Rosh Cardiology Set 2

The ECG is a reliable diagnostic tool

Which of the following statements is true regarding the condition associated with the ECG seen above? A. Pain is often relieved in the supine position B. The ECG is a reliable diagnostic tool C. Thrombolytic therapy is a potential treatment D. Ventricular dysrhythmias are common

Streptococcus viridans

Persistent fever and bacteremia are found in a 28-year-old woman with new onset murmur. She does not use intravenous drugs, and does not have any prosthetic heart valves or history of congenital heart disease. However, she has significant dental disease and poor dentition. What is the most common organism responsible for bacterial endocarditis in this patient? A. Clostridium septicum B. Escherichia coli C. Staphylococcus aureus D. Streptococcus viridans

MAP = DBP + 1/3(SBP−DBP)

/3 B. MAP = DBP + 1/3(SBP−DBP) C. MAP = DBP + 2/3(SBP−DBP) D. MAP = SBP + 1/3(SBP−DBP)

Pericarditis

A 15-year-old young man presents with sharp substernal chest pain that is relieved by sitting up and leaning forward. Cardiac auscultation is normal. What is his chest pain most likely due to? A. Coronary ischemia B. Costochondritis C. Esophageal spasm D. Pericarditis

Right, second intercostal space

A 19-year-old college student presents dead-on-arrival to the ED. An autopsy reveals significant calcification of the aortic valve cusps. Upon review of his medical history, you would most likely find documentation of a murmur heard in which of the following locations? A. Apex B. Left, fourth intercostal space C. Right, fourth intercostal space D. Right, second intercostal space

Prinzmetal angina

A 40-year-old woman complains of recurrent chest pain that occurs shortly after she wakes up in the morning. She has a history of migraine headaches and Raynaud's phenomenon. She admits to tobacco abuse and smokes 1 pack-per-day. Her chest pain is not reproducible with palpation. An ECG during an episode reveals ST-elevation in multiple leads and cardiac biomarkers are normal. Which of the following is the most likely diagnosis? A. Costochondritis B. Panic disorder C. Prinzmetal angina D. Unstable angina

Tricuspid regurgitation

A 21-year-old woman presents to the emergency department with fever, malaise, and chest pain. Her vital signs in triage are T 39.0°C, HR 122, BP 110/60, RR 30. Physical examination reveals cellulitis along the antecubital area of the left arm, jugular venous distention, a holosystolic murmur best heard at the left sternal border, right upper quadrant tenderness, and 2+ bilateral lower extremity edema. Which of the following is the most likely cause of the patient's symptoms? A. Aortic regurgitation B. Mitral stenosis C. Pulmonic stenosis D. Tricuspid regurgitation

Tricuspid valve

A 22-year-old man with a history of intravenous drug use presents to the Emergency Department with fever, chills, cough, and hemoptysis. His chest X-ray is shown above. Which of the following valves is the most likely involved? A. Aortic valve B. Mitral valve C. Pulmonic valve D. Tricuspid valve

Interferes with DNA replication

A 23-year-old man is diagnosed with bacterial pneumonia and is prescribed a fluoroquinolone. Which of the following is the mechanism of action for this drug class? A. Interferes with bacterial cell membrane synthesis B. Interferes with bacterial protein synthesis C. Interferes with DNA replication D. Interferes with RNA synthesis

Vancomycin and cefepime

A 23-year-old man with a history of intravenous heroin use presents with fever of 101.3°F (38.5°C) and mild cough. His HR is 133 bpm, and BP is 114/72 mm Hg. On examination, he is ill-appearing, and you note a III/VI diastolic murmur. A chest radiograph is unremarkable. The patient states that he was hospitalized two weeks ago for arm cellulitis. Which of the following antibiotic regimens is appropriate for this patient? A. Ceftriaxone and azithromycin B. Nafcillin C. Nafcillin and gentamicin D. Vancomycin and cefepime

Trial of a beta-blocker

A 26-year-old woman presents with anxiety and palpitations. She denies dyspnea, exercise intolerance, orthopnea, or paroxysmal nocturnal dyspnea. Neurologic review of systems is negative. She has a family history of mitral valve prolapse. Examination reveals a thin body habitus, normal peripheral pulses, clear breath sounds, absent chest wall thrills and no peripheral edema. A full neuromuscular examination reveals no gross abnormalities. While auscultating over the cardiac apex, you hear a mid-systolic click, but do not appreciate any other murmur. A chest radiograph and ECG are normal. Which of the following is the most appropriate intervention at this time? A. Begin warfarin prophylaxis B. Prescribe a low-dose daily oral prophylactic antibiotic C. Surgical referral within 1 week D. Trial of a beta-blocker

A diastolic low-pitched decrescendo murmur best heard at the cardiac apex

A 28-year-old south Asian immigrant who is in her second trimester of her first pregnancy presents to the emergency department complaining of worsening dyspnea, orthopnea and lower extremity edema. She has never experienced anything like this before. She has no past medical history; however, she admits to frequent sore throats and ear infections as a child. Which of the following is most likely to be heard on auscultatory exam? A. A diastolic decrescendo murmur heard at the left lower sternal border B. A diastolic low-pitched decrescendo murmur best heard at the cardiac apex C. A holosystolic murmur heard best at the cardiac apex D. A systolic crescendo-decrescendo murmur best heard at the right upper sternal border

Janeway lesions

A 28-year-old woman with a history of intravenous drug use presents to the emergency department with complaints of chest pain, shortness of breath, cough and fever. Which of the following physical exam findings is most suggestive of infective endocarditis? A. Hutchinson's sign B. Janeway lesions C. Koplik's spots D. Levine's sign

High output heart failure

A 28-year-old woman with no past medical history presents to the emergency department with acute dyspnea. Physical exam reveals tachycardia, warm extremities, wide-pulse pressure, bounding pulses, a systolic flow murmur, exophthalmos and a neck mass. Which of the following is the most likely diagnosis? A. Aortic regurgitation B. High output heart failure C. Low output heart failure D. Methamphetamine intoxication

Aortic regurgitation

A 30-year-old man with ankylosing spondylitis presents for a routine physical. This is the first encounter that you appreciate a murmur during cardiac auscultation. You appreciate a diastolic, high pitched, blowing murmur while listening with the diaphragm in the left sternal border. There is no palpable thrill. Which of the following is the most likely diagnosis? A. Aortic regurgitation B. Aortic stenosis C. Mitral regurgitation D. Tricuspid stenosis

Reassurance

A 30-year-old woman with no past medical history presents to the emergency department complaining of substernal chest pain for two hours. It is not worse with exertion and was not relieved by sublingual nitroglycerin. She admits to some mild nausea. She does not smoke cigarettes or use any illicit drugs. Her family history includes a grandmother who died of a myocardial infarction at 84-years-old. Labs in the emergency department are unremarkable. Point of care troponin is negative and ECG reveals sinus rhythm. What is your next step in management? A. Dobutamine stress test B. Exercise stress test C. Reassurance D. Stress echocardiography

Nifedipine

A 32-year-old woman is diagnosed with Prinzmetal's angina. She presents to clinic 2 weeks after being discharged from the hospital. She complains of 3 episodes of angina since discharge. She is concerned about future attacks. Long-term prophylaxis to reduce these attacks is best accomplished with which of the following medications? A. Atorvastatin B. Nifedipine C. Propranolol D. Warfarin

Myocarditis

A 33-year-old woman with no medical problems presents with chest pain and shortness of breath. The symptoms worsened over the previous two days and increase with exertion. The patient denies cough, but last week reports fevers, chills, coughing and myalgias. Her ECG demonstrates sinus tachycardia without ST segment changes. Vital signs are T 100.7°F, HR 120, BP 108/60, RR 16, 100% saturation on room air. Which of the following is the most likely diagnosis? A. Acute coronary syndrome B. Mediastinitis C. Myocarditis D. Pulmonary embolism

Mid-systolic click

A 34-year-old woman presents with palpitations. Which of the following might you expect to hear on examination if she has mitral valve prolapse? A. Diastolic murmur B. Early systolic murmur C. Mid-systolic click D. Split S2

Repeat duplex ultrasound

A 35-year-old woman with no past medical history, taking oral contraceptives presents for evaluation of thigh pain and swelling of her entire leg. She was seen six days ago for the same complaint and had a negative ultrasound. Which of the following is the most appropriate plan? A. CT venogram B. Diuretic therapy C. Reassurance D. Repeat duplex ultrasound

Mitral stenosis

A 54-year-old woman presents with dyspnea on exertion. She states that it has been progressively worsening over the last few months and she is losing her ability to complete activities that she was able to do before without sitting down to "catch her breath." Cardiac auscultation over the apex reveals a low-pitched, diastolic murmur and an opening snap. Which of the following is the most likely diagnosis? A. Aortic regurgitation B. Aortic stenosis C. Mitral regurgitation D. Mitral stenosis

Giant cell arteritis

A 55-year-old man presents with amaurosis fugax, headaches, scalp tenderness, jaw claudication, occasional ear pain, malaise, and intermittent fevers. On exam, you note tenderness on palpation of his left temple. Laboratory studies reveal an erythrocyte sedimentation rate of 85 mm/h. Which of the following is the most likely diagnosis? A. Giant cell arteritis B. Multiple sclerosis C. Myasthenia gravis D. Polymyositis

Labetalol

A 58-year-old man with chronic hypertension presents to the ED with acute, 10/10 tearing substernal pain that radiates to the back. All you can gather from him is that he also has some type of "collagen disorder" and diabetes. A chest radiograph reveals a widened mediastinum. As you prepare for a transesophageal echocardiogram, you would most likely start which of the following medications as a first-line agent? A. Clonidine B. Labetalol C. Lisinopril D. Nitroprusside

Administration of 60 mg of prednisone and referral to ophthalmology

A 58-year-old woman presents to your office with complaints of headache, a temperature of 101.1°F, anorexia, and morning stiffness in her hips and shoulders. She indicates that this morning her vision was blurry, whereas yesterday it was normal. Which of the following is the most appropriate next step in management? A. Administration of 60 mg of prednisone and referral to ophthalmology B. Administration of 800 mg of ibuprofen and referral to neurology C. Administration of 800 mg of ibuprofen and referral to rheumatology D. Supportive care only

Negative inotropes

A 62-year-old man with a history of hypertension and tobacco abuse presents with acute onset of sharp epigastric abdominal pain with radiation to his back. On arrival, his vitals signs are T 37.3°C, HR 100, BP 180/90 in the right arm and 80/40 in the left arm, RR 27. Which of the following agents is the first line management of this patient's condition? A. Diuretics B. Negative inotropes C. Vasodilators D. Vasopressors

Aortic stenosis

A 65-year-old man presents to his physician for a gradual decline in exertional fortitude and dyspnea on exertion that has been getting worse over the past two months. Physical exam demonstrates a mid-systolic murmur heard best at the second intercostal space near the right sternal border. The murmur decreases with isometric handgrip and Valsalva maneuvers. What is the most likely diagnosis? A. Aortic regurgitation B. Aortic stenosis C. Mitral regurgitation D. Mitral stenosis

Controlling blood pressure

A 65-year-old man presents to the clinic after being hospitalized for a type B acute aortic dissection, which was managed medically. Which of the following is the primary goal of long-term management to reduce the risk of complications and recurrent dissection? A. Controlling blood pressure B. Initiating a supervised exercise program C. Lowering cholesterol D. Smoking cessation

0.6

A 65-year-old man presents to the clinic complaining of worsening right thigh and calf pain. For the past year, he has only been able to walk two blocks before the pain intensifies to such an extent that he must stop to rest. After 10 minutes, the pain improves, and he is able to continue. On physical exam, you note that the right lower extremity is pale, shiny, and cool. His distal pulses are palpable but diminished. Given the most likely diagnosis, what do you expect the ankle-brachial index to be? A. 0.2 B. 0.6 C. 1.0 D. 1.5

Aortic and pulmonic valves

A careful cardiac examination requires close attention to the heart sounds. The second heart sound, S2, is produced by which of the following structures? A. Aortic and pulmonic valves B. Mitral and tricuspid valves C. Pericardium and chest wall D. Posterior and anterior cusps of the mitral valve

Low molecular weight heparin

A pregnant 32-year-old gravida 2 para 1 develops an acute deep-vein thrombosis in the left lower extremity at 30 weeks gestation. The patient had a cesarean delivery with her first pregnancy and wants to breastfeed. Which one of the following is the treatment of choice? A. A vena cava filter B. Low molecular weight heparin C. Unfractionated heparin D. Warfarin

Aortic dissection

A pregnant female recently diagnosed with gestational hypertension presents to the emergency department with a chief complaint of sudden onset of tearing retrosternal pain. A chest X-ray is obtained which demonstrates a widened mediastinum. What is the most likely diagnosis? A. Aortic dissection B. Mediastinal tumor C. Pericarditis D. Pulmonary embolism

Compression stockings

A previously healthy 38-year-old woman presents to your office with complaints of dilated veins and itching in both lower legs that has been worsening since the birth of her last child. The symptoms are improved with elevation of her legs. Which of the following is the next best step in management? A. Compression stockings B. Laser therapy C. Sclerotherapy D. Venous reconstruction

Low molecular weight heparin

A woman in her second trimester of pregnancy develops a left lower extremity deep vein thrombosis. Which of the following is the most appropriate choice of anticoagulation for this patient? A. Apixaban B. Dabigatran C. Low molecular weight heparin D. Warfarin

Right ventricular hypertrophy

A woman presents with dyspnea on exertion. Cardiac examination reveals an apical mid diastolic murmur. You also notice pitting edema in both her legs. She undergoes echocardiographic testing. Which of the following abnormalities would you most expect to see on the echocardiogram? A. Decreased trans-mitral mean pressure gradient B. Increased opening of the mitral valve leaflets C. Right atrial hypertrophy D. Right ventricular hypertrophy

Mitral stenosis

A woman presents with reduced exercise tolerance and dyspnea on exertion. On exam, you auscultate a diastolic murmur at the apex, heard in the audio clip above. Which of the following is the correct diagnosis? A. Aortic regurgitation B. Aortic stenosis C. Mitral regurgitation D. Mitral stenosis

Eptifibatide

A woman with chest pain presents to the ED. Her electrocardiogram shows ST elevation in leads V3 and V4. She is started on oxygen, intravenous nitroglycerin, and aspirin. You are preparing her for transfer to the interventional cardiac unit for primary percutaneous cardiac reperfusion. Her heart rate has been consistently < 60, averaging 54 over the past 30 minutes. Which of the following medications is also appropriate treatment at this time? A. Eptifibatide B. Infliximab C. Metaproterenol D. Metoprolol

Clopidogrel

An elderly man presents with 4 episodes of angina in the past 24 hours. His medical history includes diabetes and advanced COPD. Based on initial testing, you diagnose non-ST-elevation myocardial infarction. You are waiting for the cardiac team to admit him to the critical care unit. In the interim, which of the following is the most appropriate medication to begin? A. Alteplase B. Clopidogrel C. Digoxin D. Metoprolol

Rheumatic heart disease

What is the most common cause of tricuspid valve stenosis? A. Bacterial endocarditis B. Dilation and dissection of the aortic root C. Marfan syndrome D. Rheumatic heart disease

Compression ultrasonography

When considering the diagnosis of a patient with leg pain and swelling, you determine that the pretest probability of deep vein thrombosis is high. Which of the following is the most appropriate test in confirming this diagnosis? A. Compression ultrasonography B. D-dimer assay C. Factor V level D. Venography

Soft S1 and a loud, blowing holosystolic murmur

Which of the following cardiac auscultation findings is most consistent with mitral valve regurgitation? A. Harsh, crescendo-decrescendo systolic murmur B. Loud S1, opening snap, and a diastolic rumble C. Mid-systolic click and late systolic murmur D. Soft S1 and a loud, blowing holosystolic murmur

Widened mediastinum

Which of the following is most commonly seen on chest radiography in a patient with an aortic dissection? A. Abnormal aortic contour B. Calcification of the aorta C. Pleural effusion D. Widened mediastinum

Ibuprofen

Which of the following is the first-line treatment for acute pericarditis? A. Citalopram B. Ibuprofen C. Oxycodone D. Prednisone

Aortic involvement can lead to valvular disease and dissection

Which of the following statements is true regarding giant cell arteritis? A. Aortic involvement can lead to valvular disease and dissection B. Corticosteroid therapy should be initiated only when biopsy confirms the disease C. Histologic findings of inflammation are irreversible D. It is associated with sudden, painful binocular vision loss

Mechanical valves are more prone to paravalvular leaks than bioprosthetic valves are

Which of the following statements is true regarding prosthetic heart valves? A. Anticoagulation is optional with mechanical valves B. Mechanical valves are associated with less hemolysis and are less thrombogenic than bioprosthetic are C. Mechanical valves are more prone to paravalvular leaks than bioprosthetic valves are D. Mechanical valves make opening and closing sounds similar to, but louder than, those of native valves

Aortic regurgitation

Which of the following valvular disorders is characterized by an early high-pitched, blowing diastolic murmur heard best over the left sternal border, and a wide pulse pressure? A. Aortic regurgitation B. Aortic stenosis C. Mitral stenosis D. Tricuspid stenosis

Acute mitral regurgitation

A 42-year-old man presents to the Emergency Department with acute onset of severe shortness of breath. He was recently discharged from the hospital with endocarditis. Vital signs include temperature 37.6°C, HR 110, BP 110/50, RR 24, SpO2 93%. On examination, he is ill appearing with a new apical systolic murmur and bibasilar rales. Which of the following is the most likely diagnosis? A. Acute mitral regurgitation B. Aortic regurgitation C. Health care associated pneumonia D. Pulmonary embolism

Infectious endocarditis

A 42-year-old man presents to the Emergency Department with fever, chills, cough, and hemoptysis. He has a history of intravenous opioid use. Vital signs include BP 110/65 mm Hg, HR 120 beats per minute, RR 20 breaths per minute, and T 103.4F. Chest X-ray is shown above. Which of the following is the most likely diagnosis? A. Diffuse alveolar hemorrhage B. Infectious endocarditis C. Miliary tuberculosis D. Wegener's granulomatosis

Splinter hemorrhages

A 44-year-old man with a history of intravenous opioid use presents to the Emergency Department with fever, cough, and hemoptysis. Vital signs include BP 110/65 mm Hg, HR 120 beats per minute, RR 20 breaths per minute, and T 103.4F. On auscultation of the chest, you hear a faint systolic ejection murmur. Which of the following would you expect to see on physical examination? A. Diffuse erythroderma B. Palpable purpura C. Positive Nikolsky sign D. Splinter hemorrhages

Markedly elevated triglyceride levels

A 45-year-old man with a history of obesity and diabetes mellitus presents to the emergency department with abdominal pain that radiates to his back as well as nausea and vomiting. Physical examination reveals tenderness in the epigastrium. Yellow deposits are noted on the extensor surfaces of his forearms. Which of the following will most likely be seen on the patient's lipid panel? A. Markedly elevated HDL cholesterol levels B. Markedly elevated LDL cholesterol levels C. Markedly elevated total cholesterol levels D. Markedly elevated triglyceride levels

Optimizing glycemic control may improve hypertriglyceridemia

A 45-year-old woman presents to clinic to discuss her recent diagnoses of diabetes mellitus and hypertriglyceridemia. Which of the following is true regarding her glucose and triglyceride control? A. Her greatest risk is renal failure secondary to diabetes B. Hypertriglyceridemia is not linked to heart disease C. Optimizing glycemic control may improve hypertriglyceridemia D. Statins do not help to reduce triglyceride levels

Vancomycin and ceftriaxone

A 46-year-old woman presents to the Emergency Department with fever, cough, and hemoptysis. She has a history of intravenous opioid use. Vital signs are BP 110/65 mm Hg, HR 120 beats per minute, RR 20 breaths per minute, and T 103.4°F. On auscultation of the chest, you hear a faint systolic ejection murmur. Which of the following is the most appropriate initial therapy? A. Ampicillin and gentamicin B. Ceftriaxone C. Oxacillin and rifampin D. Vancomycin and ceftriaxone

ST segment elevation with reciprocal ST depression in leads aVR and V1

A 34-year-old man presents to the emergency department with complaints of worsening chest pain, fever, and malaise. The pain is pleuritic, worsens when he lies down and improves when he leans forward. On exam, he appears unwell, but is not in acute distress. Auscultation over the precordium reveals a scratchy, grating sound with a normal S1 and S2. Which of the following is the most likely electrocardiogram finding in this patient? A. Shortened PR interval and slurring of the QRS complex B. ST segment depression in leads V2-V4 C. ST segment elevation with reciprocal ST depression in leads aVR and V1 D. U waves and flat T waves

Amlodipine

A 35-year-old woman is being managed for multiple episodes of chest pain that have been awakening her from sleep on several early mornings for the past 2 months. An electrocardiogram after one episode showed ST elevation. Coronary angiography did not reveal any stenotic lesions. She has no cardiac risk factors and is otherwise healthy. Which of the following daily medications is most likely to provide relief from her condition? A. Adenosine B. Amlodipine C. Aspirin D. Propranolol

Ibuprofen

A 47-year-old man presents to the emergency department due to acute, sharp chest pain that is relieved by leaning forward. A pericardial friction rub is auscultated on cardiac examination and an ECG shows diffuse ST elevations. Echocardiography reveals a small pericardial effusion. Which of the following is the most appropriate initial treatment? A. Atenolol B. Ibuprofen C. Nitroglycerin D. Prednisone

Atropine

A 50-year-old woman presents to the Emergency Department following a syncopal episode. On physical exam she is diaphoretic, but alert and orientated. Her blood pressure is 100/50 mm Hg, heart rate 46 beats per minute, and respirations 12 per minute. Her rhythm strip is shown above. What is the most appropriate treatment for this patient's condition? A. Adenosine B. Amiodarone C. Amlodipine D. Atropine

Sildenafil

A 65-year-old man presents to the ED with sudden onset of chest pain that began two hours prior to arrival. He has a history of hypertension treated with hydrochlorothiazide, hyperlipidemia treated with simvastatin, erectile dysfunction treated with sildenafil, and takes a daily aspirin. An ECG demonstrates an anterior wall myocardial infarction. Which of the patient's home medications serves as a contraindication for the use of nitroglycerin to treat this his chest pain? A. Aspirin B. Hydrochlorothiazide C. Sildenafil D. Simvastatin

Discontinue the ibuprofen

A 67-year-old man with diabetes mellitus, chronic lower back pain and previously stable systolic heart failure now has increasing orthopnea and shortness of breath. Physical exam reveals pulmonary crackles, jugular venous distention and lower extremity edema. He is on carvedilol, lisinopril, furosemide, insulin and ibuprofen. Which of the following is appropriate for management of this patient? A. Add a calcium channel blocker B. Decrease the dosage of furosemide C. Discontinue the carvedilol D. Discontinue the ibuprofen

Jugular venous distension

A 67-year-old woman with New York Heart Association class III congestive heart failure presents to clinic for a routine examination. Her chief complaint is worsening peripheral edema. Which of the following abnormalities would you most expect to find during a physical examination? A. Finger-nail clubbing B. Jugular venous distension C. Kussmaul breathing D. Pulsus paradoxus

Atrophic, shiny skin

A 69-year-old man with atherosclerosis presents with calf pain during ambulation. He notices a blanching of the leg skin when the pain is at its worst. If he stops walking, the pain ceases within 5 minutes. He has a 120 pack-year history of tobacco use. Examination of the toes reveals prolonged capillary refill but normal sensation. A recent work-up revealed normal cardiac function. Which of the following abnormalities would most likely be found during examination of this patient's lower extremities? A. Atrophic, shiny skin B. Intrinsic foot muscle weakness C. Pitting edema D. Varicose veins

Methylprednisolone

A 73-year-old woman with a history of hypertension presents with a unilateral headache for 3 weeks. She states she has a throbbing pain at her right temple and has pain in her jaw with opening and closing. The vision in her right eye has worsened over the previous day. Her blood pressure is 173/100 mm Hg. What treatment is indicated? A. Carbamazepine B. Labetalol C. Methylprednisolone D. Noncontrast head CT scan

Aortic stenosis

A 74-year-old woman with a history of heart failure presents to the ED with shortness of breath. Her vital signs are notable for heart rate 105 beats/minute, blood pressure 180/90 mm Hg, and oxygen saturation of 87 percent on room air. Chest X-ray shows pulmonary edema. You are considering starting nitrates. Which of the following underlying conditions puts the patient at risk of developing nitrate-induced hypotension? A. Aortic stenosis B. Myocardial infarction involving the left ventricle C. Pulmonary edema D. Volume overload

Calcified aortic valve

A 76-year-old woman presents to her primary care physician due to increasing chest pain and shortness of breath at rest. She has a history of hypertension and states that she was told 3 months ago that she has a murmur but cannot recall any other information about this diagnosis. Which of the following is the most likely diagnosis in this patient? A. Bicuspid aortic valve B. Calcified aortic valve C. Mitral stenosis D. Tricuspid regurgitation

ESR, CRP, and initiate corticosteroid therapy

A 76-year-old woman with a history of hypertension presents with left-sided headache and jaw pain. She states that over the last 4 weeks, she has had progressively worsening headaches, and the pain in her jaw makes it difficult to eat. She also complains of decreased vision in her left eye for the last 6 hours. Exam reveals tenderness over the left temple and jaw. Which of the following is the most appropriate next step in management? A. ESR, CRP, and initiate corticosteroid therapy B. ESR, CRP, and referral to a rheumatologist for further management C. Non-contrast head CT scan D. Treat her headache with NSAIDs and refer to an ophthalmologist

A drop in systolic blood pressure of 20 mm Hg upon standing

A diagnosis of orthostatic hypotension can be made in which of the following scenarios? A. A drop in diastolic blood pressure of 5 mm Hg upon standing B. A drop in systolic blood pressure of 20 mm Hg upon standing C. An increase in heart rate of 35 beats per minute upon standing D. An increase in heart rate of 5 beats per minute upon standing

TIMI Score

A man presents to the ED with angina during exertion that has increased in intensity and duration over the past 18 hours. An ECG shows T wave inversion in 4 leads. Which of the following risk stratification tools is used in the acute management of this type of angina? A. CHADS-2 Score B. Framingham 10-year Cardiovascular Disease Score C. Reynolds Score D. TIMI Score

Clopidogrel

A patient is being discharged from the hospital after having an ST-elevation myocardial infarction. During his stay, he underwent percutaneous coronary intervention with placement of a drug eluting stent. The patient is being sent home on the following medications: aspirin 81 mg, metoprolol 50 mg, nitroglycerin 0.4 mg sublingual, and atorvastatin 40 mg. Which of the following should also be added to his regimen? A. Clopidogrel B. Fish oil C. Ranolazine D. Reteplase

Pericardial knock

A patient is being evaluated for dyspnea and lower extremity swelling. On physical exam the patient has jugular venous distention with inspiration and 2 + pedal edema. Hepatojugular reflex is present. The patient has clear lung fields and no murmur is appreciated. Which of the following findings would support the diagnosis of constrictive pericarditis over restrictive cardiomyopathy? A. Cardiomegaly B. Left bundle branch block C. Pericardial knock D. S3 heart sound

Dyspnea with exertion

A patient is found to have a low pitched rumbling diastolic apical murmur. Which of the following is the most frequent presenting complaint associated with this murmur? A. Chest pain B. Dyspnea with exertion C. Hemoptysis D. Palpitations

Nitroglycerin

A woman complains of her heart racing, facial flushing and headache after taking an unknown pill in her purse. Which of the following is the most likely medication? A. Amitriptyline B. Metformin C. Metoprolol D. Nitroglycerin

Normal exercise stress test

A young woman with Raynaud phenomenon presents with a three month history of cyclical short episodes of chest pain. Her social history is positive for intermittent cocaine use. The pain occurs most commonly after she wakes in the morning, lasts for 20 minutes, then resolves. This pain occurs at rest and is not worse with exercise or increased activity. Which of the following would you most expect to find during an evaluation of these symptoms? A. Coronary artery stenosis B. Normal exercise stress test C. Pain relief during ergonivine administration D. Persistent ST elevation

Pericarditis

An eight-year-old girl was brought to the clinic due to chest pain. One week ago, she had rhinorrhea, abdominal pain, and fever. Later, she complained of stabbing chest pain that is worse with inspiration and relieved by sitting upright. On physical exam, heart rate is 120, respiratory rate is 20, blood pressure is100/80, with clear breath sounds and distant heart sounds. Which of the following is the most likely diagnosis? A. Costochondritis B. Gastroesophageal reflux C. Pericarditis D. Pulmonary embolism

During systole, blood is seen flowing from the left ventricle into the left atrium

An elderly man presents with 6 months of progressive positional dyspnea. Nine months ago, he had a mild heart attack and was properly treated. Today, you appreciate a new loud, blowing holosystolic murmur heard at the apex. Which of the following color Doppler echocardiography findings would you most expect to find based on these signs and symptoms? A. During diastole, blood flows from the right ventricle into the right atrium B. During diastole, blood is seen flowing from the aorta into the coronary arteries C. During systole, blood flows from the left ventricle into the aorta D. During systole, blood is seen flowing from the left ventricle into the left atrium

Alter the force of myocardial contraction

An inotropic drug works by which of the following mechanisms? A. Alter cardiac conduction velocity B. Alter the force of myocardial contraction C. Alter the heart rate D. Dilate blood vessels

DBP + (2 x SBP)

How do you calculate mean arterial pressure? A. MAP =

Mitral

In normal hearts, which of the following heart valves is composed of two cusps? A. Aortic B. Mitral C. Pulmonic D. Tricuspid

Continued chest pain

The emergency department staff began treatment for a woman who presented with chest pain. The pain is described as retrosternal, worse with minimal activity, better with rest, sharp in character and 9/10 in intensity. You are paged to admit her to the intensive care unit under the working diagnosis of unstable angina. Her vitals have remained stable after beginning antiplatelet, antihypertensive and antithrombotic medications. Two hours after admission, a repeat history and physical and review of available test results offers the following information: serial electrocardiograms reveal increasing R wave amplitude; an echocardiogram calculates an ejection fraction of 50%; angina is reported as 9/10 in intensity; atrial natriuretic peptide levels are elevated. Which of the following historical facts would prompt you to immediately consult interventional cardiology for invasive coronary revascularization? A. 50% ejection fraction B. Continued chest pain C. Elevated atrial natriuretic peptide D. R wave progression

Brain natriuretic peptide

Which of the following is a marker of high ventricular filling pressures? A. Brain natriuretic peptide B. Creatine kinase-MB C. Creatinine D. Troponin

Fever

Which of the following is a minor criteria for acute rheumatic fever? A. Carditis B. Fever C. Rash D. Subcutaneous nodules

4 years of age

Which of the following is a risk factor for developing Kawasaki disease? A. 4 years of age B. Congenital heart defect C. Female sex D. Preceding upper respiratory tract infection

Bicuspid aortic valve

Which of the following is a risk factor for the condition shown above? A. Bicuspid aortic valve B. Chronic heroin use C. Fibromuscular dysplasia D. Tobacco use

Ischemic heart disease

Which of the following is the most common cause of sudden cardiac arrest and sudden cardiac death? A. Anomalous coronary artery B. Cardiomyopathy C. Ischemic heart disease D. Left ventricular hypertrophy

Elevated right heart pressure

Which of the following is the most common cause of tricuspid regurgitation? A. Bacterial endocarditis B. Elevated right heart pressure C. Myxomatous degeneration D. Rheumatic heart disease

Duodenum

Which of the following is the most common location of aortoenteric fistula formation? A. Duodenum B. Esophagus C. Jejunum D. Sigmoid colon

Tricuspid regurgitation

Which of the following murmurs is associated with an increase in right atrial pressure? A. Aortic regurgitation B. Mitral regurgitation C. Mitral stenosis D. Tricuspid regurgitation

A 3-year-old girl with a systolic blood pressure of 70 mm Hg

Which of the following patients is considered hypotensive? A. A 1-year-old boy with a systolic blood pressure of 75 mm Hg B. A 2-year-old girl with a systolic blood pressure of 80 mm Hg C. A 3-year-old girl with a systolic blood pressure of 70 mm Hg D. A 6-year-old boy with a systolic blood pressure of 85 mm Hg

A 35-year-old man with a prosthetic mitral valve

Which of the following patients requires endocarditis prophylaxis for a dental procedure that involves manipulation of the gingival tissue? A. A 14-year-old boy with a Still murmur B. A 25-year-old man with a grade 3/6 systolic ejection murmur C. A 35-year-old man with a prosthetic mitral valve D. A 45-year-old man with aortic stenosis

Ejection fraction

Which of the following will help to classify heart failure as being systolic or diastolic? A. Afterload B. Ejection fraction C. Heart rate D. Preload

Low cardiac index

Which of the following would you most expect to find in a patient who presents to the emergency department in cardiogenic shock? A. Dehydration B. High pulse pressure C. Low cardiac index D. Warm, hyperemic extremities

Dyspnea

Which one of the following is the most common atypical presenting complaint in an elderly patient diagnosed with acute coronary syndrome? A. Diaphoresis B. Dizziness C. Dyspnea D. Weakness

Constrictive pericarditis

While performing a routine physical examination, a provider notices a distinct decrease in the strength of the patient's radial pulse during inspiration. Which of the following conditions does this patient likely have? A. Constrictive pericarditis B. Diabetes mellitus C. Subclavian steal syndrome D. Tietze syndrome

Tricuspid stenosis

You are concerned with hearing a new diastolic, rumbling murmur in one of your patients. This murmur is best heard with the bell over the left sternal border at the fourth intercostal space and is louder during inspiration. Which of the following is the most likely diagnosis? A. Aortic regurgitation B. Aortic stenosis C. Tricuspid regurgitation D. Tricuspid stenosis

Tricuspid insufficiency

You discover a blowing, holosystolic murmur in a newborn boy, heard loudest at the left sternal border. A pediatric cardiologist diagnoses Ebstein's anomaly. In addition to a malformed right atrium and ventricle, which of the following abnormalities would you most expect to see on this patient's echocardiogram? A. Left ventricular hypertrophy B. Overriding aorta C. Tricuspid insufficiency D. Tricuspid stenosis

Exudate with positive cytology

You receive the laboratory report of a pericardial effusion sample sent yesterday from an inpatient with metastatic lung cancer. Which of the following results would you most expect? A. Exudate with Gram-positive bacilli B. Exudate with low-protein and high glucose levels C. Exudate with positive cytology D. Transudate with elevated carcinoembryonic antigen levels

Hypotension

What is the most common side effect following administration of intravenous amiodarone? A. Bradycardia B. Hypotension C. Nausea D. Widening of the QRS interval

Swan-Ganz catheter

Which of the following is used to measure the pulmonary artery wedge pressure? A. Arterial catheter B. Flexible bronchoscope C. Foley catheter D. Swan-Ganz catheter

Aspirin

Which of the following medications has the greatest impact on reducing mortality in patients presenting with acute coronary syndrome? A. Aspirin B. Beta blocker C. Morphine D. Nitroglycerin

Colesevelam

Which of the following medications lowers cholesterol by binding bile acids and forming insoluble complexes that are excreted in the feces? A. Colesevelam B. Fenofibrate C. Gemfibrozil D. Lovastatin

Staphylococcus aureus

A 26-year-old ill-appearing man presents to the emergency department with a fever. A grade 3 murmur is detected on examination, and a transthoracic echocardiogram is ordered and reveals a 1.5 cm vegetation on the tricuspid valve. Which one of the following is the most likely causative organism? A. Pseudomonas aeruginosa B. Staphylococcus aureus C. Streptococcus bovis D. Streptococcus viridans

Coronary artery aneurysm

A 4-year-old boy presents with a 5-day history of fever. On exam he is noted to have non-tender anterior cervical lymphadenopathy, non-exudative conjunctival injection, and swollen hands and feet. Which of the following is the most common complication of this condition? A. Aplastic anemia B. Coronary artery aneurysm C. Glomerulonephritis D. Severe thrombocytopenia

Erythrocyte sedimentation rate

A 67-year-old woman presents with a gradual onset headache that has been present for several days. Examination is notable for tenderness over the left temple. Vital signs are normal. Which of the following is the most appropriate test to order? A. Erythrocyte sedimentation rate B. Lumbar puncture with opening pressure C. Non-contrast head computed tomography D. Outpatient magnetic resonance imaging

Dilation of the ascending aorta

A bicuspid aortic valve is often associated with which of the following findings? A. Abdominal aortic aneurysm B. Dilation of the ascending aorta C. Left atrial dilation D. Patent foramen ovale

Tricuspid

A 40-year-old woman, who actively uses intravenous drugs, presents to the ED with fever and fatigue for the past 3 days. In the ED, her vital signs are BP 126/82, HR 90, RR 16, oxygen saturation 99% on room air, and temperature 101.6°F. On exam, a murmur is noted. A transesophageal echocardiography is ordered for suspected endocarditis. Which of the following valves is most likely to be affected? A. Aortic B. Mitral C. Pulmonic D. Tricuspid

Lower extremity edema

An elderly patient presents to the office complaining of lower extremity skin changes and discomfort that is relieved with elevation. Which of the following would most likely be present on physical exam? A. Cold lower extremities B. Diminished pulses C. Lower extremity edema D. Palpable cord

Epinephrine 1:1,000 (1 mg/mL) 0.3 mL IM

A 17-year-old woman presents with shortness of breath, rash, and nausea after an insect bite. Her vitals are T 97.7°F, HR 128 bpm, BP 85/56 mm Hg, RR 28/min, and oxygen saturation 93%. Exam reveals diffuse hives and posterior pharyngeal swelling. Which of the following should be immediately administered? A. Epinephrine 1:1,000 (1 mg/mL) 0.3 mL IM B. Epinephrine 1:1,000 (1 mg/mL) 0.3 mL IV C. Epinephrine 1:10,000 (0.1 mg/mL) 0.3 mL IM D. Epinephrine 1:10,000 (0.1 mg/mL) 10 mL IV

Chest pain in the early morning

Which of the following is most characteristic of Prinzmetal angina? A. Chest pain associated with nausea B. Chest pain in the early morning C. Exertional chest pain D. Sub-sternal chest pain

Chest pain lessens when she sits forward

A 41-year-old woman presents with fever and retrosternal chest pain of 28 hours duration. A loud friction rub is appreciated over the left sternal border. There is widespread ST-segment elevation seen on her ECG. Which of the following physical findings do you most expect to find in this patient? A. Chest pain lessens when she sits forward B. Chest pain worsens during forced expiration C. Normal breath sounds over the left chest field D. Tympanic percussion over the left chest field

Mitral stenosis

A 55-year-old woman presents to the office with progressive dyspnea, paroxysmal dyspnea, orthopnea, and fatigue over the last several months. On auscultation of her heart, you detect a low-pitched diastolic rumble best heard in the left lateral decubitus position along with a high-pitched opening snap. Which type of valvular abnormality is associated with these findings? A. Aortic regurgitaion B. Aortic stenosis C. Mitral regurgitation D. Mitral stenosis

Bisoprolol

A 60-year-old man presents with nighttime dyspnea. His medical history is significant for chronic hypertension. A recent echocardiogram showed an increase in left ventricular chamber volume but normal ventricular wall thickness. Based on this finding alone, which of the following medications is the most appropriate treatment for this patient's dyspnea? A. Bisoprolol B. Propranolol C. Salmeterol D. Timolol

Monitor daily weights

A 68-year-old man was admitted to the hospital for an acute exacerbation of his chronic systolic congestive heart failure. What education should be given to this patient upon discharge to help prevent readmission? A. Avoid physical activity B. Elevate lower extremities C. Monitor daily weights D. Restrict fluid intake

Intravenous methylprednisolone

A 58-year-old man presents with 3 months of headache and transient diplopia. He also reports that chewing tough foods has been progressively painful. Laboratory testing reveals a normocytic anemia and ESR of 88 mm/hour. A brain CT is normal. Biopsy reveals fragmented elastic lamina, CD4+ lymphocytes and macrophages. Which of the following is the best next step to manage this patient's condition? A. Intravenous methylprednisolone B. Oral methotrexate C. Oral prednisone D. Temporal artery resection

Furosemide

A 58-year-old man ran out of his congestive heart failure medications. He presents with significant dyspnea and altered mental status. Examination reveals bibasilar crackles and jugular venous distension. An electrocardiogram shows sinus rhythm with low voltage complexes. Which of the following is most appropriate at this time? A. Amiodarone B. Disopyramide C. Furosemide D. Ventricular assist device

Cardiac tamponade

Which of the following is associated with sudden onset hypotension, tachycardia, and impaired diastolic filling? A. Cardiac tamponade B. Constrictive pericarditis C. Pericardial effusion D. Pneumopericardium

Mitral stenosis

A 58-year-old previously healthy woman presents with complaints of dyspnea on exertion and fatigue for the past one month. She denies unexplained weight loss or weight gain, chest pain, or cough. Physical exam reveals a low pitched, diastolic murmur, heard best at the apex. There is an associated opening snap. Which of the following is the most likely diagnosis? A. Aortic regurgitation B. Aortic stenosis C. Mitral regurgitation D. Mitral stenosis

Beta-type natriuretic peptide

A 58-year-old woman presents with progressive orthopnea and peripheral edema. She also gets "winded" when she climbs a full flight of stairs. Which of the following laboratory tests helps define a cardiac versus a pulmonary cause of dyspnea? A. Beta-2 microglobulin B. Beta-type natriuretic peptide C. Erythrocyte sedimentation rate D. Homovanillic acid

Draw blood cultures and admit for intravenous antibiotics and transthoracic echocardiograph

A 21-year-old woman with a history of intravenous drug use presents with fever, dyspnea, cough, and chest pain. Examination reveals an ill-appearing woman with track marks on both upper extremities. A chest X-ray reveals no infiltrate, and urinalysis is unremarkable. What management is indicated? A. Discharge with a prescription for azithromycin for a respiratory infection B. Draw blood cultures and admit for intravenous antibiotics and transthoracic echocardiograph C. Draw blood cultures and admit for intravenous antibiotics and valvuloplasty D. Start antibiotics for community-acquired pneumonia and admit

Lovastatin

A 62-year-old man who is a nonsmoker without any significant past medical history presents to your office with questions about his cholesterol. Recent laboratory results include total cholesterol 253 mg/dL, high-density lipoprotein cholesterol 38 mg/dL, low-density lipoprotein cholesterol 165 mg/dL, and triglycerides 250 mg/dL. He has a 10-year ASCVD event risk score of 9%. Which of the following is the most appropriate initial therapy? A. Fenofibrate B. Fish oil C. Gemfibrozil D. Lovastatin

Janeway lesions

18 months ago, an elderly patient received a mitral valve replacement. Unfortunately, for the past year, he has been fighting subacute bacterial endocarditis. He has been admitted to the hospital 3 times in the past 6 months. Of all things, he is most concerned with unsightly changes of his palms. During inspection, you appreciate that both palms have several nontender macules of red to brown to black coloration. His daughter is getting married in 3 weeks, and he doesn't want people to see these "weird rashes" on his hands. Which of the following correctly names these findings? A. Janeway lesions B. Raynaud's phenomenon C. Roth spots D. Splinter hemorrhages

Ibuprofen, colchicine, and prompt follow-up with primary care doctor

A 17-year-old man with no past medical history presents complaining of constant chest pain for 5 days. He states he had a cold 2 weeks ago and feels like he never got better. His vitals are T 36.8°C, HR 110 bpm, BP 122/75 mm Hg, RR 18/min, and oxygen saturation 99%. A 12-lead ECG is performed, as seen above. Which of the following is the most appropriate management for this patient? A. Aspirin 325 mg and activation of the cardiac catheterization lab B. Azithromycin 500 mg by mouth followed by 250 mg once a day for 4 days C. Ibuprofen, colchicine, and prompt follow-up with primary care doctor D. Serum D-dimer test

Vasovagal syncope

A 20-year-old woman fainted while standing in line at the grocery store. The patient admits to feeling nauseated and diaphoretic before the episode. She denies bowel or bladder incontinence and did not experience a post-ictal state. The woman in line behind her observed jerking motions of her face and fingers. She has no past medical history and does not take any medications. What is the most likely diagnosis? A. Hypertrophic cardiomyopathy B. Orthostatic hypotension C. Seizure D. Vasovagal syncope

Bacterial endocarditis

A 27-year-old woman presents to the emergency department with complaints of fever, rash, and myalgias. She also admits to night sweats and nausea. On exam, there are multiple scars in her left antecubital fossa, scattered petechiae, and tender nodules on the tips of her digits. Cardiac auscultation reveals a murmur. Which of the following is the most likely diagnosis? A. Acute pericarditis B. Bacterial endocarditis C. Community-acquired pneumonia D. Hypertrophic cardiomyopathy

Fasting lipid panel

A 28-year-old man presents to establish care at your primary care clinic. He works as an electrical engineer and reports he has a fairly sedentary lifestyle. He states he smokes half a pack of cigarettes a day, and is not interested in quitting. He denies any past medical history and states he does not take any medications. He does mention that his father had a heart attack when he was 43 years old. What is the most appropriate next step for this patient? A. Fasting lipid panel B. Health maintenance counseling only C. Point of care glucose test D. Start statin therapy

Squatting

A 32-year-old man presents to the emergency department with palpitations and occasional non-exertional chest pain. Physical examination reveals a tall, thin man with pectus excavatum. A late systolic murmur with a midsystolic click is heard on auscultation. Which of the following maneuvers will result in movement of the click later into systole? A. Inspiration B. Squatting C. Standing D. Valsalva

Obtain three sets of blood cultures

A 32-year-old man with a history of intravenous drug use presents to the emergency department with complaints of chest pain, shortness of breath, cough and fever. Physical exam reveals a temperature of 102F, new heart murmur, diffuse petechial rash and subungual hemorrhages. Which of the following is the most appropriate next step in management? A. Begin anticoagulation therapy B. Begin empiric antibiotic therapy C. Obtain three sets of blood cultures D. Order cardiovascular surgical consult

Duplex ultrasound

A 32-year-old woman presents to the ED complaining of right calf swelling for one week. She is one week postpartum, following an uneventful full-term vaginal delivery. She denies any chest pain, dyspnea, or cough. On examination, her right calf is 16 inches in circumference, and her left calf is 10 inches. Which of the following is the most accurate test to confirm the diagnosis? A. Computed tomography B. D-dimer assay C. Duplex ultrasoundCorrect Answer D. Impedance plethysmography

Myxoma is the most common cardiac primary tumor in adults

A 55-year old man is admitted to the hospital for further evaluation of a suspected cardiac tumor. The patient is concerned about his illness and asks you to explain his condition in more detail. Which of the following statements regarding cardiac tumors is true? A. Approximately 10% are located in the atrium B. Cardiac tumors are usually treated with radiation C. Most primary tumors are malignant in nature D. Myxoma is the most common cardiac primary tumor in adults

Aortoiliac segment

A 62-year-old man with a history of ongoing tobacco abuse, hypertension, dyslipidemia and erectile dysfunction complains of progressive aching pain in his right buttock and hip. The pain is worse with walking and is relieved with rest. Physical exam of the lower extremities reveals slightly diminished femoral, popliteal, and dorsalis pedis pulses. Which of the following is the most likely site of this patient's peripheral arterial disease? A. Aortoiliac segment B. Common femoral artery C. Popliteal artery D. Superficial femoral artery

Acute pericarditis; give nonsteroidal anti-inflammatory drugs

A 34-year-old woman presents to the ED with chest pain that is worse with inspiration and better upon leaning forward. She has had a runny nose and cough for the last week. In the ED, her vital signs are BP 134/78, HR 86, RR 14, oxygen saturation 99% on room air, and T101°F. On exam, a friction rub is heard. An ECG displays global ST segment elevation with PR segment depression. What is the most likely diagnosis and what would be the next step in management? A. Acute myocardial infarction; give aspirin, nitroglycerin, consult cardiology, and activate the cath lab B. Acute pericarditis; give nonsteroidal anti-inflammatory drugs C. Cardiac tamponade; perform immediate pericardiocentesis D. Pulmonary embolism; order CT angiography of the chest

Chest compressions

A 35-year-old man is evaluated in the emergency department after being the restrained driver in a motor vehicle collision. At presentation, the patient is alert, anxious, and able to verbalize a complaint of chest pain associated with some anterior chest wall bruising. There are no gross deformities on exam. Suddenly, the patient becomes unresponsive. Telemetry shows the rhythm above. No pulse can be palpated. Which of the following is the most appropriate next step in the management of this patient? A. Amiodarone drip B. Chest compressions C. Epinephrine D. Synchronized cardioversion

No additional testing

A 35-year-old woman is being evaluated at her annual well woman exam. She has no complaints and generally feels healthy. She has no past medical history and takes no medications. She walks 30 minutes five days per week with no dyspnea or discomfort. On physical exam her blood pressure is 118/68, pulse 64/min and respiration rate is 13/min. Her body mass index is 22. Cardiac auscultation reveals a 2/6 mid-systolic crescendo-decrescendo murmur heard best at the left lower sternal border without radiation. She has a normal S1 and S2 and normal cardiac impulse. Lungs are clear and peripheral pulses are normal. Electrocardiogram is normal. What is the next appropriate step in management? A. Cardiac magnetic resonance imaging B. No additional testing C. Transesophageal echocardiography D. Transthoracic echocardiography

Outpatient follow-up and oral naproxen

A previously healthy 35-year-old woman presents to the emergency department with pleuritic chest pain and malaise. She has been feeling unwell for the past few days with intermittent fever. Her pulse is 87 beats/minute, respiratory rate is 19 breaths/minute, blood pressure is 122/82 mm Hg, and temperature is 37.0°C. On exam, a pericardial friction rub is appreciated. Echocardiography is negative for pericardial effusion. Which of the following is the most appropriate management? A. Admission and intravenous acyclovir B. Admission and intravenous gentamicin C. Outpatient follow-up and oral naproxen D. Outpatient follow-up and oral prednisone

Deep venous thrombosis

A 43-year-old man is currently undergoing palliative radiation therapy for pancreatic cancer. He presents to the emergency department with a 4-day history of gradually worsening left lower extremity pain. Pain is localized to the calf and made worse with ambulation. Exam shows mild edema of the left calf without erythema or warmth. Which of the following is the most likely diagnosis? A. Cellulitis B. Deep venous thrombosis C. Peripheral artery disease D. Superficial thrombophlebitis

PR depression in II, aVF, and V4-V6

A 44-year-old woman presents with a three day history of pleuritic chest pain radiating to the back. It is worsened by lying supine. On examination, a friction rub is appreciated when she leans forward. Which of the following would you expect to see on her ECG? A. Peaked T waves in V1-V6 B. PR depression in aVR C. PR depression in II, aVF, and V4-V6 D. ST segment elevation in the anterior leads with reciprocal changes inferiorly

Arterial thromboembolism

A 45-year-old man with a history of paroxysmal atrial fibrillation presents to the ED with acute onset of severe pain and paresthesias in his right calf. On exam, you note lower extremity pallor and an absent dorsalis pedis pulse. Which of the following is the most likely diagnosis? A. Arterial atheroembolism B. Arterial thromboembolism C. Arterial thrombosis D. Arterial vasospasm

Low molecular weight heparin initially and continue anticoagulation therapy for at least twelve months

A 45-year-old woman presents with a painful, red, and swollen right leg that has gotten worse over the past couple of days. She denies any trauma, travel or insect bites or any systemic symptoms such as fevers or chills. She has a history of insulin-controlled diabetes mellitus and her average postprandial sugar is 126-136 mmol/L. She also has a history of hyperhomocysteinemia and Factor V Leiden. She had an episode of cellulitis six months ago. On physical exam her vital signs are HR 82, RR 16, BP 142/86, T 99.7°F, and oxygen saturation 98% on room air. On palpation there is a swelling and tenderness of her entire right leg compared to her left. Measurement of her right calf is 3 cm in diameter greater than her left leg. Ultrasound reveals a noncompressible popliteal vein. Which of the following treatment regimens should be initiated in this patient? A. Clindamycin B. Clindamycin and low-molecular weight heparin and continue anticoagulation therapy for six months C. Low molecular weight heparin initially and continue anticoagulation therapy for at least twelve months D. Low molecular weight heparin initially and continue anticoagulation therapy for six months

Non ST-segment elevation myocardial infarction

A 49-year-old man presents with chest pain. His medical history does not list any cardiac murmur, however, during examination, you hear a mitral regurgitant murmur. Blood pressure is equal in both the left and right arms. Although you have none to compare to, you order an electrocardiogram and there is no ST elevation. A chest radiograph is read as normal. Initial lab testing shows an elevated troponin level. Which of the following is the most correct diagnosis? A. Aortic dissection B. Non ST-segment elevation myocardial infarction C. ST-segment elevation myocardial infarction D. Unstable angina

Right-sided electrocardiogram

A 52-year-old man presents to the Emergency Department via ambulance with substernal chest pain. He received aspirin and nitroglycerin from emergency personnel in route. Vital signs include BP 95/55 mm Hg, HR 60 beats/minute, RR 20 breaths/minute, and T 97.6F. His electrocardiogram is shown above. Which of the following is the most appropriate next diagnostic study? A. Chest radiograph B. Computed tomographic angiogram of the chest C. Posterior electrocardiogram D. Right-sided electrocardiogram

Mitral valve replacement

A 52-year-old woman four days post myocardial infarction presents with a new murmur. On examination, the murmur is a grade 3/6 pansystolic murmur radiating to the axilla. She is dyspneic at rest and has rales throughout all her lung fields. Her blood pressure is 108/68 mm Hg, and her heart rate is 70 beats per minute. Which of the following would be the definitive clinical intervention? A. Coronary artery bypass surgery (CABG) B. Immediate fluid bolus C. Intra-aortic balloon counterpulsation D. Mitral valve replacement

Acute mitral regurgitation

A 54-year-old man presents to the hospital in acute respiratory distress. He was released from the hospital three days ago after undergoing a cardiac stent placement secondary to an acute myocardial infarction. His hospital course was uncomplicated. On exam, his BP is 110/60 mm Hg, HR is 115 bpm, RR is 28/min, and pulse oximetry is 91% on room air. Cardiopulmonary exam reveals a midsystolic murmur with bibasilar crackles. An ECG shows sinus tachycardia. Which of the following is the most likely diagnosis? A. Acute aortic insufficiency B. Acute mitral regurgitation C. Postmyocardial infarction syndrome D. Ventricular aneurysm rupture

Pericarditis

A 55-year-old man is being evaluated for sudden onset of chest pain. He describes the pain as sharp that is improved by sitting up and leaning forward. The chest pain is made worse by inspiration or coughing. An ECG shows new widespread ST segment elevation. Auscultation over the left sternal border reveals a superficial scratchy sound. Which of the following is the most likely diagnosis? A. Aortic stenosis B. Mitral stenosis C. Patent ductus arteriosus D. Pericarditis

Aspirin usage

A 55-year-old man presents to the emergency department with substernal chest pain. He has had three episodes of chest pain with exertion in the past 24 hours. Each has lasted 20 to 30 minutes and resolved with rest. His past medical history is significant for hypertension, hyperlipidemia, asthma, and chronic obstructive pulmonary disease. He currently smokes one pack/day of cigarettes. His family history is remarkable for early coronary artery disease in a sibling. Home medications include chlorthalidone, simvastatin, aspirin, albuterol, and home oxygen. In the emergency department, he is chest pain free after receiving three sublingual nitroglycerin tablets. ECG shows 0.8 mm ST-segment depression in V5, V6, lead I and aVL. Cardiac biomarkers are negative. Which aspects of this patient's history add to the likelihood that he might have death, myocardial infarction (MI), or urgent revascularization in the next 14 days? A. Age B. Aspirin usage C. Beta-agonist usage D. Diuretic usage

Use a cardiovascular risk calculator to determine the patient's 10-year risk for atherosclerotic cardiovascular disease

A 55-year-old man with no history of atherosclerotic cardiovascular disease or diabetes mellitus presents to your office with questions about his cholesterol. He was previously taking atorvastatin, but stopped because his fasting low-density lipoprotein (LDL) cholesterol level dropped to 90 mg/dL and he was following the lifestyle modifications you previously recommended. Based on the 2018 American College of Cardiology/American Heart Association cholesterol management guidelines, which of the following is the most appropriate next step in his management? A. Encourage the patient to continue with lifestyle modifications only B. Restart atorvastatin at the previously prescribed dose C. Start the patient on a different statin D. Use a cardiovascular risk calculator to determine the patient's 10-year risk for atherosclerotic cardiovascular disease

Dabigatran

A 58-year-old man is undergoing a pre-operative evaluation before an elective surgery scheduled in two weeks. An ECG shows atrial fibrillation with rapid ventricular response. The patient has no symptoms and is completely unaware of his dysrhythmia. He has a past medical history significant for hypertension that is treated with lisinopril. His vital signs are BP 120/80, HR 150, RR 16 and oxygen saturation is 100% on room air. What is the appropriate management with regards to anticoagulation? A. Dabigatran B. Diltiazem C. No therapy D. Warfarin and aspirin

Aortoenteric fistula

A 67-year-old man with a history of hypertension and remote abdominal aortic aneurysm repair presents to the emergency department after four episodes of gross hematemesis. He had an episode of emesis with some blood last week but dismissed it as a "stomach bug". He denies any history of alcohol abuse or liver disease. His vital signs on arrival are T 38.5°C, HR 111, BP 100/80, RR 27. His stool is guaiac positive. Which of the following is the most likely cause this patient's symptoms? A. Aortoenteric fistula B. Esophageal varices C. Mallory-Weiss tear D. Peptic ulcer disease

Anterior

A 62-year old man presents to the ED complaining of crushing substernal chest pain for the last two hours associated with diaphoresis, nausea, and lightheadedness. His pain improves with sublingual nitroglycerin. Electrocardiogram obtained in triage shows deep Q waves and ST segment elevation in leads V1-V4, with ST depression in leads III and aVF. This pattern on electrocardiogram represents infarction of which area of the myocardium? A. Anterior B. Inferior C. Lateral D. Posterior

Place the patient on a cardiac monitor, give the patient oxygen if hypoxic and administer aspirin

A 62-year-old man reports to the ED with new-onset, crushing, left-sided chest pain, radiating to the left arm that began suddenly 35 minutes prior to arrival. The patient has a history of hypertension, hypercholesterolemia, diabetes mellitus, and a 60-pack-year smoking history. His EMS ECG demonstrates ST-segment elevation in leads II, III, and aVF. In the ED, his vital signs are BP 135/75, HR 98, and RR 18. What is the most appropriate next step? A. Arrange for the patient to have an emergent stress test B. Call the cath lab emergently and prepare the patient for transport C. Give the patient nitroglycerin and draw labs, including troponins D. Place the patient on a cardiac monitor, give the patient oxygen if hypoxic and administer aspirin

Circumflex artery

A 64-year-old man presents to the emergency department with crushing chest pain, dyspnea, and diaphoresis that began approximately 30 minutes prior to arrival. An ECG is performed and shows ST elevation in leads I and AVL with reciprocal ST changes in leads III and AVF. He is prepped for immediate cardiac catheterization after stabilization. Which coronary vessel is most likely occluded? A. Circumflex artery B. Left anterior descending artery C. Posterior descending artery D. Proximal right coronary artery

Measure serial cardiac troponin levels

A 65-year old Caucasian man presents to the emergency room with a crushing substernal chest pain. He states the pain started 30 minutes before and he has never had an episode like this before. He is a smoker and has a history of diabetes. His mother had a myocardial infarction at 60 years of age. He takes insulin for his diabetes but no other medications including over-the-counter medications. He has no known allergies. His initial cardiac troponin was negative and his ECG reveals ST depression that measures 0.8 mm in anterior the leads. According to his TIMI score, which of the following is the most appropriate management? A. Administer 300 mg of clopidogrel B. Discharge the patient home with close follow up C. Measure serial cardiac troponin levels D. Perform an immediate percutaneous intervention

New murmur of aortic regurgitation

A 67-year-old man with a history of hypertension presents to the emergency department complaining of the acute onset of severe tearing chest pain and a syncopal episode. Which of the following physical exam findings would support the most likely diagnosis? A. Ankle-brachial index of 1.0 B. Mydriasis C. New murmur of aortic regurgitation D. Positive Murphy sign

Administer clopidogrel

A 65-year-old man presents to the ED for chest pain. You are concerned for acute coronary syndrome and want to administer aspirin, but the patient states that he develops angioedema to aspirin. Which of the following is the most appropriate next step in management? A. Administer clopidogrel B. Administer dipyridamole C. Administer the lower dose, 81 mg of aspirin and observe closely for angioedema D. Pretreat with corticosteroids and antihistamines and administer full-dose aspirin

III

A 65-year-old man presents to the ED with a known history of heart failure. He complains of progressive shortness of breath over the preceding month to the point that he now has to rest even when he walks from his bed to the bathroom. These symptoms resolve at rest. What is this patient's New York Heart Association classification? A. I B. II C. III D. IV

Begin intravenous hydration

A 65-year-old man presents to the emergency department with chest pain and ST-segment elevation in leads II, III, and aVF. The patient is hypotensive and physical exam reveals jugular venous distention, clear lung fields and tachycardia. No murmur or S3 is appreciated. What is the next step in management? A. Administer a beta blocker B. Administer morphine sulfate C. Administer sublingual nitroglycerin D. Begin intravenous hydration

Aortic dissection

A 65-year-old man presents to your office with sudden severe chest pain, asymmetric blood pressures in his arms, and a new evolving aortic regurgitation murmur. The patient describes the chest pain as 10 out of 10 in severity. You decide to call 911 as you suspect what acute emergency? A. Acute pericarditis B. Aortic dissection C. Myocardial infarction D. Pulmonary embolism

Initiate esmolol drip and obtain vascular surgery consultation

A 65-year-old man presents with acute onset of low back pain. His temperature is 98.3°F, blood pressure is 150/90 mm Hg and his heart rate is 110 bpm. Physical examination is notable for equal peripheral pulses in all extremities and a normal neurologic examination. A CT scan is performed which reveals a true and false lumen of the aorta and an intimal flap at the level just below the aortic arch. In addition to pain control, which of the following is the best management strategy? A. Gradual return to activity and primary care follow up B. Initiate esmolol drip and obtain vascular surgery consultation C. Recommend outpatient, interval imaging D. Start packed red blood cell transfusion and obtain vascular surgery consultation

Four weeks

A 65-year-old woman presents to the emergency department in atrial fibrillation with rapid ventricular response for an unknown duration of time. She was started on heparin and no atrial thrombus was seen on transesophageal echocardiogram. She underwent successful direct current cardioversion and is now back in normal sinus rhythm. What is the minimum period of time she must remain on anticoagulation after cardioversion? A. Five days B. Four weeks C. One year D. Three months

Diastolic blood pressure

A 68-year-old woman presents to the ED with chest pain. It occurs at rest, and has been getting worse over the past 2 hours. Her past medical history includes COPD, GERD, diabetes, urinary incontinence and Factor V Leiden. Her past surgical history is significant for carpal tunnel release four years ago and total hip arthroplasty 18 months ago. Blood pressure is 168/118 mm Hg, heart rate is 100 BPM and oxygen saturation is 95% on room air. An electrocardiogram reveals ST-elevation. An initial cardiac panel shows a positive troponin level. In this scenario, which of the following in this patient is a relative contraindication to fibrinolytic therapy? A. Diastolic blood pressure B. Factor V Leiden C. Gastroesophageal reflux disease D. Total hip arthroplasty

Dilated cardiomyopathy

A 7-year-old boy presents to the emergency department with cough and chest pain. The cough has been present for several days, but the chest pain has been present for only one day. His vital signs are notable for a temperature of 38.8°C, heart rate of 150, blood pressure of 78/49, respiratory rate of 50, and oxygen saturation of 94%. He is ill appearing, has coarse breath sounds on lung auscultation, a systolic murmur and a gallop on his cardiac exam, and his liver is palpable 4 centimeters below the right costal margin. His pulses are palpable and capillary refill is 5 seconds. Which of the following is the most likely complication? A. Aortic valve insufficiency B. Constrictive pericarditis C. Dilated cardiomyopathy D. Left ventricular outflow tract obstruction

Begin atenolol

A woman presents for her annual examination. She has a past medical history of stable angina and her home medications include aspirin and a statin. She continues to have angina 3-4 times a week, but its character, intensity, frequency and duration is unchanged. She has no history of myocardial infarction, diabetes or pulmonary disease. Which of the following interventions is most appropriate at this time? A. Begin atenolol B. Begin lisinopril C. Begin nitroglycerin D. Continue current medications and follow-up in 1 month

Common iliac artery

A 70-year-old man with a history of hypertension and hypercholesterolemia presents to the office with pain to the thigh and buttocks that has been getting increasingly worse over the past few months. He states that the pain is only present when he is walking his dog in his neighborhood but gets better when he sits down to rest. He is an active tobacco user and has been smoking a pack of cigarettes daily for the past 40 years. Based on the location of his pain, which of the following arteries is most likely affected by atherosclerosis? A. Common iliac artery B. Deep femoral artery C. Distal superficial femoral artery D. Popliteal artery

Smoking history

A 70-year-old woman with a history of hypertension presents to the Emergency Department with a complaint of abdominal pain. On physical examination, there is a pulsatile mass in the midline of her abdomen. Which of the following is the most common risk factor for the development of this condition? A. Diabetes mellitus B. Female sex C. Hypertension D. Smoking history

Add ranolazine

A 70-year-old woman with a long history of coronary artery disease is seen in cardiology clinic for routine follow up. She complains of continued angina despite medical therapy. She reports chest pain every time she walks to her mailbox. It does not occur at rest and is relieved by sublingual nitroglycerin. Her medications include carvedilol, amlodipine, daytime transdermal nitroglycerine, sublingual nitroglycerin, aspirin, and simvastatin. On physical exam her BP is 105/72, HR is 51 and RR 16. What is the next step in management? A. Add ranolazine B. Increase the dose of carvedilol C. Increase the dose of simvastatin D. Schedule 24 hour usage of transdermal nitroglycerin

ST segment elevation

A woman presents with nausea and vomiting, chest pain at rest and altered mental status. Her past medical history is significant for poorly controlled diabetes mellitus and hypertension, as well as tobacco abuse. Which of the following would you most expect to see on an electrocardiogram? A. Absent P waves B. Prolonged QT interval C. R wave greater than S wave in lead V1 D. ST segment elevation

Aortic stenosis

A 75-year-old otherwise healthy woman states that she has passed out three times in the last month during her daily brisk walk. Which one of the following is the most likely cause of her syncope? A. Aortic stenosis B. Atrial myxoma C. Orthostatic hypotension D. Vasovagal syncope

Vasodilators and diuretics should be used with caution

A 76-year-old man with a history of hypertension presents after a syncopal event. He also reports decreased exercise tolerance over the last two months. He is currently asymptomatic. His ECG is normal sinus rhythm with no changes. On examination, he has a harsh systolic murmur that radiates to the carotid arteries. Which of the following is true about the most likely cause of his syncope? A. Critical disease is defined by heart valve area less than 2 cm2 B. It typically results from rupture of the chordae tendinae C. The murmur increases with valsalva D. Vasodilators and diuretics should be used with caution

Pericardiocentesis

A 76-year-old man with colorectal cancer presents to the ED with dyspnea and fatigue. He is hypotensive, tachycardic, tachypneic and afebrile. The jugular venous pulse rides high on lateral neck inspection. Cardiac sounds, but not breath sounds, are distant. There is no discernable friction rub or murmur, however, his blood pressure decreases during inspiration. An ECG reveals normal rhythm, increased rate and decreased voltages. Which of the following treatments is most appropriate in this patient's plan of care? A. Cardioversion B. Endarterectomy C. Hemodialysis D. Pericardiocentesis

Pulsus alternans

A 76-year-old woman with a history of coronary artery disease presents to the emergency department complaining of recent-onset dyspnea and fatigue. Physical examination reveals peripheral edema and rales on auscultation. Which of the following additional physical exam findings would support the most likely diagnosis? A. Bradycardia B. Pulsus alternans C. Reduced jugular venous pressure D. Widened pulse pressure

Intravenous fluids and cardiology consultation

A 77-year-old man presents with syncope. He states he was walking to the bus when he felt chest pain, had shortness of breath, and passed out. The patient has a history of hypertension. Examination reveals dry mucous membranes and a systolic murmur that radiates to the carotids bilaterally. The patient continues to complain of chest pain. Vitals are unremarkable, and the ECG reveals left ventricular hypertrophy. What management is indicated? A. Intravenous fluids and cardiology consultation B. Morphine sulfate and admit to telemetry C. Sublingual nitroglycerin and activation of the cardiac catheterization lab D. Sublingual nitroglycerin and admit for telemetry

Gemfibrozil

A diabetic patient with secondary dyslipidemia has a triglyceride level not at goal. Which of the following medications offers the highest reduction in serum triglyceride levels? A. Atorvastatin B. Gemfibrozil C. Lovastatin D. Sitagliptin

Myocarditis

A four-year-old girl is brought to the ED by her parents due to lethargy. A week prior, the girl had a cough and cold. Later, symptoms progressed to include fever and malaise. She has been less active with decreased appetite. A few hours prior to arrival in the ER, she was having difficulty breathing. On exam, temperature is 38.3°C, respiratory rate is 35, heart rate is 126, blood pressure is 90/60, with clear breath sounds, hepatomegaly, and poor pulses. Which of the following is the most likely diagnosis? A. Bronchiolitis B. Dysrhythmia C. Myocarditis D. Pneumonia

Dressler's syndrome

A patient presents two weeks following a myocardial infarction. He complains of fever, malaise, and chest pain that improves with leaning forward. Vital signs are BP 125/70, HR 105, RR 14, and pulse oxygenation 98% on room air. Lab results reveal a leukocytosis and negative troponin. ECG shows sinus tachycardia. Which of the following is the most likely diagnosis? A. Acute myocardial infarction B. Bacterial pneumonia C. Dressler's syndrome D. Spontaneous pneumothorax

Nitroglycerin

A patient presents with chest pain and the ECG seen above. Which of the following medications is contraindicated in this patient's management? A. Aspirin B. Clopidogrel C. Heparin D. Nitroglycerin

2 mm downsloping ST-segment depression

A patient with an intermediate risk of coronary artery disease is undergoing an exercise stress test. Which of the following is the most specific finding for myocardial ischemia? A. 2 mm downsloping ST-segment depression B. 2 mm upsloping ST-segment depression C. Increase of systolic blood pressure D. Sporadic premature ventricular complexes

Initiate lipid screening at age 35

A previously healthy 30-year-old man presents to your clinic with concerns about screening for cholesterol. He has never smoked, is physically active, and is in the normal range for body mass index and blood pressure. He says that his father started taking medication for hyperlipidemia at age 66 and he wants to know when he should start being screened. Which of the following is the most appropriate next step in management according to the United States Preventative Services Task Force? A. Initiate lipid screening at age 35 B. Initiate lipid screening at age 45 C. Initiate preventative therapy with aspirin D. Initiate preventative therapy with lovastatin

Atherosclerosis

Which of the following is an important predisposing factor for the development of the condition seen in this radiograph? A. Atherosclerosis B. Hernia C. Hyperparathyroidism D. Ulcer disease

Dyspnea

Which of the following is commonly the first reported symptom of aortic stenosis? A. Chest pain B. Dyspnea C. Syncope D. Vomiting

Serum troponin is more sensitive than creatinine phosphokinase (CK-MB)

Which of the following is correct regarding cardiac markers in regards to myocardial infarction? A. Creatinine phosphokinase (CK) is specific to cardiac tissue B. Myocardial infarction can be ruled out with a single serum myoglobin C. Serum troponin is more sensitive than creatinine phosphokinase (CK-MB) D. Troponin levels return to normal in 2-3 days

Spironolactone for NYHA class III-IV heart failure and ejection fraction < 35%

Which of the following is recommended for the treatment of systolic heart failure according to New York Heart Association (NYHA) functional class? A. Anticoagulation for NYHA class I-IV heart failure regardless of ejection fraction B. Calcium channel blockers for NYHA class III-IV heart failure and ejection fraction < 40% C. Hydralazine plus nitrates for white patients with NYHA class III-IV heart failure and ejection fraction < 40% D. Spironolactone for NYHA class III-IV heart failure and ejection fraction < 35%

Pulsatile abdominal mass

Which of the following is the most common physical exam finding in an abdominal aortic aneurysm? A. Abdominal bruit B. Caput medusa C. Diminished femoral pulses D. Pulsatile abdominal mass

Heart murmur

Which of the following is the most common physical finding in patients with infective endocarditis? A. Heart murmur B. Janeway lesion C. Osler nodes D. Splinter hemorrhages

Establish large-bore IV access and administer an IV fluid bolus

An 18-year-old woman presents after having a syncopal episode. She is complaining of a 2-day history of lower abdominal pain and vaginal spotting. Her BP is 86/42, HR is 128 bpm, RR is 18 breaths/min, and oxygen saturation is 99% on room air. She is drowsy but answers questions appropriately. What is the most appropriate next step in management? A. Establish large-bore IV access and administer an IV fluid bolus B. Initiate rapid sequence induction and orotracheal intubation C. Perform a bedside urine pregnancy testing D. Perform an ultrasound of the abdomen to assess for free fluid

Presence of a third heart sound

An 81-year-old man presents to the Emergency Department in respiratory distress. He is sitting upright and appears anxious, dyspneic, and diaphoretic. Vital signs show blood pressure of 190/110 mm Hg, heart rate of 130 beats/minute, respiratory rate of 35 breaths/minute, and oxygen saturation of 85% on room air. Which of the following physical examination findings most strongly suggest heart failure as the cause of his respiratory distress? A. Jugular venous distension B. Presence of a fourth heart sound C. Presence of a third heart sound D. Wheezing

Left ventricular free wall rupture

An 84-year-old woman is recovering in the hospital from an acute anterior ST elevation myocardial infarction four days ago without complication. The patient suddenly develops chest pain, tachypnea and dyspnea. Her pulse is 115 beats per minute, respiratory rate is 26 breaths per minute, blood pressure is 85/50 mm Hg in both arms. She has elevated jugular venous pulsations and distant heart sounds. Her lungs are clear to auscultation bilaterally and no new murmur is appreciated. What is the most likely etiology of her acute decompensation? A. Acute aortic dissection B. Acute mitral regurgitation C. Left ventricular free wall rupture D. Post infarction ventricular septal defect

Orthostatic vital signs

An elderly man complains of dizziness upon standing. He denies being dizzy after standing for 5 minutes, and also denies being dizzy when supine or seated. He denies associated chest pain, palpitations, or dyspnea. Which of the following tests should first be performed during the evaluation of this positional dizziness? A. Chest radiograph B. Head-up tilt-table testing C. Orthostatic vital signs D. Transesophageal echocardiography

Duplex ultrasonography

An elderly woman presents with intermittent leg pain. She states it is a burning heaviness that is not necessarily associated with activity. Inspection reveals several dilated and tortuous veins about the lower legs. The skin is edematous and speckled with dark brown areas of capillary dilation but no specific pallor. Distal motor and sensory examinations are intact. Which of the following is the most appropriate initial tests in the evaluation of these symptoms? A. Angiography B. Coagulation panel C. Duplex ultrasonography D. Electrodiagnostics

Use compressive stockings during the day

An obese 45-year-old man works for the local electric company as a utility-pole lineman. He presents with painful, tortuous superficial veins on his lower legs. These areas are not associated with erythema, warmth or skin breaks. Which of the following initial plans is most appropriate at this time? A. Dangle your legs at night over the side of your bed for 30 minutes B. Increase your daily exercise routine C. Schedule an appointment with a vascular surgeon D. Use compressive stockings during the day

Past medical history of coronary artery disease

Which of the following is the most predictive risk factor for cardiac ischemia? A. Diabetes mellitus B. Family history of coronary artery disease C. Past medical history of coronary artery disease D. Tobacco use

42-year-old man with hypertension; aneurysm size 3.9 cm with 0.9 cm expansion in 6 months

Elective surgical repair should be offered to which of the following patients with asymptomatic abdominal aortic aneurysm? A. 22-year-old man with Ehlers-Danlos syndrome; aneurysm size 3.5 cm B. 42-year-old man with hypertension; aneurysm size 3.9 cm with 0.9 cm expansion in 6 months C. 52-year-old man with positive family history; aneurysm size 4.5 cm D. 62-year-old man with tobacco use; aneurysm size 4.5 cm with aneurysm growth 0.2 cm in two years

Prednisone

Examination of a 75-year-old woman reveals a tender, dilated, right temporal artery. She also complains of right-sided jaw pain when chewing. Her temperature is 38.1°C (100.5°F). Which of the following is the most appropriate initial treatment for this patient? A. Carbamazepine B. Cyclophosphamide C. Low-dose aspirin D. Prednisone

Reducing both preload and afterload

Nitrate therapy works by which of the following mechanisms? A. Reducing afterload B. Reducing both preload and afterload C. Reducing cardiac contractility D. Reducing preload

5.5 cm

What diameter does an abdominal aortic aneurysm need to exceed for elective surgical repair to be generally recommended in asymptomatic patients? A. 2.5 cm B. 4.0 cm C. 5.0 cm D. 5.5 cm

S3

What is the abnormal heart sound heard in the above audio recording? A. Holosystolic murmur B. S3 C. S4 D. Systolic ejection murmur

Midsystolic click

What is the classic auscultatory feature of mitral valve prolapse? A. Crescendo-decrescendo systolic murmur B. Loud S1 and an opening snap in diastole C. Midsystolic click D. Soft diastolic murmur

Hyperacute T waves

What is the earliest change seen on electrocardiogram in an acute ST elevation myocardial infarction? A. Hyperacute T waves B. J point elevation C. PR depression D. ST segment elevation

Chest pain

What is the most commonly seen symptom or sign in patients with acute aortic dissection? A. Aortic insufficiency murmur B. Chest pain C. Pulse deficit D. Syncope

Obesity

Which of the following can decrease levels of brain natriuretic peptide? A. Elderly age B. Female sex C. Kidney failure D. Obesity

Constrictive pericarditis

Which of the following conditions is associated with a pericardial knock on auscultation? A. Acute pericarditis B. Constrictive pericarditis C. Pericardial tamponade D. Restrictive cardiomyopathy

Dilated cardiomyopathy

Which of the following conditions is associated with low-output heart failure? A. Anemia B. Dilated cardiomyopathy C. Pregnancy D. Thyrotoxicosis

Abdominal mass

Which of the following conditions is most suggestive of an asymptomatic abdominal aortic aneurysm? A. Abdominal bruit B. Abdominal mass C. Hypertension D. Hypotension

Crystalloids are the preferred treatment of hypotension in the setting of aortic dissection

Which of the following describes the correct management of aortic dissection? A. All aortic dissections eventually need surgical or endovascular repair B. Crystalloids are the preferred treatment of hypotension in the setting of aortic dissection C. Stanford type A dissections should be managed chronically with negative inotropes D. Vasodilators are the preferred treatment of hypertension in the setting of aortic dissection

Arteriovenous fistula

Which of the following is a cause of high output heart failure? A. Aortic stenosis B. Arteriovenous fistula C. Chronic hypertension D. Dilated cardiomyopathy

Biliary disease

Which of the following is a contraindication for the use of gemfibrozil in patients with hypertriglyceridemia? A. Active peptic ulcer disease B. Biliary disease C. Myopathy D. Severe asthma

Dressler syndrome

Which of the following is a late complication of acute myocardial infarction? A. Cardiogenic shock B. Complete heart block C. Dressler syndrome D. Pulmonary edema

Intravenous immunoglobulin 2 grams/kg

Which of the following is a mainstay for the treatment of Kawasaki disease during the acute febrile phase? A. Aspirin 3-5 mg/kg/day B. Dexamethasone 0.6 mg/kg C. Intravenous immunoglobulin 2 grams/kg D. Warfarin 0.2 mg/kg/day

Recent major surgery

Which of the following is a risk factor for the development of deep vein thrombosis? A. Alcohol consumption B. Female sex C. Recent major surgery D. Younger than 40 years old

A 55-year-old woman with a history of hypertension but no prior cardiac disease who complains of one episode of chest pressure that began while pushing her grocery cart and lasted 30 minutes

Which of the following patients should be classified as having unstable angina? A. A 51-year-old woman who had chest pain three days ago but now is chest pain free and is found to have a positive troponin with Q waves in leads II, III, and aVF, without ST elevations B. A 55-year-old woman with a history of hypertension but no prior cardiac disease who complains of one episode of chest pressure that began while pushing her grocery cart and lasted 30 minutes C. A 65-year-old man with a known history of coronary artery disease who gets chest pain and shortness of breath every time he climbs the steps to his bedroom D. A 71-year-old man who underwent a coronary catheterization one month ago for early morning chest pain that showed minimal coronary artery disease with no fixed lesions presents with recurrent early morning chest pain that is relieved by nitroglycerin

19-year-old woman with a history of endocarditis who is undergoing a dental extraction

Which of the following patients should receive prophylactic antibiotics to prevent endocarditis? A. 18-year-old pregnant woman with a history of a repaired congenital heart defect, with an impending vaginal delivery B. 19-year-old woman with a history of endocarditis who is undergoing a dental extraction C. 20-year-old man with a prosthetic heart valve who requires a Foley catheter due to urinary obstruction D. 21-year-old man with a history of a heart transplant and valvulopathy who is undergoing suture repair of a simple facial laceration

Edema

Which of the following signs or symptoms is most likely to be associated with a patient with chronic venous insufficiency? A. Edema B. Hair loss C. Muscle atrophy D. Pallor

Up to 33% of patients diagnosed with acute myocardial infarction do not have chest pain on presentation

Which of the following statements is most accurate regarding acute ischemic heart disease? A. Elderly patients present more often with typical chest pain than atypical symptoms B. Reproducible chest wall tenderness excludes ischemia as a cause of chest pain C. Up to 33% of patients diagnosed with acute myocardial infarction do not have chest pain on presentation D. Women rarely present with atypical features of acute coronary syndrome

Electrocardiogram

Which of the following studies is recommended in all patients who present with syncope? A. Blood glucose B. Computed tomography of the head C. Electrocardiogram D. Stool guaiac test

Aspirin

Which of the following treatments has a proven mortality benefit in ST-elevation myocardial infarction? A. Aspirin B. Morphine C. Nitroglycerin D. Oxygen

Pneumococcal

You have recently diagnosed a reduced ejection fraction in a 50-year-old man with congestive heart failure. He is currently stable and adherent to his medications. Which of the following vaccinations is indicated for this patient at this time to prevent further exacerbations? A. Hepatitis A B. Meningococcal C. Pneumococcal D. Varicella

Short systolic duration

You see a one-year-old girl in your office. The girl was brought by her parents to the clinic for a well child examination. The girl has been doing well and has gained weight appropriately. The parents deny respiratory difficulties or diaphoresis. On physical exam, you note a murmur. Which of the following features is usually associated with an innocent murmur? A. Blowing quality B. Grade 3 intensity C. Increased intensity with upright position D. Short systolic duration