Cardiology Rosh
Methyldopa
A 33-year-old woman is seen in clinic for pregnancy induced hypertension. Which of the following antihypertensives is considered safe during pregnancy? A. Lisinopril B. Losartan C. Methyldopa D. Nitroprusside
Furosemide
A 35-year-old man presents to the emergency department after a motor vehicle collision with prolonged extrication. He complains of severe pain in his leg, which was trapped under the car for 3 hours. A 12-lead ECG obtained in triage is shown above. Which of the following interventions will decrease total body potassium stores? A. Calcium gluconate B. Furosemide C. Insulin D. Magnesium sulfate
Adenosine
A 39-year-old woman presents with palpitations and lightheadedness. Her rhythm strip is shown above. Which of the following treatments is indicated? A. Adenosine B. Defibrillation C. Procainamide D. Sedation with etomidate following by electrical cardioversion
Normal sinus rhythm
A 46-year-old woman is in your office for her yearly physical. What is your interpretation of her ECG? A. Atrial fibrillation B. Atrial flutter C. Normal sinus rhythm D. Sinus tachycardia
Fusion beats
A 72-year-old man presents for evaluation of palpitations. He has a regular, wide complex tachycardia at a rate of 140 bpm. Which of the following supports a diagnosis of ventricular tachycardia? A. Discordance of the QRS axis in the precordial leads B. Fusion beats C. Leftward axis D. ST elevation greater than 5 mm
COPD
What is the most likely underlying chronic medical problem in the patient with the following ECG? A. Cardiomyopathy B. COPD C. Hyperthyroidism D. Mitral stenosis
Complete heart block
Which of the following best describes the rhythm seen in the ECG above? A. Complete heart block B. First degree heart block C. Mobitz I (Wenckebach) D. Mobitz II
Tetralogy of Fallot
Which of the following congenital disorders results in a cyanotic child? A. Atrial septal defect B. Coarctation of the aorta C. Tetralogy of Fallot D. Ventricular septal defect
Flecainide
Which of the following is a class IC anti-arrhythmic? A. Amiodarone B. Flecainide C. Lidocaine D. Procainamide
Tetralogy of Fallot
A 1-month-old newborn is being evaluated for perioral cyanosis while feeding that is associated with sweating and difficulty breathing. His rectal temperature is 100.1°F, blood pressure is 80/45 mm Hg, heart rate is 180 beats per minute, and his respiratory rate is 22 breaths per minute. On physical exam, a grade 3/6 harsh systolic ejection murmur with a single loud S2 is heard at the left upper sternal border. ECG shows right ventricular hypertrophy with right axis deviation. Chest X-ray reveals a boot-shaped heart and decreased pulmonary vascular markings. Which of the following is the most likely diagnosis? A. Atrial septal defect B. Coarctation of the aorta C. Tetralogy of Fallot D. Total anomalous pulmonary venous return
Adenosine
A 12-year-old boy with Wolff-Parkinson-White syndrome presents with palpitations for the past hour. His blood pressure is 110/62 mm Hg and pulse is 166 bpm. The ECG reveals a narrow-complex tachycardia. Vagal maneuvers are ineffective. Which of the following is the next most appropriate management? A. Adenosine B. Cardioversion C. Procainamide D. Radiofrequency ablation
Coarctation of the aorta
A 13-year-old boy presents to the office with pain in his legs with activity that has gradually become worse over the past month. He is unable to ride a bicycle with his friends due to the pain in his legs. Examination of the heart reveals an ejection click and accentuation of the second heart sound. Femoral pulses are weak and delayed compared to the brachial pulses. Blood pressure obtained in both arms is elevated. Chest X-ray reveals rib notching. Which of the following is the most likely diagnosis? A. Abdominal aortic aneurysm B. Coarctation of the aorta C. Pheochromocytoma D. Thoracic outlet syndrome
Cease all physical activity until further evaluation can be performed
A 14-year-old boy presents to the clinic for a well child check. He has been growing well and has no medical complaints. On exam, he is found to have a III/VI systolic crescendo-decrescendo murmur heard best over the left sternal border. The murmur increases when moving from a squatting position to a standing position, and increases with Valsalva maneuver. The point of maximal impulse is displaced laterally. Which of the following is the next best step in management? A. Cease all physical activity until further evaluation can be performed B. Encourage hydration during physical activity C. Perform genetic testing D. Prescribe a beta-blocker
Obtain blood pressure readings in the upper and lower extremities
A 16-year-old girl presents to the ED for a minor laceration repair of her forehead after a picture frame fell off the wall and hit her. Her vital signs are blood pressure 175/75 mm Hg, HR 80 bpm, and RR 14/min. The patient states on review of systems that she has had headaches, chest pain, and fatigue over the previous few months. You note a systolic murmur in the left infraclavicular area and under the left scapula. Which of the following is the most important next step in management? A. Arrange for outpatient follow-up for repeat blood pressure B. Obtain blood pressure readings in the upper and lower extremities C. Obtain urinary metanephrines D. Order a renal ultrasound with Doppler
First-degree atrioventricular block
A 16-year-old man presents to the clinic for a sports physical. He never experiences any chest pain or shortness of breath and exercises frequently. An ECG is performed and is shown above. What is the most likely diagnosis? A. First-degree atrioventricular block B. Second-degree atrioventricular block (Mobitz Type II) C. Sinus arrhythmia D. Sinus bradycardia
Standing
A 19-year-old man presents to the ED after a syncopal event. The patient states that he was moving a large pile of wood in his backyard and then suddenly became dizzy. He awoke with his neighbor standing over him, asking if he was okay. On exam, you note a loud crescendo-decrescendo systolic murmur at the left lower sternal border. He has a family history of a "heart condition." Which of the following maneuvers will accentuate the murmur? A. Leg elevation B. Squatting C. Standing D. Trendelenburg
Reassurance
A 23-year-old man is admitted for a femur fracture. An admission ECG is shown above. What management is indicated? A. Atropine B. Beta blocker C. Reassurance D. Transvenous pacing
Basilar crackles and peripheral edema
A 23-year-old woman delivers her first child. Her family history is positive for three uncles who needed early-in-life surgery for "heart defects." You are asked to assess her 1-day-old infant who does not "appear well" according to the nursing staff. During your examination, which of the following findings most suggests the presence of congenital heart disease? A. Basilar crackles and peripheral edema B. Fever C. Symmetric brachial and femoral pulses D. Systolic murmur
Valsalva maneuver
A 23-year-old woman presents with acute onset dizziness and palpitations. Her ECG reveals evidence of AV nodal reentrant tachycardia with a rate of 170. Her blood pressure is 140/70 mm Hg. Which of the following is the most appropriate initial treatment? A. Atropine B. Cardioversion C. Valsalva maneuver D. Verapamil
Ebstein's anomaly
A 24-year-old pregnant woman presents to the urgent care clinic where you are working. During your assessment, she states that she saw her obstetrician when she first became pregnant but has not had any follow-up care since. You also find out that she has bipolar disorder and took lithium throughout the first trimester. What congenital abnormality is the fetus at risk of developing? A. Ebstein's anomaly B. Eisenmenger's syndrome C. Pulmonary atresia D. Tetralogy of Fallot
Adenosine
A 24-year-old woman presents to the Emergency Department with complaints of palpitations and lightheadedness for the past 30 minutes. A rhythm strip is performed and is shown above. She has no significant past medical history and denies any drug or alcohol use. Vital signs show a blood pressure of 132/86 mm Hg and an oxygen saturation of 96 percent on room air. Which of the following medications is the most appropriate for the treatment of this condition? A. Adenosine B. Amiodarone C. Amrinone D. Atropine
Treat the patient's pain and reassess the blood pressure
A 24-year-old woman with no past medical history presents with left wrist pain after a fall. The left extremity is grossly deformed, and the patient complains of severe pain. The patient has a blood pressure of 183/100 mm Hg. What management is indicated for the patient's elevated blood pressure while awaiting X-rays? A. Arrange admission for blood pressure control B. Start an oral beta-blocker and monitor for response C. Start intravenous beta-blocker and admit to the intensive care unit D. Treat the patient's pain and reassess the blood pressure
Conduction reentry
A 26-year-old woman presents with dizziness and palpitations. She reports episodes of these symptoms beginning about 1 week ago, which initially only lasted a few minutes. However, for the past two days, she has had about 4 episodes a day which last about 20 minutes each. Her social history is significant for heavy caffeine intake. Her pulse is 166 bpm and her blood pressure is 140/70. Her rhythm strip is seen above. Which of the following best describes the most likely underlying cardiac pathology responsible for this patient's symptoms? A. Conduction reentry B. Dilated cardiomyopathy C. Myocardial infarction D. Valvular abnormality
Instruct the patient to follow-up with his private physician within 2 months for recheck
A 28-year-old man presents to the emergency department with a 1 cm laceration to the left forearm. The patient is in good health and has no other complaints. At triage, the patient's blood pressure is noted to be 155/94 mm Hg. The remainder of his vital signs are normal. Following repair of the laceration, the patient's blood pressure is rechecked and found to be unchanged. What is the best approach to this patient's elevated blood pressure? A. Administer labetalol or nifedipine with observation until systolic BP is < 140 mm Hg B. Evaluate for end organ damage with chest X-ray, ECG, electrolytes, BUN/creatinine, and urinalysis C. Instruct the patient to follow-up with his private physician within 2 months for recheck D. No further ED management required
Console the child in a knee-chest position
A 3-week-old baby girl with an unknown birth history presents to the emergency department with 3 days of poor feeding and recurrent cyanotic episodes. On exam, she is agitated, tachypneic, tachycardic with central cyanosis and a harsh systolic crescendo decrescendo murmur along the left mid-to-upper sternal border. An arterial oxygen saturation is 78% and a chest X-ray shows a boot-shaped heart. What is the best initial step in management? A. Administer morphine 0.2 mg/kg IM B. Administer propanolol 0.01 mg/kg IV C. Console the child in a knee-chest position D. Start positive pressure ventilation
Hypertrophic cardiomyopathy
A 32-year-old man presents after a syncopal episode. He was running on the track when he developed shortness of breath followed by witnessed syncope. He was not post-ictal and had no seizure activity. He reports that his father's brother died while playing basketball. Physical examination is notable for a midsystolic crescendo-decrescendo murmur. Which of the following is the most likely diagnosis? A. Aortic stenosis B. Arrhythmogenic right ventricular dysplasia C. Hypertrophic cardiomyopathy D. Wolff-Parkinson-White syndrome
Observation
A 32-year-old previously healthy man presents to the ED with a 4-hour history of palpitations. He denies chest pain, shortness of breath, or history of similar palpitations. He does admit to heavy alcohol use in the past week, drinking 1 pint of vodka and a 24-pack of beer each day. In the ED, his vital signs are BP 135/75, HR 115, RR 14, and oxygen saturation 98% on room air. An irregularly irregular rhythm is heard on auscultation and an ECG shows atrial fibrillation. What is the next step in management? A. Chemical cardioversion B. Observation C. Rate control D. Synchronized cardioversion
Orthodromic atrioventricular reentrant tachycardia
A 35-year-old man presents to the emergency department after a syncopal episode. He describes the sensation of palpitations prior to losing consciousness. Witnesses state he was unconscious for approximately 30 seconds and was not confused upon awakening. ECG in the emergency department shows the rhythm above. Which of the following is the most common dysrhythmia associated with this condition? A. Antidromic atrioventricular reentrant tachycardia B. Atrial fibrillation C. Atrioventricular nodal reentrant tachycardia D. Orthodromic atrioventricular reentrant tachycardia
Widened QRS complex
A 37-year-old man presents to the emergency department with chest pain and shortness of breath. His medical history is significant for uncontrolled type I diabetes and end-stage renal disease on hemodialysis. His last dialysis was four days ago and he missed his appointment this morning. His labs are notable for a fingerstick blood glucose 300 mg/dL, potassium 7.0 mmol/L, magnesium 2.0 mEq/L, and phosphorus 4.0 mmol/L. Which of the following findings is most likely to be seen on this patient's ECG? A. Osborn waves B. QT interval prolongation C. U waves D. Widened QRS complex
Cardioversion
A 37-year-old woman with a history of Wolff-Parkinson-White presents to the emergency department with shortness of breath and lightheadedness. Her vital signs on arrival are T 36.9°C, HR 160, BP 80/50, RR 27. Her ECG reveals a narrow complex regular tachycardia. Which of the following is the most appropriate next step in the management of this patient? A. Adenosine B. Cardioversion C. Fluid bolus D. Procainamide
Symptomatic care and discharge
A 39-year-old man presents to the ED complaining of general weakness. He has signs of an upper respiratory infection on exam. His rhythm strip is seen above. Which of the following is the most appropriate next step in management? A. Administer 325 mg aspirin and send for a troponin B. Apply transcutaneous pacemakers and admit C. Consult cardiology D. Symptomatic care and discharge
Initiate propranolol
A 44-year-old woman presents to the Emergency Department with palpitations following the death of her mother 2 days prior. Her ECG is consistent with normal sinus rhythm with a QTc interval of 520 msec. Her heart rate is 86 bpm and blood pressure is 117/82 mm Hg. Her medications include lisinopril and metformin. She took lorazepam yesterday for anxiety related to the loss of her mother. What is the most appropriate next step? A. Administer adenosine B. Discontinue lorazepam C. Initiate propranolol D. Perform vasovagal maneuvers
Adenosine 12 mg intravenous
A 45-year-old woman presents to the emergency department with palpitations. She is placed on the monitor which shows a rapid narrow-complex tachycardia. Her heart rate is 160 bpm and blood pressure is 120/70 mm Hg. Vagal maneuvers are attempted and fail. Next, adenosine 6 mg IV is given intravenously without a change in her rhythm. Repeat vitals show a heart rate 165 bpm and blood pressure 120/70 mm Hg. What is the most appropriate next step in management? A. Adenosine 12 mg intravenous B. Adenosine 6 mg intravenous C. Synchronized cardioversion D. Vagal maneuvers
Chronic obstructive pulmonary disease
A 46-year-old man presents to his primary care provider with a headache, shortness of breath, and palpitations. He reports that his symptoms started after a long weekend of binge drinking. He typically drinks seven beers per day. He has a 35 pack-year history and quit smoking five years ago when he was diagnosed with COPD. He has a history of hypertension and is currently taking lisinopril 40 mg PO daily. His family history is significant for a father who passed away from a myocardial infarction at 44 years of age and a brother who had a stroke at 32 years of age. His rhythm strip is shown above. Which of the following is the most likely underlying cause of the patient's dysrhythmia? A. Chronic obstructive pulmonary disease B. Excessive alcohol use C. Family history of coronary artery disease D. Hypertension
Ventricular septal defect in the membranous portion
A 5-week-old infant suffers from dyspnea and fluid overload, but not cyanosis. Auscultation reveals a loud, holosystolic murmur at the lower left sternal border. You suspect a congenital cardiac defect. Echocardiography would most likely show which of the following abnormalities? A. Aorta is connected to the right ventricle B. Pulmonary artery is connected to the left ventricle C. Ventricular septal defect in the membranous portion D. Ventricular septal defect in the muscular portion
Echocardiogram
A 5-year-old girl with Turner syndrome is found to have systolic hypertension. Further examination reveals diminished femoral pulses. Which of the following is the most appropriate tool for establishing this patient's likely diagnosis? A. Cardiac catheterization B. Chest X-ray C. Echocardiogram D. Electrocardiogram
Atropine
A 50-year-old woman presents to the emergency department following a syncopal episode. On physical exam she is diaphoretic. She is alert and oriented. Her blood pressure is 90/50 mm Hg and respirations are 12 per minute. Her rhythm strip is shown above. What is the most appropriate pharmacologic treatment for this patient's condition? A. Adenosine B. Amiodarone C. Amlodipine D. Atropine
Warfarin
A 50-year-old woman with a history of mitral stenosis secondary to rheumatic fever presents with atrial fibrillation. She does not have a history of heart failure, hypertension, diabetes mellitus or previous stroke or transient ischemic attack. What is the most appropriate management for this patient? A. Aspirin B. Dabigatran C. No anticoagulation D. Warfarin
No intervention
A 52-year-old man presents from his primary care physician's office for evaluation of an abnormal electrocardiogram. His ECG is seen above. He has no symptoms. What is the appropriate intervention? A. Measurement of cardiac enzymes B. No intervention C. Telemetry observation D. Transcutaneous pacer pad placement
Enalapril
A 52-year-old man presents to discuss his elevated blood pressure. He brings in his home blood pressure readings which have been between 150-160/90-100 for the past two weeks. The patient's past medical history includes type 2 diabetes and hyperlipidemia. Which of the following is the most appropriate treatment for this patient's hypertension? A. Doxazosin B. Enalapril C. Furosemide D. Metoprolol
Resume outpatient medication
A 52-year-old man states he took his blood pressure and it was elevated to 180/100 mm Hg. He states that he missed his regular dose of antihypertensive medication because he was traveling for business and returned home today. His blood pressure now is 176/102 mm Hg. The patient is otherwise asymptomatic and has a normal physical exam. What is the most appropriate action? A. Admission for blood pressure monitoring B. Obtain an ECG C. Reduce mean arterial pressure by 25% with an intravenous antihypertensive D. Resume outpatient medication
Magnesium sulfate
A 54-year-old man with a history of schizophrenia presents to the ED after a syncopal episode. During your evaluation, he becomes diaphoretic and complains of dizziness. You are able to feel a radial pulse, and he is alert and talking with you. His rhythm strip is seen above. Which of the following represents the first-line treatment of this disorder? A. Amiodarone B. Labetalol C. Magnesium sulfate D. Synchronized cardioversion
Atropine
A 55-year-old man presents after a syncopal event. He states he just started a new blood pressure medication. His heart rate is 41 beats/minute and his blood pressure is 95/60 mm Hg. Electrocardiogram shows sinus bradycardia. Which of the following medications should be administered? A. Adenosine B. Atropine C. Diltiazem D. Procainamide
Synchronized cardioversion at 200 joules
A 55-year-old man presents to the emergency department complaining of palpitations, nausea, and dizziness for 30 minutes. He is afebrile, his pulse is 140 beats per minute, and his blood pressure is 78/50 mm Hg. As the nurse attaches him to the cardiac monitor, you see the rhythm strip shown above. What is the most appropriate treatment? A. Adenosine 6 mg IV push B. Defibrillation at 360 joules C. Procainamide 18 mg/kg infused over 30 minutes D. Synchronized cardioversion at 200 joules
Discontinue the lisinopril and start the patient on hydrochlorothiazide
A 58-year-old African-American man with a history of hypertension presents to your office for his annual exam. His BP is 145/95 and HR is 75. He is taking lisinopril as previously prescribed. According to JNC-8 hypertension guidelines, which of the following is the most appropriate next step in his management? A. Continue the lisinopril and start the patient on an angiotensin receptor blocker B. Continue the lisinopril and start the patient on hydrochlorothiazide C. Discontinue the lisinopril and start the patient on an angiotensin receptor blocker D. Discontinue the lisinopril and start the patient on hydrochlorothiazide
Defibrillation
A 58-year-old man is brought to the ED for chest pain that started 30 minutes prior to arrival while he was jogging in the park. Initially, the patient's cardiac monitor shows sinus tachycardia with a rate of 120 beats per minute. However, while you are interviewing the patient in the resuscitation bay, he suddenly becomes pale, pulseless, and the above rhythm is seen on the cardiac monitor. Which of the following is the definitive next step to manage this rhythm? A. Chest compressions B. Defibrillation C. Epinephrine D. Synchronized cardioversion
Cotton wool spots
A 58-year-old man presents to the emergency department with complaints of a moderate headache and blurry vision over the past few hours. On exam, his blood pressure is 210/110 mm Hg. Which finding are you most likely to observe during the funduscopic exam? A. Cherry red spot B. Cotton wool spots C. Hollenhorst plaques D. Roth spots
Restrictive cardiomyopathy
A 59-year-old woman has furosemide-resistant peripheral edema and ascites. Her medical history is significant for sarcoidosis. You order an echocardiogram which reveals increased wall thickness and decreased cavity size of the right ventricle, enlarged atria and a normal appearing left ventricle. Cardiac MRI shows no fatty deposition in the ventricular walls. Which of the following is the most likely diagnosis? A. Arrhythmogenic right ventricular cardiomyopathy B. Dilated cardiomyopathy C. Hypertrophic cardiomyopathy D. Restrictive cardiomyopathy
Ventricular tachycardia
A 60-year-old man presents with the ECG seen above. His blood pressure is 80/60 mm Hg. Which of the following is the most likely diagnosis? A. Atrial flutter B. Atrioventricular reentry tachycardia C. Supraventricular tachycardia D. Ventricular tachycardia
No bridging agent is necessary
A 60-year-old man with a history of hypertension and paroxysmal atrial fibrillation is scheduled to undergo an elective dental extraction. His paroxysmal atrial fibrillation is rate controlled with a beta blocker and he is on chronic anticoagulation with warfarin. Anticoagulation must be discontinued for the procedure. His medications include metoprolol tartrate, lisinopril and warfarin. In addition to discontinuing warfarin, which of the following is the most appropriate next step in management? A. Bridge with aspirin B. Bridge with intravenous unfractionated heparin C. Bridge with low molecular weight heparin D. No bridging agent is necessary
Make a medication adjustment
A 60-year-old woman with a history of hypertension, dyslipidemia and coronary artery disease was sent to the emergency department from her primary care physician's office for a heart rate of 40/min. She has no complaints except for mild fatigue. Her medications include metoprolol, atorvastatin, lisinopril and baby aspirin. Her ECG reveals sinus bradycardia and her labs and physical exam are within normal limits. Which of the following is the most appropriate next step in management? A. Administer atropine B. Make a medication adjustment C. Schedule her for a temporary pacemaker D. Watchful waiting
Second-degree Mobitz type I AV block
A 61-year-old woman presents to the Emergency Department after several episodes of syncope. Her rhythm strip is shown above. Which of the following atrioventricular blocks is present? A. First-degree AV block B. Second-degree Mobitz type I AV block C. Second-degree Mobitz type II AV block D. Third-degree AV block
Restrictive cardiomyopathy
A 62-year-old man with a history of sarcoidosis presents with dyspnea, fatigue, and signs of right-sided heart failure. Physical exam shows elevated jugular venous pressure and hepatomegaly. Echocardiogram shows reduced diastolic filling. Magnetic resonance imaging shows gadolinium hyperenhancement. Which of the following is the most likely diagnosis? A. Dilated cardiomyopathy B. Hypertrophic cardiomyopathy C. Restrictive cardiomyopathy D. Takotsubo cardiomyopathy
Calcium gluconate, albuterol, regular insulin and glucose, furosemide
A 63-year-old man with a history of stage 3 chronic renal insufficiency presents feeling weak. Blood testing demonstrates a potassium of 6.7. An electrocardiogram is obtained as seen above. What combination of medications is appropriate for the treatment of this patient? A. Calcium gluconate, albuterol, regular insulin and glucose, furosemide B. Calcium gluconate, penicillin, warfarin C. Digoxin, metoprolol, furosemide D. Regular insulin and glucose, Aldactone
Give the patient a prescription for his medications and refer to his primary doctor in 48 hours
A 64-year-old man with a history of hypertension presents to the Emergency Department requesting medication refills. He states that he has not taken his medications for the last 2 weeks. His blood pressure is 190/100 mm Hg. He has no complaints at this time. He has prescription bottles for atenolol and hydrochlorothiazide. What management is indicated? A. Change his medications to a calcium-channel blocker B. Give the patient a prescription for his medications and refer to his primary doctor in 48 hours C. Start intravenous labetalol and admit to the floor D. Start intravenous labetalol and admit to the intensive care unit
Procainamide
A 65-year-old man is brought to the ED complaining of nausea for the last two hours. On arrival to the emergency department, he has the cardiac rhythm seen above. His blood pressure is 110/70 mm Hg. He denies any headache, chest pain, or difficulty breathing. Which of the following is the most appropriate next step in management? A. Defibrillation B. Magnesium sulfate C. Procainamide D. Synchronized cardioversion
Atrial fibrillation
A 65-year-old man presents to the Emergency Department complaining of palpitations for the last week. The palpitations are intermittent, but more severe in the last 3 hours. His heart rate is 140 and blood pressure is 130/80 mm Hg. His ECG is shown above. What is the cardiac rhythm shown on the ECG? A. Atrial fibrillation B. Atrial flutter C. Paroxysmal atrial tachycardia D. Sinus tachycardia
Stress-induced cardiomyopathy
A 65-year-old woman presented to the emergency department with sub-sternal chest pain and dyspnea. Her cardiac biomarkers were mildly elevated and there was ST-segment elevation in the anterior leads. Apical ballooning was seen on echocardiography and coronary angiography revealed normal coronary arteries. She has no past medical history and takes no medications. Recently the patient lost her husband of 40 years. What is the most likely diagnosis? A. Non-ST-elevation myocardial infarction B. Pericarditis C. ST-elevation myocardial infarction D. Stress-induced cardiomyopathy
Amlodipine
A 67-year-old African-American man established care with you two months ago after being told at a community health fair that his blood pressure was elevated. The blood pressure readings done in your office include 168/94, 158/98 and 162/96. You determine that the patient has primary essential hypertension. Lifestyle measures have already been instituted but you decide that medication is also warranted at this time. Which of the following is the best initial agent for blood pressure control in this patient? A. Amlodipine B. Clonidine C. Metoprolol D. Prazosin
Pacemaker
A 67-year-old woman with sick sinus syndrome complains of significant lightheadedness. If she is driving and a "dizzy spell" begins, she has to pull off the road and wait for it to pass. You capture an ECG during one of her spells in the office and note a bradycardia in the 50s. Which of the following is the best treatment recommendation? A. Atenolol B. Defibrillator C. Digitalis D. Pacemaker
Verapamil
A 68-year-old man is being managed on a multi-drug antihypertensive regimen for essential hypertension. His blood pressure is at goal, but he notes persistent constipation and bilateral pedal edema. Which of the following medications is most likely responsible for these side effects? A. Enalapril B. Losartan C. Metoprolol D. Verapamil
Sick sinus syndrome
A 71-year-old woman presents with 2 days of dizziness and "almost passing out." Her ECG shows episodes of alternating bradycardia and tachycardia with narrow QRS complexes. Which of the following is the most likely diagnosis? A. Atrial flutter B. Digitalis toxicity C. Sick sinus syndrome D. Ventricular tachycardia
First degree atrioventricular block
A 72-year-old man has been more fatigued lately. As a result, his primary practitioner orders an electrocardiogram. A P wave is present for every QRS complex and the PR interval is 225 milliseconds in length. Which of the following is the diagnosis? A. First degree atrioventricular block B. High-grade atrioventricular block C. Mobitz type I atrioventricular block D. Third degree atrioventricular block
Synchronized cardioversion
A 72-year-old woman presents to the ED with an acute onset of dyspnea and palpitations that began four hours prior to arrival. Vital signs include a heart rate of 144 beats per minute, blood pressure of 80/50 mm Hg, respiratory rate of 28 breaths per minute, temperature of 98.6°F (37.0°C), and a pulse oximetry of 88% on room air. The above 12-lead ECG is obtained. What is the most appropriate next step in the management of this patient? A. Anticoagulation with enoxaparin followed by warfarin B. Chemical cardioversion using procainamide C. Rate control using diltiazem D. Rate control using esmolol E. Synchronized cardioversion
Hypertensive emergency
A 74-year-old man presents to the ED with chest pain radiating to the jaw and dyspnea. His past medical history is significant for hypercholesterolemia, hypertension and diabetes. He denies illicit drug use. His blood pressure is 210/122 mm Hg. Physical exam and chest X-ray are normal. His ECG is consistent with left ventricular hypertrophy. Which of the following is the most likely diagnosis? A. Autonomic dysreflexia B. Hypertensive emergency C. Hypertensive urgency D. Sympathetic crisis
Atropine
A 78-year-old man presents to the emergency department with generalized weakness and confusion. His electrocardiogram is shown above. His blood pressure is 82/51 mm Hg. While transcutaneous pacing is being prepared, which of the following is the most appropriate initial drug therapy? A. Atropine B. Glucagon C. Procainamide D. Verapamil
Ligation
A continuous systolic-diastolic murmur is auscultated in a 3-week-old dyspneic infant. She is tachypneic and diaphoretic. Her mother reports weight loss and poor feeding. Doppler color-flow imaging reveals high velocity jets in the pulmonary artery. This patient will most likely undergo which of the following corrective surgeries? A. Arterial-switch B. Ligation C. Shunting D. Valvulotomy
Urinalysis
A detailed history and examination does not aid in the evaluation of new-onset hypertension in a 47-year-old man. In an attempt to search for an underlying cause, you order a basic metabolic panel, complete blood count, lipid panel and ECG. Which of the following tests should also be added to this standard diagnostic screen of secondary hypertension? A. Aortic ultrasound B. Echocardiogram C. Renal angiogram D. Urinalysis
Intravenous labetalol, to goal within 1 to 2 hours
A man presents to the emergency department with a blood pressure of 200/136 mm Hg and laboratory evidence of acute renal failure. Which of the following medications and initial blood pressure response rates are the most appropriate at this time? A. Intravenous labetalol, to goal within 1 to 2 hours B. Intravenous nicardipine, to goal within 6 to 12 hours C. Oral clonidine, to a goal within 3 to 6 days D. Oral magnesium sulfate, to a goal within 1 to 2 days
Type I second-degree AV block
A man who presents with syncope is placed on the cardiac monitor. On the monitor you note a repeating trend of 6 P waves, 5 of which are followed by a narrow QRS complex and 1 of which is not followed by a QRS complex. The PR interval during this trend progressively increases. Which of the following is the most likely diagnosis? A. First-degree AV block B. Third-degree AV block C. Type I second-degree AV block D. Type II second-degree AV block
Hypertrophic cardiomyopathy
A man with dyspnea-on-exertion presents for cardiac evaluation. Physical exam is significant for a left sternal border systolic murmur which is louder during a Valsalva maneuver. An S4 is also appreciated. The ECG shows large QRS complexes. An echocardiogram reveals a decrease in left ventricular chamber volume and normal left atrial measurements. Which of the following is the most likely diagnosis? A. Aortic stenosis B. Dilated cardiomyopathy C. Hypertrophic cardiomyopathy D. Mitral stenosis
Tetralogy of Fallot
A newborn is being evaluated for cyanosis. Physical examination shows a prominent right ventricular impulse and a systolic thrill. A crescendo-decrescendo murmur with a harsh systolic ejection quality is heard along the left upper sternal border. Based on these findings, which of the following is the most likely diagnosis? A. Tetralogy of Fallot B. Transposition of the great arteries C. Tricuspid atresia D. Truncus arteriosus
Tetralogy of Fallot
A one-year-old girl presents to the emergency room after her mother noticed that she became blue while crying. The patient subsequently squatted on the ground and the mother noticed a resolution in the cyanosis. On physical exam, the patient is now calm and vital signs are normal. A loud systolic ejection murmur is noted on physical exam. Chest X-ray demonstrates a "boot-shaped" heart. Which of the following is most likely the diagnosis? A. Coarctation of the aorta B. Tetralogy of Fallot C. Transposition of the great arteries D. Ventricular septal defect
Bundle of Kent
A patient is being evaluated for palpitations in the emergency department. An ECG reveals a short PR interval, widened QRS and slurred upstroke of the QRS complex. Which of the following is the name of bypass pathway associated with this condition? A. Bachmann's bundle B. Bundle of His C. Bundle of Kent D. Left bundle branch
Atrial flutter
A patient presents with palpitations and dyspnea. She is placed on a cardiac monitor as seen above. Which of the following is the most likely diagnosis? A. Atrial fibrillation B. Atrial flutter C. Ventricular fibrillation D. Ventricular tachycardia
Cardiac transplantation
A patient with dyspnea and angina fails medication management of his symptoms with beta-blockers, ACE-inhibitors and calcium channel blockers. He undergoes complete cardiac evaluation which uncovers the presence of nonobstructive, end-stage hypertrophic cardiomyopathy. Which of the following is the most appropriate treatment at this point in time? A. Aggressive diuresis B. Cardiac transplantation C. Implantable intracardiac pacing D. Surgical myectomy
Magnesium sulfate
A patient with palpitations presents to the ED. Her rhythm strip is seen above. Which of the following is the most appropriate initial management? A. Amiodarone B. Cardioversion C. Magnesium sulfate D. Transvenous pacing at 60-80 bpm
Prednisone
A patient with sarcoidosis presents with progressive peripheral edema. Echocardiography reveals restrictive cardiomyopathy. In addition to diuresis and heart rate control, which of the following is also appropriate? A. Buspirone B. Melphalan C. Phlebotomy D. Prednisone
Cyanotic congenital heart disease
A patient with which one of the following congenital heart diseases would benefit from palivizumab administration? A. Cyanotic congenital heart disease B. Patent ductus arteriosus C. Pulmonic stenosis D. Secundum atrial septal defect
Polymorphic ventricular tachycardia
A previously healthy 16-year old boy presents to your office after having a syncopal episode at the start of track practice. An ECG reveals a QTc of 520 ms. This is confirmed on a subsequent ECG. This finding is associated with which one of the following rhythm abnormalities? A. Paroxysmal supraventricular tachycardia B. Polymorphic ventricular tachycardia C. Sinus arrest D. Third degree atrioventricular block
Tetralogy of Fallot
A six-week old infant presents to the ED with his mother who states he has not been feeding well. She notes that he grunts with feeding and that his fingers seem to turn blue. On physical exam, you observe cyanosis under the tongue and in the distal extremities. A chest radiograph is seen above. Which of the following is the likely cause of this infant's presentation? A. Coarctation of the aorta B. Patent ductus arteriosus C. Tetralogy of Fallot D. Ventricular septal defect
Reassurance and discharge home
A term 20-day-old infant presents to the ED from urgent care for an abnormal ECG obtained for fussiness. His mother had routine prenatal care and states he has not had fever, is gaining weight, eating well without sweating or cyanosis, and making normal wet and dirty diapers. At this time, his symptoms have resolved. Your exam is unremarkable and his vitals are within normal limits for age. The ECG is only remarkable for a rightward axis of +140°. Which of the following is the best next step in the management of this patient? A. Chest X-ray for heart size B. Emergent echocardiogram C. Outpatient holter monitor D. Reassurance and discharge home
Defibrillation
A woman with known coronary artery disease presents to the ED with chest pain and ventricular tachycardia. Five minutes after admission she becomes unresponsive. Her rhythm strip is seen above. Which of the following is the most appropriate intervention? A. Beta-blockade B. Cardioversion C. Defibrillation D. Vasopressin
Bradykinin
Closure of the ductus arteriosus begins when levels of which of the following substances increases in the immediate post-natal period? A. Adrenocorticotrophic hormone B. Bradykinin C. Prostaglandin E1 D. Pulmonary surfactant
Oxygenated blood from left to right atria
The typical flow of blood across an atrial septal defect occurs in which of the following fashions? A. Deoxygenated blood from left to right atria B. Deoxygenated blood from right to left anterior descending coronary arteries C. Oxygenated blood from left to right atria D. Oxygenated blood from right to left atria
Flecainide
Which of the following antiarrhythmic medications is contraindicated in the setting of coronary artery or structural heart disease? A. Amiodarone B. Dofetilide C. Dronedarone D. Flecainide
Left bundle branch block
Which of the following best describes the finding seen in the ECG above? A. Left bundle branch block B. Right bundle branch block C. Second-degree atrioventricular block D. Sinoatrial block
Right bundle branch block
Which of the following best describes the finding seen in the ECG above? A. Left bundle branch block B. Right bundle branch block C. Third-degree AV block D. Type I second-second degree AV block
A 55-year-old man with a blood pressure of 185/90 mm Hg whose creatinine has increased from 1.0 to 2.5 mg/dL within 36 hours
Which of the following clinical scenarios can be defined as a hypertensive emergency? A. A 25-year-old pregnant woman in her second trimester with a blood pressure of 155/100 mm Hg with a normal urinalysis B. A 55-year-old man with a blood pressure of 185/90 mm Hg whose creatinine has increased from 1.0 to 2.5 mg/dL within 36 hours C. A 59-year-old asymptomatic man requesting a medication refill and found to have a blood pressure of 210/110 mm Hg and an ECG consistent with left ventricular hypertrophy (LVH) D. A 63-year-old woman with a history of poorly controlled hypertension who presents with a finger laceration and is noted to have a blood pressure of 200/105 mm Hg
Pulmonary hypertension
Which of the following conditions would most likely result in right axis deviation on an ECG? A. Aortic valve stenosis B. Chronic hypertension C. Excess abdominal fat D. Pulmonary hypertension
The PR interval is shortened in sinus rhythm
Which of the following describes ECG findings in Wolff-Parkinson-White Syndrome? A. The delta wave reflects rapid conduction through the AV node B. The PR interval is shortened in sinus rhythm C. The QRS complex is typically narrow in sinus D. The QT segment is prolonged in sinus rhythm
Wolff-Parkinson-White syndrome
Which of the following diseases is characterized by the presence of a delta wave on an electrocardiogram? A. Charcot-Marie-Tooth disease B. Parkinsonism C. Parkinson's disease D. Wolff-Parkinson-White syndrome
Nicardipine
Which of the following drugs is classified as a calcium channel blocker? A. Alendronate B. Calcitonin C. Nicardipine D. Olanzapine
Ethanol
Which of the following drugs is most likely to be associated with the development of atrial tachydysrhythmias? A. Ethanol B. Gamma hydroxybutyrate (GHB) C. Lorazepam D. Phenobarbital
Hypocalcemia
Which of the following is a cause of torsades de pointes? A. Drugs that shorten the QT interval B. Hyperkalemia C. Hypocalcemia D. Marijuana use
Tetralogy of Fallot
Which of the following is a cyanotic congenital heart disease? A. Atrial septal defect B. Coarctation of the aorta C. Patent ductus arteriosus D. Tetralogy of Fallot
Propranolol
Which of the following is a medical treatment for congenital long QT syndrome? A. Flecainide B. Propafenone C. Propranolol D. Quinidine
Coarctation of the aorta
Which of the following is an acyanotic congenital cardiac defect? A. Coarctation of the aorta B. Ebstein's anomaly C. Hypoplastic left heart syndrome D. Pulmonary atresia
Primary aldosteronism
Which of the following is an independent cause of secondary hypertension? A. Addison's disease B. Atrial fibrillation C. Hypercholesterolemia D. Primary aldosteronism
Asymptomatic Mobitz type II second degree heart block
Which of the following is an indication for permanent pacemaker placement? A. Asymptomatic Mobitz type I second-degree AV block B. Asymptomatic Mobitz type II second degree heart block C. Asymptomatic sinus bradycardia with heart rate of 40/min D. Asymptomatic three second sinus pauses
Wolff-Parkinson-White syndrome
Which of the following is associated with a shortened PR interval? A. Brugada syndrome B. Mobitz second-degree atrioventricular block C. Wellens syndrome D. Wolff-Parkinson-White syndrome
Coarctation of the aorta
Which of the following is most likely to present as a ductal-dependent cardiac lesion? A. Atrial septal defect B. Coarctation of the aorta C. Isolated ventricular septal defect D. Mitral valve prolapse
Ventricular septal defect
Which of the following is the most common congenital heart defect? A. Atrial septal defect B. Coarctation of the aorta C. Patent ductus arteriosus D. Ventricular septal defect
Procainamide
Which of the following is the treatment of choice in antidromic atrioventricular reciprocating tachycardia in a hemodynamically stable patient? A. Adenosine B. Diltiazem C. Electrical cardioversion D. Procainamide
Ibutilide
Which of the following medications can be used in the treatment of hemodynamically stable atrial fibrillation with concomitant Wolff-Parkinson-White syndrome? A. Adenosine B. Diltiazem C. Ibutilide D. Metoprolol
A 66-year-old man with a history of hypertension, diabetes, and ethanol abuse
Which of the following patients with atrial fibrillation has the greatest risk for complications from anticoagulation therapy? A. A 64-year-old woman with hypertension and history of colon cancer B. A 66-year-old man with a history of hypertension, diabetes, and ethanol abuse C. A 79-year-old man with a history of heart failure D. A 90-year-old otherwise healthy woman
Ocular fundus
Which of the following should be assessed in the physical exam of a patient with essential hypertension? A. Costovertebral angle tenderness B. Deep tendon reflexes C. Ocular fundus D. Pupillary response
Dilated cardiomyopathy
You are examining an afebrile 78-year-old woman in the emergency department. During cardiac examination, you auscultate a low-intensity, low-pitch extra heart sound, which occurs in early diastole. You do not hear any murmurs. Her ECG appears normal. Which of the following is the most likely diagnosis? A. Bacterial endocarditis B. Dilated cardiomyopathy C. Right bundle branch block D. Tricuspid stenosis
Patent ductus arteriosus
You are performing a newborn exam on a one-day-old baby girl. In doing so, you hear a continuous, rough, machinery-like murmur during cardiac auscultation. Which of the following heart lesions is most closely associated with the murmur you heard? A. Atrial septal defect B. Patent ductus arteriosus C. Still's murmur D. Ventricular septal defect
Decreasing glomerular blood flow
You prescribe ramipril to a 65-year-old man with uncontrolled hypertension and severe renovascular disease. At a follow-up visit four weeks later his creatinine is noted to be 2.3. His creatinine before starting the ramipril was 1.0. By what mechanism did the ACE inhibitor cause this change? A. Activating the arachidonic acid pathway B. Decreasing glomerular blood flow C. Increasing angiotensin II activity D. Increasing serum kinin levels
Surgical repair
An 8-month-old infant with a ventricular septal defect has significant growth failure. He also suffers from recurrent pneumonia. Which of the following is the best management of this patient? A. Atenolol B. Furosemide C. Indomethacin D. Surgical repair
Atrial fibrillation
An elderly patient is admitted to the hospital for multiple episodes of syncope. Telemetry reveals periods of sinus bradycardia in the 30s followed by a tachydysrhythmia with heart rates that fluctuate in the 100 to 160 range. During several of the bradycardia episodes the patient becomes hypotensive and symptomatic with shortness of breath, lightheadedness, and dizziness. Which of the following is the most likely underlying tachydysrhythmia associated with this patient's most likely diagnosis? A. Atrial fibrillation B. Atrial flutter C. Multifocal atrial tachycardia D. Sinus tachycardia
Concentric left ventricular hypertrophy
Aortic stenosis can lead to which of the following general patterns of left ventricular remodeling? A. Asymmetric left ventricular hypertrophy B. Concentric left ventricular hypertrophy C. Eccentric left ventricular hypertrophy D. Mixed concentric/eccentric left ventricular hypertrophy
Torsades de pointes
Which one of the following cardiac dysrhythmias is associated with antipsychotic use? A. Atrial fibrillation B. Third degree heart block C. Torsades de pointes D. Wolff-Parkinson-White syndrome
Holter monitor
A 35-year-old woman with alcohol abuse presents to clinic complaining of "skipped heart beats." Her examination is normal. An in-office ECG is also normal. Laboratory testing is nonspecific. Which of the following is the next most appropriate test? A. Echocardiogram B. Electromyography C. Holter monitor D. Sestamibi scan
Multifocal atrial tachycardia
A 73-year-old man with a history of hypertension and COPD presents with the ECG seen above. Which of the following is the correct diagnosis? A. Atrial fibrillation B. Atrial flutter C. Multifocal atrial tachycardia D. Wandering pacemaker
Atrial fibrillation
A 74-year-old man is having a pre-operative ECG performed. What is your interpretation of his ECG? A. Atrial fibrillation B. Atrial flutter C. Normal sinus rhythm D. Sinus tachycardia
Atrial fibrillation
A 74-year-old man is having a preoperative ECG performed. What is your interpretation of his ECG? A. Atrial fibrillation B. Atrial flutter C. Normal sinus rhythm D. Sinus tachycardia
Vagal maneuvers
A 27-year-old man with known Wolff-Parkinson-White syndrome presents to the emergency department with palpitations. He denies chest pain, shortness of breath, or lightheadedness. His vitals are HR 120, RR 15, BP 110/70. Which of the following is the most appropriate next step in the management of this patient? A. Adenosine B. Electrical cardioversion C. Procainamide D. Vagal maneuvers
Ventricular septal defect
A 3-day-old baby girl has a holosystolic murmur along the left lower sternal border. What is the most likely diagnosis? A. Aortic stenosis B. Atrial septal defect C. Patent ductus arteriosus D. Ventricular septal defect
24-48 hour continuous ambulatory ECG monitor
A 35-year-old woman is seen in the clinic with a chief complaint of frequent palpitations associated with symptoms of pre-syncope. She experiences these episodes two to three times per day. Her resting ECG in the office is normal sinus rhythm with heart rate 65/min. Her physical exam is unremarkable. Which of the following is the most appropriate next step in management? A. 24-48 hour continuous ambulatory ECG monitor B. Electrophysiologic testing C. Implantable loop recorder D. Post-symptom event recorder
Apnea
A 1-week-old boy born at term to a 16-year-old primigravida mother without complications presents to the ED for lethargy. In the ED, his vital signs include a T 37°C, HR 166 bpm, RR 82/min, and oxygen saturation of 80%. On exam, he is lethargic with diffuse pulmonary rales and rhonchi, cold extremities, and decreased peripheral pulses. Given concern for a ductal-dependent cardiac lesion, you administer an infusion of prostaglandin E1. Which of the following is a known adverse reaction of prostaglandin E1 infusion? A. Apnea B. Hypertension C. Hypothermia D. Thrombocytosis
Atrioventricular reentrant tachycardia
A 10-year-old boy presents to the emergency department complaining of sudden-onset lightheadedness and chest discomfort. His vital signs are T 98.6°F, heart rate 205 beats per minute, respiration rate 30 breaths per minute, and 98% oxygen saturation. His electrocardiogram is shown above. What is the most likely diagnosis? A. Atrial fibrillation B. Atrial flutter C. Atrioventricular reentrant tachycardia D. Ventricular tachycardia
Admit to a telemetry unit for cardiology consult and AICD placement
A 22-year-old man presents to the Emergency Department after a syncopal episode. His ECG is shown above. He is currently asymptomatic with normal vital signs. Which of the following is the most appropriate next step in management? A. Admit to a telemetry unit for cardiology consult and AICD placement B. Discharge with cardiology follow up as an outpatient C. Order emergent echocardiogram D. Start amiodarone for treatment of presumed ventricular tachycardia
Premature ventricular contraction
A 78-year-old man complains of his "heart -stopping". After reviewing his ECG, you appreciate intermittent, large, wide QRS complexes which are not preceded by a P wave. Otherwise, the rhythm strip appears normal without PR interval, ST segment, P wave or T wave abnormalities. Which of the following is the most likely diagnosis? A. Atrial fibrillation B. Multifocal atrial tachycardia C. Non-ST-elevation myocardial infarction D. Premature ventricular contraction
Ventricular tachycardia
An 81-year-old man with 10 years of coronary artery disease presents with chest pain and altered mental status. His ECG shows consecutive, large and wide QRS complexes. P waves cannot be appreciated. His pulse is 188 bpm. Which of the following is the most likely diagnosis? A. Atrial fibrillation B. Atrial flutter C. Ventricular fibrillation D. Ventricular tachycardia
< 150/90 mm Hg
According to JNC-8, patients older than 60 years with hypertension and no other medical history, should be treated to which of the following blood pressure goals? A. < 120/80 mm Hg B. < 130/85 mm Hg C. < 140/85 mm Hg D. < 150/90 mm Hg
Hypertrophic cardiomyopathy
An 18-year-old man presents after a syncopal episode. The patient states he was running, when he suddenly felt lightheaded and nauseated, leading to him passing out. On presentation, he is asymptomatic with normal vital signs. Examination reveals a healthy man with a crescendo-decrescendo murmur heard at the left sternal border. What diagnosis should be suspected in this patient? A. Hypertrophic cardiomyopathy B. Hypovolemic state C. Vasovagal syncope D. Wolff-Parkinson-White syndrome
Ventricular fibrillation
An 18-year-old man undergoes an electrocardiogram as part of a sports physical for his college soccer team. The electrocardiogram was read as abnormal, and he was sent to the ED for evaluation. His electrocardiogram is shown above. Which of the following is the most common complication found with the suspected diagnosis? A. Atrial fibrillation B. Eisenmenger syndrome C. Type 2 second-degree heart block D. Ventricular fibrillation
Atrial fibrillation
An 18-year-old man with a history of Wolff-Parkinson-White presents with a one hour history of palpitations. His triage ECG is shown above. Which of the following is the most likely diagnosis? A. Antidromic atrioventricular reciprocating tachycardia B. Atrial fibrillation C. Orthodromic atrioventricular reciprocating tachycardia D. Ventricular tachycardia
Widely split and fixed S2
An 8-month-old boy fails to obtain age-appropriate milestones. His mother feels that he is too fatigued to properly feed. An echocardiogram reveals a large atrial septal defect. Which of the following physical examination abnormalities would you most expect to find in this infant? A. Bradycardia B. Cyanosis C. Prominent left ventricular impulse D. Widely split and fixed S2
Cardiac dysrhythmia
An 83-year-old is being evaluated in the emergency department after an episode of syncope. The woman was preparing dinner when she felt her heart start to race. The next thing she remembers is waking up on the floor. She experienced a similar episode about three weeks ago. She has never had anything like this before. Her past medical history is remarkable for hypertension, hyperlipidemia and hypothyroidism. Her medications include lisinopril, atorvastatin and levothyroxine. On physical exam her blood pressure is 142/83, heart rate 76/min, and respiration rate 13/min. Cardiac auscultation reveals no murmur. The remainder of her physical exam is normal. Electrocardiogram reveals normal sinus rhythm with left axis deviation. No cardiac rhythm abnormalities are detected. What is the most likely etiology of this patient's syncope? A. Aortic stenosis B. Cardiac dysrhythmia C. Orthostatic hypotension D. Vasovagal
Diltiazem
An 85-year-old woman presents with generalized weakness for five days. Her vital signs are unremarkable except for a HR of 130-150 bpm. Her ECG is shown above. Which of the following represents the first-line treatment for this patient? A. Adenosine B. Amiodarone C. Diltiazem D. Synchronized cardioversion
Digoxin
An elderly man with congestive heart failure presents to the ED with a complaint of "not feeling normal." He is on several different medications. His ECG is shown above. Which of the following medications is the most likely cause of this ECG abnormality? A. Digoxin B. Furosemide C. Metoprolol D. Warfarin
Overriding aorta
An infant with episodes of cyanosis and respiratory difficulty is diagnosed with Tetralogy of Fallot. Which of the following defects would you expect to see on echocardiographic examination? A. Aorta-pulmonary artery transposition B. Atrial septal defect C. Left ventricular hypertrophy D. Overriding aorta
Eisenmenger syndrome
In which of the following conditions is hypoxemia caused by a right-to-left shunt? A. Asthma B. Eisenmenger syndrome C. Patent foramen ovale D. Pulmonary embolism
Right bundle branch → Purkinje fibers
Which of the following states a correct order of electrical current through the heart during one cycle of normal cardiac depolarization? A. Atrioventricular node → sinoatrial node B. Bundle of His → atrioventricular node C. Left bundle branch → right bundle branch D. Right bundle branch → Purkinje fibers
Verapamil
Which of the following treatments is contraindicated in the treatment of a 5-month-old with supraventricular tachycardia? A. Adenosine B. Ice bag to face C. Propranolol D. Verapamil
Heart rate of 160 beats per minute
Which of the following vital signs is considered abnormal in a 2-year-old patient? A. Heart rate of 160 beats per minute B. Oxygen saturation of 98% on room air C. Respiratory rate of 26 breaths per minute D. Systolic blood pressure of 85 mm Hg
Ventricular tachycardia
Capture beats and fusion beats confirm the diagnosis of which cardiac dysrhythmia? A. Atrial fibrillation B. Supraventricular tachycardia C. Ventricular fibrillation D. Ventricular tachycardia
It is safe for him to play any sport, including baseball
During a well-child visit, a 9-year-old boy and his father ask about health safety and sports activity. The boy wants to play baseball. His medical history is significant for tetralogy of Fallot, which was surgically corrected when he was 3-years-old. His last echocardiogram shows a right ventricular pressure to be < 50 mm Hg. Which of the following recommendations do you make? A. A functional capacity evaluation is needed first B. He may only play leisure sports, like golf or cycling C. It is safe for him to play any sport, including baseball D. The boy should abstain from all sports and physical education class
A patient with a left ventricular ejection fraction < 35% and heart failure NYHA Functional Class II or III
In which of the following clinical scenarios is an implantable cardioverter-defibrillator indicated for the prevention of ventricular dysrhythmias and sudden cardiac death? A. A patient with a left ventricular ejection fraction < 35% and heart failure NYHA Functional Class II or III B. A patient with a normal left ventricular ejection fraction and asymptomatic structural heart disease C. A patient with sustained ventricular tachycardia in the setting of an acute myocardial infarction D. A patient with sustained ventricular tachycardia in the setting of hyperkalemia
High-output cardiac failure
What cardiac complication is associated with hyperthyroidism? A. Aortic Dissection B. High-output cardiac failure C. Pericarditis D. Ventricular dysrhythmias
Pacemaker
What is the treatment of choice for the bradycardic component of sick sinus syndrome? A. Ablation of accessory pathways B. Chronotropic medications C. No treatment is necessary D. Pacemaker
Inverted P' wave following the QRS
Which of the following ECG findings is most characteristic of a premature junctional contraction? A. Inverted P' wave following the QRS B. Peaked T wave C. Premature P' wave D. Widened QRS > 120 msec
Carvedilol
Which of the following agents is first line for rate control in atrial fibrillation with rapid ventricular response in the setting of compensated systolic heart failure? A. Amiodarone B. Carvedilol C. Digoxin D. Diltiazem
Continue enalapril and add amlodipine
You are managing the blood pressure of a 49-year-old Caucasian woman with enalapril 20 mg twice a day. She does not have diabetes or chronic kidney disease. She has been taking the enalapril for over 1 month. Repeated blood pressure readings in both arms average out to 138/96. Which of the following is the most appropriate treatment at this time? A. Continue enalapril and add amlodipine B. Continue enalapril and add losartan C. Continue enalapril and add nothing, as she is at goal with just one medication D. Double the dose of enalapril
Chlorthalidone
You are seeing an African-American 42-year-old man for an initial primary care visit. His medical history is significant for diabetes, seasonal allergies, obesity, and rotator cuff repair. His medications include insulin and desloratadine. Proper blood pressure readings are taken: 154/98 and 148/94. Which of the following medications is most appropriate when initiating antihypertensive management in this patient? A. Candesartan B. Captopril C. Carvedilol D. Chlorthalidone
Aortic coarctation
You suspect a cardiac structural defect in a 6-month-old infant with peripheral edema and hypertension. Skin color is normal. A murmur is not appreciated. However, the blood pressure is markedly higher in the arms than legs. Which of the following is the most likely diagnosis? A. Aortic coarctation B. Great artery transposition C. Patent ductus arteriosus D. Tetralogy of Fallot
