B2E3 Study Cases/Questions

Yes

A 1-month-old child was seen in the emergency room for bruising. Physical examination revealed bruises to the buttocks, chest, and eye. The parents reported that the child received the buttock bruise after being dropped by the father, that the chest bruise was from the child's seat belt, and the eye bruise was from accidentally hitting the child with an elbow while cosleeping. The social worker was consulted in the emergency room, and found no concerning "red flags" in the family. The emergency room physician felt the findings were because of inexperienced parents. Should you report this case to CPS?

Adenosine

A 12-year-old girl is brought to the ED with intermittent symptoms of dizziness and syncope. Her ECG shows that she has paroxysmal supraventricular tachycardia (PSVT). What is the drug of choice to rapidly terminate the PSVT?

Skeletal Survey

A 15-month-old child is brought to the ED by the police after a relative called 911. The child and his mother attended a family gathering where concerned relatives viewed the mother's story that the child "falls a lot" with suspicion. On examination there were many signs of physical abuse. His face was covered with bruises, especially around the right eye and cheek. His axilla showed signs of being gouged with fingernails. What test would you order to further document your suspected diagnosis?

Patent Ductus Arteriosus (PDA) w/ Heart Failure

A 2-month-old girl presents to her pediatrician's office for her well-child check. She was born vaginally at 35 weeks' gestation after an uncomplicated pregnancy. She was discharged at 3 days of age and has had no significant medical issues. The baby was noted to have a murmur at birth; the mother reports she was told, "it should be watched." Since the previous checkup, her mother has noticed that her daughter is not breastfeeding as well as usual and becomes sweaty while eating. On examination, growth parameters show her weight to be at the 24th percentile (previously 78th percentile at 2 weeks), HR is 158 beats per minute, and RR is 58 breaths per minute. She has nasal flaring and subcostal retractions. Auscultation of the lungs reveals diffuse crackles. She has bounding pulses and a grade 3/6 continuous machine-like murmur at the left infraclavicular area. What is the most likely diagnosis?

Panic Disorder

A 21-year-old college student presents to your office for evaluation. She is complaining of feeling stressed out. She is taking classes full-time and is also in one of the military reserve units at the college. One weekend a month, she must attend drill that involves handling weapons. Although she did not have problems handling the weapons initially, she now gets very emotional and upset when she thinks about having to use them at the next drill weekend. She is nervous and is afraid that she might accidentally fire a weapon. She knows that her fears are silly, and she has been telling herself to "just get over it." Last weekend, while in class, she suddenly felt that she was going to have a heart attack. She developed tightness in her chest, her heart was racing, and she felt unable to breathe. Although the symptoms eventually abated, the episode made her even more alarmed, and now she is worried that it will happen again, and she will have a heart attack. She comes to see if you can help. She does not smoke, doesn't use recreational drugs, and doesn't drink alcohol; she drinks 1 cup of coffee on weekday mornings before class. Her physical examination is normal. Her mental status examination is remarkable for a neutral mood, a restricted and anxious affect, but no suicidal thoughts, and no psychotic symptoms. The laboratory tests you order are normal. What is the most likely diagnosis?

Pericarditis

A 40-year-old man presented to ED with a 2-day history of chest pain. He also has a 1-week history of sore throat, runny nose, dry cough, and generalized body aches. Yesterday, he woke up with chest pain, which he describes as a severe, sharp, substernal chest pain that is aggravated by cough, deep breathing, and lying down. No dyspnea, orthopnea, paroxysmal nocturnal dyspnea, palpitations, or syncope. He is physically active and is training for a 20-mile marathon. He has a history of HTN, diabetes type 2, and dyslipidemia. No medication allergies. He drinks 1 glass of red wine on most nights. No history of tobacco or illicit drug use. He is on hydrochlorothiazide, metformin, and lovastatin. On examination, he appears to be in moderate distress from the chest pain. Vitals signs are within normal limits. Cardiac examination shows normal heart sounds with a pericardial rub. The remainder of the physical examination is unremarkable. Complete blood count is normal; basic metabolic profile is within normal range. Cardiac enzymes are normal. Electrocardiogram done in the emergency room shows diffuse ST segment elevation without reciprocal changes and PR segment depression in the limb leads. Chest radiograph is within normal limits. What is the most likely diagnosis?

Neurocardiogenic (Vasovagal) syncope

A 21-year-old college student was brought to the ED by EMS following an episode of loss of consciousness on a hot summer afternoon. She is accompanied by her friends who witnessed the episode. She is awake and alert, and claims to be in her usual state of health now. She was in the cheer team and she lost consciousness just before the half time. She felt light-headed and weak prior to the episode with vague abdominal pain and nausea. She has no recollection after that and the next thing she can remember is that her friends were calling her name when she was lying on the floor. As per the friends, she looked pale initially and had shaky movements of the limbs for a few seconds. She was unconscious for less than a minute. After that her color returned and regained consciousness spontaneously. She was in her usual state of health until a few seconds prior to the episode. She never lost consciousness in the past. She has negative review of systems and takes oral contraceptive pills for birth control. Patient denies tobacco, alcohol, or illicit drug use. No significant family history. Vitals signs including orthostatic BP are normal. Examination including neurological examination is unremarkable. EKG is normal. Urine pregnancy test is negative. What is the most likely diagnosis?

Lymphangitis

A 22 yo female comes to see you for throbbing pain in her arm. She reports fever and chills over the past 2 days. Physical exam is notable for nail biting and a red and tender streak in her arm (pictured). What is the most likely diagnosis?

Start the patient with an antidepressant such as paroxetine.

A 22-year-old man with BPD patient loses his job at a local restaurant, the first job he has held for longer than a month. His mother dies suddenly 3 weeks later. One month after his mother's death, the patient tells his therapist, whom he has been seeing once a week, that he has trouble sleeping, waking up at 3 AM and then unable to go back to sleep. He has lost 13 lb in 5 weeks without trying to do so. He reports low energy and a decreased interest in his usual hobbies. He states that he feels depressed but then grins and says, "But I'm always depressed, aren't I?" Based on his history, how would you treat this patient?

Cephalexin <2h prior procedure

A 23-year-old man with a history of congenital heart disease presents for routine follow-up with his primary care provider. Two months prior to date, he underwent cardiac catheterization with successful placement of an ASD closure device. He is allergic to penicillin. At his visit, he mentions that he has had tooth pain for the past 3 weeks. Panorex is obtained and reveals a dental abscess. He is scheduled for evaluation and likely extraction with his dentist later that week. What is your recommendation regarding IE prophylaxis and timing in this patient?

Borderline Personality Disorder

A 23-year-old woman is admitted to the inpatient psychiatric unit after slashing both wrists when her therapist left for a week's vacation. The cuts were superficial and did not require stitches. The patient says that she is angry with her psychiatrist for "abandoning her." She claims that she is often depressed, although the depressions last "only a couple of hours." When she was first admitted to the hospital, she told the admitting psychiatrist that she heard a voice saying, "I will never amount to anything," but she subsequently denies having heard the voice. This is the patient's fourth hospital admission, and all of them have been precipitated by someone in her life leaving, even temporarily. After 3 days in the unit, the patient's psychiatry resident gets into an argument with the nursing staff. He says that the patient has been behaving very well, responding to his therapy, and is deserving of a privilege. The nurses claim that the patient is not following unit rules, sleeping through her group meetings, and ignoring the limits set. Both parties go to the unit director complaining about the other. What is the most likely diagnosis?

Adenosine

A 24-year-old female presents to the ED with a history of tachycardia and the rhythm strip attached Her BP is 115/70 mm Hg with an oxygen saturation of 98% on room air. There are no associated symptoms of chest pain, dyspnea, etc. The appropriate treatment of this patient is:

Atrial fibrillation

A 24-year-old male presents to your clinic with a 50-hour history of an irregular heart rate. He is generally well but has a history of hypertension (too many super-jumbo burgers ... with bacon ... he's been "supersized"), which he has been trying to control with exercise and diet (he switched to tofu burgers yesterday). There is no prior history of cardiac disease or palpitations. He did "have a bit to drink" celebrating ... well, whatever, just celebrating ... who needs a reason! He was embarrassed about his drinking and thus waited 2 days to seek care. There is no family history of heart disease and the patient does not smoke. Vital signs reveal an irregular pulse of 130 bpm and a blood pressure of 160/100 mm Hg. The patient is afebrile and has normal respirations. He has no heart murmur. The ECG is attached. What does the attached ECG show?

Dialectical behavioral therapy

A 24-year-old woman is seen in the ED after superficially cutting both her wrists. Her explanation is that she was upset because her boyfriend of 3 weeks just broke up with her. When asked about other relationships, she says that she has had numerous sexual partners, both male and female, but none of them lasted more than several weeks. Which type of psychotherapy might she be most likely to respond to?

Wolff-Parkinson-White syndrome

A 25-year-old man presents to the hospital with light-headedness and palpitations for the past 2 hours. He had four or five previous episodes of palpitations in the past, but they had lasted only a few minutes and went away on their own. These episodes were not associated with any specific activity or diet. He denies any chest pain. On physical examination, he is noted to be tachycardic with a HR of 180 bpm and a BP of 105/70 mm Hg. An ECG shows a narrow complex tachycardia at 180 bpm. The tachycardia terminates suddenly, and the patient's HR drops to 90 bpm. A repeat ECG shows sinus rhythm with a short PR interval and a wide QRS with a slurred upstroke (delta wave). What is the most likely Diagnosis?

Post-Traumatic Stress Disorder (PTSD)

A 26-year-old male presents to primary care clinic to establish care. He is accompanied by his wife. He has no chronic medical problems and has never had any surgeries. He does not take any medications. He smokes approximately 1 pack of cigarettes daily and drinks alcohol occasionally. He returned from a military deployment in Iraq approximately 3 months ago. His wife expresses concerns that he has been very irritable and having frequent outbursts of anger since he returned. The patient refuses to discuss this with his wife in the room. You ask his wife to wait outside while you continue your visit. What diagnosis are you concerned this patient may have?

Mitral Stenosis

A 28-year-old Haitian woman presents to labor and delivery at 38 weeks' gestation for a repeat elective cesarean section. She has had an uneventful pregnancy with a singleton fetus. The patient's past medical history is significant for mitral stenosis. During her pregnancy, she noticed dyspnea on exertion with walking one flight of stairs, which has remained stable. She is unable to lay flat in bed, and props herself up on two pillows to sleep. She has taken Coumadin in the past, but has taken low-molecular-weight heparin since becoming pregnant. With the consent of her cardiologist, she has not taken any anticoagulant for the past 2 days. Her only other medication is prenatal vitamins. She has no known drug allergies, does not smoke, and has not consumed any alcohol since becoming pregnant. The patient is 5 ft 3 in tall and weighs 75 kg. Auscultation of the chest reveals a III/VI diastolic murmur. Her lungs are clear to auscultation, though she has +2 edema of both lower extremities to the knee. She has very mild jugular venous distension. Which valvular lesion is this murmur most characteristic of?

Infectious Endocarditis

A 28-year-old man comes to the emergency center complaining of 6 days of fever with shaking chills. Over the past 2 days, he has also developed a productive cough with greenish sputum, occasionally streaked with blood. He reports no dyspnea, but sometimes he experiences chest pain with deep inspiration. He does not have a headache, abdominal pain, urinary symptoms, vomiting, or diarrhea. He has no significant past medical history. He smokes cigarettes and marijuana regularly, drinks several beers daily, and denies intravenous drug use. On examination, his temp is 102.5 °F, HR is 109 bpm, BP is 128/76 mm Hg, and RR is 23 bpm. He is alert and talkative. He has no oral lesions, and fundoscopic examination reveals no abnormalities. His jugular veins show prominent V waves. He is tachycardic with a regular rhythm and has a harsh holosystolic murmur at the left lower sternal border that becomes louder with inspiration. Chest examination reveals inspiratory rales bilaterally. He has linear streaks of induration, hyperpigmentation, and a few small nodules overlying the superficial veins on either forearm, but no erythema, warmth, or tenderness. Labs are significant for an elevated WBC count of 17,500/mm3, with 84% polymorphonuclear cells, 7% band forms, and 9% lymphocytes; a Hgb concentration of 14 g/dL; HCTof 42%; and platelet count of 189,000/mm3. Liver function tests and urinalysis are normal. A chest radiograph shows multiple peripheral, ill-defined nodules, some with cavitation. What is the most likely diagnosis?

Pulmonary HTN

A 28-year-old woman with no significant past medical history presents to clinic with complaints of progressive SOB; she becomes dyspneic with less activity compared to 1 year ago. If she exerts herself beyond a brisk walk, she becomes lightheaded, pre-syncopal, and feels tightness in her chest. She also notes generalized fatigue. Your examination discloses a HR of 105 bpm and normal BP. Resting transcutaneous oximetry is 92% on room air. BMI is 24 kg/m2. She has JVD but clear lungs. A grade 2/6 mid-systolic murmur is heard over the left upper sternal border. Electrocardiogram is shown What is the most likely diagnosis?

Superior Vena Cava Obstruction

A 28yo male comes to the urgent care complaining of a 3 day history of headaches and facial swelling. Vitals include BP 126/76, HR 120, RR 22. He has a 50 pack-year smoking history. On examination you note the patient has facial redness and edema, as well as dilation of collateral veins in the trunk and neck. What is the most likely diagnosis?

SVT

A 30-year-old female is admitted with fever, elevated WBC, diarrhea, and abdominal pain and found to have C. difficile colitis. The patient complains of palpitations associated with anxiety. The nurse reports the patient's BP is 130/70 with a HR of 150 bpm. The EKG is attached. What does the EKG show?

Fluoxetine

A 30-year-old woman presents to your office for the evaluation of fatigue. For the past 2 months she has felt run down. She says that she doesn't feel like participating in activities that she previously enjoyed, such as her weekly softball games. She has not been sleeping well and has not had much of an appetite. On questioning, she admits to feeling "down in the dumps" most of the time and has found herself crying frequently. She has never gone through anything like this before. She denies any thoughts of wanting to hurt herself or anyone else. She denies any symptoms now or previously of mania. She also denies any visual/auditory hallucinations, paranoia, delusions, or other psychotic symptoms. Other than becoming tearful during her interview, her physical examination is normal. Her blood tests, including a complete blood count and thyroid function, are normal. A serum pregnancy test is negative. What is your initial treatment?

Pericarditis

A 35-year-old man presents to the ED with complaints of chest pain. The pain is described as 8 on a scale ranging from 1 to 10, retrosternal, and sharp in nature. It radiates to the back, is worse with taking a deep breath, and is improved by leaning forward. On review of systems, he has noted a "flu-like illness" over the past several days, including fever, rhinorrhea, and cough. He has no medical history and is taking no medications. He denies tobacco, alcohol, or drug use. On physical examination, he appears in moderate distress from pain, with a BP of 125/85 mm Hg, HR 105 bpm, RR 18/min, and oxygen saturation of 98% on room air. He is currently afebrile. His head-and-neck examination is notable for clear mucus in the nasal passages and a mildly erythematous oropharynx. The neck is supple, with shotty anterior cervical lymphadenopathy. The chest is clear to auscultation. Jugular veins are not distended. Cardiac examination is tachycardic with a three-component high-pitched squeaking sound. Abdominal and extremity examinations are normal. What diagnosis is highest on your DDx?

Mitral Valve prolapse

A 35-year-old woman presents to your office complaining of skipped or "irregular heartbeats" for the past few weeks. At first, she attributed her symptoms to job-related stress and thought they would disappear. Instead, the skipped beats have increased in frequency to twice a day, lasting up to 2 minutes per episode. Her father, who has coronary heart disease, urged her to see a doctor. She denies chest pain, SOB, or presyncopal symptoms. She drinks two cups of caffeinated coffee per day, does not smoke, and rarely drinks alcohol. She recently tried some over-the-counter diet pills to lose weight but stopped taking them when her symptoms became more frequent. On examination, her temp is 98.6 °F (37 °C), BP is 130/85 mm Hg, HR is 92 beats/min, RR is 16 breaths/min, and BMI is 27 kg/m2. Neck examination is without thyromegaly, nodule, or mass and without jugular venous distention or bruit. Lung examination is bilaterally clear to auscultation. Cardiac examination reveals regular rate and rhythm with normal S1 and S2. A midsystolic click followed by a late systolic crescendo murmur is heard at the fifth intercostal space at the midclavicular line. Abdominal examination is unremarkable. Examination of the extremities reveals palpable symmetric distal pulses in all four extremities. What is the most likely diagnosis?

SSRI

A 37-year-old woman presents to establish care with you in the office today. She complains of low energy levels and difficulty sleeping for the past 4 years. She has gained 30 lb over the past 2 years. She reports a family history of alcoholism in her mother and her older brother, and completed suicide in her father. She thinks her mother was hospitalized for a suicide attempt many years ago, but she does not know any more details. When you ask about her social history, she hesitates in giving her answer, and then becomes tearful as she tells you with great difficulty that she was in a physically and sexually abusive marriage for 10 years. The marriage finally ended over 1 year ago, but the patient still expresses guilt about its end and says she feels worthless every day. She admits that she had suicidal thoughts on and off in the past but has none currently. She has never had a suicide attempt. She drinks 3 beers nightly. Her vital signs and complete physical examination are normal except for a labile affect. What treatment option will you offer to the patient?

Physical/Child Abuse

A 4-month-old boy presents to the urgent care center for irritability for 7 days. The mother states that the child cries constantly and cannot be consoled with formula or change of diapers. She denies any illnesses, emesis, or diarrhea. He lives with his mother, stepfather, 21-month-old sister, and 3-year-old brother, all of whom have been healthy and without illness. On physical examination, the infant has right thigh swelling and tenderness. The mother denies any trauma or injury. Radiographs of the right lower extremity reveal a transverse femur fracture. What is the most likely diagnosis?

History and Physical

A 47-year-old female with a history of obesity and osteoarthritis presents to your primary care practice for evaluation of acute chest pain. She is accompanied by her elderly mother of 86 years who you also care for and know to be of sound mind and health. The pain began today while cleaning the kitchen, is described as substernal with radiation to the left arm and neck, characterized as a "heavy" feeling on her chest, made worse with deep inspiration, improved with rest, lasted 4 to 5 minutes, and associated with nausea. There was no shortness of breath or emesis. Her mother is scared and thinks her daughter's complaints are all due to "stressful times" in the home. Do you want to order imaging or ask more history and physical first?

prolongation of RR intervals and an increase in the regularity of RR intervals.

A 47-year-old man with uncomplicated atrial fibrillation is prescribed diltiazem. What effect with diltiazem have on the ECG of this patient?

Niacin/Fish Oil

A 48-year-old woman seeks health care after her older sister (age 52 years) was diagnosed with CAD. The patient reports that her sister was told she has "high cholesterol." The patient is not taking any medications and is a nonsmoker. BP is 155/90 mm Hg, but the rest of physical examination is unremarkable. The patient agrees to screening laboratories including a fasting lipid panel. Total cholesterol is 270 mg/dL, HDL cholesterol 34 mg/dL, LDL cholesterol 178 mg/dL, and triglycerides 292 mg/dL. Fasting plasma glucose, serum creatinine, and markers of liver function are unremarkable. The patient agrees to take atorvastatin 10 mg daily. Six weeks later, a repeat fasting lipid panel shows total cholesterol 209 mg/dL, HDL cholesterol 36 mg/dL, LDL cholesterol 124 mg/dL, and triglycerides 248 mg/dL. What else can be added to manage TG?

Thrombophlebitis

A 48yo man was admitted for infection requiring IV Antibiotics. On hospital day 5 the patient complains of a dull achy pain in the back of his leg. On examination, you notice some erythema and tenderness (pictured). What is the most likely diagnosis?

Nitroglycerin + Aspirin + Beta Blocker + Oxygen

A 51-year-old man presents to the ED with chest pain. He states that he has had chest discomfort or pressure intermittently over the last year especially with increased activity. He describes the chest pain as a pressure behind his breastbone that spreads to the left side of his neck. Unlike previous episodes, he was lying down, watching television. The chest pain lasted approximately 15 minutes then subsided on its own. He also noticed that he was nauseated and sweating during the pain episode. He has no medical problems that he is aware of and has not been to a physician for several years. On examination, he is in no acute distress with normal vital signs. His lungs were clear to auscultation bilaterally, and his heart had a regular rate and rhythm with no murmurs. Electrocardiography (ECG) revealed ST segment elevation and peaked T waves in leads II, III, and aVF. Serum troponin I and T levels are elevated. What is your initial treatment for this patient?

Erectile Dysfunction meds (PDE5i)

A 52-year-old man who suffers from angina when he climbs stairs or participates in similar activities receives a prescription for nitroglycerin (glyceryl trinitrate). He is instructed to take a tablet 1 or 2 minutes before he expects to climb stairs to prevent the angina. What drug combinations should be avoided?

High Intensity Statin (Atorvastatin/Rosuvastatin)

A 52-year-old woman with a history of angina, HTN (BP of 140/80 mm Hg), and type 2 diabetes suffers an acute myocardial infarction and receives angioplasty and a stent to open a blocked coronary artery. She has been taking medications for her HTN and diabetes, but no other medications. She smokes a pack of cigarettes each day. Before she is discharged from the hospital, her fasting blood lipids are measured: total cholesterol, 240 mg/dL; HDL-C, 30 mg/dL; LDL-C, 160 mg/dL; triglycerides, 220 mg/dL. What will you treat this patient with?

Stable Angina

A 53-year-old male with a history of hypertension and smoking, but no family history of cardiac disease, presents to your office complaining of a chest pain. The pain is substernal, radiates to his left arm, and is associated with exertion. The patient notes that this same pain has been going on for the last 6 months and has not changed at all in duration, intensity, or characteristic. It generally lasts 5 minutes or so and resolves with rest. What is the most likely diagnosis?

Torsade De Pointes

A 53-year-old woman visits the ED after losing consciousness while working in her garden. She says she has recently had episodes of dizziness and fainting. Her ECG looks unremarkable except that the QT interval is prolonged. What is a likely cause of her recent fainting spells?

Atrial Fibrillation

A 55-year-old male with a past medical history of HTN, hyperlipidemia, and obesity presents to the outpatient internal medicine clinic with a 3-day history of fatigue and decreased exercise tolerance. He used to be able to walk 2 blocks without shortness of breath, but now he gets winded even walking in from the parking garage. He feels as though his heart is beating fast but denies palpitations. He has no chest pain, dizziness, visual changes, edema, or orthopnea. His medications include chlorthalidone, lovastatin, and aspirin. On physical examination, his BP is 120/60 mm Hg, HR is 100 bpm, RR is 16/min, and pulse oximetry is 96% on room air. He is alert and answers questions appropriately. His lungs are clear to auscultation. His cardiac examination reveals an irregularly irregular rhythm that is tachycardic. Extremities reveal no edema. EKG is attached. What is the most likely diagnosis?

Carotid Artery Stenosis/Occlusive Cerebrovascular Disease

A 55-year-old man describes a temporary weakness in his right hand that occurred 3 days ago during breakfast. He was unable to move his arm or lift his fork for 45 minutes, but then his strength resolved without recurrence. His past medical history is significant for HTN and coronary artery disease with stable angina. He has a 55-pack-year smoking history and currently smokes 10 cigarettes a day. His medications include aspirin, nitrates, and a beta-blocker. On examination, bruits can be auscultated over both carotid arteries. The remainder of his physical examination is unremarkable. What is the most likely diagnosis?

SL Nitro PRN

A 55-year-old man presents to the clinic with complaints of chest pain. He states that for the past 5 months he has noted intermittent substernal chest pressure radiating to the left arm. The pain occurs primarily when exercising vigorously and is relieved with rest. He denies associated shortness of breath, nausea, vomiting, or diaphoresis. He has a medical history significant for HTN and hyperlipidemia. He is taking atenolol for his high blood pressure and is eating a low-cholesterol diet. His family history is notable for a father who died of myocardial infarction at age 56 years. He has a 50-pack-year smoking history and is currently trying to quit. His physical examination is within normal limits with the exception of his BP, which is 145/95 mm Hg, with a HR of 75 bpm. What should you prescribe this patient?

Although this patient would certainly be considered to have HTN on this visit, he would not yet be diagnosed with hypertension. He will need 2 consecutive readings that are high after at least 2 weeks.

A 56-year-old black man presents to the clinic for a routine physical examination. He has not seen a physician for 10 years. On arrival, he is noted to have a BP of 160/90 mm Hg. Does this patient have HTN?

Unstable Angina

A 56-year-old man is brought to the ED complaining of chest discomfort for about 90 minutes. He has had occasional symptoms for a month, but it is worse today. Today's symptoms began while he was walking his dog and decreased slightly with rest but have not resolved. He describes the feeling as a pressure sensation in the left substernal area of his chest associated with shortness of breath and mild diaphoresis. He does not have any radiation of the discomfort today, but he has experienced radiation to the left upper extremity in the past. The patient denies any health problems, but his wife reports that he has not seen a physician in years. His wife made him come in because his younger brother had a heart attack 6 months ago. He has smoked 1½ packs of cigarettes per day for more than 30 years and denies drinking alcohol or any drug use. On Exam, he is an anxious, obese gentleman who appears pale and has a moist brow. His temp is 98.8 °F (37.1 °C), HR is 105 beats/min, RR are 18 breaths/min, BP is 190/95 mm Hg, his height is 74 inches, his weight is 250 lb, and his oxygen saturation is 97%. Cardiac examination reveals a regular rhythm without murmur, but he has an S4 gallop. His lungs are clear to auscultation, and his neck is without carotid bruits or jugular venous distension. His abdomen is normal. He does have a right femoral bruit. Extremities show trace edema but no clubbing or cyanosis. He has 2+ pulses in radial and dorsal pedalis arteries. What is the most likely diagnosis?

Peripheral Arterial Disease

A 58-year-old male smoker with a history of type 2 diabetes mellitus presents with complaints of easy fatigability and pain in his thighs when exerting himself. The left leg is worse than the right. The pain resolves after resting and is no worse going downhill than uphill. He works as a carpenter, and the leg pain is now limiting his ability to work. He will not quit smoking ("It's the only thing I truly love, Doc"). The patient states that his symptoms are better when he hangs his leg over the side of the bed at night. The etiology of this patient's leg pain is most likely:

Myocardial Infarction (STEMI)

A 59-year-old man complains of tight chest pressure and shortness of breath after lifting several boxes in his garage approximately 2 h ago. He perceives that his heart is skipping beats. His medical history is significant for HTN and cigarette smoking. On examination, his HR is 55 beats/min and regular, and his lungs are clear to auscultation. An electrocardiogram shows bradycardia with an increased PR interval and ST-segment elevation in multiple leads including the anterior leads, V1 and V2. What is the most likely diagnosis?

Aortic Stenosis

A 59-year-old man is brought to the ED by ambulance after experiencing a syncopal episode. He states that he was running in the park when he suddenly lost consciousness. He denies any symptoms preceding the event, and he had no deficits or symptoms upon arousing. On review of systems, he does say that he has had substernal chest pressure associated with exercise for the past several weeks. Each episode was relieved with rest. He denies shortness of breath, dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. His medical history is notable for multiple episodes of pharyngitis as a child. He is otherwise well. He has no significant family history. He was born in Mexico and moved to the United States at age 10 years. He does not smoke, drink alcohol, or use illicit drugs. On examination, his BP is 110/90 mm Hg, HR 95 bpm, RR 15/min, and oxygen saturation 98%. Neck examination reveals both pulsus parvus and pulsus tardus. Cardiac examination reveals a laterally displaced and sustained apical impulse. He has a grade 3/6 midsystolic murmur, loudest at the base of the heart, radiating to the neck, and a grade 1/6 high-pitched, blowing, early diastolic murmur along the left sternal border. An S4 is audible. Lungs are clear to auscultation. Abdominal examination is benign. He has no lower extremity edema. What valve disease is the patient presenting with?

Acute Mitral Regurgitation

A 59-year-old man presents to the ED with a 4-hour history of "crushing" chest pain. His cardiac examination is normal with no murmurs and normal heart sounds. An ECG reveals ST segment elevation in the lateral precordial leads, and cardiac enzymes show evidence of myocardial injury. He undergoes emergent cardiac catheterization that shows a thrombus in the left circumflex artery. He undergoes successful angioplasty, and a stent is placed. He is monitored in the cardiac intensive care unit. He does well until the next day, when he develops sudden shortness of breath and decreasing oxygen saturations. Physical examination now reveals jugular venous distention, rales at both lung bases, and a blowing holosystolic murmur loudest at the apex, radiating into the axilla. What likely accounts for this patient's sudden decompensation?

Defibrillation + IV Amiodarone

A 59-year-old man suddenly loses consciousness in a shopping mall. A security guard at the mall cannot detect a pulse and uses an automated external defibrillator (AED) to resuscitate the man. He regains consciousness and is taken by ambulance to a nearby hospital. In the ED waiting room, he loses consciousness again. His ECG shows that he is in ventricular fibrillation. What treatment will this patient receive in the ED?

Amiodarone, procainamide, lidocaine, cardioversion

A 60-year-old male presents with dizziness and palpitations. The patient has a BP of 100/60 mm Hg and a pulse of 160 bpm. His ECG is attached: What treatments would be appropriate for this patient?

Aspirin

A 61-year-old man arrives at the ED (ED) complaining of chest pain. The pain began 45 minutes ago while watching television and is described as severe and pressure-like. It is substernal in location, radiates to the jaw and left shoulder, and is associated with shortness of breath. The patient has hyperlipidemia and HTN and takes simvastatin and hydrochlorothiazide. His BP is 160/110 mm Hg, HR rate is 93 beats per minute, RR rate is 22 breaths per minute, temperature is 37.1°C, and oxygen saturation is 97%. The patient appears anxious, is diaphoretic and vomited once. On auscultation, faint crackles are heard at both lung bases. The cardiac and abdominal examinations are unremarkable. What therapy(ies) should be instituted immediately?

Lisinopril + Hydrochlorothiazide

A 62-year-old Caucasian man comes to see you in clinic as a new patient. His former doctor diagnosed him with HTN in his early 40s and had prescribed him a medicine for this. However, he heard that there could be "sexual side effects" from this medicine and simply never started the medicine; he also never returned to his doctor's office and has not been seen in over 12 years. However, a friend's recent stroke prompted him to be seen today to reassess his BP. He brings in a copy of his medical records. His family history is notable for the fact that his father has type 2 diabetes mellitus, HTN, and coronary artery disease (with his first myocardial infarction at age 54). He also has two sisters with HTN. The patient does not smoke. His BP today is 164/102 mm Hg. When you review his prior medical records, you notice that he had several office visits with BP in the 160s/high 90s. How will you treat this patient?

Echo to r/o structural heart disease

A 62-year-old female presents to your office with a history of occasional palpitations that are of great concern to her. She notes that she feels a racing heart that lasts for a matter of seconds and occurs every 7 days or so. However, when she has the symptoms, she will generally get four to five episodes during that day. She denies any chest pain, dyspnea, lightheadedness, or other associated symptoms. You order an event monitor and it shows that the patient is having nonsustained episodes of monomorphic ventricular tachycardia lasting 4 beats or less each. She is asymptomatic except for the palpitations. You check a panel of laboratory studies including thyroid function tests, electrolytes, magnesium, glucose, and CBC for your patient with concerning palpitations and dyspnea. They are all within normal limits. You suggest that the patient avoid potential triggers such as caffeine and sympathomimetics. "Darn," she sighs. "I have to quit my crystal meth?" The next step for this patient is to:

Congestive heart failure (CHF) and cardiogenic acute pulmonary edema

A 63-year-old woman arrives in the ED in respiratory distress. The paramedics who transported her were not able to obtain any information about her past medical history but did bring her bag of medications, which included furosemide. On examination, her temperature is 37.5°C (99.5°F), BP is 220/112 mm Hg, HR is 130 beats per minute, RR is 36 breaths per minute, and oxygen saturation is 93% on a non-rebreather mask. The patient's skin is cool, clammy, and diaphoretic. She is alert but can only answer yes-or-no questions because of dyspnea. She has jugular venous distention to the angle of the jaw, rales in both lung fields, and +2 pretibial edema bilaterally. Her heart sounds are regular but tachycardic, with an S3/S4 gallop. What is the most likely diagnosis?

Aortic Regurgitation

A 64-year-old man presents to the clinic with a 3-month history of worsening shortness of breath. He finds that he becomes short of breath after walking one block or one flight of stairs. He awakens at night, gasping for breath, and has to prop himself up with pillows in order to sleep. On physical examination, his BP is 190/60 mm Hg and his pulses are hyperdynamic. His apical impulse is displaced to the left and downward. On physical examination, there are rales over both lower lung fields. On cardiac examination, there are three distinct murmurs: a high-pitched, early diastolic murmur loudest at the left lower sternal border, a diastolic rumble heard at the apex, and a crescendo-decrescendo systolic murmur heard at the left upper sternal border. Chest x-ray film shows cardiomegaly and pulmonary edema. What valve disease is the patient presenting with?

Add diuretic and stop ibuprofen

A 64-year-old man who suffered a myocardial infarction at the age of 56 complains of difficulty sleeping because he wakes up feeling out of breath. Chest sounds reveal crackles and rales. He has difficulty walking more than 150 feet before having to stop to catch his breath. He is taking a β adrenergic blocker (metoprolol) and an ACE inhibitor (captopril). He also takes ibuprofen every day to relieve pain in his knees. What drugs, if any, should be added, changed, or withdrawn?

bile acid-binding resins, niacin, fibrate, and ezetimibe

A 64-year-old man with highly elevated total cholesterol and LDL-C is not responding adequately to high-dose statin therapy.What additional drug therapies are available to lower this patient's serum cholesterol?

Ischemia

A 65-year-old female with a history of HTN and DM type 2 was admitted to the general medical floor with fever and cough for 3 days. The patient was diagnosed with community-acquired pneumonia and was started on levofloxacin. She improved and her fever resolved. On hospital day 3, the patient complained of severe pressure-like substernal chest pain with radiation to the left shoulder of 20 minutes duration. The pain was associated with sweating and nausea. The on-call internal medicine resident was paged. The patient was sitting on the edge of the bed and looked very distressed. Her vital signs showed temperature of 36.5°C, HR of 88 bpm, BP of 160/95, RR of 24/min, and blood oxygen saturation of 98% on room air. The patient has a history of poorly controlled diabetes mellitus type 2, HTN, and hypercholesterolemia. She is a heavy ex-smoker. Physical examination is significant only for crackles over the right lower lung base. The nurse had already done an ECG before the resident arrived (attached) What do you think is wrong with this patient?

Implantable pacemaker

A 65-year-old woman comes in for her Welcome to Medicare examination. She has a history of HTN and diabetes mellitus type 2. On questioning, she says she has had 2 syncopal episodes in the past week. On physical examination, her BP is 138/78 mm Hg, her HR is 80 bpm, and her RR is 14/min. Lungs are clear to auscultation. Cardiovascular examination reveals a regular rate and rhythm with no murmurs, gallops, or rubs. Her extremities have no edema. Her EKG is attached: What is the definitive treatment for this diagnosis?

Pericardial Tamponade

A 65-year-old woman is hospitalized with a large anterior myocardial infarction. After 4 days in the hospital, she is doing well and plans are being made for discharge to a rehabilitation facility to help her regain her strength and recover her cardiac function. While going to the bathroom, she passes out suddenly. On examination, her BP is 60/40 mm Hg, her HR is 120, she has increased JVP noted, and she has distant heart sounds. What is the most likely diagnosis?

Atherosclerosis

A 65-year-old woman presents to the clinic to establish care. Her past medical history is notable for type 2 diabetes and HTN. She has a 45-pack-year smoking history. A few weeks ago, she was shovelling her driveway when she had to stop owing to tightness in her chest. She does not get any regular exercise because her calves become very painful after walking one block. What is the underlying cause to this patients diagnosis?

Abdominal Aortic Aneurysm

A 67-year-old African American man is found to have discovered a mass in his abdomen while buttoning his shirt. The mass has not caused any symptoms. He currently smokes and has smoked one pack of cigarettes per day for 40 years. He has had type 2 diabetes for 20 years, for which he takes on an oral agent, as well as HTN for 15 years, for which he takes an angiotensin-converting enzyme (ACE) inhibitor. On examination, his BP is 130/85 mm Hg and HR is 80 beats per minute. The pulsatile abdominal mass appears to be large. What is the most likely diagnosis?

Beta Blocker

A 67-year-old woman with mild heart failure (LVEF = 45%) has anginal pain with exercise. What is your first line treatment?

Add ACE-I

A 68-year-old woman is being treated with 25 mg of hydrochlorothiazide for her HTN. During her most recent checkup, her BP was 161/93 and she was also diagnosed with type 2 diabetes. What changes should be made in her treatment?

Multifocal Atrial Tachycardia

A 69-year-old gentleman is admitted with pneumonia and COPD exacerbation. The nurse calls you saying the patient has developed tachycardia and active wheezing, and his rhythm is irregular. She is worried and wants you to look at the EKG. The nurse shows you the following 12-lead EKG from the patient: What is the most likely diagnosis?

Hypertensive Emergency

A 70yo F was evaluated in the ED for acute onset of dyspnea with severe frontal headaches and diaphoresis. She was diagnosed with a left adrenal pheochromocytoma a week ago, and surgery is scheduled next week. Her PMH is otherwise not significant. Current medications include phenoxybenzamine and propranolol. On physical examination, the patient appears anxious, dyspneic, and diaphoretic. BP is 220/120 mm Hg; HR is 130/min; RR is 30/min; oxygen saturation is 92% on room air. On auscultation, lungs reveal bibasilar crackles and heart examination reveals tachycardia. She has 2+ pedal edema. CBC and BMP are normal. Chest x-ray (CXR) shows cardiomegaly and pulmonary congestion. EKG shows no evidence of ischemia. What is the most likely diagnosis?

Orthostatic Hypotension

A 72-year-old African-American woman with mild heart failure comes in for her annual check-up. During her examination, she complains of occasional dizziness, especially when she stands up quickly. She is taking an ACE inhibitor, thiazide diuretic, and β blocker. Her lung sounds are normal and there is no evidence of peripheral edema. What is the most likely diagnosis?

Pacemaker

A 72-year-old man is brought to the ED after fainting while in church. He stood up to sing a hymn and then fell to the floor. His wife, who witnessed the episode, reports that he was unconscious for approximately 2 or 3 minutes. When he woke up, he was groggy for another minute or two and then seemed himself. No abnormal movements were noted. This had never happened to him before, but his wife does report that for the last several months he has had to curtail activities, such as mowing the lawn, because he becomes weak and feels light-headed. His only medical history is osteoarthritis of the knees, for which he takes acetaminophen. On examination, he is alert, talkative, and smiling. He is afebrile, his HR is 35 beats per minute (bpm), and his BP is 118/72 mm Hg, which remains unchanged on standing. He has contusions on his face, left arm, and chest wall, but no lacerations. His chest is clear to auscultation, and his heart rhythm is regular but bradycardic with a nondisplaced apical impulse. He has no focal deficits. Laboratory examination shows negative cardiac enzymes and normal blood counts, renal function, and serum electrolyte levels. His rhythm strip is attached. What is the treatment for this patient?

Aortic Valve Stenosis

A 72-year-old man presents to the clinic complaining of worsening exertional dyspnea. Previously, he had been able to work in his garden and mow the lawn, but now he feels short of breath after walking 100 ft. He does not have chest pain at rest but has experienced retrosternal chest pressure with strenuous exertion. He occasionally feels light-headed while climbing a flight of stairs, as if he were about to faint, but this resolves after sitting down. He now uses three pillows when he sleeps; otherwise, he wakes up at night feeling short of breath, which is relieved within minutes by sitting upright in bed. He notes occasional swelling of his lower extremities. He denies any significant medical history, takes no medications, and prides himself on the fact that he has not seen a doctor in years. He does not smoke or drink alcohol. On PE, he is afebrile, HR 86, BP 115/92, RR 16. Examination of the head and neck reveals a normal thyroid gland and distended neck veins. Bibasilar inspiratory crackles are appreciated. On cardiac examination, his heart rhythm is regular with a normal S1 and S2, with an S4 at the apex, a leftward displaced apical impulse, and a late-peaking systolic murmur at the right upper sternal border that radiates to his carotids. The carotid upstrokes have diminished amplitude. What is the most likely cause of the patient's diagnosis?

Metoprolol

A 73-year-old woman presents to the ED complaining of palpitations and new shortness of breath with minor exertion for the past 2 weeks. Previously, she could walk everywhere, but now she becomes fatigued climbing the stairs of her home. Occasionally, she has felt her heart racing even when she is at rest. Her past medical history is notable for diet controlled diabetes and HTN, for which she takes hydrochlorothiazide and amlodipine. On physical examination, she appears comfortable and speaks in full sentences without difficulty. Her BP is 130/90 mm Hg, HR is 144 beats per minute, RR is 18 breaths per minute, oxygen saturation is 98% on room air, and temperature is 37°C (98.6°F). The head and neck examination is unremarkable. Her lungs are clear to auscultation. Her heartbeat is irregular and rapid, without murmurs, rubs, or gallops. She has no extremity edema or jugular venous distension. Her abdomen is soft and nontender, without masses. Labs show a normal complete blood count (CBC), normal electrolytes, blood urea nitrogen (BUN), creatinine, troponin, brain natriuretic peptide (BNP), and thyroid stimulating hormone. A chest x-ray reveals a normal cardiac silhouette with no pulmonary edema. The ECG is attached: What is your initial treatment?

Second-degree heart block type II

A 75-year-old female presents to your office complaining of episodic palpitations with episodes of lightheadedness that are not concurrent with the palpitations. You perform an electrocardiogram in your office: What rhythm does this represent?

Peripheral Venous Insufficiency

A 75-year-old gentleman with long-standing compensated congestive heart failure and mild dementia presents with a nonpainful "sore" on his left shin. He isn't sure how long it has been there. His vital signs are normal. He is not experiencing any pain. His exam is significant for an S4 gallop, clear lungs, and unchanged 2+ pitting bilateral lower extremity edema. On the anterior aspect of his right medial malleolus, you note a 3 x 2 cm shallow ulcer surrounded by chronic edema beneath thick, brownish skin. Pedal pulses are palpable bilaterally. What is the most likely etiology of the sore?

Aortic Stenosis

A 75-year-old male presents to your office for a complete physical examination before prostate surgery. On examination, you notice a 3/6 harsh, mid-systolic ejection murmur heard best at the upper right sternal border and radiating to the neck. S1 and S2 are normal. What would an echo show?

Initiate code and cardioversion

A 75-year-old male with HTN, DM2, ESRD, PVD, and CAD with a CABG in the past is admitted with an acute ST elevation myocardial infarction status post-cardiac stent placement. He has a BP of 90/50, and a HR of 110 bpm early in the morning. You are at the nurses' station and the telemetry monitor goes off showing the rhythm attached: What is the next best step?

Ventricular Tachycardia

A 75-year-old male with a past medical history significant for HTN, diabetes, and coronary artery disease presents to the ED with a 1-hour history of sudden shortness of breath and generalized weakness. On examination, he is noted to have a BP of 90/58. He is clammy and diaphoretic. His lungs are clear to auscultation. His heart examination reveals tachycardia. His EKG is attached What is the most likely diagnosis?

Hyperkalemia

A 75-year-old patient with chronic kidney disease and diabetes presents to your ED for chest tightness, fatigue, and palpitations, and has the ECG shown What is the most likely electrolyte abnormality in this patient?

Change to combo product Vytorin (Simvastatin-80/Ezetimibe-10)

A male patient's LDL-C levels remain high even with maximal dosing (80 mg daily) of simvastatin. What is your next treatment option?

Third Degree Heart Block w/ Atrial Tachycardia

A patient presents with a history of lightheadedness when he stands and has the ECG shown

No

A previously healthy 41-year-old African American man woke up feeling his heart racing. He also had 7 out of 10 chest tightness and shortness of breath. HR is 90 beats per minute and BP is 130/72 mm Hg. An electrocardiogram (ECG) shows atrial fibrillation. Should he receive chronic anticoagulation?

Surveillance US q6m

A primary care provider identifies a pulsatile mass in the abdomen of an asymptomatic 64-year-old man on a routine visit. The patient's past medical history is significant for HTN and stable angina. He has a 40-pack-year smoking history. His current medications include aspirin, a beta-blocker, and nitrates. The patient describes himself as an active man who just retired and plays 18 holes of golf two times a week. On examination, the carotid pulses and upper extremity pulses are normal. Pulses in the femoral and popliteal regions are readily palpable and appear more prominent than usual. Ultrasound evaluation confirms a 4.8-cm infrarenal abdominal aortic aneurysm. What is the best treatment option for this patient?

Myocarditis

An 18-year-old male presents to primary care clinic with a 3-day history of intermittent and severe chest pain. He had a bad cold about one week ago. He has not been to the ED for fear that he would no longer be allowed to play football. His father adds that he has been recruited to play at the college level. What might you suspect is the cause of the patients' chest pain?

Ventricular fibrillation

An 82-year-old female slumps over in church (it's always the bathroom or church—avoid these and you will live forever). Luckily, there is a nurse present who just happens to have a monitor/defibrillator. The nurse lets you know she can't feel a pulse. You quickly hook the patient up a cardiac monitor and see the rhythm attached. "Well, shit", you think. You astutely identify the rhythm as:

Normal sinus rhythm with artifact due to the tremor (Parkinson's)

An 82-year-old man with a history of Parkinson's disease presents with no complaints but wants to start an exercise program at the local senior center. An electrocardiogram (ECG) is required before he can enroll. He has no history of cardiac disease, HTN, diabetes, or pulmonary disease. What does the ECG note?

Atrial Fibrillation

An asymptomatic 75-year-old Asian woman presents to primary care clinic for her health maintenance exam. Her pulse is irregular in pattern and amplitude. Her electrocardiogram (ECG) shows an irregularly irregular rhythm with absent p-waves and varying R-R intervals . What is the most likely diagnosis?

Lifestyle Modifications and follow up in 2-6 weeks

An overweight (BMI of 29 kg/m2) 53-year-old postmenopausal woman comes to see you in clinic to follow up after she was treated for osteoarthritic knee pain, which started after she began an exercise program to help her lose weight. She has been taking over-the-counter naproxen for the pain, which has improved. You note that her BP (BP) today at the time of triage into the clinic was 158/98 mm Hg. This measurement was taken by the clinic staff with an automated cuff. You repeat her BP measurement with an appropriate-sized cuff (two measurements) and determine that her BP is 138/88 mm Hg. A quick review of her chart shows that she has no prior elevated BP measurements recorded. What is your first-line treatment?

ACE/ARB

Chris is a 54-year-old man who presents to primary care clinic for an initial evaluation as a new patient. He has not seen a doctor in years, because he "hasn't needed one" and takes no medications. His chief complaint today is fatigue. He describes progressively worsening dyspnea when walking briskly and climbing stairs. He must rest several times in order to complete mowing his lawn, whereas 6 months ago he could easily complete this task without resting. He feels fine at rest. He finds himself awakening frequently at night feeling "congested" but this has improved somewhat after putting bricks under the head of his bed. He denies any chest discomfort or palpitations. He has never smoked, but he drinks "a few beers" every night. He is unaware of any family history of heart disease. On exam, he is overweight (BMI 31 kg/m2)), HR is 83 bpm, and BP is 184/98 mm Hg. Jugular veins are nondistended without hepatojugular reflux. Lungs are clear. The point of maximal impulse (PMI) is displaced laterally. Heart sounds are regular with a 2/6 systolic murmur at the apex without gallop. Liver is nonpulsatile, and there is no lower extremity edema. The EKG shows left ventricular hypertrophy and left atrial enlargement. The CBC, BMP, and thyroid function tests (TFTs) are normal. Fasting glucose was 105 mg/dL. The fasting lipid panel shows a LDL of 123 mg/dL, HDL of 34 mg/dL, and triglycerides of 198 mg/dL. His CXR shows a mildly enlarged cardiac silhouette with mild pulmonary vascular enlargement. What is the most important initial medication to start Chris on right now?

Ventricular Septal Defect

During a routine athletic physical, a 15-year-old boy is found to have a systolic thrill that is palpable at the lower left sternal border accompanied by a harsh, pansystolic murmur that is heard best at the site of the thrill. He is asymptomatic and has no evidence of HTN, cyanosis, or edema. An electrocardiogram and a chest radiograph are normal. What is the most likely diagnosis?

Ruptured Abdominal Aortic Aneurysm

Mr Jones is a 75-year-old gentleman admitted with a hx of fever, cough, and SOB. He was diagnosed with CAP and started on levofloxacin. On admission his vitals were stable. The on-call intern gets a call at 2 AM by the nurse, stating Mr Jones has been complaining of excruciating constant abdominal pain (epigastric and periumbilical pain) radiating to the flank for the past 15 to 20 minutes. His pain is associated with nausea and vomiting but no fever or chills, hematuria, dysuria, or chest pain. He had a normal bowel movement today. Past medical history includes HTN, type 2 DM, and CAD; no h/o renal or gallstones. Social history is significant for smoking, and the patient reports no alcohol use. Medications include levofloxacin, hydrochlorothiazide, aspirin, metoprolol, and lovastatin; no NSAID use is noted. On physical examination, he looks to be in moderate distress. BP lying down is 120/60, HR is 100, and the patient is afebrile. Heart and lung examinations are unremarkable. Abdominal examination reveals obese abdomen with moderate, diffuse tenderness without guarding or rigidity; bowel sounds are present but hypoactive. Pulses are diminished in the lower extremities. Rectal examination reveals Hemoccult-negative stool. What should you include in your DDx?

Atrial Fibrillation (AFib)

This ECG tracing is from an 80-year-old female with a history of heart failure with a preserved ejection fraction (HFpEF) who often feels an irregular heartbeat. She complains of a "fluttering sensation" in her chest and is lightheaded but is having no pain. Her vitals are unremarkable except for a rapid, irregular pulse. What does the EKG strip show?

Supraventricular Tachycardia (SVT)

This electrocardiogram (ECG) tracing is from a 27-year-old female with a history of multiple episodes of a rapid HR. These usually resolve when she coughs or bears down (Valsalva). However, she is tired of this and wonders what you can do. What does the EKG strip show?

Brugada Syndrome

This is the ECG of a 28-year-old man who presented in cardiac arrest with polymorphic ventricular tachycardia. He was successfully resuscitated and had the ECG above while normothermic and awake 2 days after the event. There is a history of sudden death in the family. What does the ECG note?

second-degree heart block type II (Mobitz II)

This is the ECG of a 45-year-old man who had chest pain earlier in the day. He was treated in the ED with aspirin and sublingual nitroglycerin and is currently pain free but notes lightheadedness and weakness. He has an elevated troponin. His vitals reveal a HR of 42 with a BP of 90/40. What is noted?

Ischemic ST-T changes inferiorly (II, III, AVF) along with an accelerated junctional rhythm

This is the ECG of a 48-year-old woman who presents with chest pain radiating to the left arm, dyspnea, and diaphoresis. What does the EKG show?

Atrial tachycardia with a third-degree heart block

This is the ECG of a 54-year-old man with a history of cardiomyopathy who is on digoxin for symptom control. He presents complaining of weakness, increasing SOB, and one episode of syncope. What does the EKG show?

Anterior Wall STEMI

This is the ECG of a 55-year-old man with a history of HTN and diabetes. He complains of substernal pressure with radiation to the right arm. He is diaphoretic and short of breath. What is noted?

WPW (?!?)

This is the ECG of an 18-year-old patient who was running cross-country track and had a syncopal episode. He has noticed palpitations in the past associated with lightheadedness and chest discomfort, but this is his first episode of syncope. He is currently stable but is mildly hypotensive with a BP of 100/60. What does the ECG note?

WPW

This is the electrocardiogram (ECG) of a 20-year-old man who notes several episodes of an irregular, rapid heart beat which were associated with lightheadedness, but which resolved spontaneously. He is now feeling back to normal with normal vital signs. What does the ECG note?

J-Waves, Hypothermia

This is the electrocardiogram (ECG) of a 29-year-old man who was winter camping and got lost. He was found after 3 days with a core temperature of 32̊C (90̊F). What does the ECG note?

Ventricular Tachycardia

This is the electrocardiogram (ECG) of an unconscious 56-year-old man who was exercising, clutched his chest, and lost consciousness. He has no palpable pulse. What does the ECG note?

J wave; Hypothermia

This is the rhythm strip of a 45-year-old man who abuses alcohol and was found outside on his porch after a night with an ambient temperature of −1̊C (30̊F). His core temperature is 33̊C. What is the arrow pointing to and what is the likely diagnosis?

Atrial Flutter

This rhythm strip is of a 92-year-old woman who is feeling lightheaded and weak. She has no chest pain. What does the Strip note?

Acute Pericarditis

What does the ECG Show?

Junctional Escape Rhythm

What does the ECG Show?

Ventricular Escape Rhythm

What does the ECG Show?

Hypokalemia

What does the ECG show?

Left Atrial Hypertrophy with LVH Present

What does the ECG show?

LBBB

What does the attached ECG show?

First-Degree Block with RBBB & LAFB

What does the attached ECG show? (Sorry)

Inferior wall myocardial infarction

What is the proper diagnosis of the ECG shown?

Second-degree heart block, type I

What is the rhythm on the rhythm strip shown?

Pericardial effusion

What is this EKG consistent with?

Pericarditis

What is this EKG consistent with?

Torsades de pointes

YIKES!! The patient becomes unresponsive and you look at the monitor. You obtain an ECG which shows the attached ECG. What is the patient's rhythm?

Lifestyle Modifications for increased risk of HF

You are counseling a 34-year-old woman who is moderately overweight, and has mild HTN and type II diabetes. Her father had his first myocardial infarction when he was 45 and died of a subsequent myocardial infarction when he was 52. What is your initial management for this patient?

Stop Verapamil

You are reviewing the medications of a 67-year-old man who has recently developed mild pulmonary congestion and peripheral edema. He has a history of mild heart failure, HTN, and he occasionally suffers from angina. The drugs he is prescribed to take on a daily basis are aspirin, furosemide, lisinopril, lovastatin, metoprolol, and verapamil. He is also on a low-salt diet. What can be done to relieve this patient's symptoms?

Major Depressive Disorder

You are seeing a 48-year-old female who presents with a 3-month history of low mood, low energy, poor concentration, and irritability. She has lost interest in most things she had enjoyed and has also noticed a 20-lb weight gain. She has been having frequent headaches, has been short-tempered, and has noticed that it is hard to wake up in the morning. She reports no thoughts of suicide but has wondered if death would be a relief. She says she has felt restless for a while and feels that she is a bad person. Her mother suffered from depression. She does not consume alcohol or any other substances. She is divorced and has no children. What is the most likely diagnosis?

Secondary Hypertension

You see a 65-year-old man in clinic who has difficult-to-control hypertension (188/114 mm Hg) while on maximum doses of a diuretic, beta blocker, ACE inhibitor, and a CCB. He developed hypertension at age 55 and has no family history of essential hypertension. What should you consider?

Wolf-Parkinson-White (WPW) syndrome

You treat your patient with SVT with adenosine but there is no response. Thus, you choose to try a CCB. Unfortunately, the patient rapidly deteriorates with the CCB, and her HR actually increases, so you successfully cardiovert the patient. The ECG done after cardioversion is attached: This ECG represents:

Rate control

Your patient confides that he was indeed out celebrating the end of Block 2 and Cardio several days ago and had a bit too much to drink. This is quite unusual for the patient... He generally drinks 2 to 3 beers per week, but on this particular night had 12 or more (...as he should). The patient's pulse increases to 160 bpm, but he remains asymptomatic. The INITIAL goal for this patient, suspected of having 50 hours of atrial fibrillation, is:

Vitamin K

Your patient misunderstands your instructions of reducing warfarin dosage and takes an extra dose of warfarin that evening and for the next 2 days. He returns to your clinic and his INR is now 13. What is the best option for therapy at this point?

HFpEF

Your patient with heart failure does well and is d/c from the hospital after a couple of days. You are just beginning to think that the authors are tired of writing questions about heart failure ... but you are wrong. The patient's 70-year-old wife shows up with SOB. Her physical examination is consistent with heart failure. You send her to get an echocardiogram. You also order the recommended tests: CBC, electrolytes, ECG, thyroid functions, etc. The results of the echocardiogram show a concentric thickening of the left ventricle with an ejection fraction of 75%. This is most consistent with:

Percutaneous transluminal coronary angioplasty (PTCA) and stent placement is superior to tPA or other thrombolytic, for this patient.

Your patient's pain continues despite treatment with nitroglycerin, and you obtain another ECG, attached: What treatment path would you consider for this patient?

Congestive Heart Failure

A 40yo F smoker is admitted to the inpatient service with SOB. The SOB is worse with exertion, chronic in nature, and has progressed in severity over the last year. She reports a history of asthma, but does not recall having any formal testing done for this in the past. At the time of admission, she is short of breath even with minimal activity. A CXR is done that shows b/l opacities that are interpreted as possible pneumonia. Treatment for this admission is started with IV corticosteroid therapy, antibiotics, and frequent nebulization with bronchodilators to treat asthma exacerbation with pneumonia. By the 4th hospital day, despite aggressive treatment, she does not appear to have had any clinical improvement in her symptoms. In fact, she feels as if she has become worse, not better. On examination, she is anxious in appearance and in clear respiratory distress. She is able to communicate in only a few words at a time, between her labored breaths. She is afebrile, with a HR of 95 beats/min, and a BP of 150/100 mm Hg. Her JVP is estimated at 16 cm. Lung examination is remarkable for very harsh breath sounds with coarse sounding expiratory wheezes b/l, and decreased breath sounds at the bases. Cardiac examination reveals a systolic murmur prominent at the apex. 2+ LE pitting edema up to knees is found. When questioned further, in addition to her history of SOB with exertion, the pt notes frequent nighttime episodes of SOB, requiring her to sit up in bed for extended periods before sleeping again to allow her to "catch her breath." A remote history of extended febrile illness is recalled from childhood, for which she does not recall getting specific treatment. What is the primary diagnosis?

SSRI

A 42-year-old man comes to his outpatient psychiatrist with complaints of a depressed mood, which he states is identical to episodes of depression he has experienced previously. He was diagnosed with major depression for the first time 20 years ago. At that time, he was treated with imipramine (tricyclic antidepressant), up to 150 mg/d, with good results. During a second episode that occurred 15 years ago, he was treated with imipramine, and once again his symptoms remitted after 4 to 6 weeks. He denies illicit drug use or any recent traumatic events. The man states that although he is sure he is experiencing another major depression, he would like to avoid imipramine this time because it produced unacceptable side effects such as dry mouth, dry eyes, and constipation. What is the best therapy for this patient?

Calcium Channel Blockers

A 42-year-old woman develops symptoms of angina at rest. She has not had angina before and has no history of cardiovascular disease. After an exercise stress test and other tests, she is diagnosed as having variant angina. What treatment option can you offer to this patient?

Lifestyle Modifications + Antihypertensive

A 43-year-old man has a BP of 138/88 taken during his annual examination. He has no other health problems and his blood laboratory results are in the normal range. He is modestly overweight and has a family history of cardiovascular disease. What, if any, are the therapeutic options for this patient?

Pulmonary HTN

A 44-year-old woman is scheduled for a vaginal hysterectomy for dysmenorrhea that has failed medical therapy. Although she had been otherwise healthy, over the past year, she has increasingly noticed exertional dyspnea, particularly when shopping in large stores. These symptoms have worsened, to the point that she sometimes felt as though she was about to "pass out.". The patient's vital signs on presentation include a BP 102/56 mm Hg, HR 90 bpm, 94% O2 saturation. On physical examination, she has clear lungs to auscultation, mild ankle edema, a 2/6 systolic murmur, and an S4 gallop. The ECG shows right axis deviation and right ventricular hypertrophy. An echocardiogram demonstrates mild right ventricular (RV) enlargement, and a right ventricular systolic pressure (RVSP) of 35 mm Hg. What is the most likely diagnosis?

Mitral Stenosis

A 45-year-old man presents with a history of shortness of breath, irregular heartbeat, and hemoptysis. He notes that over the past 2 weeks, he has become easily "winded" with minor activities. Also, he has coughed up some flecks of blood on a few occasions. He has noted a fast heartbeat and, on occasion, a pounding sensation in his chest. He gives a history of being ill for several weeks after a severe sore throat in childhood. On physical examination, his HR rate is noted to be 120-130 bpm and his rhythm is irregularly irregular. He has distended jugular venous pulses and rales at the bases of both lung fields. On cardiac examination, there is an irregular heartbeat as well as a soft diastolic decrescendo murmur, loudest at the apex. An ECG shows atrial fibrillation as well as evidence of left atrial enlargement. What valve disease is the patient presenting with?

Varicose Veins

A 45-year-old woman presents to her physician's office with complaints of heaviness and fatigue in her legs. She does not experience the symptoms in the morning, but they become more noticeable as the day progresses and with prolonged standing. When she stands for many hours, she develops swelling in both of her legs. The symptoms are concentrated over her medial calf, where she has prominent tortuous veins. She first noted the veins approximately 20 years ago when she was pregnant. Initially, they did not cause her any discomfort but have progressively enlarged now and over the past 10 years have become increasingly painful. She recalls that her mother had similar veins in her legs. What is the most likely diagnosis?

Lifestyle modifications & Thiazide/ACE/ARB/CC6B

A 46-year-old woman with a prior elevated BP (BP) comes to see you in clinic for follow-up of her elevated BP. Her diagnosis was based on the average of two or more properly measured, seated BP recordings at each of her last two office visits. She has no history of diabetes, coronary heart disease (CAD), stroke, or chronic kidney disease (CKD). Of note, her mother and her older brother both have essential HTN. Her BMI is 28 kg/m2. Her BP today was recorded as 138/88 mm Hg (seated, taken after 5 min). You repeat her BP measurement with an appropriate-sized cuff and confirm that her BP is elevated (138/86 mm Hg). Based on the 2017 HTN guidelines, how will you treat this patient?