EMed Exam 1: Clinical Scenarios

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A 16 year-old female presents to the office with a rash. She was healthy until one week ago when she developed a fever, headache, generalized lymphadenopathy and a rash on her trunk. On physical examination you note an erythematous rash with central clearing. Her left knee is swollen with painful range of motion. She recently returned from Girl Scout Camp. Which of the following is the most likely diagnosis? A. Rocky Mountain spotted fever B. Lyme disease C. Juvenile rheumatoid arthritis D. Babesiosis

B. Lyme disease

An immunocompromised patient presents with signs and symptoms consistent with Legionella pneumophila who has not responded to initial antibiotic therapy with a macrolide. Which of the following should be added? A. Clarithromycin (Biaxin) B. Rifampin (Rifadin) C. Levofloxacin (Levaquin) D. Amoxicillin-clavulanate (Augmentin)

(c) B. Rifampin should be used as an adjunct in patients with either a macrolide or quinolone antibiotic, who have failed therapy, are immunocompromised or have severe illness **The macrolides (Clarithromycin) and fluoroquinolones (Levofloxacin) should be used for initial treatment, but not for adding to failed treatments when a macrolide was already used.

A 65 year-old male with coronary artery disease, hypertension, and diabetes mellitus is admitted with dyspnea and lower extremity edema. The chest x-ray reveals small bilateral pleural effusions. Echocardiogram shows an ejection fraction of 30% with no valvular heart disease. The patient is treated in the hospital with furosemide (Lasix) and lisinopril (Zestril). What education should be given to this patient upon discharge to help prevent readmission? A. Elevate the head of bed at home B. Avoid physical activity C. Monitor daily weights D. Restrict fluid intake

(c) C. Strategies to prevent rehospitalization can include monitoring daily weights, case management and patient education regarding self-adjustment of diuretics.

While examining a patient's chest you discover an area with absent breath sounds, increased tactile fremitus and egophony. Which of the following conditions do these findings most likely represent? A. Pleural effusion B. Pneumothorax C. Pneumonia D. Pulmonary hypertension

(c) C. These physical exam findings most often correlate with an increased density of the pulmonary tissues. This would most commonly be caused by a consolidation secondary to pneumonia

A 75 year-old man with a long history of COPD presents with acute onset of worsening dyspnea, increased productive cough, and marked agitation. While in the emergency department he becomes lethargic and obtunded. His ABG reveals a PaO2 40 mmHg, PaCO2 65 mmHg, and arterial pH 7.25. Which of the following is the most appropriate management at this point? A. Oxygen supplementation with a 100% non-rebreather mask B. Noninvasive positive pressure ventilation (NIPPV) C. Endotracheal intubation and mechanical ventilation D. Emergency tracheostomy

(c) C. This patient is in severe respiratory arrest with markedly impaired mental status; conventional mechanical ventilation is required

Which of the following clinical pictures best defines acquired immune deficiency syndrome (AIDS)? A. HIV +, CD 4 lymphocyte count of 250 cells/mcL B. Non-Hodgkin lymphoma with or without evidence of HIV infection C. HIV +, community acquired pneumonia (CAP) D. Mycobacterium avium complex with or without evidence of HIV infection

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

(u) A. Resistant hypertension is the failure to reach blood pressure control in patients who are compliant with a 3 drug regimen including a diuretic. (u) B. Hypertensive urgency is a systolic BP > 220 or a diastolic BP > 125 in a patient who is asymptomatic or who has disk edema, progressive target organ complications. Hypertensive urgency must be treated within a few hours of presentation. (u) C. Hypertensive emergency is similar to hypertensive urgency, however the BP is significantly elevated and must be lowered within an hour. (c) D. Malignant hypertension is significantly elevated BP with progressive retinopathy, including papilledema, encephalopathy, and headache.

***85 y/o with h/o HDL, HTN, CAD with stents, h/o HF in the past, unable to get their meds because the pharmacy is on holiday. They are coughing, short of breath and have frothy sputum. BP is 190/110, HR 120, Pulse ox 88% RA, Temp 98.2 RR 26. EKG shows T wave flattening with sinus tachycardia. What is the next step in management of this patient?

1. Start IV nitroglycerin drip 2. Simultaneously start lasix (will start working within 4-6 hours)

An elderly female presents for evaluation of exertional syncope, dyspnea, and angina. She admits that previous to these symptoms she had insidious progression of fatigue that caused her to curtail her activities. Which of the following is the most likely diagnosis? A. Aortic stenosis B. Aortic regurgitation C. Mitral stenosis D. Mitral

A. Aortic stenosis

DONT PEEK..FLIP THE CARD d) adenosine--drug of choice for narrow complex SVT. adenosine temporarily blocks the AV node thereby terminating the reentry of the impulse

34yo pt presents w/ palpitation. pt is hemodynamically stable. the following rhythm is seen on the monitor. which of the following is the management of choice: a) synchronized cardioversion b) unsynchronized cardioversion c) amiodarone d) adenosine e) atropine

DON'T PEEK....FLIP THE CARD! d) acute pericarditis--the EKG shows diffuse ST elevations w/ associated PR depression in the same leads. in aVR, there is usually ST depression & PR segment elevation.

42yom presents w/ acute, constant, sharp chest pain worsen with inspiration and lying down. based on the EKG, which of the following is the most likely diagnosis? a) brugada syndrome b) acute inferior wall MI c) acute lateral wall MI d) acute pericarditis e) unstable angina

DON'T PEEK....FLIP THE CARD! e) anterior wall MI anterior wall MI frequently involves the left anterior descending artery. on EKG it manifests as ST elevations in leads V1-V4.

45yom w/ hx of DM2 presents w/ sudden onset of chest pain while shoveling snow. the following EKG is obtained. what's the diagnosis? a) lateral wall MI b) posterior wall MI c) non ST elevation MI d) inferior wall MI e) anterior wall MI

An HIV positive patient presents with worsening dementia, fever, headache, and right hemiparesis. MRI of the brain reveals six lesions throughout the brain that show ring enhancement and surrounding edema. Which of the following is the treatment of choice? A. Sulfadiazine and pyrimethamine B. Trimethoprim-sulfamethoxazole C. Radiation therapy D. Ventricular shunt placement

A. Sulfadiazine and pyrimethamine Tx was not in slides but I thought worth including just in case

A 70 year-old male is admitted to the ICU with fever, leukocytosis and purulent sputum. Sputum culture shows methicillin-resistant gram-positive cocci in clusters. Which of the following medications should be ordered for this patient? A. Vancomycin (Vancocin) B. Clindamycin (Cleocin) C. Azithromycin (Zithromax) D. Astreonam (Azactam)

A. Vancomycin (Vanc`ocin)

A patient presents with moderate mitral stenosis. Which of the following complications is associated with an increased risk of systemic embolization in this patient? A. atrial fibrillation B. pulmonary hypertension C. increased left atrial pressure D. left ventricular dilatation

A. atrial fibrillation (c) A. 50-80% of patients with mitral stenosis will develop paroxysmal or chronic atrial fibrillation; 20-30% of patients with atrial fibrillation will have systemic embolization

A 76 year-old active female with history of hypertension and hypothyroidism presents with complaints of palpitations and dyspnea on exertion. On examination vital signs are BP 120/80 mmHg, HR 76 bpm, irregular, RR 16. Heart examination reveals an irregularly, irregular rhythm without murmur. Lungs are clear to auscultation and extremities are without edema. Which of the following is the most important medication to initiate for chronic therapy in this patient? A. Warfarin (Coumadin) B. Verapamil (Calan) C. Amiodarone (Cordarone) D. Digoxin (Lanoxin)

A. Warfarin (Coumadin)

DONT PEEK JUST FLIP acute pericarditis

A 29 year-old male presents with complaint of substernal chest pain for 12 hours. He has had a cough and runny nose for the past week. The patient admits to recent upper respiratory symptoms. On examination vital signs are BP 126/68, HR 86, RR 20, temp 100.3 degrees F. There is no JVD noted. Heart exam reveals regular rate and rhythm with no S3 or S4. Lungs are clear to auscultation. EKG shows the following. What is the most likely dx?

DONT PEEK JUST FLIP inferior wall MI

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 the following. BP 150/95, HR 116, RR 20, Temp 97.8. You administer a bolus of aspirin and start a heparin drip. What is the most likely diagnosis? A. Lateral wall MI B. Septal Wall MI C. Anterior wall MI D. Inferior wall MI E. NSTEMI

DONT PEEK JUST FLIP Anterior wall MI --> LAD

A 75 year-old female with pmhx HTN, DM, CAD presents with chest pain and shortness of breath for the past hour. She admits to associated nausea, vomiting, and feeling weak. 12 lead EKG reveals the following. BP 150/95, HR 116, RR 20, Temp 97.8. She receives sublingual nitrogen, is hooked up to a cardiac monitor and two large bore IVs are placed. After administering a bolus of aspirin and starting a heparin drip, you bring her to the Cath lab for PCI. What coronary artery is blocked in this MI?

A 59 year-old male with longstanding uncontrolled hypertension presents with nausea and a 5 pound weight gain in the last 2 days. He states "my belly is getting bigger and I can't fasten my pants." Which of the following physical examination findings would be most likely in this patient? A. Ankle edema and elevated jugular venous pressure B. Dry cough and mitral regurgitation murmur C. Hypotension and cyanotic extremities D. S3 heart sound heard along the left sternal border and bilateral wheezing

A. Ankle edema and elevated jugular venous pressure RHF with bloating

A 59 year-old otherwise healthy female develops acute dyspnea and chest pain one week post total abdominal hysterectomy. Echocardiogram demonstrates normal heart size with normal right and left ventricular function. Lung scan demonstrates two segmental perfusion defects. Which of the following is the next step in the management of this patient? A. Anticoagulation B. Embolectomy C. Thrombolysis D. Inferior vena cava filter

A. Anticoagulation PE

A 59 year-old otherwise healthy female develops acute dyspnea and chest pain one week post total abdominal hysterectomy. Which of the following is the next step in the management of this patient? A. Anticoagulation B. Embolectomy C. Thrombolysis D. Inferior vena cava filter

A. Anticoagulation PE with normal ventricular function

DONT PEEK JUST FLIP Inferior wall MI --> Right coronary artery

A quickie. What coronary artery is affected in this MI?

A 70 year-old female with history of hypertension, diabetes, and hypothyroidism presents with complaint of sudden onset of left lower extremity pain. Examination reveals a cool left lower extremity with a mottled appearance. Dorsalis pedis and posterior tibialis pulses are absent. Which of the following is the most likely diagnosis? A. Acute arterial occlusion B. Thromboangiitis obliterans C. Deep vein thrombosis D. Peripheral neuropathy

A. Acute arterial occlusion

A 25 year-old male presents to the emergency department for evaluation of a wound on his hand. He cut his hand while tearing down a chicken coop. On examination of his right hand you note a dirty 3cm jagged laceration. The patient is unaware of his tetanus immunization status. Besides cleaning and debriding the wound, what is the recommended clinical intervention in this patient? A. Administer tetanus-diptheria toxoid (Td) and tetanus immune globulin (TIG) B. Administer diphtheria, tetanus, and pertussis vaccine (DTP) C. Administer tetanus toxoid vaccine (TT) and tetanus immune globulin (TIG) D. No tetanus immunization or tetanus immune globulin is necessary in this patient

A. Administer tetanus-diptheria toxoid (Td) and tetanus immune globulin (TIG)

A 60 year-old patient with COPD characteristic of emphysema presents with a cough and increased sputum production. The following information is noted: Temperature 100°F (37.8°C); Respiratory rate 20/min; Heart rate 88 beats/min; pH 7.44; PaO2 75 mmHg; PaCO2 40 mmHg; O2 saturation 92%. Physical examination is remarkable for increased AP diameter, diminished breath sounds without wheezes, rhonchi, or other signs of respiratory distress. Which of the following would be an appropriate treatment for this patient? A. Broad-spectrum antibiotic B. Admission to the hospital C. Oxygen at 6 L/min by nasal cannula D. Brief course of oral theophylline

A. Broad-spectrum antibiotic A. Sputum production is extremely variable from patient to patient, but any increase in sputum with a history of COPD reported by a patient must be regarded as potentially infectious and treated promptly

A 45 year-old male presents to the Emergency Department complaining of sudden onset of tearing chest pain radiating to his back. On examination the patient is hypertensive and his peripheral pulses are diminished. Electrocardiogram shows no acute ST-T wave changes. Which of the following is the diagnostic study of choice in this patient? A. Computed tomography (CT) scan B. Transthoracic echocardiogram C. Magnetic resonance imaging (MRI) D. Cardiac catheterization

A. Computed tomography (CT) scan ACUTE AORTIC DISSECTION

In a patient with a low probability of pulmonary embolism (PE) based on the Wells criteria, which of the following lab studies is most helpful in ruling out a PE? A. D dimer assay B. PT with INR C. Factor V assay D. Clotting time

A. D dimer assay

Which of the following is the most effective outpatient treatment for Mycoplasma pneumonia? A. Doxycycline (Doryx) B. Amoxicillin (Amoxil) C. Trimethoprim (Septra) D. Cephalexin (Keflex)

A. Doxycycline (Doryx)

A 24 year-old male presents complaining of a 9 month history of increasing shortness of breath, dyspnea on exertion, and a cough productive of white sputum, mostly in the mornings. He denies orthopnea, PND, peripheral edema, fever, chills, night sweats, recent changes in weight, palpitations, chest pain, food intolerances, or other complaints. Patient has a history of recurrent lung infections. He states that his father had chronic pulmonary problems and died at age 42 from unknown lung disease. The patient denies smoking, alcohol or illicit drug use. On physical examination, the respiratory rate is 22 per minute, pulse of 98 bpm, temperature of 98.7 degrees. Pulmonary exam reveals end-expiratory wheezes bilaterally and hyperresonance to percussion. His cardiac exam is normal. Chest x- ray shows decreased lung markings. ECG is normal. Pulmonary function tests show an FEV1 63% of expected and residual capacity is 123% of expected. Which of the following is the most likely diagnosis? A. Emphysema B. Pulmonary fibrosis C. Ventricular septal defect D. Congestive heart failure

A. Emphysema A. This person has an obstructive lung disease based on PFTs. Emphysema is the most likely diagnosis, and may be related to alpha-1 antitrypsin deficiency based on family history and lack of smoking history and young age.

You are discharging a patient who had a myocardial infarction with a post infarction ejection fraction of 35%. You place the patient on the following medications: atorvastatin (Lipitor), metoprolol (Toprol-XL), aspirin, and nitroglycerin spray. Which of the following is also indicated in the patient provided there are no contraindications? A. Enalapril (Vasotec) B. Felodipine (Plendil) C. Furosemide (Lasix) D. Valsartan (Diovan

A. Enalapril (Vasotec) prevents LV dilation and onset of HF, prolongs survival

A 26 year-old female comes to the office for evaluation of a painful lump on her right buttock for the past week. Initially, it was a firm, tender nodule that has increased in size and tenderness in the past two days. On physical examination of the right buttock, there is a 3-cm fluctuant tender red nodule. Which of the following is the most appropriate initial intervention? A. Incision and drainage b. Mupirocin ointment C. Systemic antibiotics D. Moist compresses

A. Incision and drainage ABSCESS

A 19 year-old male presents to the ED complaining of a sudden onset of dyspnea and left sided chest pain. He denies fever, chills, cough or sore throat. General survey shows that he is 6 feet 2 inches tall and weighs 135 lbs. Vital signs are BP 86/60 mmHg, HR 130 bpm, RR 28, temp. 98.6 degrees F. Which of the following would you likely find on examination of his thorax? A. Left-sided hyperresonance B. Increased tactile fremitus of left base C. Scattered rales throughout D. Increased anterior/posterior diameter

A. Left-sided hyperresonance - pneumothorax

A 55 year-old female presents to the emergency department with complaints of dyspnea, chest pain and coughing with hemoptysis. Past medical history includes breast cancer 5 years ago, currently in remission. Vital signs are Temp. 98.6 degrees F, BP 150/90 mmHg, P 110 bpm, RR 20. Physical examination shows her right leg swollen with pain on palpation of deep veins. Which of the patient's history or examination findings is most suggestive of a pulmonary embolus (PE)? A. Leg swelling and pain with palpation of deep veins B. Heart rate > 100 C. Hemoptysis D. Past history of cancer

A. Leg swelling and pain with palpation of deep veins

A 58 year-old with a 20 pack-year history of tobacco use presents to the emergency department with sudden onset of severe, progressive right-sided chest pain and shortness of breath. She denies fever, nausea and productive cough but reports returning from a mission trip to South Africa yesterday. Her exam reveals tachycardia, tachypnea, clear lung fields and 3+ edema and erythema of the left leg. Her chest radiograph is normal. Which of the following is the most likely diagnosis? A. Pulmonary embolism B. Pneumothorax C. Pneumonia D. Pleurisy

A. Pulmonary embolism

A. Sputum production is extremely variable from patient to patient, but any increase in sputum with a history of COPD reported by a patient must be regarded as potentially infectious and treated promptly.

A 78 year-old patient who is in acute distress with near-syncope and lightheadedness is being examined. The patient's pulse is 40/min and blood pressure is 90/56 mm Hg. Examination of the patient at 45 degrees of elevation reveals cannon "a" waves. Which of the following is the most likely explanation for these abnormal waves? A. atrioventricular dissociation B. aortic stenosis C. systolic hypertension D. left ventricular hypertrophy

A. atrioventricular dissociation (c) A. The patient is in a third-degree heart block with the atria contracting against a closed atrioventricular valve, which would be the scenario in a patient who has an escape rate of 40. Elderly patients are at risk for heart conduction problems such as complete heart block

Which of the following animals is the major cause of human rabies in the United States and, therefore, poses the highest risk? A. bats B. rabbits C. rodents D. dogs

A. bats

A 68 year-old patient presents after a syncopal episode. The patient has a history of coronary artery disease and ischemic cardiomyopathy. Echocardiogram shows an ejection fraction of 20%. Electrophysiology study reveals inducible sustained ventricular tachycardia from the left ventricle. Which of the following is the most appropriate therapy in this patient? A. implantable defibrillator B. metoprolol (Lopressor) C. radiofrequency ablation D. warfarin (Coumadin)

A. implantable defibrillator A. Patients with symptomatic ventricular tachycardia (VT) or sustained VT and left ventricular dysfunction are at increased risk for sudden cardiac death. An implantable defibrillator is the treatment of choice.

A 14 year-old male presents to the ED experiencing a severe asthma attack. His respiratory effort is shallow and he is using accessory muscles to breathe. Auscultation of his chest reveals no audible wheezing. Vital signs include BP 90/60 mmHg, P 160 bpm, RR 52. An arterial blood gas (ABG) is ordered. Normal ABG values at your institution are pH 7.35-7.45, CO2 35-45, pO2 80-95. Which of the following ABG findings suggests the poorest prognosis? A. pH = 7.27 pCO2 = 46 pO2 = 56 B. pH = 7.60, pCO2 = 18 pO2 = 80 C. pH = 7.44, pCO2 = 38 pO2 = 90 D. pH = 7.52, pCO2 = 28, pO2 = 80

A. pH = 7.27 pCO2 = 46 pO2 = 56

A 47 year-old HIV positive female presents with a complaint of a nonproductive cough. She is febrile, tachypneic and tachycardic. Lung exam reveals bilateral rales. Chest x-ray shows diffuse interstitial infiltrates. What is the recommended treatment in this patient? A. trimethoprim-Sulfamethoxazole (Bactrim) B. tetracycline (Sumycin) C. amantadine (Symmetrel) D. ticarcillin (Ticar)

A. trimethoprim-Sulfamethoxazole (Bactrim) TMP-SMX drug of choice for PCP PNA

82 y/o M presents with diffuse area of erythema on his left lower leg, tender and warm to palpation. BP 138/91, HR 96, RR 18, Temp 102.1. He reports that his PCP started him on a course of augmentin which he completed 3 days ago, however symptoms have persisted and he now notes that redness is creeping up towards his thigh. There is no evidence of induration or purulent drainage. You order a CBC and CMP, and blood cultures which shows MRSA. How do you treat?

Admit (cellulitis worsening despite outpatient course of abx) and start on one of these: • Clindamycin • Vancomycin IV • Doxycycline IV *Ampicillin - sulbactam IV has no MRSA coverage

An intoxicated patient is brought to the ED with a two day history of acute onset of severe fever, chills and chest pain with frequent cough and dyspnea. His past history is significant for a 30 pack year history of tobacco use, alcoholism for the past 20 years and hypertension. A chest radiograph reveals a left lower lobe infiltrate. Which of the following is the most likely causative organism? A. Chlamydia B. Klebsiella C. Legionella D. Mycoplasma

B. Klebsiella - rapid onset, alcoholism, CXR findings idk if we know this but here it is

80 y/o F presents with complaint of dyspnea and exertional chest pain for the past 2 months. She is brought in by her caretaker after transiently losing consciousness as she was walking from her bedroom to her kitchen this morning. A FAST exam reveals left ventricular hypertrophy. What is the most likely dx?

Aortic Stenosis

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

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

Which of the following medications used in the treatment of supraventricular tachycardia is able to cause sinus arrest and asystole for a few seconds while it breaks the paroxysmal supraventricular tachycardia? A. Digoxin (Lanoxin) B. Adenosine (Adenocard) C. Verapamil (Calan) D. Quinidine (Quinaglute)

B. Adenosine (Adenocard)

Which of the following is the minimum criteria in millimeter diameter of induration for a positive tuberculosis skin-test screening result in an HIV-positive patient? A. 0 B. 5 C. 10 D. 15

B. 5 Current minimum criteria for a positive skin test is 5 mm in diameter for individuals at very high risk, including those who are HIV infected and recent contacts

A patient who recently emigrated from Southeast Asia presents with a 6 month history of weight loss, frequent cough with hemoptysis and fever. A sputum smear is positive for acid fast bacilli. Which of the following lab tests are most important in routine treatment of this condition? A. Amylase/lipase B. AST/ALT C. PT/PTT D. Sodium/potassium

B. AST/ALT TB drugs are hepatotoxic

An elderly patient with poorly-controlled Type 2 diabetes and renal disease develops a fever of 102°F orally, productive cough, and dyspnea. Physical examination demonstrates a respiratory rate of 32/min, labored breathing, 47 and rales at the left base. Pulse oximetry is 90%. Which of the following is the next appropriate step in the management of this patient? A. Administer nebulized corticosteroids B. Admit to the hospital C. Oral antimicrobial therapy D. Endotracheal intubation

B. Admit to the hospital B. Community acquired pneumonia is the most deadly infectious disease in the U.S. Important risk factors for increased morbidity and mortality include advanced age, alcoholism, comorbid medical conditions, altered mental status, respiratory rate greater than 30 breaths/min, hypotension, and a BUN greater than 30. **Due to the age of the patient, comorbid diseases, and current signs of respiratory distress, intravenous not oral antimicrobial therapy is indicated

A 38 year-old female with history of coarctation of the aorta repair at the age of two presents with fevers for four 39 weeks. The patient states that she has felt fatigued and achy during this time. Maximum temperature has been 102.1 degrees F. She denies cough, congestion, or other associated symptoms. Physical examination reveals a pale tired appearing female in no acute distress. Heart reveals a new grade III-IV/VI systolic ejection border at the apex, and a II/VI diastolic murmur at the right sternal border. What is the most likely diagnosis? A. Acute myocardial infarction B. Bacterial endocarditis C. Acute pericarditis D. Restrictive cardiomyopathy

B. Bacterial endocarditis (c) B. Bacterial endocarditis presents as febrile illness lasting several days to weeks, commonly with nonspecific symptoms, echocardiogram often reveals vegetations on affected valves

A 38 year-old female with history of coarctation of the aorta repair at the age of two presents with fevers for four weeks. The patient states that she has felt fatigued and achy during this time. Maximum temperature has been 102.1 degrees F. She denies cough, congestion, or other associated symptoms. Physical examination reveals a pale tired appearing female in no acute distress. Heart reveals a new grade III-IV/VI systolic ejection border at the apex, and a II/VI diastolic murmur at the right sternal border. What is the most likely diagnosis? A. Acute Pericarditis B. Bacterial endocarditis C. Pulmonary Embolsim D. Restrictive cardiomyopathy

B. Bacterial endocarditis presents as febrile illness lasting several days to weeks, commonly with nonspecific symptoms, echocardiogram often reveals vegetations on affected valves.

A 67 year-old presents as a new patient complaining of progressive dyspnea. Examination reveals 3+ pitting edema of the lower extremities bilaterally and wheezing audible in lower lung fields bilaterally. Which of the following tests is the most appropriate initial study in the patient? A. Electrocardiogram B. Brain natriuretic peptide C. Spiral computed tomography D. Spirometry

B. Brain natriuretic peptide

A 75 year-old female with history of coronary artery disease and dyslipidemia presents for routine follow-up. Physical examination reveals loss of hair on the lower extremities bilaterally with thinning of the skin. Femoral pulses are +2/4 bilaterally, pedal pulses are diminished bilaterally. Ankle brachial index is reduced. Which of the following signs or symptoms is this patient most likely to have? A. Lower extremity edema B. Calf pain with walking C. Numbness of the lower extremities D. Itching of the lower extremities

B. Calf pain with walking ARTERIAL OCCLUSION

A 63 year-old patient was admitted with an acute non-ST elevation myocardial infarction 3 days ago confirmed by elevated CK, CK-MB, troponin I and troponin T. He begins to experience recurrent chest pain. Which laboratory study is most appropriate to evaluate his recurrent chest pain? A. Creatine kinase B. CK-MB C. Troponin D. Myoglobin (Mb)

B. Cardiac specific markers of myocardial infarction include quantitative determinations of CK-MB, troponin I and T. Troponins are more sensitive and specific than CK-MB. All tests should become positive as early as 4-6 hours after onset of a myocardial infarction and should be abnormal by 8-12 hours. Troponins may remain elevated for 5-7 days or longer. CK-MB generally normalizes within 24 hours, thus being more helpful for evaluation of reinfarction.

A 56 year-old female with a 35 pack year smoking history presents to the clinic with shortness of breath and cough. On examination, she is thin with no recent weight loss. She appears uncomfortable, breath sounds are diminished without adventitious sounds. Pulmonary function tests show a marked increase in total lung capacity (TLC) and a decreased FEV1. What is the most likely diagnosis for this patient? A. Persistent asthma B. Chronic obstructive pulmonary disease C. Idiopathic fibrosing interstitial pneumonia D. Sarcoidosis

B. Chronic obstructive pulmonary disease

An elderly patient with poorly-controlled Type 2 diabetes and renal disease develops a fever of 102°F orally, productive cough, and dyspnea. Physical examination demonstrates a respiratory rate of 32/min, labored breathing, and rales at the left base. Pulse oximetry is 90%. Which of the following is the next appropriate step in the management of this patient? A. Administer nebulized corticosteroids B. Admit to the hospital C. Oral antibiotics D. Endotracheal intubation

B. Community acquired pneumonia is the most deadly infectious disease in the U.S. Important risk factors for increased morbidity and mortality include advanced age, alcoholism, comorbid medical conditions, alteredmental status, respiratory rate greater than 30 breaths/min, hypotension, and a BUN greater than 30.

Which of the following is most likely to cause a false negative PPD? A. Aspirin allergy B. Diagnosis of AIDS C. BCG immunization D. Pregnancy

B. Diagnosis of AIDS - any process that results in a reduced immune response can cause false negative BCG = false positive

A 35 year-old male status-post patent ductus arteriosus repair at 5 years of age, presents with low-grade fever, fatigue and dyspnea worsening over the past 10 days. Prior to the onset of these symptoms, he was healthy and free of any complaints. Examination is significant for petechiae on the palate, a high pitched holo-systolic murmur heard best at the apex, and splinter hemorrhages on both hands under his fingernails. Which of the following is the most appropriate next step in the evaluation of this patient? A. Cardiac catheterization B. Echocardiogram C. MUGA scan D. Chest radiograph

B. Echocardiogram infectious endocarditis

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? A. Anterior B. Inferior C. Lateral . Posterior

B. Inferior

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. Serial echocardiograms B. Pericardiocentesis C. Cardiac catheterization D. Pericardiectomy

B. Pericardiocentesis CARDIAC TAMPONADE

A patient admitted with substernal chest pain undergoes cardiac catheterization. Angiography reveals 98% occlusion of the right coronary artery. All other vessels are 100% patent. Which of the following is the most expected electrocardiogram finding in this patient? A. ST elevation in leads I, avL, V5 and V6 B. ST elevation in leads II, III, and avF C. ST elevation across V2, V3 and V4 D. Tall upright R and T waves in V1 and V2

B. ST elevation in leads II, III, and avF inferior wall is fed by right coronary artery

A 72 year-old male presents to the emergency department with crushing chest pain, dyspnea and palpitations for 2 hours in duration. Enzymes are pending and he has been given aspirin and sublingual nitroglycerin. He is rushed to the catheterization lab where they find a totally occluded distal right coronary artery. Which of the following electrocardiogram (ECG) findings supports the diagnosis? A. Q waves in leads I, aVL, V5-V6 B. ST segment elevation in leads II, III, aVF C. Hyperacute T waves in leads I, aVL D. Flipped T waves with repolarization changes in leads V1-V4

B. ST segment elevation in leads II, III, aVF, represents an acute process in the right coronary artery.

A 60 year-old male nonsmoker with history of coronary artery disease presents with complaint of worsening dyspnea on exertion for three weeks. He admits to orthopnea and lower extremity edema, but denies chest pain, palpitations, and syncope. The patient's last echocardiogram revealed an ejection fraction of 30%. Which of the following would you most likely find on physical examination? A. Pericardial friction rub B. Third heart sound C. Accentuated first heart sound D. Mid-systolic click

B. Third heart sound HEART FAILURE

77 210. Scientific Concepts/Cardiology Which of the following is the most common cause for acute myocardial infarction? A. Occlusion caused by coronary microemboli B. Thrombus development at a site of vascular injury C. Congenital abnormalities D. Severe coronary artery spasm

B. Thrombus development at a site of vascular injury (c) B. Acute myocardial infarction occurs when a coronary artery thrombus develops rapidly at a site of vascular injury. In most cases, infarction occurs when an atherosclerotic plaque fissures, ruptures, or ulcerates and when conditions favor thrombogenesis, so that a mural thrombus forms at the site of rupture and leads to coronary artery occlusion.

A post-op patient has signs and symptoms highly suggestive of a pulmonary embolism. The results of the CT scan of the lung is nondiagnostic. What is the most appropriate next step in the evaluation? A. Ventilation perfusion (V/Q) scan B. Ultrasound of the legs C. Echocardiography D. D-dimer

B. Ultrasound of the legs B. In a patient with a high likelihood of pulmonary embolism or an inpatient, as in this case, ultrasound of the legs would be the next diagnostic step after a nondiagnostic CT (u) A. Ventilation perfusion scans are performed prior to the CT scan of the chest and would not likely add additional information to this clinical scenario. (u) C. Although echocardiography may show right ventricular free wall hypokinesis with normal motion of the apex suggestive of pulmonary embolism, more than 50% of patients with a pulmonary embolism will have normal echocardiography. Echocardiography is not used in the diagnosis on inpatients. (u) D. In a post-op patient, a d-dimer will be positive regardless of the presence or absence of a pulmonary embolism.

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

A new patient with a history of hypertension on verapamil (Calan) presents for routine examination. Electrocardiogram reveals irregular R-R intervals, with narrow QRS complexes. There are no definable P-waves. Which of the following is most appropriate for this patient? A. Annual echocardiogram B. Warfarin (Coumadin) therapy C. Internal defibrillator D. Infective endocarditis prophylaxis

B. Warfarin (Coumadin) therapy A Fib

A 36 year-old male developed a sore throat and was treated with IM penicillin. Within 20 minutes, he felt faint and became dyspneic. Upon entry to the emergency department, he was pale and apprehensive. He had a thready pulse, and systolic blood pressure was 40 mmHg. Which of the following is the most appropriate initial agent to use? A. dopamine B. epinephrine C. hydrocortisone D. diphenhydramine

B. epinephrine

A 15 year-old male was seen last week with complaints of sore throat, headache, and mild cough. A diagnosis of URI was made and supportive treatment was initiated. He returns today with complaints of worsening cough and increasing fatigue. At this time, chest x-ray reveals bilateral hilar infiltrates. A WBC count is normal and a cold hemagglutinin titer is elevated. The most likely diagnosis is A. tuberculosis. B. mycoplasma pneumonia. C. pneumococcal pneumonia. D. staphylococcal pneumonia.

B. mycoplasma pneumonia. B. The insidious onset of symptoms, the interstitial infiltrate on chest x-ray, and elevated cold hemagglutinin titer make this diagnosis the most likely

FLIP 3rd Degree HB Pacing

BP 70/30, HR 30, RR 14 and the following EKG. How do you treat?

***85 y/o with h/o HDL, HTN, CAD with stents, h/o HF in the past, unable to get their meds because the pharmacy is on holiday. They are coughing, short of breath and have frothy sputum. BP is 190/110, HR 120, Pulse ox 88% RA, Temp 98.2 RR 26. EKG shows T wave flattening with sinus tachycardia. You start them on a nitro drip, however their pulse ox remains at 88%. What is the next step in the management of this patient?

BiPAP

A 56 year-old male presents to the office with a history of abdominal aortic aneurysm. He was told that he will need ongoing evaluation to assess whether the aneurysm is expanding. What is the recommended study to utilize in this situation? A. plain film of the abdomen B. serial abdominal exam C. ultrasound of the abdomen D. angiography of the abdominal aorta

C. ultrasound of the abdomen

50 y/o F presents to ED with BP 190/135. She was sent by urgent care, where she went first this morning for a cough. She denies headache, nausea, vomiting, abdominal pain, or blurred vision. EKG shows normal sinus rhythm. No neurological deficits on physical exam. What is the next step? A. Admit and start IV metoprolol, with the goal of 25% reduction of BP B. Order a head CT to rule out ischemic stroke C. Rx 1 week of PO metoprolol and discharge home with recommendation to follow up with PCP within the week D. STAT vascular surgery consult

C. If no underlying cause and no end organ damage, consider oral anti-hypertensives and prompt referral to primary care.

A 23 year-old female with history of asthma for the past 5 years presents with complaints of increasing shortness of breath for 2 days. Her asthma has been well-controlled until 2 days ago. Since yesterday, she has been using her albuterol inhaler every 4 to 6 hours. She is normally very active, however yesterday she did not complete her 30 minute exercise routine due to increasing dyspnea. She denies any cough, fever, recent surgeries, or use of oral contraceptives. On examination, you note the presence of prolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable. Which of the following is the most appropriate initial diagnostic evaluation prior to initiation of treatment? A. Chest x-ray B. ABG C. Peak flow D. Ventilation-perfusion scan

C. A peak flow reading will help you to gauge her current extent of airflow obstruction and is helpful in monitoringt he effectiveness of any treatment interventions.

28 y/o M presents with sudden onset shortness of breath. BP 130/93, HR 101, RR 22, Pulse ox 94%. On ultrasound, you note an absence of lung sliding, however CXR is unremarkable. What is the next step in management of this patient? A. Admit patient and repeat CXR in 1 hour B. Immediate needle decompression, followed by chest tube insertion C. Perform a chest CT D. Get a D Dimer

C. Chest CT to look for blebs. CT esp good if high suspicion for PTX, but CXR is equivocal

A recent Haitian immigrant presents to the clinic for an employment physical examination before starting work at a local hospital. The patient has a history of receiving bacilli Calmette-Guerin (BCG) vaccination. Screening for tuberculosis for this employee should include which of the following tests? A. Sputum induction B. PPD skin test C. Chest x-ray D. No screening needed

C. Chest x-ray is test of choice in pts where PPD is not indicated (in this pt PPD would give a false positive due to BCG vaccine)

Which of the following physical exam findings is consistent with moderate emphysema? A. Increased tactile fremitus B. Dullness to percussion C. Distant heart sounds D. Deviated trachea

C. Distant heart sounds due to hyperinflation of lungs

Which of the following diagnostic tests should be ordered initially to evaluate for suspected deep venous thrombosis of the leg? A. Venogram B. Arteriogram C. Duplex ultrasound D. Impedance plethysmography

C. Duplex ultrasound

A 26 year-old man is stung by a bee, and shortly thereafter, a wheal develops at the site of the sting. He soon feels flushed and develops hives, rhinorrhea, and tightness in the chest. Immediate therapy should be to A. Give high flow O2 B. Intubate immediately C. administer IM epinephrine D. administer solumedrol, benadryl and pepcid

C. Epi Looks and smells like anaphylaxis

A 30 year-old male presents with sudden onset of chills, fever, chest pain and a cough productive of greenish-brown sputum. On examination his temperature is 102 degrees F. He appears acutely ill and his respirations are shallow. Chest x-ray demonstrates left lower lobe consolidation. Which of the following findings would most likely be present on examination of his left lower lung? A. Hyperresonance B. Vesicular breath sounds C. Increased tactile fremitus D. Wheezing

C. Increased tactile fremitus occurs in the presence of fluid or a lung consolidation such as lobar pneumonia.

A patient with COPD presents to the ED, confused and disoriented, with a 3 day history of increasing shortness of breath with exertion and cough productive of purulent sputum. His ABG reveals following: pH of 7.15, PaCO2 100 mmHg and PaO2 of 70 mmHg. Which of the following is the most appropriate next step in his treatment? A. Administer high flow O2 B. Administer oral corticosteroids. C. Intubate the patient D. Start patient on started on albuterol/ipratropium nebulizer

C. Intubate - Severely hypercapnic (>50) - Altered mental status *Dont give O2 to these patients

A patient with severe COPD presents to the Emergency Department with a 3 day history of increasing shortness of breath with exertion and cough productive of purulent sputum. An arterial blood gas reveals a pH of 7.25, PaCO2 of 70 mmHg and PaO2 of 50 mmHg. He is started on albuterol nebulizer, nasal oxygen at 2 liters per minute, and an IV is started. After one hour of treatment, his arterial blood gas now reveals a pH of 7.15, PaCO2 100 mmHg and PaO2 of 70 mmHg. Which of the following is the most appropriate next step in his treatment? A. Decrease the oxygen flow rate. B. Administer oral corticosteroids. C. Intubate the patient. D. Administer salmeterol (Serevent)

C. Intubate the patient. This person has increasing respiratory failure as indicated by the raising PaCO2 levels. Intubation is required at this time

A patient with a history of chronic venous insufficiency presents for routine follow-up. Which of the following findings is most likely on physical examination? A. Cold lower extremities B. Diminished pulses C. Lower extremity edema D. Palpable cord

C. Lower extremity edema

A 21 year-old college student presents with a 3 week history of slowly worsening dry cough, generalized fatigue and most recently low-grade fevers. He denies nasal congestion, sore throat and nausea and has no past history of pulmonary disease or tobacco use. He does note that many other dorm residents have had similar symptoms over the past two months. Examination reveals mild inspiratory crackles but is otherwise normal. Chest radiograph is clear and CBC is normal. Which of the following is the most likely causative organism? A. Staphylococcus B. Pseudomonas C. Mycoplasma D. Klebsiella

C. Mycoplasma

A 29-year-old highly promiscuous male with dysuria and purulent urethral discharge presents to an STD clinic for the first time. You send out a nucleic acid amplification test to confirm the diagnosis. Pending the results, how do you treat?

Ceftriaxone + Azithromycin Chlamydia and gonorrhea usually co-exist

C. Peak flow A peak flow reading will help you to gauge her current extent of airflow obstruction and is helpful in monitoring the effectiveness of any treatment interventions

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)

C. Percutaneous coronary intervention (PCI)

An 80 year-old female presents with syncope and recent fatigue and lightheadedness over the past month. She denies chest pain or dyspnea. Physical examination reveals BP 130/70 mmHg, HR 40 bpm, regular, and RR 16. Electrocardiogram reveals two p waves before each QRS complex. Which of the following is the treatment of choice for this patient? A. Cardio defibrillator insertion B. Atropine as needed C. Permanent dual chamber pacemaker insertion D. Ritalin therapy daily

C. Permanent dual chamber pacemaker insertion - symptomatic second degree AV block Mobitz type II, pacing is Tx of choice

What is the mechanism of action of salmeterol (Serevent) in the treatment of asthma? A. Anti-inflammatory B. Immunotherapy for specific allergens C. Relaxing of bronchial smooth muscle D. Reduction of leukotriene production

C. Relaxing of bronchial smooth muscle

Which of the following is the most common cause of infective endocarditis in an IV drug abuser? A. Haemophilus parainfluenza B. Enterococci C. Staphylococcus aureus D. Viridans streptococci

C. Staphylococcus aureus

A 62 year-old homeless patient presents complaining of fever, weight loss, anorexia, night sweats and a chronic cough that recently became productive of purulent sputum that is blood streaked. On physical examination, the patient appears chronically ill and malnourished. Which of the following chest x-ray findings supports your suspected diagnosis? A. Hyperinflation and flat diaphragms B. Interstitial fibrosis and pleural thickening C. Cavitary lesions involving the upper lobes D. "Eggshell" calcification of hilar lymph nodes

C. This patient most likely has tuberculosis. A chest x-ray finding of cavitary lesions involving the upper lobes would support this suspected diagnosis.

You are evaluating a patient who was brought in secondary to an acute onset of repeated syncopal episodes. His electrocardiogram (ECG) shows wide QRS complexes with a fixed R-R interval at a rate of 40 bpm. The P waves occur with a fixed P-P interval at a rate of 70 bpm. The PR interval is variable. Which of the following is the most appropriate initial treatment for this condition? A. Balloon angioplasty B. Endarterectomy C. Transthoracic pacemaker D. Unsynchronized cardioversion

C. Transthoracic pacemaker 3rd degree heart block, need permanent pacing

A 26 year-old man is stung by a bee, and shortly thereafter, a wheal develops at the site of the sting. He soon feels flushed and develops hives, rhinorrhea, and tightness in the chest. He is seen in the urgent care center. Immediate therapy should be to A. transfer him to a local hospital emergency department. B. apply a cold compress to site of the sting. C. administer subcutaneous epinephrine. D. administer oral albuterol.

C. administer subcutaneous epinephrine.

Which of the following is the most effective way for patients with persistent asthma to monitor the severity of their symptoms? A. call the health care provider regularly B. keep a diary of symptoms C. monitor peak flow D. ask a family member to monitor symptoms

C. monitor peak flow

Which of the following ECG findings is consistent with hyperkalemia? A. prolonged QT interval B. delta wave C. peaked T waves D. prominent U waves

C. peaked T waves

A 28 year-old patient presents with complaint of chest pain for two days. The patient describes the pain as constant and sharp. It is worse with lying down, better with sitting up and leaning forward. Vital signs are BP 120/80, HR 80, regular, RR 14 and Temperature 100.1 degrees F. Which of the following would you expect to find on physical examination? A. lower extremity edema B. carotid bruit C. pericardial friction rub D. splinter hemorrhages

C. pericardial friction rub pericarditis

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

C. previous hemorrhagic stroke

***pt presents with ripping pain to back. BP is 140/80. What is Dx modality of choice to confirm aortic dissection?

**68 yo M with PMHx HDL, DM, HTN, s/p CABG and stents, presents with chest and abdominal pain. He says it feels like a tearing pain that radiates towards the back. BP 180/110, HR 116, RR 20, Temp 97.8. EKG shows normal sinus rhythm. Your order a CBC, CMP, PTT/PT, T&S and troponins. What imaging would be most appropriate to order to confirm your suspected diagnosis?

CT More sensitive than ultrasound Patient is hypertensive so OK to go to CT

60 yo former smoker with controlled HTN presents to you with chest pain that he rates 10/10. He mentions he also has some back pain. EKG shows nonspecific T wave changes and PE shows BP 140/80. What is your next step in Dx?

CT - aortic dissection

70 y/o presents to ED with fever, chills, and cough with rust colored sputum. RR 34, BP 85/55, Pulse ox 89%, appears disoriented and confused as to how she ended up in the emergency room. How do you treat?

Community Acquired PNA - Admit (in accordance with CURB-65) and manage inpatient - IV levaquin or moxifloxacin - Another option: Ceftriaxone + Azithromycin

45yo brought into the ED unresponsive. on PE, there is increased jugular venous pressure worsened w/ inspiration, a BP of 90/60, muffled heart sounds and normal breath sounds. which of the following is the recommended management of this pt? a) chest tube thoracostomy b) pericardial window c) pericardiocentesis d) pericardiectomy e) administration of IV furosemide

c) pericardiocentesis classic Beck's triad: systemic hypotension, muffled heart sounds (pericardial effusion) & increased jugular venous distention = hallmark for pericardial tamponade. 1st line tx = pericardiocentesis

On a frontal chest radiograph view, you notice a visceral pleural line with a radiolucent area devoid of vascular and pulmonary markings on the right side only. Which of the following is the most likely diagnosis? A. Asthma B. Emphysema C. Pneumonia D. Pneumothorax

D. Pneumothorax

Which of the following mechanisms leads to a primary pneumothorax? A. Penetrating or blunt trauma forces B. Underlying lung cancer C. Pressure of air in the pleural space exceeds room air pressure D. Rupture of subpleural apical blebs due to high negative intrapleural pressures

D. Rupture of subpleural apical blebs due to high negative intrapleural pressures

30 y/o F, 5 pack year smoker, on OCP, hx of asthma presents with shortness of breath and chest pain with deep inhalation. BP 125/94, RR 24, HR 125, Pulse ox 94%. She says she's not sure if this feels like her past asthma attacks. On physical exam, she is tachycardic and her lungs are clear to auscultation; you hear no wheezing. What of the following will best help you make your dx? A. Peak flow B. D-Dimer C. EKG D. CXR E. Echo

D-Dimer

A 34 year-old female with a history of asthma presents with complaints of increasing asthma attacks. The patient states she has been well-controlled on albuterol inhaler until one month ago. Since that time she notices that she has had to use her inhaler 3-4 times a week and also has had increasing nighttime use averaging about three episodes in the past month. Spirometry reveals greater than 85% predicted value. Which of the following is the most appropriate intervention at this time? A. Oral prednisone B. Oral theophylline (Theo-Dur) C. Salmeterol (Serevent) inhaler D. Beclomethasone (Qvar)inhaler

D. Beclomethasone (Qvar)inhaler This patient has progressed to mild persistent asthma. In addition to her inhaled beta2-agonist (albuterol), she should be started on an anti-inflammatory agent. Inhaled corticosteroids, such as beclomethasone, are preferred for long-term control.

A 23 year-old female with history of palpitations presents for evaluation. She admits to acute onset of rapid heart beating lasting seconds to minutes with associated shortness of breath and chest pain. The patient states she can relieve her symptoms with valsalva. Which of the following is the most appropriate diagnostic study to establish a definitive diagnosis in this patient? A. Cardiac catheterization B. Cardiac MRI C. Chest CT scan D. Electrophysiology study

D. Electrophysiology study Electrophysiology study is useful in establishing the diagnosis and pathway of complex arrhythmias such as supraventricular tachycardia.

A 71 year-old male with a history of diabetes and dyslipidemia presents to the emergency department with complaints of exertional chest pain for the past two hours. He gets some relief with rest but admits to associated nausea and left- sided jaw pain. On examination he appears diaphoretic and tachypnic. Electrocardiogram (ECG) is unchanged from a previous ECG 1 year ago. His cardiac enzymes are within normal limits. Which of the following is the most appropriate next step? A. Referral to cardiology for outpatient thallium stress test B. Discharge patient home with nitroglycerine C. Transfer to cardiac catheterization lab D. Monitor with repeat enzymes and ECG in 4-6 hours

D. In one-fourth to one-half of patients with acute MI, the first ECG does not demonstrate typical ST segment changes. Serial ECG's should be obtained to increase diagnostic yield. Serologic identification of myocyte necrosis is another beneficial diagnostic tool. CK-MB is detectable in the blood within 3-6 hours of the onset of the MI. Troponins begin to rise within 4-6 hours and remain elevated for 7-10 days

A 29 year-old male presents with complaint of substernal chest pain for 12 hours. The patient states that the pain radiates to his shoulders and is relieved with sitting forward. The patient admits to recent upper respiratory symptoms. On examination vital signs are BP 126/68, HR 86, RR 20, temp 100.3 degrees F. There is no JVD noted. Heart exam reveals regular rate and rhythm with no S3 or S4. There is a friction rub noted. Lungs are clear to auscultation. EKG shows diffuse ST segment elevation. What is the treatment of choice in this patient? A. Pericardiocentesis B. Nitroglycerin C. Percutaneous coronary intervention D. Indomethacin (Indocin)

D. Indomethacin (Indocin) c) D. Indomethacin, a nonsteroidal anti-inflammatory medication, is the treatment of choice in a patient with acute pericarditis

A 6 year-old boy is brought to the pediatric clinic by his mother for an evaluation of his asthma. He coughs about 3 days out of the week with at least 2-3 nights of coughing. Which of the following would be the most appropriate treatment for this patient? A. Mast cell stabilizer B. Long acting beta agonist C. Leukotriene receptor antagonist D. Low dose inhaled corticosteroid

D. Low dose inhaled corticosteroid

A 53 year-old male with history of hypertension presents complaining of recent 4/10 left-sided chest pain with exertion that is relieved with rest. He states the pain usually lasts approximately 4 minutes and is relieved with rest. Heart examination reveals regular rate and rhythm with no S3, S4, or murmur. Lungs are clear to auscultation bilaterally. Electrocardiogram reveals no acute changes. Which of the following is the most appropriate initial step in the evaluation of this patient? A. Cardiac catheterization B. CT Angiogram of the chest C. Echocardiogram D. Nuclear stress test

D. Nuclear stress test

A 23 year-old male with recent upper respiratory symptoms presents complaining of chest pain. His pain is worse lying down and better sitting up and leaning forward. Electrocardiogram shows widespread ST segment elevation. Which of the following is the most likely physical examination finding in this patient? A. Elevated blood pressure B. Subungual hematoma C. Diastolic murmur D. Pericardial friction rub

D. Pericardial friction rub

A 34 year-old male presents with an acute onset of fatigue and dyspnea. He has experienced repeated episodes of near-syncope and an unresolved chest discomfort described as a "fluttering" sensation over the past 3 hours. His electrocardiogram reveals no definable p waves and his R-R interval is irregular. His blood pressure is 88/60 mmHg. Which of the following is most appropriate for this patient? A. Initiate warfarin (Coumadin) therapy to an INR target of 2.0 B. Consult for radiofrequency ablation therapy C. Transfer to cardiac catherization lab D. Sedate for synchronized cardioversion

D. Sedate for synchronized cardioversion - pt has A Fib, in shock/severe hypotension, pulmonary edema, or ongoing MI/ischemia you need urgent cardioversion

Empiric treatment for infective endocarditis should target which organism? A. Haemophilus influenzae B. Moraxella catarrhalis C. Mycoplasma pneumoniae D. Staphylococcos aureus

D. Staphylococcos aureus empiric regimens for endocarditis should include staph, strep, and enterococci coverage

The most common pathogen identified in community acquired pneumonia (CAP) is A. Mycoplasma pneumoniae. B. Staphylococcus aureus. C. Legionella pneumophila. D. Streptococcus pneumoniae.

D. Streptococcus pneumoniae.

A 42 year-old male is brought to the emergency department with a stab wound to his right lateral chest wall. On physical examination, the patient is stable with decreased breath sounds on the right with dullness to percussion. An upright chest x-ray reveals the presence of a moderate pleural effusion. Subsequent diagnostic thoracentesis contains bloody aspirate. Which of the following is the next most appropriate intervention? A. Thoracotomy B. Needle aspiration C. Close observation D. Tube thoracostomy

D. This patient has a hemothorax. Drainage of a hemothorax is best obtained through insertion of a chest tube (tube thoracostomy).

A 29 year-old female with history of IV drug abuse presents with ongoing fevers for three weeks. She complains of fatigue, worsening dyspnea on exertion and arthralgias. Physical examination reveals a BP of 130/60 mmHg, HR 90 bpm, regular, RR 18, unlabored. Petechiae are noted beneath her fingernails. Fundoscopic examination reveals exudative lesions in the retina. Heart examination shows regular rate and rhythm, there is a grade II-III/VI systolic murmur noted, with no S3 or S4. Lungs are clear to auscultation bilaterally, and the extremities are without edema. Which of the following is the diagnostic study of choice in this patient? A. Electrocardiogram B. CT angiogram of the chest C. Cardiac catheterization D. Transesophageal echocardiogram

D. Transesophageal echocardiogram infective endocarditis

A 55 year-old male presents with complaint of sudden ripping chest pain that radiates into the abdomen. On examination the patient is found to have diminished peripheral pulses and a diastolic murmur. EKG reveals left ventricular hypertrophy. Which of the following is the most likely diagnosis? A. acute myocardial infarction B. pulmonary embolism C. acute pericarditis D. aortic dissection

D. aortic dissection

A 42 year-old male with unremarkable past medical history is admitted to the general medical ward with community- acquired pneumonia. He has a 20 pack-year history of cigarette smoking. He is empirically started on ceftriaxone (Rocephin). Which of the following antibiotics would be most appropriate to add to his empiric treatment regimen? A. piperacillin (Pipracil) B. vancomycin (Vancocin) C. clindamycin (Cleocin) D. azithromycin (Zithromax)

D. azithromycin (Zithromax) CAP needs beta lactam + macrolide

A 64 year-old female with a 50 pack year smoking history, presents with worsening dyspnea on exertion, a persistent cough, and increasing oxygen requirement from 2 to 3 liters. She denies any cardiac history. What is the most likely chest x-ray finding in this patient? A. pulmonary vascular congestion B. left lower lobe infiltrate C. apical infiltrates D. hyperinflation with bullae

D. hyperinflation with bullae

A 56 year-old male, status post myocardial infarction, is noted to have left ventricular hypertrophy and an ejection fraction of 38%. Which of the following medications should be prescribed to prevent the development of heart failure symptoms? A. amlodipine (Norvasc) B. furosemide (Lasix) C. hydrochlorothiazide (HCTZ) D. lisinopril (Zestril)

D. lisinopril (Zestril) ACE inhibitors have been shown to markedly improve survival and are also recommended for prevention of symptoms in patients at risk for heart failure.

Which of the following is an expected finding in a patient with a diagnosis of an arterial embolism? A. lower extremity edema B. stasis dermatitis C. palpable cord D. pulselessness

D. pulselessness

Which of the following is the most appropriate therapeutic agent for acute influenza? A. azithromycin (Zithromax) B. acyclovir (Zovirax) C. tetracycline (Sumycin) D. zanamivir (Relenza)

D. zanamivir (Relenza)

a pt in the ED who is suspected as having cardiac ischemia has an initial troponin level of 0.08ng/dL. what can be concluded from this finding? a) the pt is having a MI b) this is a normal lab result, so the pt may be discharged c) this is a normal finding but a repeat level must be obtained d) this level confirms the pt is suffering from angina

c) this is a normal finding but a repeat level must be obtained

85 y/o with h/o HDL, HTN, CAD and HF presents with cough, shortness of breath and frothy sputum. BP is 80/60, HR 120, Pulse ox 88% RA, Temp 98.2 RR 26. On physical exam, you appreciate diffuse crackles in bilateral lung fields. EKG shows T wave flattening with sinus tachycardia. What is the next step in management of this patient? A. Intubate B. Start nitroglycerin drip C. Start patient on BiPaP D. Start dobutamine E. Initiate dual antiplatelet therapy with plavix and heparin

Dobutamine

**72 y/o F presents with HTN, HLD, DM, CAD presents complaining of chest pain and clutching her chest. The chest pain is L sided and radiates down her arm. Its worse when she walks around. Her last echo and stress test was two years ago. VS: 170/90, HR 110, 98% RA, RR 16, T 98.4. EKG shows T wave inversions in leads AvL, V5 and V6. She is tachycardic, but lungs are clear, appears non diaphoretic, and she is in no acute distress. CBC, CMP is normal, electrolytes normal, PT/PTT WNL, troponin is 0.15. CXR is normal. She is given SL nitro for pain, and a bolus of aspirin. What are the next steps in her management?

Dual antiplatelet therapy and thrombotics 1. Aspirin (already given) 2. Plavix 3. Heparin drip Admit to telemetry *This is an NSTEMI

18yo college student presents w/ a 5day hx of runny nose, sneezing & productive cough. she denies chest pain or SOB. her VS are all WNL. on PE her lungs are clear to auscultation b/l w/ no adventitious breath sounds. CXR shows no infiltrates or other abnormalities. EKG shows normal sinus rhythm w/ no ST or T wave changes. a D-dimer is WNL. which of the following is most likely diagnosis? a) sarcoidosis b) acute pulmonary embolism c) typical bacterial PNA d) acute bronchitis e) chronic bronchitis

d) acute bronchitis

59 y/o F with Pmhx of metastatic breast can cancer presents with chest pain and SOB. BP is 85/50, RR 20, HR 104. On physical exam, heart sounds are distant. EKG demonstrates low voltage QRS. What is the test of choice to confirm your dx?

Echo *This is pericardial effusion

65 y.o F with end stage renal disease on hemodialysis presents with cough, shortness of breath, nausea, and fever. On physical exam, you appreciate a rumbling diastolic murmur at the apex, and 2mm erythematous lesions on the palms bilaterally. You order CBC, CRP, procalcitonin and blood cultures x 2. How do you treat?

Endocarditis Vancomycin (to cover MRSA) + A broad spectrum abx like Gentamicin

53yom who is of relatively good health except his hx of tobacco use is brought to the ED c/o severe substernal chest pain that radiates to his back. the pain began with an acute onset of a "ripping sensation." He called 911 immediately. after arriving in the ED, he was placed on the monitor. his BP was 190/128mmHg. based on his hx, what is his most likely diagnosis? a) acute coronary syndrome b) mitral valve stenosis c) cariogenic shock d) aortic dissection

d) aortic dissection

pt presents to the ED w/ ST elevation in leads II, III, & aVF. the pt is hemodynamically stable. what measure should you use to limit the size of infarction in this pt? a) NSAIDs b) glucocorticoids c) CCB d) fibrinolytic agents

d) fibrinolytic agents

the tx of an asx pt w/ 1st degree AV block w/ a HR of 80bpm is a) pacemaker b) atropine c) isoproterenol d) no tx

d) no tx

81yof is admitted to the hospital w/ new-onset afib. when considering whether to heparinize her, which of the following is an absolute CI for the use of thrombolytic therapy? a) BP of 170/102mmHg on admission b) age >72 c) active peptic ulcer disease d) suspicion of aortic dissection

d) suspicion of aortic dissection

34yof w/ "saw tooth" pattern on EKG w/ a ventricular rate of 140bpm. QRS complexes are narrow. no associated chest pain or SOB. her BP is 140/90. which of the following is the next appropriate management? a) atropine b) amiodarone c) synchronized cardioversion d) verapamil e) radio frequency ablation

d) verapamil BB & CCB are 1st line in afib &aflutter

80yo M pmhx HTN, CAD presents with altered mental status and productive cough, fever 102F, MAP 50, SC02 60% and serum lactate 4.5, BP 70/40. After giving him a bolus of fluids, you perform an ultrasound, which shows a collapsed IVC. His BP is now 73/44. What is the next step in management?

Give another bolus of fluids

**32 y/o M with no remarkable PMhx presents with retrosternal aching chest pain that radiates to the back x 4 hours. The pain is worse is worse when he moves his arm. He works as a delivery driver and has never had pain like this before, or tried anything for his symptoms. BP 120/85, RR 16, HR 94, Temp 98.8. EKG shows normal sinus rhythm. On physical exam, heart is RRR, lungs are clear, pectoral muscles are tender to palpation. CXR is unremarkable. What are the next steps for management of this patient?

Give ibuprofen and discharge home

65 y/o F 3 days s/p cholecystectomy with fever, chills, productive cough. Pulse ox 90%, BP 88/58, HR 120. CXR reveals an infiltrate in the right upper lung. How do you treat?

Hospital acquired PNA Vancomycin (MRSA coverage) + Cefepime OR zosyn (broad spectrum)

35 y/o F G1PO presents with severe abdominal cramps for the past hour. BP is 80/60, HR is 140, RR 22, Pulse ox 93%, Temp 95.9. On physical exam, she appears pale and diaphoretic. What type of shock is this?

Hypovolemic (some sort of uterine hemorrhage lets say) - Narrow pulse pressure - Preserved diastolic - Cool temps

HIV pt with CD4 of 45 cells/mm3 presents with fever, headache, altered mental status, and focal neurologic deficits. Neuroimaging is normal, CSF shows cryptococcal antigen testing. What is the Tx for this patient?

IV amphotericin B and oral flucytosine

**68 yo M with PMHx HDL, DM, HTN, s/p CABG and stents, presents with chest and abdominal pain. He says it feels like a tearing pain that radiates towards the back. BP 180/110, HR 116, RR 20, Temp 97.8. EKG shows normal sinus rhythm. Your order a CBC, CMP, PTT/PT, T&S and troponins. CT demonstrates a type B aortic dissection. How do you manage this patient now?

IV esmolol to control BP Pain control (morphine) Arrange for vascular surgery

***pt presents with pain out of proportion to the exam, and palpable gas in their left extremity. What is the next step?

surgery or consult surgery

60 y/o M presents with complaint that he can't walk more than a block without having to stop and rest. He also reports decreased sensation between his first and second toes. On physical exam, his legs are hyperpigmented bilaterally, with notably absent hair, and his toenails are thickened. The skin is cool to palpation. ABI is 0.24. How do you treat?

Intermittent claudication 1. Start on heparin as bridge to surgery 2. Aspirin 3. ASAP vascular surgery consult for angioplasty or femoral/popliteal bypass

36 y/o F presents with chest pain and shortness of breath. She denies any prior medical history, stating she is in good health and even just spent all of last month backpacking in the appalachian mountains. BP 134/90, HR 125, RR 20, Pulse ox 98%. EKG reveals a left bundle branch block. You order a CBC, ESR, CRP, LFTs and an Elisa test. Given your suspected diagnosis, how do you treat?

Lyme carditis Admission with continuous cardiac monitor Ceftriaxone 2g QD x 14 days

A 29-year-old highly promiscuous male with dysuria and purulent urethral discharge presents to an STD clinic for the first time. You give him I gm of azithro and ceftriaxone IM, and order a nucleic acid amplification test to confirm you dx. What is the best way to get a sample?

Males - Urine

***pt presents with ventricular tachycardia. You check their radial pulses and do not feel any. what is the best Tx at this point?

defibrillate

***pregnant patient with calf pain, swelling. What is the Dx test of choice?

doppler US

40 y/o M presents to the ED after a motor vehicle accident. He is short of breath, complains that his leg hurts a lot, and appears disoriented. BP is 84/62, HR 130, RR 25, Pulse ox 92%, Temp 96. You do a Fast Exam which reveals no evidence of internal hemorrhage, but his jugular vein is notably enlarged. What type of shock is this?

Obstructive (due to cardiac tamponade)

FLIP Sinus Bradycardia Atropine 0.5mg q3-5min

Patient with BP 92/62, RR 14, HR 38 and the following EKG. How do you treat?

68 y/o F with Pmhx of metastatic ovarian cancer presents with chest pain and SOB. BP is 85/50, RR 22, HR 115. On physical exam, heart sounds are distant. EKG demonstrates low voltage QRS and ultrasound reveals a hypoechoic line beneath the LV border. How do you manage this patient?

Pericardiocentesis hypoechoic line = fluid

FLIP Torsades Unstable --> cardioversion

Patient is 80/50, HR 160, RR 22 and presents with the following EKG. How do you treat?

A 66 year-old female with a history of CAD presents with a new onset of dizziness and fatigue. BP is 80/60. ECG reveals a heart rate of 50 with a normal PR interval followed by a normal QRS. There are several non-conducting P waves and no lengthening of the PR interval. What intervention is the therapy of choice?

Patient is hypotensive/unstable 1. Start Atropine 2. External pacing

DON'T PEEK JUST FLIP SVT and unstable: Immediate synchronized cardioversion

Patient presents with palpitations and lightheadedness. BP 70/40, HR 160, RR 20. EKG demonstrates the following. How do you treat?

FLIP Pulseless V Tach - Defibrillation

Patient presents with the following EKG. No pulse can be detected. How do you treat?

40 y/o M presents with fever, chills, malaise and body aches x 5 days. He denies recent sick contacts, noting he hasn't even been around anyone because he's been camping in the woods alone for the past month. Physical exam and labs are unremarkable. Rapid flu test is negative. How do you treat?

Sounds like lyme to me Doxycycline 100mg BID x 14d

77yo M pmhx HTN, HLD, T2DM, Asthma, CAD, s/p DAS 2009, HFrEF 40% BIBEMS from assisted living for altered mental status and new cough with thick green sputum, found with fever to 102F PO. SvCO2 53%, MAP 55, serum lactate 2.5. After giving him a bolus of fluids, you perform an ultrasound, which shows an IVC of normal caliber and his BP is still 70/40. What is the next step in management?

Start vasopressors: norepinephrine

40 y/o F presents with complaint of productive cough, fever and palpitations x 3 days. On physical exam, she is tachypnic, tachycardic and you can appreciate rales in the left lower lung field. What is the most common cause of this illness?

Strep Pneumo

***pt presents with chronic cough, hemoptysis, and night sweats. What is your first thought?

55 y/o M with hx of HTN and DMII presents with chest pain and shortness of breath x 2 hours. He states that he usually only has these symptoms while walking, but it's now become more frequent and intense, and persists at rest. EKG reveals T wave flattening in leads II, V1, V5 and V6. You give him ASA 81 x 4, and a sublingual nitro. Troponin is 0.2. What's the next step in your management?

Unstable Angina - Admit for observation: Serial EKGs Trend the troponin Maybe later: stress testing +/- angiogram

32yo physician who recently moved to the US from mainland China presents to clinic for yearly TB screening. the pt is asked during routine hx about any sxs and he denies chest pain, hemoptysis, wt loss, fever or chills. PPD is placed & 48hrs later reveals 10mm of induration & 5mm of erythema. CXR shows no acute cardiopulmonary disease or granuloma. which of the following is considered the management of choice? a) isoniazid + pyridoxine (B6) total duration tx for 9mths b) rifampin+ isoniazid + pyrazinamide + ethambutol (for 9mths) c) rifampin+ isoniazid + pyrazinamide + streptomycin (for 6mths) d) isoniazid + pyridoxine (B6) total duration tx for 12mths e) ceftriaxone + azithromycin

a) isoniazid + pyridoxine (B6) total duration tx for 9mths 1st step: determine if pt is +. PPD test (>10m), healthcare worker (physician) & immigrant (from China). He's + 2nd step: CXR to r/o active TB. CXR was negative and no sxs so his dx is latent TB infection. tx = mono therapy of Isoniazid (+pyridoxine (B6)) x 9mths

60 yo former smoker with controlled HTN presents to you with chest pain that he rates 10/10. He mentions he also has some back pain. PE shows pulse deficit in his radial arteries with BP 70/50. What is your next step in Dx?

bedside US then immediate surgery - aortic dissection

***pt presents with ripping pain to back. BP is 88/50. What is Dx modality of choice to confirm aortic dissection?

bedside US with urgent surgery

23yo thin male w/ 5 pack yr smoking hx presents to the ED w/ sudden onset of sharp chest pain worsened with inspiration and SOB. a CXR is obtained which shows a pneumothorax occupying 35% of the lung field & an otherwise unremarkable xray. which of the following is the next most appropriate step? a) chest tube thoracotomy b) observation & oxygen therapy c) insertion of large bore needle into the pleural space through the 2nd intercostal space followed by the chest tube thoracostomy d) avoid high altitudes or unpressurized aircrafts e) instillation of a sclerosing agent into the pleural space

a) chest tube thoracotomy c= tx for tension PTX

pt w/ long hx of innocent palpitations comes to the clinic complaining now of presyncopal sxs. She is admitted for evaluation & definitive therapy. which condition is a likely indication for implantation of a permanent cardiac pacemaker in this pt? a) 1st degree AV block b) Mobitz type I heart block w/ a HR of 72bpm c) 3rd degree heart block d) fascicular block w/o AV block

c) 3rd degree heart block

Which of the following would provide the most specific information regarding the functional cardiac status in a patient with chronic heart failure? A. Electrocardiogram B. Chest x-ray C. Serum electrolytes D. Echocardiogram

c) D. Echocardiogram will estimate ejection fraction, which is an indicator of left ventricular function.

23yom presents to ED w/ high fever, HA, joint pain& chest pain. his EKG is positive for 2nd degree heart block, which was not present in prior EKGs. a lumbar puncture is performed and is consistent w/ Lyme meningitis. which of the following is the tx of choice? a) oral amoxicillin b) IV ampicillin/sulbactam c) IV Ceftriaxone d) IV Gentamicin e) oral Doxycycline

c) IV Ceftriaxone

an IV drug user presents to the ED with persistent fever for the last 48hours. on PE, there is a holosystolic murmur that radiates to the axilla. echocardiogram shows vegetations on the mitral& tricuspid valves. preliminary gram stain shows gram+ cocci in clusters. which of the following is the recommended management of this pt? a) IV Ceftriaxone & gentamicin b) IV nafcillin & gentamicin c) IV vancomycin d) IV gentamicin e) IV penicillin G & gentamicin

c) IV vancomycin

82yof w/ hx of HTN & CAD presents to ED w/ orthopnea & dyspnea on exertion. she denies angina. over the past several days, she has noted a worsening of her dyspnea & now sleeps using 4 pillows. she now complains of dyspnea when she climbs the stairs to her bedroom. on PE, you note she is comfortably resting in the sitting position, her vitals are WNL she has 3cm of JVD, & 4+ pitting edema. she is not using accessory muscles to breathe & her pulse oximetry is 92% on RA. she has normal heart sounds other than an S4. rales are heard at the bases of the lung fields b/l; there is dullness to percussion over the lung bases as well. What is the lab test that you should order to confirm her diagnosis? a) arterial blood gas b) B-type natriuretic peptide c) dobutamine stress test d) CBC & troponin levels

b) B-type natriuretic peptide in HF associated w/ both normal& depressed LV function, B-type natriuretic peptide level is elevated.

65yof w/ poor dentition presents w/ a 4wk hx of fever of unknown origin. during the w/u, she is noted to have splinter hemorrhages and new onset of holosystolic murmur that radiates to the axilla (which was not present 2mths ago). she denies any IV drug use and there are no needle marks on the arms or legs. which of the following are the most likely echo and blood cx findings expected in this pt? a) Staphylococcus aureus & pulmonic valve b) Streptococcus viridans & mitral valve c) Staphylococcus aureus & tricuspid valve d) Staphylococcus epidermis & mitral valve e) Enterococcus & aortic valve

b) Streptococcus viridians & mitral valve infective endocarditis. MCC of subacute endocarditis is Streptococcus viridans which is part of the normal flora. in pts w/ poor dentition or gingivitis transient bacteremia w/ S. viridan causes subacute endocarditis. MC affects mitral > aortic > tricuspid > pulmonic

40yom presents to ED w/ generalized, pruritic rash consistent w/ urticaria. on PE, there are clear lung fields and no evidence of uvula or pharyngeal edema. which of the following is the management of choice? a) topical corticosteroids b) diphenhydramine oral c) fluconazole oral d) clonidine oral e) observation

b) diphenhydramine oral

48yo pt w/ hx of ionizing radiation to the chest wall presents to the ED with dyspnea & fatigue. PE reveals tachycardia, 4cm JVD, & slight peripheral edema of the extremities. ECG shows low-voltage QRS complexes & CXR demonstrates normal lung fields & cardiac silhouette. what test should be ordered next in this pt? a) Holter monitor b) echocardiogram c) cardiac catheterization d) stress test

b) echocardiogram

43yo previously healthy female presents to the ED w/ chest pain and palpitations. the sxs continue despite O2 & IV fluid therapy. her BP is 80/60. she is diaphoretic, dizzy & unable to speak in full sentences. her pulses are palpable but rapid. an ECG is performed, showing a regular, narrow complex tachycardia at 180bpm. there are no ST or T wave changes consistent w/ MI and the pt has no significant cardiac risk factors. which of the following is the recommended management of this pt? a) atropine b) synchronized cardioversion c) adenosine d) amiodarone e) unsynchronized cardioversion

b) synchronized cardioversion pt has an unstable tachycardia evident by CP, hypotension & persistent sxs. synchronized cardioversion is 1st line management of unstable tachycardia

A 59-year-old man presents to the emergency department (ED) complaining of new-onset chest pain that radiates to his left arm. He has a history of hypertension, hypercholesterolemia, and a 20-pack-year smoking history. His electrocardiogram (ECG) is remarkable for T-wave inversions in the lateral leads. Which of the following is the most appropriate next step in management? a. Give the patient two nitroglycerin tablets sublingually and observe if his chest pain resolves. b. Place the patient on a cardiac monitor, administer oxygen, and give aspirin. c. Call the cardiac catheterization laboratory for immediate percutaneous coronary intervention (PCI). d. Order a chest x-ray; administer aspirin, clopidogrel, and heparin. e. Start a β-blocker immediately.

b. Place the patient on a cardiac monitor, administer oxygen, and give aspirin.

***HIV pt presents with hypoxemia. Bronchoscopy and specimen analysis shows PCP PNA. What is the Tx?

bactrim PO 2 DS tabs TID daily or inpatient IV

24yof w/ premature atrial contractions (PACs) is quite symptomatic with her irregular heartbeat. Her HR is causing her to be very anxious about her health as well. what is the 1st line therapy for this woman? a) Class Ic antiarrhythmics b) digoxin c) metoprolol d) radio frequency ablation

c) metoprolol

which of the following is the 1st line management of choice for torsades de pointes in a pt w/ a palpable pulse? a) unsynchronized cardioversion b) procainamide c) amiodarone d) IV magnesium sulfate e) adenosine

d) IV magnesium sulfate

in evaluation of a pt with dizziness. an EKG shows constant PR interval of 0.24seconds w/ occasional dropped narrow QRS complexes. which of the following is the most likely diagnosis? a) 3rd degree heart block b) 1st degree heart block c) 2nd degree heart block Mobitz I d) 2nd degree heart block Mobitz II w/ aberrancy e) 2nd degree heart block Mobitz II

e) 2nd degree heart block Mobitz II

DONT PEEK..FLIP THE CARD e) verapamil--this rhythm strip shows afib. BB or CCB are 1st line management for afib or aflutter

in a hemodynamically stable pt with the following EKG, which of the following is considered the management of choice if vagal maneuvers fail to decrease the HR? a) adenosine b) unsynchronized cardioversion c) synchronized cardioversion d) amiodarone e) verapamil

pt presented with acute asthma attack. You treated and now want to test to see if they're back at their baseline. What should you do?

peakflow

***30 yo pt presents post-URI with chest pain. EKG shows ST elevations in leads I, II, III, AvF, AvL. What is the cause?

pericarditis

A quickie. MC causative organism of endocarditis?

staph aureus followed by strep

A 22 year-old patient complains of sudden onset of chest pain accompanied by shortness of breath. The patient appears dyspneic. On examination, the trachea is deviated to the left, breath sounds are faint on the right, and the right chest is hyperresonant to percussion. What is the next step in treating this patient? A. Perform an immediate tracheostomy. B. Perform a chest thoracostomy, placed in the 5th ICS anterior to the axillary line C. Perform a needle thoracotomy in the right 2nd intercostal space D. Get a Chest CT to confirm suspected diagnosis

tension pneumothorax --> C. 1. Immediate needle decompression (2nd ICS as mid clavicular line) THEN 2. Tube thoracostomy (4th - 5th ICS above rib just anterior to axillary line)

50 yo pt presents with dyspnea and orthopnea. PE shows tachycardia, rales, and a systolic murmur that diminishes before S2. Rales present bilaterally but CXR is normal. What Dx modality is your next step?`

transthoracic echo -suspect acute mitral regurg in pt with new onset marked pulmonary edema and normal CXR

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