IM - CHF & EKG, pericarditis, cardiac tamponade, atheroembolism, MVP, Aortic regurg

Adenosine - Pt presents w/ supraventricular tachycardia -A) ECG characteristics include: ---1) (1) Narrow QRS complex (< 120 ms, often times < 80 msec) ---(2) Absent p waves -------(or retrograde p waves in ST segment) ---(3) Short RP interval (if P waves are identifiable) -B) Signs/Symptoms ---1) Usually presents in young pts ---2) Feeling of Fluttering chest/palpitations/funny heart rate ---3) ± lightheadedness -B) MGMT ---1) Valsalva/Carotid massage ---2) Adenosine Procainamide - Used to treat sustained monomorphic ventricular tachycardia (SMVT), -A) Defined by the following characteristics: ---(1) Regular, wide QRS complex tachycardia at a rate of >100 beats/minute ---(2) Consecutive beats have a stable QRS morphology ---(3) Arrhythmia lasts ≥30 seconds or causes hemodynamic collapse ------[ECG does not show this]

(Q 1/2) A 17-year-old boy presents to the emergency department following a 10 minute period of "fluttering in his chest" while he was watching TV. He states that he has experienced numerous episodes of "funny heart rate" in the past few years, normally at rest and lasting less than ten minutes. The episode today was associated with some chest pressure and lightheadedness, which was new and concerning to him. He is otherwise healthy and takes no daily medications. He has no family history of heart disease or sudden death. He does not smoke, drink alcohol or use illicit drugs. During the evaluation, he begins to experience another episode of chest palpitations. His heart rate is 160/min and blood pressure is 110/60 mm Hg. His ECG is shown below. Which of the following is the next appropriate step in the management of this patient? (Adenosine VS Procainamide)

Impaired myocardial relaxation - Pt presents w/ CHF w/ preserved EF -A) Etiology ---1) Chronic → HTN Most common cause -B) Pathophysio ----Chronic HTN leads to a BIG, STIFF Heart (impaired relaxation) Systemic AV fistulas - Can present w/ High-output cardiac heart failure (assocaited w/ Pagets disease) - However, key differences are: ---1) Presents w/ HYPER-DYNAMIC circulation signs, including: ---a) Bounding pulse w/ quick upstroke ---b) Subungual capillary pulsations ---c) Venous hums -----[none present in this pt]

(Q 1/2) A 68-year-old man comes to the emergency department because of a 1-week history of worsening bouts of shortness of breath at night. He has had a cough for 1 month. Occasionally, he has coughed up frothy sputum during this time. He has type 2 diabetes mellitus and long-standing hypertension. Two years ago, he was diagnosed with Paget disease of bone during a routine health maintenance examination. He has smoked a pack of cigarettes daily for 20 years. His temperature is 37°C (98.6°F), pulse is 110/min, respirations are 25/min, and blood pressure is 145/88 mm Hg. Current medications include metformin, alendronate, hydrochlorothiazide, and enalapril. Examination shows bibasilar crackles. Cardiac examination shows a dull, low-pitched sound during late diastole that is best heard at the apex. There is no jugular venous distention or peripheral edema. Arterial blood gas analysis on room air shows: - pH---------------------------------7.46 - PCO2------------------------------29 - PO2--------------------------------83 - HCO3------------------------------18 Echocardiography shows a left ventricular ejection fraction of 55%. Which of the following is the most likely underlying cause of this patient's current condition? (Impaired myocardial relaxation VS Systemic AV fistulas)

Wolf-Parkinson-White - The classic sinus rhythm findings of WPW syndrome are as follows: ---(1) Short PR interval (< 120 msec) ---(2) Delta wave - the gentle upward slope of the PR segment into the QRS complex. - The most common arrhythmia associated with WPW syndrome is atrioventricular reentrant tachycardia (AVRT) ----(seen in question 1) Multifocal atrial tachycardia - The diagnosis of multifocal atrial tachycardia requires: --1) The identification of at least 3 p waves with different morphologies, ------(which is not consistent with the patient's initial ECG) ---2) Furthermore, the patient's repeat ECG demonstrates delta waves → which are pathognomonic for WPW

(Q 2/2) After appropriate medical management, his tachycardia resolves. He is seen in clinic one week later. A new ECG is shown below. Based on his history and ECG findings, which of the following is the most likely diagnosis? (Wolf-Parkinson-White VS Multifocal atrial tachycardia)

Furosemide - In the absence of other life-threatening conditions (e.g., acute coronary syndrome, shock) that require immediate attention → symptomatic treatment of this patient's pulmonary edema should come first in management Metoprolol - ALMOST NEVER USED UN ACUTE HF ----Used in Long-term MGMT of CHF ----(this pt is in acute setting) - His volume status should be the top priority

(Q 2/2) The serum brain natriuretic peptide and N-terminal pro-BNP are elevated. A diagnosis of heart failure with preserved ejection fraction is made. In addition to supplemental oxygen therapy, which of the following is the most appropriate initial step in management? (Metoprolol VS Furosemide)

Mg+ Sulfate - Pt is at high risk for developing Torsades (AGAIN) -A) Signs/Symptoms ----1) Qt prolongation --------a) Most likely caused by Sotalol & electrolyte abnormalities -----------1) Hyponatremia -----------2) Hypokalemia -----------3) ↑ BUN:Cr ------------4) Hypomagnesemia ----------------a) Pt MOST LIKELY has ----------------b) Hypomagnesemia should ALWAYS BE SUSPECTED in pts w/ electrolyte abnormalities (like the ones above) -B) MGMT → (For Torsades) -----a) TMT ---------1) Mg+ Sulfate → (DOC) ---------2) Temporary pacemaker -------------(if MG+ Sulfate ineffective) ---------3) IV isoproterenol -------------(if MG+ Sulfate ineffective) Procainamide - Contraindicated in pts w/ QT prolongation - QT prolongation is described in stem

(UWS2E1) A 56M, presents to the ED d/t 2 episodes of syncope over a 12-hrs period. The first episode occurred when he was having his morning breakfast, & the second episode happened while he was watching evening TV. He describes the episodes as sudden blackouts lasting 1-2 mins w/out any confusion afterwards. The pt has been feeing well otherwise w/ the exception of mild generalized weakness & a few recent bouts of diarrhea that he attributes to food poisoning. PMHx is sig for for CAD & paroxysmal A-fib. He underwent right coronary artery stent 3 years ago. Meds include simvastatin, aspirin, clopidogrel, & lisinopril. He also recently started sotalol for maintenance of sinus rhythm. In the ED, BP is 130/90 & pulse is 60/min w/ a regular rhythm. Chest exam reveals clear lungs & normal heart sounds. An ECG done in the ED shows normal sinus rhythm. PR interval prolongation to 0.21 sec, QT prolongation to 0.56 sec, & no significant ST segment or T-wave changes. Labs show: - Na+-----------------------------133 - K+-------------------------------3.1 - BUN----------------------------32 - Cr-------------------------------1.3 Which of the following is the best initial TMT for this pt? (Mg+ Sulfate VS Procainamide)

Metoprolol - Certain β-blockers have been shown to improve symptoms & overall long-term survival in stable pts w/ CHF & LV systolic dysfunction (defined as pts LV EF <40%) -A) Meds include: ----1) Metoprolol ----2) Carvedilol ----3) Bisoprolol - Other meds that improve survival in CHF + LV dysfunction are: ----1) ACEI's/ARBs ----2) Aldosterone antagonists ----3) Hydralazine (African Americans) ----4) Nitrates (African Americans) Amlodipine - Used primarily to treat HTN - Not used in CHF

(UWS2E1) A 63M, presents for SOB on exertion. He can barely walk 1 block w/out becoming SOB & has to sleep w/ multiple pillows b/c he had been uncomfortable lying flat recently. The pt also has heaviness in his legs & gained 10-lbs over the last 2 months despite having a decreased appetite. He does not have any chest pain or wheezing but has occasional palpitations. PMHx is sig for DM II, HTN, & hyperlipidemia. He sustained an anterior MI 10 years ago but has had very poor medical follow-up since. He was taking Metformin & aspirin in the past but stopped more than 1 year ago. He is an ex-smoker w/ a 35-py Hx. He does not drink & is not allergic to any meds. His BP is 134/85 & pulse is 75/min & regular. His BMI is 30. He is not in acute respiratory distress. PE reveals moist mucous membranes & scattered bibasilar lung crackles. The cardiac point of max impulse is displaced to the left & a third heart sound is heard. The abd is soft & non-tender to palpation. He has 1+ bilateral pithing ankle edema. Fingerstick glucose is 144 & serum Cr is 0.9. After optimal diuresis w/ loop diuretics, which of the following meds should be used for the best long-term outcomes? (Metoprolol VS Amlodipine)

Calcification of vascular leaflets - A systolic ejection murmur is classically associated w/ Aortic stenosis - Both Answer choices can cause aortic stenosis - Differentiation is based on age: ----A) Older Pt (>60) --------Calcification of leaflets ----b) Younger Pt (40-50) ---------Bicuspid aortic valve

(UWS2E1) A 72M, presents for a routine PE. He reports that he feels well overall. He walks 2-3 miles/day w/out SOB or chest pain. He takes no meds aside from a Multivitamin every day. On PE, his BP is 150/80 & HR is 75/min. Auscultation of the right upper sternal border reveals a systolic ejection murmur that radiates to the carotids. Which of the following is the most likely cause of this pts PE finding? (Calcification of the vascular leaflets VS Bicuspid aortic valve)

Amiodarone -aMio → ----"M" → monomorphic tachy (wide) - pt presents w/ MONOMORPHIC Ventricular tachycardia -A) ECG findings associated w/ MONOMORPHIC V-tach include: -----1) WIDE, REGULAR QRS complex ---------(QRS complex last longer than 140msec) -A) MGMT → (dependent on HEMODYNAMIC STATUS) ---a) Hemodynamically stable --------1) Amiodarone → (Class IA antiarrhythmics) --------2) Lidocaine → electric cardioversion ---b) Hemodynamically unstable --------1) Immediate high-quality chest compressions & Direct-current cardioversion Adenosine -Used in the TMT of PAROXYSMAL SVT -This also presents as tachycardia -Howeever the key differences include: ---1) ABRUPT onset & termination -------[pt had an abrupt onset but it HAS NOT terminated] ---2) ECG characteristics ------a) NARROW QRS complex ----------[pt has WIDE QRS complex]

(UWS2T1) A 53M, presents to the ED from a local restaurant after he had a sudden onset of retrosternal burning & dizziness. The pt has a PMHx sig for hyperlipidemia & HTN that is well-controlled. He has NKA to medications. On PE, he appears uncomfortable but is interactive & speaking in full sentences, w/no respiratory distress & no chest pain. BP is 100/60 & pulse is 210/min. Pulse Ox is 95% on room air. Cardiac exam is notable for sig tachycardia w/no audible murmurs; lung exam is unremarkable. ECG is shown. Which of the following meds is most likely to improve this pts condition? (Adenosine VS Amiodarone)

Early reperfusion - Pt presents w/ acute pericarditis → specifically PERI-INFARCTION pericarditis -1) Presentation ---a) presents 2-4 days following MI - 2) Prevention ---Early reperfusion therapy (High dose Aspirin) Antibiotics - Prevents endocarditis (not pericarditis)

A 78M, w/ mild dementia is hospitalized d/t chest discomfort, breathing difficulty, & agitation. The initial Dx was exacerbation of COPD, but he was later Dx'd w/ acute MI. The pt gets confused in the evening & refuses meds. On the 3rd day of hospitalization, he has sharp chest pain & does not want to lie down. A friction rub Is heard along the left sternal border. Which of the following would have most likely prevented this pts current condition? (Antibiotics OR Early reperfusion)

Bicuspid aortic valve -A) Signs/Symptoms (of aortic valve insufficiency include: ---1) Wide pulse pressure ------(pt has 132/60 BP) ---2) Decrescendo early diastolic murmur best heard long left sternal border ---3) Head bobbing ---4) Hx of dyspnea & palpitations ---5) Hx of rheumatic disease Myxomatous degeneration - Also presents w/ palpitations & dyspnea - However, key differences are: ---1) Usually presents w/ Marfans, Ehlers-Danlos ------(pt does not have this in Hx) ---2) Murmur presentation ------Murmur associated w/ myxomatous degeneration is MVP ------MVP presents w/ a Systolic murmur w/ click --------[pt has a diastolic murmur]

A 20-year-old man comes to the emergency room because of palpitations and mild dyspnea for the last 2 hours. He has had similar episodes in the past that resolved within 20 minutes, but they have been worsening since he started training for his first marathon 1 month ago. Ten years ago, he was treated for streptococcal pharyngitis with a 10-day course of penicillin. His maternal uncle passed away unexpectedly from a heart condition at age 40. He is 180 cm (5 ft 11 in) tall and weighs 85 kg (187 lb); BMI is 26.2 kg/m2. His temperature is 36.5°C (97.7°F), pulse is 70/min, respirations are 18/min, and blood pressure is 132/60 mm Hg. On examination, there is a decrescendo early diastolic murmur heard best along the left sternal border. His head slightly bobs about every second. The remainder of the examination shows no abnormalities. Which of the following is most likely to be present? (Myxomatous degeneration VS Bicuspid aortic valve)

IV ceftriaxone - Pt presents w/ Lyme carditis -A) RF ---1) Had a camping trip 6 weeks ago ------(typically occurs 3-10 weeks after bite) -B) Signs/symptoms ---1) Had an episode of flu + fever & chills ~1 month ago ---2) Dyspnea & palpitations that have worsened -C) Labs ---1) Positive two-step serology -D) ECG ---1) Mobitz Type 1 → 2nd degree AV heart block -------(characteristic for lyme carditis) -E) MGMT ---1) Ceftriaxone (3rd gen cephalosporin) → FIRST LINE Beta Blocker - Contraindicated in AV block b/c it can LOWER the pts BP ---(pt is bradycardic) Doxy - Used to treat patients with localized and some manifestations of early disseminated lyme disease → including mild carditis (palpitations) - However, the pt presents w/ SEVERE carditis evident by the AV block → which requires a 3rd gen cephalosporin

A 24-year-old woman comes to the emergency department because she has had dyspnea and palpitations occurring with mild exertion for the past 8 days. At first, the symptoms subsided immediately after cessation of activity, but they have become worse and now last up to 45 minutes. The patient returned from a summer camping trip in Vermont 6 weeks ago. Except for an episode of flu with fever and chills a month ago, she has no history of serious illness. Her father had a myocardial infarction at the age of 56. She drinks two to four beers on social occasions and occasionally smokes marijuana. Her temperature is 37°C (98.6°F), pulse is 47/min, respirations are 20/min, and blood pressure is 150/70 mm Hg. A resting ECG is shown. Two-step serological testing confirms the diagnosis. Which of the following is the most appropriate next step in management? (Beta-Blocker therapy VS Doxy VS IV ceftriaxone)

Bedside cardiocentesis - Pt presents w/ cardiac tamponade - MGMT is based on the CAUSE & Hemodynamic status - Hemodynamic status takes PRIORITY -A) MGMT ---a) Hemodynamically UNSTABLE (REGARDLESS OF CAUSE) -------a) Bedside cardiocentesis ---b) Hemodynamically stable + CAUSE SPECIFIC TMT ------1) NSAIDS & prednisone ----------Stable + Pericarditis ----------(Pt has a Hx of Low-grade fever → which suggests PERICARDITIS as the cause) Pericardial window - long-term treatment for: ---1) Recurrent pericardial effusion ---2) An unstable trauma patient in the operating room ------[not a TMT for cardiac tamponade]

A 37-year-old man presents to the Emergency Department with chest pain and shortness of breath. He explains that he has also had a low-grade fever for the past week. Upon arrival his temperature is 38.1°C (100.5°F), pulse is 105/minute, respirations are 24/minute, and blood pressure is 90/50 mm Hg and his systolic blood pressure is noted to drop to 75 mm Hg upon inspiration. On physical examination, the patient appears to be in distress. Cardiac auscultation reveals tachycardia and muffled heart sounds without murmurs, rubs, or gallops. His neck veins appear distended. No carotid bruits are present. Respiratory examination is unremarkable. Which of the following is the most appropriate next step in this patient's care? (Bedside cardiocentesis VS Pericardial window VS NSAIDs & Prednisone)

Accessory Av pathway - Pt presents w/ WPW syndrome -A) ECG characteristics ----1) Initial SLURRING of upstroke ----2) SHORT PR interval & WIDE QRS complex -A) Pathophysio ----1) Most common cause is accessory AV pathway Ectopic Foci w/in ventricles - This is the pathophysio of premature ventricular beats - Can also present w/ lightheadedness, dizziness, & palpitations - However, key differences include: ---1) Characteristic ECG findings: ------a) QRS complexes w/ BLOCK-LIKE morphology ------b) Often a compensatory phase after each QRS complex ---2) Additionally, PVB DO NOT usually cause loss of consciousness

A 40-year-old man is brought to the emergency department 20 minutes after his wife found him unconscious on the bathroom floor. On arrival, he is conscious and alert. He remembers having palpitations and feeling lightheaded and short of breath before losing consciousness. He takes captopril for hypertension and glyburide for type 2 diabetes mellitus. His vitals are within normal limits. Physical examination shows no abnormalities. Random serum glucose concentration is 85 mg/dL. An ECG shows a short PR interval and a wide QRS complex with initial slurring. Transthoracic echocardiography reveals normal echocardiographic findings with normal left ventricular systolic function. Which of the following is the most likely underlying cause of this patient's findings? (Accessory AV pathway VS Ectopic foci w/in ventricles)

Neutrophilic infiltration of the pericardium - Pt presents w/ pericarditis -A) Pathophysio of pericarditis includes: ---1) ACUTE pericardium changes → (Pt presented w/in the last 3 days) -------a) Neutrophilic infiltration of the pericardium ---2) LONG-TERM pericardium changes -------a) Fibrotic thickening of the pericardium

A 51-year-old woman comes to the physician because of a 3-day history of worsening shortness of breath, nonproductive cough, and sharp substernal chest pain. The chest pain worsens on inspiration and on lying down. The patient was diagnosed with breast cancer 2 months ago and was treated with mastectomy followed by adjuvant radiation therapy. She has hypertension and hyperlipidemia. Current medications include tamoxifen, valsartan, and pitavastatin. She has smoked a pack of cigarettes daily for 15 years but quit after being diagnosed with breast cancer. Her pulse is 95/min, respirations are 20/min, and blood pressure is 110/60 mm Hg. Cardiac examination shows a scratching sound best heard at the left lower sternal border. An ECG shows sinus tachycardia and ST segment elevations in leads I, II, avF, and V1-6. Which of the following is the most likely underlying cause of this patient's symptoms? (Fibrotic thickening of the pericardium VS Neutrophilic infiltration of the pericardium)

Occlusion of the LAD - Pt has persistent elevations in -A) ECG values that indicate the LAD are ST elevations in: ---1) Lead I ---2) aVL ---3) V1-V6 → most prominent between V2-V4 RCA -A) ECG values associated w/ RCA occlusion can cause two infarctions ----1) Inferior wall ----2) Right ventricle -A) INFERIOR WALL infarction would include ST elevations in: ---1) Lead II ---2) Lead III ---3) aVF -A) RV infarction would include ST elevations in ---1) V1 ---2) V3-V6 -On right sided ECG -B) Signs & symptoms ---1) RV infarction would lead to SEVERE HYPOTENSION -------[pt BP is NORMAL]

A 57-year-old man is brought to the emergency department for crushing substernal chest pain at rest for the past 2 hours. The pain began gradually while he was having an argument with his wife and is now severe. He does not take any medications. He has smoked 1 pack of cigarettes daily for 35 years. He is diaphoretic. His temperature is 37.1°C (98.8°F), pulse is 110/min, respirations are 21/min, and blood pressure is 115/65 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Cardiac examination shows an S4 gallop. The lungs are clear to auscultation. An ECG is shown. Which of the following is the most likely underlying cause of this patient's condition? (Occlusion of the RCA VS Occlusion of the LAD)

Atheroembolism - Pt most likely has an atheroembolism based on -A) RF ---1) Coronary catheterization & stent placement ---2) Hx of significant atherosclerotic disease ------(funduscopy reveals plaques in renal arterioles) -B) Signs/Symptoms ---1) Mottled lace-like bluish rash & pain on BILATERAL LE's → especially toes Arterial thromboembolism - Can also be a cause of embolism - However, key differences are ---1) Coronary catheterization & Stent placement are not a RF for arterial thromboembolism - Pt would have Hx of pain w/ increased activity (claudication) or with cold (Raynauds) - Arterial thromboembolism and acute limb ischemia presents with the classic 6 Ps: --1) Pain, --2) Pallor, --3) Pulselessness, --4) Poikilothermia, --5) Parasthesia, and --6) Paralysis. - Furthermore, arterial thromboembolism of the limbs is most commonly unilateral -----[Pts LE are affected BILATERALLY] Venous thromboembolism - Can also be a cause of embolism - However, key differences are ---1) Coronary catheterization & Stent placement are not a RF for venous thromboembolism ---2) Venous thromboembolism of the lower extremity presents with unilateral swelling, erythema and warmth - Not associated w/ changes in skin color ----[pt has blue toes] ----[Pts LE are affected BILATERALLY]

A 63-year-old man presents to the emergency department complaining of bilateral toe pain for the past three hours. The pain came on suddenly while he was sleeping earlier in the morning. He is also complaining of a diffuse headache that began one hour ago. His medical history is significant for type 2 diabetes mellitus, hyperlipidemia, angina, and hypertension. Three weeks ago he suffered a myocardial infarction and underwent emergency coronary catheterization and stent placement. On physical examination, his temperature is 38.0ºC (100.4ºF), heart rate is 100/min, respirations are 16/min, and blood pressure is 185/100 mm Hg. Fundoscopic examination reveals plaques in the retinal arterioles. On cardiac ascultation, there is a normal S1 and S2 with a regular rate and rhythm. Lungs are clear to auscultation. Abdomen is moderately tender to palpation in all quadrants, without rebound or guarding. There is a mottled, lace-like bluish rash on his lower extremities, and his toes are dusky and painful to touch. Which of the following is the most likely explanation for the patient's current condition? (Arterial thromboembolism VS Atheroembolism VS Venous thromboembolism)

Atrial gallop - Pt presents w/ signs concerning for ATYPICAL MI -A) RF ---1) Diabetic pt ---2) Female -B) Signs/Symptoms (of Atypical MI) ---1) dyspnea, ---2) nausea/vomiting, ---3) palpitations -------(as opposed to typical chest pain → due to diabetic neuropathy of the autonomic nervous system) -C) ECG findings ---1) ST-elevation confirms the presence of MI -D) Cardiac Exam findings ---1) Atrial gallop ------(as a result of a LARGE, STIFF VENTRICLE) Ventricular gallop -Caused by a sudden deceleration of blood flow from the left atrium into the left ventricle during early diastole - This finding can be normal in: ---1) young adults (< 40 years) ---2) pregnant women, -------[but it is ABNORMAL IN OLDER ADULTS]

A 64-year-old woman comes to the physician because of worsening intermittent nausea and burning pain in her upper abdomen for 4 hours. She has not had retrosternal chest pain, shortness of breathing, or vomiting. She has hypertension and type 2 diabetes mellitus. She has smoked one pack of cigarettes daily for 20 years. Her only medications are lisinopril and insulin. Her temperature is 37°C (98.6°F), pulse is 90/min, respirations are 12/min, and blood pressure is 155/75 mm Hg. The lungs are clear to auscultation. The abdomen is soft, with mild tenderness to palpation of the epigastrium but no guarding or rebound. Bowel sounds are normal. An ECG is shows ST elevation. This patient's current condition is most likely to cause which of the following findings on cardiac examination? (Ventricular gallop VS Atrial Gallop)

Clopidogrel - Pt presents w/ an MI and RECEIVES REPERFUSION THERAPY - MGMT for pts that are POST-reperfusion therapy includes -A) MGMT ---1) Dual anti-PLTS therapy → Usually aspirin + Clopidogrel -------(for 6-12 months) ---2) ACEI ---3) β-blocker ---4) High-dose statin Spironolactone - Treatment with an aldosterone receptor antagonist is indicated following an acute myocardial infarction in patients with: ---1) left ventricular dysfunction (LVEF ≤ 40%) who develop symptoms of congestive heart failure, including --------a) paroxysmal nocturnal dyspnea, --------b) dyspnea on exertion, --------c) orthopnea, --------d) lower extremity edema --------e) or have a history of diabetes mellitus ----[pt does not meet this criteria] Propranolol - This is used as post-reperfusion prophylaxis - However, dual anti-PLTS therapy is most important → therefore should administered first

A 65-year-old man is brought to the emergency department 30 minutes after the onset of acute chest pain. He has hypertension and asthma. Current medications include atorvastatin, lisinopril, and an albuterol inhaler. He appears pale and diaphoretic. His pulse is 114/min and blood pressure is 130/88 mm Hg. An ECG shows ST-segment depressions in leads II, III, and aVF. Laboratory studies show an increased serum troponin T concentration. The patient is treated for acute coronary syndrome and undergoes percutaneous transluminal coronary angioplasty. At the time of discharge, echocardiography shows a left ventricular ejection fraction of 58%. In addition to aspirin, which of the following drugs should be added to this patient's medication regimen? (Clopidogrel VS Spironolactone VS Propranolol)

Echo - Pts presents w/ CHF -A) MGMT ---a) Diagnostic test ------1) Echo ---------(b/c it can calculate the extent of valve damage) CT - Will show cardiomegaly, but cannot give any details on the extent of valve damage

A 67-year-old man presents to the outpatient clinic complaining of a 3-month history of worsening dyspnea on exertion. He is fairly sedentary, but even minor activities, such as climbing the stairs or walking one block, leave him short of breath. He has been sleeping with three pillows at night because, "it's harder to breathe when I lay flat." He denies productive cough, fever, or chills. He denies chest pain, nausea, diaphoresis, palpitations, lightheadedness or syncope. Past medical history is significant for coronary artery disease with a multi-vessel coronary artery bypass surgery completed 4 years ago. His medications include aspirin, lisinopril, and atorvastatin. He has a 50-pack-year history of smoking and quit one year ago; he does not drink alcohol. His temperature is 36.7ºC (98.3ºF), pulse is 78/min, respirations are 14/min and non-labored, and blood pressure is 144/88 mm Hg. Jugular venous pulsation is measured at 10 cm. Lungs are clear and cardiac exam reveals an S3 gallop but not additional murmurs. Hepatojugular reflex is negative. There is no jaundice or stigmata of liver disease on skin examination. There is 3+ lower extremity edema to the shins bilaterally. A chest x-ray is shown. Which of the following is the next appropriate step in the diagnosis of this patient's underlying condition? (Echo VS CT of chest)

Myxomatous valve degneration - Pt presents a/ acute mitral regurg -A) Signs/Symptoms (of myxomatous valve degeneration) ---1) Usually presents w/ Marfans, Ehlers-Danlos ------(pt does not have this in Hx) ---2) Anxiety, palpitations ---3) Occasional sharp chest pain -B) Murmur presentation ----1) Murmur associated w/ myxomatous degeneration is MVP → presents w/ a Systolic murmur w/ click -------(pt has holo-SYSTOLIC murmur w/ mid-systolic CLICK Overproduction of catecholamines - This describes a pheochromocytoma → which can also presents w/ anxiety, palpitations, & chest pain - However, key differences are: ---1) Pheo usually presents as a group in other disorders (MEN I, MEN II) ------[Pt has no Hx of this] ---2) Pheo also presents w/ other key characteristics including: -------a) Headaches -------b) Pallor -------c) Diaphoresis -------d) HTN crisis ----3) Pheo NOT ASSOCIATED w/ holosystolic murmur w/ a click or acute mitral regurg symptoms (i.e., dyspnea)

A 68-year-old man comes to the emergency department because of a 1-week history of difficulty breathing. He has had recurrent palpitations over the past 2 years. During this time, he has also had several episodes of anxiety despite no change in his daily life. He has occasional sharp chest pain localized to the left upper sternal border. He has no abdominal pain or leg swelling. Two years ago, he had streptococcal pharyngitis, which was promptly treated with a 10-day course of penicillin. He has never traveled outside of the country. His temperature is 36.5°C (97.7°F), pulse is 82/min, and blood pressure is 140/85 mm Hg. Physical examination shows a 3/6 holosystolic murmur that is loudest at the apex and radiates to the axilla with a mid-systolic click. Bilateral fine crackles are heard on lung auscultation. Which of the following is the most likely cause of this patient's symptoms? (Myxomatous valve degneration VS Overproduction of catecholamines)

Hyperkalemia - Aldosterone has two main actions ---1) Na+ absorption ---2) K+ excretion - If we block the action of aldosterone, well will have DECREASED K+ excretion leading to HYPERKALEMIA

A 75-year-old Caucasian man presents to his cardiologist for evaluation of worsening dyspnea on exertion. For the past three weeks he has had increasing difficulty performing his daily tasks without getting short of breath and now cannot walk a full block without stopping to rest. His past medical history is notable for a coronary artery disease, hypertension, hyperlipidemia, and obesity. His medications include aspirin, pravastatin, labetalol, lisinopril, and an over-the-counter multivitamin. On physical examination, his temperature is 37.0ºC (98.6ºF), pulse is 88/min, respiratory rate is 16/min, and blood pressure is 132/108 mm Hg. There is jugular venous distension, a III/VI systolic murmur at the apex, and bilateral crackles on lung auscultation. An echocardiogram is completed and is significant for an estimated left ventricular ejection fraction of 35-40%. His cardiologist decides to initiate treatment with an aldosterone antagonist. Which of the following electrolyte abnormalities may be expected in this patient after treatment initiation? (Hypokalemia VS Hyperkalemia)

Decreased serum Na+ - In pts w/ CHF → ADH secretion INCREASES (d/t baroreceptors) - This causes an INCREASE in free water absorption leading to decreased Na+ absorption (HYPONATREMIA) Increased heart rate variability - In patients with CHF, DECREASED beat-to-beat variation in heart rate is associated with a poor prognosis → because it signifies sympathetic overactivity

A 75-year-old man is brought to the emergency department for a 5-day-history of worsening dyspnea, orthopnea, and lower leg swelling. He has a history of hypertension, hyperlipidemia, non-alcoholic fatty liver disease, and myocardial infarction 10 years ago. Current medications include metoprolol, lisinopril, ethacrynic acid, eplerenone, and aspirin. He drinks 1 beer daily. He has a 30-pack-year smoking history. He is allergic to sulfonamides. His temperature is 37.0°C (98.6°F), his pulse is 120/min, and his blood pressure is 120/80 mm Hg. Physical examination reveals jugular venous distention and 3+ pitting edema in his lower legs. Crackles are heard at both lung bases. The point of maximal impulse is 2 cm to the left of the midclavicular line in the 6th intercostal space. Which of the following additional findings would be most strongly associated with increased mortality? (Decreased serum Na+ VS Increased heart rate variability)

Procainamide - The patient has sustained monomorphic ventricular tachycardia (SMVT), -A) Defined by the following characteristics: ---(1) Regular, wide QRS complex tachycardia at a rate of >100 beats/minute ---(2) Consecutive beats have a stable QRS morphology ---(3) Arrhythmia lasts ≥30 seconds or causes hemodynamic collapse - B) MGMT → Dependent on hemodynamic status ---a) Hemodynamically STABLE -------1) IV procainamide → (also amiodarone/sotalol) ---b) Hemodynamically UNSTABLE -------2) Cardioversion Adenosine - Adenosine is used to diagnose and treat narrow QRS complex supraventricular tachycardia (SVT), not ventricular tachycardia -A) Supraventricular tachycardia ECG characteristics include: ---(1) Narrow QRS complex (< 120 ms, often times < 80 msec) ---(2) Absent p waves -------(or retrograde p waves in ST segment) ---(3) Short RP interval (if P waves are identifiable)

A 76-year-old woman is hospitalized for altered mental status. Urinalysis shows >50 white blood cells per HPF and many bacteria. She is started on empiric antibiotics while urine cultures and sensitivities are pending. Her past medical history is significant for myocardial infarction seven years ago and type 2 diabetes mellitus, for which she takes aspirin, metoprolol, lisinopril, metformin, and glipizide. On the third day of hospitalization, she has an abnormal tracing on telemetry. On physical examination, her heart rate is 140/min, and blood pressure is 135/88 mm Hg. She is awake, alert, and fully oriented. She denies any lightheadedness, chest pain, or palpitations. A portion of her ECG is shown. Which of the following is the next best step in the management of this patient? (Adenosine VS Procainamide)

Increased insulin release - Pt most likely has re-feeding syndrome -A) RF ----1) Chronically malnourished pt has re-initiation of nutrition -B) Abnormal labs ----1) Causes an INTRACELLULAR SHIFT of --------(Ca+, K+, Mg2+. Phosphorus) -C) Signs/Symptoms -----1) Paresthesias -----2) Prolonged QT -----3) Palpitations -----4) Cardiac arrhythmias/murmurs -----5) Bradycardia -----6) Hypotension -----7) peripheral edema Uncompensated metabolic acidosis - Can also causes paresthesias, QT prolongation & arrhythmias/palpitations - And Would present in the setting of Hypocalcemia & hypokalemia ---1) Uncompensated metabolic acidosis usually seen in the setting of: -------a) Eating disorders (Anorexia/bulimia) -------b) Laxative abuse ---2) However - KEY DIFFERENCE: -------a) PHOSPHORUS would be NORMAL -------------[pt has DECREASED phosphorus]

Four days after admission to the hospital for anorexia nervosa, a 20-year-old woman has new-onset palpitations and paresthesias in all four limbs. Prior to admission, she was found unconscious by her parents on the floor of a residential treatment center. The patient was started on a trial of nutritional rehabilitation upon arrival to the hospital. Her temperature is 36°C (96.8°F), pulse is 47/min, and blood pressure is 90/60 mmHg. She is 160 cm tall and weighs 35 kg; BMI is 14 kg/m2. The patient appears emaciated. Examination shows lower leg edema. A 2/6 holosystolic murmur is heard over the 5th intercostal space at the midclavicular line. AN ECG shows intermittent supraventricular tachycardia and QTc prolongation. Serum studies show: ------------------------DAY 1----------DAY2---------- - Ca+-------------------8.5-------------7.8----------- - K+---------------------3.5-------------2.7----------- - Mg2+------------------1.2-------------0.5----------- - Phosphorus-----------3.6-------------1.5---------- Which of the following is the most likely underlying cause of this pts condition? (Uncompensated metabolic alkalosis VS Increased insulin release)

Pericardial window -The pt presents w/a cardiac tamponade d/t pleural effusion → Effusion is most likely caused by malignancy -A) MGMT ----b) TMT --------1) Pericardiocentesis/pericardial window Administration of increased dose of furosemide - Although the pt presents w/ signs of fluid overload (Bilateral lung crackles), the presence of: ----1) Distant heart sounds ----2) Hypotension ----3) Alternating QRS amplitude on ECG ----4) Cardiomegaly on CXR -Indicate cardiac tamponade - Cardiac tamponade is quickly fatal & must take priority

NBME CK 7 A 50F, w/a 5-year Hx of metastatic breast cancer has had SOB for 8 hours. Pulse is 116/min, RR are 32/min, & BP is 90/60. End-inspiratory crackles are heard at the base of both lung fields. Exam shows JVD. Distant heart sounds are heard. ABG shows: -pH------------------7.50 -PCO2---------------28 -PO2-----------------78 A CXR shows cardiomegaly. An ECG shows alternating amplitude of QRS patterns. Echo shows paradoxical motion of the IV septum & pericardial effusion. Which of the following is the most appropriate next step? (Pericardial window OR Administration of increased dose of furosemide)

Lorazepam - Pt is presenting w/ signs of cocaine induced cardiac dysfunction -A) ECG findings ----1) Signs of myocardial ischemia -------a) ST elevations (I, aVL, V1-V6) -B) Signs/symptoms ----1) Tachycardia & Chest pain -C) MGMT ----a) TMT -------1) Lorazepam, Nitroglycerin, aspirin (FIRST LINE) -------2) PCI & Coronary angiography ----------a) Pts refractory to first line meds Nifedipine - Can also be used IN PLACE of Benzos → ONLY if BENZOS are NOT AVAILABLE - However, Benzos are PREFERRED

SGU A 24-year-old woman presents to the emergency department for chest pain that began approximately 1 hour ago. She denies any trauma to the chest and describes the pain as a "pressure-like" sensation affecting the middle of the chest. She has no medical history and takes oral contraceptive pills. A few hours ago she attended a party where she was smoking crack cocaine and subsequently developed this chest pain. Her blood pressure is 175/105 mmHg, pulse is 108/min, and respirations are 18/min with an oxygen saturation of 99% on room air. Chest auscultation is unremarkable. An electrocardiogram is demonstrated in Figure A. Which of the following is the most appropriate next step in management? (Nifedipine VS Lorazepam)

Fibrofatty replacement of the myocardium - Pt has signs of arrhythmogenic right ventricular cardiomyopathy (ARVC) -A) ECG findings ----1) Epsilon wave w/ T-wave inversions + prolonged S-wave upstroke -B) Signs/Symptoms ----1) Palpitations ----2) Syncope ----3) Chest pains, cardiac death -C) MGMT ----a) TMT -------1) Sotalol -------2) Implantable cardiac defibrillator Cardiac muscle hypertrophy - Also presents w/ Syncope & palpitations - However, key differences include: ---1) ECG w/ Increased voltages ---2) Symptoms would occur DURING EXERCISE/PHYSICAL ACTIVITY -------[pt was not exercise prior to syncope]

SGU A 27-year-old man presents to the emergency department after an episode of palpitations followed by syncope. He awoke after being unconscious for several seconds but still has a sensation of palpitations. The patient is not currently followed by a primary care doctor but states that he has never had any health problems. His temperature is 98.5°F (36.9°C), blood pressure is 133/91 mmHg, pulse is 95/min, respirations are 19/min, and oxygen saturation is 99% on room air. An electrocardiogram (ECG) is performed as seen in Figure A. Which of the following is the most likely diagnosis? (Cardiac muscle hypertrophy VS Fibrofatty replacement of the myocardium)

Sodium Bicarbonate - Pt most likely presents w/ TCA OD -A) Related ECG findings -----1) QRS widening → (MOST SPECIFIC TO TCA OD) -B) Signs/Symptoms → (anti-cholinergic symptoms) -----1) Dry mouth -----2) Dry eyes -----3) Hot/flushed dry/moist skin -----4) Constipation -----5) Altered mental status Flumazenil - Given in case of Opioid OD - However, Pts RR would be <8 -----[pts RR is 13]

SGU A 27-year-old woman was found unconscious by one of her roommates. When the roommate was unable to arouse the patient, she immediately brought her into the emergency department. The roommate states that the night before, they had held a party at their house. The roommate admits that there was considerable alcohol and substance use at the event. The patient is currently minimally responsive. The patient has a past medical history of asthma, severe anxiety, alcohol dependence, marijuana use, and occasional IV drug use. An EKG is obtained as seen in Figure A. A head CT is normal. Lab results are ordered and are below: - Na+----------------------------------------142 - Cl------------------------------------------105 - K+------------------------------------------4.2 - HCO3--------------------------------------24 - BUN----------------------------------------11 - Glucose------------------------------------69 - Cr-------------------------------------------1.1 - Ca+-----------------------------------------9.8 - AST-----------------------------------------14 - ALT------------------------------------------15 - Hb-------------------------------------------13 - HCT-----------------------------------------39% - Leukocyte count---------------------------6K - PLTS----------------------------------------150K Her temperature is 99.5°F (37.5°C), pulse is 112/min, blood pressure is 100/70 mmHg, respirations are 13/min, and oxygen saturation is 97% on room air. The patient is not responsive enough for a full physical exam. The patient's pupils are responsive to light, and her skin is warm and moist. Which of the following is the next best step in management? (Flumazenil VS Sodium Bicarbonate)

Adenosine - Pt is showing signs concerning for SUPRA-ventricular tachycardia -A) ECG findings ----1) Tachycardia ----2) NARROW QRS complexes -B) MGMT -----a) Dx test --------1) ECG -----b) TMT → Based on hemodynamic status --AA) Hemodynamically STABLE ------1) Vagal maneuvers/carotid massage → BEST INITAL TMT ----------a) Breath holding, Valsalva, urination ------2) Adenosine/verapamil ------------a) PTs REFRACTORY to INITIAL TMT ------------a) Adenosine > Verapamil --BB) Hemodynamically UN-stable -------1) DC cardioversion Lidocaine - NOT A TMT for Supraventricular Tachycardia - Used as a TMT for Ventricular Tachycardia → which presents w/ WIDE QRS complexes -----[NARROW QRS complexes are associated w/ VENTRICULAR tachycardia]

SGU A 33-year-old female with no significant medical history presents to the emergency department complaining of shortness of breath and palpitations. The patient was in her usual state of health until 30 minutes ago when she bent over to lift her son and she suddenly felt like "my heart began to beat out of my chest." She denies losing consciousness or any prior episodes of palpitations or syncope. She takes a daily multivitamin and oral contraceptive pill. On presentation to the ED her temperature is 98.6°F (37°C), blood pressure is 124/86 mmHg, pulse is 180/min, and respirations are 16/min. Physical exam is unremarkable. Her EKG is shown in Figure A. Carotid sinus massage and Valsalva maneuvers are attempted with no improvement in symptoms. What is the best next step in MGMT? (Lidocaine VS Adenosine)

Ablation - Pt is presenting w/ signs concerning for supraventricular tachycardia → in the setting of WPW syndrome -A) Pathophysio ---1) Supraventricular tachycardia is caused by AV re-entry/recirculating Circuit -B) ECG findings ----1) Supraventricular tachycardia characteristics --------a) Narrow QRS + Tachycardia --------b) ± inverted P-waves ----2) WPW SPECIFIC characteristics --------a) Delta wave -C) MGMT ----a) Dx tests -------1) ECG ----b) TMT → BASED ON HEMODYNAMIC STABILITY -------aa) Hemodynamically STABLE ------------1) Vagal maneuvers (INITAL) ------------2) AV nodal blocking agents (INITAL) ----------------a) Adenosine > Verapamil ------------3) Symptomatic MGMT ----------------a) IV procainamide ------------4) Long-term MGMT ----------------a) Ablation -------bb) Hemodynamic UN-stable ------------1) Immediate DC cardioversion

SGU A 34-year-old man presents to the emergency department with anxiety and palpitations. This has happened to him before but intermittently. Each time he was treated and sent home. The patient's past medical history is non-contributory, and he is generally healthy. His temperature is 98.3°F (36.8°C), blood pressure is 127/85 mmHg, pulse is 190/min, respirations are 14/min, and oxygen saturation is 99% on room air. An ECG is performed as seen in Figure A. The patient is given adenosine and a repeat ECG is seen in Figure B. Which of the following is the best definitive TMT for this pt at this point of his workup? (No further TMT indicated VS Ablation)

CT scan - Pt most likely presents w/ a retroperitoneal hematoma -A) RF ----1) Cardiac catheterization -B) Signs/Symptoms ----1) Flank pain, ----2) Hypotension, ----3) Tachycardia --------a) WITHOUT signs of impaired cardiac function (i.e., JVD/pulmonary crackles) -C) MGMT ----a) Dx tests -------1) CT ----------a) To localize the hematoma Aspirin & clopidogrel - This would be part of LONG-TERM MGMT post-MI - However, pt is still in acute setting & he has a RF that supports retroperitoneal hematoma as the most likely Dx

SGU A 45-year-old man presents to the emergency department with crushing substernal chest pain. The patient has a past medical history of obesity, diabetes, and hypertension. He drinks 5 alcoholic drinks every night and has a 40 pack-year smoking history. The patient works as a truck driver and leads a sedentary lifestyle. His initial electrocardiogram (ECG) is notable for ST elevation in I and AVL with inferior reciprocal changes. The patient is sent for cardiac catheterization, and several stents are placed. The patient is being monitored after the procedure, when he suddenly becomes less responsive. His temperature is 98.5°F (36.9°C), blood pressure is 87/48 mmHg, pulse is 150/min, respirations are 18/min, and oxygen saturation is 97% on room air. Jugular venous distension is absent and pulmonary exam is notable for clear breath sounds bilaterally. The patient states that he is experiencing back and flank pain and is tender to palpation over his lumbar back and flanks. The patient is given 3 liters of Lactated Ringer solution and his blood pressure improves to 110/70 mmHg and his pulse is 95/min. Which of the following is the best next step in management? (Aspirin & clopidogrel VS CT scan)

A-fib - Pt has RFs & signs concerning for A-fib -A) ECG findings ----1) No Ischemic findings -------a) No ST elevation/depression -------b) No T-wave changes ----2) Irregularly irregular rhythm ----3) No discernible P-waves ----4) Narrow-Complex Tachy cardia -B) Commonly associated w/ ---1) Hyperthyroidsim Supraventricular tachy - Presents w/ WIDE QRS complexes

SGU A 46-year-old man comes to the emergency department complaining of weakness and chest tightness on and off over the last 24 hours. He has no past medical history. He does not use tobacco, alcohol, or illicit drugs. The patient's father had a myocardial infarction at age 68, and his mother has myasthenia gravis. An electrocardiogram is performed. What is the most likely Dx? (A-fib VS Supraventricular Tachycardia)

Transvenous pacing - Pt presents w/ signs concerning for Cardiogenic shock → most likely d/t an inferior wall infarction -A) ECG -----1) Inferior wall characteristics ---------a) ST elevation in leads II, II, aVF -B) MGMT --a) Cardiogenic shock WITH HYPOTENSION ----aa) TMT --------1) Atropine (OR Norepinephrine) -----------b) NE is the same as Atropine so giving NE after atropine is shown to BE UNRESPONSIVE doesn't make sense --------2) Dobutamine ------------a) Appropriate for pts that are NOT severely hypotensive --------2) Transvenous pacing ------------a) Indicated in pts who do not respond to Atropine

SGU A 55-year-old man is admitted to the hospital for exploratory laparotomy for colon cancer resection. He has a medical history of hypertension, hyperlipidemia, and hypothyroidism. Five days later a code was called for unresponsiveness. His temperature is 99°F (37.2°C), blood pressure is 75/40 mmHg, and pulse is 29/min. There are no murmurs on cardiac auscultations. An ECG demonstrates sinus bradycardia and evidence of ST-segment elevation in leads II, III, and aVF. The patient received an intravenous normal saline fluid bolus and intravenous atropine. His blood pressure is 78/45 mmHg and pulse is 31/min. The patient received a total of 3 mg of intravenous atropine with no effect. Which of the following is the most appropriate next step in MGMT? (Norepinephrine VS Transvenous pacing)

Coronary artery occlusion - Pt is showing signs of Coronary artery occlusion (LAD occlusion) -A) ECG findings ----1) DeWinter T-waves -------a) ST depression & peaked T waves in precordial leads -------b) Seen in roughly 2% of LAD occlusions -B) RF ----1) Age >50 ----2) DM -C) Signs/Symptoms ----1) Chest pain Bundle branch block -A) ECG findings ---1) Rabbit ear ------a) If left block → DECREASE in V1 ------b) If Right block → INCREASE in V1

SGU A 55-year-old man with a past medical history of diabetes and hypertension presents to the emergency department with chest pain. His symptoms started yesterday and seem to be worsened by exertion. He is currently not experiencing any pain. An ECG is obtained while the patient is in triage as seen in Figure. Which of the following is the most likely diagnosis? (Bundle branch block VS Coronary artery occlusion)

Anti-Digoxin antibodies - Pt presents w/ Symptoms & ECG findings that are specific for Digoxin toxicity, including: -A) ECG findings ----1) Bi-directional bi-ventricular tachycardia -B) Signs/Symptoms ----1) HF-life symptoms --------a) Hypotension --------b) Chest pain --------c) SOB, Hypoxemia -C) MGMT ----a) TMT --------1) Digitox → (anti-digoxin antibodies) Synchronized Cardioversion - Is indicated in pts w/ Supraventricular Tachycardia that are hemodynamically UN-stable - Also presents w/ Hypotension & Tachycardia - However, key difference is ---1) ECG FINDINGS ARE CHARACTERISTIC FOR DIGOXIN TOXICITY

SGU A 65-year-old man presents with chest pain and shortness of breath. He has a history of congestive heart failure, renal failure on dialysis, and diabetes. He is a current smoker. His temperature is 99°F (37.2°C), blood pressure is 97/58 mmHg, pulse is 130/min, respirations are 27/min, and oxygen saturation is 90% on room air. An echocardiogram (ECG) is obtained as seen in Figure A. Cardiac troponins are notable for a value of 0.60 ng/mL from a baseline of 0.59 ng/mL. Which of the following is the best initial treatment for this patient? (Synchronized Cardioversion VS Anti-Digoxin antibodies)

Glucagon - Pt shows signs of beta blocker OD, including: -A) Signs/Symptoms ----1) Diffuse wheezing → (MOST SPECIFIC SYMPTOM) ----2) Hypotension -------a) ± Cold clammy hands ----3) Bradycardia ----4) AV block -B) MGMT ----a) TMT --------1) IV fluids & secure airways --------2) IV atropine -----------a) For initial TMT of hypotension & bradycardia --------3) Glucagon -----------a) For pts w/ refractory/profound hypotension -----------b) MOA → ↑cGMP Digoxin specific antibody - Also can present w/ bradycardia, hypotension, & AV block - However, key differences include: ---1) DIGOXIN SPECIFC SYMPTOMS ------a) Disturbed Color perception ------b) Blurred vision ------c) Fatigue, anorexia, nausea ------d) Arrhythmias ---------[pt has NONE of these symptoms] ---2) WHEEZING not characteristic of digoxin toxicity

SGU A 59-year-old man is brought to the emergency department after a suicide attempt. He was found lethargic by his wife, who also discovered a suicide note. The patient has a history of coronary artery disease and hypertension. His temperature is 37.7 C (100 F), blood pressure is 76/40 mm Hg, pulse is 40/min, and respirations are 12/min. Examination shows diffuse bilateral wheezing. Extremities are cold and clammy. Electrocardiogram is shown below. The patient is given intravenous fluids and atropine; however, his bradycardia and hypotension do not improve. In addition to ensuring adequate oxygenation, which of the following is the most appropriate next step in management? (Digoxin-specific antibody VS Glucagon)

IV fluids - Pt has signs of a Inferior wall MI -A) ECG findings ----1) ST elevations in leads II, III, aVF -B) Pathophysiology -----1) Inferior wall MIs are preload dependent → so MGMT is focused on INCREASING PRELOAD -C) MGMT ---a) TMT ------1) IV fluids → (MAINSTAY OR TMT) ------2) Heparin, Beta-blockers, morphine Nitroglycerin - This is CI in preload dependent pathology b/c it can lead to SEVERE HYPOTENSION

SGU A 59-year-old man presents to the emergency department with chest pain and shortness of breath. The patient has a past medical history of diabetes, obesity, and hypertension, and he smokes cigarettes daily. His temperature is 99.5°F (37.5°C), blood pressure is 117/88 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. An electocardiogram (ECG) is performed as seen in Figure A. The patient is given aspirin en route to the hospital. Which of the following is the best next step in MGMT? (Nitroglycerin VS IV fluids)

V-Aneurysm - Pt is described as having a POST-OP MI -A) Time frames for common complications from MI are: ----1) V-fib → w/in first 24 hours ----2) Fibrinous pericarditis → 1-3 days ----3) Myocardial wall/Papillary muscle rupture → 1-2 weeks ----4) V-aneurysm → >2 weeks

SGU A 60-year-old man status-post emergent laparoscopic appendectomy for a ruptured appendix is brought to the attention of the on-call surgery resident by his nurse for persistent tachycardia. Medical history is significant for hypertension. The surgery was uneventful, and the patient had been given fentanyl about 30 minutes ago for pain management. The surgery resident suspects insufficient hydration and orders a bolus of normal saline. Thirty minutes later, a code is activated for ventricular fibrillation for this patient. After 3 minutes of resuscitation, the patient has return of spontaneous circulation. Bedside echocardiogram reveals dyskinetic wall movement. A 12-lead electrocardiogram is shown in Figure A. After an extended 2-week hospital stay that was free from further complications, the patient is prepared for discharge. What is the most likely complication on which the patient should be educated at this time? (V-Fib VS V- Aneurysm)

Nitrates - Pt is presenting w/ signs of a STEMI of RIGHT VENTRICLE -A) ECG findings ----1) Inferior wall portion -------a) ST elevations in leads II, II, aVF ----2) RV portion -------a) Reciprocal ST depressions in aVL -------b) + ST Elevation in leads V3-V6 -B) MGMT ----a) Dx tests -------1) RV ECG ----b) TMT -------1) IV fluids -------2) Heparin, morphine, beta-blockers ***CONTRAINDICATED*** ----Nitrates ------a) RV infarction leads to a DECREASE in PRELOAD (preload dependent pathology) ------B) Nitrates would FURTHER DECREASE preload lead to SEVERE HYPOTENSION

SGU A 65-year-old male with a history of hypertension and diabetes presents to the emergency department with severe chest pain. He states that his pain began approximately 2 hours ago, is 10/10 in severity, and has been accompanied by heavy sweats and nausea. On exam, the patient is pale and diaphoretic. An EKG is obtained which is demonstrated in Figure A. The emergency physician immediately activates the catheterization lab. Which of the following interventions should be avoided in the patient? (Beta-blockers VS Nitrates)

Synchronized cardioversion - Pt presents w/ signs concerning for A-fib -A) ECG findings ----1) No discernible P-waves ----2) Irregularly irregular rhythm ----3) NARROW QRS complexes -B) MGMT ----a) Dx test -------1) ECG ----b) TMT → based on HEMODYNAMIC STATUS ---1A) Hemodynamically UN-stable -------1) Pulseless → Defibrillator -------2) Pulse + Hypotension → DC cardioversion ---1B) Hemodynamically STABLE ------1) Embolism/Stroke prophylaxis ---------a) Warfarin (also dabigatran, apixaban) ------2) Rate control → preferred in pts >65 ---------a) Beta blockers ---------b) Ca+ channel blockers -------------(Diltiazem, verapamil) ------3) Rhythm control ---------a) Amiodarone, propafenone, dofetilide, flecainide, Sotalol ------4) Cardioversion indications in Hemodynamically STABLE pts ---------a) Symptomatic A-fib DESPITE rate control w/ beta-blocker/Ca+ blocker ---------b) First time occurrence of A-fib ONLY IF: -------------1) Onset known to be w/in last 2 days -------------2) Only if pt has been anti-coagulated for at least 3 weeks

SGU A 65-year-old man presents to the emergency department with a strange sensation in his chest. He states that it started this morning and has not been improving. The patient works as a farmer and has never seen a physician. He drinks alcohol regularly and smokes a pipe. He was working in the field when his symptoms began. His temperature is 98.6°F (37.0°C), blood pressure is 85/58 mmHg, pulse is 140/min, respirations are 18/min, and oxygen saturation is 95% on room air. An ECG is performed as seen in Figure A. Which of the following is the best initial step? (Vagal maneuvers VS Synchronized cardioversion)

Lateral wall, LCX - Leads V5 & V6 are most specific for the LV wall → which is supplied by LCX IV Septum, LAD - Most specific for V1-V3 leads

SGU A 65-year-old man presents to the emergency department with severe substernal chest pain of 2 hour's duration. The patient was taking a morning walk when the onset of pain led him to call 911. His past medical history includes coronary artery disease, hyperlipidemia, and hypertension. Medications include aspirin, losartan, and atorvastatin. An electrocardiogram reveals ST elevations in the inferior leads II, III, and avF as well as in leads V5 and V6. The ST elevations found in leads V5-V6 are most indicative of pathology in which of the following areas of the heart? (Lateral wall of LV, LCX VS IV septum, LAD)

Increased cGMP - Pt most likely presents w/ a RV MI -A) ECG findings (specific to RV include): -----1) Inferior wall portion --------a) ST elevation in leads II, III, aVF -----2) RV portion --------a) Reciprocal ST depression in aVL --------b) + ST elevation in leads V3-V6 -B) Pathophysio -----a) Inferior wall MI are preload dependent -----b) BP in pt is initially 90/70 -----c) After administration of POST-MI meds his BP decreases to 80/65 -----d) Of the POST-MI MEDS → Nitroglycerin is CI in RV infarction b/c it will lead to SEVERE HYPOTENSION -----e) The MOA of nitroglycerin is ↑cGMP (venodilation) Beta-Adrenergic blockade - This med is not CI in RV wall infarction - Additionally, it would not cause a severe drop in BP

SGU A 67-year-old male presents to the emergency department with sudden onset shortness of breath and epigastric pain. The patient has a past medical history of GERD, obesity, diabetes mellitus type II, anxiety, glaucoma, and irritable bowel syndrome. His current medications include omeprazole, insulin, metformin, lisinopril, and clonazepam as needed. The patient's temperature is 99.5°F (37.5°C), pulse is 112/min, blood pressure is 90/70 mmHg, respirations are 18/min, and oxygen saturation is 95% on room air. On physical exam the patient's lungs are clear to auscultation bilaterally. JVD is notable and cardiac auscultation is not revealing. An EKG is obtained in the emergency department and shown below. The patient is given a bolus of fluids and his pulse becomes 80/min with a blood pressure of 105/75 mmHg. The patient is then started on beta-blockers, oxygen, nitroglycerin, morphine, IV fluids, and aspirin. Repeat vitals demonstrate a blood pressure of 80/65 mmHg. Which of the following is the best explanation of this patient's current vital signs? (Beta-adrenergic blockade VS Increased cGMP)

Slowed conduction thru the AV node via increased CN IX firing - Pt is showing signs of supraventricular tachycardia -A) ECG findings ----1) NARROW QRS complexes (that are normal-looking) ----2) Tachycardia -B) MGMT -----a) Dx test --------1) ECG -----b) TMT → Based on hemodynamic status --AA) Hemodynamically STABLE ------1) Vagal maneuvers/carotid massage → BEST INITAL TMT ----------a) Breath holding, Valsalva, urination ------2) Adenosine/verapamil ------------a) PTs REFRACTORY to INITIAL TMT ------------a) Adenosine > Verapamil --BB) Hemodynamically UN-stable -------1) DC cardioversion

SGU A 68-year-old man presents to the emergency department with difficulty breathing and a sensation of anxiety. This started suddenly this afternoon and has persisted for the past several hours. The patient has a past medical history of obesity, sleep apnea, diabetes, hypertension, and osteoarthritis. His current medications include atorvastatin, lisinopril, insulin, metformin, and ibuprofen. Laboratory values are ordered as seen below: - Na-------------------------------------139 - Cl--------------------------------------100 - K+--------------------------------------4.2 - HCO3----------------------------------24 - BUN------------------------------------20 - Glucose--------------------------------124 - Creatinine------------------------------1.1 - Ca2+------------------------------------10.1 - AST--------------------------------------11 - ALT--------------------------------------11 Which of the following is the best initial therapy? (Slowed conduction thru the AV node via increased CN IX firing VS Adenosine)

Add Lisinopril - Pt is presenting for a follow-up following an MI -A) MGMT → Mnemonic "POST MI TMT "BAAA(N)S" a second MI" -----1) Beta-blockers -----2) ACEIs/ARBs -----4) Aspirin & clopidogrel -----5) Nitroglycerin -----6) Statin -B) Meds that DECREASE MORTALITY include: -----1) Beta-blockers -----2) ACEIs/ARBs -----3) Aspirin & clopidogrel -----4) Statin ****Only nitroglycerin does not***

SGU A 69-year-old patient presents to the emergency department with shortness of breath and substernal pain. The patient has a past medical history of obesity, anxiety, and constipation. He is currently not taking any medications and has not filled his prescriptions for over a year. An EKG is obtained and is seen in Figure A. The patient is managed appropriately and is discharged on atorvastatin, metoprolol, aspirin, clopidogrel, and sodium docusate. His vitals at discharge are a blood pressure of 100/70 mmHg and a heart rate of 85/minute. The patient visits his primary care physician four weeks later and claims to be doing better. He has been taking his medications and resting. At this visit, his temperature is 99.5°F (37.5°C), blood pressure is 130/87 mmHg, pulse is 80/min, respirations are 11/min, and oxygen saturation is 96% on room air. The patient states he feels better since the incident. Which of the following is the best next step in MGMT? (Continue current meds & schedule follow-up VS Add lisinopril)

Amiodarone - Pt shows signs of V-tach -A) ECG findings ----1) WIDE QRS complex -B) Signs/Symptoms ----1) Palpitations ----2) Tachycardia -C) MGMT → Based on hemodynamic status ----a) TMT -------1) Hemodynamically STABLE ----------a) Amiodarone/elective cardioversion w/ lidocaine -------2) Hemodynamically UN-stable -----------b) High-quality chest compressions + DC Cardioversion

SGU A 75-year-old man presents to the emergency department with a sensation of a flutter in his chest. He has a past medical history of diabetes and hypertension but is generally not compliant with his medications. His temperature is 98.0°F (36.7°C), blood pressure is 122/78 mm Hg, pulse is 110/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for an obese man who is not confused, moving all extremities spontaneously, and has a rapid heart rate. An ECG is obtained as seen in Figure A. The patient is asked to bear down while he is laid flat and his legs are elevated resulting in no change in his symptoms or rhythm strip. Which of the following is the best next step in management? (Cardioversion VS Amiodarone)

Angiography - Pt is presenting w/ signs of Angina most likely d/t stenosis ± STEMI - This pt may progress to an MI so must do angiography -A) ECG findings ----1) Wellens Syndrome --------a) Inverted/bi-phasic T-waves→ w/ an ST-segment that may NORMAL SIZE -B) Signs/Symptoms ----1) Asymptomatic ----2) Chest pain that presents w/ activity & resolves w/ rest -C) Additional labs ----1) NORMAL/SLIGHTLY ELEVATED Troponins -D) MGMT ----a) Dx tests ------1) Angiography Cardiac stress testing - This would be indicated in pts w/ angina - Angina also presents w/ chest pain that presents w/ activity & resolves w/ rest - However, key differences include: ---1) NO ASSOCIATED ECG CHANGES w/ angina -------[pt has Wellens syndrome on ECG, which is indicative of LAD stenosis]

SGU A 78-year-old man presents to the emergency department with chest pain that occurred while he was walking during his usual exercise routine. Upon arrival to the emergency department, he states that he feels asymptomatic and is requesting to go home. His temperature is 98.4°F (36.9°C), blood pressure is 158/106 mmHg, pulse is 92/min, respirations are 14/min, and oxygen saturation is 99% on room air. The patient's physical exam is unremarkable. Blood work reveals his initial set of troponins are within normal limits. An ECG is performed as seen in Figure A. Which of the following is the best next step in management for this patient? (Cardiac stress testing VS Angiography)

Amiodarone - Pt is presenting w/ signs symptoms of ventricular tachycardia -A) ECG findings ----1) WIDE QRS complex ----2) Tachycardia -B) Signs/Symptoms → (tachycardia related) ----1) Palpitations/diaphoresis -C) MGMT ----a) Dx tests -------1) ECG ----b) TMT → Based on HEMODYNAMIC STATUS --AA) Hemodynamically STABLE ------1) Amiodarone/Lidocaine --BB) Hemodynamically UN-stable ------1) DC cardioversion + Immediate high-quality chest compressions

SGU A 80-year-old man presents to the emergency department with a sensation of a palpitations in his chest. He has a past medical history of psoriasis, diabetes and hypertension but is generally not compliant with his medications. His temperature is 98.0°F (36.7°C), blood pressure is 132/78 mm Hg, pulse is 134/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for an obese man who is not confused, moving all extremities spontaneously, and has a rapid heart rate. An ECG is obtained as seen in Figure A. The patient is asked to bear down while he is laid flat and his legs are elevated resulting in no change in his symptoms or rhythm strip. Which of the following is the best next step in MGMT? (Adenosine VS Amiodarone)

Synchronized cardioversion - Pt presents w/ signs concerning for Supraventricular Tachy -A) ECF findings ----1) NARROW QRS complexes -B) Signs/Symptoms ----1) Episodes of syncope/dizziness → caused by stress, fatigue, etc ----2) Signs resolve w/ vagal maneuvers -C) MGMT ----a) Dx tests -------1) ECG ----b) TMT → BASED ON HEMODYNAMIC STABILITY -------aa) Hemodynamically STABLE ------------1) Vagal maneuvers (INITAL) ------------2) AV nodal blocking agents (INITAL) ----------------a) Adenosine > Verapamil ------------3) Symptomatic MGMT ----------------a) IV procainamide ------------4) Long-term MGMT ----------------a) Ablation -------bb) Hemodynamic UN-stable ------------1) Immediate DC cardioversion (synchronized cardioversion) Unsynchronized cardioversion - Describes De-fibrillation - Only indicated in PULSELESS pts

SGU A 24-year-old man is brought to the emergency department due to dizziness and palpitations that started abruptly an hour ago. He has had similar episodes provoked by fatigue, stressful environments or strong emotions. The patient can usually terminate the episodes by squatting and taking a deep breath. However, this time he states the maneuvers did not work. Blood pressure is 75/40 mm Hg and pulse is 244/min. He is diaphoretic and his extremities are cold. ECG is shown below. Which of the following is the best next step in management of this patient? (Unsynchronized cardioverison VS Synchronized cardioversion)

Coffee - Pts ECG is showing Premature atrial contractions -A) MGMT ----1) Avoidance of tiggers -------a) Caffeine, alcohol, nicotine, drugs Anxiety - Would be a cause tachycardia - Can also presents w/ Chest pain - However, key differences include: ---1) ECG findings ------a) In supraventricular tachy the QRS complexes are EVENLY SPACED ---------[pts ECG shows QRS that appear randomly, indicating premature ATRIAL contractions]

SGU A 29-year-old man presents to the emergency department for chest pain. The patient states that it has happened before, but this time it is persistent. He states that pain started about 1 hour ago and has not been improving. The patient is a medical resident and states that he is in good health. He has not been sleeping well due to his studies but otherwise says he eats a balanced diet and exercises regularly. The patient's father died of a myocardial infarction at the age of 45, and his mother currently has diabetes mellitus. The patient is not currently taking any medications. His temperature is 98.9°F (37.2°C), blood pressure is 126/68 mmHg, pulse is 119/min, respirations are 19/min, and oxygen saturation is 99% on room air. An EKG is performed as seen in Figure A. Which of the following is a potential underlying cause of this pts chief concern? (Anxiety VS Coffee)

Diltiazem - Pt has signs concerning for A-fib -A) ECG findings ----1) Irregularly irregular rhythm ----2) No discernible P-waves ----3) Narrow-Complex Tachy cardia -B) MGMT ----a) TMT - Based on hemodynamic status ---1A) Hemodynamically STABLE ------1) Embolism/Stroke prophylaxis ---------a) Warfarin (also dabigatran, apixaban) ------2) Rate control → preferred in pts >65 ---------a) Beta blockers ---------b) Ca+ channel blockers -------------(Diltiazem, verapamil) ------3) Rhythm control ---------a) Amiodarone, propafenone, dofetilide, flecainide, Sotalol ------4) Cardioversion indications in Hemodynamically STABLE pts ---------a) Symptomatic A-fib DESPITE rate control w/ beta-blocker/Ca+ blocker ---------b) First time occurrence of A-fib ONLY IF: -------------1) Onset known to be w/in last 2 days -------------2) Only if pt has been anti-coagulated for at least 3 weeks ---1B) Hemodynamically UN-stable -------1) Pulseless → Defibrillator -------2) Pulse + Hypotension → DC cardioversion Carotid sinus massage - Not a TMT for A-fib

SGU A 68-year-old man with a history of sleep apnea, hypertension and diet-controlled, diabetes mellitus comes to the office due to weakness and palpitations for the past 3 weeks. An echocardiogram last year showed mild left atrial dilation and left ventricular hypertrophy. The patient's medications include lisinopril and hydrochlorothiazide. Blood pressure is 170/90 mm Hg. ECG is shown in the exhibit. Which of the following is the most appropriate next step in management of this patient? (Carotid sinus massage VS Diltiazem)

Loud first heart sound, S2, then an opening snap followed by a mid-diastolic rumble - Pt has RF and signs concerning for Rheumatic heart disease -A) Murmur Characteristics of Rheumatic heart disease includes: ----1) Loud first heart sound --------a) due to wide closing excursion of the leaflets ----2) Prominent P2 of second heart sound --------a) P2 is accentuated due to elevated pulmonary artery pressures ----3) Opening snap --------a) caused by the sudden tensing of the leaflets after they've completed their opening excursion ----4) Mid-diastolic rumble --------a) due to increased flow across the stenotic mitral valve during atrial contraction High-pitched blowing, holosystolic murmur best heard at the apex - Describes the murmur in Mitral Regurg - Also caused by Rheumatic fever - However, key differences include: ---1) TIME LINE -------a) Usually presents in ACUTE Rheumatic fever -------b) Usually presents in YOUNGER PTS (1st, 2nd decade of life) ---------[pt is 37 & has CHRONIC rheumatic heart disease]

TRUE LEARN A 37-year-old woman presents for evaluation of progressive fatigue and shortness of breath. She immigrated to the United States from Cambodia when she was 17-years-old. She denies fever, night sweats, and weight loss. She does note occasional blood tinged sputum. She quit smoking 10 years ago but previously had smoked one pack per day for 10 years. She does not drink and denies any history of illicit or intravenous drug use. On physical examination, her temperature is 37.0ºC (98.6ºF), heart rate is 80/min, respirations are 16/min, and blood pressure is 113/82 mm Hg. She is thin and appears fatigued but is in no apparent distress. There is a pinkish-purple papular and patch-like rash on her face. There are prominent a waves on examination of her neck. Lungs are clear to auscultation. There is 1+ edema in the lower extremities bilaterally. Which of the following murmurs is most likely present on cardiac exam? (High-pitched blowing, holosystolic murmur best heard at the apex VS Loud first heart sound, S2, then an opening snap followed by a mid-diastolic rumble)

Adenosine - Pt presents w/ SUPRA-ventricular tachycardia -A) ECG characteristics ----1) NARROW QRS complexes ----3) Tachycardia ----4) -B) MGMT ----a) Dx tests -------1) ECG ----b) TMT → BASED ON HEMODYNAMIC STABILITY -------aa) Hemodynamically STABLE ------------1) Vagal maneuvers (INITAL) ------------2) AV nodal blocking agents (INITAL) ----------------a) Adenosine > Verapamil ------------3) Symptomatic MGMT ----------------a) IV procainamide ------------4) Long-term MGMT ----------------a) Ablation -------bb) Hemodynamic UN-stable ------------1) Immediate DC cardioversion Amiodarone - Used to treat VENTRICULAR Tachycardia -Also presents w/ Tachycardia - However, key differences include: ---1) ECG Findings ------a) WIDE QRS complexes are characteristic ---------[pts ECG shows NARROW QRS complexes]

TRUE LEARN A 40-year-old woman with a history of hyperthyroidism comes to the emergency room complaining of palpitations. She denies any loss of consciousness, chest pain, or exacerbating factors. On admission to the emergency room, her temperature is 37°C (98.6°F), heart rate is 165/min, blood pressure is 135/70 mm Hg, and her oxygen saturation is 92% on 100% O2 non-rebreather mask. Her ECG rhythm strip is shown. Serum TSH is normal. Which of the following is the best next step in MGMT? (Adenosine VS Amiodarone)

Peri-oral paresthesias - Pt is most likely started on Furosemide - The pt presents w/ signs of fluid overload including ---a) SOB ---b) Bilateral crackles on chest auscultation - Furosemide is a Sulfa containing drug -A) AE of Furosemide ----1) Increased urination, ----2) Metabolic alkalosis, ----3) Hypokalemia, ----4) Hypocalcemia, --------a) leading to per-oral paresthesias ----5) Hypomagnesemia, ----6) Ototoxicity ----7) Allergic reactions Altered mental status - Not likely to be caused by Furosemide as it has no effect on Na+ levels

TRUE LEARN A 56-year-old African-American man presents for evaluation of shortness of breath. For the past 2 months, he has had progressive dyspnea on exertion and now has difficulty going up the front steps to his house. His past medical history is significant for a myocardial infarction nine years ago, obesity, hypertension and hyperlipidemia. His current medications include aspirin, lisinopril, spironolactone, simvastatin, labetalol, hydrochlorothiazide, and nitroglycerin tablets, which he has never used. On physical examination, his temperature is 37.0ºC (98.6ºF), pulse is 88/min, respiratory rate is 18/min, and blood pressure is 130/100 mm Hg. He has a grade II/VI systolic murmur at the apex and bilateral crackles on pulmonary auscultation. After confirming that he is not allergic to sulfa drugs, his physician decides to start him on another medication. Which of the following medication side effects may be present in this patient when he returns for his next follow-up appointment? (Altered mental status VS Peri-oral paresthesias)

Metoprolol - Pt is showing signs of an MI (acute coronary syndrome) -A) MGMT (Acute Coronary syndrome MGMT) ----a) TMT --------1) PCI/Fibrinolysis -----------a) PCI > fibrinolysis -------2) Supplemental O2 → (if hypoxia) -------3) Nitroglycerin → (± morphine) -------4) β-blocker → (eg, metoprolol) -------5) Statin → (eg, atorvastatin) -------6) Anticoagulation → (eg, heparin) -------7) Dual antiplatelet therapy → (ie, aspirin plus P2Y12 inhibitor) Lisinopril - This TMT is indicated in POST-MI MGMT - It is parts of BAAA(N)S TMT → aimed at PREVENTING a second MI -B → Beta-blocker -A&A → ACEI/ARB -A → Aspirin/Clopidogrel -N → Nitroglycerin -S → Statin

TRUE LEARN A 63-year-old man presents to the emergency department for evaluation of nausea and diaphoresis. He awoke from sleep early this morning with severe nausea, one episode of vomiting, and diaphoresis. His wife noted that he "looked pale." He also complains of vague chest "pressure" for the past hour. His medical history is significant for poorly controlled type II diabetes, hypercholesterolemia, and stable angina, for which he takes metformin, glipizide, lovastatin, and sublingual nitroglycerin. He smokes one pack of cigarettes per day and drinks one to two glasses of red wine most evenings of the week. On exam his temperature is 37.0oF (98.6oF), heart rate is 98 beats/minute, respirations are 20 breaths/minute, and blood pressure is 143/89 mm Hg. He is pale, diaphoretic and in moderate distress. Lung exam is unremarkable. Cardiac exam reveals an S4 gallop. An ECG demonstrates sinus tachycardia with ST-segment elevation in leads V2-V5. Which of the following medications should be included in his treatment regimen? (Lisinopril VS Metoprolol)

Diltiazem - Pt is showing signs concerning for A-Fib -A) ECG findings ----1) No discernible P-waves ----2) Irregularly irregular QRS ----3) Narrow QRS complex ----2) Tachycardia -B) Signs/Symptoms ----1) Palpitations -------a) i.e., funny feeling in her chest -C) MGMT ----a) TMT - Based on hemodynamic status ---1A) Hemodynamically STABLE ------1) Embolism/Stroke prophylaxis ---------a) Warfarin (also dabigatran, apixaban) ------2) Rate control → preferred in pts >65 ---------a) Beta blockers ---------b) Ca+ channel blockers -------------(Diltiazem, verapamil) ------3) Rhythm control ---------a) Amiodarone, propafenone, dofetilide, flecainide, Sotalol ------4) Cardioversion indications in Hemodynamically STABLE pts ---------a) Symptomatic A-fib DESPITE rate control w/ beta-blocker/Ca+ blocker ---------b) First time occurrence of A-fib ONLY IF: -------------1) Onset known to be w/in last 2 days -------------2) Only if pt has been anti-coagulated for at least 3 weeks ---1B) Hemodynamically UN-stable -------1) Pulseless → Defibrillator -------2) Pulse + Hypotension → DC cardioversion Amiodarone - Used in TMT of Ventricular Tachycardia - Also presents w/ tachycardia & palpitations - However, key differences include: ---1) ECG FINDINGS -------a) SVT presents w/ WIDE QRS complexes -----------[pt has NARROW QRS complexes]

TRUE LEARN A 77-year-old woman is hospitalized for community acquired pneumonia. On the fourth day of hospitalization, she complains of a "funny feeling" in her chest. Over the past several months she has experienced a few episodes of chest palpitations per month. She denies lightheadedness or loss of consciousness. Her heart rate is 175/min and blood pressure is 116/74 mm Hg. Stat ECG is shown below. Which of the following is the most appropriate next step? (Diltiazem VS Amiodarone)