crackles. The cardiac examination revealed an irregular rhythm without murmurs. Electrocardiogram demonstrated ST elevations in leads I and aVL and ST depressions in leads II, III, aVF, V5, and V6. What additional lab test result is most likely to be elevated?
A. ACTH
B. Blood lactate
C. Leucocyte count
D. Plasma histamine
E. Serum potassium
17. A 79-year-old woman presents with nausea, vomiting and chest discomfort and shortness of breath for 2 hours. She has a long history of atrial fibrillation and is currently being treated with warfarin. Her past history is otherwise unremarkable. She is afebrile with a heart rate of 130 beats per minute, and a blood pressure of 70/45 mmHg. Her oxygen saturation was 90% on 4 l/min via nasal cannula. She is in respiratory distress with a respiratory rate of 30 per minute. No petechia nor edematous changes are noted on her skin. Auscultation of the chest reveals diffuse bilateral crackles. The cardiac examination revealed an irregular rhythm without murmurs. Electrocardiogram demonstrated ST elevations in leads I and aVL and ST depressions in leads II, III, aVF, V5, and V6. What is most likely causing her low blood pressure?
A. Abnormal vascular dilation
B. Internal hemorrhage
C. Large vessel thrombosis
D. Non-hemorrhagic fluid loss
E. Ventricular dysfunction
18. A 79-year-old woman presents with nausea, vomiting and chest discomfort and shortness of breath for 2 hours. She has a long history of atrial fibrillation and is currently being treated with warfarin. Her past history is otherwise unremarkable. She is afebrile with a heart rate of 130 beats per minute, and a blood pressure of 70/45 mmHg. Her oxygen saturation was 90% on 4 l/min via nasal cannula. She is in respiratory distress with a respiratory rate of 30 per minute. No petechia nor edematous changes are noted on her skin. Auscultation of the chest reveals diffuse bilateral crackles. The cardiac examination revealed an irregular rhythm without murmurs. Electrocardiogram demonstrated ST elevations in leads I and aVL and ST depressions in leads II, III, aVF, V5, and V6. What is the diagnosis?
A. Anaphylactic shock
B. Cardiogenic shock
C. Hypovolemic shock
D. Obstructive shock
E. Septic shock
19. Use this case for the next 4 questions. A 79-year-old man presents with dizziness and shortness of breath for one day. He denies history of coughing, fever, or chest pain. He has a history of type II diabetes for 20 years and deep vein thrombosis for 7 years. He does not smoke cigarette, or drink alcohol, and never used any illicit substance. He has a temperature of 100.1F, heart rate of 121 bpm, blood pressure of 70/40 mm Hg, and a respiratory rate of 31/minute. His skin is cool with focal cyanosis. Cardiopulmonary and abdominal examination were unremarkable. He has bilateral lower extremity edematous changes. His CBC results are within normal ranges. Blood tests reveals a creatinine of 3.5 mg/dL (normal 0.6-1.2 mg/dL) and BUN of 38 mg/dL (8-18 mg/dL). Other blood tests including glucose, HbA1c and lipid profiles are within normal ranges. His coagulation and liver function tests are within normal ranges. EKG is unremarkable. Chest CT reveals no evidence of pulmonary embolism. Sonography exam reveals bilateral femoral vein thrombosis. What additional exam would most likely identify the cause of his presentations?
A. Blood culture
B. Coronary angiography
C. Cardiac enzymes
D. Urine sodium concentration
E. Venography of inferior vena cava
20. A 79-year-old man presents with dizziness and shortness of breath for one day. He denies history of coughing, fever, or chest pain. He has a history of type II diabetes for 20 years and deep vein thrombosis for 7 years. He does not smoke cigarette, or drink alcohol, and never used any illicit substance. He has a temperature of 100.1F, heart rate of 121 bpm, blood pressure of 70/40 mm Hg, and a respiratory rate of 31/minute. His skin is cool with focal cyanosis. Cardiopulmonary and abdominal examination were unremarkable. He has bilateral lower extremity edematous changes. His CBC results are within normal ranges. Blood tests reveals a creatinine of 3.5 mg/dL (normal 0.6-1.2 mg/dL) and BUN of 38 mg/dL (8-18 mg/dL). Other blood tests including glucose, HbA1c and lipid profiles are within normal ranges. His coagulation and liver function tests are within normal ranges. EKG is unremarkable. Chest CT reveals no evidence of pulmonary embolism. Sonography exam reveals bilateral femoral vein thrombosis. Venography of inferior vena cava reveals near complete occlusion of distal inferior vena cava, and thrombosis in bilateral common and external iliac veins. What is most likely causing his low blood pressure?
A. Abnormal vascular dilation
B. Internal hemorrhage
C. Increased afterload
D. Reduced ventricular filling
E. Ventricular dysfunction
21. A 79-year-old man presents with dizziness and shortness of breath for one day. He denies history of coughing, fever, or chest pain. He has a history of type II diabetes for 20 years and deep vein thrombosis for 7 years. He does not smoke cigarette, or drink alcohol, and never used any illicit substance. He has a temperature of 100.1F, heart rate of 121 bpm, blood pressure of 70/40 mm Hg, and a respiratory rate of 31/minute. His skin is cool with focal cyanosis. Cardiopulmonary and abdominal examination were unremarkable. He has bilateral lower extremity edematous changes. His CBC results are within normal ranges. Blood tests reveals a creatinine of 3.5 mg/dL (normal 0.6-1.2 mg/dL) and BUN of 38 mg/dL (8-18 mg/dL). Other blood tests including glucose, HbA1c and lipid profiles are within normal ranges. His coagulation and liver function tests are within normal ranges. EKG is unremarkable. Chest CT reveals no evidence of pulmonary embolism. Sonography exam reveals bilateral femoral vein thrombosis. Venography of inferior vena cava reveals near complete occlusion of distal inferior vena cava, and thrombosis in bilateral common and external iliac veins. What is most likely causing his elevated BUN and creatinine?
A. Diabetic nephropathy
B. GI-tract bleeding
C. Glomerulonephritis
D. High-protein diet
E. Reduced kidney blood flow
22. A 79-year-old man presents with dizziness and shortness of breath for one day. He denies history of coughing, fever, or chest pain. He has a history of type II diabetes for 20 years and deep vein thrombosis for 7 years. He does not smoke cigarette, or drink alcohol, and never used any illicit substance. He has a temperature of 100.1F, heart rate of 121 bpm, blood pressure of 70/40 mm Hg, and a respiratory rate of 31/minute. His skin is cool with focal cyanosis. Cardiopulmonary and abdominal examination were unremarkable. He has bilateral lower extremity edematous changes. His CBC results are within normal ranges. Blood tests reveals a creatinine of 3.5 mg/dL (normal 0.6-1.2 mg/dL) and BUN of 38 mg/dL (8-18 mg/dL). Other blood tests including glucose, HbA1c and lipid profiles are within normal ranges. His coagulation and liver function tests are within normal ranges. EKG is unremarkable. Chest CT reveals no evidence of pulmonary embolism. Sonography exam reveals bilateral femoral vein thrombosis. Venography of inferior vena cava reveals near complete occlusion of distal inferior vena cava, and thrombosis in bilateral common and external iliac veins. What is most likely the diagnosis?
A. Anaphylactic shock
B. Cardiogenic shock
C. Hypovolemic shock
D. Obstructive shock
E. Septic shock
23. Use this case for the next 4 questions. A 39-year-old man presents with hematemesis and chest discomfort for 3 hours. He could not recall any specific inducing factors. He denies history of fever, diarrhea or abdominal pain. He has hepatitis B since age 5. His medical and social history is otherwise unremarkable. Upon physical examination, he appears to be alert. He has a heart rate of 131 bpm and a blood pressure of 80/45. His skin and conjunctiva are pale. His chest and abdomen examinations are unremarkable. His CBC reveals a hemoglobin 7.3 g/dL (normal 14-18 g/dl), white cell count of 13.2 x 109/L (normal 5-11 x 109/L), platelet count 314 x 109/L (normal 150-450 x 109/L). Additional laboratory test results include albumin 3.9 g/dL, total bilirubin 1.9 mg/dL, AST of 55 U/L (10-40 U/L) and ALT of 70 U/L (10-55 U/L). His renal function tests are within normal ranges. What exam would most likely confirm the cause of his presentations?
A. Blood culture
B. Coronary angiography
C. Chest X-ray
D. Plasma tryptase
E. Upper GI tract endoscopy
24. A 39-year-old man presents with hematemesis and chest discomfort for 3 hours. He could not recall any specific inducing factors. He denies history of fever, diarrhea or abdominal pain. He has hepatitis B since age 5. His medical and social history is otherwise unremarkable. Upon physical examination, he appears to be alert. He has a heart rate of 131 bpm and a blood pressure of 80/45. His skin and conjunctiva are pale. His chest and abdomen examinations are unremarkable. His CBC reveals a hemoglobin 7.3 g/dL (normal 14-18 g/dl), white cell count of 13.2 x 109/L (normal 5-11 x 109/L), platelet count 314 x 109/L (normal 150-450 x 109/L). Additional laboratory test results include albumin 3.9 g/dL, total bilirubin 1.9 mg/dL, AST of 55 U/L (10-40 U/L) and ALT of 70 U/L (10-55 U/L). His renal function tests are within normal ranges. What is the cause of his low blood pressure?
A. Abnormal vascular dilation
B. Increased afterload
C. Low circulation volume
D. Reduced ventricular filling
E. Ventricular dysfunction
25. A 39-year-old man presents with hematemesis and chest discomfort for 3 hours. He could not recall any specific inducing factors. He denies history of fever, diarrhea or abdominal pain. He has hepatitis B since age 5. His medical and social history is otherwise unremarkable. Upon physical examination, he appears to be alert. He has a heart rate of 131 bpm and a blood pressure of 80/45. His skin and conjunctiva are pale. His chest and abdomen examinations are unremarkable. His CBC reveals a hemoglobin 7.3 g/dL (normal 14-18 g/dl), white cell count of 13.2 x 109/L (normal 5-11 x 109/L), platelet count 314 x 109/L (normal 150-450 x 109/L). Additional laboratory test results include albumin 3.9 g/dL, total bilirubin 1.9 mg/dL, AST of 55 U/L (10-40 U/L) and ALT of 70 U/L (10-55 U/L). His renal function tests are within normal ranges. What additional exam result can be expected?
A. Elevated cardiac enzymes
B. Increased absolute eosinophilic count
C. Low urine sodium concentration
D. Pericardial fluid
E. Positive blood culture
26. A 39-year-old man presents with hematemesis and chest discomfort for 3 hours. He could not recall any specific inducing factors. He denies history of fever, diarrhea or abdominal pain. He has hepatitis B since age 5. His medical and social history is otherwise unremarkable. Upon physical examination, he appears to be alert. He has a heart rate of 131 bpm and a blood pressure of 80/45. His skin and conjunctiva are pale. His chest and abdomen examinations are unremarkable. His CBC reveals a hemoglobin 7.3 g/dL (normal 14-18 g/dl), white cell count of 13.2 x 109/L (normal 5-11 x 109/L), platelet count 314 x 109/L (normal 150-450 x 109/L). Additional laboratory test results include albumin 3.9 g/dL, total bilirubin 1.9 mg/dL, AST of 55 U/L (10-40 U/L) and ALT of 70 U/L (10-55 U/L). His renal function tests are within normal ranges. What is most likely the diagnosis?
A. Anaphylactic shock
B. Cardiogenic shock
C. Hypovolemic shock
D. Obstructive shock
E. Septic shock
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