Clinical Medicine II Exam 6 - Cardiology Part 2

A 51-year-old man with a history of Marfan syndrome presents to the emergency department with tearing chest pain that radiates to the back and neck. On examination, the patient is hypertensive; a high-pitched decrescendo diastolic murmur at the left sternal border and diminished peripheral pulses are noted. Based on the patient's most likely diagnosis, what is the immediate diagnostic imaging modality of choice?

CT scan of the chest and abdomen

A 39-year-old male patient presents with a 1-week history of severe chest pain. He states that the pain seems to worsen when he lies down. He describes the pain as radiating to the back and worsening when he takes a deep breath. Blood pressure 124/84 mm Hg, respirations 18/min, temperature 38.3°C (101°F), pulse 74/min. On auscultation of the chest, S1 or S2 cannot be distinguished, but a scratching or grating sound is heard. In addition to rest, what is the first step in the pharmacological treatment of this patient?

NSAIDs

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

amiodarone

A 42-year-old man presents with a 3-day history of intermittent sharp stabbing chest pain that has become progressively worse and more continuous over the past 24 hours. The pain is aggravated by deep breathing and lying flat; it is relieved by sitting and leaning forward. He has no previous cardiac history. Upon further questioning, he mentions that he recently "had the flu." Physical examination reveals an anxious patient in moderate distress. Vital signs are as follows: BP 138/90 mm Hg Left Arm, HR 104 bpm and regular, RR 18/min and shallow, T 99.8°F. Normal breath sounds and a pericardial friction rub are noted upon auscultation of the chest. A stat ECG reveals diffuse ST elevation. What therapy should be initiated for this patient?

anti-inflammatory medications (ASA or NSAIDs)

A 47-year-old man presents for his annual physical exam. His past medical history is not significant, and he is not currently on any medications. He consumes 2 beers weekly and does not smoke. His blood pressure is normal during this visit. His primary care physician orders a fasting lipid panel with the following results: ComponentValueTriglyceride135HDL36LDL220 In addition to diet and exercise, what medication should be started in this patient?

atorvastatin

A 60-year-old man presents for routine follow-up. He has no present concerns. He denies fevers/chills, changes in vision, headaches, chest pain, shortness of breath, PND, orthopnea, peripheral edema, dizziness, and syncope. Past medical history is significant for a coronary artery bypass grafting x 4 approximately 3 years ago, GERD, and obesity. He is currently on isosorbide mononitrate, metoprolol, and aspirin. Routine lipid panel: LipidResultTriglycerides145 mg/dLHDL34 mg/dLLDL135 mg/dL Given his lipid profile, how can this patient most appropriately be managed?

atorvastatin 80 mg daily

A 42-year-old woman with a history of dizziness and difficulty exercising presents seeking help. She reports fatigue, shortness of breath, and weakness for the past month. Upon physical exam, an EKG is conducted and an irregularly irregular heartbeat of 90 beats a minute. Laboratory findings showed no abnormal findings. Upon ECHO, there do not appear to be any abnormalities. What is the most likely explanation of the findings?

atrial fibrillation

A 67-year-old man is recovering following an uncomplicated total hip arthroplasty. His past medical history is significant for hypertension and mild asthma. On postoperative day 2, he begins to note stiffness in his right leg. On exam, his right calf is noted to be swollen and slightly warmer than the left leg. The remainder of the exam is unremarkable. He is afebrile, and his vital signs are stable. What diagnostic evaluation is most appropriate in this situation?

compression ultrasonography

A 58-year-old man presents with worsening shortness of breath (SOB); it has been especially problematic over the last 4 months. He states that the SOB has been noticeably severe with exertion, and this has drastically decreased his ability to do any physical activities. He is now experiencing SOB at rest. Physical examination reveals mild abdominal distension secondary to ascites and 4+ bilateral peripheral lower extremity edema. Past medical history includes that the patient underwent radiation and chemotherapy for lung cancer about 7 years ago. Given the most likely diagnosis, what is a primary goal when utilizing pharmacologic agents for this patient?

decrease pulmonary congestion

A 55-year-old woman presents with bumps around her eyes. She states they have been worsening over the past 3-4 months. They are not painful, but she is worried they may be something serious, especially since they seem to be increasing in size. The patient is currently taking a regular dose aspirin, which was suggested by her gynecologist, but she is not on any other daily medications. Family history is pertinent for her father dying at age 82 due to a heart attack and her mother still living at the age of 79 with a known medical history of hypertension and high cholesterol. On physical examination, slightly raised yellowish well-circumscribed plaques along the nasal portion of both eyelids are noted. What is the most likely diagnosis?

hypercholesterolemia

A 33-year-old man presents for an initial visit to a new primary care office. He has not seen a healthcare provider in the past 5 years. His past medical history reveals a coarctation of the aorta repair at age 13, after which he saw a cardiologist yearly until age 18. Since then, he has not had insurance and has only sought care for urgent problems in acute care clinics. What is a common complication of coarctation that primary care should regularly monitor this patient?

hypertension

A 40-year-old obese Caucasian man says that his father recently passed away after having a heart attack. He is worried and wants to know whether he is at risk for cardiovascular disease. He is hypertensive; however, he does not take any medications. His BP in the office today is 140/96 mm Hg, and his BMI is 31. You explain to him that the risk factors for cardiovascular disease may be non-modifiable or modifiable. What is the modifiable risk factor for CAD in this man?

hypertension

A 30-year-old woman presents for routine analysis of cholesterol levels. The results show plasma cholesterol levels of 300 mg/100 mL. You prescribe the drug simvastatin (Zocor). She is reluctant to take drugs to treat her hypercholesterolemia. After further discussion, she agrees to take a vitamin to treat the elevated cholesterol. She also has questions concerning familial hypercholesterolemia. What vitamin is effective in reducing circulating cholesterol levels when given in pharmacological doses?

nicotinic acid

A 62-year-old woman presents with extreme fatigue and shortness of breath. The symptoms began about 24 hours ago and have progressively worsened within the last 4 hours. Vital signs on arrival are as follows: HR 90 beats per minute; BP 165/72 mm Hg; RR 16/min; SpO2 98% on 4 L/min supplemental oxygen by nasal cannula. 12-lead ECG demonstrates ST-segment elevation of 2 mm in leads V4-V6. In addition to an aspirin tablet, what medication would be most appropriate in the emergency management of this patient?

nitroglycerin

A 65-year-old African American man with a past medical history of hypertension, hyperlipidemia, and diabetes experiences substernal chest pain while shoveling snow. The patient says the pain started after 10 minutes of shoveling wet snow and eventually resolved after he sat down and rested. The patient described the pain as a "heaviness" that did not radiate to any other part of his body and as a 4 or 5/10 on a subjective pain scale, and he experienced this discomfort for approximately 1-2 minutes total. The patient's current vital signs are blood pressure 168/98 mm Hg, pulse 92, and respirations 16. What drug would be the best choice to rapidly reduce the patient's chest pain in a future similar situation?

nitroglycerin 0.4 mg SL

A 2-month-old female infant presents for a well-child visit. Her mother states that she is concerned about the patient's lack of interest in feeding and her rapid breathing spells. You acknowledge these concerns, and during the physical examination, you note severe tachypnea, bounding peripheral pulses, and a rough machinery murmur that is auscultated best near the second left intercostal space. What is the most likely diagnosis?

patent ductus arteriosus

A 2-week-old female neonate presents for her scheduled newborn visit. The mother notes that the newborn has been feeding poorly and seems to have difficulty catching her breath when crying. On examination, a continuous machine-like murmur is heard at the left first intercostal space. What is the most likely diagnosis?

patent ductus arteriosus

A newborn child is routinely evaluated in the pediatrician's office 1 month after delivery. The mother reports that the patient is behaving normally and is feeding well. The physical exam is remarkable for a murmur, which is located at the second left intercostal space. The murmur is continuous throughout cardiac systole and diastole, non-radiating, and of a "machinery" quality. There is additionally a widened pulse pressure. The skin and mucosa are without cyanosis, and there is no evidence of fluid retention. What is the most likely diagnosis?

patent ductus arteriosus

A preterm female infant born to a 32-year-old woman with no known past medical illnesses presents for the infant's 1-week follow-up. The mother reports that the patient is behaving normally and is feeding well. The physical exam is remarkable for a murmur, which is located at the second left intercostal space. The murmur is continuous throughout cardiac systole; it is diastolic, non-radiating, and of a "machinery" quality. There is also a widened pulse pressure. The skin and mucosa are without cyanosis, and there is no evidence of fluid retention. Based on the physical exam finding, what is the most likely diagnosis?

patent ductus arteriosus

A 44-year-old man with a history of coronary heart disease presents to the emergency department with crushing chest pain and heart palpitations. He smokes 3 packs of unfiltered cigarettes daily. He has periods of wide-complex rapid regular tachyarrhythmia at 160 beats per minute that last for 20-30 seconds. When you reach his examination room, you note his monitor also reveals evidence of a QRS width of 0.16 seconds. What is this patient's most likely rhythm?

ventricular tachycardia

A 40-year-old man presents with irregular heartbeats over several days. His past medical history is significant for the presence of mitral valve stenosis and atrial fibrillation (AF). He takes beta blockers regularly. His ECG shows atrial fibrillation with an irregular heart rhythm around 80 bpm. What medication would you prescribe in addition to electrical cardioversion to prevent complications?

warfarin

A 21-year-old man with a history of cocaine and methamphetamine abuse is brought to the emergency department after being found unconscious. He is placed on a non-rebreather mask and admitted to the ICU with findings of acute heart failure. Echo shows enlarged left ventricle, decreased cardiac contractility, and systolic dysfunction. He vastly improves over 24 hours. He is currently awake and alert. No history of cardiac disease. BP 132/88 mm Hg, HR 86 and regular, RR 20, Temp 98.2°F, and O2 sat of 100% on 3L via nasal cannula. Physical exam reveals no murmur, clear lung sounds, and no peripheral edema. What is the most appropriate therapy?

wean oxygen

A 62-year-old man with a 15-year history of hypertension presents with severe tearing chest pain radiating through to the back. Blood pressure is 180/110 mm Hg, heart rate is 120 bpm, and respiratory rate is 34/min. Physical examination findings include neck negative for bruits/JVD, lungs clear to auscultation, regular heart rhythm, normal S1/S2 with an S4 present, and a grade III/IV diastolic rumbling murmur noted with the patient leaning forward. Radial pulses are 1+ on right and 3+ on left. EKG reveals a sinus tachycardia and evidence of left ventricular hypertrophy. A STAT chest X-ray is obtained. What finding is most consistent with the presumptive diagnosis?

widening of the superior mediastinum

A 55-year-old man with no significant past medical history presents for a routine evaluation and fasting bloodwork. He does not note any symptoms at this time. His physical examination reveals an obese body mass index with a waist circumference of 120 cm and a blood pressure of 140/90 mm Hg. Physical exam is otherwise unremarkable. His fasting bloodwork is drawn. What laboratory finding would qualify a diagnosis of metabolic syndrome in this patient?

HDL value of 35 mg/dL

A 39-year-old previously well Caucasian man presents to the emergency department with a 10-day history of fever >101°F and acute dyspnea with pleuritic chest pain. His past medical history is notable only for childhood asthma (no recurrences since age 12) and appendectomy. He has no known drug allergies. He denies taking prescribed medications on a regular basis. Vital signs show: Temperature 100.8°F, pulse 108, respirations 24, and blood pressure 98/60. O2 saturation is 90% on room air. Physical examination reveals mild crackles of the mid-lung fields bilaterally and a grade II/VI soft systolic murmur, loudest at the left lower sternal border. Oral exam shows overall poor dentition. Skin exam shows non healed puncture wound in left antecubital region surrounded by old granulomas and scarring. A spiral CT reveals evidence of multiple pulmonary emboli. He is admitted to the general medical floor of an acute care hospital. Additional diagnostic tests are ordered; preliminary results of blood cultures showed 4+ growth of gram-positive cocci. Infectious Diseases is consulted and he is started on an IV antibiotic regimen. What is the most likely causative risk factor for this patient's underlying diagnosis?

IV drug abuse

A 65-year-old man presents to the office due to 6 months of bilateral buttock and thigh cramping pain. It occurs after walking 20 feet and is completely and quickly relieved with resting. His past medical history includes hypertension treated with atenolol, and he had a stroke 3 years ago. He also reports impotence for approximately the same duration of time. What is the patient's physical exam likely to include?

absent femoral, popliteal, and pedal pulses

A 54-year-old man presents with chest pain. He has a past medical history of hypertension and diabetes mellitus. The pain is located in the middle of his chest and radiates to his jaw. The pain began about 20 minutes ago, and he rates the pain as a 10 on a 0-10 point scale, with 10 being the worst pain he has ever felt. He has had 3 similar episodes, but they have always resolved after 5 minutes or so of rest. He has smoked 1 pack of cigarettes a day for the past 36 years. He drinks 2 or 3 beers on Friday nights. Review of systems (ROS) is positive for diaphoresis, acute dyspnea, and sense of impending doom. ROS is negative for fever, chills, and malaise. Physical exam shows an obese, middle-aged man in moderate distress. BP is 148/80, pulse is 100, and respirations are 26. Except for tachycardia and tachypnea, heart and lung exams are normal. He has no pedal edema. Electrocardiogram (ECG) shows ST elevation in leads II, III, and AVF; this is a new finding when compared to an ECG from 3 months ago. What is the most likely diagnosis?

acute myocardial infarction

A 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

A 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

A 66-year-old man with a past medical history of myocardial infarction 2 years ago, aortic regurgitation, congestive heart failure, atrial fibrillation, and chronic obstructive pulmonary disease is presently being monitored in the hospital. Myocardial infarction has been ruled out. An EKG performed upon admission revealed significant Q waves in the anterior leads but no evidence of an acute myocardial infarction. A diagnostic echocardiogram confirms moderate aortic and mitral valve regurgitation and a left-ventricular ejection fraction of 30%. He denies any complaints upon bedside evaluation. His physical exam reveals a blood pressure of 95/55 mm Hg and tachycardia. Continuous bedside ECG monitoring notes wide monomorphic QRS complexes with a heart rate of 160 beats per minute that spontaneously resolve within 20 seconds, reverting to the pattern identified upon admission. What antiarrhythmic agent would be the pharmacologic treatment of choice in the management of this patient?

amiodarone

A 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

A 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. 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

A 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

A 62-year-old man with a 15-year history of hypertension presents with severe tearing chest pain radiating through to the back. Blood pressure is 180/110 mm Hg, heart rate 120 bpm, and respiratory rate 34/min. Physical examination findings include lungs clear to auscultation, heart regular rhythm, normal S1/S2 with an S4 present, and grade III/IV diastolic rumbling murmur noted with the patient leaning forward. Radial pulses are 1+ on right and 3+ on left. Neck is negative for JVD and no carotid bruits present. EKG reveals a sinus tachycardia and evidence of left ventricular hypertrophy. A STAT chest X-ray shows a widening of the mediastinum. What medication class delivered intravenously is now needed to stabilize the patient?

beta blocker

A 55-year-old man presents with a 2-day history of confusion, increased respiratory rate, rapid pulse, notable malaise, thirst, and less-than-normal urination. In the morning, his wife gave him a multivitamin pill hoping that it would help; she tells you that he has long-standing hypertension and he injured his neck in a car accident 1 week ago. On examination, you find BP 92/41 mm Hg, HR 150, RR 35, rapid and weak pulse, cutis marmorata, cold edematous extremities, and bluish discoloration of the tongue and nails. What kind of shock does this patient probably have?

cardiogenic

A 77-year-old man presents to the emergency department with chest pain and difficulty breathing. His heart rate is 120 beats/minute and blood pressure is 70/45 mm Hg. Physical examination is remarkable for cool extremities, and urinary output is minimal. Despite aggressive fluid resuscitation, the patient's symptoms appear to be worsening. Bedside ECG indicates ST elevation in leads II and III and aVF. Hemodynamic monitoring indicates large V waves on PCWP tracing. How would this patient's shock be categorized?

cardiogenic shock

A 70-year-old male patient with a past medical history of hyperlipidemia presents with recurrent chest pain that has been occurring over the past month. This pain is provoked with activity, especially of his upper torso and left arm. The pain is described as sharp and generally located in the left pectoral area. He denies any weight changes, fever, or chills. He also denies cough, wheezing, pleurisy, calf pain, wheezing, vomiting, diarrhea, changes in bowel habits, cigarette, drug or alcohol use, sick contacts, and travel. Physical exam reveals an older man in no acute distress. Vital signs, skin, cardiopulmonary, abdominal, and peripheral vascular exams are found to be within reference range. What additional historical or physical exam finding would suggest a non-ischemic etiology of this patient's chest pain?

chest pain that is reproduced with palpation

A 1-month-old full-term male infant has been diagnosed with tetralogy of Fallot. His disease is being classified as moderate, and he has been admitted to the neonatal intensive care unit for monitoring. He is now stable and is doing well. During a consultation between the infant's parents and the pediatric cardiologist, treatment options are being discussed. What is the pediatric cardiologist likely to recommend as definitive treatment?

closure of ventricular septal defect and pulmonary valvulotomy

A 6-week-old boy presents at your pediatric practice office, brought by his mother. She reports that for the past week he has not been feeding well and he breaks out into a cold sweat on his forehead while feeding. Upon further questioning, she reports that he becomes extremely breathless, irritable, and extremely pale after extended periods of crying. The mother reports a normal vaginal delivery and denies any problems with her son at the time of discharge from the hospital following his birth. She reports a family history of congestive heart failure. Vitals are as follows: pulse 130-regular, respiration 34-regular, blood pressure R arm 96/62 L arm 92/54 and R leg 70/42 L leg 74/40. Cardiac exam reveals 4+ carotid pulses bilaterally, 2+ brachial pulses bilaterally and absent femoral pulses bilaterally. A loud harsh systolic ejection murmur is noted at the base of the heart. The EKG reveals normal sinus rhythm with left ventricular hypertrophy. What is the most likely diagnosis?

coarctation of the aorta

While rounding on a 2-hour-old male neonate at the hospital, his mother remarks that although her pregnancy and delivery were unremarkable and the baby was term, she has attempted to initiate breastfeeding even though the neonate "doesn't seem interested." On heart auscultation of the neonate, a late systolic murmur that radiates to the back is appreciated. Vital signs while the baby is awake are BP 90/50 mm Hg in the right arm and 58/42 mm Hg in the right lower extremity, HR 140, RR 40, axillary temp 37.0° C, and O2 sat 90% on room air. What is the most likely diagnosis?

coarctation of the aorta

A 54-year-old man presents with chest pain. He has a past medical history of hypertension and diabetes mellitus. The pain is located in the middle of his chest and radiates to his jaw. The pain began about 20 minutes ago, and he rates the pain as a 10 on a 0-10 point scale, with 10 being the worst pain he has ever felt. He has had 3 similar episodes, but they have always resolved after 5 minutes or so of rest. He has smoked 1 pack of cigarettes a day for the past 36 years. He drinks 2 or 3 beers on Friday nights. Review of systems (ROS) is positive for diaphoresis, acute dyspnea, and impending doom. ROS negative for fever, chills, and malaise. Physical exam shows an obese, middle-aged man in moderate distress. BP is 126/80 mm Hg, pulse is 100, and respirations are 26. Heart and lung exams are normal, except for tachycardia and tachypnea. He has no pedal edema. What aspect of the patient's history is the most influential risk factor for an acute myocardial infarction?

diabetes mellitus

A 50-year-old man presents with the acute onset of chest pain. He describes the pain as sharp, worse with deep breaths, and improved with leaning forward. Physical exam is remarkable for a pericardial friction rub on cardiac auscultation. What EKG finding is expected with this patient's condition?

diffuse ST elevation

A 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

A 52-year-old Caucasian man who frequently visits the emergency department presents due to "being short of breath." He is currently homeless, in and out of shelters. Past presenting problems that have brought him to the emergency department indicate that he has a chronic issue with alcohol overuse. Today, the patient is experiencing severe shortness of breath at rest. Physical examination findings reveal rales auscultated in bilateral lung fields, an S3 gallop, and elevated JVP. What is the most likely diagnosis?

dilated cardiomyopathy

A 43-year-old patient presents with a 3-hour history of acute onset of palpitations and dyspnea. There is no other significant medical history. Chest X-ray and echocardiography are normal. EKG reveals absence of P wave, with variable R-R interval with atrial rate of 300/min and ventricular rate of 120/min. Patient is afebrile, radial pulse is 90/min, BP is 110/70 mm Hg, and RR is 18/min. A diagnosis of newly detected atrial fibrillation is made. What is the next course of action?

diltiazem

A 45-year-old female patient presents with chest pain. The precordial pain developed about 1 hour before arriving in the emergency department. No positional or pleuritic component is present. Nitroglycerin relieved the pain. EKG reveals ST elevations. She undergoes cardiac catheterization; all of the vessels are clean, and no revascularization is performed. Given the most likely diagnosis, what is the most appropriate pharmaceutical option for the long-term management of this patient?

diltiazem

A 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

A 5-day-old female newborn was born 5 weeks prematurely and presents to her first pediatrician's appointment. She did not have any feeding or breathing issues, so mother and child had only a 2-day stay at the hospital. During the cardiovascular examination, the pediatrician notes that the newborn has a distinct murmur with a rough machine-like quality that is maximal at the second intercostal space at the left sternal border. The murmur starts after S1 and passes through S2 into diastole. What study is the first choice to confirm it the most likely diagnosis?

echocardiography

A 14-year-old boy is seen for a sports physical for the freshman basketball team. Past history is significant for a high degree of myopia bilaterally (first diagnosed at age 4) and a dislocated shoulder at age 10 that was easily reduced. Family history is significant for several unidentified ancestors having died in their 40s of an unidentified cardiovascular disorder. Physical examination revealed normal vital signs. Height is 6'1" and weight 145 lb. The upper to lower segment ratio is 0.65 (decreased). Arm span was 76". The palate is highly arched and mild pectus excavatum is present. A 2/6 early diastolic murmur is present and best heard at the second intercostal space at the right sternal border. Arachnodactyly of the fingers and toes and generalized loose jointedness and pes planus are also present. What should be advised?

echocardiography needs to be performed with follow-up

A 79-year-old man with a past medical history of coronary artery disease, diabetes mellitus, hypertension, smoking, alcohol use, and hyperlipidemia presents with severe chest pain and dyspnea. He appears pale, apprehensive, and diaphoretic. He is in a confused state and agitated. His pulse is weak and tachycardic, with a systolic blood pressure of 60 mm Hg. He has a narrow pulse pressure, tachypnea, a weak apical impulse, and significant jugular venous distention. His lungs are free of crackles. Bedside electrocardiogram revealed anterolateral ST segment elevations and "tombstones" across the precordial leads. Following stabilization, what health maintenance advice should be provided to this patient?

eliminate smoking and alcohol

A 74-year-old man with a history of diabetes mellitus, hypertension, and hyperlipidemia presents with severe chest pain and dyspnea. On exam, he is confused, agitated, pale, apprehensive, and diaphoretic. His pulse is weak and tachycardic; systolic blood pressure is 80 mm Hg. He has a narrow pulse pressure, tachypnea, a weak apical impulse, significant jugular venous distention, and pulmonary crackles. Bedside electrocardiogram reveals ST-segment elevations in the anterior and septal leads, while a portable chest X-ray notes diffuse pulmonary congestion. What is the most appropriate step in the management of this patient?

emergent percutaneous coronary intervention

A 78-year-old woman is an inpatient status post-colectomy for colon cancer. On postoperative day 3, her oral temperature is noted to be elevated to 100.6°F. Chest X-ray and urinalysis are both negative for signs of infection. An infectious disease consult is placed in order to better define the patient's new fever. You suspect superficial thrombophlebitis. What physical examination findings would support your suspicion?

erythema and tenderness along the vein with IV insertion

A 1-month-old infant is evaluated for rapid breathing, feeding difficulty, lethargy, and poor weight gain. Physical exam is notable for tachypnea, tachycardia, a cardiac gallop, and a medium-pitched systolic murmur best heard posteriorly in the interscapular area with radiation to the left axilla, apex, and anterior precordium. A prominent anterior chest heave is also observed. The lower extremities demonstrate a 12 mm Hg pressure difference compared to the upper extremities. There are delayed femoral pulsations; upper extremity pulsations are normal. What is the best next step in management?

evaluation by a cardiovascular surgeon

A 37-year-old overweight woman presents for a follow-up after an ER visit 4 days ago; her ER visit was the result of a fainting episode. Except for a blood pressure of 140/100, vital signs are all within normal limits. The patient denies a prior history of hypertension. Although the patient had an elevated BP, the ER physician felt that her fainting episode was more likely due to stress and poor eating habits; she had been attempting to lose weight before her wedding, which is occurring in a month. She was released from the ER with instructions to follow up with her PCP for evaluation and treatment of high blood pressure. Since this is her first visit to your clinic, a complete blood workup is done. TestResultNormal RangeWBC4.0 x 103/mcL4.8-10.8 x 103/mcLRBC5.3 x 103/mcL4.7-6.1 x 103/mcLHgb13.5 g/dL12.0-15.5g/dLHct40%35-45%ALT12 units/L7-56 units/LAST14 units/L0-35 units/LAlkaline phosphatase86 units/L41-133 units/LBUN10 mg/dL8-20 mg/dLCreatinine1.0 mg/dL0.6-1.2 mg/dLTriglycerides250 mg/dL<150 mg/dLCholesterol189 mg/dL<200 mg/dLTSH2 mcU/mL0.4-6 mcU/mL What medical condition does this patient have in addition to hypertension?

hypertriglyceridemia

A 26-year-old female patient presents after a syncopal episode. She has lost consciousness 3 times over the past 12 months. Each event occurred during or shortly after physical exercise. BP 110/70 mm Hg, HR 75/min, unremarkable S1/S2, III/VI systolic ejection murmur is heard best at the left sternal border that decreases with squatting. EKG shows a normal sinus rhythm with diffuse increased QRS voltage. What is the most likely diagnosis?

hypertrophic cardiomyopathy

A 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

A preterm newborn is routinely evaluated 1 month after delivery. The mother reports that the newborn (now infant) has been breathing quickly, has had difficulty feeding, and is not gaining weight. The physical exam is remarkable for tachypnea, diaphoresis, and low weight. There is a murmur located at the second left intercostal space. The murmur is continuous throughout cardiac systole and diastole, non-radiating, and of a "machinery" quality. There is a widened pulse pressure. The skin and mucosa are without cyanosis, and there is no evidence of fluid retention. A doppler-enhanced echocardiogram shows retrograde turbulent color flow in the pulmonary artery. What pharmacologic agent is the most preferred for this patient at this time?

indomethacin

You are currently on an inpatient pediatric hospitalist team; you see a preterm infant who has signs of failure to thrive. Other signs and symptoms found during the history and physical examination include tachypnea, bounding peripheral pulses, and a rough machine-like murmur. Considering the most likely diagnosis at this time, what clinical intervention should be initiated?

indomethacin

A 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

A 55-year-old man became intoxicated at a bar after a serious argument with his wife about his diet and habits (he is overweight and a heavy smoker). On the way back home, he developed chest pain radiating to the left shoulder, shortness of breath, sweating, and anxiety. ECG shows pathological Q wave and ST elevation. Laboratory results are remarkable for an elevated troponin. What caused the rise in troponin levels in this patient?

injury to myocardial cell membrane

A 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

A 55-year-old man presents with severe central chest pain that started suddenly and radiates to the back and neck. He feels sick but has not vomited. He has no major illnesses and knows of none that run in his family. He does not use alcohol, tobacco, or recreational drugs. He is allergic to sulfa drugs. On exam, he appears in extreme pain and lying on his side. Temperature is 98.6°F, heart rate is 110 bpm, blood pressure of 180/105 mm Hg in left upper arm and 156/86 mm Hg in right upper arm, and respiratory rate is 20. Cardiac exam reveals normal S1 and S2 without rubs or gallop. The top of his internal jugular venous column is present at 2-3 cm above the sternal notch. Chest auscultation shows normal vesicular breathing. He has normal active bowel sounds tympanic to percussion. ECG shows left ventricular hypertrophy. Chest x-ray shows widened mediastinum. What treatment should be given immediately to this patient?

intravenous labetalol

A 37-year-old Caucasian man presents with shortness of breath. History reveals that the patient has been extremely fatigued the last few weeks, experiencing excessive night sweats with a worsening cough, chest pain, and general aches and pains. He is not taking any medications and is allergic only to penicillin. He has a history of on-and-off intravenous drug use and admits to last using around 1 month ago. Along with an urgent inpatient admission, you plan to initiate orders to have the patient undergo an echocardiogram and obtain blood cultures, among other actions. Based on the most likely diagnosis, what pharmaceutical intervention is most appropriate?

intravenous vancomycin

A 26-year-old African American man with no significant past medical history presents with a history of dyspnea on exertion that occurs after running. The dyspnea is associated with mild substernal chest pain. All symptoms are relieved with rest. He denies fever, chills, cough, wheezing, pleurisy, calf pain, abdominal problems, peripheral edema, cigarette, drug, or alcohol use, sick contacts, or travel. His physical exam reveals a harsh murmur best heard at the left lower sternal border and an S4 gallop. A bedside electrocardiogram was remarkable for left ventricular hypertrophy and septal Q waves in the inferolateral leads. An echocardiogram noted asymmetric LVH, anterior motion of the mitral valve during systole, a small and hypercontractile LV, and delayed relaxation and filling of the LV during diastole. The septum was twice the thickness of the posterior wall. What is expected to be true regarding the murmur in this patient?

it decreases with squatting

A 76-year-old man presents with acute myocardial infarction. He quickly develops hypotension, altered mental status, cold clammy skin, and metabolic acidosis evident on laboratory tests. Based on the most likely diagnosis, what diagnostic study will be most helpful in demonstrating the severity of this patient's condition?

lactate levels

A 4-year-old boy presents with poor weight gain, small size for his age, and dyspnea upon feeding. His mother notes that the child suffers from frequent upper respiratory tract infections. On physical exam, the child is underweight for his age. You note a precordial bulge, a prominent right ventricular cardiac impulse, and palpable pulmonary artery pulsations. You also find a widely split and fixed second heart sound as well as a mid-diastolic rumble at the left sternal border. What pharmacologic agent would be most appropriate in the medical management of this patient at this time?

lasix (furosemide)

A 79-year-old man presents with severe chest pain and dyspnea. He has a past medical history of diabetes mellitus, hypertension, and hyperlipidemia. He appears pale, apprehensive, and diaphoretic. He is in a confused state and agitated. His pulse is weak and tachycardic, with a systolic blood pressure of 60 mm Hg. He has a narrow pulse pressure, tachypnea, a weak apical impulse, and significant jugular venous distention. His lungs are free of crackles. Bedside electrocardiogram reveals ST-segment elevations in the anterior and septal leads. What concerning this patient's diagnosis is true?

leading contributory cause is myocardial ischemia

A 78-year-old man has a past medical history of HIV, hepatic cirrhosis secondary to chronic alcohol use and hemochromatosis, obesity, and thiamine deficiency; he presents with a 7-month history of progressive exertional shortness of breath, lower extremity edema, and lightheadedness. Symptoms are improved with rest. Physical examination reveals rales, elevated JVP, cardiomegaly, S3 gallop rhythm, high-pitched blowing holosystolic murmur at the apex, peripheral edema, and abdominal distension that suggests ascites. Bedside EKG notes sinus tachycardia, with non-specific ST-T wave changes and Q waves. An echocardiogram shows dilated ventricular chambers and systolic dysfunction. What health maintenance recommendation can be made for this patient?

limited water consumption as disease progresses

A 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

A 57-year-old woman presents with pain and swelling in her left leg. Her chart shows a history of osteoarthritis of the knees, mild hypertension, and type 2 diabetes mellitus that is controlled on medication. She was well until 1 week ago when she noted a bulge behind her left knee. Yesterday, she woke up with pain, redness, and swelling in her calf and stayed in bed most of the day with her leg propped up on a pillow. She has had no fever or chills, no new pain or swelling in her right leg, no shortness of breath, and does not otherwise feel ill. She denies recent travel or immobility. Vital signs are within normal limits. Significant on her physical exam is a red warm swollen left calf with trace pitting. There is no swelling in the thigh or toes, feet are warm and pedal pulses are intact. The left calf is tender to palpation posteriorly and is 1 cm larger than the right calf on measurement. The rest of her exam is unremarkable. A sensitive assay D-dimer blood test is negative. Based on this information, what is the likelihood of deep vein thrombosis and the next step in the care plan?

low d/t negative sensitive D-dimer test. consider ultrasound to further evaluate knee

temporal arteritis affects what size vessels?

medium-large sized

A 12-year-old female patient presents with hypertension. There is a cardiac gallop and a medium-pitched systolic murmur best heard posteriorly in the interscapular area, with radiation to the left axilla, apex, and anterior precordium. A prominent anterior chest heave is observed. The lower extremities demonstrate a 16 mm Hg pressure difference compared to the upper extremities. There are delayed femoral pulsations; upper extremity pulsations and the remainder of the physical exam are unremarkable. A recent chest x-ray shows cardiomegaly and rib notching. What pharmacotherapeutic agent will be most beneficial to this patient?

metoprolol

A 74-year-old man presents with progressive exertional shortness of breath, lower extremity edema, and lightheadedness for 7 months. He has a past medical history of HIV, hepatic cirrhosis secondary to chronic alcohol abuse and hemochromatosis, obesity, and thiamine deficiency. Symptoms improve with rest. Blood pressure 108/68 mm Hg, heart rate 90 bpm regular, oxygen saturation 92% on room air, and respirations 18/minute. The physical examination reveals rales, elevated JVP, cardiomegaly, S3 gallop rhythm, high-pitched, blowing holosystolic murmur at the apex, peripheral edema, and abdominal distension suggestive of ascites. Bedside EKG notes sinus tachycardia with non-specific ST-T wave changes and Q waves. An echocardiogram shows a dilated left ventricle, thinning of ventricular walls, and decreased systolic function. The patient is admitted to the hospital for appropriate therapy. What medication will reduce mortality in this patient?

metoprolol

A 48-year-old man with hypertension and coronary artery disease presents with protracted fever, fatigue, anorexia, weight loss, night sweats, and non-specific non-radiating joint pains. Symptoms began insidiously following routine dental cleaning and progressed over 4 weeks. He denies chills, myalgias, sore throat, palpitations, shortness of breath, cough, abdominal pain, nausea, vomiting, diarrhea, peripheral edema, trauma, travel, insect bites, or sexual contact within the past year. Physical exam is remarkable for fever of 101.3°F. Petechiae of the soft palate and palpebral conjunctiva noted. Fundoscopic examination is notable for cytoid bodies and hemorrhages. Oral mucosa shows conjunctival petechiae. There is a palpable purpuric skin rash of the lower extremities, reduced bilateral radial and ulnar pulsations, linear hemorrhages under the nails not reaching the nail margin, and erythematous nodules occurring in the pulp of the fingers. Cardiac exam demonstrates a soft medium-pitched holosystolic murmur located at the apex with radiation to the axilla. What pharmacotherapeutic agent is most appropriate for this patient?

penicillin G

A 56-year-old man is hospitalized with sudden onset of symptoms of chest pain, sweating, palpitation and shortness of breath. ECG showed ST elevation of 3 mm above isoelectric ECG line, and troponin I of 6 ng/mL. His BP is 130/75 mm Hg, and HR is 65 bpm. The next morning, Doppler and transesophageal echocardiography were performed following new onset of chest pain, shortness of breath and systemic hypotension, which established mitral regurgitation with papillary muscle rupture. What would be the most appropriate therapeutic intervention at this point?

perform mitral valvuloplasty

A 19-year-old man is brought into the ED following a motor vehicle crash in which he, the driver, sustained blunt trauma to the anterior trunk from striking the steering wheel and dashboard. The patient is alert, short of breath, hypotensive, and complains of acute chest pain. On auscultation, muffled heart sounds are heard. What is your initial diagnosis?

pericardial tamponade

A 45-year-old man with no significant medical history presents with what he refers to as "anxiety attacks." He describes them as recurring bouts of palpitations, headaches, anxiety, and sweating that he has experienced for a few weeks. Last night, his wife witnessed him having an episode during dinner. She was concerned and immediately took his blood pressure: 195/105 mm Hg, so she brought him in today. On further questioning, he comments that he sometimes gets lightheaded when he stands up too rapidly; his mother had similar problems. On physical examination, his blood pressure is 165/90 mm Hg and his heart rate is 80 beats/min. A 24-hour collection of his urine test is positive for vanillylmandelic acid. What is the most likely diagnosis?

pheochromocytoma

A 45-year-old man is admitted to the hospital with fever, weakness, weight loss, extremity pain, and a rash on his legs. He states that his symptoms began about 1 week ago. He denies recent illness or injury and states that he has been in good health for as long as he can remember. On physical exam, the patient was well-developed, well-nourished, and in mild physical distress. His lower extremities have ulceration near his medial malleoli and a diffuse lace-like purplish discoloration on his bilateral lower extremities. His blood pressure was elevated at 152/94 mm Hg, and a chest radiograph was negative. Laboratory analysis revealed an elevated sedimentation rate and C-reactive protein, elevated BUN, and creatinine. His red blood cell count was decreased, and his ANCA was negative. Hepatitis B tests were also negative. Biopsy of the leg ulceration reveals a fibrinoid necrosis of an arterial wall with a leukocytic infiltrate. What is the most likely cause of this patient's symptoms?

polyarteritis nodosa

A routine EKG 5 weeks ago determined that a 59-year-old Caucasian man had developed new-onset atrial fibrillation. The atrial fibrillation was asymptomatic and was not associated with dizziness, palpitations, chest pain, or shortness of breath. He was started on warfarin 5 mg daily for anticoagulation and his Toprol dose was adjusted. Cardioversion was scheduled as a subsequent elective outpatient procedure. The patient's past medical history is notable for hypertension and coronary artery disease with prior RCA stent. He has no history of stroke or TIA. Allergies: bee stings. Usual home medications: aspirin 81 mg daily, hydrochlorothiazide 25 mg daily, metoprolol tartrate 50 mg b.i.d., warfarin 5 mg daily. He quit smoking 20 years ago. He now presents to the outpatient cath lab for a planned elective cardioversion procedure. Patient reports no new medical problems or symptoms since his diagnosis of new-onset atrial fibrillation. He claims compliance to his medical regimen. He denies chest pain or shortness of breath. His vital signs are stable. Physical exam reveals clear lung fields and an irregular cardiac rhythm. EKG shows atrial fibrillation with a ventricular rate of 87 beats per minute. Review of his lab work from 3 days prior shows the following: WBC6.2 K/mcLSodium140 mEq/LHgb11.2 g/dLPotassium4.8 mEq/LHct42%Chloride102 mEq/LPlatelets342 K/mcLCO224 mEq/LProtime16.2 secondsBUN19 mmol/LINR1.7Creatinine1.1 mg/dL Today's lab work shows protime 19.2 seconds and INR 2.1. What is the most appropriate course of action?

postpone cardioversion procedure

A 16-year-old boy with no significant past medical history presents to learn the results of a lipid panel that was performed. The lipid panel was ordered due to periorbital and extensor tendon xanthomas on the patient's body. The patient consumes a low-fat and low-calorie diet, and he exercises daily. He denies any bothersome symptoms, and his physical exam is otherwise unremarkable. What is the most likely mechanism for this patient's metabolic disorder?

reduction in the amount of LDL receptors on hepatocytes

A 72-year-old man presents with "being short of breath"; he feels as though his belly is bloated and his legs are swollen. Past medical history includes high blood pressure (for which he is currently taking lisinopril) and high cholesterol controlled with diet modifications. The patient also has a past diagnosis of mediastinal lung cancer around 5 years ago for which he received radiation treatment as part of his prescribed therapeutic regimen. Physical examination reveals an elevated jugular venous pressure and Kussmaul sign. Moderate pitting edema and ascites are also observed. Chest radiograph reveals only mild cardiomegaly. Echocardiogram reveals a normal left ventricle chamber size, normal LVEF, and a thickened atrial septa. What is the most likely diagnosis?

restricted cardiomyopathy

A 15-year-old girl is referred to a cardiologist's office for workup of hypertension. Her mother reports a normal pregnancy and birth. There is no family history of heart disease. On physical exam, BP 140/70 left and right upper extremities, 90/70 left and right lower extremities, HR 85/min, RR 20/min. Brachial and femoral pulses are incongruent. There are pulsations in the suprasternal notch. Cardiac auscultation reveals a III/VI systolic ejection murmur. What is expected on chest radiography?

rib notching and a notch in the aorta

A 72-year-old woman presents with a severe unilateral headache, jaw pain, and scalp tenderness. The patient states the headache is of a piercing quality; her jaw hurts only when she chews, and feels better a few minutes after she stops chewing. A pulsation of the temporal artery on the same side as her headache cannot be appreciated, and prednisone is prescribed until the patient can see a specialist. What is the reason prednisone is prescribed in this case?

risk for blindness

A 49-year-old Caucasian man well known to your practice presents due to his history of hypertriglyceridemia. He seeks evaluation of his recent cholesterol lab values. He has a significant family history of cardiovascular disease; his mother had a heart attack at age 57, and his father had open heart surgery at age 60. The patient has had low HDL levels in several past cholesterol screening tests. At the last office visit, lifestyle modifications were implemented by the patient. He has been extremely conscientious about his diet; for the past year, he has also been participating in physical activity 6 days a week. In addition, he has significantly limited his alcohol intake. Current fasting lab values for the patient are as follows: total cholesterol of 235 mg/dL, triglycerides of 350 mg/dL, HDL of 35, and an LDL of 175 mg/dL. You decide to initiate pharmacologic therapy to treat the patient's cholesterol and triglyceride levels. What medication should you prescribe?

rosuvastatin

A 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. 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 pulmonary vascular congestion and Kerley B lines. What assertion can be made from the diagnostic workup of this patient?

serum lactate levels will be elevated

A 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

A 55-year-old man presents for a follow-up from a recent hospitalization. He had two coronary stents placed 3 days ago after presenting to the emergency department with chest pain and a 40 pack-year smoking history. He quit smoking 2 years ago. He was not on any medications when he presented to the ER. Lipid panel revealed total cholesterol 200 mg/dL, LDL cholesterol 100 mg/dL, HDL cholesterol 40 mg/DL, triglycerides 395 mg/dL. What is the most appropriate treatment to reduce future cardiovascular risk in this patient?

statin

A 5-year-old boy presents with a 6-day history of fever, fatigue, and rash. He has no significant past medical history. His vaccinations are current, except for varicella, which his parents have refused in the past. On exam, his temperature is 101.3°F, heart rate is 110 bpm, and blood pressure is 94/62 mm Hg. He has bilateral conjunctival injection, an erythematous pharynx without exudate, cracked red lips, and an erythematous right tympanic membrane. He has shotty enlarged anterior cervical lymph nodes bilaterally, the largest nodes measuring 1.6 cm on the right side and 1.5 cm on the left side. His lungs are clear, and his heart has a regular rhythm. His abdomen is soft. He is in no acute distress, and he has a generalized maculopapular rash. What other possible findings are associated with his probable diagnosis?

sterile pyuria, leukocytosis

A 54-year-old man presents with a 6-month history of increasing intolerance to exercise. He describes "breathlessness" with exertion, as well as fatigue and 2-pillow orthopnea. He denies tobacco use but does admit to 4 or 5 whiskey sours daily for the last 20 years. He is a businessman and often entertains clients, which "involves drinking alcohol." Chest X-ray reveals an enlarged cardiac silhouette. EKG reveals normal sinus rhythm. A surface echocardiogram reveals an ejection fraction of 35%, mild mitral regurgitation, and dilated left ventricle. What statement about this patient's illness is true and should be shared with the patient?

symptoms can significantly improve with alcohol cessation

A 3-month-old White male infant presents for a well-baby check. There have been no other changes since the last visit. Upon exam, the infant is well-oxygenated and well-appearing. Cardiovascular exam reveals a grade III/VI high-pitched, harsh pansystolic murmur heard best at the left sternal border, fourth intercostal space (ICS). No additional murmurs are heard. The remainder of the exam is unremarkable. What is the most likely diagnosis?

ventricular septal defect

A 15-year-old girl presents with a 1-hour history of rapid heartbeat, faintness, sweating, and nervousness. She is also experiencing shortness of breath and chest pain. The patient has no significant past medical history. There is no history of similar episodes. The patient is on no medications and she denies illicit drug use. On exam, BP is 70/60 mm Hg, and pulse is 200 bpm. RR is 22/min. She is afebrile, looks pale, and her palms are slightly sweaty. She is not comfortable sitting up, so she prefers lying down. She looks slightly apprehensive. Her heart and lung exam are negative except for the tachycardia; except for cool sweaty hands, a brief abdominal and extremity exam are non-revealing. The physician quickly places the paddles on the patient's chest to record the rhythm; this shows a narrow-complex regular tachycardia at 210 bpm. He requests oxygen, IV line, and continuous monitoring. An EKG is in the process of being completed. How should the patient's condition be managed?

synchronized cardioversion

A 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

A 68-year-old man with a past medical history of hypertension, hyperlipidemia, cluster headaches, polymyalgia rheumatica, and type 2 diabetes mellitus presents due to a 2-day history of constant left-sided throbbing headache of moderate severity. He admits to associated symptoms, such as pain across his mandible when he eats, fever, fatigue, and muscle aches. Most alarming to the patient was a single episode of complete left eye blindness that lasted for 30 minutes but has since resolved. He denies extremity numbness, tingling, muscle weakness, incontinence, and changes in mental status. He further denies rhinorrhea, ocular discharge, nausea, and vomiting. The physical exam was remarkable only for a tender left scalp with a noticeable pulsation underlying the tender area. What is the most likely diagnosis?

temporal arteritis

what condition is characterized by h/a, jaw claudication, polymyalgia rheumatica, visual disturbances (blurred vision, diplopia, amaurosis fugax, complete loss of vision), a markedly elevated ESR, fever (of unknown origin), pain with chewing, and scalp tenderness?

temporal arteritis

A 6-week-old boy presents with his mother, who reports that he has episodes of turning "blue all over," especially when eating or when he becomes upset. Physical exam reveals cyanosis of the lips when he is crying. Cardiac exam reveals a harsh systolic crescendo-decrescendo murmur in the left upper sternal border. A chest X-ray reveals right ventricular hypertrophy. What is the most likely diagnosis?

tetralogy of fallot

A 3-month-old male infant presents for a routine evaluation. His mother states that the child is gaining weight, is feeding appropriately, and has been without fever, chills, dyspnea or other abnormal objective signs. Upon physical examination, the examiner noticed a loud, harsh holosystolic murmur in the left third and fourth interspaces along the sternum that was associated with a systolic thrill. There were no other abnormalities. Given the most likely diagnosis, what patient education do you give this patient's mother?

the louder associated murmur is a good sign

A 62-year-old man with a 15-year history of hypertension presents with severe tearing chest pain radiating through to the back. His blood pressure is 180/110 mm Hg, heart rate is 120 BPM, and respiratory rate is 34/min. Physical exam findings include lungs clear to auscultation, heart regular rhythm, normal S1/S2 with an S4 present, and a grade III/IV diastolic rumbling murmur noted with the patient leaning forward. Radial pulses are 1+ on right and 3+ on left. No evidence of JVD and carotids are negative for bruits. EKG reveals a sinus tachycardia and evidence of left ventricular hypertrophy. What is the most likely diagnosis?

thoracic aortic dissection

A 70-year-old woman presents to the ER with a 1-week history of palpitations, dyspnea, and generalized weakness. She also gives history of decreased oral intake and weight loss. The patient has no significant previous medical history. On exam, the patient is afebrile. Pulse is 130/min, BP is 100/68 mm Hg, RR is 14/min, oxygen saturation of 97% on room air. Skin appears warm and smooth without cyanosis or edema. Cardiovascular exam reveals normal S1 and S2, no murmurs, rubs, or gallops. Lung sounds are clear bilaterally. Chest X-ray shows no acute cardiopulmonary disease. Electrocardiogram shows atrial fibrillation with rapid ventricular rate of 135 bpm. Normal QRS and QT intervals. What is the next step in management of this patient?

thyroid function tests

A 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

A 72-year-old man is admitted with an acutely severe myocardial infarction. His status quickly deteriorates. His symptoms include hypotension, altered mental status, cold clammy skin, and metabolic acidosis seen on laboratory tests. What is the most appropriate initial pharmaceutical choice for a patient in this type of shock?

vasopressors