Summative Exam Questions with Correct answers 2023/2024 Latest Update

Summative Exam Questions with Correct answers 2023/2024 Latest Update Summative Exam Questions with Correct answers 2023/2024 Latest Update An 80-year-old man was treated for ventricular arrhythmias. He presents 1 month later with joint pain. He also has an unusual mask-like rash over his face and body. Discontinuation of drug therapy causes the symptoms to abate. What drug was most likely administered to this patient? 1 Tocainide 2 Quinidine 3 Procainamide 4 Phenytoin 5 Propranolol Correct Answer Procainamide - often prescribed for long-term control of arrhythmias. May cause lupus like SE. A 62-year-old woman with a long-standing history of hypertension presents with severe headache; it started this morning and is rapidly worsening. During the interview, she suddenly collapses. Your brief examination shows that she responds with extensor posturing on external stimuli. Her deep tendon reflexes are 3, and you elicit Babinski bilaterally. You also notice that her breathing has a peculiar pattern: deep inspiration with a pause at full inspiration, followed by a brief insufficient release and the end-inspiration pause. How do you best describe her respiratory pattern? Answer Choices 1 Cheyne-Stokes 2 Apneusis 3 Ataxic 4 Cluster 5 Central neurogenic hyperventilation Correct Answer Her breathing pattern is apneustic. Apneustic breathing pattern characterizes *deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release and the end-inspiration pause before expiration.* What is the mechanism of LMWH? Correct Answer Both unfractionated heparin and low molecular weight Heparin act by *forming a complex with antithrombin III.* A 5-day-old male infant has subtle, unusual facial features (i.e., a triangular face, hypertelorism, and down-slanting eyes). He also has a webbed neck and low-set ears. Suspecting a congenital disorder, you order a complete work-up, including a CBC, coagulation profile, cardiac evaluation, karyotyping, and mutation analysis. PTPN11 (protein-tyrosine phosphatase, nonreceptor-type 11) mutations are detected. Echocardiography detects a cardiac defect. What's most likely to be found on echo? Correct Answer This neonate most likely has Noonan syndrome (NS). Pulmonary stenosis is the most common cardiac defect in this condition. Noonan syndrome is a sporadic, or autosomal dominant, congenital disorder with typical phenotypical features that may not be visible to the casual onlooker. The most common facial features include hypertelorism and low-set, backward-rotated ears with a thick helix. The philtrum is deeply grooved in more than 90% of cases. Congenital cardiac defects, bleeding disorders, mental retardation, webbed neck, and a short stature are other features. A 35-year-old woman presents for follow-up. She has a 6-month past medical history of hypertension; it has responded poorly to lifestyle approaches. She denies using any medications; she does not smoke or use illicit drugs. Her review of systems is notable for muscular weakness, paresthesias, headaches, polyuria, and polydipsia. On physical exam, her blood pressure is 155/95 mm Hg. She has generalized muscular weakness that is measured in all 4 extremities. The remainder of her exam is unremarkable. Laboratory analysis reveals hypokalemia and a hemoglobin A1c level of 5.5. What dx test result is most likely? 1 Metabolic alkalosis 2 Low serum aldosterone to plasma renin activity ratio 3 Hyponatremia 4 Increased erythrocyte sedimentation rate 5 Hypoglycemia Correct Answer The correct response is metabolic alkalosis. This patient is demonstrating signs and symptoms consistent with primary hyperaldosteronism, which is most commonly caused by a unilateral adrenocortical adenoma (Conn's syndrome), but in a minority of patients, it is caused by adrenal hyperplasia. A 40-year-old man presents with atrial flutter with 2:1 atrioventricular (AV) conduction, giving him a pulse of 150 per minute, which is perfectly regular. His blood pressure is 70/40 mm Hg. He takes no medications regularly. You plan to provide him with urgent direct current cardioversion with conscious sedation. What would be an appropriate level of energy for cardioversion in order to restore sinus rhythm in this patient? 1. 10 Joules 2. 15 Joules 3. 50 Joules 4. 200 Joules 5. 300 Joules 6. 360 Joules Correct Answer Of all of the arrhythmias, both supraventricular and ventricular, atrial flutter is the easiest to cardiovert back to a regular sinus rhythm. Direct cardioversion is usually successful with low energy - 25 to 100 Joules. There is no need to apply especially high energies such as 200 Joules, 300 Joules, or 360 Joules as the initial energy for cardioversion in case of atrial flutter, as higher energies have a greater probability of causing burns or broken bones. On the other hand, 10 or 15 Joules is unlikely to result in a successful cardioversion. *50* A 48-year-old man is brought to the ER complaining of difficulty breathing, fatigue, and intermittent chest pain for the past month. On further questioning, he states that the breathing seems to worsen when lying down. On physical exam, you note elevated respiratory and heart rates and pale, sweaty skin. On auscultation, rales are noted as well as a 3rd heart sound. Which of the following is the most likely diagnosis? 1 Right Ventricular failure 2 Pulmonary Embolism 3 Mitral Valve Stenosis 4 Left Ventricular failure 5 Chronic Obstructive Pulmonary Disease (COPD) Correct Answer Left Ventricular failure The clinical picture is suggestive of left ventricular failure (LVF). Clinical presentation includes dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. The patient may also have hemoptysis, chest pain, fatigue, nocturia, and confusion. On physical exam, the patient may present with cold, pale sweaty skin, tachypnea and tachycardia, rales, and 3rd and 4th heart sounds. This is diagnostically different from right ventricular failure. Right ventricular failure (RVF) has a clinical picture of shortness of breath, pedal edema, and abdominal pain. On PE, RVF will present with a S3, jugular venous distention (JVD) and may have signs of LVF. A 41-year-old woman presents for follow-up regarding elevated blood pressure. This is her third visit to the office, and her blood pressure has been elevated on multiple readings at each visit. She has a history of eczema but is otherwise healthy. Labs reveal the following: WBC: 14.5 k/uL Hgb: 13.5 g/dL HCT: 41% PLT: 152 k/uL Na: 135 mmol/L K: 2.8 mmol/L Cl: 99 mmol/L CO2: 32 mmol/L BUN: 10 mmol/L Cr: 1.02 mmol/L What lab abnormality is most likely to be causing her secondary htn? Correct Answer *Hypokalemia is correct.* Patients with primary hypertension should not have abnormalities in serum electrolytes. The patient's hypokalemia suggests a secondary cause of hypertension. *The most common cause of secondary hypertension is renal artery stenosis caused by fibrosmuscular dysplasia.* If the adult is middle-aged, then the most common secondary cause of hypertension would be *aldosteronism and a highly recommended initial diagnostic test would be an aldosterone/renin ratio.* Age is incorrect. This patient is 41 years old. Secondary hypertension is more likely in patients under 30 years old or over 50 years old. Female gender is incorrect. Primary hypertension is more common in middle-aged males than middle-aged females. The gender distribution for secondary hypertension varies with the specific cause of secondary hypertension. Hypokalemia is the most suggestive risk factor of secondary hypertension in this patient. Eczema is incorrect. Eczema is not a risk factor for secondary hypertension Leukocytosis is incorrect. Leukocytosis is not associated with secondary hypertension. A 78-year-old man with known left-sided congestive heart failure presents with a complaint of cough, worsening dyspnea with exertion, and orthopnea. What is the most direct cause of his symptoms? 1. Tricuspid insufficiency 2. Left ventricular hypertrophy 3 .Decreased peripheral vascular resistance 4. Increased pulmonary venous pressure 5. Mucus plugging Correct Answer Increased pulmonary venous pressure In left-sided congestive heart failure, the predominant feature is *low cardiac output and elevated pulmonary venous pressure, resulting in dyspnea.* As dyspnea worsens, the patient will also begin to experience shortness of breath at rest, which is worsened in the supine position. Tricuspid function is not related to CHF. Peripheral vascular resistance typically increases in CHF, which is designed to help maintain perfusion to vital organs. Mucus plugging is not associated with CHF. A 58-year-old woman presents with a 3-month history of postprandial abdominal pain. This crampy pain occurs 30 minutes after eating, every time. Due to these symptoms, the patient has lost 30 pounds and is afraid to eat. Her past medical history includes hypertension treated with enalapril, coronary artery disease for which she has undergone a right coronary artery stent, and she underwent a carotid endarterectomy for symptomatic carotid stenosis. She has smoked 2 packs of cigarettes a day for 30 years. What is the best initial test for this patient? 1 Mesenteric angiogram 2 Mesenteric duplex ultrasound 3 Computerized tomography (CT) 4 Magnetic resonance angiography (MRA) 5 Computerized tomography angiography (CTA) Correct Answer The symptoms of chronic mesenteric ischemia have a typical presentation, including a cachectic, middle-aged patient with crampy abdominal pain after eating. The risk factors for chronic mesenteric ischemia are the same as those for atherosclerosis. Treatment aimed at restoration of mesenteric blood flow is required to restore blood supply, prevent bowel necrosis, and restore normal weight. *Mesenteric duplex ultrasound is an excellent screening test to detect chronic mesenteric ischemia;* however, angiography allows for confirmation of the diagnosis. Combined B-mode and color Doppler ultrasound analyze flow though the mesenteric arteries and identifies stenosis as an elevated velocity. Limiting factors include obesity and intestinal gas, which may obstruct the ability to obtain a good ultrasound image. A 73-year-old man with no significant past medical history presents with a 1-month history of light-headedness, dizziness, and near-faintness; it has been occurring in response to sitting up and standing from a supine position. He denies chest pain, palpitations, shortness of breath, cough, loss of consciousness, vision or speech changes, nausea or vomiting, numbness, tingling, paresthesias, and focal weakness. His physical exam is noteworthy for a drop of systolic blood pressure of 24 mm Hg from a supine to standing position. What test is most helpful in identifying the cause of this patient's symptoms? 1. Hemoglobin A1c 2. Tilt-table test 3. Cardiac enzymes 4. CT scan of the head 5. Urinalysis. Correct Answer The correct response is tilt-table test. This patient is presenting with signs and symptoms consistent with orthostatic hypotension. It is defined as a reduction in systolic blood pressure of at least 20 mm Hg or diastolic blood pressure of at least 10 mm Hg within 3 minutes of standing or head-up tilt on a tilt table. It is a manifestation of sympathetic vasoconstrictor (autonomic) failure. A 62-year-old woman presents with extreme fatigue and shortness of breath. The symptoms began about 24 hours ago and have progressively worsened within the last 4 hours. Vital signs on arrival are as follows: HR 90 beats per minute; BP 165/72 mm Hg; RR16/min; SpO2 98% on 4L/min supplemental oxygen by nasal cannula. 12-lead ECG demonstrates ST-segment elevation of 2 mm in leads V4-V6. In addition to an aspirin tablet, what medication would be most appropriate in the emergency management of this patient? 1. Dobutamine 2. Dopamine 3. Morphine 4. Nitroglycerin 5. Vasopressin Correct Answer Nitroglycerin The patient's presentation is consistent with acute myocardial infarction. Emergency department management of patients with acute coronary syndromes - which include acute myocardial infarction and unstable angina - should consist of supplemental oxygen to maintain SpO2 90%, oral aspirin 160-325 mg, and sublingual nitroglycerin unless contraindicated (for example, in the context of hypotension). A 48-year-old man with hypertension and coronary artery disease presents with protracted fever, fatigue, anorexia, weight loss, night sweats, and non-specific, non-radiating joint pains. These symptoms began insidiously following a routine dental cleaning, but they have progressed over the past 4 weeks. He denies any chills, myalgias, sore throat, palpitations, shortness of breath, pleurisy, cough, wheezing, abdominal pain, nausea, vomiting, diarrhea, peripheral edema, trauma, travel, insect bites, or sexual contact within the past year. His physical exam is remarkable for a fever of 101.3°F. His fundoscopic examination is notable for cytoid bodies and hemorrhages, while his oral mucosa displays conjunctival petechiae. There is a palpable purpuric skin rash of the lower extremities, reduced bilateral radial and ulnar pulsations, linear hemorrhages under the nails not reaching the nail margin, as well as tender, erythematous nodules occurring in the of the fingers. His cardiac exam demonstrates a soft, medium-pitched holosystolic murmur located at the apex with radiation to the axilla, while his foot exam reveals the findings in the attached image. A comparison to the patient's last physical exam reveals no abnormal physical exam findings. What pharmacotherapeutic agent is most appropriate for this patient? 1 Penicillin G 2 Rifampin 3 Linezolid 4 Doxycycline 5 Ampicillin Correct Answer This patient's presentation is most consistent with native valve endocarditis caused by Viridans group streptococci ( -hemolytic streptococci). These are a frequent cause of community-acquired native valve endocarditis. Viridans streptococci are normal residents of the oropharynx and easily gain access to the circulation after dental or gingival trauma. Adult native valve endocarditis caused by penicillin-susceptible S. viridans, S. bovis, and other streptococci should be treated with one of the following regimens: penicillin G at 12 - 18 million U/d IV by continuous pump or in 6 equally divided doses for 4 weeks, ceftriaxone at 2 g/d IV for 4 weeks, or penicillin G or ceftriaxone and gentamicin at 1 mg/kg (based on ideal body weight) every 8 hours for 2 weeks. The emergence of methicillin-resistant S. aureus (MRSA) and penicillin-resistant streptococci has led to a change in empiric treatment with liberal substitution of vancomycin in lieu of a penicillin antibiotic. A 75-year-old African-American man presents with a 5-month history of gradually progressive dyspnea that is especially pronounced when climbing stairs. He also has been noticing that his ankles and lower legs have "gotten larger" over roughly the same time period, which no longer allows him to fit into his sneakers. He denies fever, chills, chest pain, palpitations, cough, pleurisy, calf pain, abdominal complaints, sick contacts, or travel. His psychosocial history is noteworthy for chronic alcohol use. His physical exam reveals bibasilar rales, JVD of 5cm, an S3 gallop, a holosystolic murmur at the apex that radiates to the left axilla, and 2+ pitting edema to the level of the mid-calves bilaterally. A bedside echocardiogram was remarkable for biventricular enlargement. What additional physical exam finding would be expected in this patient? 1 Tachycardia 2 Fever 3 Asymmetric upper extremity blood pressures 4 Warm, moist skin 5 Acanthosis nigricans Correct Answer This patient's presentation is significant for dilated cardiomyopathy. Dilated cardiomyopathy occurs more often in African Americans than Caucasians, and it occurs in men more frequently than women. Often no cause can be identified, but chronic alcohol abuse, major catecholamine discharge, myocarditis, postpartum, and doxorubicin are frequent causes. Chronic tachycardia may also precipitate a dilated cardiomyopathy that may improve over time if rate control can be achieved. Amyloidosis, sarcoidosis, hemochromatosis, and diabetes may rarely present as dilated cardiomyopathies, as well as the more classic restrictive picture. A 62-year-old man has a 15-year history of hypertension, hyperlipidemia, myocardial infarction, and congestive heart failure. He presents with a 10-day history of shortness of breath. He finds it difficult to walk short distances due to shortness of breath. He also notes cough, orthopnea, nocturnal dyspnea, and generalized abdominal discomfort. He has been taking large doses of his furosemide without relief. He denies cough, fever, chills, diaphoresis, anxiety, chest pain, pleurisy, nausea, vomiting, diarrhea, rashes, lightheadedness, and syncope. On physical examination, the patient is acutely dyspneic at rest. He is afebrile, but tachypnic and diaphoretic. There is a diminished first heart sound, S3 gallop, laterally displaced PMI; the lungs have bibasilar rales. The abdominal exam reveals distension with hepatomegaly in the right upper quadrant. There is 2+ pitting edema of the lower extremities to the level of the mid-calf. What is the most likely expected diagnostic test result in this case? 1 Hyponatremia 2 Reduced BUN levels 3 Hyperchloremia 4 Hyperalbuminemia 5 Hyperkalemia Correct Answer his patient is experiencing an acute exacerbation of congestive heart failure. In cases of severe heart failure, prolonged, rigid sodium restriction, coupled with intensive diuretic therapy and the inability to excrete water, may lead to dilutional hyponatremia. This occurs because of a substantial expansion of extracellular and intravascular fluid volume and a normal or increased level of total body sodium. A 74-year-old man with a past medical history of diabetes mellitus, hypertension, and hyperlipidemia presents with severe chest pain and dyspnea. On examination, he is confused, agitated, pale, apprehensive, and diaphoretic. His pulse is weak and tachycardic, with a systolic blood pressure of 80 mmHg. He has a narrow pulse pressure, tachypnea, a weak apical impulse, significant jugular venous distention, and pulmonary crackles. Bedside electrocardiogram reveals ST-segment elevations in the anterior and septal leads, while a portable chest X-ray notes diffuse pulmonary congestion. What is the most appropriate step in the management of this patient? 1 Crystalloid infusion 2 Initiate intravenous β-Blocker therapy 3 Begin phenylephrine 4 Nitrates and morphine 5 Emergent percutaneous coronary intervention Correct Answer This patient's exhibits signs and symptoms of cardiogenic shock due to myocardial infarction with pulmonary edema. Treatment of cardiogenic shock includes general supportive measures of oxygen, aspirin, heparin, and "gentle" fluid challenges (250 cc) if there is no overt pulmonary edema. In cardiogenic shock, early revascularization with percutaneous coronary intervention (angioplasty) or coronary artery bypass graft is the treatment of choice. Survival from cardiogenic shock is highest with emergency coronary intervention, followed by intra-aortic balloon pump combined with thrombolytic therapy, and with thrombolytic therapy alone being least effective in reducing mortality. The greatest short-term benefit is reported in patients 75 years of age, those without previous MI, and those treated within 6 hours of symptom onset. A 32-year-old man with no significant past medical history presents to his primary care provider with a 2-month history of increased dyspnea upon exertion, which becomes apparent following walking 10 city blocks. He denies any other associated symptoms such as fever, chills, changes in weight, chest pain, abdominal pain, nausea, or vomiting. He further denies any history of cigarette smoking, occupational risk factors, sick contacts, or recent travel. His physical exam revealed normal vital signs and no distension of his jugular vein. However, there was a prominent right ventricular impulse along the lower-left sternal border associated with a palpable pulmonary artery and a midsystolic ejection murmur at the upper left sternal border that does not vary in intensity with respiration. There is a fixed split second heart sound. The remainder of his examination is normal. Following diagnostic testing, this patient was referred for surgical repair. What is the major long-term complication that requires monitoring following surgical repair? 1 Hypertension 2 Myocardial infarction 3 Mitral valve prolapse 4 Supraventricular arrhythmia 5. TIA Correct Answer This patient's presentation represents an atrial septal defect. The major long-term complication following surgical transcatheter device closure of ASD is the development of supraventricular arrhythmias, although the risk is lowered when the ASD is closed in childhood. The persistence of this risk despite relief of right-sided volume overload is thought to be related to incomplete atrial remodeling or due to the presence of the atriotomy scar. Longer follow-up is required to determine whether device closure alters the risk of atrial dysrhythmias. A 12-year-old presents with an injury of his left arm and leg. He states that he felt dizziness during the 2nd mile of the long distance run organized by the school. He fell and lost the consciousness for several seconds, but after that he felt "normal". His father has been diagnosed with Emery-Dreifuss muscular dystrophy type 1. On examination, you find a few superficial excoriations; there is also symmetric humero-peroneal weakness involving the biceps, triceps, and peroneal muscles. There is also atrophy and contractures of Achilles-heel, elbows, and posterior neck. After taking care of his injuries, what test should you order? 1 CK 2 LDH 3. EKG 4. EEG 5. CT Correct Answer Both family history and clinical presentation in this patient are consistent with Emery-Dreifuss muscular dystrophy. Cardiac disease in Emery-Dreifuss muscular dystrophy is nearly universal. It usually begins after the onset of weakness, and it manifests as syncope in the 2nd or 3rd decade of life; it can also be a cause of sudden cardiac death. Cardiac disease can take form of the bradycardia, atrial arrhythmias (including atrial fibrillation/flutter), AV conduction defect, or even atrial or ventricular cardiomyopathy. Pacemakers are often needed by the age of 30. Minimal follow up requirements in patients are annual cardiac assessment (ECG, Holter, echocardiography) and the monitoring of respiratory function. While doing rounds one morning, you come upon a 42-year-old man suspected of having an infective endocarditis and currently undergoing an extensive workup. Which of the following represents the most definitive diagnosis of Infective Endocarditis based on Modified Duke Criteria? 1. 1 positive blood culture with Staphylococcus aureus with Osler's nodes and Roth spots 2. 2 positive blood cultures with Streptococcus pneumoniae with cutaneous hemorrhages and glomerulonephritis 3. Evidence of endocardial vegetation on echocardiography with Osler's nodes 4. 2 positive blood cultures with Staphylococcus aureus and development of a new regurgitant murmur 5. Fever 100.4 degrees Fahrenheit (38 degrees Celsius) with evidence of endocardial vegetation on echocardiography and glomerulonephritis Correct Answer Clinical criteria is also known as the Modified Duke criteria and is widely utilized to establish the diagnosis of endocarditis. The criteria are classified as either Major criteria (two positive blood cultures for a microorganism that is typical to cause endocarditis; evident of endocardial involvement via an echocardiogram ((vegetation, abscess)); development of a new regurgitant murmur. Minor criteria include: vascular phenomena (skin hemorrhages, emboli, aneurysms, or pulmonary infarction), fever 100.4 degrees Fahrenheit (38 degrees Celsius), immunologic phenomenon (glomerulonephritis, Osler's nodes, Roth spots, rheumatoid factor), and positive blood cultures that do not meet the specifics of the major criteria. The correct answer is 2 positive blood cultures with Staphylococcus aureus and development of a new regurgitant murmur. Since two Major criteria are identified, a definitive diagnosis of infective endocarditis can be made with 80% accuracy. The presence of one major criterion and three minor criteria or even if there are five minor criteria listed can also qualify in this 80% accuracy diagnosis range. The diagnosis is possible but not highly likely to be infective endocarditis if the patient displays the following: one major and one minor criterion or three minor criterions are met. Any less than these should lead a healthcare provider to suspect a different diagnosis. Choice A only has one minor criterion; Choice B has one major and only two minor criteria; Choice C has only one major and one minor criterion and finally Choice D only has two minor criteria. A 4-year-old boy presents with poor weight gain, small size for his age, and dyspnea upon feeding. His mother notes that the child suffers from frequent upper respiratory tract infections. On physical exam, the child is underweight for his age. You note a precordial bulge, a prominent right ventricular cardiac impulse, and palpable pulmonary artery pulsations. You also find a widely split and fixed second heart sound as well as a mid-diastolic rumble at the left sternal border. What pharmacologic agent would be most appropriate in the medical management of this patient at this time? 1 Lasix (Furosemide) 2 Coumadin (Warfarin) 3 Procardia (Nifedipine) 4 Inderal (Propranolol) 5 Indocin (Indomethacin) Correct Answer The correct response is Lasix (Furosemide). This patient's manifestations suggest a diagnosis of an atrial septal defect (ASD). ASD with moderate-to-large left-to-right shunts result in increased right ventricular stroke volume across the pulmonary outflow tract, creating a crescendo-decrescendo systolic ejection murmur. This murmur is heard in the second intercostal space at the upper left sternal border. Patients with large left-to-right shunts often have a rumbling middiastolic murmur at the lower left sternal border because of increased flow across the tricuspid valve. Definitive therapy for ASD includes closure of the defect, which is achieved surgically or through interventional catheterization. No specific or definitive medical therapy is available; however, patients with significant volume overload or atrial arrhythmias may require specific drug therapy. For patients with large shunts and heart failure, diuretics, digoxin, and ACE inhibitors should be used before surgery. Which of the following complications is commonly associated with subarterial VSD? 1 Infective endocarditis 2 Pulmonary hypertension 3 Congestive cardiac failure 4 Cor pulmonale 5 Aortic insufficiency (AI) Correct Answer In subarterial VSD, the defect occurs in the outlet septum and is also known as the supracristal, conoseptal, or outlet VSD. It is referred to as subarterial VSD, as the aortic and pulmonary valves are in fibrous continuity with the outlet septum. Subarterial VSDs are commonly associated with aortic insufficiency. The VSDs that are complicated by AI are restrictive with high velocity shunting through the VSD. This creates a low-pressure zone, which impacts the adjacent aortic valve cusp, resulting in aortic valve prolapse (AVP), and subsequent AI. A 36-year-old woman presents with chronic dyspnea that is worse while lying prone. The patient reports progressive worsening of the symptoms. On physical examination, a heart murmur is detected upon cardiac auscultation, heard best with the bell over the apex. The murmur is a non-radiating, low-pitched diastolic rumble. A loud S1 and opening snap can also be heard in addition to an apical thrill and decreased pulse pressure. An EKG is done and shows an arrhythmia. What is the patient's most likely underlying condition? 1 Aortic regurgitation 2 Pulmonic stenosis 3 Mitral stenosis 4 Hypertrophic subaortic stenosis 5 Mitral valve prolapse Correct Answer This patient has mitral stenosis. Dyspnea and orthopnea are symptoms that can be seen with mitral stenosis. The murmur of mitral stenosis is heard best over the apex area with the bell. It is a non-radiating, low-pitched diastolic rumble. A loud S1 and opening snap is consistent with mitral stenosis. Atrial fibrillation can sometimes be seen because of dilation of the left atrium. Mitral stenosis most often occurs after an episode of rheumatic fever. A 52-year-old woman presents for a routine checkup. She has 2 children, and she attained menopause 1 year prior to presentation. Pap smears, mammogram, and DEXA bone scan are normal. She is a non-smoker. Her previous biennial checkups were always normal. Her BP is 142/96 mm Hg; pulse is 72 bpm. Her lab values are below. Fasting Blood sugar: 112 Post Prandial Blood sugar: 138 Total cholesterol: 190 LDL: 102 TSH: Normal levels What is the next best step in the management of this patient? 1 Reassurance 2 Thiazide 3 Diet and exercise 4 Statin 5 Metformin Correct Answer Diet and exercise is the correct answer. The patient has an elevated blood pressure and borderline blood sugar levels. Since all previous checkups have been normal, initiation of therapy at this stage is unwarranted. A 61-year-old male presents with a recent history of increased fatigue with mildly increased exertional dyspnea. Patient denies any significant past medical history but states that he had some heart problems as a child, though he was never clear as to what was the problem. On cardiac examination, you hear an early diastolic, soft decrescendo murmur with a high pitch quality, especially when patient is sitting and leaning forward. No thrill is felt. Based on this patient's presentation, you expect the patient to have... 1. Tricuspid stenosis 2 Aortic regurgitation 3 Mitral stenosis 4 Mitral valve prolapse 5 Pulmonic stenosis Correct Answer The correct answer is aortic regurgitation, as it presents as a soft, early diastolic, high-pitched murmur heard best when sitting and leaning forward. It is often a result of rheumatic heart disease, which may be inferred by the patient's history. A 42-year-old woman was diagnosed with deep vein thrombosis of the left leg 3 weeks ago, and therapy was initiated with heparin. History includes smoking and birth control pills for endometriosis several years ago. On exam lungs show a decrease in air entry bilaterally. Which of the following is most likely?? 1. Lupus anticoagulant 2 Oral contraceptive induced thrombosis 3 Trousseau's syndrome 4 Heparin induced thrombosis 5 Paroxysmal nocturnal hemoglobinuria (PNH) Correct Answer Trousseau's syndrome, or migratory thrombophlebitis, is a malignancy associated hypercoagulable state that is characterized by a recurrent thrombosis in a migratory pattern and involvement of superficial veins in unusual sites. It is generally associated with an occult neoplasm (50%), usually an adenocarcinoma. This patient has an extensive smoking history and possibly has an adenocarcinoma of the lung. Several mechanisms for enhanced thrombosis by tumor cells have been proposed: (1) release of a thromboplastic tissue factor, which activates the extrinsic clotting pathway (2) activated protein C resistance (3) tumor cell membranes causing direct activation of the platelets (4) tumor cells releasing a procoagulant, which activates factor X directly (5) the indirect effects on tissue factor, thrombomodulin, and other factors by cytokines derived or induced by tumor cells. Treatment is with heparin, since warfarin is ineffective, and is continued till the malignancy has been adequately eradicated. In order to test for orthostatic changes, blood pressure and pulse are measured with the patient first supine then standing. What are the criteria for a positive orthostatic change (going from supine to standing)? Correct Answer When an individual experiences a loss of blood volume, for whatever reason, he or she may become orthostatic. Causes include antihypertensive and other medications, severe dehydration or anemia, prolonged bedrest, and autonomic instability. When such a person has their blood pressure and pulse measured first in the supine position, then again while standing, both the systolic and diastolic blood pressure drop, and the pulse increases. In order to be considered significant, the systolic pressure should drop by at least 20 mm Hg, the diastolic pressure should drop by at least 10 mm Hg, and the pulse should increase by at least 20 beats per minute. A 32-year-old man with no significant past medical history presented with dyspnea, palpitations, feelings of anxiety, and dizziness, all of which occurred earlier in the morning following a brisk walk. He denied any prior episodes, illicit drug use, alcohol or cigarette use, skipping meals, or caffeine intake. He further denied fever, chills, chest pain, history of murmurs, cough, edema, rashes, syncope, headache, psychiatric, or focal neurological complaints. The physical examination demonstrated a fast, regular pulse with a constant-intensity first heart sound, but was otherwise normal. An EKG was performed, which revealed a short PR interval plus a slurred upstroke at the beginning of the QRS complex. What is the most likely mechanism responsible for this patient's presentation? 1. Conduction delay in the proximal part of the right or left branches 2. Pre-excitation occurring via an atrio-His bundle 3. Spontaneous ectopy from muscular sleeves of pulmonary veins 4. Early excitation due to accessory pathways between the atria and ventricles 5. Inappropriately enhanced automaticity of sinus node pacemaker cells Correct Answer Patients with Wolff-Parkinson-White syndrome have an additional aberrant muscular or nodal tissue connection (bundle of Kent) between the atria and ventricles. This conducts more rapidly than the slowly conducting AV node, and one ventricle is excited early. The manifestations of its activation merge with the normal QRS pattern, producing a short PR interval and a prolonged QRS deflection slurred on the upstroke, with a normal interval between the start of the P wave and the end of the QRS complex ("PJ interval"). The QRS complexes show an abnormal morphology with a width greater than the baseline QRS complex (often 0.11 second), with the characteristic initial slurring referred to as a delta wave. The paroxysmal atrial tachycardias seen in this syndrome often follow an atrial premature beat. This beat conducts normally down the AV node but spreads to the ventricular end of the aberrant bundle, and the impulse is transmitted retrograde to the atrium. A circus movement is thus established. Less commonly, an atrial premature beat finds the AV node refractory but reaches the ventricles via the bundle of Kent, setting up a circus movement in which the impulse passes from the ventricles to the atria via the AV node. What is not a common cause of aortic stenosis? 1 Rheumatic heart disease 2 Chronic intravenous drug abuse 3 Congenital bicuspid aortic valve 4 Monckeberg senile calcific changes 5 Age greater than 60 years Correct Answer Correct answer: Chronic intravenous drug abuse Explanation Intravenous drug abuse has not been described as a common cause of aortic stenosis. Common causes of aortic stenosis are: (1) Infants, children and adolescents (a) congenital aortic stenosis (b) congenital subvalvular aortic stenosis (c) congenital supraclavicular aortic stenosis (2) Young adults to middle age: (a) calcification and fibrosis of congenitally bicuspid aortic valve (b) rheumatic aortic stenosis (3) Middle aged to elderly (a) calcification of bicuspid valve (b) senile degenerative aortic stenosis (c) rheumatic aortic stenosis A 25-year-old woman with a history of a childhood murmur has chronic exertional dyspnea associated with intermittent chest pain, hemoptysis, and lightheadedness. She denies smoking, a history of travel, medication usage, fever, chills, cough, palpitations, abdominal pain, and peripheral edema. Her physical exam reveals central cyanosis, a right ventricular parasternal heave, JVD of 4 cm, and an accentuated P2 heart sound. A loud, harsh holosystolic murmur in the left third and fourth interspaces was present along the sternum, with a systolic thrill. An electrocardiogram noted right atrial enlargement, RVH, and right axis deviation. A bedside echocardiogram confirmed RVH, right atrial enlargement, and tricuspid regurgitation with a bidirectional ventricular shunt. What health maintenance recommendations should be made to this patient? 1. The patient should avoid using oral contraceptives. 2. This patient should avoid foods containing iron. 3. Daily use of aspirin is recommended. 4. Regular, strenuous aerobic exercise should be strongly encouraged. 5. Routine CBC, EKG, and echocardiograms should not be made available. Correct Answer The patient should avoid using oral contraceptives. This patient's presentation and diagnostic testing most likely reveals Eisenmenger's syndrome with a ventricular septal defect. Eisenmenger syndrome is a general term applied to pulmonary hypertension and shunt reversal in the presence of a congenital defect, including VSD, ostium primum ASD, AV canal defect, aortopulmonary window, or PDA. In the Eisenmenger VSD patient, chronic hypoxemia in cyanotic CHD results in secondary erythrocytosis due to increased erythropoietin production. Normal white cell counts with normal to decreased platelet counts are typical. Patients with decompensated erythrocytosis fail to establish equilibrium with unstable, rising hematocrits, and recurrent hyperviscosity symptoms. Iron-deficiency occurs from erythrocytosis and may be exacerbated by phlebotomy. Progressive symptoms after recurrent phlebotomy in decompensated patients with Eisenmenger's syndrome are usually due to iron depletion with hypochromic microcytosis. Iron depletion results in a larger number of smaller (microcytic) hypochromic red cells that are less capable of carrying oxygen and less deformable in the microcirculation; as such, iron-depleted erythrocytosis results in increasing symptoms due to decreased oxygen delivery to the tissues. Thus, this patient will benefit from increased iron supplementation. Higher RBCs counts relative to plasma volume will increase viscosity versus an equivalent hematocrit with fewer, larger, iron-replete, deformable cells. Owing to the risk of clot formation and vascular thrombosis due to hyperviscosity, oral contraceptives are often contraindicated for cyanotic women. A 52-year-old patient, with a known case of renovascular hypertension, presents in the with poorly-controlled hypertension. He has been treated with both enalapril and nifedipine. He had been diagnosed with unilateral left renal artery stenosis, but recent tests have demonstrated mild changes in the right renal artery also. What should be the next step in management? 1 Diuretics 2 Reduction of NaCl consumption 3 Percutaneous transluminal angioplasty 4 Add atorvastatin and observe 5 Left nephrectomy Correct Answer The correct choice would be percutaneous transluminal angioplasty because the patient is already on 2 antihypertensives, yet his hypertension is poorly controlled. Also, he is gradually developing bilateral renal artery stenosis. This will probably worsen his hypertension. If there are no contraindications for a surgical repair of the arteriosclerotic artery, it is the preferred course of action. It cures the hypertension without the need for medication. Percutaneous transluminal angioplasty is the procedure of choice in symptomatic stenosis. Additional stenting can also be done. This procedure has shown 90% success rates. A patient is presenting with substernal crushing chest pain and shortness of breath for just 15 minutes prior to arriving to the emergency department. An EKG is obtained and appears suspicious for an acute myocardial infarction. What would most likely be seen in this patient's EKG? 1 S-T segment depression 2 T-wave changes 3 Ventricular bigeminy 4 Q-wave elongation 5 Hyperacute T-wave Correct Answer The earliest presentation of an acute myocardial infarction is the hyperacute T wave. If found, this is treated the same as an ST segment elevation type of infarction (STEMI). The hyperacute T wave is considered very rare in clinical practice, as it only exists for 2-30 minutes after the onset of an infarction. Hyperacute T waves must also be distinguished from the characteristic peaked T waves, which commonly are seen with hyperkalemia. A patient is presenting with substernal crushing chest pain and shortness of breath for just 15 minutes prior to arriving to the emergency department. An EKG is obtained and appears suspicious for an acute myocardial infarction. What would most likely be seen in this patient's EKG? 1. S-T segment depression 2 T-wave changes 3 Ventricular bigeminy 4 Q-wave elongation 5 Hyperacute T-wave Correct Answer The earliest presentation of an acute myocardial infarction is the hyperacute T wave. If found, this is treated the same as an ST segment elevation type of infarction (STEMI). The hyperacute T wave is considered very rare in clinical practice, as it only exists for 2-30 minutes after the onset of an infarction. Hyperacute T waves must also be distinguished from the characteristic peaked T waves, which commonly are seen with hyperkalemia. A 68-year-old man with a past medical history of diabetes mellitus type II, hyperlipidemia, myocardial infarction 1 year ago, and congestive heart failure with left ventricular ejection fraction of 35% is rushed to his local emergency room by his wife after he collapsed and became unresponsive at their residence. He admitted to her that he had been experiencing severe chest pain and pressure, fatigue, palpitations, diaphoresis, and lightheadedness for several minutes prior to his collapse. His present medications include aspirin, atorvastatin, lisinopril, glipizide, and carvedilol. Upon physical exam, he is found to have a blood pressure of 60/palpable, is pulseless, and has gasping respirations. His troponin T level was found to be elevated at 0.2 ng/ml, and troponin I level elevated and measured to be 0.25 ng/ml. The admission ECG revealed bizarre, irregular, random waveform, no clearly identifiable QRS complexes or P waves, and a wandering baseline. Following appropriate stabilization, what is best next step for this patient? 1 Prophylactic lidocaine 2 Implanatable cardioverter-defibrillator (ICD) implantation 3 Long-term metoprolol use 4 Percutaneous coronary intervention (PCI) 5 Discontinue aspirin, atorvastatin, and lisinopril Correct Answer This patient has most likely experienced ventricular fibrillation (VF) due to a myocardial infarction. External electrical defibrillation remains the most successful treatment of VF. Patients with depressed left ventricular function at least 40 days post-STEMI are referred for insertion of an implantable cardioverter/defibrillator (ICD) if the LVEF is 30-40% and they are in NYHA class II-III or if the LVEF is 30-35% and they are in NYHA class I functional status. Patients with preserved left ventricular function (LVEF 40%) do not receive an ICD regardless of NYHA functional class. Cardiac electrophysiologists should be involved in the care of these patients. ICDs, which effectively provide early defibrillation, are used for patients at high risk for recurrent VF. Survivors of VF have a recurrence rate on the order of 20-25% per year, making ICD placement important in most patients. The annual VF rate in patients with these devices has been reduced from 25% to 1-2%. Studies indicate that patients with VF arrest who receive ICDs have improved long-term survival rates compared with those receiving only medications. However, patients with ICDs may also require oral antidysrhythmic therapy to minimize recurrent device activation. A 60-year-old man, following up after a recent myocardial infarction, presents with sharp inspiratory chest pain. Other than his recent myocardial infarction, his past medical history is significant for peptic ulcer and renal insufficiency. You suspect Dressler's syndrome after seeing diffuse ST elevations on an electrocardiogram. What is the most appropriate treatment for this patient? 1. Indomethacin 2 Ibuprofen 3 A corticosteroid taper 4 Hydrocodone 5 Diclofenac sodium Correct Answer Administering a corticosteroid taper in this patient is the safest option given his peptic ulcer history and renal insufficiency. A 60-year-old man presents to your outpatient clinic for work up after having a syncopal episode during a walk 2 days prior to presentation. He mentions generalized fatigue for several months as well as "just not feeling well". He describes a non-specific mild angina that has been coming and going for the last several months; however, he has not sought medical care. Exam reveals a harsh systolic ejection murmur that radiates to the neck and is louder when the patient leans forward. Lung auscultation is clear throughout. He has no peripheral edema or calf pain. You obtain an EKG, which reveals left ventricular hypertrophy; a chest X-ray shows cardiac enlargement with small bilateral pleural effusions. What is the most appropriate treatment plan for this patient? 1. Admit to the hospital in order to undergo further testing 2 Order an outpatient echocardiogram 3 Start the patient on anticoagulation therapy 4 Order a troponin, BNP, TSH, and chest CT; based on those result, you should decide if a referral to cardiology is necessary 5 Arrange for the patient to undergo a cardiac stress test Correct Answer The patient should be admitted to the hospital so that he might undergo further testing. The patients' history, exam, and diagnostics are consistent with a diagnosis of aortic stenosis. Due to the fact that the patient is symptomatic (syncope and angina) and there is diagnostic evidence of heart failure (pleural effusions, cardiomegaly, left ventricular hypertrophy), there is significant concern that this patient may deteriorate quickly. The best course of action at this time is hospital admission for continued diagnostic work up and treatment. A 55-year-old man presents with severe central chest pain. He is a farmer and describes the pain as tearing, saying it started suddenly and is radiating. He is only able to lie comfortably on his side. He denies any previous symptoms. He feels nauseous but has not vomited. He has no major illnesses and knows of none that run in his family. He does not use alcohol, tobacco, or illicit substances. He is allergic to sulfa drugs. On physical exam he appears to be in extreme pain, despite lying on his side. His temperature is 37.0°C, heart rate is 110 BPM, blood pressure is 180/105 mm Hg, and his respiratory rate is 20/min. Cardiac exam reveals normal S1 and S2 without rubs or gallop. The top of his internal jugular venous column is present at 2 to 3 cm above the sternal notch. Chest auscultation reveals no abnormalities. He has normal active bowel sounds tympanic to percussion. Extremity exam was normal and the lower motor and sensory function is intact. ECG shows left ventricular hypertrophy and chest X-ray shows widened mediastinum. Labs show: Hemoglobin 13.5 g/dL Leukocyte count 5,000 cells/dL Platelet count 190.000 cells/mL Urea 70 mg/dL Creatinine 2.5 mg/dL Sodium 139 mmol/dL Potassium 4.8 mmol/dL Calcium 8.9 mg/dL Bicarbonate 30 mEq/L Troponin T 0.03 Creatinine Kinase 150 IU What is the best test for diagnosing this patient's condition? 1 CT angiography 2 Magnetic resonance angiography (MRA) 3 Transesophageal echocardiography 4 Troponin 5 Chest X-ray Correct Answer This patient has an aortic dissection. Aortic dissections are more common in patients with hypertension, connective tissue disorders, congenital aortic stenosis or bicuspid aortic valve, and in those with first-degree relatives with history of thoracic dissections. Chest pain is the most common presenting symptom. The pain is usually sudden and severe and described as ripping or tearing. Magnetic resonance angiography (MRA) is currently the best test for the detection and assessment of an aortic dissection. It will produce a 3-D reconstruction of the aorta, allowing the physician to determine the location of the intimal tear, the involvement of branch vessels, and locate any secondary tears. It is a non-invasive test, does not require the use of iodinated contrast material, and can detect and quantify the degree of aortic insufficiency. A 72-year-old man with a past medical history of hyperlipidemia, inferior wall myocardial infarction 6 months ago, and congestive heart failure has presented to his local medical office with complaints of increased tiredness and fatigue upon ambulation over the past several weeks. He denies edema, syncope, lightheadedness, dizziness, chest pain, palpitations, cough, shortness of breath, abdominal pain, fever, or chills. An EKG was performed, which revealed a first degree AV block. What is the most likely physical exam finding expected in this patient? 1 Increased intensity of S1 heart sound 2 An irregular cardiac rhythm 3 Systolic murmur decreased with squatting 4 Delayed carotid upstrokes 5 Blowing apical diastolic murmur Correct Answer Blowing apical diastolic murmur This patient's EKG finding suggests a primary atrioventrucular heart block. First-degree AV block is the most common conduction disturbance and is characterized by a PR interval that is prolonged for greater than 0.2 seconds. In general, the PR interval is constant, and each atrial impulse is conducted to the ventricles; a regular cardiac rhythm is expected. First-degree AV block can be a normal variant in young or athletic individuals due to excessive vagal tone. It also occurs in elderly patients without underlying heart disease. It is also associated with myocarditis, mild digoxin toxicity, and inferior wall myocardial infarction secondary to AV nodal ischemia. The intensity of the first heart sound (S1) is decreased in patients with first-degree AV block. Patients with first-degree AV block may have a short, soft, blowing, diastolic murmur heard at the cardiac apex. This diastolic murmur is not caused by diastolic mitral regurgitation, because it reaches its peak before the onset of regurgitation. The diastolic murmur is thought to be related to antegrade flow through closing mitral valve leaflets that are stiffer than normal. A harsh, medium-pitched systolic murmur at the 3rd and 4th interspaces that is reduced with squatting and increased with strain from Valsalva or standing is consistent with a diagnosis of hypertrophic cardiomyopathy. Delayed carotid upstrokes characterized by a small and slow rise of amplitude suggests underlying aortic stenosis. A 20-year-old woman presents for counseling after being diagnosed as a carrier of Emery-Dreifuss muscular dystrophy. She manifests a mild form of the disease, with only contractures of the Achilles' heels and elbows. Both her brother and her father have been diagnosed with the disease. What test will help to change the course of the disease in this young woman? 1 Electrocardiography 2 Creatine kinase 3 Electromyography 4 Muscle biopsy 5 Antibodies to emerin Correct Answer An electrocardiogram (ECG) should be obtained in all Emery-Dreifuss muscular dystrophy patients, including female carriers. Conduction defects may occur even with minimal musculoskeletal and joint involvement. It is estimated that 10 - 20% of female carriers have atrial arrhythmias or conduction defects and need to be monitored with yearly ECG to try to prevent sudden cardiac death. Early ECG changes include low amplitude P waves and a prolonged PR interval that progress to bradycardia, absent P waves, irregular atrial rhythm, atrial fibrillation/flutter, AV-conduction defects, and a late cardiomyopathy. There is no electrical and mechanical activity of the atria; the myocardium, not the conduction system, is affected. No specific treatment for Emery-Dreifuss muscular dystrophy exists. Supportive care to preserve muscle activity and functional ability, as well as the treatment of cardiac and/or pulmonary complications, are currently the only options. Early pacemaker implantation can change the course of the disease. A 35-year-old woman presents with fatigue and yellowish coloration of her eyes and skin that started several weeks after noneventful implantation of the prosthetic mechanical heart valve. Physical examination reveals the presence of regurgitant murmur and subicterus. Laboratory results are: hemoglobin 7.0 g/dL; reticulocytes 21%; white blood cells 11,500/µL; platelets 80,000/µL; and undetected levels of haptoglobin. In lactate dehydrogenase, the direct and indirect bilirubin levels are all elevated (3,100 U/L, 2.1 and 1.2 mg/dL, respectively). Peripheral blood smear shows burr and helmet cells (schistocytes) and polychromasia. Both direct and indirect Coombs' tests are negative. You suspect microangiopathic hemolytic anemia. What is the next step in management?? 1. Hemoglobin electrophoresis 2 Glucose-6-phosphate dehydrogenase deficiency 3 Echocardiography 4 Hepatitis B panel 5 Direct agglutination test Correct Answer Anemia, reticulocytosis, and jaundice are the characteristics of hemolytic anemias. Red blood cells (RBC) survival is shortened; bone marrow increases erythroid production that results in the increased number of reticulocytes; and RBC breakdown manifests as increased unconjugated bilirubin and lactate dehydrogenase and decreased (undetectable) haptoglobin. Microangiopathic hemolytic anemia occurs when the red cell membrane is damaged in circulation, leading to intravascular hemolysis and the appearance of schistocytes (fragmented erythrocytes). Hemolytic anemia due to mechanical damage is seen with prosthetic mechanical heart valves. Your first and most important next step in the management of this patient will be to find out if there is a dysfunction of the prosthetic valve. Echocardiography will reveal the presence of significant leaking or valve dysfunction. Hemolytic anemias are generally caused by intrinsic (defects in erythrocytes membranes, enzyme systems, and hemoglobin; mostly hereditary) and extrinsic factors (immune and microangiopathic hemolytic anemias). Hemoglobin electrophoresis will be useful in the diagnosis of thalassemia or sickle cell anemia that is caused by intrinsic hemoglobin defect. Anemias in those disorders are usually hypochromic and microcytic. A 22-year-old woman presents with an 8-month history of amenorrhea. Further questioning elicits additional pertinent positives of backaches, headaches, hirsutism, and acne. Physical examination reveals a female patient with a moon-shaped facies, multiple purple striae, and significant central obesity (body mass index of 36). Considering the likely diagnosis, what other abnormality would be expected? 1 Hyperkalemia 2 Hypotension 3 Hypertension 4 Exophthalmos 5 Carotid bruit Correct Answer This patient likely is suffering from Cushing syndrome, which is also known as hypercortisolism. Consequences of excessive levels of circulating cortisol, no matter the etiology, will lead to signs and symptoms such as central obesity but thin extremities, a moon face, a buffalo hump, supraclavicular fat pads, protuberant abdomen, hirsutism; there may also be oligomenorrhea, amenorrhea, or in men, possible erectile dysfunction. Backaches, headaches, acne, purple striae, and impaired wound healing may also be found in these patients. The correct response is (secondary) hypertension; although secondary hypertension only accounts for 5 - 10% of all hypertension cases, Cushing's syndrome has been found to be a potential cause for these cases. Its main cause is via the mineralocorticoid effects of excess glucocorticoids. A 66-year-old man with a past medical history of myocardial infarction 2 years ago, angina pectoris, aortic regurgitation, congestive heart failure, atrial fibrillation, and chronic obstructive pulmonary disease is presently being monitored in the hospital status-post admission for chest pain 1 day ago. Myocardial infarction has been ruled out. An EKG performed upon admission revealed a prolonged Qt interval and significant Q waves in the anterior leads. A diagnostic echocardiogram confirms moderate aortic and mitral valve regurgitation and a left-ventricular ejection fraction of 30%. He denies any complaints upon bedside evaluation. His physical exam reveals a blood pressure of 105/70 mm Hg and tachycardia. Continuous bedside ECG monitoring notes wide, monomorphic QRS complexes with a heart rate of 160 beats per minute that spontaneously resolve within 20 seconds, reverting to the pattern identified upon admission. What antiarrhythmic agent is considered to be the pharmacologic treatment of choice in the management of this patient? 1 Lidocaine 2 Procainamide 3 Verapamil 4 Sotalol 5 Amiodarone Correct Answer The bedside electrocardiogram was remarkable for nonsustained, monomorphic ventricular tachycardia. The patient with hemodynamically stable VT in the setting of significant left ventricular dysfunction should be treated with intravenous amiodarone. When antiarrhythmic drug therapy is chosen to prevent recurrence or when VT is accompanied by hemodynamic instability, amiodarone is the treatment of choice. Patients in VT with hemodynamic compromise, congestive heart failure, chest pain, or ischemia should be treated promptly with DC cardioversion. A 27-year-old woman presents with a 3-day history of "sharp", diffuse chest pain. She states the pain is worse with movement and deep breathing. On examination, it is noted that the patient prefers to sit upright and lean forward; she states, "I feel better in this position". Vital signs include a BP of 126/72 mm Hg; HR is 82, RR is 18, O2 sat is 96% RA, and temp is 101.3? F. On exam, you appreciate a friction rub. What set of diagnostics should you order? CXR, EKG, ECHO, DDimer, and BHCG 2 CBC, BMP, BHCG, and EKG 3 CBC, BHCG, EKG, ECHO, and CXR 4 CXR, EKG, DDimer, and BHCG 5 CXR, CBC, BMP, BHCG, EKG, and ECHO Correct Answer The correct response is CXR, CBC, BMP, BHCG, EKG, and ECHO. This patient presents with acute pericarditis. Inflammation of the pericardium can occur as the result of an infectious source (including viruses, bacteria, TB, fungal, and parasitic sources), medications, systemic diseases (such as SLE), post MI (also known as Dressler's syndrome), uremia, or malignancy; there may also be no known cause.1 Pericarditis typically presents with substernal cheat pain that is aggravated by deep breathing and alleviated by leaning forward.1 The hallmark of pericarditis the finding of pericardial friction rub on exam.1 In addition to exam findings, patients with suspected pericarditis should undergo a CXR (may reveal cardiomegaly if a pericardial effusion is present), a CBC (often demonstrates leukocytosis), a BMP (to evaluate for uremia), a BHCG (necessary prior to imaging in a woman of childbearing age), EKG (may demonstrate diffuse ST segment elevation), and an ECHO (needed to evaluate for pericardial effusion and/or tamponade).1 A DDimer is not necessary in this patient; the possibility of a PE being the cause of her symptoms is low. Review of the patient's vital signs reveal a fever with a normal HR and O2 sat, making PE an unlikely cause. A 56-year-old man presents with a 1-week history of palpitations and shortness of breath. He has a long-standing history of poorly controlled hypertension. Physical examination reveals an elevated blood pressure of 190/98 mm Hg, elevated jugular venous pressure (JVP), mild hepatomegaly, bilateral pedal edema, and rales at the lung bases. Diagnostic studies reveal concentric left ventricular hypertrophy without significant valvular abnormalities on echocardiogram. What drug is beneficial in the treatment of the patient's condition by virtue of both afterload and preload reduction? 1. Loop diuretics (e.g., furosemide) 2. Angiotensin-converting enzyme inhibitor (e.g., enalapril) 3 Positive inotropic agents (e.g., digoxin) 4 Sodium channel blocker (e.g., procainamide) 5 Arterial vasodilators (e.g., hydralazine) Correct Answer Angiotensin-converting enzyme (ACE) inhibitors reduce both preload and afterload. The above signs and symptoms suggest a diagnosis of congestive heart failure (CHF), wherein the heart fails to adequately maintain the circulation of blood. The manifestations of CHF are cardiomegaly, elevated JVP, hepatomegaly, pedal edema, and pulmonary edema. The increased JVP, pedal edema, and hepatomegaly are due to the backflow pressure. The pulmonary edema is due to an imbalance between the mechanisms that keep the interstitium and alveoli dry and the opposing forces that are responsible for fluid transfer into the interstitium. Since the patient is having poorly controlled hypertension, 1 of the modalities of treatment in this patient is the administration of ACE inhibitors (e.g., enalapril). ACE inhibitors inhibit the conversion of angiotensin I to angiotensin II (AII) through ACE; this results in the favorable modification of the neurohormonal activation in heart failure. They cause favorable hemodynamic effects by causing peripheral vasodilatation, afterload, and blood pressure reduction. They also bring about reduction in the preload through the reduction of aldosterone, which in turn decreases sodium and fluid retention. A 52-year-old man is hospitalized due to an acute myocardial infarction. Cardiac enzymes are as follows: Myoglobin: Normal CK-MB: Elevated Troponin T: Elevated Troponin I: Elevated Given the above information, when did the patient's myocardial infarction most likely occur? 1. Within 2 hours of when the cardiac enzymes were drawn 2. Within 12 hours of when the cardiac enzymes were drawn 3. Within 2 days of when the cardiac enzymes were drawn 4. Within 5 days of when the cardiac enzymes were drawn 5. Within 10 days of when the cardiac enzymes were drawn Correct Answer Within 2 days of when the cardiac enzymes were drawn is the correct answer. The above patient has normal myoglobin with elevated CK-MB and troponins T and I. While myoglobin is a nonspecific marker for myocardial infarction, it typically appears within 1 - 4 hours of ischemia and normalizes by 1 day. CK-MB and troponins T and I all rise about 4 - 9 hours following myocardial infarction. CK-MB will normalize by 2 - 3 days, whereas the troponins take 1 - 2 weeks to normalize. Since the patient's myoglobin is negative, but his CK-MB is elevated, it suggests that the patient has had an acute myocardial infarction within the last 1 - 3 days. 'Within 2 days of when the cardiac enzymes were drawn' is the only answer that fits this window. A 70-year-old male presents with acute onset back pain for one hour. His past medical history includes coronary artery disease, for which he has undergone a coronary artery bypass grafting , 3 times, two years ago. He also has hypertension, and has smoked a pack of cigarettes per day for fifty years. His physical exam includes a BP of 80/76 mm Hg, pulse of 116/min, and has a palpable infraumbilical pulsatile abdominal mass with left lower quadrant fullness. What is the best diagnostic test to use in the diagnosis of this patient's condition? 1. Computed Tomography(CT) 2. Aortogram 3. Magnetic Resonance Imaging(MRI) 4. Venogram 5. Abdominal x-ray Correct Answer Computed Tomography(CT) Explanation This patient has a ruptured abdominal aortic aneurysm, which is defined as a localized dilation of the abdominal aorta greater than or equal to twice the normal diameter, with a disruption which allows blood outside the aortic wall. Abdominal aortic aneurysm is seen in 5-7% of people above age 60 years in the US. The incidence rises sharply after 55 years of age in men and 70 years of age in women. Men outnumber women by a ratio of approximately 4 to 1. Most abdominal aortic aneurysms encountered by primary care physicians are intact, asymptomatic, and found incidentally on routine physical examination, or in radiographic studies performed for other indications. Cigarette smoking, family history and hypertension are all risk factors for abdominal aortic aneurysms. Due to the high death rate from rupture (35-80%), elective surgical repair or implantation of