{"id":687,"date":"2023-03-29T01:38:00","date_gmt":"2023-03-29T01:38:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=687"},"modified":"2026-01-08T12:34:25","modified_gmt":"2026-01-08T20:34:25","slug":"usmle-step-1-question-of-the-day-left-heart-failure","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-left-heart-failure","title":{"rendered":"USMLE\u00ae Step 1 Question of the Day: Left heart failure"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-left-heart-failure\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_1_Question_is%E2%80%A6\" >The correct answer to today&#8217;s USMLE\u00ae Step 1 Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-left-heart-failure\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-left-heart-failure\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-left-heart-failure\/#Major_Takeaway\" >Major Takeaway<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-left-heart-failure\/#References\" >References<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><em><strong>This week, we&#8217;re sharing another USMLE\u00ae Step 1-style practice question about a 66-year-old person with shortness of breath with exertion. What&#8217;s the pathophysiology of this patient\u2019s pulmonary findings?<\/strong><\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A <strong>66-year-old nonbinary individual<\/strong> presents to the emergency department for evaluation of <strong>shortness of breath with exertion<\/strong>. The patient reports increasing shortness of breath over the <strong>past several weeks<\/strong> to the point where <strong>they can no longer climb a flight of stairs<\/strong> <strong>without becoming winded<\/strong>. Past medical history includes <strong>hypertension, hyperlipidemia, <\/strong>and <strong>deep vein thrombosis<\/strong> following a knee replacement surgery ten years ago. The <strong>patient has not seen a physician in years<\/strong> and is currently <strong>not on any medications<\/strong>. They currently <strong>smoke one pack of cigarettes daily<\/strong>. <strong>Temperature is 36.1\u00b0C (97.0\u00b0F), pulse is 78\/min, respirations are 22\/min, blood pressure is 188\/92 mmHg, <\/strong>and <strong>O2&nbsp;saturation is 91% on room air<\/strong>. Physical examination demonstrates an <strong>additional heart sound heard just after S2<\/strong>, and diffuse rales on <strong>lung auscultation<\/strong>. <strong>Jugular venous distension, pitting edema, <\/strong>and <strong>hepatomegaly<\/strong> are <strong>absent<\/strong>. A chest X-ray is obtained and demonstrated below. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Which of the following <em>best describes the pathophysiology<\/em> of this patient\u2019s <strong>pulmonary <\/strong>findings?<\/p>\n\n\n\n<figure class=\"wp-block-image aligncenter size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"458\" height=\"452\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/98.png\" alt=\"A chest x-ray\" class=\"wp-image-689\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/98.png 458w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/98.png?resize=300,296 300w\" sizes=\"auto, (max-width: 458px) 100vw, 458px\" \/><figcaption class=\"wp-element-caption\">Image reproduced from&nbsp;<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Pulmonary_oedema.jpg\" target=\"_blank\" rel=\"noreferrer noopener\">Wikimedia Commons<\/a><\/figcaption><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Increased pulmonary venous pressure<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Decreased pulmonary venous pressure<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Increased central venous pressure<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Decreased pulmonary capillary wedge pressure<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-left wp-block-paragraph\"><strong>E. Recurrent pulmonary embolism<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down to find the answer!<\/em><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_1_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s USMLE\u00ae Step 1 Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Increased pulmonary venous pressure<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Before we get to the <strong>Main Explanation<\/strong>, let&#8217;s look at the <strong>incorrect answer explanations<\/strong>. Skip to the bottom if you want to see the <strong>correct answer<\/strong> right away!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Decreased pulmonary venous pressure&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>\u00a0Increased, not decreased, <strong>pulmonary venous pressure<\/strong> likely underlies this patient\u2019s <strong>pulmonary findings<\/strong>. With <strong>left-sided heart failure<\/strong>, poor <strong>ejection fraction<\/strong> manifests with <strong>increased pulmonary capillary wedge pressure<\/strong>, <strong>increased pulmonary venous pressure<\/strong>, and subsequent <strong>transudation of fluid into the lung parenchyma<\/strong>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Increased central venous pressure&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:\u00a0Increased central venous pressure<\/strong> occurs in the setting of <strong>right heart failure<\/strong>. <strong>Right heart failure<\/strong> can manifest with <strong>pitting edema<\/strong>, <strong>hepatosplenomegaly<\/strong>, and <strong>jugular venous distension<\/strong>. In contrast, these findings are absent in this patient.\u00a0<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Decreased pulmonary capillary wedge pressure<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:\u00a0<\/strong>Increased, not decreased, <strong>pulmonary capillary wedge pressure<\/strong> leads to the development of <strong>pulmonary edema<\/strong>.\u00a0<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Recurrent pulmonary embolism<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:\u00a0<\/strong>While this patient has a history of a <strong>remote deep vein thrombosis<\/strong>, he has no evidence of <strong>right heart failure<\/strong> on examination. This patient\u2019s <strong>pulmonary findings<\/strong> are more likely secondary to <strong>left-sided heart failure<\/strong> and a <strong>different underlying etiology<\/strong>.\u00a0<br><a href=\"https:\/\/www.osmosis.org\/plans\/md\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><a href=\"https:\/\/www.osmosis.org\/plans\/md\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/08\/79.png?w=700\" alt=\"Osmosis ad\" class=\"wp-image-513\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/08\/79.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/08\/79.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This patient presents with <strong>clinical features consistent with left-heart failure<\/strong> including an <strong>S3 gallop<\/strong> and <strong>pulmonary edema<\/strong>. The <strong>primary pathophysiology underlying pulmonary edema secondary to left-sided heart failure<\/strong> is an <strong>increase in pulmonary venous pressure<\/strong> and subsequent <strong>transudation of fluid into the lung parenchyma<\/strong>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Left-sided heart failure<\/strong> refers to the <strong>anatomical failure of the left side of the heart<\/strong> only and presents with <strong>characteristic symptoms and examination findings<\/strong>. Notably, patients present with <strong>orthopnea<\/strong> (shortness of breath when lying supine), <strong>paroxysmal nocturnal dyspnea<\/strong> (breathless awakening from sleep), and <strong>pulmonary edema<\/strong>. The former two findings are largely due to <strong>increased venous return<\/strong> and <strong>redistribution of blood<\/strong> when lying flat, whereas <strong>pulmonary edema<\/strong> results from <strong>impaired forward arterial blood flow<\/strong> and <strong>vascular congestion<\/strong>.<\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"602\" height=\"432\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/99.png\" alt=\"HEART FAILURE \n\nLeft Heart Failure\nClinical Features:\n* Pulmonary edema causing dyspnea\n* Orthopnea (dyspnea when recumbent)\n* Paroxysmal nocturnal dyspnea (awakening with severe dyspnea)\n\nOther Findings:\n* Hemosiderin-laden macrophages (\u201cheart failure\u201d cells) in the lungs\n\nCommon Causes:\n* Ischemic heart disease\n* Systemic hypertension\n* Cardiomyopathy\n* Mitral or aortic valve disease\n\nRight Heart Failure\nClinical Features:\n* Hepatosplenomegaly\n* Jugular venous distention\n* Peripheral edema\n\nOther Findings:\n* Nutmeg liver\n\nCommon Causes:\n* Left heart failure*\n* Cor pulmonale\n\n  * Primary pulmonary hypertension\n  * Chronic obstructive pulmonary disease\n  * Recurrent pulmonary embolism\n  * Obstructive sleep apnea\n* Right ventricular infarction\n* Pulmonary or tricuspid valve disease\n\n*The most common cause of right heart failure is left heart failure.\" class=\"wp-image-691\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/99.png 602w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/99.png?resize=300,215 300w\" sizes=\"auto, (max-width: 602px) 100vw, 602px\" \/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Left-sided heart failure<\/strong> refers to <strong>dysfunction of the left heart<\/strong>. The condition results in <strong>clinical features including orthopnea, paroxysmal nocturnal dyspnea, and pulmonary edema.<\/strong>\u00a0<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Kumar, V., Abbas, A.K., Aster, J.C., Perkins, J.A., Robbins, S.L. (2018)\u00a0<em><strong>Robbins basic pathology (10th ed.)<\/strong><\/em>. Philadelphia, PA: Elsevier. ISBN: 978-0323353175.<\/li>\n\n\n\n<li>Luk, A., Ahn, E., Soor, G.S., Butany, J. (2009)\u00a0<em><strong>Dilated <\/strong><\/em><strong><em>cardiomyopathy: A review. Journal of Clinical Pathology<\/em>.<\/strong> 62(3), 219\u2010225. Doi:10.1136\/jcp.2008.060731.<\/li>\n\n\n\n<li>Veselka, J., Anavekar, N.S., Charron, P. (2017)\u00a0<em><strong>Hypertrophic obstructive cardiomyopathy.<\/strong><\/em>\u00a0Lancet. 389(10075), 1253-1267. Doi: 10.1016\/S0140-6736(16)31321-6.<\/li>\n\n\n\n<li>Yancy, C.W., Jessup, M., Bozkurt, B., et al. (2013)\u00a0<em><strong>2013 ACCF\/AHA guideline for the management of heart failure: A report of the American College of Cardiology Foundation\/American Heart Association Task Force on practice guidelines<\/strong>.<\/em>\u00a0Circulation. 62(16), e147-e239. Doi: 10.1161\/CIR.0b013e31829e8807.<br><a href=\"https:\/\/www.osmosis.org\/ultimate-guide\/usmle-step-1\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image size-large\"><a href=\"https:\/\/www.osmosis.org\/ultimate-guide\/usmle-step-1\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/usmle-step-1-everything-you-need-to-know-banner.png?w=700\" alt=\"Osmosis ad\" class=\"wp-image-615\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/usmle-step-1-everything-you-need-to-know-banner.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/usmle-step-1-everything-you-need-to-know-banner.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><figcaption class=\"wp-element-caption\"><em><sub>The United States Medical Licensing Examination (USMLE\u00ae) is a joint program of the Federation of State Medical Boards (FSMB\u00ae) and National Board of Medical Examiners (NBME\u00ae). Osmosis is not affiliated with NBME nor FSMB.&nbsp;<\/sub><\/em><\/figcaption><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em>Want more <strong>USMLE\u00ae Step 1<\/strong> practice questions? Try <strong>Osmosis from Elsevier<\/strong> today! Access your\u00a0<em><a href=\"https:\/\/www.osmosis.org\/plans\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>free trial<\/strong><\/a><\/em>\u00a0and find out why millions of <strong>current and future clinicians and caregivers<\/strong> love <strong>learning by Osmosis<\/strong>.<\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A patient with left heart failure presents with shortness of breath and an S3 gallop. Learn how increased pulmonary venous pressure causes pulmonary edema and related symptoms.<\/p>\n","protected":false},"author":202,"featured_media":688,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[27,20,1369,44],"tags":[195,2181,2182,2157,2175,2174,84,995,2177,2178,2173,2179,2176,2180,664],"class_list":["post-687","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-step-1-questions","category-step-1","tag-cardiology","tag-cardiovascular-pathology","tag-clinical-cardiology","tag-congestive-heart-failure","tag-heart-failure-symptoms","tag-left-heart-failure","tag-medical-education","tag-nclex-prep","tag-orthopnea","tag-paroxysmal-nocturnal-dyspnea","tag-pulmonary-edema","tag-pulmonary-findings","tag-pulmonary-venous-pressure","tag-s3-gallop","tag-usmle-step-1"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 1 Question of the Day: Left heart failure - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-left-heart-failure\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 1 Question of the Day: Left heart failure - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"A patient with left heart failure presents with shortness of breath and an S3 gallop. Learn how increased pulmonary venous pressure causes pulmonary edema and related symptoms.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-left-heart-failure\" \/>\n<meta property=\"og:site_name\" content=\"Osmosis Blog\" \/>\n<meta property=\"article:published_time\" content=\"2023-03-29T01:38:00+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2026-01-08T20:34:25+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/32.webp\" \/>\n\t<meta property=\"og:image:width\" content=\"1081\" \/>\n\t<meta property=\"og:image:height\" content=\"1080\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/webp\" \/>\n<meta name=\"author\" content=\"Marina Horiates Kerekes, MD &amp; Team\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":[\"Article\",\"BlogPosting\"],\"@id\":\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-left-heart-failure#article\",\"isPartOf\":{\"@id\":\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-left-heart-failure\"},\"author\":{\"name\":\"Marina Horiates Kerekes, MD &amp; 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