Mr. Hammond, a 57-year-old African American male, presented to the emergency department with chest pain radiating down his left arm. His lipid panel showed high total cholesterol, LDL, triglycerides and low HDL. He was diagnosed with an acute inferior wall myocardial infarction.

1. CC: “I have been having terrible chest and arm pain for the
past 2 hours and I think I am having a heart attack.”
HPI: Mr. Hammond is a 57-year-old African American male
who presents to the Emergency Department with a chief
complaint of chest pain that radiates down his left arm. He
states that he started having pain several hours ago and says the
pain “it feels like an elephant is sitting on my chest”. He rates
the pain as 8/10. Nothing has made the pain better or worse. He
denies any previous episode of chest pain. Denies nausea,
dyspnea, or lightheadedness. He was given 0.4 mg
nitroglycerine tablet sublingual x 1 which decreased, but not
stopped the pain.
Lipid panel reveals Total Cholesterol 324 mg/dl, high density
lipoprotein (HDL) 31 mg/dl, Low Density Lipoprotein (LDL)
122 mg/dl, Triglycerides 402 mg/dl, Very Low-Density
Lipoprotein (VLDL) 54 mg/dl
His diagnosis is an acute inferior wall myocardial infarction.
1 of 2 Questions:
Why is HDL considered the “good” cholesterol?
2 points
QUESTION 2
CC: “I have been having terrible chest and arm pain for the

2. past 2 hours and I think I am having a heart attack.”
HPI: Mr. Hammond is a 57-year-old African American male
who presents to the Emergency Department with a chief
complaint of chest pain that radiates down his left arm. He
states that he started having pain several hours ago and says the
pain “it feels like an elephant is sitting on my chest”. He rates
the pain as 8/10. Nothing has made the pain better or worse. He
denies any previous episode of chest pain. Denies nausea,
dyspnea, or lightheadedness. He was given 0.4 mg
nitroglycerine tablet sublingual x 1 which decreased, but not
stopped the pain.
Lipid panel reveals Total Cholesterol 324 mg/dl, high density
lipoprotein (HDL) 31 mg/dl, Low Density Lipoprotein (LDL)
122 mg/dl, Triglycerides 402 mg/dl, Very Low-Density
Lipoprotein (VLDL) 54 mg/dl
His diagnosis is an acute inferior wall myocardial infarction.
2 of 2 Questions:
Explain the role inflammation has in the development of
atherosclerosis.
3 points
QUESTION 3
A 45-year-old woman with a history of systemic lupus
erythematosus (SLE) presents to the Emergency Room (ER)
with complaints of sharp retrosternal chest pain that worsens
with deep breathing or lying down. She reports a 3-day
history of low-grade fever, listlessness and says she feels

3. like she had the flu. Physical exam reveals tachycardia and a
pleural friction rub. She was diagnosed with acute pericarditis.
Question:
What does the Advanced Practice Registered Nurse (APRN)
recognize as the result of the pleural friction rub?
1 points
QUESTION 4
A 15-year-old adolescent male comes to the clinic with his
parents with a chief complaint of fever, nausea, vomiting,
poorly localized abdominal pain, arthralgias, and “swollen
lymph nodes”. States he has felt “lousy” for a couple weeks.
The fevers have been as high as 102 F. His parents thought
he had the flu and took him to an Urgent Care Center. He
was given Tamiflu® and sent home. He says the Tamiflu didn’t
seem to work. States had a slight sore throat a couple weeks
ago and attributed it to the flu. Physical exam revealed thin
young man who appears to be uncomfortable but not acutely
ill. Posterior pharynx reddened and tonsils 3+ without
exudate. + anterior and posterior cervical lymphadenopathy.
Tachycardic and a new onset 2/6 high-pitched, crescendo-
decrescendo systolic ejection murmur auscultated at the left
sternal border. Rapid strep +. The patient was diagnosed
with acute rheumatic heart disease (RHD).
Question:
Explain how a positive strep test has caused the patient’s
symptoms.

4. 1 points
QUESTION 5
The APRN sees a 74-year-old obese female patient who is 2
days post-op after undergoing left total hip replacement. The
patient has had severe post op nausea and vomiting and has
been unable to go to physical therapy. Her mucus
membranes are dry. The patient says she feels like the skin
on her left leg is too tight. Exam reveals a swollen, tense, and
red colored calf. The patient has a duplex ultrasound which
reveals the presence of a deep venous thrombosis (DVT).
Question:
Describe the factors that could have contributed to the
development of a DVT in this patient explain how each of the
factors could cause DVT.
1 points
QUESTION 6
A 45-year-old woman is 10 days status post partial small bowel
resection for Crohn Disease and has been recuperating at
home. She suddenly develops severe shortness of breath,
becomes weak, and her blood pressure drops to 80/40 mmHg
(previous readings ~130/80s mmHg). The pulse oximetry is
89% on room air. The APRN suspects the patient experienced a
massive pulmonary embolus.

5. Question:
Explain why a large pulmonary embolus interferes with
oxygenation.
1 points
QUESTION 7
A 45-year-old woman is 10 days status post partial small bowel
resection for Crohn Disease and has been recuperating at
home. She suddenly develops severe shortness of breath,
becomes weak, and her blood pressure drops to 80/40 mmHg
(previous readings ~130/80s mmHg). The pulse oximetry is
89% on room air. While waiting for the Emergency Medical
Service (EMS) to arrive, the APRN places EKG leads and
the EKG demonstrates right ventricular strain.
Question:
Explain why a large pulmonary embolism causes right
ventricular strain.
1 points
QUESTION 8
A 12-year-old girl is brought to the Emergency Room (ER) by
her mother with complaints of shortness of breath, wheezing,
tachypnea, tachycardia, and a non-productive cough. The
mother states they had just come from a fall festival where
the entire family enjoyed a hayride. The symptoms began
shortly after they left the festival but got better a couple

6. hours after they returned home. The symptoms began again
about 6 hours later and seem to be worse. The mother states
there is no history of allergies or frequent respiratory
infections. The child is up to date on all vaccinations. The
child was diagnosed with asthma. The nurse practitioner
explained to the mother that her child was exhibiting
symptoms of asthma, and probably had an early asthmatic
response and a late asthmatic response.
Question 1 of 2:
Explain early asthmatic responses and the cells responsible for
the responses.
2 points
QUESTION 9
A 12-year-old girl is brought to the Emergency Room (ER) by
her mother with complaints of shortness of breath, wheezing,
tachypnea, tachycardia, and a non-productive cough. The
mother states they had just come from a fall festival where
the entire family enjoyed a hayride. The symptoms began
shortly after they left the festival but got better a couple
hours after they returned home. The symptoms began again
about 6 hours later and seem to be worse. The mother states
there is no history of allergies or frequent respiratory
infections. The child is up to date on all vaccinations. The
child was diagnosed with asthma. The nurse practitioner
explained to the mother that her child was exhibiting
symptoms of asthma, and probably had an early asthmatic
response and a late asthmatic response.

7. Question 2 of 2:
Explain late asthmatic responses and the cells responsible for
the responses.
2 points
QUESTION 10
A 64-year-old man with a 40 pack/year history of cigarette
smoking has been diagnosed with emphysema. He asks the
APRN if this means he has COPD.
Question 1 of 2:
Explain the pathophysiology of emphysema and how it relates
to COPD
.
2 points
QUESTION 11
A 64-year-old man with a 40 pack/year history of cigarette
smoking has been diagnosed with emphysema. He asks the
APRN if this means he has COPD.
Question 2 of 2:
Explain the pathophysiology of chronic bronchitis and how it
relates to COPD.

8. 2 points
QUESTION 12
Mr. Jones is a 78-year-old gentleman who presents to the
clinic with a chief complaint of fever, chills and cough. He
also reports some dyspnea. He has a history of right sided
CVA, COPD, dyslipidemia, and HTN. Current medications
include atorvastatin 40 mg po qhs, lisinopril, and
fluticasone/salmeterol. He reports more use of his albuterol
rescue inhaler.
Vital signs Temp 101.8 F, pulse 108, respirations 21. PaO2 on
room air 86% and on O2 4 L nasal canula 94%. CMP WNL,
WBC 18.4. Physical exam reveals thin, anxious gentleman with
mild hemiparesis on left side due to CVA. HEENT WNL except
for diminished gag reflex and uneven elevation of the uvula,
CV-HR 108 RRR without murmurs, rubs, or click, no bruits.
Resp-coarse rhonchi throughout lung fields. CXR reveals
consolidation in right lower lobe. He was diagnosed with
community acquired pneumonia (CAP).
Question:
Patient was hypoxic as evidenced by the low PaO2. Explain the
pathologic processes that caused this patient’s hypoxemia.

9. 1 points
QUESTION 13
A 64-year-old woman with moderately severe COPD comes to
the pulmonary clinic for her quarterly checkup. The APRN
reviewing the chart notes that the patient has lost 5% of her
body weight since her last visit. The APRN questions the
patient and patient admits to not having much of an appetite
and she also admits to missing some meals because it “takes
too much work” to cook and consume dinner.
Question:
The APRN recognizes that COPD has a deleterious effect on
patients. Explain why patients with COPD are at risk for
malnutrition.
1 points