USMLE Step 2 CK Medical Subject Review: Internal: Diseases of the Heart and Blood Vessels
45-year-old male reports to your office to discuss his lipid profile drawn on the previous visit. His total cholesterol is 278mg/dl, TG - 200mg/dl, and HDL is 32mg/dl. The patient is a current smoker. If you initiate pharmacological therapy with simvastatin 40mg/day in this patient, what would be maximum overall risk reduction possible to achieve in this patient?
58%
63-year-old woman presents to her family practitioner complaining of increasing amounts of lower extremity edema. On examination, she is noted to have a jugular venous pressure 3-cm above the sternal angle. To what central venous pressure is this approximately equivalent?
8 cm
52-year-old man presents to his internist for a routine physical. The cardiac examination reveals paradoxical splitting of the S2 heart sound. What is the most likely cause?
A left bundle branch block
48-year-old male comes to the emergency room complaining of awareness of his heartbeat. The palpitation started suddenly an hour ago after ingestion of excessive amounts of alcohol. This is the first time the patient has experienced such a symptom, and has no previous health problems. On examination, the patient looks sweaty and pale, with irregular pulse, B.P =90/60 mmHg and irregular apical impulse with variable intensity of the first heart sound. Both chest X-ray and echocardiography are normal. What are the typical ECG findings that will be seen in atrial fibrillation?
Absent P wave with irregular R-R interval
63-year-old woman presents with a 1-hour history of left shoulder pain and nausea. She has a past medical history of coronary artery disease and had a stent placed 5 years ago. Troponin is elevated. An ECG shows large R waves and ST segment depression in leads V1, V2, and V3. These ECG findings are most consistent with what condition?
Acute posterior myocardial infarction
32-year-old woman is brought in via ambulance due to a fast heart rate. Her blood pressure is 114/76 mm Hg, and her heart rate is 156 bpm. She reports mild chest pain and shortness of breath. Her 12-lead EKG reveals retrograde P-waves that occur simultaneously with the QRS complexes but appear "hidden." After mechanical measures fail, what pharmacologic agent should be tried first?
Adenosine 6 mg IV
60-year-old man presents to your outpatient clinic for workup after a syncopal episode during a walk 2 days ago. He mentions generalized fatigue for several months and "just not feeling well." He describes a non-specific mild angina that has been coming and going for the last several months, but he has not sought medical care. Exam reveals a harsh systolic ejection murmur that radiates to the neck and is louder when the patient leans forward. Lung auscultation is clear throughout. He has no peripheral edema or calf pain. An EKG reveals left ventricular hypertrophy; a chest X-ray shows cardiac enlargement with small bilateral pleural effusions. What is the most appropriate treatment plan for this patient?
Admit to the hospital to undergo further testing.
45-year-old female presents with history of increasing exertional dyspnea with occasional anginal pain. On examination, you hear a faint systolic ejection murmur. An ECHO is performed and she is found to have a bicuspid aortic valve. In explaining the meaning of this finding to her, your most appropriate statement is that
An aortic valve prosthesis may eventually need to be placed
57-year-old female is brought to the emergency room with complaints of chest pain and palpitations that started about 6 hours ago. Her blood pressure is 124/78mmHg and her pulse is 84bpm. The ECG registers atrial fibrillation with ventricular rate of 105bmp. Review of systems is unremarkable. Out of the following, what would be the most appropriate sequence of steps to take in the emergency room?
Anticoagulate, apply cardioversion, use amiodarone if needed
60-year-old male comes in with the history of sudden onset of tearing pain in the chest radiating to the back. Patient has history of poorly controlled hypertension. On examination, P 90/min, RR 20/min, BP 150/100 mmHg. No abnormal heart sounds are audible on auscultation. Chest X-ray reveals a widened mediastinum. The most probable cause of this is
Aortic dissection
55-year-old male presents with severe dyspnea on exertion, occasional anginal pain, and a history of syncope. On examination, he has a systolic ejection murmur on auscultation. The chest X-ray shows enlarged left ventricle with enlargement of the left atrium. The echocardiography shows calcified aortic valve, with hypertrophied left ventricle. The patient is diagnosed with severe aortic stenosis with a valvular gradient > 60 mmHg. What would be the treatment of choice for such a clinically significant aortic stenosis?
Aortic valve replacement
65-year-old man previously admitted with a diagnosis of anteroseptal infarction has developed a new murmur and parasternal thrill. Ventricular septal perforation is a lethal complication of myocardial infarction (MI) and large v wave seen in pulmonary capillary wedge tracing is a non-specific finding. Which of the following auscultatory and cardiac catheterization findings is consistent with a diagnosis of ventricular septal perforation?
Apical systolic murmur, with right ventricle showing stepped-up oxygen concentration
55-year-old male, with a history of poorly controlled hypertension for about 5 years and uncontrolled diabetes mellitus for 20 years, presents to you with sudden onset of severe abdominal pain. The patient also gives history of dull aching groin pain for the past 2 weeks. On examination, patient is afebrile, pulse 110/min, BP 150/100 mmHg, and has a pulsatile abdominal mass with abdominal bruit. Examination also reveals decreased pulses in the lower extremities. His serum creatinine is not increased. Which of the following is the most probable cause of these findings?
Atherosclerotic aortic aneurysm
32-year-old man with no significant past medical history presents with a 2-month history of increased dyspnea upon exertion; the dyspnea becomes apparent after walking 10 city blocks. He denies associated symptoms, such as fever, chills, changes in weight, chest pain, abdominal pain, nausea, and vomiting. He also denies any history of cigarette smoking, occupational risk factors, sick contacts, and recent travel. His physical exam reveals normal vital signs and no distension of his jugular vein, but there is a prominent right ventricular impulse along the lower-left sternal border that is associated with a palpable pulmonary artery. There is also a mid-systolic ejection murmur at the upper left sternal border that does not vary in intensity with respiration. There is a fixed split second heart sound. The remainder of his examination is normal. What is the most likely diagnosis?
Atrial septal defect
47-year-old Caucasian woman presents for evaluation of a 4-week history of dyspnea. Symptoms started when on vacation in Colorado. She initially attributed the symptoms to the altitude, but she continued to have shortness of breath with mild activity after returning home: walking more than 100 feet, walking up one flight of stairs. Symptoms resolve with rest. She also reports mild exertional chest tightness and easy fatigability. She denies paroxysmal nocturnal dyspnea, orthopnea, edema, palpitations, and syncope. Past medical history includes usual childhood illnesses, no previous surgeries, and no known allergies. She takes a daily multivitamin and occasional Tylenol for headache. She does not smoke, rarely drinks alcohol, and denies use of recreational drugs. Physical exam shows temp 96.9°F, pulse 80 and regular, respirations 16, and BP 136/82. O2 sat is 96% on room air. The patient is an alert Caucasian woman in no acute distress, with no obvious jugular venous distention; non-labored respirations; lung fields clear to auscultation and percussion; and no rhonchi, rales, or wheezes. Heart shows RV heave present; normal S1 with fixed, split S2 with prominent P2 component; and grade II/VI systolic murmur at the left upper sternal border at the second intercostal space. The remainder of exam is within normal limits. CBC and BMP are unremarkable. Free T4 and TSH are within normal limits. EKG shows normal sinus rhythm with right ventricular hypertrophy, right atrial enlargement, and right axis deviation. There is an RSR in leads v1 and v2. What congenital heart defect does this patient most likely have?
Atrial septal defect
During rounds on the cardiology wing of a hospital, a doctor asks one of the students to auscultate the chest of one of the patients. The student reports hearing a loud aortic sound and a diastolic murmur of grade 3/6, loudest at the left sternal border in the third to fourth intercostal spaces. The murmur is accentuated with the patient in the sitting position, leaning forward, and breath held in expiration. Which of the following murmurs may also be found in this condition?
Austin-Flint murmur
48-year-old man with hypertension and coronary artery disease is evaluated for protracted fever, fatigue, anorexia, weight loss, night sweats, and nonspecific, nonradiating joint pains, which began following a routine dental cleaning. His physical exam is remarkable for a fever of 101.3°F, oral mucosa, conjunctival petechiae, palpable purpuric skin rashes, reduced bilateral peripheral pulsations, linear subungual hemorrhages, small, flat, irregular erythematous spots on the palms and soles, and tender, erythematous nodules occurring in the fingers. His funduscopic examination was remarkable for cytoid bodies and hemorrhages while his cardiac exam demonstrated a soft, medium-pitched holosystolic murmur located at the apex with radiation to the axilla. A comparison to the patient's last physical exam reveals no abnormal physical exam findings. Three separate blood cultures over 24 hours for typical organisms were requested. What is the next step in the management of this patient?
Begin empiric treatment with IV ceftriaxone and gentamicin
28-year-old African American man presents with dyspnea associated with mild substernal chest pain and dizziness. Symptoms are provoked by sporting activities, and they are relieved with rest. His physical exam reveals a harsh murmur best heard at the left lower sternal border; it decreases in intensity upon squatting. There is also an S4 gallop. A bedside electrocardiogram was remarkable for left ventricular hypertrophy and septal Q waves in the anterolateral leads. An echocardiogram noted asymmetric LVH and a septum that was twice the thickness of the posterior wall. What would be the next step in the management of this patient?
Begin this patient on a beta-adrenergic blocker.
54-year-old male has chest pain radiating to the left arm for the past 7 hours. On admission to the ER his electrocardiograph (ECG) shows inferior wall myocardial infarction (MI). His vitals are BP 170/100 mmHg and pulse 90/min. Which of the following is an absolute contraindication for initiation of thrombolytic therapy in patients with MI?
Bleeding diathesis
Your patient is a 35-year-old man complaining of syncope that started several months ago without any reason. He has experienced 3 episodes so far. There are no symptoms prior to the syncopal event. The duration of his loss of consciousness is around a minute or two, and after that he feels "normal." There are no witnesses of these events. His physical is normal, and there are no positional changes in blood pressure. What will be the most probable diagnosis?
Cardiac rhythm disturbance
An internist notices that his 64-year-old male patient has soft, pitting, brawny edema of the calves and feet with some skin thickening. Ulceration and pigmentary changes are present, and the edema is bilateral. What is the most likely diagnosis?
Chronic venous insufficiency
14-year-old girl presents because she has not yet had her first menstrual period; she has no other health problems. Her mother states that her daughter suffers from what seems to be mild intellectual disabilities and attends special education classes. On examination, the girl is 4'5", her neck skin shows web-like folds on the side, her breasts are not fully developed, and the nipples are widely separated. No heart murmurs are detected; the lower limb pulse is weaker than that of the upper extremities. What is the most probable cause of the feeble pulse in the lower limb?
Coarctation of aorta
Your patient is a 75-year-old man complaining of fatigue, weak appetite, palpitations, and weakness, as well as sore tongue, frequent stomach upsets, and indigestion problems. He also has tingling in both legs, dizziness, and started forgetting things. During the last year, he fell several times. Your examination reveals low blood pressure, swollen beefy tongue, sinus tachycardia, pallor, and loss of vibratory sensation in lower extremities. What will be your next step in diagnosis?
Complete blood count
53-year-old woman presents to her physician with a history of frequent headaches. Her blood pressure is found to be 210/130 on examination. A thorough history, physical, and lab work evaluation reveals a cause for her hypertension. Which of the following is a possible cause?
Conn's syndrome
58-year-old man with recently diagnosed type 2 diabetes on metformin has developed Stage I hypertension over the past 3 months. When deciding what antihypertensive medication to begin for this patient, what is the primary reason for using an ACE inhibitor?
Delay the progression to end-stage renal disease
19-year-old male presents with exertional dyspnea and syncope. On examination, he has a reduced pulse pressure with an ejection systolic murmur. The chest X-ray shows enlarged left ventricle with dilated ascending aorta. Echocardiography demonstrates a calcified aortic valve and hypertrophied left ventricle. The doctors decide that he has to have the aortic valve replaced because he has aortic stenosis. His aortic valve is replaced with porcine bioprosthesis. He is told that the valve will have to be replaced again before ten years because of
Deterioration with calcification
55-year-old man presents with a 5-day history of sharp chest pain. He has a history of rheumatic fever that occurred when he was 15. Further questioning reveals that the patient has had a high fever along with this chest pain. The pain itself seems to vary with positioning and movement, but it extends into the shoulder; he gains mild relief sitting up, but when he is laying down, the pain becomes intense. Physical examination reveals a pericardial friction rub. You order an ECG to be performed. Considering the most likely diagnosis, what findings would confirm your suspicion?
Diffuse ST-segment elevation
34-year-old man came to the ER at 3 am due to stabbing pain in his chest radiating to the back. It started an hour ago and increased in severity. The blood pressure is 100/70 mm Hg and the pulse is 100 per minute. The patient is 187 cm tall, weight 75 kg. ECG was done and didn't show any major changes. He has always been concerned about his blood pressure and has always been hypotensive. He was diagnosed previously by an ophthalmologist to have bilateral lens subluxation, which was not affecting his vision. What is the most likely diagnosis?
Dissecting aneurysm
60-year-old man presents with severe, cramping pain in his lower extremities. He states that over the past 6 months he has noticed pain in his lower legs when he walks; when walking for several blocks, the pain extends to his hips and buttocks. The pain goes away with a period of rest. On physical examination, his legs are pale, cool to the touch, and atrophy of the muscles is noted bilaterally. The femoral pulses are diminished upon palpation, and a bruit can be heard over the iliac and femoral arteries. What diagnostic modality would be performed initially to assist in obtaining a diagnosis?
Doppler ultrasound
37-year-old male reports to your office with complaints of fatigue and palpitations. His blood pressure is 135/78 mmHg with the heart rate of 78 bpm. The patient is a non-smoker and denies alcoholism. The family history is negative for coronary heart disease, hypertension, and stroke. On the auscultation, the patient's S1 and S2 are rhythmic, there are no S3 or S4 identified. You proceed with obtaining the ECG (refer to the image). You notice that in lead II, the patient has U-waves. The meaning of that finding is
Early repolarization
10-year-old boy is brought to his pediatrician's office after his parents noticed that he was becoming increasingly short of breath with daily activities. The child had been previously healthy, but over the past few weeks, it became evident that he needed to stop and rest much more frequently while playing. He also began to complain of some chest pain and dizziness. Physical examination shows a well-developed, well-nourished 10-year-old boy in no acute distress. His lungs are clear, and he has an obvious gallop that was not noted on previous examinations. He is also found to be in atrial fibrillation. His vital signs are as follows: Blood Pressure 110/60 mm Hg, Pulse 122 beats per minute, Respiration Rate 22 per minute (at rest), and a temperature of 97.2°F. Laboratory and diagnostic tests were performed and a diagnosis of hypertrophic cardiomyopathy was made. The major test used to make the diagnosis of hypertrophic cardiomyopathy is
Echocardiogram
3-month-old male infant is brought into the pediatric clinic for assessment. The mother states that her child is not gaining adequate weight despite a regular breastfeeding schedule. She notes that the child appears to get "very tired and inactive" during and after feedings and that she can feel copious amounts of sweat on the child's skin following feedings. She denies any known illness in her child and recalls a normal birth. The general survey reveals a weight and length in the 40th percentile, tachycardia, and tachypnea. The cardiac exam is remarkable for a bounding and hyperdynamic precordium, a holosystolic harsh murmur audible over the lower sternal border (LSB), and a loud second component of the second heart sound. What is the best diagnostic tool to confirm the diagnosis?
Echocardiogram
42-year-old man, with a prior history of rheumatic fever as a child, suddenly develops acute aphasia and a right hemiparesis. On auscultation of the heart, a diastolic murmur is heard over the mitral area. He also reports a history of 'irregular heart beats'. What is the best diagnostic test to confirm the suspected etiology of the patient's stroke?
Echocardiography
57-year-old male is brought to the emergency department with complaints of palpitations and shortness of breath. The patient has a history of hypercholesterolemia and hypertension. He tells that the episode of palpitations started about an hour ago. He had to call the paramedics since he felt palpitations and tightness in his chest. The patient's BP is 140/85mmHg, HR is 113bpm, and respirations are 24 per minute. The patient denies vertigo, chest pain, and numbness in the extremities. On auscultation, there is a mild murmur over the mitral valve with no apparent abnormalities. Lung fields are also clear on auscultation. Neurological exam is satisfactory and review of systems is otherwise unremarkable. You obtain the ECG (refer to the image). You make the decision to admit the patient for a cardioversion. What is the sequence of events you are most likely to establish before you send the patient to the catheterization laboratory?
Echocardiography; troponin measurement
55-year-old female comes at 2 a.m. to the ER. She presents with tightness in the chest since one hour. The pain started at rest, and has gradually increased. The pain is at the center of the chest and radiates to the neck and the left arm. Patient has never had similar symptoms before. Patient is anxious with increased respiratory rate. On examination, her BP is 170/110mmHg, P is 100/min, air entry is bilaterally equal. You suspect an acute myocardial infarction. What would be your first investigation of choice?
Electrocardiograph (ECG)
63-year-old woman with a significant history of hypertension, hyperlipidemia, and myocardial infarction presents to the emergency room with shortness of breath at rest. She has found it difficult to walk short distances due to shortness of breath. Additionally, she complains of orthopnea, nocturnal dyspnea, and generalized abdominal discomfort. She denies cough, fever, chills, anxiety, chest pain, pleurisy, nausea, vomiting, diarrhea, rashes, lightheadedness, and syncope. She is afebrile, but tachypnic and diaphoretic. There is a diminished first heart sound, S3 gallop, laterally displaced PMI, bibasilar rales and dullness to percussion, and expiratory wheezing noted. The abdominal exam reveals distension, with hepatomegaly in the right upper quadrant. There is 2+ pitting edema of the lower extremities to the level of the mid calf, and the extremities are cool. What additional finding is expected in this patient?
Elevated jugular venous distension
50-year-old female suffers from throbbing headache with extreme tenderness over the right temple. The right temporal artery is palpably firm. Her ESR is 104 mm/hr. Biopsy of the temporal artery will show
Giant cell arteritis
60-year-old female dies due to complications of Parkinson's disease. At autopsy it is found that she had an enlarged heart, predominantly the left ventricle and the left atrium. The mitral valve shows shortening of the chordae tendineae, resulting in diminished size of the valvular opening. The aortic valve cusps are also thickened with partial fusion of the commissures that resulted in a narrow orifice. Which of the following conditions is most likely to have contributed to the appearance of the heart described in this patient?
Group A streptococci infections
55-year-old man presents for re-evaluation of his blood pressure; he has no significant past medical history. At his visit 3 weeks ago, his blood pressure was 145/90 mm Hg. He admits to somnolence, confusion, and non-specific bilateral visual disturbances over the past month; he denies any eye pain, blindness, ocular discharge, or floaters. His blood pressure today is 185/110 mm Hg. His fundoscopic exam reveals the following. Refer to the image.What is an additional expected manifestation in this case?
Headache
56-year-old male is admitted to the hospital with complaints of tightness in his chest not relieved by two sublingual nitroglycerin tablets. His troponin I is at 6U/L and echocardiography registers anterior and anteroseptal hypokinesia. In these settings, what would be a contraindication to therapy with IIb/IIIa antagonists?
History of hemorrhagic stroke
70-year-old man has persistent blood pressure levels averaging 160/80, although his diastolic pressure has never been above 90 mmHg. What drug would have the best chance of controlling the blood pressure as a single medication in reasonable dosages?
Hydrochlorothiazide/triamterene (Dyazide), a combination thiazide diuretic and potassium-saving diuretic
77-year-old presents to your office with mild shortness of breath and dizziness since yesterday. Electrocardiogram shows new-onset atrial fibrillation. Review of systems reveals only chronic diarrhea and recent weight loss. Which of the following is the most likely cause of the arrhythmia?
Hyperthyroidism
65-year-old woman was recently admitted following an episode of ventricular fibrillation that she was able to survive. She is being seen by a cardiology team in the hospital, who are reviewing all of her recent labs and diagnostic studies. There appears to be evidence of only an old myocardial infarction, and she is currently stable. What is the best recommended long-term treatment for this patient?
Implantable cardioverter-defibrillator
64-year-old man with a history of a remote myocardial infarction and congestive heart failure presents for his 3-month follow-up. A recent echocardiogram reveals severe left ventricular dysfunction. What intervention has been shown to reduce the risk of sudden cardiac death in similar patients?
Implantation of a cardioverter-defibrillator device
45-year-old female complains of palpitations, exertional dyspnea, fatigue, tiredness and has ankle and leg edema. The chest X-ray shows enlarged left atrium and ventricle with signs of pulmonary venous hypertension. She is diagnosed with chronic rheumatic valvular disease. She now presents with acute symptoms of fever with splinter hemorrhages on the nail bed. Which of the following lab tests results are least likely to accompany infective endocarditis and aid the diagnosis of this condition?
Increased CK-MB fraction
The pathological feature of coagulation necrosis with fading nuclei and decreased cross-striations of myocytes is most likely to be associated with which of the following lab findings?
Increased creatinine kinase-MB fraction
42-year-old man with a past medical history of hypertension presents with a 6-week history of intermittent fever. He has an associated cough, dyspnea, anorexia, arthralgias, abdominal pain, diarrhea, a widespread rash throughout his body, and back pain. He has come to see you because he has experienced painless hematuria since this morning. The patient admits to a dental extraction approximately 6 weeks ago. He denies chills, a history of travel, sick or confined contacts, exposure to animals, bites, stings, cigarette smoking, otalgia, sore throat, swollen glands, drug use, dysuria, preceding GI or GU infections, previous surgeries, or sexual contact in the past year. Physical exam is remarkable for low-grade fever of 101°F, a generalized petechial rash and petechiae of the mucous membranes, dark red linear lesions of the nailbeds, tender subcutaneous nodules of the digital pads, and nontender maculae on the palms and soles. His heart is notable for a new harsh, medium pitched pansystolic murmur at the apex with radiation to axilla, and splenomegaly. What is the most likely diagnosis?
Infective endocarditis
58-year-old man who is a long standing patient of yours is experiencing worsening symptoms and signs of his dilated cardiomyopathy; symptoms include fatigue, dyspnea with mild exertion, paroxysmal nocturnal dyspnea, severe lower extremity edema, clubbing, an S3 gallop, and jugulovenous distention. Medications that this patient is taking on a daily basis include a β-blocker, adult dose aspirin, and an ACE inhibitor. What intervention would be the most logical next step in helping resolve his current symptoms?
Initiation of a diuretic
45-year-old woman presents with vision loss. The patient states that she was watching TV the other day and experienced vision loss in her right eye for a few minutes. She describes the loss as a curtain being brought down over the right eye; it stayed there for a few minutes and then lifted back up. In what artery is the etiology of this symptom located?
Internal carotid artery
70-year-old woman with a history of hypertension, hyperlipidemia, and myocardial infarction presents with a 3-day history of shortness of breath at rest. She has found it difficult to walk short distances due to shortness of breath and is experiencing orthopnea and nocturnal dyspnea. She denies cough, fever, chills, nausea, abdominal pain, vomiting, diarrhea, or rashes. Upon physical examination, the patient is short of breath, requiring numerous pauses during conversation. General assessment reveals the patient is tachycardic and diaphoretic Cool extremities. Heart exam reveals a diminished first heart sound, S3 gallop, and laterally displaced PMI. Lung exam reveals dullness to percussion, bibasilar rales, and expiratory wheezing. 2+ pitting edema of the lower extremities to the level of the mid-calf. There is no JVD noted. What intervention will provide the greatest symptomatic relief to this patient?
Intravenous diuretic
84-year-old man with poorly controlled hypertension is evaluated for severe chest pain that came on suddenly; the pain is accompanied by an episode of syncope. The chest pain is described as "ripping," and it radiates to the abdomen and back. There is no known history of trauma, injuries, or accidents. He denies any fever, chills, cough, dyspnea, palpitations, nausea, vomiting, or diarrhea. The physical exam is notable for tachycardia, a blood pressure of 188/120 mm Hg, and a high-pitched blowing decrescendo murmur at the right second interspace. What agent is the preferred initial treatment in the management of this patient?
Labetalol
50-year-old male arrives at the family physicians clinic for a checkup. He was found to have a blood pressure of 184/100 mmHg during routine medical examination 1 year ago and was started on enalapril. He admits to taking the drug irregularly. He is irregular in his follow up as well and has not had a checkup in the past year. On examination, his vitals are PR -80/min, BP- 140/96 mmHg, and RR -26/min. On auscultation, chest is clear, heart sounds are normal, and there is no murmur. ECG findings show strain pattern with the V1 S wave and V5 R wave summation being 40mm. Which of the following conditions is most likely to be the cause of the ECG pattern in this patient?
Left ventricular hypertrophy
A family practitioner notices that his 47-year-old female patient has minimal nonpitting bilateral edema of the calves (without feet involvement) without skin thickening, ulceration, or pigmentary changes. What is the most likely diagnosis?
Lipedema
45-year-old woman, with diabetes and an estimated glomerular filtration rate of 58 mL/min/1.73 m2, has had blood pressure readings in the 150 - 160/80 - 90 mm Hg range over her past several visits. Her pulse has been in the low 60s. The remainder of her examination is normal, and she is asymptomatic. Her family history is notable for renal disease. What should be the initial therapy for her blood pressure?
Lisinopril
50-year-old man with a history of DM and CKD presents to your office for a follow-up appointment for his hypertension. He reports some non-specific muscle weakness, so you decide to perform an ECG. The ECG demonstrates peaked T waves in several leads without any other abnormality. His labs reveal BUN 12, CO2 22, creatinine 1.0, Glucose 97, K 7.2, Cl 101, and Na 137. What medication is most likely to cause this ECG finding?
Lisinopril
The patient you are seeing is a 63-year-old male with a history of a myocardial infarction. The course of his myocardial infarction a year ago was complicated by ventricular tachycardia. Amiodarone was prescribed at the time of myocardial infarction and the patient remained on it since then. Today, he presents to your office with complaints of generalized weakness, anorexia and lethargy. He is normotensive and his HR is 65bpm. ECG is consistent with a prior myocardial infarction unchanged since the last follow-up visit. Your work-up plan is to obtain
Liver and thyroid function tests
30-year-old male presents with back pain and abdominal pain. With the help of an ultrasound and CT scan he is diagnosed with an aortic aneurysm. He is noted to have spider fingers, high-arched palate and ectopic lenses with a tall stature. His father had a similar disease. Which syndrome does he have?
Marfan syndrome
54-year-old man diagnosed with pancreatic cancer was admitted for TPN. Now he presents with pain and swelling of his left foot. On examination, the skin of the foot is dark purple in color and cold. The patient describes having this previously in his right foot twice. What is the most likely diagnosis?
Migratory thrombophlebitis
You are seeing a 24-year-old female patient with complaints of palpitations occurring both on exertion and at rest. Her BP and HR are normal. At the physical examination, you notice that her extremities and digits are disproportionately longer. Which of the choices most accurately presents other abnormalities associated with the condition that your patient has?
Mitral valve prolapse, tricuspid valve prolapse, aortic dissection
50-year-old female is brought to the emergency room unconscious. Heart sounds are faint or barely audible. The peripheral pulses are absent. Blood pressure is low and a paradoxical pulse with a greater than 10-mmHg inspiratory decrease in systolic pressure is noted. Pericardiocentesis is performed and 250 ml of frank bloody fluid is removed. These findings are most suggestive of
Motor vehicle accident
32-year-old man presents with fatigue and mid-sternal chest pain that started a few months ago. Symptoms appear during exercise and are sometimes accompanied by shortness of breath, fluttering in the chest, and dizziness. He describes the pain as dull, aching, and sometimes as a sensation of "pressure," "tightness," and "squeezing." Pain is not related to position or respiration. His physical is normal, and pain is not elicited by chest palpation. Laboratory analyses, including C-reactive protein and troponin, are all within normal limits. His ECG shows left ventricular hypertrophy, and his echocardiogram shows asymmetric septal hypertrophy and enhanced contractility. What is the most probable cause of his symptoms?
Myocardial hypertrophy
37-year-old man presents to the emergency department complaining of dyspnea, edema, and tachycardia. He has a history of cocaine use, but otherwise has a medical history that is unremarkable. His ECG shows tachycardia, but no other ST or T-wave changes. Laboratory studies reveal leukocytosis, elevated sedimentation rate, and an elevation in troponin I. What is the most likely cause of his symptoms?
Myocarditis
53-year-old female presents to you with complaints of occasional lightheadedness that goes away after a period of time. The first symptoms appeared 2 years ago; however, the patient notices that now they have become more frequent. The patient also has a history of migraines. The migraines and lightheadedness do not occur at the same time. Patient's mother died at the age of 35 years due to a cardiovascular event. On physical exam, BP is 140/95 mmHg, HR is 75 bpm. On auscultation, a bruit is heard over the right carotid artery. Your next step in the management of this patient will be
Obtaining Doppler ultrasound
56-year-old woman presents with a 1-week history of lightheadedness. She usually experiences it when she gets up from her bed. She is hypertensive and is taking hydrochlorothiazide. She gave a 3-day history of diarrhea. She reported eating some old food. She doesn't have any hearing problems, ear pain, tinnitus, or discharge. She denies any headache, vomiting, abnormal weakness, or sensations. What is the next step in diagnosis?
Orthostatic vital signs
50-year-old male reports to your office with BP of 145/92mmHg. The patient has a family history of coronary artery disease. Physical examination and ECG are inconclusive of the presence of coronary pathology. You decide to obtain the patient's calcium score with EBCT. Out of the following choices, what is the total calcium EBCT score is proportional to?
Overall plaque burden
25-year-old male is brought in to the emergency department with a stab wound to the chest. He was reportedly involved in a gang fight, which resulted in him being stabbed with a knife in the 5th intercostal space 3 cm from the midline on the left side. The patient is conscious and well oriented to time, place, and person. He is coherent and responds to commands readily. His vital signs are as follows: Temp. 37 C, Pulse 87/min, BP 110/80 mmHg and Resp. 22/min. IV Ringer's lactate is started and blood is sent for typing and crossmatching. Re-examination of the patient 5 minutes later reveals a Pulse of 95/min, BP 90/70 mmHg and a Temp. of 36.5 C. The jugular venous pulsations are visible 10 cm above the sternoclavicular joint when the patient is reclining at an angle of forty-five degrees. Breath sounds are audible on both sides with no added sounds, the heart sounds are diminished but no murmurs are heard. The patient has started to slip in and out of consciousness. What would be the next step in management?
Pericardiocentesis
25-year-old female, primigravida, comes for her routine checkup in the 12th week. She is taking folate and iron tablets as advised. The USG shows complete failure of development of the spiral septum in the developing fetal heart. Which of the following conditions would be present in this child due to complete failure of development of the spiral septum in the first trimester?
Persistent truncus arteriosus
75-year-old woman presents with several hours of drooling, nausea, vomiting, palpitations, dizziness, and diarrhea. She also tells you that she sees yellow halos around objects and that every sound is unbearably loud. During the last several days, she became progressively tired and drowsy. She thinks that symptoms might be caused by an upper respiratory tract infection, for which she is taking clarithromycin, and that bad sleep contributes to her tiredness; she does not sleep well because recently she started having nightmares. Her medical history is significant for heart failure, for which she is taking chlorothiazide, enalapril, spironolactone, carvediol, and digoxin. You strongly suspect that your patient has a condition that will be confirmed by the testing of what?
Plasma digoxin
72-year-old man presents with a 2-hour history of a nosebleed that will not stop. His nose began dripping blood at breakfast; there is no known trauma. He denies pain. He has tried applying nasal pressure and laying down to rest. Until the bleeding began, the patient had not been experiencing any nasal symptoms, such as congestion, impaired nasal patency, or rhinitis. The patient has no diagnosed medical conditions, and he takes no medications. He denies prior episodes of severe nosebleeds, easy bruising, and any known bleeding disorder. The man is holding a large towel to his nose; there is continued brisk bleeding. He is otherwise in no apparent distress. On rhinoscopy, bleeding is observed from bilateral nares. No foreign body, mass, lesions, or abrasions are visualized. The bleeding site cannot be identified. A nasal tampon is placed, but it is unsuccessful in stopping the brisk nasal bleeding. Weight 148 lb Height 69" Pulse 98 Blood pressure 166/96 mm Hg Temperature 97.4°F/36.3°C Test Result Normal range Units WBC 7.2 3.6-9.0 K/μL RBC 5.1 4.18-5.22 M/μL Hemoglobin 13 12.9-15.5 g/dL Hematocrit 38.1 34.6-50.1 % MCV 82.4 80.0-100.0 fL MCH 30.2 27.0-34.0 pg MCHC 32.8 30.0-37.0 g/dL RDW 16.1 11.0-17.0 % Platelets 348 140-440 K/μL MPV 9.9 6.5-12.0 fL WBC differential Normal What is the most likely diagnosis?
Posterior epistaxis
30-year-old man presents with persistent palpitations. His history is significant for cocaine abuse. His blood pressure is 130/95 mm Hg and his heart rate is 115 BPM. Physical exam is negative for edema, clubbed fingers, and cyanosis. Auscultation does not reveal S3. The patient is placed on continuous electrocardiograph (ECG) monitoring, part of which is presented to you. Refer to the image.
Premature ventricular contractions
8-year-old boy presents with increasing dyspnea. On examination, you find that he has digital clubbing with cyanosis. The patient is hypoxic. His medical records show that he was born with a ventricular septal defect, which was not corrected surgically until now. The reason for these symptoms is
Pulmonary hypertension
47-year-old male is receiving doxorubicin as part of treatment for his leukemia. Which noninvasive technique is best for monitoring myocardial toxicity from doxorubicin therapy?
Radio-nuclear ventriculography
42-year-old man has his blood pressure taken weekly at a local medical clinic. He notices that his systolic blood pressures are reading lower than usual for him when a new nurse starts taking them. What is a possible reason for this?
Repetitive inflations of the blood pressure cuff
45-year-old female has worsening congestive cardiac failure with symptoms of breathlessness and peripheral edema for several years. She also has increasing difficulty swallowing. She underwent open-heart surgery. The appearance of excised portion of the mitral valve that was replaced with a mechanical prosthesis shows thickened and fused chordae tendineae. She was suffering from which of the following underlying condition?
Rheumatic heart disease
The mother of a 1-week old infant arrives at a pediatric clinic with complaints that her infant is lethargic and has had feeding difficulty since birth. The infant also experiences excessive sweating during feeds. The interpretations of electrocardiograms (ECG) in neonates are different from those of adults. Which of the following is the normal ECG finding in a neonate?
Right axis deviation
29-year-old female reports to your office with complains of persistent palpitations. ECG shows bigeminy, BP is 130/85mmHg, HR 89bpm. Physical examination and review of systems is unremarkable. In patient's words, the palpitations do not change with exercise or rest. MRI study of cardiac anatomy and function is done. Refer to the image (left image - end diastole, right image - end systole). What structure does bigeminy originate from?
Right ventricle
A mother of a 2-month-old male infant presents because her son is consistently blue. She said that she noticed it when he was born and thought it would improve with time. The infant was born full term by non-complicated spontaneous vaginal delivery, and there were no other problems during or after birth. On examination, the patient is cyanosed; his conjunctiva and lips are blue. After listening to his heart, you note there is a murmur. A chest X-Ray is ordered; it shows a characteristic boot shape, and the patient is diagnosed with Fallot tetralogy. Which of the following is a component of the patient's syndrome?
Right ventricular outflow obstruction
68-year-old woman with long-standing hypertension has difficulty breathing. She needs to use three pillows to sleep at night. She has had several episodes where she awakens in the middle of the night and runs to open the window for air. Based on her medical history and physical examination, she is diagnosed with left-sided heart failure. What finding is most expected in this patient?
S3
60-year-old woman presents with a 4-day history of a cold and painful feet. Her blood pressure is 150/85 mm Hg and heart exam is notable for an S4. Her lung exam is normal, peripheral pulses are reduced, and lower extremities are cold but not edematous. Her ankle brachial index is 0.7. She has no blue discoloration or ulcers on her feet or toes. She has been taking simvastatin and hydrochlorathazide for 1 year, but takes them inconsistently. Lab tests are ordered. What laboratory results are consistent with the patient's symptoms and lower extremity exam?
Serum creatinine of 1.5 mg/dL
76-year-old man with a past medical history of hyperlipidemia and diabetes mellitus presents to the emergency room with a 2-hour history of acute, severe, "crushing" left precordial chest pain; it is associated with nausea, vomiting, diaphoresis, and altered mental status. His physical exam is notable for an ashen and cyanotic appearance, hypotension, rapid and weak peripheral pulsations, distant heart sounds, elevated jugular venous distension and pulmonary crackles. A stat bedside chest X-ray reveals the following image. What is correct regarding the diagnostic work-up of this patient?
Serum lactate levels are expected to be elevated
38-year-old man has suffered from redness and swelling of the first metatarsophalangeal joint 3 times over the past 2 years. In the past, the attacks subsided without treatment, but this time the pain is persistent. What investigation would be useful in the diagnosis of this patient?
Serum uric acid
64-year-old white female presents with left sided calf tenderness. You determine through ultrasound that she has a deep vein thrombosis (DVT) to the calf and thigh as well. She has no known risk factors. You will be ordering labs and studies for the work up for her DVT. You decide that you want to treat her DVT in an outpatient setting with enoxaparin. Which of the following would preclude this decision?
She shows signs of hemodynamic instability
22-year-old man presents with what he describes as a change in his heart rate. He indicates that his heart rate seems to speed up and then slow down for the past few hours. He adds no other symptoms. An EKG is ordered: irregular rhythm, a PR interval of 0.16 seconds, a P to QRS ratio of 1:1, heart rate of 75 bpm when exhaling and 86 bpm when inhaling, PP interval varies >0.12 seconds, and an RR interval that is noted to accelerate and decelerate during the respiratory cycle similar to the way the patient described. What is the most likely diagnosis?
Sinus arrhythmia
20-year-old female presents with complaints of palpitations and chest pain, for the past 2 days, without any risk factors for ischemic heart disease (IHD). She is noted to have an apical midsystolic click consistent with the diagnosis of mitral valve prolapse. Which of the following statements is true with regard to auscultatory findings in this condition?
Standing during auscultation might move the click closer to S1
76-year-old female reports to your office for her regular visits to follow-up treatment of her congestive heart failure. She states that she is more fatigued and is more short of breath than at the last visit. Today she is hypotensive (90/54mmHg) and her pulse is 89bpm. On auscultation, a pronounced S3 gallop is identified together with bilateral rales in lower lung fields. The patient is being treated with enalapril, isosorbide dinitrate, metoprolol -XL and aspirin. You decide to admit the patient to the hospital. The most appropriate plan is to
Stop metoprolol, administer dobutamine IV and furosemide
75-year-old African American man presents with a 5-month history of gradually progressive dyspnea that is especially pronounced when climbing stairs. He also has been noticing that his ankles and lower legs have "gotten larger" over roughly the same time period, which no longer allows him to fit into his sneakers. He denies fever, chills, chest pain, palpitations, cough, pleurisy, calf pain, abdominal complaints, sick contacts, or travel. His psychosocial history is noteworthy for chronic alcohol use. His physical exam reveals bibasilar rales, JVD of 5 cm, an S3 gallop, a holosystolic murmur at the apex that radiates to the left axilla, and 2+ pitting edema to the level of the mid-calves bilaterally. A bedside echocardiogram was remarkable for biventricular enlargement. What additional physical exam finding would be expected in this patient?
Tachycardia
60-year-old male develops an anterior tearing type of chest pain that radiates to the back. Within minutes the patient is unconscious. Patient has hypertension, which is uncontrolled. A recent treadmill test had revealed no cardiac disease. When the patient is brought to the emergency room, his blood pressure is falling. Which of the following would you suspect?
Tear in the aortic intima
60-year-old man reports to your office for a routine follow-up after a CABG procedure about one year ago. Following an episode of chest pain, he was catheterized and then a triple bypass grafting was performed for a 90% LAD and 75% LCX stenoses. The patient has mild hypertension and a normal lipid profile. Since then, the patient has been treated with isosorbide dinitrate, lisinopril, simvastatin, and aspirin. Today, he complains about an increased chest pain when walking. After CABG, his ejection fraction has been 64%. What is most appropriate test to perform in order to assess the patient's prognosis and a possible need for angiography?
Thallium SPECT with adenosine or dipyridamole
During a sports physical examination, a 17-year-old is noted to have a murmur. You perform maneuvers in an attempt to delineate which type of murmur you are auscultating. What findings would be associated with the highest risk of sudden death for this patient?
The intensity of the murmur increases during a Valsalva maneuver
A second year medical student taking her physical diagnosis course is told by her instructor to listen to the murmur in the tricuspid area of a patient, but she is not sure where that is. The tricuspid area, according to her classmate, is
The left fifth interspace just to the left of the sternum
29-year-old woman presents with a previous history of mitral valve prolapse with murmur of regurgitation confirmed on echocardiogram with prosthetic valve replacement 1 year ago. Based on the recommendations by the American Heart Association, what procedure is antibiotic prophylaxis recommended for in this patient?
Tooth extraction
50-year-old male staying in New York City has a long history of chronic alcoholism. He now presents with increasing leg edema as well as shortness of breath. He does not have chest pain. His vital signs include P: 84/min, RR: 24/min, BP: 124/74 mmHg and patient is afebrile. His neck veins are distended. The echocardiography shows dilation of all the four chambers of the heart. You diagnose this as dilated cardiomyopathy. The patient undergoes orthostatic heart transplantation. A year later, the patient presents with myocarditis. Which of the following would be the most probable cause for myocarditis in this patient?
Toxoplasma gondii
54-year-old man presents with progressive shortness of breath, lower extremity edema unresponsive to diuretic therapy, and fatigue upon exertion. His past medical history is significant for hypertension and he is a former smoker. On examination, his temperature is 37 degrees C; respiratory rate is 18 breaths per minute; and his BMI is 26 kg/m2. His lungs are clear. Heart auscultation reveals normal S1, physiologically split S2, accentuated P2, 3/6 holosystolic murmur on the left upper sternal border that increases with inspiration, and 2/6 diastolic murmur on pulmonic area. His liver is palpable by 2 fingers. There is pitting edema in his lower extremities. The rest of his physical examination is normal. What diagnostic test will be most useful in the evaluation of the etiology of this patient's chief complaints?
Transthoracic echocardiogram
38-year-old woman with a past medical history of rheumatic fever and endocarditis presents with progressive dyspnea on exertion associated with palpitations and intermittent episodes of left-sided chest pain. Both symptoms resolve at rest. Her physical exam reveals resting tachycardia and a widened pulse pressure. The cardiac exam is notable for a decrescendo diastolic high-pitched murmur, loudest at the left sternal border and accentuated with the patient leaning forward in full expiration. Abrupt distention and quick collapse are observed upon palpation of the peripheral arterial pulses. Booming systolic and diastolic sounds are auscultated over the femoral arteries. What is the diagnostic test of choice to confirm this patient's most likely diagnosis?
Transthoracic echocardiography
33-year-old male develops low-grade fever. A week later, he develops dyspnea and palpitations. He dies suddenly and unexpectedly. During the autopsy the medical examiner finds a diffusely enlarged flabby heart with no focal lesions. The coronary arteries show minimal atherosclerosis with no narrowing. The most likely etiology for these findings is
Viral myocarditis
74-year-old man presents with a 1-hour history of constant moderate to severe "squeezing, pressure, and tight" left-sided chest pain, accompanied by nausea. He has a past medical history of type 2 diabetes mellitus, hypothyroidism, and hyperlipidemia. He also has a 1-week history of similar recurrent chest pain about 10 minutes in duration; the pain occurs following exposure to cold weather and consumption of a meal. He denies fever, chills, abdominal pain, diarrhea, cough, pleurisy, and shortness of breath. What additional findings would be most consistent with his most likely diagnosis?
Vomiting, diaphoresis, and weakness
After successful cardioversion for atrial fibrillation (AF), a 65-year-old woman with rheumatic mitral valve disease patient feels better, with the exception of slight weakness in her left arm as a consequence of previous ischemic stroke. Her blood pressure is 120/80; her EKG is normal and shows sinus rhythm with rate 75. What chronic medical therapy is recommended?
Warfarin
47-year-old woman with essential hypertension visits her primary care physician to discuss non-pharmacological measures to reduce blood pressure. She is 5' 3" and 180 lbs, drinks two glasses of wine each day, smokes one pack per day of cigarettes, adds salt to everything she eats, and does no exercise. Which of the following measures is most likely to be associated with a significant reduction in blood pressure?
Weight reduction
Your patient is suffering from increased intracranial pressure from an increase in intracranial blood volume. The fastest maneuver to lower increased intracranial pressure (ICP) that is caused by increased intracranial blood volume is which of the following?
hyperventilation
Your patient, a 65-year-old African American female, has been admitted for cerebral angiography to assess the extent of atherosclerosis in the collateral circulation around the circle of Willis. This procedure involves injection of x-ray contrast dye via transfemoral catheterization. The advantages of selective cerebral angiography must be balanced in each patient against complications that occur in 0.5 to 3 percent. The major neurologic morbidity of cerebral angiography is
ischemic stroke
