PA Easy Cardio

Anticoagulation for atrial fibrillation in a 65-year-old with hypertension aims for an international normalized ratio (INR) of: < 1.0 1.0 to 2.0 2.0 to 3.0 3.0 to 4.0 > 5.0

2.0 to 3.0

What is the peak incidence of age for a patient who presents with acute rheumatic heart disease? <5 years old 5 to 15 years 20 to 35 years 40 to 55 years >55 years old

5 to 15 years

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

A 22-year-old man with a history of mitral valve replacement prior to tooth extraction

A 66-year-old female is admitted to the hospital with atrial fibrillation. Her past medical history has hypertension, diabetes mellitus type II, hypercholesterolemia, and rheumatoid arthritis. During her evaluation for work up it is noted that the patient has had recurring symptomatic episodes of atrial fibrillation for the last year, some resulting in the patient not being able to ambulate due to hypotensive events. Her current blood pressure is 146/83, and her heart rate is 87. Given this clinical scenario, what is the most appropriate procedure for this patient? Ablation therapy Cardiac catheterization Synchronized cardioversion Permanent pacemaker insertion Pacemaker and defibrillator insertion

Ablation therapy (The clinical scenario for patients who have recurrent symptomatic episodes related to atrial fibrillation is ablation therapy. Cardiac catheterization is sometimes performed based on suspicion of coronary artery disease, but does not address the electrophysiological reasons for the patient's episodes. Cardioversion would not address a patient who is having recurrent episodes, and there is no clinical indication for pacing or defibrillation needs)

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? Synchronized cardioversion Cardiac catheterization Ablation therapy Pacemaker insertion Long-term telemetry monitoring

Ablation therapy (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 23-year-old female who has a history of supraventricular tachycardia is having an acute episode again. She has attempted a valsalva maneuver without success in breaking the arrhythmia. The ECG confirms SVT. What is the next step in therapy for this patient? Atropine Amlodipine Adenosine Amiodarone Metoprolol

Adenosine (Intravenous adenosine is the treatment of choice in this clinical situation. If successful the adenosine will break the cycle of tachycardia, usually with a pause. The initial dose is 6mg, followed by two, 12 mg doses if unsuccessful.)

What is the most common cause of restrictive cardiomyopathy? Amyloidosis Pericarditis Marfans syndrome Fatty infiltrative disease Sarcoidosis

Amyloidosis (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.)

A 70-year-old man with a history of hypertension, DM Type 2, and hyperlipidemia is seen for pre-operative 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. Utilizing isometric hand grip exercises, the murmur increases in intensity and can be heard radiating to the left sternal border and apex. Given the patient's physical exam findings, which of the following is the most likely diagnosis? Aortic stenosis Ventricular septal defect Mitral stenosis Aortic regurgitation/insufficiency Mitral regurgitation/insufficiency

Aortic regurgitation/insufficiency (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 that is 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)

A 75-year-old woman with a history of hypertension is seen for preoperative evaluation prior to bladder suspension. On auscultation, a crescendo-decrescendo systolic ejection murmur is heard at the upper right sternal border, radiating to the carotids bilaterally. Given the patient's physical exam findings, which of the following is the most likely diagnosis? Aortic stenosis Aortic regurgitation/insufficiency Mitral stenosis Tricuspid regurgitation/insufficiency

Aortic stenosis (as the murmur of aortic stenosis is usually described as a crescendo-decrescendo or systolic ejection murmur that is heard best at the right upper sternal border. In addition, the murmur of aortic stenosis is frequently transmitted to the carotid arteries.)

A 71-year-old male who has a history of hypertension presents with a new finding of atrial fibrillation. He is independent, drives his own car, and tends to his daily activities without assistance. He is currently having no symptoms, and his heart rate is 90, with a blood pressure of 146/76. Given this clinical scenario, what is the best pharmacologic anticoagulation treatment for this patient? No anticoagulation Aspirin Aspirin and warfarin Aspirin and clopidogrel Warfarin and clopidogrel

Aspirin (This patient has a lower CHADS2 score of 1 (HTN) and would have adequate risk reduction with the therapy of aspirin alone (B). Higher risk patients with a CHADS2 score of 2 or higher qualify for adding warfarin (C), and the use of aspirin and clopidogrel (D) is not indicated)

What is the most common embolic source of acute arterial occlusion in the lower extremities? Atrial fibrillation Aortic aneurysm Myocardial infarction Prosthetic cardiac valve Iliac artery thrombus

Atrial fibrillation (The heart accounts for 80% of all emboli, with atrial fibrillation making up 70% of that)

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? Ventricular tachycardia Atrial flutter Ventricular fibrillation Ventricular bigeminy Torsades de pointes

Atrial flutter (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.)

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? Atrial septal defect Coarctation of the aorta Patent ductus arteriosus Tetralogy of fallot Aortic stenosis

Atrial septal defect (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 78-year-old male presents to the office due to increasing exertional dyspnea and cough for the past week. Physical exam reveals an S3 gallop, mild JVD, and 2+ pitting edema of the bilateral lower extremities. The patient has had mild congestive heart failure in the past. A chest x-ray reveals prominent pulmonary vasculature without any additional complications. Which of the following is released by the ventricular myocardium in response to elevated ventricular pressure and overload? B-Type natriuretic peptide (BNP) Creatine kinase MB (CK-MB) Plasma d-dimer Total creatine kinase (CK) Troponin

B-Type natriuretic peptide (BNP) (Two markers, B-type natriuretic peptide (BNP) and N-terminal pro-BNP, provide representation of the ventricular response to volume and pressure overload, and are elevated in hypervolemic states. These markers provide diagnostic information, including differentiating dyspnea causes. They may also be used to monitor CHF patient prognosis and progression.)

A 21-day-old male is brought to the pediatric clinic for concern of irritability, sweating with feeds, and fatigue. Upon examination, there is a discrepancy in the pulse between the arms and legs. The femoral pulses are diminished when compared to the brachial pulses. A murmur is present, and heard in the left axilla and the left back. An EKG is obtained, which show right ventricular hypertrophy. Echocardiography shows a localized narrowing of the aortic arch, just distal to the origin of the left subclavian artery. What is the best definitive treatment for this patient? Intravenous infusion of normal saline Placement of a pericardial patch Balloon angioplasty of the abnormality Long-term use of propranolol Performing an atrial switch operation

Balloon angioplasty of the abnormality (This patient has coarctation of the aorta. Balloon angioplasty of the abnormality is the correct answer, and is a corrective repair)

In your family practice, you perform an ankle brachial index (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? Begin the patient on aspirin 81 mg and clopidogrel 75 mg daily. Begin the patient on prasugrel 60 mg loading dose followed by 10 mg daily and refer to cardiology. Begin the patient on a low-molecular weight heparinoid (LMWH) and refer to a vascular surgeon for further evaluation. Begin the patient on warfarin 5 mg daily and titrate to an INR of 2.0 to 3.0.

Begin the patient on aspirin 81 mg and clopidogrel 75 mg daily. (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.)

Which medication is the treatment of choice for symptomatic patients with hypertrophic cardiomyopathy? Calcium channel blockers Nitrates Thiazide diuretics Alpha antagonists Beta-blockers

Beta Blockers (The use of beta-blockers in symptomatic hypertrophic cardiomyopathy is useful for gaining rate control. This will allow for the optimal amount of filling in order to maintain enough of an ejection fraction.)

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 S 1 , 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. On echocardiogram, mitral stenosis is noted. Which of the following is the most appropriate next step in management of this patient? Beta blockade and support stockings ACE inhibitor Mitral valve replacement Cardiac catheterization Increased sodium intake to maintain fluid volume

Beta blockade and support stockings (In pregnancy, blood volume, cardiac output, and heart rate are increased. In pregnant patients with mitral stenosis, this increases the pressure across the mitral valve and can lead to pulmonary edema. The use of appropriate beta blockade is helpful for decreasing the heart rate, and may be used in conjunction with digoxin if the patient develops atrial fibrillation, a common dysrhythmia in this patient population. Support stockings are helpful in preventing venous pooling in the lower extremities, which can lead to large fluctuations in hemodynamics.)

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 80 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? Stop flecanide Ablation therapy Beta blocker with flecanide Beta blocker without flecanide Stop flecanide, add diltiazem

Beta blocker with flecanide (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 60-year-old marathon runner has noticed a progressive decline in his exercise tolerance over the past year. He is now dypsneic while walking up one flight of stairs, and notices increased lower extremity edema. He experienced an episode of chest pressure while playing racquetball, and underwent a nuclear stress test, which was found to be normal. On physical exam, a grade 2/6 crescendo-decrescendo murmur is noted, radiating to the carotid arteries. An echocardiogram is ordered. Which of the following results would be expected, based on the patient's history and physical exam findings? Bicuspid aortic valve with severe stenosis Small patent foramen ovale Tricuspid regurgitation Pulmonic stenosis Apical aneurysm

Bicuspid aortic valve with severe stenosis

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 is the most appropriate treatment regimen? 24-hour nitroglycerin dermal patch Thiazide diuretics Loop diuretics Calcium channel blockers Aspirin

Calcium channel blockers (calcium channel blockers, and long-acting nitrate therapy have been proven to be effective for preventing recurrences of episodes of Prinzmetal angina, with short-acting sublingual or IV nitroglycerin useful for relieving acute episodes.)

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? Cardiac catheterization Exercise nuclear stress test Holter monitor Tilt table test Transesophageal echocardiogram

Cardiac catheterization (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 cardiac catheterization, with likely percutaneous coronary intervention, would be recommended, as this patient is at high risk for acute myocardial infarction.)

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 S 1 , 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. On transthoracic echocardiogram, severe mitral valve stenosis and mitral regurgitation is noted. Which of the following is the most appropriate therapy or treatment for this patient? Cardiac catheterization, followed by mitral valve replacement Monitoring via repeat transthoracic echocardiogram in 6 months Monitoring via transesophageal echocardiogram in 6 months Treadmill exercise stress test Automatic internal cardiac defibrillator placement

Cardiac catheterization, followed by mitral valve replacement (In symptomatic patients demonstrating significant mitral valve stenosis, mitral valve replacement after cardiac catheterization,is recommended, to evaluate for associated valvular disease and coronary artery disease.)

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, pulsus paradoxus is noted. Which of the following is the most likely diagnosis given the patient's physical exam findings? Aortic stenosis Cardiac tamponade Mitral regurgitation Hypertrophic cardiomyopathy Atrial fibrillation

Cardiac tamponade

What is the most common clinical cardiac abnormality that is associated with acute rheumatic heart disease? Hypotension Arrhythmia Ischemia Ventricular aneurysm Carditis

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 patient is scheduled for a mitral valve replacement. Which of the following pharmacologic agents would be recommended for surgical prophylaxis? There are no known drug allergies. Cefazolin Vancomycin Ciprofloxacin Nafcillin

Cefazolin (Cefazolin is used as prophylaxis for the majority of clean surgical procedures. For cases in which there is an increased likelihood of encountering gram-negative organisms or anaerobic bacteria, a second-generation cephalosporin is recommended to provide broader coverage. Vancomycin is an alternative if the patient has an allergy to cephalosporin antibiotics)

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. Serial troponin elevations above the 99 th percentile of normal are noted. Which of the following would be the most appropriate next step in the management of this patient? Clopidogrel, heparin, and aspirin, followed by cardiac catheterization Nuclear stress test Treadmill stress test Thiazide diuretics and loop diuretics Dobutamine stress echocardiogram

Clopidogrel, heparin, and aspirin, followed by cardiac catheterization (In patients with non-ST-segment myocardial infarction, such as this patient with ischemic symptoms and serial troponin elevation above the 99 th percentile of normal, clopidogrel, aspirin, and heparin prior to cardiac catheterization are recommended)

A 66-year-old male with a history of hypertension, diabetes mellitus, and hypercholesterolemia presents by emergency medical services (EMS) to the emergency department complaining of severe chest pain with radiation into his back. The patient states that he was feeling well in the morning, but while performing some light activity he felt a "ripping" sensation in his back, which he initially thought was a pulled muscle. The pain continued and the patient started to have chest pain, shortness of breath, and lightheadedness. On initial examination the patient is still in pain, pale, diaphoretic, and has a blood pressure of 85/40. His chest is clear to auscultation, and he has a 3/6 diastolic murmur best appreciated at the base of the heart. Given this clinical scenario, what is the best test to definitively diagnose this medical problem? Chest x-ray Transthoracic echocardiography Transesophageal echocardiography Cardiac catheterization Computed tomography

Computed tomography (This patient is exhibiting a history and physical examination that is consistent with a thoracic aneurysm. The patient's history of hypertension, along with the "ripping" sensation in his back and hypotension give a clinical presentation that is suggestive of a thoracic aneurysm dissection. Given this clinical situation, the best test to evaluate for a potential dissection is by computed tomography)

A father brings his son to the family practice clinic for a concern for coarctation of the aorta. The father was recently diagnosed with this disease, and he is concerned that his 5-year-old son may have it as well. What is the cardinal physical finding in coarctation of the aorta? Decreased or absent femoral pulses Systolic machinery-type murmur Holosystolic murmur at the lower left sternal border Thrill in the carotid arteries Cyanosis at birth

Decreased or absent femoral pulses

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? Diffuse ST segment elevation Peaked T waves Inferior Q waves Loss of R-wave amplitude U waves

Diffuse ST segment elevation (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)

A 67-year-old, 220-pound female presents to your family practice office for a presurgical clearance examination for a total hip replacement in one week. Past medical history includes hypertension, atrial fibrillation, a prior percutaneous transluminal coronary angioplasty (PTCA) with drug-eluting stent seven months ago, and type 2 diabetes mellitus . Her medication include: lisinopril, metoprolol ER, a baby aspirin, clopidogrel, and metformin. Her blood pressure is 128/78 mm&thinsp;Hg, pulse is 72 beats/min, temperature 98.6˚F, and respirations of 17 breaths/min. Her heart and lung sounds are normal. The abdominal examination is benign. Her x-ray and EKG are normal, as are all required labs. Which of the following is recommended for this patient prior to her surgery? Discontinue metoprolol one week prior to surgery. Discontinue metformin one week prior to surgery. Discontinue the aspirin and clopidogrel five to seven days prior to surgery. Reschedule the surgery until patient has reduced their weight by 7%.

Discontinue the aspirin and clopidogrel five to seven days prior to surgery. (The timing and consideration of discontinuing anti-platelet agents is complicated. Generally speaking, for minor procedures (such as a tooth extraction) in patients with risk, discontinuation is not necessary. But for major and/or bloody procedures, such as a total joint replacement, discontinuation is necessary. When considering major surgeries, most anti-platelet therapies should be stopped five to seven days prior to the surgery. Consultation with the patient's cardiologist may be beneficial.)

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 S 3 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 initial diagnostic test gives you the best information regarding this patient's pathology? Exercise stress test Pulmonary function test Echocardiogram Ventilation/perfusion scan CT scan of chest

Echocardiogram (Echocardiogram is indicated in determining the extent of the cardiomyopathy. This test will examine aspects of wall motion and valvular competency, as well as estimate an ejection fraction.)

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 sternal border. His EKG demonstrates NSR @ 80 bpm, with evidence of left ventricular hypertrophy. His troponin levels are negative for ischemia. What is the next most appropriate test or procedure? Echocardiography VQ scan CT scan of the head Serum D-dimer levels MRI of the heart

Echocardiography

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. Which of the following diagnostic studies will best help you in establishing the diagnosis? Electrocardiography Echocardiography Angiocardiography Chest x-ray Serial cardiac enzymes

Echocardiography

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? Cardiac catheterization Chest x-ray ECG Echocardiography Nuclear stress test

Echocardiography (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 22-year-old African American male presents to the emergency department with complaints of syncope, which occurred during intense physical exertion. He did not have symptoms prior to exercise, but states that he started having chest pain and shortness of breath right before the syncopal episode. Upon physical examination, he is afebrile, his pulse rate is 93, his respiratory rate is 16, and his blood pressure is 142/100. His lungs are clear, and a cardiovascular examination reveals a bisferiens carotid pulse and a loud S 4 . The electrocardiogram shows a normal sinus rhythm with ventricular hypertrophy, and q-waves in the septal leads. Which of the following tests is most useful to render an accurate diagnosis? Echocardiography Holter monitor Exercise treadmill Chest x-ray Electrophysiology study

Echocardiography (This patient presents with a history that is consistent with restrictive cardiomyopathy. While this is not a common diagnosis, it usually presents in younger males who experience symptoms while exerting themselves. Echocardiography is the best assessment test to determine wall motion and thickness of the myocardium. It can also assess any valvular disorders or areas of decreased wall motion abnormalities)

A 55-year-old woman with a history of emphysema, who is undergoing chemotherapy for lung cancer, comes to the emergency room complaining of a sudden increase in dyspnea, with exertion and fatigue. On physical exam, hypotension, pulsus paradoxus, and muffled heart sounds are noted. On transthoracic echocardiography, cardiac tamponade is noted with over 200 mL of pericardial fluid described. Which of the following is the most appropriate next step in management? Enoxaparin 1 mg/kg subcutaneously Q 12 H EKG Cardiac catheterization Penicillin V 500 mg PO BID x 10 days Emergent pericardiocentesis

Emergent pericardiocentesis

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? Cardiac catheterization Exercise nuclear stress test Holter monitor Tilt table test Transesophageal echocardiogram

Exercise nuclear stress test (exercise nuclear stress testing, would provide information regarding exercise tolerance and exercise-induced dysrhythmias, as well as information regarding myocardial ischemia)

A 22-year-old African American male presents to the emergency department with shortness of breath, which started 2 hours prior to arrival. He does not have a history of pulmonary disease that he is aware of, and he states that in the past at random events he has had similar episodes. He does nothing to get the episodes to stop, and he also states that he feels his chest pounding at the same time of the shortness of breath. He has no medical history that he is aware of, and he takes no medications or any illicit drugs. On examination he is alert, awake, and oriented. His vital signs show T 99.0, P 142, R 18, and BP 132/82. His chest x-ray is negative for any acute cardiopulmonary disease, and his electrocardiogram has an irregularly irregular rate of 142 with visible delta waves. Given the clinical situation above, what is the best medication for managing this patient's condition with a long-term approach? Amiodarone Atropine Hydralazine Flecainide Digoxin

Flecainide (This patient has Wolff-Parkinson-White (WPW) syndrome along with atrial fibrillation and a rapid ventricular response. Of the choices given in managing this patient's tachycardia, oral flecainide will serve to slow the process within the accessory pathway and prolong the refractory period)

A 46-year-old male presents to your office for consultation of supraventricular tachycardia (SVT). His history shows that he has had multiple episodes of SVT, and on three occasions has been treated in the emergency department with adenosine, which has converted his rhythm back to sinus. The patient is otherwise healthy, has no medical problems, and is on no medications. His vital signs are stable and his physical examination is within normal limits. Based on this history, which medication is the best choice for treating this patient long-term? Magnesium sulfate Spironolactone Digoxin Flecanide Diltiazem

Flecanide (Flecanide doses up to 200 mg BID can be used to help control rate and prevent recurrences of reentry tachycardias)

A 76-year-old man with a history of three myocardial infarctions, CABG x 4, COPD, HTN, and hyperlipidemia presents to the emergency department with complaints of increasing dyspnea with exertion. He now has to sit in his recliner to sleep. He complains of lower extremity edema, now above the knees. On physical examination, he exhibits jugular venous distention to the angle of the jaw at 90 degrees of truncal elevation, diffuse bilateral rales on auscultation of the lung, and a blowing systolic murmur that is heard best at the left lower sternal border. Which abdominal physical exam finding would be most likely given this patient's history? Periumbilical ecchymoses Murphy's sign Tenderness at McBurney's point Hepatomegaly Absent bowel sounds

Hepatomegaly (the patient is demonstrating signs and symptoms of congestive heart failure, which can lead to hepatic congestion and hepatomegaly)

A 36-year-old man with a history of tobacco use notices palpitations after attending a Super Bowl party. He admits to drinking at least six bottles of beer and several mixed drinks, which is much more than he usually drinks. He denies chest discomfort or dyspnea. On physical exam, his BP is 139/82, P 136, RR 22, and Temp 37°C. On auscultation, his heart rate is tachycardic and irregular, without S3 or murmur appreciated. His echocardiogram demonstrates normal LV systolic function, normal left atrial dimensions, and normal valvular function. Based on his history, what is the most likely diagnosis regarding his palpitations? Sinus tachycardia Wolff-Parkinson-White syndrome Normal sinus rhythm with PACs Alcohol withdrawal Holiday heart syndrome

Holiday heart syndrome (In young patients without left ventricular systolic dysfunction or valvular dysfunction, binge drinking can lead to episodes of atrial fibrillation, also known as holiday heart syndrome. This is a syndrome in which atrial fibrillation is linked with excessive alcohol intake frequently higher than usual)

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 S 3 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. What is the initial medication of choice for treatment of this patient's edema? Hydrochlorothiazide Diltiazem Amiodarone Terazosin Metoprolol

Hydrochlorothiazide (Thiazide diuretics are indicated for the initial treatment of fluid overload related to dilated cardiomyopathy)

Classic EKG findings for: hyperkalemia hypokalemia Hypocalcemia Hypercalcemia

Hyperkalemia: peaked T waves and widening of the ST segment Hypokalemia: Flattened T waves, U waves, and ST depression is characteristic of hypokalemia. Hypocalcemia: Prolongation of the QT interval Hypercalcemia: shortening of the QT interval is

A 55-year-old woman with a history of mitral valve replacement and 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 for the past few weeks she has 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. Her INRs have been therapeutic for the past 4 weeks. Which of the following is the most appropriate next step in treating this patient? IV quinidine IV ibutilide IV vasotec IV amiodarone IV dopamine

IV ibutilide (IV ibutilide, has been found to be most effective in converting atrial flutter to sinus rhythm out of all the choices listed)

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? IV ibutilide after 4 weeks of anticoagulation with warfarin IV ibutilide alone IV quinidine after 4 weeks of anticoagulation with warfarin IV quinidine alone IV dopamine

IV ibutilide alone (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)

A 49-year-old female with a known history of hypertension presents to the emergency department with a generalized headache that is throbbing. She states she had run out of her normal blood pressure medication about a week ago and since then she has noticed that her headache came about and has been getting worse. She denies any nausea, vomiting, visual changes, chest pain, or other symptoms. On exam the patient has a BP 227/120, P 78, R 18. Her HEENT exam is essentially normal, lungs are clear to auscultation, and heart is a regular rhythm without murmur or gallop. Given this clinical situation, which medication would be the most appropriate to address the patients condition? IV nitroprusside Oral furosemide Spironolactone IV labetalol Oral hydralazine

IV labetalol (This patient's clinical situation is one of a hypertensive emergency. In this situation the goal is to bring down the systolic pressure to prevent end organ damage. Given the possible choices, the best choice would be intravenous labetalol)

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? IV dextrose alone IV thiamine IV enalapril IV dopamine IV diltiazem

IV thiamine (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)

A 70-year-old man, with a history of HTN and aortic valve replacement 3 months ago, presents with complaints of arthralgia, myalgia, anorexia, fatigue, and weight loss over the last month, with recent dyspnea on exertion and lower extremity edema. Vital signs are as follows: Temperature 38°C, BP 102/64, P 98, RR 20. On physical exam, a new high-pitched, blowing, decrescendo diastolic murmur is noted along the left lower sternal border. Two separate blood cultures are positive for S. aureus, and found to be methicillin-resistant. A transesophageal echocardiogram demonstrates a paravalvular abscess. Which of the following is the most appropriate therapy in the management of this patient? IV vancomycin IV vancomycin, IV gentamicin, and PO rifampin with surgical treatment IV amphotericin plus flycytosine, and surgical treatment Outpatient IV ceftriaxone IV penicillin G

IV vancomycin, IV gentamicin, and PO rifampin with surgical treatment (In patients with prosthetic valve infection with methicillin-resistant S. aureus, the treatment of choice is IV vancomycin for 6 to 8 weeks, plus IV or IM gentamicin for the initial 2 weeks secondary to nephrotoxicity, and PO rifampin for 6 to 8 weeks, with susceptibility to gentamicin determined before initiation of rifampin. Surgical therapy decreases mortality in patients with S. aureus endocarditis, from over 70% with medical therapy alone to 25%, and should be considered in patients with paravalvular abscesses and symptoms suggestive of moderate to severe refractory congestive heart failure)

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

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.)

What is the treatment for a patient who has recurrent ventricular tachycardia with no reversible cause, and has failed oral medication therapy? Biventricular pacemaker insertion Ablation therapy Heart transplantation Implantable defibrillator Single chamber pacemaker

Implantable defibrillator (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.)

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? Acetaminophen Indomethacin Propranolol Ranitidine Sildenafil

Indomethacin (Indomethacin is an NSAID and inhibits prostaglandin synthesis, allowing for closure of the patent ductus arteriosus in preterm infants)

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. The murmur is heard over the second and third left intercostal spaces. An S 3 is appreciated. Abdominal exam reveals hepatomegaly and splenomegaly. Which of the following maneuvers would be the most appropriate to choose for better identification of the murmur? Left lateral decubitus position listening with the bell of the stethoscope Standing Seated leaning forward Inspiration Expiration

Inspiration (inspiration will increase the intensity of the murmur of pulmonic regurgitation/insufficiency. The Valsava maneuver will diminish the intensity of the murmur)

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 99 th 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? Ischemic symptoms New right bundle branch-block on EKG J wave on EKG Pulmonary vascular congestion on CXR Elevated WBC count

Ischemic symptoms

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? Isometric hand grip exercise Listening with the bell at the apex with the patient in the left lateral decubitus position Inspiration, followed by the patient holding his/her breath The Valsalva maneuver Having the patient lie flat with the knees bent

Isometric hand grip exercise

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? Isometric hand grip exercise Listening with the bell at the apex, with the patient in the left lateral decubitus position Inspiration, followed by the patient holding his/her breath Valsalva maneuver Having the patient lie flat with the knees bent

Isometric hand grip exercise (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.)

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 S 1 , 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? Isometric hand grip exercise Listening with the bell at the apex, with the patient in the left lateral decubitus position Inspiration, followed by the patient holding his/her breath Valsalva maneuver Having the patient lie flat with the knees bent

Listening with the bell at the apex, with the patient in the left lateral decubitus position (the murmur described is mitral stenosis)

What is the most common electrolyte that can effect the initiation of ventricular tachycardia? Magnesium Sodium Chloride Phosphorus Calcium

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

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 S 3 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? Amlopidine Minoxidil Isosorbide mononitrate Metoprolol Atropine

Metoprolol (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.)

Which valve is the most commonly affected in a case of rheumatic heart disease? Aortic Mitral Tricuspid Pulmonic Bicuspid aortic valve

Mitral (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.)

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. 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 likely diagnosis? Aortic stenosis Aortic regurgitation/insufficiency Mitral stenosis Mitral regurgitation/insufficency Tricuspid regurgitation

Mitral regurgitation/insufficency (The murmur of mitral regurgitation can be described as a holosystolic murmur, usually heard best at the apex. 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. The murmur of mitral regurgitation is heard best at the apex. Radiation, if it occurs, is frequently to the axilla.)

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 S 1 , 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? Tricuspid regurgitation Tricuspid stenosis Atrial septal defect Aortic regurgitation/insufficiency Mitral stenosis

Mitral stenosis

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 S 1 , 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? Tricuspid regurgitation Tricuspid stenosis Atrial septal defect Aortic regurgitation/insufficiency Mitral stenosis

Mitral stenosis (mitral stenosis, is the most likely finding in a patient with a history of rheumatic fever presenting with a possible opening snap, loud S 1 , 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)

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, jugular venous distension is appreciated. Auscultation of the chest reveals a possible opening snap, loud S 1 , and a very soft diastolic rumbling murmur is auscultated at the left lower sternal border. When the patient is placed in the left lateral decubitus position, the murmur is accentuated, and heard best at the apex. Both hepatomegaly and splenomegaly are noted. On EKG, no evidence of right ventricular hypertrophy is noted, despite the obvious signs and symptoms of right heart failure. Which of the following valvulopathies should be suspected given this patient's history and physical exam findings? Mitral stenosis and aortic stenosis Mitral stenosis and aortic regurgitation Mitral stenosis and tricuspid stenosis Aortic stenosis and mitral regurgitation Mitral stenosis and pulmonic stenosis

Mitral stenosis and tricuspid stenosis (Both murmurs are similar in character, with the main difference that the murmur of tricuspid stenosis is heard best at the left lower sternal border, and the murmur of mitral stenosis is heard best in the left lateral decubitus position with the bell at the apex. Because they are similar in nature, a high level of suspicion for tricuspid stenosis should be maintained, so that tricuspid stenosis is not overlooked)

A 62-year-old female complains of headaches and swelling in her legs for the past 3 months. Her current medications included in the choices below. Which of these medications is most likely responsible for both of her symptoms? acetaminophen hydrochlorothiazide (HCTZ) olmesartan nifedipine atorvastatin

Nifedipine (Nifedipine, a calcium channel blocker, is the most likely cause for the patient's complaints. Calcium channel blockers, especially those in the dihydropyridine class, are commonly associated with side effects of headaches and peripheral edema)

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? Beta-blockers Definitive electrophysiology study No treatment, only monitoring Ablation therapy Calcium channel blockers

No treatment, only monitoring (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.)

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? Left ventricular hypertrophy Normal ECG Right axis deviation Supraventricular tachycardia Sick sinus syndrome

Normal 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.)

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? This patient does not require any further evaluation. Obtain an echocardiogram. Perform and EKG. Perform a chest radiograph. Refer her to a rheumatologist.

Obtain an echocardiogram. (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 echocardiogram is an appropriate, non-invasive initial first-step to begin your investigation to rule out significant valvular and/or aortic root abnormalities.)

A 33-year-old IV drug user presents to the emergency department with chills, diaphoresis, anorexia, and malaise. On physical exam, her temperature is 40°C, BP 98/55, P 115 bpm, and RR 22. Two separate blood cultures are positive for S.aureus. Which of the following physical exam findings would confirm a clinical diagnosis of infective endocarditis, according to the Duke criteria? Increase in valvular regurgitation Irregularly irregularly pulse Osler's nodes Buccal hemmorhages Koplik spots

Osler's nodes (Osler's nodes, confirms the clinical diagnosis of infective endocarditis, as it is a minor criteria. The Duke criteria for the clinical diagnosis of infective endocarditis requires the documentation of two major criteria, or one major criteria and three minor criteria, or five minor criteria. The patient demonstrates the presence of one major criteria (two separate blood cultures with typical microorganisms for infective endocarditis) and two minor criteria (fever greater than 38.0°C and predisposing condition of IV drug use).

What is the treatment of choice for rheumatic fever? Macrolides Cephalosporin Fluoroquinolone Aminoglycosides Penicillin

Penicillin

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 a "water bottle" cardiac silhouette. Which of the following are serious consequences of acute pericarditis, which require careful monitoring? Pericardial effusion Aortic dissection Myxedema Chylopericardium Acute myocardial infarction

Pericardial effusion (pericardial effusion, is a serious consequence of acute pericarditis, which requires careful monitoring to ensure that progression of the pericardial effusion does not lead to cardiac tamponade, which can be fatal if not treated promptly)

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. Prior to examining him, you have reviewed his chart. Laboratory findings demonstrate troponins x 3, which are negative for myocardial ischemia. His EKG demonstrates diffuse ST segment elevations throughout. Which of the following physical exam findings would be most likely in this patient? Roth spots Splenic enlargement Janeway lesions Pericardial friction rub Splinter hemorrhages

Pericardial friction rub (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. All other choices are physical exam findings seen in acute bacterial endocarditis)

A 22-year-old man is brought to the emergency department by paramedics after having sustained a single stab wound along the left sternal border at the fourth intercostal space. Upon arrival to the emergency department, he was hypotensive and tachycardic. The neck veins were distended and heart sounds were muffled. Which of the following interventions is the most appropriate first-line management of this patient? Left tube thoracostomy Pericardiocentesis Fluid resuscitation Immediate intubation

Pericardiocentesis (Cardiac tamponade is classically described by the triad of jugular venous distension (JVD), arterial hypotension, and muffled heart sounds. In the emergency department, suspicion of this clinically entity is usually confirmed by ultrasonography and is acutely treated by pericardiocentesis, which will be diagnostic, therapeutic, and buy time until a definitive procedure can be done)

An 84-year-old male is admitted to the hospital for the chief complaint of syncope. The history provided states that the patient was in his normal state of health and feeling well when he had fallen, with an apparent loss of consciousness for 25-30 seconds. He has a history of hypertension and arthritis, and is well managed on medications that include lisinopril and acetaminophen. During his time on the telemetry unit it's noted that the patient has periods of sinus bradycardia in the 30s, followed by normal sinus rhythms that fluctuate in the 60 to 120 range. During several of the bradycardia episodes the patient becomes symptomatic with shortness of breath, lightheadedness, and dizziness. His blood pressure during these episodes is measured at 88/56. Given this clinical scenario, what is the most appropriate treatment for this patient? Observation Increase in lisinopril Cardiac catheterization Permanent pacemaker insertion Beta blocker therapy

Permanent pacemaker insertion (This patient is having sick sinus syndrome, in which the patient has developed an aberrancy wherein the heart is not able to regulate a steady rate and maintain an adequate blood pressure. Because of the patient having syncope, observation only is not advised. Increasing the ACE inhibitor is contraindicated given the patient experiencing hypotension. This is also true with beta-blocker therapy. The best treatment for this clinical situation would be permanent pacemaker insertion)

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? Pericarditis Acute myocardial infarction Costochondritis Prinzmetal angina Myocarditis

Prinzmetal angina (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)

Examination of a female newborn demonstrating cyanosis after feeding reveals a systolic ejection click that is heard best at the third left intercostal space, and a short grade III/VI systolic ejection murmur that is heard best at the second left intercostal space. Given this patient's physical exam findings, which of the following is the most likely finding on an echocardiogram? Pulmonic stenosis Aortic stenosis Mitral regurgitation Aortic regurgitation Mitral stenosis

Pulmonic stenosis (pulmonic stenosis, is the most likely finding on echocardiogram, as severe pulmonic stenosis frequently presents with a newborn infant presenting with cyanosis after feeding, and a systolic ejection murmur heard best at the second left intercostal space. Congenital pulmonic stenosis occurs in 1 in 10 patients with congenital heart disease)

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? Mitral stenosis Pulmonic stenosis Tricuspid stenosis Atrial septal defect Aortic regurgitation

Pulmonic stenosis (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.)

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 parvus Pulsus alternans Bisferiens pulses Pulsus bigeminus Pulsus paradoxus

Pulsus paradoxus (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.)

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? Crackles at the lung bases bilaterally Tachycardia Pulsus paradoxus Soft S1, S2 Wheezing

Pulsus paradoxus (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.)

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? Reassurance and monitoring with periodic transthoracic echocardiogram Cardiac catheterization Infectious endocarditis prophylaxis Mitral valve replacement Transesophageal echocardiogram

Reassurance and monitoring with periodic transthoracic echocardiogram (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.)

A 64-year-old African American female presents to the clinic for evaluation of her hypertension, which she has had for several years. In the past she had been taking hydrochlorothiazide and lisinopril, with little effect on her blood pressure management. At today's visit, she has no complaints and feels well. Her vitals show T m 96.6, P 85, R 18, BP 191/99. She has no jugular venous distention seen on the neck exam, her lungs are clear, and cardiac exam has a regular rate and rhythm without murmur or gallop. Her abdomen is soft, non-tender, and a bruit is appreciated at the mid-abdomen just a few centimeters below the epigastric region. There is no fullness or enlargement of the abdominal aorta on palpation. Based on the history and clinical findings, what is the most appropriate procedure for this patient? Hepatic venous angiography Renal artery angiography Cardiac catheterization Lower extremity arteriography Venous duplex ultrasound of lower extremities

Renal artery angiography

A 64-year-old African American female presents to the clinic for evaluation of her hypertension, which she has had for several years. In the past she had been taking hydrochlorothiazide and lisinopril, with little effect on her blood pressure management. At today's visit, she has no complaints and feels well. Her vitals show T m 96.6, P 85, R 18, BP 191/99. She has no jugular venous distention seen on the neck exam, her lungs are clear, and cardiac exam has a regular rate and rhythm without murmur or gallop. Her abdomen is soft, non-tender, and a bruit is appreciated at the mid-abdomen just a few centimeters below the epigastric region. There is no fullness or enlargement of the abdominal aorta on palpation. Based on the history and clinical findings, what is the most appropriate next test for this patient? Computed tomography of the abdomen Nuclear exercise stress test Renal duplex ultrasound Echocardiogram Electrocardiogram

Renal duplex ultrasound (Based on the information of the presentation, the patient most likely has renal artery stenosis, which is causing uncontrolled hypertension. The most appropriate test for confirmation of this is a renal duplex ultrasound)

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 common abnormality present on an ECG? Atrioventricular heart block Atrial fibrillation Bifasicular block Right axis deviation Supraventricular tachycardia

Right axis deviation (The most likely diagnosis is an atrial septal defect, which usually shows right axis deviation on ECG. The other ECG abnormalities listed do not commonly occur with an atrial septal defect.)

During a hospitalization for pneumonia, 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 99 th percentile of normal. If acute myocardial infarction is ruled out, which of the following disease entities could also cause troponin elevation? Mitral regurgitation Gout Parkinson's disease Sepsis Herpes zoster

Sepsis (sepsis is one of a long list of disease entities that can cause troponin elevation, including arrhythmias (both tachycardic and bradycardic), aortic valve disease, hypertrophic cardiomyopathy, invasive cardiac surgeries and procedures, severe pulmonary hypertension, pulmonary embolism, myocardial infiltrative diseases (such as amyloidosis, sarcoidosis, scleroderma, and hemochromatosis), acute respiratory failure, burns, pericarditis, endocarditis, myocarditis, and even occasionally due to extreme athletic activities such as marathon running)

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? Transesophageal echocardiogram Nuclear stress test Cardiac catheterization Serial serum troponin levels CXR

Serial serum troponin levels (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)

A 67-year-old woman with a history of gastric ulcers is admitted with complaints of recent onset of dyspnea with exertion, 3 pillow orthopnea, lower extremity edema, and palpitations, in which she describes her heart as racing. Which of the following is likely to be the cause of her high-output congestive heart failure? Mitral regurgitation Aortic stenosis Uncontrolled hypertension Ruptured chordae tendinae Severe anemia

Severe anemia (anemia may result with progression of gastric ulcers, and is the only high-output cause of congestive heart failure among the choices offered)

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. She denies a history or rheumatic fever. On auscultation, a crescendo-decrescendo systolic ejection murmur is heard at the upper right sternal border radiating to the carotids bilaterally. Given the patient's physical exam findings, which of the following is the most likely diagnosis? Severe aortic stenosis secondary to congenital bicuspid aortic valve Aortic regurgitation/insufficiency Mitral stenosis Aortic regurgitation/insufficiency Tricuspid regurgitation/insufficiency

Severe aortic stenosis secondary to congenital bicuspid aortic valve (the murmur of aortic stenosis is usually described as a crescendo-decrescendo or systolic ejection murmur heard best at the right upper sternal border. In addition, the murmur of aortic stenosis is frequently transmitted to the carotid arteries)

An 84-year-old male is admitted to the hospital for the chief complaint of syncope. The history provided states that the patient was in his normal state of health and feeling well when he had fallen, with an apparent loss of consciousness for 25-30 seconds. He has a history of hypertension and arthritis, and is well managed on medications that include lisinopril and acetaminophen. During his time on the telemetry unit it's noted that the patient has periods of sinus bradycardia in the 30s, followed by normal sinus rhythms that fluctuate in the 60 to 120 range. During several of the bradycardia episodes the patient becomes symptomatic with shortness of breath, lightheadedness, and dizziness. His blood pressure during these episodes is measured at 88/56. Given this clinical scenario, what is the most likely diagnosis for this patient? Ventricular tachycardia Sick sinus syndrome First-degree AV block Wolff-Parkinson-White syndrome Premature atrial contractions

Sick sinus syndrome

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. On physical exam, a mid-systolic click is noted. Which of the following maneuvers would be the most appropriate to choose for better identification of the murmur? Left lateral decubitus position listening with the bell of the stethoscope Standing Seated leaning forward Inspiration Expiration

Standing (standing, will cause the mid-systolic click associated with mitral valve prolapsed to move toward S1 or become more audible. Rolling the patient to the left lateral decubitus position, is most useful in identification of the murmur of mitral stenosis.)

A 33-year-old IV drug user presents to the emergency department with chills, diaphoresis, anorexia, and malaise. On physical exam, her temperature is 40C, BP 98/55, P 115 bpm, and RR 22. Two separate blood cultures are positive for S.aureus. Which of the following diagnostic studies would be most useful in establishing this patient's diagnosis? EKG CXR Rheumatoid factor ESR TEE

TEE (TEE (or transesophageal echocardiogram), would be most useful in establishing a diagnosis of infective endocarditis, as a positive echocardiogram demonstrating presence of a vegetation would satisfy one of the Duke criteria's major criteria. TEE is more sensitive than TTE (transthoracic echocardiogram) for detecting vegetations)

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? Atrial septal defect Patent ductus arteriosus Mitral valve prolapse Tetralogy of fallot Transposition of the great arteries

Tetralogy of fallot

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/VI 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? Chest x-ray Transesophageal echocardiogram Holter monitor Treadmill exercise stress test Transthoracic echocardiogram

Transthoracic echocardiogram

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. His EKG is unchanged, demonstrating evidence of his prior infarction but no acute ST or T wave changes. Which of the following is the most appropriate next diagnostic study for this patient? Transesophageal echocardiogram Cardiac catheterization Pulmonary function testing Transthoracic echocardiogram Holter monitor

Transthoracic echocardiogram

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 S 1 , 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 appropriate next diagnostic study? Chest x-ray Transesophageal echocardiogram Holter monitor Treadmill exercise stress test Transthoracic echocardiogram

Transthoracic echocardiogram (transthoracic echocardiogram is a simple, sensitive and non-invasive diagnostic tool, which can evaluate for the presence of valvulopathy in the setting of a patient with a diastolic murmur and a history of rheumatic fever)

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? Chest x-ray Transesophageal echocardiogram Holter monitor Treadmill exercise stress test Transthoracic echocardiogram

Transthoracic echocardiogram (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)

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 2 weeks she has also noticed palpitations. On physical examination, her vital signs are stable, with a normal physical exam. On EKG, she demonstrates atrial flutter with 2:1 AV block. Which of the following is the most appropriate next diagnostic study for this patient? Transthoracic echocardiogram Cardiac catheterization Nuclear stress test Holter monitor Event recorder

Transthoracic echocardiogram (transthoracic echocardiogram, is the most appropriate next diagnostic study in this patient with atrial flutter, as it can demonstrate the presence of valvular heart disease. The presence of valvular heart disease can change the recommendations for embolism prophylaxis)

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, pulsus paradoxus and muffled heart sounds are noted. Which of the following diagnostic studies would be most effective in establishing a definitive diagnosis given this patient's physical exam findings? Chest x-ray CBC with differential Transthoracic echocardiography Pulmonary function tests Tilt-table test

Transthoracic echocardiography (In patients with a history of malignancy, sudden worsening of dyspnea and physical exam findings of pulsus paradoxus and muffled heart sounds (two of the three components of Beck's triad), a clinical suspicion of cardiac tamponade should be part of a clinician's differential diagnosis.)

A 66-year-old female is admitted to the hospital with a new onset of atrial fibrillation. Her past medical history has hypertension, diabetes mellitus type II, hypercholesterolemia, and rheumatoid arthritis. Her vital signs show a blood pressure of 136/78, pulse of 89, respirations 18, and oxygen saturation of 96%. Her lungs are clear to auscultation, and an irregularly irregular rhythm is appreciated. There is no edema on peripheral examination. Given this clinical scenario, what is the most appropriate test in determining if an intracardiac thrombus is present? Transthoracic echocardiography Electrocardiogram Transesophageal echocardiography Cardiac catheterization Magnetic resonance arteriography

Transthoracic echocardiography (The best and most appropriate test to evaluate for an intra-atrial thrombus is the transesophageal echocardiogram. This test has the better sensitivity and specificity when compared to the transthoracic echocardiogram)

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 a "water bottle" cardiac silhouette. Which of the following diagnostic studies would be considered the most appropriate next step in management of this patient? Cardiac catheterization Transthoracic echocardiography CT of the thorax VQ scan Lower extremity venous doppler

Transthoracic echocardiography (transthoracic echocardiography, would allow for monitoring of a patient with acute pericarditis, to determine if a pericardial effusion and/or cardiac tamponade develops.)

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 very soft systolic murmur is auscultated. With inspiration, the murmur increases, and is heard best at the left lower sternal border. A large and early v jugular venous wave is noted. Which of the following is the most likely finding on echocardiogram given this patient's physical exam findings? Tricuspid regurgitation Ventricular septal defect Atrial septal defect Aortic stenosis Mitral stenosis

Tricuspid regurgitation

A 65-year-old man with a history of emphysema, obstructive sleep apnea, prior inferior myocardial infarction, and pulmonary hypertension presents with complaints of increasing dyspnea over the last 6 months. He has also recently noticed increasing lower extremity edema. On physical exam, jugular venous distension is appreciated. Auscultation of the chest demonstrates a blowing holosystolic murmur along the lower left sternal border. Hepatomegaly, ascites, and lower extremity edema are noted. Which of the following would be the most likely finding on echocardiogram given the patient's physical exam findings? Tricuspid regurgitation Aortic stenosis Atrial septal defect Aortic regurgitation/insufficiency Mitral stenosis

Tricuspid regurgitation (Patients with pulmonary hypertension and right heart failure frequently demonstrate right ventricular hypertrophy, which leads to tricuspid regurgitation)

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, jugular venous distension is appreciated. Auscultation of the chest reveals a possible opening snap, loud S 1 , and a very soft diastolic rumbling murmur is auscultated at the left lower sternal border. When the patient is placed in the left lateral decubitus position, the murmur is accentuated, and heard best at the apex. Both hepatomegaly and splenomegaly are noted. On transthoracic echocardiogram, which of the following findings is most likely to be seen in addition to mitral valve stenosis? Tricuspid stenosis Atrial septal defect Aortic stenosis Ventricular septal defect Left ventricular hypertrophy

Tricuspid stenosis (tricuspid stenosis is frequently seen in association with mitral valve stenosis in patients with a history of rheumatic heart disease (between 5% and 10% of the time). Both murmurs are similar in character, with the main difference that the murmur of tricuspid stenosis is heard best at the left lower sternal border, and the murmur of mitral stenosis is heard best in the left lateral decubitus position, with the bell at the apex.)

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? CK-MB Troponin I BNP Creatine kinase Myoglobin

Troponin I (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)

A 62-year-old man presents to the office concerned about an abdominal aortic aneurysm (AAA). He has had no symptoms but states that his father died from an aortic dissection at the age of 50 and his brother was diagnosed last week with an AAA. What is the most appropriate screening tool in this situation? Abdominal radiograph Computed tomographic angiography (CTA) Palpation Ultrasound Aortography

Ultrasound (Ultrasonography is cost-effective and is the most commonly utilized screening modality for AAAs. It can be utilized for initial detection of a nonruptured AAA and for monitoring of progression)

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

Valsalva maneuver

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 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 diagnosis? Atrial septal defect Coarctation of the aorta Patent ductus arteriosus Tetralogy of fallot Ventricular septal defect

Ventricular septal defect (The patient in this scenario is exhibiting the classic signs of a ventricular septal defect. An atrial septal defect has a fixed, widely split S2, with a right ventricular heave as well as a systolic ejection murmur, which is best heard at the left sternal border second intercostal space)

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 for last 24 hours 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 is the most appropriate therapy for this patient? Aspirin 325 mg Plavix 75 mg Plavix 75 mg and aspirin 81 mg Warfarin, dosed to INRs between 2.0 and 3.0 Dipyridamole 200 mg and aspirin 25 mg

Warfarin, dosed to INRs between 2.0 and 3.0 (Patients with atrial flutter of less than 48 hour duration may be cardioverted without anticoagulation, unless they have mitral valve disease, in which case they should be treated with warfarin)

A 66-year-old male with a history of hypertension, diabetes mellitus, and hypercholesterolemia presents by emergency medical services (EMS) to the emergency department complaining of severe chest pain with radiation into his back. The patient states that he was feeling well in the morning, but while performing some light activity he felt a "ripping" sensation in his back, which he initially thought was a pulled muscle. The pain continued and the patient started to have chest pain, shortness of breath, and lightheadedness. On initial examination the patient is still in pain, pale, diaphoretic, and has a blood pressure of 85/40. His chest is clear to auscultation, and he has a 3/6 diastolic murmur best appreciated at the base of the heart. Given this clinical scenario, what would be the expected finding on chest x-ray? Normal Pleural effusion Decreased lung volume Widened mediastinum Cardiomegaly

Widened mediastinum (This patient is exhibiting a history and physical examination that is consistent with a thoracic aneurysm. The patient's history of hypertension, along with the "ripping" sensation in his back and hypotension give a clinical presentation that is suggestive of a thoracic aneurysm dissection. In this instance it would be expected that the patient would have evidence of a widened mediastinum)

A 29-year-old woman presents to the clinic with a complaint of severe diarrhea occurring over the last 3 to 4 days. Upon examination, the patient displays poor skin turgor and has a temperature of 100.2°F. In the supine position, the patient's blood pressure is 88/64 mm Hg and her heart rate is 112 beats/min. Upon standing, her heart rate further increases to 126 beats/min. Which of the following accounts for the further increase in the patient's heart rate upon standing? decreased systemic vascular resistance decreased venous return increased preload increased myocardial contractility increased peripheral vasodilation

decreased venous return (The patient is displaying signs of hypovolemia likely because of her chronic diarrhea. Upon standing, most of her low blood volume pools in the veins of her lower extremities because of the effects of gravity. As a result, even less blood returns to the heart, which leads to a decrease in both stroke volume and cardiac output as well as orthostatic hypotension. This elicits the baroreceptor reflex, which attempts to increase and maintain arterial blood pressure by raising the heart rate)

Which of the following antineoplastic medications is most likely to cause cardiac toxicity and precipitate heart failure? doxorubicin cisplatin cyclophosphamide tamoxifen 6-mercaptopurine

doxorubicin (Doxorubicin is a common antineoplastic drug used for a variety of cancers, including breast, bladder, ovarian, and endometrial, among many others. Unfortunately, it has a well-established, dose-dependent adverse effect on the heart that is linked to free-radical formation.)

Which of the following lists the common adverse effects caused by nitroglycerin when administered sublingually at high doses? constipation, blurred vision, tinnitus dyspepsia, abdominal distention, vomiting elevated pulse, facial flushing, headache photophobia, excessive salivation, excessive tearing wheezing, cough, heartburn

elevated pulse, facial flushing, headache (Sublingual nitroglycerin produces venodilation and vasodilation, which causes secondary responses of flushing and headache. The elevated pulse or tachycardia is reflexive in nature, and the heart tries to compensate for the drop in blood pressure by raising its rate.)

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? clonidine enalapril hydralazine nebivolol felodipine

enalapril (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)

Your patient is a 47-year-old female who complains of leg cramps and fatigue over the past few weeks. Her examination is completely normal. She is taking an unknown medication for hypertension, which she did not bring with her. Labs include a normal complete blood count (CBC) and a BMP that reveals a potassium level of 3.2 m&thinsp;Eq/L, otherwise normal. Which of the following is the most likely cause of her laboratory abnormalities? quinapril labetalol verapamil valsartan hydrochlorothiazide (HCTZ)

hydrochlorothiazide (HCTZ) (This patient's symptoms are likely due to hypokalemia, which is a potential side effect of thiazide diuretics such as hydrochlorothiazide. Hyponatremia may also be another possible side effect.)

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, 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. He is on a thiazide diuretic. On repeat examination, the patient's blood pressure remains high. Which medication should be added to better control the patient's blood pressure? Lisinopril Diltiazem Spironolactone Amiodarone Hydralazine

lisinopril (The use of an ACE inhibitor is a logical second order medication for this patient. Along with the diuretic, the ACE will further lower blood pressure. Calcium channel blockers are not an optimal choice, as they can worsen heart failure. ACE inhibitors can also have a protective effect on renal function, as well as improve morbidity and mortality in diabetics.)

A 65-year-old man presents to the emergency department with an acute ischemic stroke. His CT scan is normal. His blood pressure is 180/100 mm Hg. What is the most appropriate treatment for his hypertension? labetalol (Normodyne) 20 mg IV nifedipine (Procardia) 10 mg po nitroprusside (Nipride) drip at 1 mg/kg/min clonidine (Catapres) 0.1 mg po no antihypertensive at this time

no antihypertensive at this time (Blood pressure is typically elevated at the time of presentation in acute ischemic stroke. It will decline without medication in the first few hours to days. Aggressively lowering blood pressure in an acute ischemic stroke may decrease the blood flow to the ischemic but salvageable brain tissue. Blood pressure should be treated if there are other indications, such as angina or heart failure. Control of blood pressure is appropriate in patients who are receiving tissue plasminogen activator (t-Pa) for their stroke. Blood pressure should be lowered cautiously to a systolic of less than 185 mm Hg and a diastolic of less than 110 mm Hg. This is thought to decrease the incidence of intracerebral hemorrhage in these patients.)

A 24-month-old infant presents for his routine physical examination. The parents state that he has been following all of his developmental milestones. On examination, the clinician hears a grade II/VI murmur along the left sternal border, which radiates into the left axilla and the left side of the back. The child also has decreased femoral pulses bilaterally. The clinician orders a chest X-ray. Which of the following is the expected finding on X-ray based on the presentation? notching or scalloping of the ribs boot-shaped heart—right ventricular hypertrophy "egg on string"—narrowed mediastinum absence of the main pulmonary artery

notching or scalloping of the ribs (The patient's presentation is consistent with findings of coarctation of the aorta. The pathognomonic finding in coarctation is decreased or absent femoral pulses. However, the majority of children show no signs of coarctation in infancy and develop signs and symptoms during childhood, most notably unequal pulses and blood pressure between arms and legs (arms greater than legs).

You are evaluating a 72-year-old male who is referred to the emergency department from his primary care office. On examination you note a lethargic obese male with the following vitals: BP of 225/135 a P of 88, and T of 98.4˚F. He reports discontinuing all his medications for blood pressure 6 months ago due to financial reasons. Which of the following physical examination findings would be most consistent with a diagnosis of a hypertensive emergency? normal exam xanthelasma varicose veins papilledema enlarged nodular prostate

papilledema (This patient has significantly elevated blood pressure, lethargy, and evidence of hypertensive encephalopathy, which is supported by a physical examination finding of papilledema. Additional workup may be indicated to rule out other causes of his papilledema)

A 9-year-old female child presents with tachycardia, tachypnea, shortness of breath, bibasilar rales, and distended jugular veins. Which of the following is the most likely cause for her signs and symptoms? rheumatic heart disease sickle cell anemia viral myocarditis patent ductus arteriosus

patent ductus arteriosus (This patient is presenting with signs of congestive heart failure. The most common causes of heart failure in children/adolescents are due to acquired heart disease. Congenital heart diseases, such as malformations of the heart—patent ductus arteriosus and ventricular septal defects, are the most common causes of heart failure in infants-toddlers, and are second to fluid overload in neonates)

Of the following diseases, which would you consider screening for first in a 55-year-old diabetic with no other comorbidities? abdominal aortic aneurysm with a sonogram carotid arterial disease with a sonogram coronary artery disease with an angiogram peripheral arterial disease with an ABI

peripheral arterial disease with an ABI (The majority of patients with peripheral artery disease (PAD) will be asymptomatic. In fact, clinicians will miss 90% of patients with PAD if they wait for classic symptoms to appear. According to the American Heart Association, diabetics over the age of 50 are at "extremely high risk" of PAD and should be considered for screening.)

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? loratadine simvastatin pseudoephedrine acetaminophen lisinopril

pseudoephedrine (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)

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? Nocturnal cough Tachycardia Third heart sound Pleural effusion Hepatomegaly

third heart sound (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. Third heart sound is the only choice that falls under the heading of major criteria)

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? Aortic valve vegetation Tricuspid valve vegetation Mitral valve vegetation Left ventricular hypertrophy Ventricular septal defect

tricuspid valve vegetation (In almost 50% of cases involving IV drug users, the only site of infection is the tricuspid valve, and most lesions are right-sided)

Which of the following is the most common congenital heart malformation? atrial septal defect tetralogy of Fallot ventricular septal defect transposition of the great vessels

ventricular septal defect (Ventricular septal defect, a hole between the two ventricles, can be cyanotic or acyanotic based on the size of the defect, and accounts for 30% of cases of congenital heart disease.)