Cardio

A 3-year-old boy presents after a major motor car accident. He is in a shock state; his pulse can't be felt; and he has lost a lot of blood. After intubating him and ensuring airway patency, a venous access was looked for to regain his intravascular volume and stop end organ damage. No vein was found. Question What is the most suitable location to insert the canula?

Anterior tibia

A 45-year-old woman presents for the evaluation of syncope in the gym. She went to the gym despite your advice that she should be evaluated for a cardiac murmur you heard on her last physical. She claims that she has had that murmur ever since she can remember. The rest of her history is unremarkable. On examination, her temperature is 37 C; blood pressure is 120/80 mmHg; pulse is 88 /min and regular; and respiratory rate is 16/min. She has a prominent apical impulse and a 2/6 systolic murmur at the right upper sternal border that decreases in intensity with a Valsalva maneuver. Electrocardiogram shows large S waves in right precordial leads and large R waves in leads V4, V5, and V6.

Aortic Stenosis

A 45-year-old male comes to the cardiac unit. You are an intern in the cardiac unit. The senior resident tells you that the patient has calcification of one the following structures: mitral valve, foramen ovale, aortic valve, aortic root, and pulmonary arterial vasculature. Calcification is most likely in which of the following structures that was abnormal from birth?

Aortic valve

A 50-year-old male has a sudden change in mental status. He is brought to the hospital where a right-sided subarachnoid hemorrhage is detected on CT scan of the head. There is subsequent pressure effect with herniation and death. At autopsy a peripheral right parietal cerebral artery branch shows acute inflammation and necrosis with decreased aneurysmal dilation with rupture of the arterial wall. This is most likely a complication of:

Aortic valve bacterial endocarditis

A 70-year-old male is brought to your emergency room with a pulse of 35 beats per minute. His electrocardiogram reveals a complete heart block. Implantation of a permanent cardiac pacemaker is followed by a chronic low-grade fever. His febrile (fever) hospital-acquired complication is most probably due to

Aspergillus fumigatus

A 65-year-old male has congestive cardiac failure with increasing pulmonary congestion and edema for the last one year. He has no peripheral edema. The symptoms have gotten worse in the last couple of days. His blood pressure is 120/84 mmHg. He has been healthy all his life with no major illnesses. His serum glucose is 95mg/dl and serum cholesterol is 185mg/dl. The creatinine kinase is not elevated. The most likely etiology for these findings is

Calcified bicuspid aortic valve

A 67-year-old man presents to his internist with cool bilateral lower extremities. Upon examination, it is noted that his feet and lower legs are pale with elevation, but dusky red with dependency. They are not edematous. He has ulcers of the left third and right second toes. The skin is atrophic and hairless, and the nails are thickened. Pulses are greatly diminished. What is the most likely diagnosis?

Chronic arterial insufficiency

A 25-year-old male is euphoric and excited, after which he suddenly dies in a nightclub. The patient is a known intravenous cocaine drug abuser. Postmortem findings are significant of high levels of cocaine and its metabolite benzoylecgonine. The most likely pathologic findings in the heart would be

Contraction band necrosis

Five years following a cardiac transplantation for dilated cardiomyopathy, a 40-year-old male develops worsening congestive cardiac failure. He has a low BP of 90/60 mmHg, edema of the lower extremity with a high jugular venous pressure. He has had multiple episodes of rejection but a recent endomyocardial biopsy shows no evidence of rejection. The most likely etiology for his worsening cardiac function is

Coronary arteriopathy or accelerated coronary sclerosis of the small branches of the coronary arteries

A 19-year-old male presents with exertional dyspnea and syncope. On examination, he has a reduced pulse pressure with an ejection systolic murmur. The chest X-ray shows enlarged left ventricle with dilated ascending aorta. Echocardiography demonstrates a calcified aortic valve and hypertrophied left ventricle. The doctors decide that he has to have the aortic valve replaced because he has aortic stenosis. His aortic valve is replaced with porcine bioprosthesis. He is told that the valve will have to be replaced again before ten years because of

Deterioration with calcification

A 65-year-old African-American man presents to establish care. He changed jobs, so he has new health insurance. You participate in a panel of providers associated with his insurance carrier. He presents with intermittent claudication when walking his dog. His blood pressure is 125/75 mm Hg. His ankle-brachial index (ABI) is 0.8. Labs include a normal white blood count and erythrocyte sedimentation rate. What factor elicited during history or found during the exam may have contributed to the reduced ABI?

History of chronic kidney disease

You are seeing a 24-year-old female patient with complaints of palpitations occurring both on exertion and at rest. Her BP and HR are normal. At the physical examination, you notice that her extremities and digits are disproportionately longer. Which of the choices most accurately presents other abnormalities associated with the condition that your patient has?

Mitral valve prolapse, tricuspid valve prolapse, aortic dissection

A 60-year-old male is brought to the emergency room with a history of sudden loss of consciousness. On examination, his BP is 168/98 mmHg and he also exhibits paraplegia on the right side. A cerebral angiogram reveals lack of perfusion in the left middle cerebral artery distribution. The most likely cardiac lesion associated with this finding would be

Nonbacterial thrombotic endocarditis

A 22-year-old male presents to the emergency department after being found at the bottom of a flight of stairs. On closer inspection, he is found to have a 2 cm stab wound in the midline, subxiphoid space. Initially, he is hemodynamically stable. On finishing the secondary survey, he is noted to become increasingly agitated and tachycardic with a heart rate of 110 bpm. He is deemed to be stable enough to transport to the CT scanner for a trauma protocol. The included image is one of the images obtained.

OR for pericardial window

A 50-year-old male has noted increasing swelling of his lower legs along with shortness of breath for several months. On examination, his pulse is 80/min and regular. On auscultation there are no murmurs, rub or gallops. A chest X-ray reveals an increased size to the right heart border along with bilateral pleural effusions. A serum troponin level is less than 0.4 ng/ml. Which of the following conditions is he likely to have?

Pulmonary interstitial fibrosis

A 47-year-old male is receiving doxorubicin as part of treatment for his leukemia. Which noninvasive technique is best for monitoring myocardial toxicity from doxorubicin therapy?

Radio-nuclear ventriculography

A 64-year-old white female presents with left sided calf tenderness. You determine through ultrasound that she has a deep vein thrombosis (DVT) to the calf and thigh as well. She has no known risk factors. You will be ordering labs and studies for the work up for her DVT. You decide that you want to treat her DVT in an outpatient setting with enoxaparin. Which of the following would preclude this decision?

She shows signs of hemodynamic instability

A 53-year-old male was smoking for 20 years starting at the age of 23. He quit smoking 10 years ago. He reports to your office for a physical examination. The patient is not taking any medications for blood pressure and his cholesterol has not been evaluated. What would be the mortality ratio for coronary disease in this patient?

1.6

A 53-year-old-male presents to your office, with complaints of fatigue and leg edema at the end of the day. The patient also states shortness of breath after walking three or four blocks. The patient is normotensive and his heart rate is 80 bpm. On auscultation, you hear a mild S3 sound, and a murmur of mitral regurgitation. Echocardiography shows the dimensions of the left ventricle to be 67 x 102mm. Out of the following factors, which is the one most likely to be etiological cause of the patient's diagnosis?

Alcohol Abuse (DCM)

A 66-year-old woman with a history of a multinodular goiter presents to the office after a recent hospitalization for a newly diagnosed cardiac arrhythmia. She relates that she has continued to see the cardiologist and is being treated with an oral medication. She denies any symptoms of hyper or hypothyroidism. She denies any change in the size of her gland or associated dysphagia or dyspnea. Thyroid function studies continue to remain in the normal range. Question When following this patient with multinodular goiter, what cardiac drug should be avoided or monitored closely?

Amiodarone

A 47-year-old Caucasian woman, previously healthy, presents for evaluation of a 4-week history of dyspnea. Her symptoms started approximately 1 month ago when on vacation in Colorado. She initially attributed these symptoms to the altitude; however, upon return to her hometown, she continued to have shortness of breath with mild activity, such as walking more than 100 feet, walking upstairs 1 flight, vacuuming, or sweeping. Her symptoms resolve with rest. She also reports mild exertional chest tightness and easy fatigability. She denies paroxysmal nocturnal dyspnea, orthopnea, edema, palpitations, and syncope. Her past medical history includes the usual childhood illnesses, no previous surgeries, and no known allergies. She takes a daily multivitamin and occasional Tylenol for headache. She is a non-smoker, rarely uses alcoholic beverages, and denies use of illegal or illicit drugs. Physical exam shows temp 96.9°F, pulse 80 and regular, respirations 16, and BP 136/82. O2 sat is 96% on room air. The patient is an alert Caucasian woman in no acute distress, with no obvious jugular venous distention; non-labored respirations; lung fields clear to auscultation and percussion; and no rhonchi, rales, or wheezes. Heart shows RV heave present; normal S1 with fixed, split S2 with prominent P2 component; and grade II/VI systolic murmur at the left upper sternal border at the second intercostal space. The remainder of a complete physical examination is within normal limits. CBC and BMP are unremarkable. Free T4 and TSH are within normal limits. EKG shows normal sinus rhythm with right ventricular hypertrophy, right atrial enlargement, and right axis deviation. There is an RSR in leads v1 and v2. Question What severe complication sometimes develops in patients with this clinical presentation and may require treatment with combined heart-lung transplantation?

Eisenmenger

A 60-year-old woman presents with a 2-year history of dialysis via a left forearm arteriovenous fistula. Recently her fistula flow rates have decreased to 400 ml/min. She is asymptomatic; her blood pressure is 120/80 mm Hg; and her exam is normal. This week's routine laboratories were all acceptable. Question What intervention is appropriate in this case?

Fistulogram to assess stenosis and patency

A 30-year-old male comes in with complaints of fever over a couple of days. Patient has history of intravenous drug abuse. Physical examination reveals a heart murmur. Splinter hemorrhages are seen on the nails of the hands. The echocardiography reveals large vegetation involving the aortic valve. Which of the following would be the least likely complication in this patient?

Hemopericadium

A 65-year-old female with a 20 year history of diabetes mellitus presents with sudden onset of chest pain that radiates to the left arm. She is admitted to the hospital but dies four days later. The heart showed a gross pathological finding of yellowish necrosis with a hyperemic border on autopsy. Based on the gross pathological finding, which of the following would be the most likely laboratory test to be present at the time of death?

Increased Serum Troponin I

A 3-year-old boy presents after a major motor car accident. He is in a shock state; his pulse can't be felt; and he has lost a lot of blood. After intubating him and ensuring airway patency, a venous access was looked for to regain his intravascular volume and stop end organ damage. No vein was found. Question What should be the next step in management?

Intraosseous transfusion

A 20-year-old man presents to his internist with episodic weakness, paresthesias of the lower extremities, polyuria, and polydipsia. A thorough evaluation reveals an adrenal adenoma, and he is found to have primary aldosteronism. What would his blood work be expected to show?

Low renin, high aldosterone

You see a 55-year-old Caucasian American man in the office for the first time. He has not received regular medical care for >10 years. He has smoked 1 pack of cigarettes a day for 30 years. In the office, his blood pressure is 120/78 mm Hg. He had an isolated history of hematuria 30 years ago without recurrence. His physical exam is notable for decreased lower extremity pulses, shiny skin, and minimal lower extremity hair. No xanthomas, xanthalesmas, or arcus senilis are noted. No bulging veins, blue or purple discoloration, or varicosities are noted. He is non-edematous. He has no abdominal or renal bruits, and no renomegaly or costovertebral tenderness. His toe pressure is 40 mm Hg. He has a laceration at the base of left great toe without any tenderness or exudate. Question What diagnosis explains his physical findings?

Peripheral arterial disease

A 33-year-old male develops low-grade fever. A week later, he develops dyspnea and palpitations. He dies suddenly and unexpectedly. During the autopsy the medical examiner finds a diffusely enlarged flabby heart with no focal lesions. The coronary arteries show minimal atherosclerosis with no narrowing. The most likely etiology for these findings is

Viral myocarditis

A 50-year-old male staying in New York City has a long history of chronic alcoholism. He now presents with increasing leg edema as well as shortness of breath. He does not have chest pain. His vital signs include P: 84/min, RR: 24/min, BP: 124/74 mmHg and patient is afebrile. His neck veins are distended. The echocardiography shows dilation of all the four chambers of the heart. You diagnose this as dilated cardiomyopathy. The patient undergoes orthostatic heart transplantation. A year later, the patient presents with myocarditis. Which of the following would be the most probable cause for myocarditis in this patient?

Toxoplasma gondii

The USG in a 36-year-old female at 18 weeks of gestation reveals a male fetus with an endocardial cushion (atrioventricular canal) defect. Other abnormalities included increased nuchal thickening and a double bubble sign suggesting duodenal atresia. Which of the following conditions is most likely to have contributed to these findings?

Trisomy 21

A 55-year-old man has been hemodialyzed for the past year using a left forearm arteriovenous graft with acceptable waste removal as of last month. Today, he notices that the graft is less "noisy" than usual and that his left forearm is more swollen. He is otherwise asymptomatic. He is afebrile, has a blood pressure of 120/80 mm Hg, has no palpable or audible graft thrill, and has a swollen left forearm. No discharge or erythema surrounds the graft, and the remainder of his exam is normal.

graft thrombosis

You have a visit with this diabetic patient in your office, for the first time. He is a 60-year-old male, with a history of known diabetes for 15 years. He is on Insulin and his diabetes has been under control most of the time. You take his history and physical, which includes inspection of his feet. You realize that there is a non-infected blister on his left plantar surface. You teach the patient how to take care of his feet. You also advise him to have an appropriate nutritional low fat diet, keep his blood sugar under control, and have prescriptive footwear. Your patient comes back after one month. This time there is a 3 cm x 3 cm wound instead of a blister. You evaluate the wound for soft tissue infection, osteomyelitis, and vascular efficiency. Studies show inadequate blood circulation in his left foot. Which one of the following is the first intervention?

revascularization