Cardio Patient Cases

a 25-year-old woman presents the ER after a syncopal episode. She had a loss of consciousness 3 times over the past 12 months. Each event occurred during or just after physical exercise. On PE: BP 110/70 mm Hg, HR 75/min, normal S1/S2, and an III/VIsystolic ejection murmur is heard best at the left sternal border that decreases with squatting.The EKG shows a normal sinus rhythm with diffuse increased QRS voltage.

Hypertrophic CMP

a 42-year-old woman complaining of poor sleep. She has also been feeling restless and agitated for several months. Upon further questioning, she reveals that she has also been suffering from headaches and has gained 18 pounds over the same time period. She denies any chest pain, palpitations, diaphoresis, or increased appetite. She has no significant past medical history other than two uncomplicated pregnancies resulting in normal spontaneous vaginal deliveries. She denies any tobacco, alcohol, or illicit drug use. Her vital signs show Temp 37 C (98.6 F), BP 164/112 mm Hg, HR 88/min, and RR 12/min. Physical exam shows an overweight woman with no palpable thyroid nodules or abnormalities on cardiopulmonary exam. Laboratory evaluation reveals the following: Sodium 141 mEq/L, potassium 3.1 mEq/L (normal 3.5-5.0), chloride 96 mEq/L, bicarbonate 25 mEq/L, BUN 10 mg/dL, creatinine 0.8 mg/dL, glucose 220 mg/dL, and calcium 9.5 mg/dL.

(hypertension secondary to Cushing syndrome)

During an inferior wall myocardial infarction the signs and symptoms of nausea and vomiting, weakness and sinus bradycardia are a result of what mechanism? A. Increased sympathetic tone B. Increased vagal tone C. Activation of the renin-angiotensin system D. Activation of the inflammatory and complement cascade system

Answer = B Increased vagal tone is common in inferior wall MI; if the SA node is involved, bradycardia may develop

What is the EKG manifestation of cardiac end-organ damage due to hypertension? A. Right bundle branch block B. Left ventricular hypertrophy C. Right ventricular hypertrophy D. ST segment elevation in lateral precordial leads

Answer = B LVH Long-standing hypertension can lead to left ventricular hypertrophy with characteristic changes noted on EKG.

A patient with which of the following is at highest risk for coronary artery disease? A. Congenital heart disease B. Polycystic ovary syndrome C. Acute renal failure D. Diabetes mellitus

Answer = D Patients with diabetes mellitus are in the same risk category for coronary artery disease as those patients with established atherosclerotic disease.

A 55-year-old male with history of hypertension and diabetes mellitus presents to the emergency department. The patient's wife states that the patient developed progressive irritability and confusion today after complaining of a headache. Physical examination reveals a BP of 230/130 mmHg and papilledema. Which of the following is the most accurate diagnosis in this patient? A. Resistant hypertension B. Hypertensive urgency C. Hypertensive emergency D. Malignant hypertension

Answer = Malignant HTN Malignant hypertension is significantly elevated BP with progressive retinopathy, including papilledema, encephalopathy, and headache.

What is the diagnostic gold standard for arteriovenous malformations? A. Computed tomography with contrast B. Magnetic resonance imaging (MRI) C. Angiography D. Carotid Doppler ultrasound

Answer = angiography Brain AVMs can be detected on computed tomography or magnetic resonance imaging (MRI). MRI is more sensitive, particularly in the setting of an acute intracerebral hemorrhage. Angiography is the gold standard for the diagnosis, treatment planning, and follow-up after treatment of brain AVMs.

Which of the following is the most common cause of secondary hypertension? A. Renal parenchymal disease B. Primary aldosteronism C. Oral contraceptive use D. Cushing's syndrome

Answer = primary aldosteronism

a 56-year-old male with a known history of polycythemia suddenly complains of pain and paresthesia in the left leg. Physical examination reveals the left leg is cool to the touch and the toes are cyanotic. The popliteal pulse is absent by palpation and Doppler. The femoral pulse is absent by palpation but weak with Doppler. The right leg and upper extremities have 2+/4+ pulses throughout.

Arterial embolism/thrombosis

A patient presents for a follow-up visit for chronic hypertension. Which of the following findings may be noted on the fundoscopic examination of this patient? A. cherry-red fovea B. boxcar segmentation of retinal veins C. papilledema D. arteriovenous nicking

Arteriovenous nicking is common in chronic hypertension

Anginal chest pain is most commonly described as which of the following? A. Pain changing with position or respiration B. A sensation of discomfort C. Tearing pain radiating to the back D. Pain lasting for several hours

B. A sensation of discomfort Myocardial ischemia is often experienced as a sensation of discomfort lasting 5-15 minutes, described as dull, aching or pressure.

Contraindications to beta blockade following an acute myocardial infarction include which of the following? A. Third degree A-V block B. Sinus tachycardia C. Hypertension D. Rapid ventricular response to Atrial fibrillation/flutter

Beta blockade is contraindicated in second and third heart block. Beta blockade has been proven to be beneficial in sinus tachycardia, hypertension and in atrial fib/flutter with a rapid ventricular response.

a 22-year-old male is brought to the emergency room after sustaining a stab wound in the chest. He reports shortness of breath. On physical examination, his vital signs are a temperature of 37 C, heart rate 121 bpm, blood pressure 90/60 mmHg, respiratory rate 20 rpm, and oxygen saturation 99% on room air. Physical examination is significant for muffled heart sounds and a drop of BP > 10 mm Hg systolic with inspiration. You note his neck veins are distended. He does not respond to aggressive fluid resuscitation. You order a chest x-ray and the EKG reveals low voltage QRS complexes and electrical alternans.

Cardiac Tamponade

a 64-year-old female who reports five weeks of occasional shortness of breath and pain radiating from the shoulder to the chest. The patient reports that the pain is worse with inspiration and lying down and is relieved by sitting forward. On physical exam you note distant heart sounds. Her EKG shows low voltage QRS complexes and electrical alternans.

Pericardial Effusion

a 25-year-old male who presents to the clinic complaining of mild dyspnea on exertion. Examination reveals a prominent jugular pulsation and a palpable parasternal lift. There is a harsh systolic murmur best heard at the second and third left intercostal space; it radiates to the left shoulder. An early systolic sound precedes the murmur during expiration. ECG demonstrates right-axis deviation

Pulmonary Stenosis

a 60-year-old man is brought to the emergency department because of crushing substernal chest pain for the past 45 minutes. He received 325 mg of aspirin en route. Nitroglycerin does not relieve his pain. He has a history of diabetes and hypertension. Medications include carvedilol and sildenafil. His temperature is 36.8°C (98°F), pulse is 99/min, respirations are 18/min, and blood pressure is 192/88 mm Hg. He appears diaphoretic. ECG shows ST-segment elevation in leads V1, V2, and V3.

STEMI

4-year-old boy who is brought to your office by his parents because he gets tired very easily and cannot keep up with the other children. On exam, you hear a loud, harsh, holosystolic murmur at the left lower sternal border without radiation to the axillae.

Ventricular Septal Defect

A 10-month-old girl was admitted to the hospital for cardiac catheterization. Her history included cyanosis noted at about 6 weeks of age, increasing over the last 7 months and becoming more severe with crying or physical activity. The chest x-ray demonstrates a "boot shaped heart" A presumptive diagnosis of tetralogy of Fallot (TOF) was made on admission. TOF has 4 components, which of the following below is not part of the diagnosis? A. Pulmonary Valve Stenosis B. VSD C. overriding aorta D. RVH E. ASD

ASD

a 48-year-old male with type I diabetes mellitus and end-stage renal disease currently on hemodialysis with dyspnea, cough and chest pain. He describes the pain as worse during inspiration and when he is lying on his back. The patient reports significant relief oh his chest pain with sitting up or leaning forward. A basic metabolic panel is remarkable for a BUN > 60 mg/dL. On cardiac auscultation, you hear a pericardial friction rub that is heard best when the patient is upright and leaning forward. The EKG (seen here) demonstrates diffuse, ST-segment elevations in the precordial leads.

Acute Pericarditis

Which of the following is the chief adverse effect of thiazide diuretics? A. Hypokalemia B. Hypernatremia C. Hypocalcemia D. Hypermagnesemia

Answer = A Thiazide diuretics can induce electrolyte changes. Principle among those is hypokalemia.

Annual blood pressure determinations should be obtained beginning at the age of A. 3 years. B. 5 years. C. 12 years. D. 18 years

Answer = A 3 yo In 2013, the United States Preventive Services Task Force (USPSTF) concluded that there was inadequate evidence to support BP screening in asymptomatic children and adolescents to prevent subsequent cardiovascular disease (VCD). However, the measurement of BP is a readily available, noninvasive procedure in office settings and that it should remain a routine part of comprehensive clinical care of children and adolescents as noted by the 2017 AAP guidelines for high blood pressure (BP) in children and adolescents, which are endorsed by the American Heart Association (AHA). They recommend that periodic measurements of blood pressure should be part of routine preventive health assessments beginning at the age of 3 years.

A 49-year-old female presents complaining of several episodes of chest pain recently. Initial ECG in the emergency department shows no acute changes. Two hours later, while the patient was having pain, repeat electrocardiogram revealed ST segment elevation in leads II, III, and AVF. Cardiac catheterization shows no significant obstruction of the coronary arteries. Which of the following is the treatment of choice in this patient? A. Nifedipine (Procardia) B. Metoprolol (Lopressor) C. Lisinopril (Zestril) D. Carvedilol (Coreg)

Answer = A Nifedipine This patient is most likely having coronary artery spasm. This can be treated prophylactically with calcium channel blockers such as nifedipine.

60-year-old male is brought to the ED complaining of severe onset of chest pain and interscapular pain. The patient states that the pain feels as though "something is ripping and tearing". The patient appears shocky; the skin is cool and clammy. The patient has an impaired sensorium. Physical examination reveals a loud diastolic murmur and variation in blood pressure between the right and left arm. Based on this presentation what is the most likely diagnosis? A. Aortic dissection B. Acute myocardial infarction C. Cardiac tamponade D. Pulmonary embolism

Answer = Aortic dissection The scenario presented here is typical of an ascending aortic dissection. In an acute myocardial infarction the pain builds up gradually. Cardiac tamponade may occur with a dissection into the pericardial space; syncope is usually seen with this occurrence. Pulmonary embolism is usually associated with dyspnea along with chest pain.

64 year-old patient with known history of type 1 diabetes mellitus for 50 years has developed pain radiating from the right buttock to the calf. Patient states that the pain is made worse with walking and climbing stairs. Based upon this history which of the following would be the most appropriate test to order? A. Venogram B. Arterial duplex scanning C. X-ray of the right hip and L/S spine D. Venous Doppler ultrasound

Answer = Arterial duplex scanning Given the patient's long history of type 1 diabetes mellitus the patient most likely has vascular occlusive disease. Evaluation of arterial blood flow is assessed using the duplex scanner. X-ray of the L/S spine and right hip while not harmful may give information regarding bony structures. Venous Doppler ultrasound will not give information of arterial perfusion.

A 63 year-old female presents with a complaint of chest pressure for one hour, noticed upon awakening. She admits to associated nausea, vomiting, and shortness of breath. 12 lead EKG reveals ST segment elevation in leads II, III, and AVF. Which of the following is the most likely diagnosis? A. Aortic dissection B. Inferior wall myocardial infarction C. Acute pericarditis D. Pulmonary embolus

Answer = B Myocardial infarction often presents with chest pressure and associated nausea and vomiting. ST segment elevation in leads II, III, and AVF are classic findings seen in acute inferior wall myocardial infarction.

You are asked to evaluate a term infant in the delivery room. He was born a few minutes earlier by spontaneous vaginal delivery with Apgar scores of 9 and 9. The mother had good prenatal care and a normal pregnancy. No significant family history is noted. On physical examination, the infant appears alert and is active and crying. Acrocyanosis is noted on extremities. A grade 2/6 soft, systolic murmur is audible at the left upper sternal border. Otherwise, the examination is completely normal. What should be your next step in the management of this patient? A. order an echo B. perform a second detailed physical exam at 24 hours C. order an EKG and CXR D. get a cardiology consult

Answer = B This is the transient systolic murmur of patent ductus arteriosus. It is audible at the upper left sternal border and in the left infraclavicular area on the first day, and it usually disappears soon thereafter. As in older infants and children, not all heart murmurs in neonates are pathologic. More than 50% of term-born infants are found to have innocent systolic murmurs at some time during the first week of life. The prevalence is even higher in premature infants. The incidence of structural congenital heart disease is estimated to be less than 1% of all live births. The infant should have a detailed examination at 24 hours and again before discharge before any further decisions are made. Acrocyanosis, a normal phenomenon, should also be distinguished from central cyanosis.

55 year-old male is seen in follow-up for a complaint of chest pain. Patient states that he has had this chest pain for about one year now. The patient further states that the pain is retrosternal with radiation to the jaw. "It feels as though a tightness, or heaviness is on and around my chest". This pain seems to come on with exertion however, over the past two weeks he has noticed that he has episodes while at rest. If the patient remains inactive the pain usually resolves in 15-20 minutes. Patient has a 60-pack year smoking history and drinks a martini daily at lunch. Patient appears overweight on inspection. Based upon this history what is the most likely diagnosis? A. Acute myocardial infarction B. Prinzmetal variant angina C. Stable angina D. Unstable angina

Answer = D Pain in unstable angina is precipitated by less effort than before or occurs at rest

Cardiac tamponade is potentially life-threatening. What is the mechanism by which the effusion impedes stroke volume? A. direct compression increases end-diastolic volume B. increased pressure in pericardium decreases coronary blood flow C. increased pressure decreases sinus rhythm D. compression of inferior vena cava decreases preload

Answer = D compression of inferior. vena cava decreases preload Compression caused by cardiac tamponade decreases the preload, which is an important component of stroke volume. Direct compression prevents inflow of blood to the heart muscle, which will decrease the end-diastolic volume. While tamponade does increase the pressure in the heart muscle itself, stroke volume is the amount of blood that is ejected with each contraction. The increased intracardiac pressure associated with tamponade affects the patient's cardiac output. Tamponade has no intrinsic effect on the heart rate.

A 52-year-old male with history of hypertension and hyperlipidemia presents with an acute myocardial infarction. Urgent cardiac catheterization is performed and shows a 90% occlusion of the left anterior descending artery. The other arteries have minimal disease. Ejection fraction is 45%. Which of the following is the treatment of choice in this patient? A. Coronary artery bypass grafting (CABG) B. Streptokinase C. Percutaneous coronary intervention (PCI) D. Warfarin (Coumadin)

Answer = PCI Immediate coronary angiography and primary percutaneous coronary intervention have been shown to be superior to thrombolysis.

64 year-old male, with a long history of COPD, presents with increasing fatigue over the last three months. The patient has stopped playing golf and also complains of decreased appetite, chronic cough and a bloated feeling. Physical examination reveals distant heart sounds, questionable gallop, lungs with decreased breath sounds at lung bases and the abdomen reveals RUQ tenderness with the liver two finger-breadths below the costal margin, the extremities show 2+/4+ pitting edema. Labs reveal the serum creatinine level 1.6 mg/dl, BUN 42 mg/dl, liver function test's mildly elevated and the CBC to be normal. Which of the following is the most likely diagnosis? A. Right ventricular failure B. Pericarditis C. Exacerbation of COPD D. Cirrhosis

Answer = Right ventricular failure Signs of right ventricular failure are fluid retention i.e. edema, hepatic congestion and possibly ascites.

Which of the following is the most common etiology for a subarachnoid hemorrhage? A. Trauma B. Ruptured aneurysm C. Bleeding arteriovenous malformation D. Embolic stroke E. Primary intracerebral hemorrhage

Answer = Ruptured aneurysm Up to 80% of subarachnoid hemorrhages can be attributed to the rupture of saccular or berry aneurysms in nontraumatic subarachnoid hemorrhages. Most of these aneurysms arise from the anterior circulation. Most are in the anterior communicating artery. Twenty-five percent of patients will have more than one aneurysm. Because of cerebrovascular anatomy, the blood is usually confined to the subarachnoid space. Blood from a ruptured arteriovenous malformation can be intraparenchymal and cause focal neurologic symptoms. Trauma is more likely to cause epidural or subdural hematoma.

Which of the following is a cause of high output heart failure? A. myocardial ischemia B. complete heart block C. aortic stenosis D. thyrotoxicosis

Answer = Thyrotoxicosis High output heart failure occurs in patients with reduced systemic vascular resistance. Examples include: thyrotoxicosis, anemia, pregnancy, beriberi and Paget's disease. Patients with high output heart failure usually have normal pump function, but it is not adequate to meet the high metabolic demands.

A 55 year-old male is seen in follow-up for a complaint of chest pain. Patient states that he has had this chest pain for about one year now. The patient further states that the pain is retrosternal with radiation to the jaw. "It feels as though a tightness, or heaviness is on and around my chest". This pain seems to come on with exertion however, over the past two weeks he has noticed that he has episodes while at rest. If the patient remains inactive the pain usually resolves in 15-20 minutes. Patient has a 60-pack year smoking history and drinks a martini daily at lunch. Patient appears overweight on inspection. Based upon this history what is the most likely diagnosis? A. Acute myocardial infarction B. Prinzmetal variant angina C. Stable angina D. Unstable angina

Answer = Unstable angina Pain in unstable angina is precipitated by less effort than before or occurs at rest

A 45-year-old obese Caucasian gentleman arrives at your clinic for a routine check-up after having some blood work done during a workplace health screening. He is found to have an LDL cholesterol level of 720 mg/dL. He states that his father and brother had high cholesterol and both died at a young age from a heart attack. He has a follow-up appointment with his cardiologist because of some occasional chest pain and abnormalities seen on his EKG. Additionally, you notice that he has well-demarcated yellow deposits around his eyes. He is started on high dose statin and his LDL at 12 weeks is 350 mg/dL. What is the next best step in this patient's management? A. Continue high dose statin, the patient's LDL is at goal B. Add niacin 100 mg three times daily C. Add ezetimibe 10 mg daily D. Add a PCSK9 inhibitor E. Refer to a lipid specialist

Answer = add ezetimibe Familial hypercholesterolemia (FH) is the most common autosomal dominant genetic disease. The clinical syndrome (phenotype) is characterized by extremely elevated levels of low-density lipoprotein cholesterol (LDL-C) and a propensity to early-onset atherosclerotic cardiovascular disease. In general, homozygotes manifest the disease at a much earlier age than heterozygotes and the disease is more severe. Homozygous FH patients are rare and have an estimated prevalence of approximately 1:300,000 to 1:400,000. Heterozygous FH is estimated to occur in 1 in 200 to 250 individuals in the United States. The blood cholesterol level for patients homozygous for familial hypercholesterolemia is usually above 700 mg/dL. The diagnosis of heterozygous familial hypercholesterolemia (FH) is made with genetic testing or clinical criteria. A causative mutation in the LDLR, APOB, or PCSK9 gene(s) secures this diagnosis. When genetic testing is not available or not felt to be necessary, you can use the Dutch Lipid Clinic Network criteria, which assigns points based on low density lipoprotein cholesterol (LDL-C) levels, personal history of early atherosclerotic cardiovascular disease (ASCVD), family history of early ASCVD, or high cholesterol in a first-degree relative, and personal and physical examination finding If LDL-C is not at goal after 6-12 weeks on a high dose statin the next best step for the treatment of familial hypercholesterolemia is to add ezetimibe 10 mg daily and check again in 6-12 weeks. If at that time the patient's LDL is still not at goal (ideally < 150) refer to lipid specialist to consider adding a PCSK9 inhibitor

What is (are) the drug( s) of choice for the treatment of isolated hypertriglyceridemia? A. nicotinic acid B. gemfibrozil C. lovastatin D. a and b E. all of the above

Answer = gemfibrozil The drug of choice for most cases of hypertriglyceridemia is gemfibrozil or another fibric acid derivative. Hypertriglyceridemia may be associated with type IIa, type IIb, type III, or type IV hyperlipoproteinemia. The usual dose of gemfibrozil is 0.6 g twice a day. Gemfibrozil will decrease hypertriglyceridemia by 40% to 80% and will potentially increase HDL by 10% to 20%. Combining a reductase inhibitor with gemfibrozil has become a commonly used regimen, although it was once feared. This combination still should be used with caution and may be tolerated if a low dose of one drug is given 6 to 12 hours apart from a low dose of the other (e.g., pravastatin, 10 to 20 mg in the morning, with gemfibrozil, 600 mg in the evening). This dosing regimen may, however, limit the effectiveness of this option. Laboratory monitoring of this therapeutic option is necessary and with vigilance because of an increase in both hepatic and myopathic side effects. In high-risk patients, these risks are frequently outweighed substantially by the cardiac risk factor reduction.

58 year-old male who is otherwise healthy presents with chest pain and is found to have left main coronary artery stenosis of 75%. The most important aspect of his management now is A. daily aspirin to prevent MI. B. nitrate therapy for the angina. C. aggressive risk factor reduction. D. referral for coronary artery revascularization

Answer = referral for CA revascularization Although medical therapy is important, revascularization is indicated when stenosis of the left main coronary artery is greater than 50%.

Which of the following is an absolute contraindication to thrombolytic therapy in a patient with an acute ST segment elevation myocardial infarction? A. history of severe hypertension presently controlled B. current use of anticoagulation therapy C. previous hemorrhagic stroke D. active peptic ulcer disease

Answer C = previous hemorrhagic stroke Absolute contraindications to thrombolytic therapy include a previous hemorrhagic stroke, a stroke within one year, a known intracranial neoplasm, active internal bleeding, and a suspected aortic dissection. Severe, but controlled hypertension, use of anticoagulation, and active peptic ulcer disease are relative contraindications in which the risk/benefit ratio must be weighed in each patient.

Which of the following should be avoided in patients with heart failure? A. Diuretics B. Digoxin C. Anticoagulants D. Calcium channel blockers

Answer D = CCB The ACC/AHA guidelines advise that nonsteroidal anti-inflammatory drugs (NSAIDs), calcium channel blockers, and most antiarrhythmic agents may exacerbate heart failure and should be avoided in most patients. NSAIDs can cause sodium retention and peripheral vasoconstriction and can attenuate the efficacy and enhance the toxicity of diuretics and ACE inhibitors.

a 61-year-old male presents with a recent history of increased fatigue with mildly increased exertional dyspnea. Patient denies any significant past medical history but states that he had some heart problems as a child, though he was never clear as to what was the problem. On cardiac examination, you hear anearly diastolic, soft blowing decrescendo murmur with a high pitch quality, especially when the patient is sitting and leaning forward. No thrill is felt.

Aortic Regurg

a 59-year-old male with chest pain, dyspnea, and presyncope. The symptoms occurred after climbing a flight of stairs. He has a late systolic-ejection murmur (SEM) heard in the second intercostal space (ICS) at the right sternal border with radiation to the carotids and the apex. The murmur is decreased with Valsalva maneuver. EKG is suggestive of LV hypertrophy.

Aortic Stenosis

a 73-year-old female with a history of hypertension, diabetes, and coronary arterydisease presents to the emergency department with severe, tearing, knife-like back pain. She states that the pain started approximately 30 minutes ago and she has felt lightheaded and dizzy ever since its onset. On exam, her vitals are given: T: 98.6 F, HR: 115 bpm, BP: 95/53, RR: 14, SaO2: 97% on room air.

Aortic dissection

a 63-year-old illiterate female with a history of right motor partial seizures and generalization since the age of 23 years arrives at the emergency room due to acute right hemiparesis. Neurological examination reveales a right hemiparesis, right tactile and pain hypoesthesia, poor fluency, temporal and spatial disorientation, and a Mini-Mental State Examination score of 5 points (one for immediate memory, two for naming, one for repetition, and one for commands). MRI is performed demonstrating a massive AVM in the left hemisphere of the frontotemporoparietal region (9.2 × 6.0 cm) with parenchymal compression and microangiopathy.

Arteriovenous malformation

a 65-year-old woman with palpitations. Her past medical history is notable for chronic obstructive pulmonary disease (COPD) for which she has been hospitalized once in the last year. On exam her T 98.4F, HR 86, BP 105/70, RR 18, SpO2 94% on room air consistent with her baseline. The ECG demonstrates low-amplitude fibrillatory waves without discrete P waves and an irregularly irregular pattern of narrow QRS complexes.

Atrial Fib

a healthy 7-year-old girl who has reached all developmental milestones. On examination, the precordium is hyperdynamic with a prominent right ventricular heave. A grade III/VI systolic ejection murmur is present in the 2nd left intercostal space (pulmonic position) with an early to mid-systolic rumbleand fixed splitting of the second heart sound (s2) during inspiration and expiration.

Atrial Septal Defect

A 26-year-old patient is brought to the emergency department after a head on collision. The patient complains of chest pain, dyspnea and cough. Examination reveals the patient to be tachypneic and tachycardic with a narrow pulse pressure. Jugular venous distension is noted. Electrocardiogram reveals nonspecific T-wave changes and electrical alternans. Which of the following is the most appropriate management plan for this patient? A. Left tube thoracostomy B. Pericardiocentesis C. Fluid resuscitation D. Immediate intubation

B. Pericardiocentesis Urgent pericardiocentesis is the initial treatment of choice in a patient with cardiac tamponade.

A 60 year-old male with history of hypertension and hyperlipidemia presents with intermittent chest heaviness for one month. The patient states he has had occasional heaviness in his chest while walking on his treadmill at home or shoveling snow. He also admits to mild dyspnea on exertion. His symptoms are relieved with 2-3 minutes of rest. He denies lightheadedness, syncope, orthopnea or lower extremity edema. Vitals reveal a BP of 130/90, HR 70, regular, RR 14. Cardiac examination revealed a normal S1 and S2, without murmur or rub. Lungs were clear to auscultation. Extremities are without edema. EKG reveals no acute change and cardiac enzymes are negative. Which of the following is the most appropriate next diagnostic study? A. cardiac catheterization B. nuclear exercise stress test C. helical (spiral) CT D. transthoracic Echocardiogram

B. nuclear exercise stress test This patient has signs and symptoms of classic angina; nuclear stress testing is the most useful noninvasive procedure for diagnosis of ischemic heart disease and evaluation of angina in this patient.

a 45-year-old female with a long history of a heart murmur with one week of increasing fatigue and low-grade fevers. She had a dental cleaning two weeks ago. She denies any hematuria, neurological symptoms, or changes in the appearance of her hands and fingernails. Her past medical history is otherwise insignificant. On physical exam, her temperature is 38.1 C (100.6 F), heart rate is 92/min, blood pressure is 118/67, and respiratory rate is 16/min. She appears fatigued but in no acute distress. Cardiac auscultation reveals a grade III/VI holosystolic murmur heard best at the cardiac apex in the left lateral decubitus position. Pulmonary, abdominal, and extremity exams are within normal limits. An echocardiogram is performed and is shown here. The patient is admitted and started on empiric IV antibiotics. Three days later, 4/4 blood cultures grow Streptococcus viridans that is highly sensitive to penicillin.

Bacterial endocarditis

48 year-old male with a history of coronary artery disease and two myocardial infarctions complains of shortness of breath at rest and 2-pillow orthopnea. His oxygen saturation is 85% on room air. The patient denies any prior history of symptoms. The patient denies smoking. Results of a beta-natriuretic peptide (BNP) are elevated. What should be your next course of action for this patient? A. Send him home on 20 mg furosemide (Lasix) p.o. every day and recheck in one week B. Send him home on clarithromycin (Biaxin) 500 mg p.o. BID and recheck in 1 week C. Admit to the hospital for workup of left ventricular dysfunction D. Admit to the hospital for workup of pneumonia

C. Admit to the hospital for workup of left ventricular dysfunction An elevated BNP is seen in a situation where there is increased pressure in the ventricle during diastole. This is representative of the left ventricle being stretched excessively when a patient has CHF. Sending a patient home would be inappropriate in this case.

A 63 year-old male with history of hypertension and tobacco abuse presents complaining of dyspnea on exertion for two weeks. The patient admits to one episode of chest discomfort while shoveling snow which was relieved after five minutes of rest. Vital signs are BP 130/70, HR 68, RR 14. Heart exam reveals regular rate and rhythm, normal S1 and S2, no murmur, gallop, or rub. Lungs are clear to auscultation bilaterally. There is no edema noted. Which of the following is the most appropriate initial diagnostic study for this patient? A. Helical CT scan B. Chest x-ray C. Nuclear stress test D. Cardiac catheterization

C. Nuclear stress test In patients with classic symptoms of angina, nuclear stress testing is the most widely used test for diagnosis of ischemic heart disease.

a critically ill 69-year-old male with a history of coronary artery disease is hypotensive following a large anterior wall myocardial infarction. He is noticeably lethargic, somnolent and confused. He has very weak peripheral pulses, a rapid heart rate and his extremities are cool to the touch.

Cardiogenic shock

Acute rebound hypertensive episodes have been reported to occur with the sudden withdrawal of A. verapamil (Calan). B. lisinopril (Prinivil). C. clonidine (Catapres). D. hydrochlorothiazide (HCTZ)

Clonidine (Catapres) is a central alpha agonist and abrupt withdrawal may produce a rebound hypertensive crisis.

A 12 year-old boy presents to the office with pain in his legs with activity gradually becoming worse over the past month. He is unable to ride a bicycle with his friends due to the pain in his legs. Examination of the heart reveals an ejection click and accentuation of the second heart sound. Femoral pulses are weak and delayed compared to the brachial pulses. Blood pressure obtained in both arms is elevated. Chest x-ray reveals rib notching. Which of the following is the most likely diagnosis?

Coarctation is a discrete or long segment of narrowing adjacent to the left subclavian artery. As a result of the coarctation, systemic collaterals develop. X-ray findings occur from the dilated and pulsatile intercostal arteries and the "3" is due to the coarctation site with proximal and distal dilations.

an 8-year-old boy who is seen for the first time in your office. His parents report that he tires easily and often complains of weakness in his legs. Physical exam shows a healthy boy with a blood pressure of 141/91 mmHg. You notice that his lower extremities are slightly atrophic with a mottling appearance. Upon further examination, he is found to have very weak and delayed femoral pulses with a blood pressure of 96/60 in the lower extremities. He has a late systolic ejection murmur on cardiac auscultation. CXR is performed demonstrating a "figure of 3 sign"

Coarctation of the aorta

A patient is diagnosed with VSD, at this time the infant should A. have immediate cardiac Cath performed, followed by surgical closure within 3 months B. immediate surgery C. be managed with digoxin and diuretics D. none of the above

D = none of the above Watchful expectation should be pursued. The prognosis is excellent, and the defect will probably close spontaneously. As the VSD becomes smaller, the murmur becomes shorter and maintains its regurgitant characteristics (i.e., it starts off with the first heart sound). Spontaneous closure occurs in 30% to 40% of cases, even more frequently in small defects. Pediatric cardiology referral is appropriate for serial examinations and echocardiograms. Infants with a large VSD who develop congestive heart failure and growth retardation should be treated first with digoxin and diuretics. If this fails, surgical intervention is necessary within the first 6 months of life.

A 58 year-old male who is otherwise healthy presents with chest pain and is found to have left main coronary artery stenosis of 75%. The most important aspect of his management now is A. daily aspirin to prevent MI. B. nitrate therapy for the angina. C. aggressive risk factor reduction. D. referral for coronary artery revascularization

D. Referral for CA revas Although medical therapy is important, revascularization is indicated when stenosis of the left main coronary artery is greater than 50%.

A 50-year-old male with history of alcohol abuse presents with complaint of worsening dyspnea. Physical examination reveals bibasilar rales, elevated jugular venous pressure, an S3 and lower extremity edema. Chest x-ray reveals pulmonary congestion and cardiomegaly. Electrocardiogram shows frequent ventricular ectopy. Echocardiogram shows left ventricular dilatation and an ejection fraction of 30%. Which of the following is the most likely diagnosis in this patient?

Dilated CMP

Young adult presents with one week of fatigue, worsening SOB, swelling in feet & ankles. PMH unremarkable except for recent cold 2 weeks prior to this. Temp 98.6, BP 120/70, pulse 84, RR 20. Physical exam notable for bibasilar crackles, jugular venous distension, an S3 gallop (heard below), and 2+ pitting edema up to the ankles bilaterally. CXR reveals cardiomegaly with pulmonary congestion and echocardiography demonstrates left ventricular dilation and dysfunction and low cardiac output.

Dilated CMP

A 58-year-old man presents to your office 4 weeks after being hospitalized for MI. He is complaining of chest pain, fever, and multiple joint pain. Laboratory tests do not show an increase in cardiac enzymes. The most likely diagnosis is A. Dressler's syndrome B. Costochondritis C. Meigs' syndrome D. Recurrent MI E. Pneumonia

Dressler's syndrome, or postmyocardial infarction syndrome, occurs several days to several weeks after MI. The condition is characterized by chest pain, fever, pericarditis with a pericardial friction rub, pericardial effusion, pleurisy, pleural effusions, and multiple joint pain. The cause is thought to be an autoimmune response to the damaged myocardial tissue and pericardium. The difference between Dressler's syndrome and recurrent MI is difficult to determine; however, in Dressler's syndrome, there is minimal or no increase in cardiac enzymes. Treatment includes the use of aspirin, NSAIDs, and, in some cases, corticosteroids.

A patient presents with an acutely painful and cold left leg. Distal pulses are absent. Leg is cyanotic. There are no signs of gangrene or other open lesions. Symptoms occurred one hour ago. Which of the following treatments is most appropriate? A. Vena cava filter B. Embolectomy C. Amputation D. Aspirin

Embolectomy within 4 to 6 hours is the treatment of choice.

a 45-year-old female with a long history of a heart murmur with one week of increasing fatigue and low-grade fevers. She had a dental cleaning two weeks ago. She denies any hematuria, neurological symptoms, or changes in the appearance of her hands and fingernails. Her past medical history is otherwise insignificant. On physical exam, her temperature is 38.1 C (100.6 F), heart rate is 92/min, blood pressure is 118/67, and respiratory rate is 16/min. She appears fatigued but in no acute distress. Cardiac auscultation reveals a grade III/VI holosystolic murmur heard best at the cardiac apex in the left lateral decubitus position. Pulmonary, abdominal, and extremity exams are within normal limits. An echocardiogram is performed and is shown here. The patient is admitted and started on empiric IV antibiotics. Three days later, 4/4 blood cultures grow Streptococcus viridans that is highly sensitive to penicillin.

Endocarditis

Following an acute anterolateral myocardial wall infarction two days ago, a patient suddenly develops hemodynamic deterioration without EKG changes occurring. What complication can explain this scenario? A. Free wall rupture B. CVA C. Atrial fibrillation D. Sick sinus syndrome

Free wall rupture is a complication that occurs within 72 hours of infarction. It is seen mainly in Q wave transmural and lateral wall infarctions.

a 67-year-old female with a severe throbbing headache and visual impairment in the left eye. The patient describes worsening of pain with chewing or combing her hair. Lately, she reports feeling very weak and tired especially in the mornings. At times she cannot even raise her arms to reach the cabinets in her kitchen. On physical exam, she has decreased visual acuity of the left eye, scalp tenderness on the left, and an absent pulse in the left temporal area. Laboratory testing is significant for an elevated erythrocyte sedimentation rate. She is admitted

Giant cell arteritis

A 36-year-old patient with cardiomyopathy secondary to viral myocarditis develops fatigue, increasing dyspnea, and lower extremity edema over the past 3 days. He denies fever. A chest x-ray shows no significant increase in heart size but reveals prominence of the superior pulmonary vessels. Based on these clinical findings, which of the following is the most likely diagnosis? A. Heart failure B. Subacute bacterial endocarditis C. Pulmonary embolus D. Pneumonia

Given the presence of cardiomyopathy, the patient's heart has decreased functional reserve. The symptoms and chest x-ray findings are typical of congestive heart failure.

a 57-year-old female with complaints of a severe headache, vomiting, neck stiffness, and chest pain that has developed over the last several hours. Physical examination is significant for papilledema, but no focal neurologic defects are noted. The patient is afebrile and vital signs are the following: pulse is 88/min,blood pressure is 200/140 mmHg, respirations are 20/min, and SpO2 is 97% on room air. Urinalysis reveals gross hematuria and proteinuria.

Hypertensive emergencies

What is the most common presenting symptom in a patient with arteriovenous malformation? A. Headache B. Seizure C. Intracranial hemorrhage D. Focal neurologic deficit

In about half of all brain AVMs, intracranial hemorrhage is the first sign (41 to 79 percent). 11-13 percent of patients with AVM present with seizure, 0.2 percent of patients with a headache and normal neurologic examinations were found to have an AVM and focal neurologic deficits are fairly unusual for cerebral AVM.

A 59-year-old male with history of hypertension and dyslipidemia presents with complaint of substernal chest pain for two hours. The pain woke him from sleep, does not radiate, and is associated with nausea and diaphoresis. Electrocardiogram reveals ST segment elevation in leads II, III, and AVF. Which of the following walls of the ventricle is most likely at risk? Anterior, Inferior, Lateral or Posterior

Inferior wall myocardial infarction is characterized by ST segment elevation in leads II, III and AVF.

a 60-year old caucasian male with shortness of breath and fatigue on exertion. On physical exam, you note an S3 heart sound, crackles on pulmonary auscultation, and a displaced left apical impulse. He undergoes an echocardiogram and is found to have a dilated left ventricle and an ejection fraction of 35%.

Left ventricular failure

a 22-year-old female who complains of generalized, sub-sternal chest pain that is worsened with exertion. She appears anxious; she denies ETOH, tobacco and illicit drug use. You auscultate her heart and hear a midsystolic click.

MVP

A 16-year-old male presents with complaint of syncope after basketball practice today. Physical examination reveals a systolic murmur along the left sternal border that increases with Valsalva maneuver. An electrocardiogram reveals left ventricular hypertrophy. Echocardiogram shows asymmetric left ventricular hypertrophy with a hypercontractile left ventricle. Which of the following is the initial medication of choice in this patient? A Metoprolol (Lopressor) B. Cozaar C. Lisinopril (Zestril) D. Hydrochlorothiazide (Diuril)

Metoprolol. Beta blockers are initial drug of choice in a symptomatic pt w. hypertrophic CMP. Avoid nitrates and other drugs that decrease preload (diuretics, ACE, ARBs) because these decrease LV size and worsen LV function

a 64-year-old obese man with a history of hyperlipidemia and poorly controlled type 2 diabetes underwent percutaneous transluminal coronary angioplasty of the posterior descending artery 3 days ago for an ST-elevation myocardial infarction. He has so far been stable since this procedure, but overnight you are called to his bedside. He is pallid and breathing laboriously. Notable vital signs include a blood pressure of 85/45 mmHg with a heart rate of 125 beats per minute. His lung exam is notable for bibasilar crackles. On cardiac exam, you note a hyperactive precordium with a new III/VI blowing holosystolic murmur at the apex with a split S2 that radiates to the axilla.

Mitral Regurg

Which of the following American College of Cardiology (ACC) and American Heart Association (AHA) stages do the majority of patients with heart failure fall under? A. Stage A B. Stage B C. Stage C D. Stage D

Most patients with heart failure are in stage C. ACC/AHA stage C patients have structural heart disease and current or previous symptoms of heart failure; ACC/AHA stage C corresponds with New York Heart Association (NYHA) class II and III heart failure. Drugs routinely used in these patients include ACE inhibitors/angiotensin receptor blockers, beta-blockers, and loop diuretics for fluid retention. For selected patients, therapeutic measures include aldosterone receptor blockers, hydralazine and nitrates in combination, and cardiac resynchronization with or without an implanted cardiac device.

a 64-year-old man comes to the emergency department because of chest discomfort for the past 5 hours. When the patient is asked where the pain is located, he places a clenched fist to indicate a squeezing over his substernal region. The pain radiates to the neck, left shoulder, and left arm. His temperature is 36.8°C (98°F), pulse is 55/min, respirations are 17/min, and blood pressure is 117/78 mm Hg. The examination shows a diaphoretic male. ECG shows inverted U-waves in leads V5 and V6. The cardiac biomarker test shows an elevated concentration of troponin.

NSTEMI

An 8 year-old boy is brought to a health care provider complaining of dyspnea and fatigue. On physical examination, a continuous machinery murmur is heard best in the second left intercostal space and is widely transmitted over the precordium. The most likely diagnosis is

Patent Ductus Arteriosus

a 2-week-old infant with a history of prematurity presents with a pink torso and upper extremity and blue lower extremities. On cardiac auscultation, you notice a rough, continuous "machinery murmur" heard over the left sternal border at the 2nd intercostal space

Patent Ductus Arteriosus

a 49-year-old male who is being evaluated for pain and swelling of his right lower extremity. He noticed his calf appears red and denies any trauma to the affected area. A week prior to presentation, he was on a plane for over 13 hours. Medical history is significant for venous insufficiency. On physical exam, there is erythema on the posterior calf and tenderness along the course of a superficial vein.A duplex ultrasound demonstrates impaired blood flow and incompressibility of a superficial vein.

Phlebitis/thrombophlebitis

A 46 year-old female is being evaluated for a new-onset hypertension that was discovered on screening at her workplace. The patient had several readings revealing systolic and diastolic hypertension. Patient is currently on no medications. Physical examination is unremarkable. A complete laboratory evaluation revealed hypokalemia as the only abnormality. Which of the following is the most likely diagnosis for this patient? A. pheochromocytoma B. renal artery stenosis C. coarctation of the aorta D. primary aldosteronism

Primary aldosteronism has an increased aldosterone secretion, which causes the retention of sodium and the loss of potassium. This should be the primary consideration for this patient.

a 65-year old man who presents to the ED at 1 am with 90 minutes of central chest pressure that awoke him from sleep. He says he thinks he has 'indigestion.' The pain is non-radiating, with mild shortness of breath but no nausea, vomiting or diaphoresis. He is an ex-smoker with a 20 pack-year history.There is no previous history of CAD, diabetes, hypertension or high cholesterol. On arrival, he looks well, with normal heart rate (54 bpm), blood pressure (127/86) and oxygen saturation (98% on room air). His pain has improved slightly with sublingual nitrates in the ambulance, although he still has some ongoing chest discomfort. His ECG is shown below. Troponins are positive. He is admitted to hospital and undergoes emergent cardiac catheterization, where he is without obstructive coronary disease, but his symptoms can be provoked with the administration of intravenous ergonovine.

Prinzmetal variant angina

a 24-year-old male with dyspnea on exertion. Physical exam reveals a high pitched decrescendo murmur at the LUSB that increases with inspiration

Pulmonary Regurg

a 58-year-old man complaining of several months of worsening shortness of breath and ankle swelling. He denies palpitations, lightheadedness, syncope, or chest pain. He has a past medical history significant for hereditary hemochromatosis. On physical exam, his temperature is 37 C (98.6 F), pulse is 78, blood pressure is 130/72 mm Hg, and respiratory rate is 16. He has elevated jugular venous pressure, diminished breath sounds at the lung bases, tender hepatomegaly, and bilateral pitting ankle edema. There are no murmurs, rubs, or gallops. EKG shows low-voltage QRS complexes without any signs of ischemia. His chest x-ray shows a normal sized heart and bilateral pleural effusions. Echocardiography shows symmetrical thickening of the left ventricle, normal left ventricular volume, and mildly reduced systolic function.

Restrictive CMP

a 64-year-old male with a history of coronary artery disease, hypertension, hyperlipidemia, and type II diabetes with increasing shortness of breath and ankle swelling over the past month. On physical examination, you note jugular venous distention, increased hepatojugular reflex, and hepatomegaly. His lungs are clear to auscultation.

Right ventricular failure

Which of the following hypertensive emergency drugs has the potential for developing cyanide toxicity? A. Sodium nitroprusside (Nipride) B. Diazoxide (Hyperstat) C. Labetalol (Normodyne) D. Alpha-methyldopa (Aldomet)

Sodium nitroprusside metabolization results in cyanide ion production. It can be treated with sodium thiosulfate, which combines with the cyanide ion to form thiocyanate, which is nontoxic

a 50-year-old woman with a history of hyperlipidemia and diabetes type 2complaining of "chest pain attacks." She says that these attacks tend to occur while walking up five flights of stairs to get to her apartment, they last for 15-20 minutes and are relieved by rest. She describes the pain as sharp and substernal. A baseline EKG is unremarkable. Suspecting the diagnosis, you perform an exercise stress EKG and observe transient ST depressions in the anterolateral leads after significant exertion.

Stable Angina

In which of the following categories of patients do AHA/ACC guidelines indicate ICDs? A. Patients with symptomatic documented hemodynamically unstable ventricular tachycardia with an LVEF < 40% B. Patients who have no history of prior rhythm problems with an LVEF of 40% C. Patients who are asymptomatic (NYHA class I) with an LVEF of 35% D. Patients who are newly diagnosed with an LVEF of 35% 10 days post-MI

The AHA/ACC recommend ICD placement for the following categories of heart failure patients: Patients with LV dysfunction (LVEF ≤ 35%) from a previous MI who are at least 40 days post-Ml Patients with nonischemic cardiomyopathy; with an LVEF ≤ 35%; in NYHA class II or III; receiving optimal medical therapy; and expected to survive longer than 1 year with good functional status Patients with ischemic cardiomyopathy who are at least 40 days post-MI; have an LVEF of ≤ 30%; are in NYHA functional class I; are on chronic optimal medical therapy; and are expected to survive longer than 1 year with good functional status Patients who have had ventricular fibrillation Patients with documented hemodynamically unstable ventricular tachycardia (VT) and/or VT with syncope; with an LVEF < 40%; on optimal medical therapy; and expected to survive longer than 1 year with good functional status

Which of the following is the most common cause of nontraumatic cardiac tamponade? A. metastatic malignancy B. uremia C. acute idiopathic pericarditis D. hemorrhage (anticoagulant use) E. bacterial or tubercular pericarditis

The most common cause of nontraumatic cardiac tamponade is metastatic malignancy. Common symptoms include dyspnea and profound exercise intolerance. Physical examination findings include tachycardia, low systolic arterial BP with a narrow pulse pressure, and pulsus paradoxus. Less common causes of nontraumatic tamponade include acute or chronic idiopathic pericarditis, uremia, bacterial or tubercular pericarditis, hemorrhage (from anticoagulant use), systemic lupus erythematosus, radiation treatments, and myxedema.

Which is the most common pathologic murmur? A. ASD B. VSD C. patent ductus arteriosus D. MVP

The most common pathologic cardiac murmur in childhood is VSD. With a VSD, the cardiac murmur is often not present at birth but is first heard at the 2- to 4-week well-baby checkup. As discussed previously, the most common outcome of this congenital heart defect is spontaneous closure. In some cases, however, surgical closure is indicated. The most uncommon scenario is the development of congestive cardiac failure secondary to VSD. The relative frequencies of pathologic cardiac murmurs in childhood are as follows: VSD, 38%; ASD, 18%; pulmonary valve stenosis, 13%; pulmonary artery stenosis, 7%; aortic valve stenosis, 4%; patent ductus arteriosus, 4%; mitral valve prolapse, 4%; and all others, 11%.

2-week-old infant is brought to your office by his mother for a checkup and establishment of care. They have just moved into the area, and you have not seen the baby before. The mother states that the baby was born at term and she had a normal pregnancy. On examination, the infant has a grade 3/6 harsh pansystolic heart murmur heard along the lower left sternal edge. There is no radiation of the murmur. The heart rate is 82 beats/minute and regular. There is no thrill. The blood pressure is 80/60 mm Hg. No other abnormalities are found on examination. The infant is in the 50th percentile for height and weight. What is the most likely cardiac diagnosis in this infant? VSD, Innocent cardiac murmur, tetralogy of Fallot, pulmonary atersia or coarctation of aorta

This infant most likely has a small VSD. Most commonly, the murmur is detected at 2 to 6 weeks of age when the infant returns for the initial checkup after hospital discharge. The typical heart murmur associated with a VSD is harsh, pansystolic, and best heard at the lower left sternal edge. Even as the VSD becomes smaller, it maintains its regurgitant characteristic of starting off with the first heart sound (holosystolic timing). As a VSD closes and becomes smaller, the murmur can actually become louder until the VSD is closed. Infants with small VSDs are well developed and acyanotic. Infants with large VSDs may have poor weight gain or show signs of congestive heart failure before 2 or 3 months of age.

68 year-old female comes to the office for an annual physical examination. Her past medical history is significant for a 40-pack year cigarette smoking history. She takes no medications and has not been hospitalized for any surgery. Family medical history reveals that her mother is living, age 87, in good health without medical problems. Her father is deceased at age 45 from a motor vehicle crash. She has two siblings that are alive and well. From this information, how many identifiable risk factors for cardiovascular heart disease exist in this patient? 0, 1, 2, 3

This patient has 2 identifiable risk factors based upon the information provided. These include her age 68 and her history of cigarette smoking.

a 73-year-old man with a history of rheumatic fever and coronary atherosclerosis presents to the emergency department with dyspnea on exertion and orthopnea. He called 911 because he could not catch his breath. On examination, he was found to have jugular venous distention (JVD), hepatic congestion, and peripheral edema. A blowing holosystolic murmur along the left sternal border that is intensified during a Valsalva maneuver and inspiration is noted. Atrial fibrillation is noted on his ECG.

Tricuspid Regurg

a diastolic rumbling murmur heard best at the left lower sternal margin and the xiphoid, augmented during inspiration

Tricuspid Stenosis

a 58-year-old man with a history of coronary artery disease, hypertension, and hyperlipidemia presents to an emergency department for evaluation of chest pain. He reports somewhat suddenly experiencing dull left-sided chest discomfort while at rest at home that was not relieved with taking nitroglycerin. His vital signs are T 37.1, HR 94 beats per minute, BP 133/87, and O2 saturation 97% on room air. His ECG shows no ST-segment changes; serum troponin is not elevated. His chest pain subsequently resolves and he is admitted to the cardiac service for further management.

Unstable angina

a 77-year-old Hispanic female with a dull ache in her legs that is worsened with prolonged standing and relieved with rest and elevation of her legs. She has 14 grown children and a past medical history of obesity and hypertension. On physical exam, her bilateral lower legs are edematous withmultiple dilated, tortuous superficial veins.

Varicose Veins

a 22-year-old female comes to the emergency department for a syncopal episode. Just prior to the syncopal episode, the patient experienced painful menstrual cramping. She experienced a cold sweat and palpitations with the cramping. The patient describes similar episodes to her menstrual cramps in the past. Her vital signs and physical examination are normal. ECG is unremarkable.

Vasovagal hypotension

a 78-year-old female complaining of generalized pain and edema in her left leg. She denies chest pain, shortness of breath, and hemoptysis. She takes 2.5 mg warfarin daily for atrial fibrillation and her INR is 2.6. On physical examination the patient experience calf pain with dorsiflexion of the left foot. The patient has a positive D-dimer and a lower extremity ultrasound reveals the presence of a deep venous thrombosis in the left popliteal vein.

Venous Thrombosis

a 73-year-old female with complaints of heavy, restless legs and nocturnal cramping of her calves. She has a past medical history of obesity, hypertension, and previous deep venous thrombosesafter periods of long travel. On physical exam, her bilateral lower legs are edematous with brown hyperpigmentation around the ankles. There are no ulcers. She is scheduled for a duplex ultrasound.

Venous insufficiency

a 71-year-old man with a history of BPH is hospitalized for an ST-elevation myocardial infarction and undergoes percutaneous coronary intervention. Upon discharge, he is prescribed aspirin, clopidogrel, prazosin, isosorbide mononitrate, carvedilol, enalapril, and atorvastatin. One week after discharge her presents to your office with complaints of faintness, lightheadedness, dizziness, confusion, and blurred vision that occur within seconds to a few minutes of standing and resolve rapidly on lying down. On physical examination, you note a drop of > 20 mm Hg systolic and 10 mmHg diastolic after a change from supine to standing.

orthostatic hypotension

a 63-year-old male complaining of bilateral leg pain, which has been increasing gradually over the past several months. It worsens when he walks but improves with rest. Past medical and surgical history is significant for hypertension, hyperlipidemia, and coronary artery bypass graft (5 years ago). He has a 60-pack-year smoking history. Vital signs are as follows: Temp 37C, HR 70, BP 143/89, and RR 18. Physical exam of the lower extremities reveals palpable but weak posterior tibial and dorsalis pedis pulses bilaterally; they are warm and well perfused. Ankle-brachial indices are 0.7 and 0.8.

peripheral artery disease

a 72-year-old female who presents to your office for a routine check-up. While she otherwise feels well, it has been a long time since she last received medical care. On exam her you note an apical,rumbling diastolic murmur with a split s1 that occurs following an opening snap. The rumbling is loudest at the start of diastole and is heard best at the left sternal border and apex . She has no other physical exam findings and has no other past medical history.

Mitral Stenosis