Pance review Cardiology and Pulmonology

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A two-week-old female is being evaluated, and on examination she is noted to have bounding pulses with a widened pulse pressure. There is a murmur present at the second left intercostal space, and it is described as a rough machinery murmur. Cyanosis is not present. What is the most likely diagnosis in this patient?

his patient is exhibiting signs of a patent ductus arteriosus. Atrial septal defects may not have a murmur associated with them early in the infant's life, but may develop four to six weeks after birth and present as a nonspecific systolic murmur. The signs and symptoms of coarctation of the aorta consist of decreased or absent femoral pulses, with a murmur present in the left axilla and the left back. Tetralogy of fallot presents with cyanosis, easy fatigability, dyspnea on exertion, and variable digital clubbing. Ventricular septal defect presents with a holosystolic murmur at the lower left sternal border and a right ventricular heave, but presentation depends on the size of the defect and the pulmonary vascular resistance. The patient with a ventricular septal defect may also present with features of heart failure, failure to thrive, and diaphoresis with feedings.

What is the treatment for a patient who has recurrent ventricular tachycardia with no reversible cause, and has failed oral medication therapy?

Patients with recurrent symptoms benefit from the implantation of a defibrillator, which will reduce sudden death. Ablation therapy is usually not indicated. In rare cases of patients who do not have any other underlying disease, cardiac transplantation is an option. Pacemakers are options if the underlying rhythm is in need of pacing.

An 18-year-old female presents to your office with the complaint of palpitations for the last 2 months. The episodes are frequent and accompanied with lightheadedness and shortness of breath. The patient's mother has taken her pulse when some of the episodes occur and states that the rate gets as high as 170 beats per minute. On exam, she is alert, awake, and oriented. Her resting pulse is 55 and her blood pressure is 122/65. Her lungs are clear throughout, and her cardiac exam revealed a regular rate and rhythm, without murmurs, rubs, or gallops. An ECG is obtained, as shown. Based on her history, physical exam, and ECG, what is the best pharmacologic treatment plan for this patient?

This patient is presenting with Wolff-Parkinson-White syndrome, as evidenced by the delta waves on the ECG. These conditions will generally occur in individuals at the onset of early adulthood. Management for this condition pharmacologically includes the use of class IA drugs, such as flecanide. Other choices include procainamide, sotalol, and amiodarone. Digoxin therapy may worsen and widen the QRS complex and place the patient into a ventricular tachycardia.

A 57-year-old man with a history of HTN, hyperlipidemia, and chronic tobacco use, presents to the office with complaints of chest tightness that occurs every time he begins raking leaves. If he stops and rests, it is relieved within 5 minutes. He has no associated nausea or diaphoresis, but does admit to associated dyspnea. Which of the following is the most appropriate next step in the management of this patient?

exercise nuclear stress testing, would provide information regarding exercise tolerance and exercise-induced dysrhythmias, as well as information regarding myocardial ischemia. Choice A, cardiac catheterization, would be utilized in patients diagnosed with acute myocardial infarction or after a stress test suspicious for myocardial ischemia. Choice C, Holter monitor, is a useful diagnostic tool for the evaluation of patients with palpitations occurring on a daily basis. Choice D, tilt table testing, is utilized in evaluation of patients suffering from near-syncope or syncope. Choice E, transesophageal echocardiogram, is helpful in more direct visualization of heart valves, especially when transthoracic echocardiogram is unclear. (Fauci et al., 2008, Chapter 238)

A 4-year-old male has been experiencing a significant cough for the last 12 to 14 days, and initial episodes of coughing are characterized as frequent outbursts of 5 to 10 spastic coughs in a row. The patient does not report any fever, but does note that the coughing is worse at night. On examination, the patient is alert, awake, and oriented. His temperature is 97.70F, pulse rate is 89, respiratory rate is 16, and blood pressure is 110/56. The HEENT is unremarkable, and lung sounds are clear to auscultation. You suspect that the patient may have an acute case of pertussis. Based on the history and physical exam findings, which is the test of choice for confirming a diagnosis of pertussis?

A special medium culture plate (such as a Bordet-Gengou agar) is required for the nasopharyngeal swab for the diagnosis of pertussis. Throat culture, chest x-rays, and complete blood counts are helpful in ruling out other disease patterns.

What is the peak incidence of age for a patient who presents with acute rheumatic heart disease?

The bulk of the cases of acute rheumatic fever are within the pediatric population. It is rare in younger children, as well as in adults over the age of 40.

Following emergent appendectomy, a 58-year-old obese male develops a temperature of 102.4˚F, 18 hours postoperatively. His respiratory rate is 26 and his pulse is 116bpm. A physical exam reveals scattered fine rales. What is the most likely diagnosis?

Pulmonary alveoli collapse, also known as atelectasis, occurs during operative procedures for a variety of reasons, including decreased clearance of secretions and decreased intra-alveolar pressure. Postoperatively, often due to pain, patients may not mobilize secretions appropriately, also contributing to atelectasis. Atelectasis is the most common postoperative pulmonary complication, and is often associated with emergent and prolonged surgeries, especially those of the thorax and abdomen. Atelectasis is associated with fever, an increased respiratory rate, an increased pulse, and lung exam findings ranging from normal to rales and decreased breath sounds. Symptoms usually present within the first 48 hours postoperatively. Pulmonary aspiration pneumonitis, although possible, is less likely due to appropriate preoperative and intraoperative measures being utilized to decrease risk. Pneumonia is also a common postoperative complication, due to the same contributing factors as atelectasis. Physical exam findings may also be similar. However, postoperative pneumonia is likely to become evident between 24 and 96 hours postoperatively.

A postoperative pleural effusion may form, due to free peritoneal fluid as well as a complication of atelectasis, but has a lower incidence of occurrence than atelectasis alone. Patient symptoms will be based upon the size of the effusion, associated inflammation, and whether or not the effusion is infectious. Consideration must be given to pulmonary emboli for any post-surgical patient with tachypnea, tachycardia, and dyspnea. Pulmonary emboli may occur at any point postoperatively, but atelectasis remains a more common cause of postoperative fever and respiratory changes.

A 57-year-old man with a history of HTN, hyperlipidemia, and chronic tobacco use presents to the office with complaints of worsening chest tightness over the last 2 months. He initially noticed that every time he raked leaves he had a few minutes of chest tightness, which was relieved within 5 minutes if he rested. He now notices that raking will precipitate severe chest discomfort, diaphoresis, and dyspnea, which lasts for 20 minutes even if he rests. Last night, while watching football, he again noticed chest tightness, which began suddenly and slowly dissipated over 15 minutes. His physical examination is normal. Which of the following is the most likely diagnosis?

Choice E, unstable angina pectoris, is based on clinical presentation, and requires chest or arm discomfort or an anginal equivalent, that either occurs at rest or with minimal activity lasting for at least 10 minutes, recent onset of severe chest discomfort, or anginal equivalent, and/or chest discomfort or anginal equivalent that has progressively been increasing in either severity, frequency, or duration. Choice A, pericarditis, would present with chest discomfort that is worse while supine and improves while sitting forward, as well as a pericardial friction rub. Choice B, acute myocardial infarction, requires troponin elevation to establish the diagnosis. Choice C, stable angina pectoris, is chest or arm discomfort that is reliably precipitated by activity and/or emotional distress, and relieved with rest or sublingual nitroglycerin. Choice D, prinzmetal angina, or variant angina pectoris, is defined as a coronary artery spasm associated with ST-segment elevation, usually occurring at rest and frequently at the same time of the day.

Which of the following is the most reliable clinical tool for confirming endotracheal intubation in an emergency situation?

Clinical assessments and practices used to assess tube placement, and help with placement, such as auscultating for breath sounds and noise within the stomach, have not had a confirmation rate comparable to directly visualizing the tube passing through the vocal cords. Tube condensation may occur with esophageal intubation as well. The Sellick maneuver may help with correct positioning, but is not a confirmatory test. Once placement is suspected, confirmation with an end-tidal CO2 detector and chest x-ray is recommended. Pulse oximetry measurement should be performed throughout the intubation, with decreased saturations representing a worsening clinical condition and/or esophageal intubation.

A 24-year-old man with a recent history of a viral illness comes to the emergency room complaining of severe left-sided chest discomfort, which radiates through to the left trapezius region. On coming into the room, you note that he is sitting up and hunched forward. On physical examination, the patient's temperature is 39°C, blood pressure is 135/78, with a pulse of 85 bpm, and a pericardial friction rub is noted. Laboratory findings demonstrate elevated serum creatine kinase levels and normal serial troponin levels. Which of the following would be the most likely electrocardiographic findings?

In a patient with these signs, symptoms, and lab findings, acute pericarditis is the most likely diagnosis. In patients with acute pericarditis, EKG changes occur secondary to inflammation of the subepicardium, leading to widespread elevation of the ST segments, often with upward concavity, which returns to normal after several days, followed by T wave inversion. No significant QRS complex changes are noted, so choice C, the development of inferior Q waves (frequently associated with an inferior myocardial infarction), is incorrect. Choice B is frequently noted with severe hyperkalemia. Loss of R-wave amplitude, choice D, is associated with myocardial infarction. Choice E, U waves, are associated with hypokalemia.

A 62-year-old African-American male is seen for his yearly physical exam. He has no complaints. He denies any current medications or medical problems, but the occupational medicine nurse has taken his blood pressure several times in the past year and told him it was high. He denies any tobacco or alcohol use. His blood pressure is 156/92 today. What is the most likely cause of his elevated blood pressure?

The most common cause of hypertension (HTN) is essential, also known as primary hypertension, making up about 95% of patients with hypertension. Secondary causes of hypertension are less common and include sleep apnea, primary aldosteronism, pheochromocytoma, and renal artery stenosis. There is no reason to suspect these other causes in this patient, who is otherwise healthy with stage 1 hypertension based on the stated history.

A 4-month-old male presents for a well child check. He is healthy and the mother feels that the child is eating and growing well. On examination, there is no evidence of cyanosis. The peripheral pulses are normal and equal. There is a medium-pitched harsh pansystolic murmur that is heard best at the left sternal border at the fourth intercostal space. There is no heave or thrill present. The murmur radiates over the entire precordium and the S2 is physiologically split. What is the most likely finding on ECG?

In this scenario the patient most likely has a small left-to-right shunt of a ventricular septal defect, given the clinical exam findings. The ECG is most frequently normal in a patient with a small ventricular septal defect. If the patient had a large left-to-right shunt left ventricular hypertrophy would be a possibility. The other choices are not commonly seen on ECG when a ventricular septal defect is present.

What is the recurrence rate of an individual with a pneumothorax?

The recurrence rate of 30% is usually either seen right after chest tube removal by observation or by obtaining serial chest radiographs. These recurrences can be observed immediately or by delay, sometimes several weeks to months after the initial event. Once corrected by surgery the recurrence is dramatically reduced.

A 24-year-old HIV-positive man comes to the emergency department complaining of severe left-sided chest discomfort, which radiates through to the left trapezius region. On coming into the room, you note that he is sitting up and hunched forward. On physical examination, the patient's blood pressure is 135/78, with a pulse of 85 bpm, and a pericardial friction rub is noted. Laboratory findings demonstrate elevated serum creatine kinase levels and normal serial troponin levels. His EKG demonstrates peaked T waves. His CXR demonstrates no acute process. Which of the following is the most likely diagnosis in this patient?

this patient is exhibiting signs, symptoms, and EKG findings pathognomonic for acute pericarditis, which is likely infectious in the setting of a patient with HIV. A pericardial friction rub is heard best with the patient in a seated position, during expiration, and is frequently found in patients with pericarditis. Choice B, an acute myocardial infarction, is less likely in a patient of this age, especially with normal serial troponins. Acute pericarditis can sometimes present with elevated serum creatine kinase levels when the epicardium is also involved. Choice C, acute bacterial endocarditis, is less likely in a patient with these EKG changes. Choice D, aortic dissection, would present with chest pain; however, the patient would be markedly hypotensive, less stable on presentation, and a CXR would demonstrate widening of the superior mediastinum.

A 62-year-old man with a history of hypertension, diabetes mellitus type 2, hyperlipidemia, and chronic tobacco use presents to the office with complaints of a retrosternal chest pressure, associated with diaphoresis, nausea, and dyspnea, radiating down his left arm for the last 45 minutes after mowing his lawn. The patient's vital signs are stable, and on physical examination a new systolic murmur is appreciated. His EKG demonstrates evidence of acute anterolateral myocardial infarction on EKG, with ST segment elevation across the precordial leads, indicative of left anterior descending coronary artery stenosis. Which of the following cardiac markers would be expected to remain elevated one week later?

Troponin elevation in acute myocardial infarction may be noted within two hours after myocardial infarction. It is usually elevated within 6 to 10 hours, peaks at 12 hours, and may remain elevated for 7 to 10 days; thus, choice B is the answer. Troponin elevation is rapidly replacing CK-MB as the diagnostic cardiac marker of choice for AMI. Choice A, CK-MB, peaks earlier than creatine kinase, and is cleared within two days. Choice C, BNP, is a cardiac marker followed in patients with congestive heart failure, and unless the patient develops heart failure in the next 7 days, is unlikely to be elevated. Creatine kinase becomes elevated within 4 to 8 hours, peaks within 12 to 24 hours, and returns to normal within 3 to 4 days. Serum myoglobin levels rise within 3 hours of symptoms and are elevated at 6 to 8 hours. Myoglobin peaks at 4 to 9 hours, and, with normal kidney function, returns to baseline within 24 hours.

A 63-year-old woman presents with shortness of breath, cough, and proximal muscle weakness of 1-month duration. On clinical exam, she is noted to have a blood pressure of 156/102 mm Hg, facial flushing, mild hirsutism, truncal obesity, marked proximal muscle weakness of both the upper and lower extremity, and hyperpigmentation over the palms and back of the neck. Laboratory exam reveals hypercortisolism and increased ACTH. Which of the following would be the most likely primary diagnosis in this patient?

Tumor cells may secrete hormones that have the same biologic actions as the normal hormone. This patient's symptoms are consistent with adrenocorticoid hyperfunction. The most common cause of ectopic ACTH syndrome is small cell lung carcinoma. This should be suspected in any patient with risk factors for lung cancer.

A 66-year-old man with a history of a cardiac murmur since childhood presents with complaints of increasing dyspnea while walking up one flight of stairs and increased lower extremity edema. On physical examination, a late-peaking crescendo-decrescendo murmur, preceded by a systolic ejection click, is noted. An S4 gallop is appreciated. Hepatomegaly and splenomegaly are appreciated. An EKG demonstrates right ventricular hypertrophy, and no acute ST or T wave changes. Which of the following is the most appropriate next diagnostic study?

transthoracic echocardiogram, is a simple, sensitive and non-invasive diagnostic tool, which can evaluate for the presence of valvulopathy. However, in patients with pulmonic stenosis, it offers limited direct visualization of the pulmonic valve, and although it is the most appropriate next diagnostic study it is usually followed by other diagnostic procedures, such as transesophageal echocardiogram, which offer better visualization of the pulmonic valve directly. Choice A might be able to give evidence of cardiomegaly, or calcification of heart valves, but would not be sensitive enough to detect the degree of valvulopathy if present. Choice C is a useful diagnostic tool for the evaluation of patients complaining of palpitations, but is incorrect for this patient who has no symptoms of palpitations. Choice D, although a useful diagnostic tool for the evaluation of exercise tolerance and in patients complaining of chest pain, does not allow direct visualization of the heart valves to evaluate the degree of pulmonic stenosis. Choice E, cardiac catheterization in patients demonstrating severe pulmonic stenosis, is not only diagnostic, but also therapeutic, as percutaneous balloon valvuloplasty is the preferred method of treatment for critical pulmonic stenosis.

A 78-year-old Caucasian female has a 3-year history of stiffness and achiness of bilateral shoulders and hips. She has been tested for rheumatoid arthritis in the past and has been found negative. Multiple radiographs of her hips and shoulders are unremarkable. She admits that she was placed on prednisone for an allergic reaction and noted a temporary resolution of her symptoms. For the past two weeks she complains of increasing symptoms now involving her neck and pain in her jaw with chewing. Today she noticed that her scalp is sore when she brushed her hair on the right side. What test is the gold standard for diagnosis of this patient's current symptoms?

This patient has long standing symptoms of polymyalgia rheumatica (PMR) with current symptoms suggestive of giant cell (temporal) arteritis. Temporal artery biopsy is considered the gold standard for diagnosis of giant cell (temporal) arteritis. Patients with temporal arteritis may have an elevated erythrocyte sedimentation rate (ESR) or CRP, but this is not required for diagnosis. A color ultrasound of the temporal artery will sometimes show edema or stenosis of the affected artery but is not very sensitive for giant cell arteritis. MRA is used for diagnosis of larger arteries with vasculitis and not routinely used in the diagnosis of temporal arteritis.

A 44-year-old female complains of nonproductive cough for the past 6 months. She denies rhinorrhea, wheezing, dyspnea, chest pain, or hemoptysis. Her medical problems include hypertension. Medications include benazepril 10 QD, Amlodipine 5 mg QD, and HCTZ 25 mg QD. She is a nonsmoker and denies any foreign travel.

ACE inhibitors such as benazepril have a potential adverse reaction of a chronic cough. Discontinuing the ACE inhibitor is appropriate in this case while substituting this for another antihypertensive. The CXR is normal and there are no findings suggestive of pneumonia, bronchiectasis, or asthmatic bronchitis. A chronic cough is not a significant side effect of amlodipine.

A 55-year-old woman with a history of emphysema, who is undergoing chemotherapy for lung cancer, is sent to see you by her oncologist regarding a sudden increase in dyspnea, with exertion and fatigue. On physical exam, a drop in systolic blood pressure of 20 mm Hg is noted upon inspiration. What is this physical exam finding known as?

Pulsus paradoxus is defined as a decrease in systolic arterial pressure of greater than 10 mmHg. It is an accentuation of the normal decrease in systolic arterial pressure of less then 10mm Hg that normally accompanies inspiration. It is frequently noted in patients with pericardial tamponade. Pulsus parvus means a small weak pulse. Pulsus alternans is noted in patients who despite a regular rhythm, demonstrate a regular alteration of the pressure pulse amplitude. This is frequently found in patients with severe left ventricular systolic dysfunction. A bisferiens pulse is a pulse with two systolic peaks, commonly seen in patients with aortic regurgitation or hypertrophic cardiomyopathy.

Two days following an uneventful 4-vessel CABG, a 57-year-old man develops a sudden onset of lightheadedness and palpitations. His vital signs are stable, and physical examination demonstrates no abnormalities. Given the results of his EKG, as shown (Figure 2), which of the following is the most appropriate next step in management?
A.
Direct-current cardioversion
B.
Nitroglycerin patch
C.
Digoxin 0.125 mg PO daily
D.
Neurology consult
E.
Meclizine 25 mg PO Q6H

Among the choices offered here, choice A is the most appropriate next step in management of a patient with new onset atrial flutter, as determined by EKG; it most effectively converts most patients to normal sinus rhythm. Choice B is inappropriate, as the patient is not demonstrating angina pectoris, and the EKG does not demonstrate evidence of ischemia or infarction. Choice C is inappropriate, as it is the least effective agent for slowing the ventricular response when compared to beta blockade or calcium channel blockers, all of which act by blocking the AV node (digixon may occasionally convert atrial flutter to atrial fibrillation). Choice D is inappropriate, as the patient's symptoms of lightheadedness do not stem from neurologic changes. Choice E is inappropriate, as the patient's symptoms do not stem from vertigo.

A 65-year-old recent alcoholic comes to the emergency department with recent onset of dyspnea with exertion, 3 pillow orthopnea, lower extremity edema, and palpitations, in which he describes his heart as racing. Which of the following is the most appropriate treatment for his high-output congestive heart failure?
A.
IV dextrose alone
B.
IV thiamine
C.
IV enalapril
D.
IV dopamine
E.
IV diltiazem

Choice B is the most appropriate treatment, as the patient is demonstrating high output congestive heart failure secondary to beriberi, or thiamine deficiency. In 50% of patients, IV thiamine administration, along with other vitamins and glucose, will resolve the patient's symptoms. Choice A, IV dextrose alone in patients with very low thiamine stores, can worsen signs and symptoms of heart failure. Choice C, IV enalapril, is appropriate therapy for patients in need of better blood pressure control, and as an ACE inhibitor, in patients with left ventricular systolic dysfunction, which is not the cause of this patient's heart failure. Choice D, IV dopamine, is useful in patients in need of pressor support, but will not help treat high-output heart failure secondary to thiamine deficiency. Choice E, IV diltiazem, is useful for heart rate control in patients with atrial fibrillation with a rapid ventricular rate.

Which of the following is the most prevalent cause of chronic respiratory acidosis?
A.
Anemia
B.
Cerebrovascular accident
C.
Chronic obstructive pulmonary disease
D.
High altitude
E.
Pneumonia

Respiratory acidosis is associated with elevated PaCO2 levels, due to the inability of elimination to keep pace with production. This may be due to a decreased rate of ventilation due to control alteration, decreased ventilatory muscle strength, underlying lung disease, or a systemic insult such as infection or medication. Chronic respiratory acidosis is generally due to underlying lung disease, with the most prevalent cause being chronic obstructive pulmonary disease (COPD). High altitude, pneumonia, and severe anemia are associated with respiratory alkalosis. Cerebrovascular accidents may be associated with either respiratory acidosis or alkalosis, depending on the location, extent, and impact.

A 28-year-old patient who is a fire department paramedic presents for a routine physical examination to your family practice office. They are asymptomatic but their PPD is positive. Suddenly, they relate that they have tested positive "about five years ago" and that they were treated at that time with nine months of INH. What should your next step be in treating them?

Health care workers (HCWs) with positive PPD test results should have a chest radiograph as part of the initial evaluation of their PPD test; if negative, repeat chest radiographs are not needed unless symptoms develop that could be attributed to TB. However, more frequent monitoring for symptoms of TB may be considered for recent converters and other PPD-positive HCWs who are at increased risk for developing active TB (e.g., HIV-infected or otherwise severely immunocompromised HCWs). Regardless of whether the patient completes treatment for latent TB infection, serial or repeat chest radiographs are not indicated unless the patient develops signs or symptoms suggestive of TB disease.

A 45-year-old male with asthma and diabetes is diagnosed with influenza B by nasal swab. He has been ill for one and a half days. Which of the following is indicated for treating this patient?
A.
Acyclovir
B.
Amantadine
C.
Nevirapine
D.
Oseltamivir
E.
Zanamivir

The neuraminidase inhibitors, including oseltamivir and zanamivir, are associated with a reduction in duration of illness, and secondary complications for both influenza A and B viral strains. However, zanamivir, due to the oral inhalation delivery route, is relatively contraindicated in this patient, due to his history of asthma and an associated increased risk of bronchospasm. Amantadine is inactive against influenza B, as well as certain influenza A strains. Nevirapine is an antiretroviral agent used in the treatment regimen for HIV. Acyclovir is an antiviral agent, but is not indicated for influenza.

A 29-year-old female has a long history of supraventricular tachycardia, for which she has been treated with long-term flecanide, as well as prior therapy with verapamil. She continues to have repeated episodes, sometimes two to three times a week, along with shortness of breath and at times hypotension that has been recorded. What is the next best therapy for this patient?

After exhaustion of non-invasive therapies, ablation therapy can be used to try to negate the aberrant pathway for SVT. Pacemakers will not allow for an override of the pathway, and cardioversion is only a temporary solution to an acute event. Implantable telemetry monitoring is only diagnostic and not therapeutic to treat.

A 68-year-old woman with a history of hypertension and diabetes mellitus type 2 comes to the emergency department with her son, who noticed that while decorating for Christmas she seemed more dyspneic than normal, and had to sit down frequently. In addition, he noticed that she was pale and diaphoretic, and insisted on driving her to the emergency department. On questioning, she denies chest pain, but admits to being more fatigued than usual, with frequent jaw discomfort during activity. Activities such as vacuuming her house cause dyspnea, and she now has to stop several times while carrying laundry up from the basement. On physical examination, the patient's blood pressure is 90/50, pulse 99 bpm, respirations 22, and she is afebrile. Auscultation of the chest demonstrates a new systolic murmur. An EKG demonstrates normal sinus rhythm with nonspecific ST and T wave changes. Which of the following would be the most appropriate next step in the management of this patient?

checking serial serum troponin levels, is the most appropriate next step in the management of this patient. Women and diabetics may present with atypical symptoms with acute non-ST-segment myocardial infarction, including dyspnea, jaw discomfort, and epigastric discomfort. Frequently, women present much later than men with these symptoms. Therefore, a high level of suspicion should be maintained when women present with symptoms of dyspnea, even in the setting of nonspecific EKG changes, and drawing serum troponin levels before any other testing is recommended. Once non-ST-segment myocardial infarction has been ruled out, choices E and B, and also transthoracic echocardiogram, would likely be evaluated. Transesophageal echocardiogram may be required if better visualization of the heart valves is required, but not as the next step. Choice C, cardiac catheterization, would likely occur if an abnormal stress test demonstrating symptoms of myocardial ischemia is found.

Which of the following is a major contraindication for surgical resection of a lung carcinoma?
A.
Chest wall invasion
B.
Pleural effusion
C.
Superior vena cava syndrome
D.
Unilateral endobronchial tumor
E.
Vagus nerve involvement

Surgical resection of lung carcinoma is contraindicated in cases of superior vena cava syndrome, extrathoracic metastases, heart, pericardial or great vessel involvement, recurrent laryngeal or phrenic nerve involvement, esophageal or carina involvement, malignant effusion, or contralateral mediastinal lymph nodes. Other contraindications are patient and staging dependent.

A 76-year-old man with a history of HTN and diabetes mellitus, type 2, presents to the emergency department with complaints of palpitations, tachypnea, and chest pain. He denies history of CAD, stroke, TIA, or congestive heart failure. He is afebrile, with vital signs as follows: BP 145/98, HR 138, and RR 22. His EKG is shown (Figure 1). Troponins are negative X 1. His echocardiogram demonstrates normal LV systolic function and normal valvular function. Which of the following would be considered the most appropriate long-term anti-coagulation therapy for him?

warfarin 5 mg dosed to INRs between 2.0 and 3.0, is correct because the patient demonstrates non-valvular atrial fibrillation, and has a CHADS2 score of 3 (1 pt each for age > 75 years old, HTN, and diabetes), placing him at a higher risk for thromboembolism. Choices A, B and E are incorrect because there is no research data to suggest that Plavix, Aspirin, or Aggrenox is of value in the prevention of thromboembolism in atrial fibrillation. Choice C is appropriate therapy following PTCA and placement of a drug-eluting cardiac stent.

A 67-year-old female with a history of hypertension and non-insulin dependent diabetes mellitus (NIDDM) returns to the internal medicine office for a review of her labs. Her total cholesterol = 250 mg/dl, HDL = 35mg/dl, LDL = 200mg/dl. What is this patient's optimal treatment goal?A.
TC < 200
B.
HDL < 30
C.
LDL < 130
D.
TC < 160
E.
LDL < 70

The correct answer is (E). This patient has a significantly elevated LDL and risk factors for coronary artery disease (CAD) including NIDDM and hypertension. Her cholesterol should ideally be treated to reduce the LDL below 70 mg/dl due to her risk of CAD. Reduction of total cholesterol is not significant for reducing her CV risk if the LDL is still elevated. HDL has a protective effect and should be increased.

What is the hallmark finding on an EKG that is consistent with Wolff-Parkinson-White syndrome?
A.
Prolonged PR interval
B.
Long QT interval
C.
Widened QRS complex
D.
Sinus arrhythmia
E.
Delta wave formation

The delta wave appears as an up sloping curvature that begins the QRS complex (as seen on the ECG shown).

A 27-year-old African American female presents to the emergency department with low blood pressure of 100/40, palpitations, and shortness of breath. She is currently under treatment for Wolff-Parkinson-White syndrome and has been taking procainamide for the last two years. An electrocardiogram is obtained on the monitor and reveals the rhythm strip shown. What is the treatment of choice for this patient?
A.
Intravenous calcium
B.
Intravenous magnesium
C.
Oral potassium
D.
Subcutaneous epinephrine
E.
Metoprolol

The rhythm strip reveals ventricular tachycardia in the form of torsades de pointes. In this case, the primary medical intervention is to administer magnesium sulfate to counter the irregular activity. Antiarrhythmics, antidepressants, and some antibiotics can be responsible for this arrhythmia. In addition to the magnesium, administration of beta-blockers can also be helpful.

A 17-year-old female presents to your family practice office for the annual physical examination required by her cheerleading coach. Upon examination you note that her joints are more flexible than anticipated. You also note her long thin fingers. You listen to her heart and hear no murmurs. Her blood pressure is 105/65 mmHg, pulse 60 beats/min and regular, respirations of 15 breaths/min, and temperature 98.7˚F. As you are examining her she tells you that her "joints sprain and strain easily." Furthermore, you obtain family history and she tells you that some connective tissue disorder runs in her family. Before you can medically clear her you should do which of the following?
A.
This patient does not require any further evaluation.
B.
Obtain an echocardiogram.
C.
Perform and EKG.
D.
Perform a chest radiograph.
E.
Refer her to a rheumatologist.

This patient has clear signs and symptoms that are suspicious for Marfan syndrome. The complications of Marfan syndrome include cardiovascular issues, especially valvular and aortic disease. An electrocardiogram is an appropriate noninvasive initial first-step to begin your investigation to rule out significant valvular and/or aortic root abnormalities.

A 44-year-old female is involved in a motor vehicle accident, during which she suffered blunt trauma to the left chest and abdomen from the car door. She presents via rescue with marked dyspnea, tachypnea, and an oxygen saturation of 87% on room air. You obtain the chest x-ray shown. Based on the following x-ray, what is the diagnosis?

Diaphragmatic rupture is often the result of direct injury to the diaphragm or increased intra-abdominal or intrathoracic pressure. Patient symptoms are often the result of impaired lung expansion and decreased oxygenation. Additional symptoms may include bowel obstruction or other nonspecific bowel complaints. The chest x-ray shows elevation and irregularity of the left diaphragmatic border, with decreased left lung volume. Also of note is a widened mediastinum, which may suggest additional injury, including to the aorta. Lung markings extend through the lung space, which is not consistent with a hemothorax or pneumothorax. Evaluation for a pericardial effusion and/or pericarditis should be performed on this patient, based on the history, with evaluation including echocardiography and EKG. The typical x-ray result for pericardial effusion is termed a "water bottle" heart. However, this would be difficult to assess in the setting of a diaphragmatic rupture. Cor pulmonale is not associated with trauma, and is due to lung disease or pulmonary vascular disease.

What is the treatment of choice for rheumatic fever?
A.
Macrolides
B.
Cephalosporin
C.
Fluoroquinolone
D.
Aminoglycosides
E.
Penicillin

The goal is to eradicate the Streptococcus bacteria. Penicillins are the drug of choice, with the dose being benzathine penicillin G, 1.2 million units intramuscularly every four weeks as the ideal regimen. Oral penicillin does not absorb as well and has a weaker effect. The alternative to those with penicillin allergies is erythromycin 250 mg BID. Other alternatives are azithromycin or sulfadiazine.

During a hospitalization for acute exacerbation of COPD, troponin levels are drawn on a 62-year-old man with a history of hypertension, hyperlipidemia, and chronic tobacco use, and found to be elevated above the 99th percentile of normal. Which of the following choices would qualify this patient for the most recent ACC/AHA consensus guideline's definition of myocardial infarction?
A.
Ischemic symptoms
B.
New right bundle branch-block on EKG
C.
J wave on EKG
D.
Pulmonary vascular congestion on CXR
E.
Elevated WBC count

Choice A is the most appropriate choice, as troponin elevation may occur in the setting of patients who do not suffer from acute coronary syndrome. Therefore, the 2007 consensus guidelines recommended that the definition of myocardial infarction be applied to those patients who not only had troponin elevation above the 99th percentile, but also met one of the following criteria: "ischemic symptoms, new left bundle branch block (not right bundle branch-block as in choice B), new ST and T-wave changes, new Q waves, or imaging evidence of a new loss of viable myocardium or new regional wall-motion abnormality." Choice C, J wave, is characteristic of patients with hypothermia. Choice D, pulmonary vascular congestion, is frequently noted on CXR of patients with congestive heart failure. Choice E, an elevated WBC count, is indicative of an infectious process.

What is the most common cause of restrictive cardiomyopathy?
A.
Amyloidosis
B.
Pericarditis
C.
Marfans syndrome
D.
Fatty infiltrative disease
E.
Sarcoidosis

While restrictive cardiomyopathy is seen in such cases as hemochromatosis, glycogen deposition, endomyocardial fibrosis, sarcoidosis, hypereosinophilic disease, and scleroderma, amyloidosis is the most common cause among the choices provided. amyloidosis refers to a variety of conditions wherein amyloid proteins are abnormally deposited in organs or tissues and cause harm. A protein is described as being amyloid if, due to an alteration in its secondary structure, it takes on a particular aggregated insoluble form, similar to the beta-pleated sheet.[1] Symptoms vary widely depending upon where in the body amyloid deposits accumulate. Amyloidosis may be inherited or acquired.[2]

A 48-year-old African American male presents with dyspnea, 2-pillow orthopnea, and swelling to his lower legs that has developed over the last month. He also complains of fatigue and decreased exercise tolerance, stating that he has trouble climbing one flight of steps. On physical examination, his blood pressure is 178/98, pulse rate is 102, and respiratory rate is 20. There is 5 cm JVD, crackles at the bilateral lung fields, and tachycardia and an S3 is heard on cardiac auscultation. There is 2+ pitting edema to the lower extremities. His electrocardiogram reveals a sinus tachycardia at a rate of 105 and left ventricular hypertrophy. The chest x-ray reveals cardiomegaly with increased interstitial markings in all lung fields. There is a small right pleural effusion that blunts the costophrenic angle. Which medication is the treatment of choice for controlling this patient's heart rate?
A.
Amlopidine
B.
Minoxidil
C.
Isosorbide mononitrate
D.
Metoprolol
E.
Atropine

The use of beta-blockers is indicated for heart rate control. The other choices are not indicated for rate control and have no primary action on rate, but rather on blood pressure.

A 48-year-old male has a positive PPD and a negative chest x-ray. Which of the following laboratory studies must be conducted before initiating standard isoniazid therapy?
A.
Complete blood count
B.
Hepatic function panel
C.
Lipid profile
D.
PT/PTT
E.
Thyroid-stimulating hormone

Isoniazid has been associated with hepatotoxicity, as well as severe and sometime fatal hepatitis. Monitoring should begin at initiation and continue throughout the course of therapy. Isoniazid is also associated with peripheral neuropathy development, especially in patients with an increased predisposition for developing a neuropathy. Alteration of renal function and visual changes have also been associated with tuberculosis therapies, indicating that renal function testing and routing eye examination should also be performed. Additional laboratory testing may be utilized for monitoring overall patient health and determining if any other conditions are also associated with the patient, such as the other choices provided.

A 66-year-old female patient inquires about receiving the pneumococcal vaccination due to the death of a friend from pneumonia. The patient is healthy and does not have contraindications to the vaccination. Based on current clinical guidelines, which of the following is most appropriate for this patient?
A.
Inform the patient that she is healthy and does not need vaccination
B.
Emphasize the influenza vaccination prior to pneumococcal vaccination
C.
Administer the pneumonococcal vaccination
D.
Discuss the low prevention rate of the pneumococcal vaccination
E.
Repeat her pneumococcal vaccination if she had it three years ago

Current recommendations include vaccination of all individuals 65 years of age and older if there are no contraindications. Patients aged 19 to 64 with comorbid chronic conditions affecting immunity should also be vaccinated. Revaccination is recommended for patients receiving the initial vaccination between the ages of 19 and 64, with continued immunocompromising conditions or asplenia.

A 25-year-old asymptomatic, non-smoking male presents with a 9mm solitary pulmonary nodule, with dense central calcification on routine chest x-ray. The nodule's appearance is smooth and calcified with a well-defined edge. This same lesion was present on a work physical x-ray two years ago. Which of the following is the most appropriate management step for this patient?
A.
Positron emission tomograph to rule out malignancy
B.
Resection of the pulmonary nodule
C.
Thoracic magnetic resonance imaging (MRI)
D.
Watchful waiting with serial imaging
E.
Pulmonary function tests

A 25-year-old asymptomatic, non-smoking male presents with a 9mm solitary pulmonary nodule, with dense central calcification on routine chest x-ray. The nodule's appearance is smooth and calcified with a well-defined edge. This same lesion was present on a work physical x-ray two years ago. Which of the following is the most appropriate management step for this patient?
A.
Positron emission tomograph to rule out malignancy
B.
Resection of the pulmonary nodule
C.
Thoracic magnetic resonance imaging (MRI)
D.
Watchful waiting with serial imaging
E.
Pulmonary function tests

A 67-year-old male with a history of dilated cardiomyopathy, 3-vessel coronary artery disease, and an ejection fraction of 20% has a history of palpitations for the last two weeks. A 24-hour Holter monitor is ordered and reveals >1000 episodes of the attached rhythm strip. His blood pressure on examination is 102/62, and his resting pulse is 52. Based on these findings, what is the best therapy to treat the patient's symptoms?

: The rhythm strip reveals episodes of non-sustained ventricular tachycardia. Due to the patient having a low ejection fraction with the dilated cardiomyopathy, primary prevention for this patient at a minimum would be to provide him with a biventricular pacer.

A 29-year-old female who is only taking oral contraceptives presents to the emergency department with a 1-day history of worsening shortness of breath. On examination, the patient is afebrile, her pulse rate is 105, respiratory rate is 24, and blood pressure is 122/78. She has wheezing to all lung fields and appears to be in mild to moderate distress. There is no swelling or edema to the lower extremities. Based on these findings, what is the best test to order to determine the diagnosis in this patient?
A.
CT chest
B.
Chest x-ray
C.
Ventilation to perfusion scan
D.
Pulmonary arteriography
E.
MRI chest

This patient presents with a history and physical exam that is consistent with an acute pulmonary embolus (PE). The prognosis for this type of illness can be serious, and in some cases death can result. The test that is still the gold standard for determination of a PE is the pulmonary arteriogram. CT of the chest with contrast tends to be the more utilized testing modality, but the arteriogram remains the test of choice.

A soft tissue neck x-ray of a patient who complains of a progressively worsening sore throat reveals this lateral film (see image). Based on these findings, what is the initial treatment of choice for this patient?
A.
Endotracheal intubation
B.
Intravenous steroids
C.
Ribovirin injection
D.
Incision and drainage
E.
Cricoidotomy

This case of acute epiglottitis is treated with immediate intravenous steroids. Provided that the patient is able to maintain the airway and also keep oxygen saturation rates above 92%, the patient can improve with steroids and supportive care. Antiviral medications have little effect on the overall illness.

You are evaluating a 55-year-old female with a history of hypertension. Her blood pressures have been in the 120s to 130s systolic and 60s to 70s diastolic until recently. She notices some days her blood pressure is normal and other days her systolic readings are in the 150s to 160s and wonders if a medication she could be taking might be contributing to the elevation. Her blood pressure today is 142/66. Which of the following medications is most likely to result in her blood pressure being elevated?
A.
loratadine
B.
simvastatin
C.
pseudoephedrine
D.
acetaminophen
E.
lisinopril

The correct answer is (B). Decongestants, such as pseudoephedrine, are known to increase blood pressure. Discontinuing pseudoephedrine and rechecking the blood pressure off of this medication may provide further information on the need for additional antihypertensive drug therapy. Loratadine, simvastatin, and acetaminophen are not known to cause secondary hypertension. Lisinopril is an ACE inhibitor used to treat blood pressure.

A 57-year-old woman with a history of rheumatic fever is seen complaining of dyspnea while vacuuming her apartment, which has been worsening over the last few months. On physical exam, a possible opening snap, loud S1, and a very soft diastolic rumbling murmur is auscultated. Which of the following maneuvers would be the most appropriate to choose to increase the intensity of the murmur for better identification?
A.
Isometric hand grip exercise
B.
Listening with the bell at the apex, with the patient in the left lateral decubitus position
C.
Inspiration, followed by the patient holding his/her breath
D.
Valsalva maneuver
E.
Having the patient lie flat with the knees bent

Choice B is best used when listening to the murmur of mitral stenosis, which is the murmur auscultated in this patient. Choice A, isometric hand grip exercises, increase the intensity of the murmur of mitral regurgitation by increasing arterial and left ventricular pressure, which increases the flow across the mitral valve, thereby increasing the murmur's intensity. Choice C will increase the AP diameter, making it more difficult to hear the murmur. With the Valsalva maneuver, choice D, the murmur decreases in intensity. Choice E is the best position for the abdominal exam, especially in males.

A 55-year-old woman with a history of hypertension and 2 vessel CABG presents to the emergency department with increasing dyspnea while walking up one flight of stairs. She denies chest pain and discomfort, but states that for the last 24 hours she has also noticed palpitations. On physical examination, her vital signs are stable. On EKG, she demonstrates atrial flutter with 2:1 AV block. Her echocardiogram demonstrates normal LV systolic function and normal valvular function. Which of the following is the most appropriate therapy for this patient?
A.
IV ibutilide after 4 weeks of anticoagulation with warfarin
B.
IV ibutilide alone
C.
IV quinidine after 4 weeks of anticoagulation with warfarin
D.
IV quinidine alone
E.
IV dopamine

Choice B, IV ibutilide, is the most appropriate choice for this patient. Therapy for patients with atrial flutter and atrial fibrillation is the same in regards to anticoagulation; therefore, in a patient with a CHADS2 score of 1 and with symptoms of less than 48 hours duration, cardioversion to normal sinus rhythm, whether chemically or electrically, is recommended. Out of all the choices listed, IV ibutilide has been found to be most effective in converting atrial flutter to sinus rhythm. Choices B and C are contraindicated, regardless of the type of anticoagulation paired with it, as quinidine is a class I antiarrhythmic. The atrial conduction may decrease to the point that 1:1 atrial to ventricular conduction can occur with the administration of class I antiarrhythmics. The ventricular rate can then increase to rates greater than 200 bpm, and hemodynamic collapse may occur. Choice E is useful for pressor support, which is not indicated in this patient who is quite stable.

A 24-year-old man with a recent history of a viral illness comes to the emergency department complaining of severe left-sided chest discomfort, which radiates through to the left trapezius region. On coming into the room, you note that he is sitting up and hunched forward. On physical examination, the patient's temperature is 39°C, blood pressure is 135/78, with a pulse of 85 bpm, and a pericardial friction rub is noted. Laboratory findings demonstrate elevated serum creatine kinase levels and normal serial troponin levels. His EKG demonstrates peaked T waves. His CXR demonstrates no acute process. Which of the following is the most appropriate treatment for this patient?
A.
Morphine
B.
Enoxaparin
C.
Nitroglycerin
D.
Penicillin V
E.
Indomethacin

Choice E, indomethacin 25-75 mg QID, and bed rest would be the most appropriate treatment in a patient with acute viral pericarditis, as a nonsteroidal anti-inflammatory agent will ameliorate the inflammatory process. Choices A and C are appropriate in a patient suspected of acute coronary syndrome. Choice B, enoxaparin, is contraindicated in patients with pericarditis, as anticoagulants could lead to worsening of pericardial effusion and cardiac tamponade, especially if it is secondary to bleeding into the pericardial space, such as with trauma or postoperatively.

A 61-year-old man arrives at the emergency department (ED) suffering an acute myocardial infarction as a result of coronary artery thrombosis. One of the agents administered to the patient is a thrombolytic agent. From the choices below, which drug is a thrombolytic agent?
A.
abciximab
B.
alteplase
C.
warfarin
D.
heparin
E.
clopidogrel

Both warfarin and heparin are anticoagulants that are indicated for the prevention of thrombi. They do not actively lyse clots, but are capable of preventing further thrombogenesis. Both abciximab and clopidogrel are considered antiplatelet agents. Abciximab inhibits the activation of glycoprotein IIb/IIIa receptors on platelets, which helps to reduce platelet aggregation. Clopidogrel blocks adenosine diphosphate (ADP) receptors on platelets. The binding of ADP to these receptors is an important cellular mechanism in stimulating platelet aggregation. Alteplase converts plasminogen to plasmin, which then actively dissolves the fibrin threads associated with a thrombus.

A 16-year-old boy is seen for a sports physical prior to starting football. He denies any symptoms. His physical examination is normal, except for a grade II/IV holosystolic murmur auscultated at the cardiac apex. Utilizing isometric hand grip exercises, the murmur increases in intensity and can be heard radiating to the axilla. With the Valsalva maneuver, the murmur decreases in intensity. Given the patient's physical exam findings, which of the following is the most appropriate next diagnostic study?
A.
Chest x-ray
B.
Transesophageal echocardiogram
C.
Holter monitor
D.
Treadmill exercise stress test
E.
Transthoracic echocardiogram

Choice E, transthoracic echocardiogram, is a simple, sensitive, and non-invasive diagnostic tool that can evaluate for the presence of valvulopathy or congenital heart disease in this young patient. Choice A might be able to give evidence of cardiomegaly, but would not be sensitive enough to detect valvulopathy. Choice C is a useful diagnostic tool for evaluation of patients complaining of palpitations, but incorrect for this patient who has no symptoms. Choice D, although a useful diagnostic tool for the evaluation of exercise tolerance and in patients complaining of chest pain, does not allow direct visualization of the heart valves to evaluate for valvulopathy.

A 32-year-old female with history of non-insulin-dependent diabetes mellitus (NIDDM) returns to the clinic for a routine visit. She reports that she her blood sugars have been controlled. However, her vitals today show a blood pressure (BP) of 136/78 P = 72. You note the past three office visits that her blood pressures were in the mid 130s to 140 systolic. She is not currently taking anything for her blood pressure but admits that she has not been exercising as much as usual. What do you advise the patient?
A.
Advise lifestyle modification and continue to monitor BP next visit.
B.
Initiate antihypertensive therapy to target BP < 130/80.
C.
Initiate DASH diet and recheck blood pressure in 6 months.
D.
Monitor blood pressure next visit, and if > 140/90, initiate antihypertensive therapy.
E.
Her blood pressure indicates prehypertension, there is no need for treatment other than exercise at this time.

The correct answer is (B). According to the JNC-7 guidelines, a patient with diabetes mellitus (DM) or chronic kidney disease (CKD) with this patient's blood pressures should be treated to achieve a goal BP of < 130/80. Although she would be classified as prehypertensive, due to her compelling indication of DM initiation of antihypertensive treatment should begin because she is at higher risk for cardiovascular disease. Lifestyle modifications such as increased exercise, low salt diet, and weight loss are recommended, but in addition to drug therapy at this time due to her increased risk of cardiovascular disease.

Which of the following represents a positive tuberculin skin test result?
A.
A college student with 4mm of superficial erythema at site
B.
An HIV-positive patient with 2mm induration
C.
A low-risk individual with a pre-employment test result of 6mm induration
D.
A nursing home resident with 12mm induration
E.
A recent immigrant from Mexico with 8mm induration

A tuberculin purified protein derivative (also known as a TB test or PPD), is utilized to screen for latent Mycobacterium tuberculosis infection. Guidelines for interpreting test results, based upon induration, patient risk, and patient medical status, are published by the Centers for Disease Control and Prevention (summarized in Table 9-10 below). False-negative reactions may occur in immunosuppresed patients and those with extensive infection. False-positive and false-negative reactions can occur for various reasons, including previous vaccination with bacillus Calmette-Guirein (BCG), which may cause a false-positive.

A 62-year-old man with a history of hypertension, diabetes mellitus type 2, hyperlipidemia, and chronic tobacco use presents to the office with complaints of a retrosternal chest pressure radiating down his left arm, associated with diaphoresis, nausea, and dyspnea, for the last 45 minutes after mowing his lawn. The patient's vital signs are stable, and on physical examination a new systolic murmur is appreciated. According to the most recent American College of Cardiology/American Heart Association Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation MI recommendations, an EKG should be performed on patients with a clinical suspicion for acute coronary syndrome within how many minutes of their arrival to the emergency department?

the 2007 American College of Cardiology/American Heart Association Guidelines for Management of Patients with Unstable Angina/Non-ST-Elevation MI recommend that an ECG "be performed and shown to an experienced emergency physician as soon as possible after ED arrival, with a goal of within 10 minutes of ED arrival for all patients with chest discomfort or other symptoms suggestive of ACS." Although choices A and B would be optimal, the question asks for the goal time for which busy emergency departments should aim for in obtaining an EKG in at-risk patients. Choices D and E are less desirable, as times greater than 10 minutes increase both morbidity and mortality rates. (Tintinalli et al., 2011, Chapter 52)

Assuming no contraindications, which of the following class of medications is considered the preferred long-term control therapy for persistent asthma?
A.
inhaled corticosteroids
B.
leukotriene antagonists
C.
long-acting B2 agonists
D.
methylxanthines
E.
muscarinic antagonists

Inhaled corticosteroids (eg, beclomethasone, fluticasone, triamcinolone, etc) are the preferred long-term control therapy for persistent asthma in all patients because of their potency and consistent effectiveness. Low- to medium-dose inhaled corticosteroids offer several advantages over other medications, including the ability to reduce bronchial hyper-responsiveness, improve overall lung function, and reduce severe exacerbations that often lead to emergency department visits and hospitalizations. (Chesnutt et al., 2008, p. 209; Kelly and Sorkness, 2008, pp. 485-486;)

A chest x-ray on an 81-year-old male with a four-day history of productive cough, dyspnea, fever, chills, and shortness of breath reveals a left sided pleural effusion. Pleural fluid analysis reveals a decreased glucose level, elevated lactate dehydrogenase, and 20,000 polymorphonuclear white blood cells/mcL. What is the most likely cause of this effusion?
A.
Bacterial pneumonia
B.
Congestive heart failure
C.
Malignancy
D.
Pulmonary embolus
E.
Tuberculosis

A pleural effusion is a collection of fluid within the pleural space, due to an increased rate of fluid formation with decreased absorption. Pleural effusions are classified as transudative versus exudative, based on the underlying cause. This patient exhibits pleural fluid analysis results that are consistent with a parapneumonic effusion. Malignancy and tuberculosis also cause exudative effusions, with different fluid analysis results and various patient presentations (see Table 9-23). Congestive heart failure and pulmonary embolism are associated with transudative effusions.

What is the most common electrolyte that can effect the initiation of ventricular tachycardia?
A.
Magnesium
B.
Sodium
C.
Chloride
D.
Phosphorus
E.
Calcium

Hypomagnesia and hypokalemia are the two electrolyte disorders for ventricular tachycardia.

A 47-year-old male presents to the hospital with complaints of palpitations. He has a history of hypertension, for which he takes diltiazem. On exam he is alert, awake, and oriented. His blood pressure is 144/76, his pulse rate is 52, and his respiratory rate is 18. Lung sounds are clear, and cardiac is a regularly irregular rhythm. There is no peripheral edema noted, and a neurological exam is non-focal. The rhythm strip shown is produced. Based on these findings, what is the next step in the treatment of this patient?

This patient has a second-degree AV block, Mobitz Type I, or Wenckebach. In this case, putting the patient on a calcium channel blocker can increase the vagal tone and slow the rate down. The best intervention for this patient is to stop the diltiazem. If there is a suspicion of ischemia, then cardiac catheterization is warranted. There is no indication for a pacer or surgery.

A 4-year-old female is brought in by her parents due to an increased nightly cough and low grade temperature. The x-ray shown reveals a classic finding for which of the following diagnoses?

Croup, also known as laryngotracheobronchitis, is associated with upper tracheal narrowing and edema, which is visible on an anteroposterior soft tissue neck x-ray. This is termed the "steeple sign." Epiglottitis is associated with a thickened epiglottis on a lateral soft-tissue neck x-ray, termed the "thumb" sign. Foreign body aspiration and tracheal carcinoma may have x-ray findings based on the location, size, and components present. Peritonsillitis is best visualized on physical exam. If assessing for a potential peritonsillar abscess, a contrasted CT is recommended.

A patient is being evaluated for fatigue, weight loss, a two-week cough, and erythema nodosum. Today, the patient noted eye symptoms and your exam reveals iritis. A chest xray reveals hilar and paratracheal lymphadenopathy. You suspect sarcoidosis. Which of the following is the most appropriate next step of evaluation to determine the diagnosis?

A diagnosis of sarcoidosis must incorporate clinical findings and radiologic findings, ruling out other conditions and obtaining definitive information. A biopsy should be performed, and may be performed utilizing tissue from any affected organ, including skin or from a transbronchial biopsy, which has a high conclusive yield. Histologically, sarcoidosis is associated with noncaseating granulomas; however, other granulomatous disease must be ruled out. The additional testing listed may also be utilized for further evaluation, but is considered adjunctive

A 70-year-old man with a history of hypertension, DM Type 2, and hyperlipidemia is seen for preoperative evaluation prior to left knee replacement. On auscultation, a very soft high-frequency decrescendo early diastolic murmur is heard at the upper left sternal border. Which of the following maneuvers would be the most appropriate to choose to increase the intensity of the murmur for better identification?
A.
Isometric hand grip exercise
B.
Listening with the bell at the apex with the patient in the left lateral decubitus position
C.
Inspiration, followed by the patient holding his/her breath
D.
The Valsalva maneuver
E.
Having the patient lie flat with the knees bent

Isometric hand grip exercises will increase the intensity of the murmur of aortic regurgitation, which is usually described as a high-frequency decrescendo early diastolic murmur heard best at the left upper sternal border or at the right upper sternal border. Radiation, if it occurs, is frequently to the lower left sternal border and the apex. Isometric hand exercises increase arterial and left ventricular pressure, which increases the flow across the aortic valve, thereby increasing the murmur's intensity. Choice B is best used when listening to the murmur of mitral stenosis. Choice C will increase the AP diameter, making it more difficult to hear the murmur. Choice D, the Valsalva maneuver, will decrease the intensity of the murmur. Choice E is the best position for the abdominal exam, especially in males. (Crawford et al., 2009, Chapter 1)

Which of the following indicates EKG changes consistent with a suspected pulmonary embolus?
A.
Increased QRS amplitude with tall R waves in limb leads and deep S waves in V1 and V2
B.
Notched P wave in leads I and II with an increased duration
C.
Prolonged PR interval with peaked T waves
D.
Prolonged QRS duration with QS complex in V1, monophasic R wave in leads I and V6
E.
Sinus tachycardia with a right ventricular strain pattern, prominent S in lead I, Q wave and inverted T in lead III

Approximately 70% of patients with a pulmonary embolus will demonstrate EKG changes. The changes present may range from sinus tachycardia to findings consistent with marked right heart strain and dilatation. The correct answer also includes the classic "S1Q3T3" pattern of changes associated with pulmonary embolism. The findings in choice A are consistent with left ventricular hypertrophy. Choice B is indicative of left atrial enlargement. Choice C is consistent with hyperkalemia. Choice D indicates left bundle branch block. These changes are not commonly associated with pulmonary embolism.

What is the most common cause of pneumothorax in a healthy patient?
A.
Traumatic
B.
Infectious
C.
Ruptured bleb
D.
Surfactant abnormality
E.
Malignancy

Rupture of a bleb is thought to be more relevant to young, thin men, and also patients who have a family history of them, and smoking.

What is the most likely reason for a patient to have cardiogenic shock?
A.
Acute myocardial infarction
B.
Sepsis
C.
Trauma
D.
Aortic dissection
E.
Pericardial effusion

While trauma can account for a patient being subjected to cardiogenic shock, the overwhelming etiology for the shock comes from an MI.

An 8-month-old female is diagnosed with respiratory syncytial virus bronchiolitis while in the emergency department. Which of the following strongly indicates a need for admission to the hospital and continued monitoring?
A.
Age of 8 months
B.
Birth at 36 weeks
C.
Feeding difficulty with decreased oxygen saturation
D.
Oxygen saturation of 96%
E.
Respiratory rate of 45bpm

Brochiolitis patients must be considered at risk of developing severe disease and/or apnea when certain criteria are present, thus requiring admission. This includes, but may not be limited to, the following: birth <37 weeks gestation, age <12 weeks, witnessed apnea, underlying cardiopulmonary disease, immunodeficiency, tachypnea based on expected respiratory rate per age, decreased oral intake or feeding difficulty with associated decreased oxygen saturation, decreased oxygen saturation with varying ranges based on source (most being <95%), a history of previous intubation, and a caregiver ability to adequately provide care and monitoring.

A 62-year-old man with a history of hypertension, diabetes mellitus type 2, hyperlipidemia, and chronic tobacco use presents to the office with complaints of retrosternal chest pressure radiating down his left arm, associated with diaphoresis, nausea, and dyspnea for the last 45 minutes after mowing his lawn. The patient's vital signs are stable, and on physical examination a new systolic murmur is appreciated. His EKG demonstrates normal sinus rhythm with minor nonspecific changes. Which of the following would be the most appropriate next step in management of this patient?

repeating the EKG with addition of the posterior leads (leads V7 through V9), can uncover hidden posterior ST-segment elevation in patients with symptoms suggestive of acute coronary syndrome (Figure 4). These patients should then be treated following acute STEMI guidelines, including acute reperfusion therapy. A new systolic murmur would not occur with anxiety or costochondritis, and in a patient with numerous cardiac risk factors, with symptoms suggestive of acute coronary syndrome, neither anxiolytics nor anti-inflammatory therapy would be appropriate. Choices C and E may be considered later in this patient's treatment plan, once acute myocardial infarction has been ruled out, for further investigation of this patient's new murmur.

What is the initial treatment for a patient who is having an acute episode of supraventricular tachycardia?
A.
Caffeine
B.
Beta blockers
C.
Valsava maneuver
D.
No treatment
E.
Synchronized cardioversion

The initial treatment that should be attempted is a simple vagal maneuver to break the reentry tachycardia. If this is unsuccessful, pharmacologic therapy is indicated.

A 43-year-old male farmer from the Southwest United States has been working in a very contaminated barn with rodent feces for the last week. He presents to your office with complaints of fever, non-productive cough, malaise, and decreased appetite. His physical exam reveals a temperature of 1020F, pulse rate of 98, blood pressure of 98/62, and O2 saturation of 93%. Lung sounds have diffuse crackles throughout, and the rest of the exam is unremarkable. Based on the history and exam findings, what is the most likely pathogen for this type of illness?

The history of the patient being exposed to the rodent feces is a typical presentation of a pneumonia caused by the hantavirus. There is no treatment for this type of pneumonia, only supportive care.

A patient presents with mild dyspnea, increased cough, and rhinorrhea. On physical exam, you auscultate low-pitched, sonorous, and adventitious sounds over the bilateral upper lung fields, which are suggestive of secretions. Which of the following terms is defined by these findings?
A.
Crackles
B.
Rales
C.
Rhonchi
D.
Vesicular breath sounds
E.
Wheezes

Rhonchi are defined as low-pitched, often harsh breath sounds, with increased secretions and inflammation. Rhonchi due to secretions may improve with coughing. Crackles, also known as rales, are due to an increase of fluid shifting from the intravascular space into the alveoli, and are often described as brief, nonmusical sounds with popping. Wheezes, which are high-pitched, musical sounds, are due to the narrowing of the airway related to mucosal edema, secretions, and bronchospasm. Vesicular breath sounds are normal lung sounds found over the periphery.

In the emergency department, you are asked to evaluate a 77-year-old man with a history of HTN who had a syncopal episode while chasing after his dog. He admits to recent episodes of chest discomfort, also associated with activity, as well as dyspnea at lower levels of activity, including walking up one flight of stairs. On physical exam, a grade III/IV crescendo-decrescendo systolic ejection murmur can be heard best over the right upper sterna border. His EKG demonstrates NSR @ 80 bpm, with evidence of left ventricular hypertrophy. His troponin levels are negative for ischemia. Based on your physical exam findings, what is the most likely diagnosis?
A.
Micturition syncope
B.
Myocardial infarction
C.
Severe aortic stenosis
D.
Cerebrovascular accident
E.
Acute exacerbation of COPD

Choice C is correct, as his symptoms of angina pectoris, effort syncope, and exertional dyspnea, in conjunction with a systolic ejection murmur, are classic for aortic stenosis. Micturition syncope, choice A, is usually experienced after urination, and would not be associated with a cardiac murmur. Choice B, myocardial infarction, has been ruled out with negative troponins; however, stress testing or cardiac catheterization is likely to follow, in preparation for open heart surgery, in the event that the patient might require coronary artery bypass grafting concomitantly with aortic valve replacement. Choices D and E are not supported by his history and physical exam findings.

In patients with dilated cardiomyopathy who have multiple runs of symptomatic non-sustained ventricular tachycardia, what is the best intervention to treat this condition?
A.
Ablation therapy
B.
Heart transplantation
C.
Medical therapy alone
D.
Diet modification
E.
Implantable defibrillator

It is recommended for patients with a history of dilated cardiomyopathy who have documented non-sustained ventricular tachycardia to have implantable defibrillators inserted for primary prevention of sudden cardiac death. Medical therapy alone does not protect the patient from arrhythmias, and ablation therapy is not indicated for this type of arrhythmia.

A 67-year-old female with a history of oxygen dependent emphysema presents with a 4-hour history of increasing shortness of breath and pleuritic chest pain on the right side. Her resting oxygen saturation rate is 90%, and she is having pain on inspiration. On examination, the patient has decreased lung sounds with wheeze on the left and absent sounds on the right. There is also tympany to percussion on the right. Based on these findings, what is the best therapy for this patient?
A.
Needle insertion to right chest wall
B.
Supportive care
C.
Increased oxygen delivery
D.
Chest tube insertion
E.
Nebulized albuterol

The treatment for this patient, who has a pneumothorax, is chest tube insertion and reinflation of the lung. Once the air leak has been eliminated and the lung appears reinflated on serial chest x-rays, the chest tube may be removed.

What is the most common hematologic finding in a patient with pulmonary hypertension?
A.
Anemia
B.
Thrombocytopenia
C.
Polycythemia
D.
Leukocytosis
E.
Elevated mean corpuscular volume (MCV)

Polycythemia is the most common finding. Hematocrits that are >60% usually require phlebotomy, to reduce the numbers and prevent a hypercoagulable state.

A 45-year-old man with a history of NSTEMI, CABG X 3, HTN, and hyperlipidemia presents to your office with complaints of progressive dyspnea over the last three weeks, to the point that he is now dyspneic while walking across the room. In the last few days, he has noticed bilateral lower extremity edema. Which of the following findings on physical exam would meet the criteria for a diagnosis of congestive heart failure, according to the modified Framingham clinical criteria for the diagnosis of heart failure?
A.
Nocturnal cough
B.
Tachycardia
C.
Third heart sound
D.
Pleural effusion
E.
Hepatomegaly

Diagnosis of heart failure requires that the findings of two major criteria, or one major and two minor criteria, cannot be attributed to another medical condition. The patient demonstrates two minor criteria: bilateral lower extremity edema and dyspnea on ordinary exertion. Only choice C (third heart sound) falls under the heading of major criteria. Choice A, B, D, and E all fall under the heading of minor criteria. A third heart sound, or S3, is representative of early rapid filling of the left ventricle, and can occur in any condition in which there is an increased left ventricular volume, such as congestive heart failure.

A 42-year-old woman with a history of migraine cephalgia and Raynaud's phenomenon comes to the emergency department with complaints of severe chest discomfort that occurs at rest every morning (at approximately 10 AM). An EKG performed during an episode of chest discomfort demonstrates transient ST segment elevation, which is relieved with sublingual nitroglycerin. There is no troponin elevation. Cardiac catheterization is performed, and reveals coronary artery spasm, which corresponds with ST segment elevation, and no significant coronary artery stenosis. Which of the following choices is the most likely diagnosis?
A.
Pericarditis
B.
Acute myocardial infarction
C.
Costochondritis
D.
Prinzmetal angina
E.
Myocarditis

Prinzmetal angina, or variant angina pectoris, is defined as coronary artery spasm associated with ST-segment elevation, and usually occurs at rest and at the same time of the day. Patients with a history of migraine cephalgia and Raynaud's phenomenon demonstrate Prinzmetal angina more frequently than the rest of the patient population. This can occur in patients with normal coronary arteries and with coronary artery stenosis. Choice A, pericarditis, would present with chest discomfort that is worse while supine and improves with sitting up, as well as a pericardial friction rub. Choice B, acute myocardial infarction, would present with troponin elevation, and is unlikely in the setting of a patient with normal coronary arteries on cardiac catheterization. Choices C and E would not be relieved with sublingual nitroglycerin or demonstrate transient ST-segment elevation.

A 22-year-old recent immigrant from Vietnam, who is 28 weeks pregnant with her first child, presents to the emergency department with complaints of worsening dyspnea and lower extremity edema. She is unable to answer definitively whether or not she has a history of rheumatic fever. On physical examination, a possible opening snap, loud S1, and a very soft diastolic rumbling murmur is auscultated. When the patient is placed in the left lateral decubitus position, the murmur is accentuated, and heard best at the apex. With inspiration, the murmur does not increase in amplitude. Which of the following is the most likely finding on echocardiogram?
A.
Tricuspid regurgitation
B.
Tricuspid stenosis
C.
Atrial septal defect
D.
Aortic regurgitation/insufficiency
E.
Mitral stenosis

Choice E, mitral stenosis, is the most likely finding in this patient, who presents with physical exam findings including a possible opening snap, loud S1, and a very soft diastolic rumbling murmur which is heard best at the cardiac apex and accentuated by placing the patient in the left lateral decubitus position. Although rheumatic fever was not positively confirmed, the patient likely did have a history, given that the majority of cases of mitral stenosis are secondary to rheumatic heart disease. Patients from Asia, Central America, and South America are exposed more frequently than their counterparts in more developed countries, where antibiotic use is more common. Choices A and B, tricuspid regurgitation and tricuspid stenosis, are also linked with patients with rheumatic heart disease. The murmur of tricuspid regurgitation, however, is a systolic murmur, which increases with inspiration and is heard best at the left lower sternal border. Tricuspid stenosis presents with a diastolic murmur, and with inspiration the murmur increases. It, too, is heard best at the left lower sternal border. Choice C, an atrial septal defect, if large, could present with similar symptoms of exertional dyspnea secondary to a large shunt, but auscultation would reveal a moderately loud systolic ejection murmur that is heard best in the second and third interspaces. This is secondary to increased pulmonary arterial flow. Choice D, aortic regurgitation/insufficiency, is also a diastolic murmur; however, it is usually a diastolic decrescendo murmur that is heard best at the left sternal border.

What is the most common cause of treatment failure in tuberculosis?
A.
Drug resistance
B.
Noncompliance to therapy
C.
Inappropriate selection of medication
D.
Sepsis
E.
Death

The usual reason for failure is simply due to the patient not continuning their treatment plan, regardless of the severity of the disease. Drug resistence, while present in some cases does not preclude the patient from treatment failure. Ongoing sepsis is not a reason to have treatment failure.

Your 25-year-old female patient is a smoker, takes oral contraceptives, and complains of shortness of breath and wheezing, which forced her to stop smoking less than a week ago. She has no cough and her lungs are clear on your examination. Her vital signs are as follows: Pulse 72, respirations 14, blood pressure 115/70 mm Hg, and her pulse oximetry is 94%, and her height is 64 inches. In an effort to distinguish between various pathologies, you order spirometry followed by a beta2-agonist nebulizer treatment, and then after 10 minutes a repeat spirometry. Her repeat spirometry FEV1 improves by 225 ml which is approximately 16% and from this you tell her that you are diagnosing her with which of the following?
A.
acute exacerbation of chronic bronchitis
B.
asthma
C.
chronic obstructive pulmonary disease
D.
hyperventillation syndrome
E.
pulmonary embolism

Clinicians are able to identify airflow obstruction on examination, but they have limited ability to assess it or to predict whether it is reversible. The evaluation for asthma should include spirometry (FEV1, FVC, FEV1/FVC) before and after the administration of a short-acting bronchodilator. These measurements help determine the presence and extent of airflow obstruction and whether it is immediately reversible. Airflow obstruction is indicated by a reduced FEV1/FVC ratio. Significant reversibility of airflow obstruction is defined by an increase of 12% and 200 mL in FEV1 or 15% and 200 mL in FVC after inhaling a short-acting bronchodilator. A positive bronchodilator response strongly confirms the diagnosis of asthma but a lack of responsiveness in the pulmonary function laboratory does not preclude success in a clinical trial of bronchodilator therapy. Severe airflow obstruction results in significant air trapping, with an increase in residual volume and consequent reduction in FVC, resulting in a pattern that may mimic a restrictive ventilatory defect.

A 37-year-old female, who is two weeks post caesarean section, develops acute dyspnea and chest pain. A chest CT reveals a left segmental perfusion defect. Which of the following is the next step in the management of this patient?
A.
Aspirin
B.
Embolectomy
C.
Heparin
D.
Pulmonary angiography
E.
Streptokinase

Heparin is indicated as initial therapy for acute pulmonary thromboembolism, followed by oral anticoagulation with warfarin. Heparin promotes the effect of antithrombin, which inhibits factors Xa, IXa, Xia, and XIIa, and has been shown to decrease mortality and recurrent pulmonary embolism. Streptokinase, a thrombolytic agent, is recommended for hemodynamically unstable patients being treated with heparin, but with continued risk of death. Embolectomy, although associated with increased mortality, is another alternative for these patients. Pulmonary angiography, the gold standard for pulmonary embolus diagnosis, is being replaced with helical contrasted CT, due to angiography's invasiveness, time involvement, and cost. Aspirin, an antithrombotic agent, inhibits platelet aggregation and is effective for preventing platelet thrombosis. It also has a role in thrombosis prevention. However, anticoagulation with heparin remains the mainstay of therapy for pulmonary embolus.

Which of the following lab results reflect acute anxiety neurosis hyperventilation?
A.
Acidotic pH, PCO2 increased, HCO3 decreased
B.
Acidotic pH, PCO2 decreased, HCO3 decreased
C.
Acidotic pH, PCO2 increased, HCO3 normal
D.
Alkalotic pH, PCO2 increased, HCO3 increased
E.
Alkalotic pH, PCO2 decreased, HCO3 normal

Acute hyperventilation, associated with anxiety and other disorders, results in decreased PCO2 and leads to acute respiratory alkalosis. Acute respiratory alkalosis is associated with an increased pH and a decreased PCO2. Chronic respiratory alkalosis will result in compensatory bicarbonate (HCO3) level changes; in this scenario, the bicarbonate is expected to be normal initially. Respiratory alkalosis has other causes (as shown in Table 21-26).

The other answers represent a variety of acid-base disorders including, mixed acid-base disorder (choice A), metabolic acidosis with compensation (choice B), uncompensated respiratory acidosis (choice C), and metabolic alkalosis with compensation (choice D). These disorders, and the respective expected compensation, are reviewed in Table 21-12.

The mother of a four-month-old brings her son in for evaluation of cyanosis. The mother noted the cyanosis in the last two days, and it is most evident when he is feeding or crying. He was previously healthy with no medical problems. On physical examination, a grade III/VI systolic ejection murmur is present at the left sternal border in the third intercostal space, and radiates to the back. What is the most likely diagnosis?
A.
Atrial septal defect
B.
Patent ductus arteriosus
C.
Mitral valve prolapse
D.
Tetralogy of fallot
E.
Transposition of the great arteries

Tetralogy of fallot is the correct answer. The epsiodes of cyanosis described by the mother represent "tet spells." Atrial septal defect is incorrect, as it is not associated with cyanosis; while the murmur may be located at the left sternal border, it is most often heard in the second intercostal space and is associated with a widely split S2. Patent ductus arteriosus (PDA) is incorrect, as this does not lead to cyanosis, and the description of this murmur is classically described as a rough machinery systolic murmur. PDA murmur may radiate to the anterior lung fields, but does not radiate well to the posterior lung fields. Mitral valve prolapse is incorrect, as it is not associated with cyanosis and the murmur is described as a systolic click. Transposition of the great arteries is incorrect, as there is typically no significant murmur present and they present as neonates with profound cyanosis.

A 1400-gram preterm infant has a symptomatic patent ductus arteriosus. What medication has the best chance of closing the patent ductus arteriosus in this patient?
A.
Acetaminophen
B.
Indomethacin
C.
Propranolol
D.
Ranitidine
E.
Sildenafil

Indomethacin is an NSAID and inhibits prostaglandin synthesis, allowing for closure of the patent ductus arteriosus in preterm infants. None of the other medications listed play a role in closure of a patent ductus arteriosus.

You are reviewing laboratory results on a 60-year-old male from 2 days prior and note that the patient's potassium was 5.6 mEq/L but otherwise his BMP is normal. You speak to the patient on the phone; he states he feels fine. Which of the following medications would most likely be responsible for the abnormal potassium?
A.
clonidine
B.
enalapril
C.
hydralazine
D.
nebivolol
E.
felodipine

Hyperkalemia is a potential adverse reaction of ACE inhibitors such as enalapril. ACE inhibitors should be suspected as a cause of hyperkalemia and may require discontinuation. Choices (A), (C),(D), and (E) do no cause hyperkalemia.

A 2-month-old female presents for a well child check. The mother has no concerns and feels that the child is doing well. On exam, there is no evidence of cyanosis and the peripheral pulses are normal and equal. However, there is a fixed and widely split S2, a right ventricular heave, and a systolic ejection murmur present. The murmur is heard best at the left sternal border second intercostal space. What is the most likely diagnosis?
A.
Atrial septal defect
B.
Coarctation of the aorta
C.
Patent ductus arteriosus
D.
Tetralogy of fallot
E.
Aortic stenosis

The patient in this scenario is exhibiting the classic signs of an atrial septal defect. Coarctation of the aorta has absent or diminished femoral pulses and a blowing systolic murmur. A patent ductus arteriosus (PDA) is not associated with cyanosis, and the description of this murmur is classically described as a rough machinery systolic murmur. Tetralogy of fallot can have associated cyanosis with hypoxemic spells during infancy, easy fatigability, and dyspnea on exertion. Tetralogy of fallot also has the presence of a right ventricular lift and a rough, systolic ejection murmur, present along the left sternal border in the third intercostal space that radiates to the back. Aortic stenosis has a harsh systolic ejection murmur present at the right sternal border, and associated thrill in the carotid arteries.

A 55-year-old woman with a history of mitral stenosis (secondary to rheumatic heart disease) presents to the emergency department with increasing dyspnea while walking up one flight of stairs. She denies chest pain and discomfort, but states that recently she has also noticed palpitations. She also admits to lower extremity edema, which is new within the last week. On EKG, she demonstrates atrial flutter with 2:1 AV block. Which of the following medications is contraindicated in treatment of her atrial flutter?
A.
Diltiazem
B.
Carvedilol
C.
Lopressor
D.
Lisinopril
E.
Quinidine

In patients with atrial flutter, choices A, B, and C would help to achieve better heart rate control. Choice D, lisinopril, would not be contraindicated, but would not assist with heart rate control. Choice E, quinidine, is contraindicated as the atrial conduction may decrease to the point that 1:1 atrial to ventricular conduction can occur with the administration of class I antiarrhythmics. The ventricular rate can then increase to rates greater than 200 bpm, and hemodynamic collapse may occur.

A 14-year-old male presents for his asthma follow up. He states that he has symptoms three to four days per week and awakens from sleep three times a month, requiring the use of his inhaler. He occasionally has to sit out of gym class due to his symptoms, but overall he functions well. He currently uses a short-acting 2-agonist as needed. What is the preferred pharmacologic agent to add to this patient's regimen?
A.
Inhaled long-acting 2-agonist
B.
Leukotriene receptor antagonist
C.
Long-acting mediator inhibitor
D.
Low-dose inhaled corticosteroid
E.
Low-dose systemic corticosteroid

Asthma management follows a stepwise approach, which is based upon medication action, disease progression, and patient compliance. It also involves determining the asthma classification of the patient, as well as previous response to medications. This approach also incorporates patient education, environmental control, and comorbidity management (see Figure 9-2).

A 50-year-old woman with a history of hypertension complains of chest tightness and dyspnea while walking up one flight of stairs. She recently experienced an episode of near-syncope while walking her dog. She denies a history of rheumatic fever. On auscultation, a crescendo-decrescendo systolic ejection murmur is heard at the upper right sternal border, radiating to the carotids bilaterally. Troponin levels are negative at 0, 3, and 6 hours. Her EKG demonstrates evidence of left ventricular hypertrophy. Given the patient's physical exam findings and recent symptoms, which of the following is the most appropriate next diagnostic study?
A.
Chest X-ray
B.
Transesophageal echocardiogram
C.
Holter monitor
D.
Treadmill exercise stress test
E.
Transthoracic echocardiogram

transthoracic echocardiogram, is a simple, sensitive, and non-invasive diagnostic tool which can evaluate for the presence of valvulopathy in a patient in this age group, who is likely demonstrating severe aortic stenosis secondary to a congenital bicuspid valve. Patients with a congenital bicuspid aortic valve typically develop symptoms once the valve leaflets have become calcified and thickened, secondary to the undue stress over many years on a structurally abnormal aortic valve. Choice A might be able to give evidence of cardiomegaly or calcification of heart valves, but would not be sensitive enough to detect the degree of valvulopathy, if present. Choice B, transesophageal echocardiogram, would give information regarding valvulopathy, but is a more invasive test; therefore, choice E is more appropriate. Choice C is a useful diagnostic tool for evaluation of patients complaining of palpitations, but incorrect for this patient, who has no symptoms of palpitations. Choice D, although a useful diagnostic tool for the evaluation of exercise tolerance and in patients complaining of chest pain, does not allow direct visualization of the heart valves to evaluate the degree of aortic stenosis; as the patient is likely demonstrating severe aortic stenosis, cardiac catheterization to evaluate for coronary artery disease prior to surgery will need to be performed.

A 1-year-old female is having a 2-day history of fever (1020F oral), rhinorrhea, and dry cough, with a decreased appetite. The mother states that her daughter has been less active, and her fluid intake has decreased for her age. On exam, the child is non-toxic appearing, has a rectal temperature of 100.20F, and has nasal flaring and a respiratory rate of 45, rhinorrhea, moist mucous membranes, and a minimal wheeze heard bilaterally. Her chest x-ray has no specific findings. What is the initial treatment of choice for this patient with these symptoms?
A.
Antibiotics
B.
Oxygen therapy
C.
Supportive care
D.
Antiviral medications
E.
Plasmaphoresis

The choice for treatment of acute bronchiolitis is supportive care. Oxygen therapy is only reserved for those patients who are hypoxic, and antiviral medications have not proven to be effective in shortening or eradicating the infection.

An aspirated peanut that is causing a partial obstruction of the trachea in a child is most likely to cause which of the following physical exam findings?
A.
Aphonia
B.
Inability to cough
C.
Stridor
D.
Progressive cyanosis
E.
Rhonchi

Incomplete airway obstruction due to a foreign body will cause turbulent air flow in the airway and an inspiratory wheeze sound, known as stridor. Attempts should be made to remove the foreign body, leaving the patient with a partial obstruction to utilize the cough reflex to remove the foreign body. If unsuccessful, or if findings such as aphonia, an inability to cough, progressive cyanosis, or unconsciousness occur, a complete obstruction is present and definitive intervention must convene. Age appropriate measures, utilizing back blows and chest compressions in infants younger than the age of one and abdominal thrusts in children over the age of one, should be attempted.

What is the most common clinical finding on vital signs in a patient with cardiogenic shock?
A.
Fever
B.
Hypertension
C.
Hypotension
D.
Tachypnea
E.
Bradycardia

hypoperfusion to the body is what generally causes the end organ failure associated with shock. The patient may also be tachycardic, but may not have fever or an increased respiratory rate as part of the abnormality. In most cases patients will have tachycardia unless they suffer a significant pump failure, which may cause bradycardia.

An 18-year-old female presents to your office with the complaint of palpitations for the last 2 months. The episodes are frequent and are accompanied with lightheadedness and shortness of breath. The patient's mother has taken her pulse when some of the episodes occur and states that the rate gets as high as 170 beats per minute. On exam, she is alert, awake, and oriented. Her resting pulse is 55 and her blood pressure is 122/65. Her lungs are clear throughout, and her cardiac exam revealed a regular rate and rhythm, without murmurs, rubs, or gallops.

The patient has been treated with flecanide for several months, and has done well until she started experiencing more episodes of tachycardia. Her blood pressure remains stable in the 125 to 135 systolic range, and her symptoms are mild when the tachycardia occurs. What therapy should be given next for this patient?
A.
Stop flecanide
B.
Ablation therapy
C.
Beta blocker with flecanide
D.
Beta blocker without flecanide
E.
Stop flecanide, add diltiazem

Patients currently on flecanide with ongoing symptoms can benefit from the addition of a beta-blocker, to help control rate and symptoms. This would be started prior to ablation therapy, provided that the patient's vital signs can tolerate the added medication. A calcium channel blocker would potentially worsen the patients arrhythmia.

A 48-year-old male presents with an 8-day history of productive cough, subjective fevers, and malaise. He is otherwise healthy without any active medical problems. He is a social drinker of alcohol, and denies any tobacco or drug use. On physical examination, the patient is alert and oriented. His temperature is 100.40F, pulse rate is 56, respiratory rate is 18, and blood pressure is 133/64. HEENT is within normal limits and a chest exam has diffuse expiratory wheeze with decreased sounds to the right lower lung fields. Blood labs reveal WBC 14.4, Hgb 11.3, Plt 233, ALT 65, AST 102, and PO4 2.1. A chest x-ray reveals a dense consolidation with bulging fissures. Based on these findings, what is the most likely pathogen affecting this patient?
A.
Klebsiella pneumoniae
B.
Legionella pneumophila
C.
Pseudomonas aeurginosa
D.
Mycoplasma pneumoniae
E.
Streptococcus pneumoniae

Dense consolidation with bulging fissures is pneumonia consistent with Legionella pneumophila. Pleural effusions may also occur, as well as nodular irregularities in the immunocompromised host.

According to the American Heart Association's most recent guidelines regarding infective endocarditis, which of the following patients requires infective endocarditis prophylaxis?
A.
A 65-year-old man with a history of rheumatic fever prior to colonoscopy
B.
A 29-year-old woman with a history of bicuspid aortic valve prior to vaginal hysterectomy
C.
A 42-year-old man with a history of mitral valve regurgitation prior to vasectomy
D.
A 22-year-old man with a history of mitral valve replacement prior to tooth extraction
E.
A 44-year-old woman with a history of mitral valve prolapse prior to open cholecystectomy

According to the American Heart Association's most recent guidelines regarding infective endocarditis prophylaxis, only those patients with prosthetic heart valves, prior history of bacterial endocarditis, unrepaired or incompletely repaired cyanotic congenital heart disease (including those with palliative shunts and conduits), completely repaired congenital heart disease during the first 6 months after surgery if a prosthetic material or device was used, whether placed surgically or via catheter, repaired congenital heart disease that has residual defects at or adjacent to the site of repair, and heart transplant recipients with valvulopathy, and then in these populations of patients, only with certain procedures including tooth extraction. Therefore, the only patient among the choices offered who requires infective endocarditis prophylaxis is choice D. Choices A, B, C, and E are not considered at significant risk for infective endocarditis, regardless of the procedure.

A 66-year-old man with a history of a cardiac murmur since childhood presents with complaints of increasing dyspnea while walking up one flight of stairs and increased lower extremity edema. On physical examination, a late-peaking crescendo-decrescendo murmur, preceded by a systolic ejection click, is noted. An S4 gallop is appreciated. Hepatomegaly and splenomegaly are appreciated. Which of the following is the most likely finding on echocardiogram?
A.
Mitral stenosis
B.
Pulmonic stenosis
C.
Tricuspid stenosis
D.
Atrial septal defect
E.
Aortic regurgitation

Choice B, pulmonic stenosis, is the most likely finding on echocardiogram, given the patient's physical exam findings. Pulmonic stenosis can present with symptoms of right heart failure in the later stages. Patients may exhibit symptoms similar to aortic stenosis, including dyspnea with exertion, angina, fatigue and syncope, and evaluation through echocardiogram is recommended. Choice A, mitral stenosis, presents with a systolic murmur that is heard best in the left lateral decubitus position, with the bell of the stethoscope at the apex. Choice C, tricuspid stenosis, presents with a diastolic murmur that increases with inspiration. It is heard best at the left lower sternal border. Choice D, atrial septal defect, if large, could present with similar symptoms of exertional dyspnea secondary to a large shunt, but auscultation would reveal a moderately loud systolic ejection murmur that is heard best in the second and third interspaces. This is secondary to increased pulmonary arterial flow. Choice E, aortic regurgitation, presents with a soft diastolic murmur that is heard best at the left sternal border.

In your family practice, you perform an ABI on your 66-year-old diabetic who smokes with the results being 0.71 on the left and 0.68 on the right. Which of the following is the most appropriate next step?
A.
Begin the patient on aspirin 81 mg and clopidogrel 75 mg daily.
B.
Begin the patient on prasugrel 60 mg loading dose followed by 10 mg daily and refer to cardiology.
C.
Begin the patient on a low-molecular weight heparinoid (LMWH) and refer to a vascular surgeon for further evaluation.
D.
Begin the patient on warfarin 5 mg daily and titrate to an INR of 2.0 to 3.0.

This patient has peripheral arterial disease (PAD). This can be treated with antiplatelet agents, including aspirin and/or clopidogrel. Warfarin is an anticoagulant and is not FDA-approved for use in PAD. Your other consideration is referral to a cardiologist and/or vascular surgeon for further evaluation, depending upon the degree of symptoms. Patients with PAD have approximately one in six chance of have significant atherosclerosis in at least one other vascular bed, including carotids and coronary, and with a diabetic history, aggressive treatment of all co-morbidities could be life-saving. Effient, LMWH, and warfarin are not FDA-approved for treatment of PAD

A 55-year-old woman with a history of emphysema, who is undergoing chemotherapy for lung cancer, is sent to see you by her oncologist regarding a sudden increase in dyspnea, with exertion and fatigue. Which of the following physical exam findings would predict a cardiac etiology for her dyspnea instead of a pulmonary etiology?
A.
Crackles at the lung bases bilaterally
B.
Tachycardia
C.
Pulsus paradoxus
D.
Soft S1, S2
E.
Wheezing

pulsus paradoxus is frequently seen in patients with cardiac tamponade. Patients diagnosed with cancer, particularly of the lung and breast, may accumulate fluid within the pericardial sac, leading to cardiac tamponade. The finding of pulsus paradoxus is defined as a decrease in systolic arterial pressure of greater than 10 mmHg. It is an accentuation of the normal decrease in systolic arterial pressure of less than 10mm Hg that normally accompanies inspiration. Symptoms of dyspnea and fatigue in a patient with lung cancer and emphysema are not uncommon. The other choices are nonspecific to a cardiac etiology. Choice A, crackles at the bases, could be in pulmonary etiology. Choice B, tachycardia, is also nonspecific, and can be found in patients who are febrile, or with lung disease. Choice D, a soft S1, S2, may be found in patients with emphysema and an increased AP diameter. Choice E is likely pulmonary.

A 42-year-old male presents with a history of low grade fever, cough, and myalgias for five days. He states that these symptoms began after a cave exploration trip along the Ohio River two weeks ago, and have since worsened. An x-ray reveals focal consolidation, and you suspect Histoplasmosis pneumonia. Which of the following is the first line treatment of choice?
A.
Azithromycin
B.
Doxycycline
C.
Itraconazole
D.
Terbinafine
E.
Trimethoprim-sulfamethoxazole

Histoplasmosis is caused by a dimorphic fungus, most commonly Histoplasma capsulatum (although other species exist). Within the United States, endemic areas include the Ohio and Mississippi river valleys. Additional areas of risk include other parts of North, South, and Central America, Africa, Mexico, and Central Asia. Large amounts of bird and bat droppings within specific soils promote the growth of the fungus, and exposure typically occurs during activities that disrupt the soil and aerosolize the spores. Depending upon the length and intensity of exposure, and the patient's immune system and previous lung history, infections may range from asymptomatic to severe. Treatment is based upon the patient's clinical picture, with mild to moderate disease being treated with oral antifungal agents.

What is the treatment of choice for a patient who is HIV positive and has a confirmed pneumonia caused by Pneumocystosis jiroveci (as shown above)?
A.
trimethoprim-sulfamethoxazole
B.
Azithromycin
C.
Aztreonam
D.
Cephalexin
E.
Erythromycin

For a confirmed bacteria or suspected case of pneumonia caused by Pneumocystosis jiroveci, TMP-SMX is the antibiotic of choice for this patient.

A 22-year-old woman with a history of scoliosis presents to the office with complaints of a retrosternal chest discomfort, occurring frequently at rest and lasting for several hours at a time. She is currently experiencing this chest discomfort during the office visit. On physical exam, a mid-systolic click is noted. With standing, the click moves closer to S1. An EKG demonstrates normal sinus rhythm at 76 bpm, with no acute ST or T wave changes. Which of the following diagnostic studies would be the most appropriate next step given this patient's physical exam findings?
A.
Chest x-ray
B.
Transesophageal echocardiogram
C.
Holter monitor
D.
Treadmill exercise stress test
E.
Transthoracic echocardiogram

Choice E, transthoracic echocardiogram, is a simple, sensitive, and non-invasive diagnostic tool, which can evaluate for the presence of valvulopathy or congenital heart disease in this young patient. Choice A might be able to give evidence of cardiomegaly, but would not be sensitive enough to detect valvulopathy. Choice C is a useful diagnostic tool for evaluation of patients complaining of palpitations, but incorrect for this patient who has no symptoms of palpitations. Choice D, although a useful diagnostic tool for the evaluation of exercise tolerance and in patients complaining of chest pain, does not allow direct visualization of the heart valves to evaluate for valvulopathy. Given her relative youth and lack of other cardiac risk factors, transthoracic echocardiogram should be performed before stress testing.

A 33-year-old female presents to the emergency department for the complaint of palpitations that have been present for the last month. She states that she feels like they are beating out of her chest, and at times they are accompanied by mild shortness of breath. She denies any orthopnea, dyspnea on exertion, syncope, weakness, or headaches. On physical exam, she is alert, awake, and in no distress. Her vital signs are as follows: temperature is 98.9, pulse is 100, respiratory rate is 18, and blood pressure is 132/90. Her HEENT is within normal limits, her neck is supple with a slightly enlarged thyroid that is non-tender without nodules, her lungs are clear, and cardiac is a regularly irregular rhythm. Based on these findings, what is the best therapy for this patient?
A.
No therapy
B.
Ablation therapy
C.
Beta blockers
D.
Digoxin
E.
Verapamil

This patient has asymptomatic bigeminy. In this case, the patient is otherwise healthy and has no other medical problems. Patients with this presentation require no therapy, and this is an incidental finding on her evaluation. Only monitoring of the patient is considered.

A 57-year-old man with a history of HTN, hyperlipidemia, and chronic tobacco use presents to the office with complaints of chest tightness that occurs every time he begins raking leaves. If he stops and rests, it is relieved within 5 minutes. He has no associated nausea or diaphoresis, but does admit to associated dyspnea. Which of the following is the most likely diagnosis?
A.
Pericarditis
B.
Acute myocardial infarction
C.
Stable angina pectoris
D.
Prinzmetal angina
E.
Myocarditis

Choice C, stable angina pectoris, is chest or arm discomfort that is reliably precipitated by activity and/or emotional distress, and relieved with rest or sublingual nitroglycerin. Choice A, pericarditis, would present with chest discomfort that is worse while supine and improves while sitting up, as well as a pericardial friction rub. Choice B, acute myocardial infarction, requires troponin elevation to establish the diagnosis. Choice D, prinzmetal angina, or variant angina pectoris, is defined as coronary artery spasm associated with ST-segment elevation, usually occurring at rest, and frequently at the same time of the day.

A 16-year-old boy is seen for a sports physical prior to starting football. On auscultation, a grade II/IV holosystolic murmur is appreciated at the apex. Which of the following maneuvers would be the most appropriate to choose to increase the intensity of the murmur for better identification?
A.
Isometric hand grip exercise
B.
Listening with the bell at the apex, with the patient in the left lateral decubitus position
C.
Inspiration, followed by the patient holding his/her breath
D.
Valsalva maneuver
E.
Having the patient lie flat with the knees bent

Utilizing isometric hand grip exercises, the murmur increases in intensity and may be heard radiating to the axilla. Isometric hand grip exercises increase the intensity of the murmur of mitral regurgitation by increasing arterial and left ventricular pressure, which increases the flow across the mitral valve, thereby increasing the murmur's intensity. Choice B is best used when listening to the murmur of mitral stenosis. Choice C will increase the AP diameter, making it more difficult to hear the murmur. With the Valsalva maneuver, choice D, the murmur decreases in intensity. Choice E is the best position for the abdominal exam, especially in males.

A 2-year-old male presents with a 10-day history of fever, cough, and decreased appetite and fluid intake. He is normally healthy. On examination, the child appears ill, has a temperature of 102.2 0F, a pulse rate of 122, and a respiratory rate of 36. On auscultation of the lungs there are rhonchi heard on the right lung fields, as well as a small amount of wheeze. A chest x-ray is ordered, which reveals the presence of pneumatoceles. Based on these findings, what is the most likely pathogen causing this patient's infection?
A.
Streptococcus pneumoniae
B.
Hemophilus influenza
C.
Staphylococcal aureus
D.
Pseudomonas aeurginosa
E.
Chlamydia pneumoniae

Pneumatoceles, pyopneumothorax, and empyemas are frequently encountered in pediatric Staphylococcal aureus pneumonias.

A 34-year-old male has a one and one-half day history of fever, chills, a non-productive cough, and malaise. He is otherwise healthy with no long-standing medical history, and is taking no chronic medications. On examination, the patient has a temperature of 101.30F, BP 123/63, P 78, R 18. His HEENT reveals mild rhinorrhea, moist mucous membranes, clear lung sounds, and a regular rate and rhythm. The rapid nasal viral test for influenza B is positive. Based on this information, what is the medication treatment for this patient?
A.
Amantadine
B.
Oseltamavir
C.
Ramantadine
D.
Famciclovir
E.
Azithromycin

Oseltamivir is the best antiviral medication for the treatment of acute influenza. This medication is ideally started within the first onset of illness, usually within the first 24 to 36 hours. Amantadine and Ramantidine have been shown to not be effective, and there is growing resistance to the medication.

Which valve is the most commonly affected in a case of rheumatic heart disease?
A.
Aortic
B.
Mitral
C.
Tricuspid
D.
Pulmonic
E.
Bicuspid aortic valve

The mitral valve is affected in about 75 to 80% of all cases of rheumatic heart disease. The aortic valve is second, and it is rare that the right-sided valves get diseased.

During the physical exam of a patient with a suspected pleural effusion, you ask the patient to make the sound "eee." You note on auscultation that the transmission is auscultated as "ay," suggestive of resonance through fluid. What is the name of this exam technique?
A.
Bronchophony
B.
Diaphragmatic excursion
C.
Egophony
D.
Tactile fremitus
E.
Whispered pectoriloquy

Normal lungs transmit spoken sounds faintly and with indistinct syllables, except over main bronchi. An area of fluid, such as a pleural effusion, consolidation or atelectasis, and areas of fibrosis will increase sound transmission and alter the distinction of the sound. This occurs for both whispered and spoken sounds. The utilization of the spoken sound "eee," auscultating for a change to "ay" due to fluid within the lung fields, is termed egophony. The use of whispered sounds and generally spoken sounds to determine lung changes are termed whispered pectoriloquy and bronchophony respectively. Diaphragmatic excursion is performed to determine the thoracic diaphragmatic movement during respiration. Tactile fremitus assesses chest vibration during vocalization, with changes being noted in the presence of consolidation (increases fremitus) and pleural effusion (decreased or absent fremitus).

At what stage of hospitalization can active tuberculosis patients be placed in a non-negative pressure room?
A.
When patient is afebrile
B.
When patient is on a minimum of three days of antibiotics
C.
When there is a clear chest x-ray
D.
When there is a clear sputum gram stain
E.
When patient is absent of leukocytosis

Once the patient has had a documented clear sputum gram stain that shows no evidence of the tuberculin bacteria, then the patient can be cleared. Chest x-rays can lag on clearing and would not be an effective measure of clearance. Leukocytosis does not rule in or rule out the infection and is not a reliable indicator.

A 77-year-old female who was admitted to the hospital for acute coronary syndrome was found to have the rhythm strip shown when she arrived to the floor. Her initial vital signs were as follows: temperature is 99.0, pulse rate is 140, blood pressure is 100/65, and respiratory rate is 16. An initial bolus and infusion of amiodarone was started, with little success of slowing the rate or converting the patient's rhythm. About an hour later, the blood pressure dropped to 80/55 and she was becoming diaphoretic, with increased dyspnea and some mild chest discomfort. What is the next step in treating this patient?
A.
Synchronized cardioversion
B.
Increase dose of amiodarone
C.
Infusion of magnesium sulfate
D.
Intravenous metoprolol
E.
Adenosine

This patient has unstable, sustained ventricular tachycardia. Because of the symptoms, and most importantly the blood pressure, it is critical to intervene immediately to prevent a cardiac arrest. The treatment option of choice in this case is synchronized cardioversion. Adenosine is not a viable option and may put the patient into a lethal arrhythmia.

A two-week-old female is being evaluated in the clinic, and on examination she is noted to have bounding pulses with a widened pulse pressure. There is a rough, machinery sounding murmur present at the second left intercostal space. Cyanosis is not present. Which of the following diagnostic tests would be the most useful in confirming the suspected diagnosis in this patient?
A.
Cardiac catheterization
B.
Chest x-ray
C.
ECG
D.
Echocardiography
E.
Nuclear stress test

The suspected diagnosis is a patent ductus arteriosus. The most useful test in confirming the diagnosis is echocardiography. This test provides direct visualization, and confirms the direction and degree of shunting. Cardiac catheterization is not required for diagnosis, but the catheterization lab is used to perform the surgical procedure to close the patent ductus arteriosus. A chest x-ray may be normal in cases of a small shunt. ECG may also be normal if the size of the shunt is small. A nuclear stress test is not used in evaluation of a patent ductus arteriosus.

A 57-year-old man with a history of HTN, hyperlipidemia, and chronic tobacco use presents to the emergency department with complaints of worsening chest tightness over the last 2 months. He initially noticed that every time he raked leaves, he had a few minutes of chest tightness, which was relieved within 5 minutes if he rested. He now notices that raking will precipitate severe chest discomfort, diaphoresis, and dyspnea, which lasts for 20 minutes even if he rests. Last night, while watching football, he again noticed chest tightness, which began suddenly and slowly dissipated over 15 minutes. His physical examination is normal. An EKG performed during an episode of chest discomfort demonstrates normal sinus rhythm at 90 bpm with ST-segment depression. Beta blockers, IV nitroglycerin, aspirin, and oxygen are started. Serial troponin levels are negative. A repeat EKG continues to demonstrate ST segment depression, along with t-wave inversion. The patient's chest discomfort is decreased in intensity and duration, but returns periodically. Which of the following is the most appropriate next step in the management of this patient?
A.
Cardiac catheterization
B.
Exercise nuclear stress test
C.
Holter monitor
D.
Tilt table test
E.
Transesophageal echocardiogram

In patients with unstable angina pectoris, if symptoms and EKG changes are not stabilized with appropriate medical therapy, including beta blockade, aspirin, oxygen, and nitroglycerin, then choice A, cardiac catheterization, with likely percutaneous coronary intervention, would be recommended, as this patient is at high risk for acute myocardial infarction. Choice B, exercise nuclear stress testing, would provide information regarding exercise tolerance and exercise-induced dysrhythmias, as well as regarding myocardial ischemia, but in this unstable patient, it would not be recommended. In patients whose conditions stabilize with medical therapy, nuclear stress testing is a viable option. Choice C, Holter monitor, is a useful diagnostic tool for evaluation of patients with palpitations occurring on a daily basis. Choice D, tilt table testing, is utilized in the evaluation of patients suffering from near-syncope or syncope. Choice E, transesophageal echocardiogram, is helpful in more direct visualization of heart valves, especially when transthoracic echocardiogram is unclear.

A 55-year-old woman with a history of mitral stenosis, secondary to rheumatic heart disease, presents to the emergency department with increasing dyspnea while walking up one flight of stairs. She denies chest pain and discomfort, but states that recently she has also noticed palpitations. She also admits to lower extremity edema, which is new within the last week. Which of the following tachyarrhythmias is she most likely to demonstrate on EKG?
A.
Ventricular tachycardia
B.
Atrial flutter
C.
Ventricular fibrillation
D.
Ventricular bigeminy
E.
Torsades de pointes

Choice B is correct. As patients with mitral stenosis age, and their mitral stenosis progresses to moderate or moderately severe mitral stenosis (most commonly after their fourth decade), the incidence of atrial arrhythmias—including premature atrial contractions, paroxysmal tachycardia, atrial flutter, and atrial fibrillation—increases. Choices B, C, D, and E are less likely, given that they are ventricular arrhythmias.

A 22-year-old woman with a history of scoliosis presents to the office with complaints of retrosternal chest discomfort, occurring frequently at rest and lasting for several hours at a time. She is currently experiencing this chest discomfort during the office visit, but has never experienced this while working out three days per week. On physical exam, a mid-systolic click is noted. With standing, the click moves closer to S1. An EKG demonstrates normal sinus rhythm at 76 bpm, with no acute ST or T wave changes. A transthoracic echocardiogram reveals mild prolapse of the posterior leaflet of the mitral valve. Which of the following would be the most appropriate next step in the management of this patient?
A.
Reassurance and monitoring with periodic transthoracic echocardiogram
B.
Cardiac catheterization
C.
Infectious endocarditis prophylaxis
D.
Mitral valve replacement
E.
Transesophageal echocardiogram

Choice A, reassurance and monitoring with periodic transthoracic echocardiogram, is the most appropriate choice given the patient's findings on echocardiogram. Most patients with mitral valve prolapse are asymptomatic, and do not demonstrate significant progression of their valvulopathy over their lifetime. Periodic transthoracic echocardiogram allows a noninvasive, highly sensitive method of monitoring. Choice B, cardiac catheterization, is useful for evaluation of coronary artery anatomy and for evaluation of valvulopathy; however, it is invasive, and usually reserved for investigation of serious valvular dysfunction, and/or following a stress test suggestive of myocardial ischemia. The chest pain experienced by patients with mitral valve prolapse is varied in presentation, and in this setting, with a young patient with no cardiac risk factors, unlikely to be secondary to coronary artery disease. According to the American Heart Association's most recent guidelines, patients with mitral valve prolapse alone do not require infectious endocarditis prophylaxis, so choice C is inappropriate. Choice D, mitral valve replacement, is only indicated with severe mitral valve prolapse, resulting in severe mitral regurgitation. Choice E, transesophageal echocardiogram, while an excellent diagnostic tool for the evaluation of mitral valve disease, would be more invasive than monitoring via transthoracic echocardiogram, and thus would not be an appropriate choice in this patient with only mild mitral valve prolapse.

Which lobe is most affected by infection of tuberculosis?
A.
Left lower lobe
B.
Left upper lobe
C.
Right upper lobe
D.
Right lower lobe
E.
Right middle lobe

The apical sections of the lung fields are the most typical areas where tuberculosis occurs. The right side is more prevalent than the left. Other findings on chest x-rays can include pleural effusions, Gohn lesions (calcified primary focus), and cavitation.

What is the most common pathogen that causes an acute bronchitis?
A.
Viral
B.
Bacterial
C.
Fungal
D.
Unknown
E.
Spirochetal

Respiratory viruses are the most common cause of acute bronchitis. In clinical medicine, it is rare to obtain cultures for patients who present with bronchitis symptoms.

An 84-year-old female complains of intermittent dyspnea and dizziness over the past 4 months. She is found to have an irregular rhythm on exam. Her EKG findings are below. Based on the EKG findings, which single laboratory test may lead to finding a secondary cause?
A.
B12 level
B.
folic acid
C.
lipid profile
D.
erythrocyte sedimentation rate (ESR)
E.
thyroid-stimulating hormone (TSH)

The correct answer is (E). This patient has atrial fibrillation, which can occur in patients with hyperthyroidism, Therefore, it is important to check a TSH in patients who present with atrial fibrillation, especially in the elderly. Choices (A), (B), (C), and (D) are not secondary causes of atrial fibrillation.

What is the most common clinical cardiac abnormality that is associated with acute rheumatic heart disease?
A.
Hypotension
B.
Arrhythmia
C.
Ischemia
D.
Ventricular aneurysm
E.
Carditis

Carditis is the most common finding in rheumatic heart disease. This can present with the sequelae of pericarditis, cardiomegaly, heart failure (either right or left sided), and either a mitral or aortic murmur.

A 63-year-old male with a longstanding history of chronic obstructive pulmonary disease and a recent exacerbation, is also found to have new onset rapid atrial fibrillation. Which of the following medications, used for atrial fibrillation, should be used cautiously as it is associated with bronchospasm and pulmonary function changes?
A.
Amiodarone
B.
Digoxin
C.
Diltiazem
D.
Ibutilide
E.
Metoprolol

Initial atrial fibrillation management will depend on the stability of the patient, and may involve emergent electrocardioversion if the patient is unstable. Several types of medications are used for medication cardioversion and subsequent rate management in atrial fibrillation patients, including each of the medications listed in the answer choices. Caution should be used when administering a beta-blocker, even a cardioselective choice, to a patient with longstanding lung disease and recent exacerbation, as this may promote bronchospasm and associated dyspnea.

It is a busy day in the internal medicine office. A 49-year-old noncompliant male with history of non-insulin-dependent diabetes mellitus (NIDDM) and hypertension returns for his 3-month follow-up, now 1 year later. His blood pressure is 156/92, P = 88, BS 250 mg/dl fasting, urine +microalbumin, +glucose, -ketones. He is not taking any medications at this time. You request that he resume his metformin from his last visit, but want to give him something else based on your current findings. What single medication would be best choice for this patient to treat both his blood pressure and microalbuminuria?
A.
atenolol
B.
lisinopril
C.
amlodipine
D.
hydrochlorothiazide (HCTZ)
E.
terazosin

The correct answer is (B). ACE inhibitors, such as lisinopril, or ARBs are both ideal choices for treating patients with diabetes that have hypertension and microalbuminuria. Although beta blockers (atenolol), calcium channel blockers (amlodipine), and diuretics (HCTZ) are recommended for use in diabetes to control blood pressure, they are not the first choice for patients with chronic kidney disease and will not reduce microalbuminuria. Terazosin (alpha blocker) would not be recommended first-line for a diabetic with hypertension and has no effect on microalbuminuria.

A 23-year-old female presents to the clinic for evaluation of a pre-employment physical examination with evidence of a first-degree AV block on ECG. She is otherwise healthy and without any medical history, is not on any medications, and is symptom free. Based on this history, what is the treatment for this patient?
A.
Beta-blockers
B.
Definitive electrophysiology study
C.
No treatment, only monitoring
D.
Ablation therapy
E.
Calcium channel blockers

First-degree AV block needs no immediate therapy. The treatment is to monitor the patient for any changes that may occur if a new disease presents itself.

Which of the following findings would be evidence of a patient who has longstanding chronic obstructive pulmonary disease (COPD)?
A.
a decreased FEV1 on spirometry that is not fully reversible with nebulizer treatment
B.
chest radiograph with an elevated hemidiaphragm
C.
FEV1/FVC ratio > 0.7
D.
a decreased A-a-Do2 on arterial blood gas
E.
an abnormal sweat test

Spirometry provides objective information about pulmonary function and assesses the results of therapy. Pulmonary function tests early in the course of COPD reveal only evidence of abnormal closing volume and reduced midexpiratory flow rate. Reductions in FEV1 and in the ratio of forced expiratory volume to vital capacity (FEV1% or FEV1/FVC ratio) occur later. In severe disease, the FVC is markedly reduced. Lung volume measurements reveal a marked increase in residual volume (RV), an increase in total lung capacity (TLC), and an elevation of the RV/TLC ratio, indicative of air trapping, particularly in emphysema.

Arterial blood gas measurements characteristically show no abnormalities early in COPD other than an increased A-a-DO2. Indeed, they are unnecessary unless (1) hypoxemia or hypercapnia is suspected, (2) the FEV1 is < 40% of predicted, or (3) there are clinical signs of right heart failure.

Radiographs of patients with chronic bronchitis typically show only nonspecific peribronchial and perivascular markings. Plain radiographs are insensitive for the diagnosis of emphysema; they show hyperinflation with flattening of the diaphragm in less than half of cases.

What is the most common ECG abnormality in patients with a pulmonary embolism (PE)?
A.
Atrial fibrillation
B.
Sinus tachycardia
C.
Ventricular ectopy
D.
Sinus bradycardia
E.
High grade AV block

In most cases, sinus tachycardia is the only abnormality in patients with a PE. You may also find some ECGs that will have non-specific ST-T wave changes. Sinus bradycardia and AV blocks are not common findings that are associated with PE.

Which of the following is the most prevalent fatal cancer in the United States?
A.
Cervical
B.
Colon
C.
Esophageal
D.
Liver
E.
Lung

Lung cancer continues to lead as the major cause of cancer deaths in both men and women in the United States, with cigarette smoking causing greater than 90% of cases. Despite educational campaigns highlighting the risks of smoking, lung cancer continues to kill more individuals that colorectal, breast, and prostate cancers combined.

A 33-year-old IV drug user presents to the emergency department with pleuritic chest pain, cough, chills, diaphoresis, anorexia, and malaise. On physical exam, her temperature is 40°C, BP 98/55, P 115 bpm, and RR 22. No murmur could be appreciated. Two separate blood cultures are positive for S.aureus. An EKG, CXR, and transesophageal echocardiogram are ordered. Which of the following lesions is most likely to be seen on TEE in this patient?
A.
Aortic valve vegetation
B.
Tricuspid valve vegetation
C.
Mitral valve vegetation
D.
Left ventricular hypertrophy
E.
Ventricular septal defect

In almost 50% of cases involving IV drug users, the only site of infection is the tricuspid valve, and most lesions are left-sided, so choice B is the most appropriate answer. Left ventricular hypertrophy, choice D, is seen in patients with a history of hypertension. Choice E, ventricular septal defect, is frequently associated with a holosystolic murmur.

You evaluate a 72-year-old male for a pre-operative physical examination prior to total left-knee replacement. He has a 20-year history of hypertension and is currently taking lisinopril 10 mg QD and HCTZ 25 mg QD. He denies any complaints. You obtain the EKG below. What finding on this patient's EKG is a potential complication of sustained hypertension?
A.
acute STEMI
B.
atrial flutter
C.
atrial fibrillation
D.
left ventricular hypertrophy
E.
congestive heart failure

The EKG represents left ventricular hypertrophy (LVH) with strain pattern. A finding of LVH on an EKG in a patient with hypertension suggests an increased cardiovascular risk. The EKG does not show ST elevations consistent with a STEMI and the patient is asymptomatic. Congestive heart failure (CHF) cannot be diagnosed by this EKG alone, but patients with CHF may have LVH. The patient has a sinus rhythm with distinguishable P waves, which are not consistent with atrial fibrillation or flutter.

A 70-year-old man with a history of pulmonary hypertension and obstructive sleep apnea presents with complaints of increasing dyspnea while walking his dog. He has also recently noted increased lower extremity edema. On physical examination, jugular venous distension is noted. Auscultation of the chest demonstrates a high-pitched blowing diastolic murmur. With inspiration, the murmur increases in intensity and is heard over the second and third left intercostal spaces. An S3 is appreciated. Palpation of the precordium reveals a hyperdynamic right ventricle, and both a systolic and diastolic thrill. The abdominal exam reveals hepatomegaly and splenomegaly. Based on this patient's history and physical exam findings, which of the following is the most likely finding on echocardiogram?
A.
Tricuspid regurgitation
B.
Aortic stenosis
C.
Atrial septal defect
D.
Pulmonic regurgitation/insufficiency
E.
Mitral stenosis

This patient is demonstrating signs and symptoms of right heart failure, and with a history of pulmonary hypertension and a high-pitched diastolic blowing murmur (Graham Steell murmur), choice D is the most likely of the choices offered. A blowing holosystolic murmur at the left lower sternal border is characteristic for tricuspid regurgitation, choice A. Choice B, aortic stenosis, presents with a systolic ejection murmur. An atrial septal defect, choice C, if large, could present with similar symptoms of exertional dyspnea secondary to a large shunt, but auscultation would reveal a moderately loud systolic ejection murmur that is heard best in the second and third interspaces. This is secondary to increased pulmonary arterial flow. Choice E, mitral stenosis, presents with a systolic murmur heard best in the left lateral decubitus position, with the bell of the stethoscope at the apex.

A 24-year-old female HIV-positive patient, who is not currently on medication, presents to the emergency department with acute dyspnea, tachycardia, fever, nonproductive cough, and a room air oxygen saturation of 92%. She admits feeling poorly for the past five days. A physical exam reveals bilateral basilar crackles. An x-ray reveals Pneumocystis jiroveci pneumonia. The patient has no drug allergies. Which of the following is the first-line treatment of choice?
A.
Amphotericin B
B.
Clarithromycin
C.
Clindamycin
D.
Pentamidine
E.
Trimethoprim-sulfamethoxazole

Based upon current clinical data, the preferred agent for treatment of Pneumocystis jiroveci infections is oral trimethoprim-sulfamethoxazole. Second-line medications may include single agent or combination therapy, utilizing clindamycin, primaquine, dapsone, pentamadine, and/or atovaquone. Clarithromycin is the agent of choice for Mycobacterium avium complex infection, and amphotericin B would be indicated for Cryptococcal meningitis, as well as other fungal infections.

What dietary restrictions should be placed on a patient with dilated cardiomyopathy?
A.
Low carbohydrate
B.
High fructose
C.
Low sodium
D.
High calcium
E.
High protein

A diet low in sodium is useful in the treatment goals of dilated cardiomyopathy. This is especially true in cases of acute heart failure.

A 76-year-old man with a history of HTN and diabetes mellitus, type 2, presents to the emergency department with complaints of palpitations, tachypnea, and chest pain. He denies history of CAD, stroke, TIA, or congestive heart failure. He is afebrile, with vital signs as follows: BP 145/98, HR 138, and RR 22. His EKG is shown (Figure 1). Troponins are negative X 3. His echocardiogram demonstrates normal LV systolic function and normal valvular function. Which of the following questions, when answered, will help to determine the next course of therapy?
A.
How long has the patient been a diabetic?
B.
Has the patient ever had an allergic reaction to aspirin?
C.
Does the patient have a family history of dysrhythmia?
D.
Is the patient a smoker?
E.
How long has the patient been experiencing palpitations?

Choice E is the most important question to ask to determine the next course of therapy. If the patient has been experiencing definitive symptoms for less than 48 hours, direct current cardioversion can be performed, as the risk of atrial clot formation and thromboembolism is low. Choice A is incorrect because the CHADS2 scoring system does not take into account how long the patient has been diabetic. Choice B is incorrect because aspirin therapy is not utilized. Choice C is incorrect because family history is not a factor in determining the patient's treatment plan. Choice D is incorrect because smoking status is used in calculating Framingham risk score, not a CHADS2 score.

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