1. Cardiology practice

Diagnostic Studies/Cardiology A 72 year-old male with a new diagnosis of congestive heart failure and atrial fibrillation, develops episodes of hemodynamic compromise secondary to increased ventricular rate. A decision to perform elective cardioversion is made and the patient is anticoagulated with heparin. Which test should be ordered to assess for atrial or ventricular mural thrombi? A. Electrocardiogram B. Chest x-ray C. Transesophageal Echocardiogram D. C-reactive protein

(u) A. Electrical conduction will not assess for mural thrombi. (u) B. A chest x-ray will not visualize the left atria and ventricles to assess for mural thrombi. (c) C. Transesophageal echocardiography allows for determination of mural thrombi that may have resulted from atrial fibrillation. (u) D. C-reactive protein is not going to give you any information regarding thrombi. This test is used to identify the presence of inflammation.

Clinical Therapeutics/Cardiology According to the recent JNC VII guidelines, a 34 year-old male who has type 1 diabetes mellitus and hypertension should be started on which type of antihypertensive agent? A. beta-blocker B. loop diuretic C. ACE inhibitor D. thiazide diuretic

Explanations (u) A. Beta blockers could potentially be harmful in a patient with diabetes mellitus. Use a cardioselective beta- blocker to reduce the incidence of hypoglycemia. (u) B. See C for explanation. (c) C. ACE inhibitors are effective in young patients. They are capable of providing protection to the kidney especially in diabetes mellitus. (u) D. See C for explanation.

Clinical Therapeutics/Cardiology According to the recent JNC VII guidelines, a 34 year-old male who has type 1 diabetes mellitus and hypertension should be started on which type of antihypertensive agent? Answers A. Beta-blocker B. Loop diuretic C. ACE inhibitor D. Thiazide diuretic

Explanations (u) A. Beta blockers could potentially be harmful in a patient with diabetes mellitus. Use a cardioselective beta-blocker to reduce the incidence of hypoglycemia. (u) B. See C for explanation. (c) C. ACE inhibitors are effective in young patients. They are capable of providing protection to the kidney especially in diabetes mellitus. (u) D. See C for explanation.

Clinical Intervention/Cardiology A 54 year-old female who has diabetes presents with rubor, absence of hair, and brittle nails of her left foot. She complains of leg pain that awakens her at night. Examination reveals a femoral bruit with diminished popliteal and pedal pulses on the left side. The most appropriate therapy would be A. vasodilator therapy. B. bypass surgery. C. exercise program. D. embolectomy.

Explanations (u) A. Vasodilator therapy is not indicated. (c) B. Bypass surgery is indicated in the presence of rest pain and provides relief of symptoms in 80 to 90% of patients. (u) C. While an exercise program is appropriate with claudication, rest pain is a surgical indication. (u) D. Embolectomy is used for acute arterial occlusion.

Scientific Concepts/Cardiology 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

Explanations (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. (u) B. Pulmonary hypertension can occur in patients with severe mitral stenosis with symptoms of low cardiac output and right sided heart failure. Pulmonary hypertension does not cause systemic embolization. (u) C. Patients with mitral stenosis can have increased left atrial pressures relative to the left ventricular diastolic pressures; this does not usually cause systemic embolization. (u) D. Left ventricular dilatation is more common in aortic valve disease than mitral valve disease.

Health Maintenance/Cardiology A 52 year-old obese female with a history of hypertension, tobacco abuse, and hyperlipidemia presents for routine follow-up. Which of her risk factors for coronary atherosclerosis is not modifiable? A. Age B. High LDL C. Hypertension D. Obesity

Explanations (c) A. Age is a non modifiable risk factor, as is family history of premature coronary heart disease (u) B. High LDL is a modifiable risk factor, as is Hypertension, low HDL, obesity, tobacco abuse, physical inactivity (u) C. See B for explanation. (u) D. See B for explanation.

History & Physical/Cardiology Which of the following physical findings is suggestive of atrial septal defect? A. Fixed split S2 B. Increased pulse pressure C. Continuous mechanical murmur D. Difference in blood pressure between the left and right arm

Explanations (c) A. An atrial septal defect will cause a shunt of blood from the left to the right atrium. This will result in an equalization in the amount of blood entering both the left and right ventricles which effectively eliminates the normally wide splitting that inspiration typically causes in hearts without an atrial septal defect. (u) B. Pulse pressures reflect the difference in aortic and left ventricular volumes that occur during ventricular systole Increased pulse pressures are seen in aortic regurgitation which is a different entity than atrial septal defect. (u) C. Continuous mechanical murmurs are noted in patients with patent ductus arteriosus. (u) D. Differences in blood pressure between the left and right arms are seen in conditions such as coarctation of the aorta.

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

Explanations (c) A. Beta blockade is contraindicated in second and third heart block. (u) B. Beta blockade has been proven to be beneficial in sinus tachycardia, hypertension and in atrial fib/flutter with a rapid ventricular response. (u) C. See B for explanation. (u) D. See B for explanation.

Clinical Therapeutics/Cardiology Which of the following medication classes is the treatment of choice in a patient with variant or Prinzmetal's angina? A. Calcium channel blockers B. ACE inhibitors C. Beta blockers D. Angiotensin II receptor blockers

Explanations (c) A. Calcium channel blockers are effective prophylactically to treat coronary vasospasm associated with variant or Prinzmetal's angina. (u) B. ACE inhibitors are not a treatment for coronary vasospasm. (h) C. Beta blockers have been noted to exacerbate coronary vasospasm potentially leading to worsening ischemia. (u) D. Angiotensin II receptor blockers are not a treatment for coronary vasospasm.

Clinical Therapeutics/Cardiology Which of the following antihypertensive agents is considered to have both alpha- and beta-blocker activities? A. carvedilol (Coreg) B. hydralazine (Apresoline) C. minoxidil (Loniten) D. spironolactone (Aldactone)

Explanations (c) A. Carvedilol has both alpha- and beta-blocker activities. (u) B. Hydralazine and minoxidil are considered vasodilators. (u) C. See B for explanation. (u) D. Spironolactone is a potassium-sparing diuretic.

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

Explanations (c) A. Free wall rupture is a complication that occurs within 72 hours of infarction. It is seen mainly in Q wave transmural and lateral wall infarctions. (u) B. See A for explanation. (u) C. See A for explanation. Atrial fibrillation would have EKG evidence of irregularly, irregular rate and rhythm. (u) D. Sick sinus syndrome would have EKG evidence of decreased rate and loss of P waves.

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

Explanations (c) A. Given the presence of cardiomyopathy, the patient's heart has decreased functional reserve. The symptoms and chest x-ray findings are typical of congestive heart failure. (u) B. Endocarditis occurs as a result of infection that primarily occurs in the blood stream. Endocarditis would present with signs of infection or seeding rather than signs of heart failure. (u) C. Pulmonary embolus usually presents with an acute onset of chest pain, severe dyspnea, and anxiety. (u) D. Pneumonia is less likely since there is no fever and edema is not usually associated with pneumonia.

Diagnostic Studies/Cardiology A 36 year-old male complains of occasional episodes of "heart fluttering". The patient describes these episodes as frequent, short-lived and episodic. He denies any associated chest pain. Based on this information, which one of the following tests would be the most appropriate to order? Answers A. Holter monitor B. Cardiac catheterization C. Stress testing D. Cardiac nuclear scanning

Explanations (c) A. Holter monitoring is a non-invasive test done to obtain a continuous monitoring of the electrical activity of the heart. This can help to detect cardiac rhythm disturbances that can correlate with the patient symptoms. Cardiac catheterization is an invasive procedure done to assess coronary artery disease. Stress testing and cardiac nuclear scanning are non-invasive testing maneuvers done to assess coronary artery disease. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.

Health Maintenance/Cardiology A 78 year-old male with history of coronary artery disease status post CABG and ischemic cardiomyopathy presents with complaint of progressive dyspnea and orthopnea. He also complains of lower extremity edema. The patient denies fever, chest pain, or cough. On physical examination, vital signs are BP 120/68, HR 75 and regular, RR 22, afebrile. You note the patient to have an S3 heart sound, jugular venous distention, and 2+ lower extremity edema. The patient is admitted and treated. Upon discharge from the hospital, the patient should be educated to monitor which of the following at home? A. Daily weights B. Daily spirometry C. Daily blood glucose D. Daily fat intake

Explanations (c) A. Home monitoring of daily weights can alert the health care provider to the early recognition of worsening heart failure. (u) B. Spirometry monitoring is important in a patient with asthma, not heart failure. (u) C. Daily blood glucose monitoring is important in a patient with diabetes, not heart failure. (u) D. Daily fat intake is important, but will not improve his heart failure management.

Diagnosis/Cardiology A 23 year-old male presents with syncope. On physical examination you note a medium-pitched, mid-systolic murmur that decreases with squatting and increases with straining. Which of the following is the most likely diagnosis? A. Hypertrophic cardiomyopathy B. Aortic stenosis C. Mitral regurgitation D. Pulmonic stenosis

Explanations (c) A. Hypertrophic cardiomyopathy is characterized by a medium- pitched, mid-systolic murmur that decreases with squatting and increases with straining. (u) B. Straining decreases the intensity of the murmur associated with aortic stenosis and squatting increases the intensity. (u) C. Mitral regurgitation is characterized by a blowing systolic murmur that radiates to the axilla, it is not often associated with syncope. (u) D. Pulmonic stenosis is a harsh systolic murmur with a widely split S2, and no change with maneuvers.

History & Physical/Cardiology A 58 year-old male presents with chest pain. Vital signs include blood pressure of 210/175, pulse 80, RR 20. Which of the following would you expect to find on physical examination? A. papilledema B. carotid bruit C. diastolic murmur D. absent peripheral pulses

Explanations (c) A. Malignant hypertension is characterized by marked blood pressure elevation with papilledema, often with encephalopathy or nephropathy. (u) B. Carotid bruits are associated with carotid artery stenosis. (u) C. Diastolic murmurs are associated with valvular heart disease such as aortic regurgitation and mitral stenosis. (u) D. Peripheral pulses are absent in acute arterial occlusion or severe peripheral arterial disease.

Diagnosis/Cardiology A 46 year-old male with no past medical history presents complaining of chest pain for four hours. The patient admits to feeling very poorly over the past two weeks with fever and upper respiratory symptoms. The patient denies shortness of breath or diaphoresis. On examination the patient appears fatigued. Vital signs reveal a BP of 130/80, HR 90 and regular, RR 14. The patient is afebrile. Labs reveal a Troponin I of 10.33 ug/L (0-0.4ug/L). Cardiac catheterization shows normal coronary arteries and an ejection fraction of 40% with global hypokinesis. Which of the following is the most likely diagnosis? A. myocarditis B. pericarditis C. hypertrophic cardiomyopathy D. coronary artery disease

Explanations (c) A. Myocarditis often occurs secondary to acute viral illness and causes cardiac dysfunction. Patients will commonly have a history of a recent febrile illness. Chest pain may mimic that of a myocardial infarction and Troponin I levels maybe elevated in one-third of patients. Contractile dysfunction is seen on catheterization and/or echocardiogram. (u) B. Pericarditis does not typically cause ventricular dysfunction and cardiac enzymes are usually normal. (u) C. Hypertrophic cardiomyopathy is associated with ventricular hypercontractility. (u) D. This patient had normal coronary arteries on cardiac catheterization, no signs of coronary artery disease.

Diagnosis/Cardiology A newborn is seen for an initial two week visit. Physical examination reveals a thrill and a continuous machinery murmur in the left second intercostal space. Which of the following is the most likely diagnosis? A. patent ductus arteriosus B. ventricular septal defect C. tetralogy of Fallot D. coarctation of the aorta

Explanations (c) A. Patent ductus arteriosus is characterized by a classic harsh, machinery-like murmur that is continuous through systole and diastole. This is heard best at the left second interspace and is commonly associated with a thrill. (u) B. Ventricular septal defect is characterized by a holosystolic murmur at the lower left sternal border. (u) C. Tetralogy of Fallot is characterized by a systolic thrill at the left sternal border with a systolic ejection murmur that may or may not have an associated systolic click. (u) D. Coarctation of the aorta is associated with a systolic ejection click or a short systolic murmur at the left sternal border.

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

Explanations (c) A. Periodic measurements of blood pressure should be part of routine preventive health assessments beginning at the age of 3 years. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.

Clinical Intervention/Cardiology Which of the following is first-line treatment for symptomatic bradyarrhythmias due to sick sinus syndrome (SSS)? A. Permanent pacemaker B. Radiofrequency ablation C. Antiarrhythmics D. Anticoagulation therapy

Explanations (c) A. Permanent pacemakers are the therapy of choice in patients with symptomatic bradyarrhythmias in sick sinus syndrome. (u) B. Radiofrequency ablation is used for the treatment of accessory pathways in the heart. (u) C. See A for explanation. (u) D. See A for explanation.

Clinical Intervention/Cardiology A 25 year-old male with history of syncope presents for evaluation. The patient admits to intermittent episodes of rapid heart beating that resolve spontaneously. 12 Lead EKG shows delta waves and a short PR interval. Which of the following is the treatment of choice in this patient? A. Radiofrequency catheter ablation B. Verapamil (Calan) C. Percutaneous coronary intervention D. Digoxin (Lanoxin)

Explanations (c) A. Radiofrequency catheter ablation is the treatment of choice on patients with accessory pathways, such as Wolff-Parkinson-White Syndrome. (h) B. Calcium channel blockers such as verapamil decrease refractoriness of the accessory pathway or increase that of the AV node leading to faster ventricular rates, therefore calcium channel blockers should be avoided in patients with WPW. (u) C. Percutaneous coronary intervention is indicated in the treatment of coronary artery disease, not preexcitation syndromes. (h) D. Digoxin decreases refractoriness of the accessory pathway and increases that of the AV node leading to faster ventricular rates. It should therefore be avoided in patients with WPW.

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

Explanations (c) A. Renal parenchymal disease is the most common cause of secondary hypertension. (u) B. Primary aldosteronism can cause secondary hypertension, but it is not the most common cause. (u) C. Oral contraceptives can cause small increases in blood pressure but considerable increases are much less common. (u) D. Cushing's disease is a less common cause of secondary hypertension.

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

Explanations (c) A. Signs of right ventricular failure are fluid retention i.e. edema, hepatic congestion and possibly ascites. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.

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

Explanations (c) A. Sodium nitroprusside metabolization results in cyanide ion production. It can be treated with sodium thiosulfite, which combines with the cyanide ion to form thiocyanate, which is nontoxic. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.

History & Physical/Cardiology Eliciting a history from a patient presenting with dyspnea due to early heart failure the severity of the dyspnea should be quantified by Answers A. amount of activity that precipitates it. B. how many pillows they sleep on at night. C. how long it takes the dyspnea to resolve. D. any associated comorbidities.

Explanations (c) A. The amount of activity that precipitates dyspnea should be quantified in the history. (u) B. Orthopnea or paroxysmal nocturnal dyspnea can be quantified by how many pillows a patient needs to sleep on to be comfortable. (u) C. How long dyspnea takes to resolve or associated comorbidities has no bearing on quantifying the severity of dyspnea. (u) D. See answer C above.

Diagnosis/Cardiology 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 valve prolapse

Explanations (c) A. The major symptoms of aortic stenosis are exertional syncope, dyspnea, and angina. Symptoms do not become apparent for a number of years and usually are not present until the valve is narrowed to less than 0.5 cm to 2 cm of valve surface area. (u) B. Patients with aortic regurgitation are likely to complain of an uncomfortable awareness of their heart, especially when lying down. These patients develop sinus tachycardia with exertion and complain of palpitations and head pounding with activity. (u) C. The symptoms related to mitral stenosis are related to increased pulmonary pressure after the left atrium can no longer overcome the outflow obstruction. (u) D. Patients with mitral valve prolapse are typically asymptomatic throughout their lives, although a wide range of symptoms is possible. When symptoms do occur, palpitations from arrhythmias are most common along with lightheadedness. Syncope is not part of this disease process.

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

Explanations (c) A. The scenario presented here is typical of an ascending aortic dissection. In an acute myocardial infarction the pain builds up gradually. Cardiac tamponade may occur with a dissection into the pericardial space; syncope is usually seen with this occurrence. Pulmonary embolism is usually associated with dyspnea along with chest pain. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.

Clinical Intervention/Cardiology A 48 year-old male presents to the ED with complaints of chest pressure, dyspnea on exertion, and diaphoresis that has been present for the last one hour. Electrocardiogram reveals normal sinus rhythm at 92/minute along with ST segment elevation in leads V3-V5. Initial cardiac enzymes are normal. What is the next most appropriate step in the management of this patient? Answers A. Coronary artery revascularization B. Admission for medical management C. Administer lidocaine D. Administer nitrates

Explanations (c) A. The standard of care for the management of acute ST-segment elevation MI is coronary artery revascularization. This patient is diagnosed with an ST-segment elevation MI based upon his history and EKG findings. Cardiac enzymes are normal because of the early presentation of this patient. (u) B. Although this patient will be admitted to the hospital, this patient needs to have acute management of the myocardial infarction without delay. (h) C. Prophylactic lidocaine has been shown to increase morbidity and mortality from acute MI when used in this setting. (u) D. Although pain control is a goal for patients with acute MI, it is not the essential medication that will impact this patient's care to the greatest degree.

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

Explanations (c) A. Thiazide diuretics can induce electrolyte changes. Principle among those is hypokalemia. (u) B. Hyponatremia, not hypernatremia may be a complication of thiazide diuretics. (u) C. Thiazide diuretics cause the retention of calcium and would not cause hypocalcemia. (u) D. Thiazide diuretics cause the retention of calcium and do not readily affect magnesium levels.

Clinical Therapeutics/Cardiology 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)

Explanations (u) A. Digoxin is not used for the acute termination of supraventricular tachycardia. (c) B. Adenosine is an endogenous nucleoside that results in profound (although transient) slowing of the AV conduction and sinus node discharge rate. This agent has a very short half-life of 6 seconds. (u) C. Although verapamil may be used for the termination of acute supraventricular tachycardia, it does not lead to sinus arrest in therapeutic doses. (u) D. Quinidine is rarely used today and is not indicated for the termination of supraventricular tachycardia.

Health Maintenance/Cardiology A 37 year-old female with history of Turner's syndrome and coarctation of the aorta repaired at the age of 3 presents for routine examination. The patient is without complaints of chest pain, dyspnea, palpitations, or syncope. On examination vitals signs reveal a BP of 130/76, HR 70, regular, RR 16. On cardiac examination you note a grade II/VI systolic ejection murmur at the left sternal border and a grade III/VI blowing diastolic murmur. Which of the following does this patient require? A. antibiotic prophylaxis B. beta blocker therapy C. chest CT D. exercise stress test

Explanations (c) A. This patient has a history of congenital heart disease and presently has a murmur consistent with aortic regurgitation. This patient requires antibiotic prophylaxis against infective endocarditis. (u) B. Beta blocker therapy may increase the amount of regurgitation because of increased diastolic time and is not indicated in this patient. (u) C. This patient should undergo serial echocardiograms, chest CT will not give information regarding any changes in the aortic regurgitation or ejection fraction. (u) D. This patient is without any complaints; exercise stress test is not indicated.

Health Maintenance/Cardiology A 36 year-old female presents for a refill of her oral contraceptives. She admits to smoking one pack of cigarettes per day. She should be counseled with regard to her risk of Answers A. venous thrombosis. B. varicose veins. C. atherosclerosis. D. peripheral edema.

Explanations (c) A. Women over age 35 who smoke are at increased risk for the development of venous thrombosis. (u) B. Varicose veins are the result of pressure overload on incompetent veins and not due to the use of oral contraceptives. (a) C. The defined risks of atherosclerosis includes smoking, but does not include the use of oral contraceptives. (u) D. There is no relationship between the use of oral contraceptives and the development of peripheral edema.

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

Explanations (h) A. See C for explanation. (h) B. See C for explanation. (c) C. An elevated BNP is seen in a situation where there is increased pressure in the ventricle during diastole. This is representative of the left ventricle being stretched excessively when a patient has CHF. Sending a patient home would be inappropriate in this case. (u) D. See C for explanation.

Health Maintenance/Cardiology A 44 year-old male with a known history of rheumatic fever at age 7 and heart murmur is scheduled to undergo a routine dental cleaning. The murmur is identified as an opening snap murmur. Patient has no known drug allergies. What should this patient receive for antibiotic prophylaxis prior to the dental cleaning? Answers A. This patient does not require antibiotic prophylaxis for a routine dental cleaning. B. This should receive Pen VK 250 mg p.o. QID for 10 days after the procedure. C. This patient should receive Amoxicillin 3.0 gms. p.o. 1 hour before the procedure and then 1.5 gm. 6 hours after the procedure. D. This patient should receive Erythromycin 250 mg QID for 1 day before the procedure and then 10 days after the procedure.

Explanations (h) A. See C for explanation. (u) B. See C for explanation. (c) C. These are the current recommendations from the American Heart Association if the patient is not allergic to penicillin. (u) D. See C for explanation.

Diagnostic Studies/Cardiology A 17 year-old woman presents to the office with recurrent episodes of palpitations and near syncope. Initial ECG was normal. She is concerned about these episodes since they can occur at any time. Which of the following is the most appropriate step to pursue in her evaluation? A. cardiac catheterization B. tilt table testing C. echocardiogram D. Holter monitoring

Explanations (u) A. A cardiac catheterization will not be useful since the patient is at low risk for actual coronary artery disease. (u) B. Tilt table testing is useful only in trying to determine vasodepressor syncope that is related to position. (u) C. An echocardiogram shows valves and left ventricle function, not pathways of conduction. (c) D. Holter monitoring will identify the heart rhythm; an event recorder may also be useful in this setting if the Holter monitor is not diagnostic.

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

Explanations (u) A. A patient with aortic dissection will complain of tearing, ripping pain. EKG is often normal, but may reveal left ventricular strain pattern. (c) B. Myocardial infarction often presents with chest pressure and associated nausea and vomiting. ST segment elevation in leads II, III, and AVF are classic findings seen in acute inferior wall myocardial infarction. (u) C. Acute pericarditis presents with atypical chest pain and diffuse ST segment elevation. (u) D. Pulmonary embolism often presents with either no EKG changes or sinus tachycardia. Classically described, rarely seen findings include a large S wave in lead I, a Q wave with T wave inversion in lead III, ST segment depression in lead II, T wave inversion in leads V1-V4 and a transient right bundle branch block.

Diagnosis/Cardiology A 63 year-old male is admitted to the hospital with an exacerbation of COPD. The electrocardiogram shows an irregularly, irregular rhythm at a rate of 120/minute with at least three varying P wave morphologies. These electrocardiogram findings are most suggestive of Answers A. atrial fibrillation. B. multifocal atrial tachycardia. C. atrioventricular junctional rhythm. D. third degree heart block.

Explanations (u) A. Atrial fibrillation is an irregularly, irregular rhythm with no definable P waves. (c) B. Multifocal atrial tachycardia is seen most commonly in patients with COPD. Electrocardiogram findings include an irregularly, irregular rhythm with a varying PR interval and various P wave morphologies (Three or more foci). (u) C. Atrioventricular junctional rhythm is an escape rhythm, because of depressed sinus node function, with a ventricular rate between 40-60/minute. (u) D. Third degree heart block presents with a wide QRS at a rate less than 50/minute and blocked atrial impulses.

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

Explanations (u) A. Abdominal aortic aneurysm is usually asymptomatic until the patient has dissection or rupture. It is uncommon in a child. (u) B. Pheochromocytoma classically causes paroxysms of hypertension due to catecholamine release from the adrenal medulla, but does not cause variations in blood pressure in the upper and lower extremities. (c) C. Coarctation is a discrete or long segment of narrowing adjacent to the left subclavian artery. As a result of the coarctation, systemic collaterals develop. X-ray findings occur from the dilated and pulsatile intercostal arteries and the "3" is due to the coarctation site with proximal and distal dilations. (u) D. Thoracic outlet syndrome occurs when the brachial plexus, subclavian artery, or subclavian vein becomes compressed in the region of the thoracic outlet. It is the most common cause of acute arterial occlusion in the upper extremity of adults under 40 years old.

Diagnosis/Cardiology 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 myocardial infarction B. Bacterial endocarditis C. Acute pericarditis D. Restrictive cardiomyopathy

Explanations (u) A. Acute MI presents with complaint of chest pain, SOB, not with fever and myalgias. (c) B. Bacterial endocarditis presents as febrile illness lasting several days to weeks, commonly with nonspecific symptoms, echocardiogram often reveals vegetations on affected valves. (u) C. Pericarditis does not present with systolic or diastolic murmur or vegetation, more commonly pericardial friction rub would be noted. (u) D. Restrictive cardiomyopathy will show impaired diastolic filling on echocardiogram and is not associated with fever.

Clinical Intervention/Cardiology An unresponsive patient is brought to the ED by ambulance. He is in ventricular tachycardia with a heart rate of 210 beats/min and a blood pressure of 70/40 mmHg. The first step in treatment is to Answers A. administer IV adenosine. B. DC cardiovert. C. administer IV lidocaine. D. apply overdrive pacer.

Explanations (u) A. Adenosine is used to treat PSVT. (c) B. The first step in treatment of unstable ventricular tachycardia with a pulse is to cardiovert using a 100 J countershock. (u) C. See B for explanation. (u) D. Overdrive pacing is indicated in Torsades de Pointes.

Clinical Therapeutics/Cardiology A 63 year-old female with history of diabetes mellitus presents for blood pressure follow-up. At her last two visits her blood pressure was 150/92 and 152/96. Today in the office her blood pressure is 146/92. Recent blood work shows a Sodium 140 mEq/L, Potassium 4.2 mEq/L, BUN of 23 mg/dL, and Creatinine of 1.1 mg/dL. Which of the following is the most appropriate initial medication in this patient? A. Terazosin (Hytrin) B. Atenolol (Tenormin) C. Lisinopril (Zestril) D. Hydrochlorothiazide (HCTZ)

Explanations (u) A. Alpha blockers are not the treatment of choice in a diabetic with hypertension. (u) B. Patients with hypertension and diabetes may require a Beta blocker, but it should be added to an ACE inhibitor if the ACE inhibitor is ineffective on its own. (c) C. ACE inhibitors should be part of the initial treatment of hypertension in diabetics because of beneficial effects in diabetic nephropathy and is the most appropriate initial medication. (u) D. Patients with hypertension and diabetes mellitus may require a diuretic, but it should be added to an ACE inhibitor if the ACE inhibitor is ineffective on its own.

Diagnostic Studies/Cardiology Cardiac nuclear scanning is done to detect Answers A. electrical conduction abnormalities. B. valvular abnormalities. C. ventricular wall dysfunction. D. coronary artery patency/occlusion.

Explanations (u) A. An EKG is used to determine electrical conduction abnormalities. (u) B. An echocardiogram is a non-invasive test used to determine valvular abnormalities and wall motion. (c) C. Visualization of the cardiac wall can be done with cardiac nuclear scanning. This is done to determine hypokinetic areas from akinetic areas. (u) D. Patency or occlusion is assessed with cardiac catheterization (invasive).

Diagnosis/Cardiology A patient presents with chest pain. ECG done in the emergency department reveals ST segment elevation in leads II, III, and AVF. This is most consistent with a myocardial infarction in which of the following areas? A. anterior wall B. inferior wall C. posterior wall D. lateral wall

Explanations (u) A. Anterior wall myocardial infarction is characterized by ST segment elevation in 1 or more of the precordial (V1- V6) leads. (c) B. Inferior wall myocardial infarction is characterized by ST segment elevation in leads II, III, and AVF. (u) C. Posterior wall myocardial infarction is characterized by ST segment depression in leads V1-V3 and a large R wave in leads V1-V3. (u) D. Lateral wall myocardial infarction is characterized by ST segment elevation in leads I and AVL.

Scientific Concepts/Cardiology In congestive heart failure the mechanism responsible for the production of an S3 gallop is Answers A. contraction of atria in late diastole against a stiffened ventricle. B. rapid ventricular filling during early diastole. C. vibration of a partially closed mitral valve during mid to late diastole. D. secondary to closure of the mitral valve leaflets during systole.

Explanations (u) A. Atrial contraction against a noncompliant ventricle is the mechanism responsible for S4. (c) B. Rapid ventricular filling during early diastole is the mechanism responsible for the S3. (u) C. Vibration of a partially closed mitral valve during mid to late diastole is the mechanism responsible for the Austin-Flint murmur of aortic regurgitation. (u) D. Closure of the mitral valve leaflets during systole is the mechanism responsible for part of the S1 heart sound.

Health Maintenance/Cardiology A 74 year-old patient presents with signs and symptoms of heart failure. EKG shows the patient to be in atrial fibrillation at a rate of 80 bpm. Blood pressure is 120/76. The patient denies complaint of palpitations, chest pain, or syncope. Which of the following is the most important long term therapy in this patient? A. verapamil (Calan) B. amiodarone (Cordarone) C. furosemide (Lasix) D. warfarin (Coumadin)

Explanations (u) A. Calcium channel blockers are utilized in rate control of atrial fibrillation. This patient's rate is controlled at 80bpm presently. (u) B. Antiarrhythmic therapy may be considered in patients with atrial fibrillation; however anticoagulation therapy must occur first. (u) C. Diuretics may be indicated in the acute treatment of heart failure; however they may not be needed long term. (c) D. Patients with atrial fibrillation have an increased risk for stroke, therefore these patients need anticoagulation with warfarin to an INR of 2.0-3.0.

Diagnostic Studies/Cardiology 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

Explanations (u) A. Cardiac catheterization evaluates coronary arteries but has no role in the diagnosis of supraventricular tachycardia. (u) B. Cardiac MRI cannot diagnose and define pathway of supraventricular tachycardia. (u) C. Chest CT scan will not establish definitive diagnosis of supraventricular tachycardia. (c) D. Electrophysiology study is useful in establishing the diagnosis and pathway of complex arrhythmias such as supraventricular tachycardia.

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

Explanations (u) A. Cherry-red fovea and boxcar segmentation of the retinal veins are findings seen in central retinal artery occlusion. (u) B. See letter A for explanation. (u) C. Papilledema is noted in conditions causing increased intracranial pressure. (c) D. Arteriovenous nicking is common in chronic hypertension.

History & Physical/Cardiology A 12 month-old child with tetralogy of Fallot is most likely to have which of the following clinical features? A. Chest pain B. Cyanosis C. Convulsions D. Palpitations

Explanations (u) A. Chest pain is not a feature of tetralogy of Fallot. (c) B. Cyanosis is very common in tetralogy of Fallot. (u) C. Convulsions are occasionally seen as part of severe hypoxic spells in infancy rather than a feature of tetralogy of Fallot. (u) D. Palpitations are uncommon in tetralogy of Fallot.

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

Explanations (u) A. Congenital heart disease is not an established risk factor for coronary artery disease. (u) B. While patients with polycystic ovary syndrome have hyperinsulimemia, they do not have the same poor prognosis for coronary artery disease as patients with diabetes mellitus. (u) C. Patients with acute renal failure are not at risk for coronary artery disease, although patients with diabetes and chronic renal disease do have this risk. (c) D. Patients with diabetes mellitus are in the same risk category for coronary artery disease as those patients with established atherosclerotic disease.

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

Explanations (u) A. Coronary angiography is indicated in patients with classic stable angina who are severely symptomatic despite medical therapy and are being considered for percutaneous intervention (PCI), patients with troublesome symptoms that are difficult to diagnose, angina symptoms in a patient who has survived sudden cardiac death event, patients with ischemia on noninvasive testings, a stress test is a better initial diagnostic study for this patient. (c) B. This patient has signs and symptoms of classic angina; nuclear stress testing is the most useful noninvasive procedure for diagnosis of ischemic heart disease and evaluation of angina in this patient. (u) C. Helical CT is used in the diagnosis of pulmonary embolism, not in the evaluation of angina. (u) D. Echocardiogram is used in the evaluation of valvular heart disease not in the evaluation of suspected myocardial ischemia.

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

Explanations (u) A. Coronary microemboli occlusion is a rare cause of acute myocardial infarction. (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. (u) C. Congenital abnormalities are rare causes of acute MI. (u) D. Severe coronary artery spasm is more likely to result in Prinzmetal's angina rather than true infarction.

Diagnostic Studies/Cardiology A patient with a mitral valve replacement was placed post-operatively on warfarin (Coumadin) for anticoagulation prophylaxis. To monitor this drug for its effectiveness, what test would be used? Answers A. PTT B. PT-INR C. Platelet aggregation D. Bleeding time

Explanations (u) A. PTT is a reflection of the intrinsic clotting system and is used to monitor heparin administration. (c) B. PT-INR is a reflection of the extrinsic and common pathway clotting system. Coumadin interferes with Vitamin K synthesis which is needed in the manufacture of factors II, VII, IX, X which are part of the extrinsic clotting pathway. (u) C. Platelet aggregation tests are utilized to assess platelet dysfunction. (u) D. Bleeding time is used to assess platelet function.

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

Explanations (u) A. Helical CT scan aids in the diagnosis of pulmonary embolism, not in the evaluation of angina. (u) B. Chest x-ray is not used as a diagnostic study to evaluate symptoms of angina or coronary heart disease. (c) C. In patients with classic symptoms of angina, nuclear stress testing is the most widely used test for diagnosis of ischemic heart disease. (u) D. Coronary angiography is indicated in patients with classic stable angina who are severely symptomatic despite medical therapy and are being considered for percutaneous intervention (PCI), patients with troublesome symptoms that are difficult to diagnose, angina symptoms in a patient who has survived sudden cardiac death event, patients with ischemia on noninvasive testings.

Clinical Intervention/Cardiology A 45 year-old female presents with complaint of lower extremity discomfort. The patient admits to dull aching of the left lower extremity. The discomfort is worse after standing for long periods of time. Examination reveals dilated, tortuous and elongated veins on the medial aspect of the left leg. Pedal pulses are +2/4 bilaterally. There are no skin changes or lower extremity edema noted. Which of the following is the most appropriate initial treatment of choice in this patient? A. heparin B. compression stockings C. furosemide (Lasix) D. thrombectomy

Explanations (u) A. Heparin is used in the treatment of deep vein thrombosis not varicose veins. (c) B. This patient has signs and symptoms of varicose veins. Initial treatment with compression stockings may prolong or avoid the need for surgery. (u) C. This patient has no signs of edema or venous insufficiency requiring diuretic therapy. (u) D. Thrombectomy is indicated in a patient with an arterial thrombus, this patient has intact pulses and no pallor.

History & Physical/Cardiology Which of the following conditions would cause a positive Kussmaul's sign on physical examination? A. Left ventricular failure B. Pulmonary edema C. Coarctation of the aorta D. Constrictive pericarditis

Explanations (u) A. Left ventricular failure results in the back-up of blood into the left atrium and then the pulmonary system so it would not be associated with Kussmaul's sign. (u) B. Pulmonary edema primarily results in increased pulmonary pressures rather than having effects on the venous inflow into the heart. (u) C. Coarctation of the aorta primarily affects outflow from the heart due to the stenosis resulting in delayed and decreased femoral pulses; it has no effect on causing Kussmaul's sign. (c) D. Kussmaul's sign is an increase rather than the normal decrease in the CVP during inspiration. It is most often caused by severe right-sided heart failure; it is a frequent finding in patients with constrictive pericarditis or right ventricular infarction.

History & Physical/Cardiology Which of the following conditions would cause a positive Kussmaul's sign on physical examination? Answers A. Left ventricular failure B. Pulmonary edema C. Coarctation of the aorta D. Constrictive pericarditis

Explanations (u) A. Left ventricular failure results in the back-up of blood into the left atrium and then the pulmonary system so it would not be associated with Kussmaul's sign. (u) B. Pulmonary edema primarily results in increased pulmonary pressures rather than having effects on the venous inflow into the heart. (u) C. Coarctation of the aorta primarily affects outflow from the heart due to the stenosis resulting in delayed and decreased femoral pulses; it has no effect on causing Kussmaul's sign. (c) D. Kussmaul's sign is an increase rather than the normal decrease in the CVP during inspiration. It is most often caused by severe right-sided heart failure; it is a frequent finding in patients with constrictive pericarditis or right ventricular infarction.

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

Explanations (u) A. Low output heart failure occurs secondary to ischemic heart disease, hypertension, dilated cardiomyopathy, valvular and pericardial disease, and arrhythmia. (u) B. See A for explanation. (u) C. See A for explanation. (c) D. High output heart failure occurs in patients with reduced systemic vascular resistance. Examples include: thyrotoxicosis, anemia, pregnancy, beriberi and Paget's disease. Patients with high output heart failure usually have normal pump function, but it is not adequate to meet the high metabolic demands.

History & Physical/Cardiology 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

Explanations (u) A. Lower extremity edema is seen with heart failure or venous insufficiency, not pericarditis. (u) B. Carotid bruits are associated with carotid artery stenosis, not pericarditis. (c) C. This patient has signs and symptoms of pericarditis. A pericardial friction rub is characteristic of acute pericarditis. (u) D. Subungual (splinter) hemorrhages are characteristic of infective endocarditis, not pericarditis.

History & Physical/Cardiology Which of the following would you expect on physical examination in a patient with mitral valve stenosis? A. Systolic blowing murmur B. Opening snap C. Mid-systolic click D. Paradoxically split S2

Explanations (u) A. Mitral stenosis is a diastolic, not a systolic murmur. (c) B. Mitral stenosis is characterized by a mid-diastolic opening snap. (u) C. Mid-systolic clicks are noted in mitral valve prolapse, not mitral stenosis. (u) D. Paradoxical splitting of S2 occurs in aortic stenosis not mitral stenosis.

Scientific Concepts/Cardiology Which of the following is the mechanism of action of Class III antiarrhythmic drugs? Answers A. Na+ channel blocker B. K+ channel blocker C. Beta adrenoreceptor blocker D. Ca++ channel blocker

Explanations (u) A. Na+ channel blockers are Class I. (c) B. K+ channel blockers are Class III. (u) C. Beta adrenoreceptor blockers are Class II. (u) D. Ca++ channel blockers are Class VI.

Diagnosis/Cardiology 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

Explanations (u) A. Pain associated with a myocardial infarction is commonly a retrosternal pressure, squeezing, or heaviness. ST segment elevation on EKG would be expected. (u) B. A pulmonary embolism is associated with retrosternal pain; however chest pain is not always present. Patients more commonly will have a sudden onset of dyspnea. PE is not usually associated with a diastolic murmur or diminished pulses. (u) C. Acute pericarditis is characterized by sharp, knife-like pain that is worse with lying supine and better with sitting up and leaning forward. One would expect to find a pericardial friction rub on auscultation. (c) D. Aortic dissection is characterized by a ripping or tearing type pain with radiation to the neck, back or abdomen. Left ventricular hypertrophy is often seen on EKG secondary to longstanding hypertension. A diastolic murmur is often present secondary to aortic insufficiency.

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

Explanations (u) A. Pain changing with position or respiration is suggestive of pericarditis. (c) B. Myocardial ischemia is often experienced as a sensation of discomfort lasting 5-15 minutes, described as dull, aching or pressure. (u) C. Tearing pain with radiation to the back represents aortic dissection. (u) D. Chest pain lasting for several hours is more suggestive for myocardial infarction.

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

Explanations (u) A. Pain does not resolve in an acute MI, it gradually gets worse. (u) B. Pain typically occurs at rest is one of the hallmarks of Prinzmetal variant angina. This patient has just started to develop pain at rest. (u) C. Pain in stable angina is relieved with rest and usually resolves within 10 minutes. angina does not have pain at rest. (c) D. Pain in unstable angina is precipitated by less effort than before or occurs at rest.

Diagnostic Studies/Cardiology A 19 year-old female presents with complaint of palpitations. On examination you note the patient to have particularly long arms and fingers and a pectus excavatum. She has a history of joint dislocation and a recent ophthalmologic examination revealed ectopic lentis. Which of the following echocardiogram findings would be most consistent with this patient's physical features? A. right atrial enlargement B. aortic root dilation C. pulmonic stenosis D. ventricular septal defect

Explanations (u) A. Patients with Marfan's syndrome commonly have mitral valve prolapse and possibly aortic regurgitation. Right atrial enlargement, pulmonic stenosis and ventricular septal defect are not commonly seen. (c) B. This patient has the signs and symptoms consistent with Marfan's syndrome. Ectopia lentis, aortic root dilation and aortic dissection are major criteria for the diagnosis of the disease. (u) C. See A for explanation. (u) D. See A for explanation.

History & Physical/Cardiology A 65 year-old white female presents with dilated tortuous veins on the medial aspect of her lower extremities. Which of the following would be the most common initial complaint? Answers A. Pain in the calf with ambulation B. Dull aching heaviness brought on by periods of standing C. Brownish pigmentation above the ankle D. Edema in the lower extremities

Explanations (u) A. Patients with deep venous thrombosis (DVT) may present with complaints of pain in the calf with ambulation. Secondary varicosities may result from DVT's. (c) B. Dull aching heaviness or a feeling of fatigue brought on by periods of standing is the most common complaint of patients presenting initially with varicosities. (u) C. Stasis Dermatitis and edema are most suggestive of chronic venous insufficiency. (u) D. See C for explanation.

Diagnosis/Cardiology A 24 year-old male presents for routine physical examination. On physical examination, you find that the patient's upper extremity blood pressure is higher than the blood pressure in the lower extremity. Heart exam reveals a late systolic murmur heard best posteriorly. What is the most likely diagnosis in this patient? A. Hypertrophic obstructive cardiomyopathy B. Patent foramen ovale C. Coarctation of the aorta D. Patent ductus arteriosus

Explanations (u) A. Patients with hypertrophic obstructive cardiomyopathy do not present with hypertension or weak femoral pulses. (u) B. The murmur associated with patent foramen ovale is a systolic ejection murmur heard in the second and third intercostal spaces and patients do not present with hypertension. (c) C. Coarctation of the aorta commonly presents with higher systolic pressures in the upper extremities than the lower extremities and absent or weak femoral pulses. (u) D. Patent ductus arteriosus is rare in adults and patients are noted to have a continuous rough, machinery murmur.

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

Explanations (u) A. Percutaneous coronary intervention is a better, less invasive alternative to CABG for single vessel coronary artery disease. (h) B. Streptokinase is not commonly used for treatment of acute myocardial infarction because it is ineffective at opening the occluded artery and reducing mortality. Streptokinase would be harmful because it would increase the risk of bleeding. (c) C. Immediate coronary angiography and primary percutaneous coronary intervention have been shown to be superior to thrombolysis. (u) D. Warfarin is used to prevent thrombosis and not for acute treatment.

Clinical Therapeutics/Cardiology 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)

Explanations (u) A. Pericardiocentesis is the treatment of choice in a patient with a pericardial effusion and cardiac tamponade, there is no evidence of either of these in this patient. (u) B. Nitroglycerin is indicated in the treatment of chest pain related to angina. (u) C. Percutaneous coronory intervention is the treatment of choice in a patient with an acute myocardial infarction. (c) D. Indomethacin, a nonsteroidal anti-inflammatory medication, is the treatment of choice in a patient with acute pericarditis.

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

Explanations (u) A. Pheochromocytoma will result in an increase in the production and release of catecholamines, which results in an increase in urinary metanephrines on testing. (u) B. Renal artery stenosis is identified by an abnormal radionuclide uptake on the affected kidney. (u) C. Coarctation of the aorta is identified by delayed and weakened femoral pulses along with a blood pressure in the lower extremities significantly lower than in the upper extremities. (c) D. Primary aldosteronism has an increased aldosterone secretion, which causes the retention of sodium and the loss of potassium. This should be the primary consideration for this patient.

Clinical Therapeutics/Cardiology Long term use of which of the following drugs may cause a drug-induced lupus-type eruption? A. prednisone B. tetracycline C. procainamide D. oral contraceptives

Explanations (u) A. Prednisone is not implicated in drug-induced skin reactions. (u) B. Tetracycline and sulfonamides are known to cause a photosensitive rash on sun exposed areas of the skin. (c) C. Procainamide and hydralazine are the most common drugs that may cause a lupus-like eruption. (u) D. Oral contraceptives may induce erythema nodosum.

Diagnostic Studies/Cardiology 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

Explanations (u) A. Prolonged QT interval is seen in hypocalcemia. (u) B. Delta wave is a sign of ventricular preexcitation seen in Wolf-Parkinson-White (WPW) Syndrome. (c) C. Narrowing and peaking of T waves are the beginning EKG changes associated with hyperkalemia. (u) D. Prominent U waves are a sign of prolonged ventricular repolarization seen in hypokalemia.

Clinical Therapeutics/Cardiology Which of the following beta-adrenergic blocking agents has cardioselectivity for primarily blocking beta-1 receptors? Answers A. Propranolol (Inderal) B. Timolol (Blocadren) C. Metoprolol (Lopressor) D. Pindolol (Visken)

Explanations (u) A. Propranolol and timolol are nonselective beta-adrenergic antagonists. (u) B. See A for explanation. (c) C. Metoprolol is selective for beta-1 antagonists (u) D. Pindolol is an antagonist with partial agonist activity.

History & Physical/Cardiology A 22 year-old male received a stab wound in the chest an hour ago. The diagnosis of pericardial tamponade is strongly supported by the presence of Answers A. pulmonary edema. B. wide pulse pressure. C. distended neck veins. D. an early diastolic murmur.

Explanations (u) A. Pulmonary edema may result with low output states as seen with myocardial contusions, but it is not strongly suggestive of tamponade. (u) B. Wide pulse pressure is seen in conditions of high stroke volume such as aortic insufficiency or hyperthyroidism. Narrow pulse pressure is seen with cardiac tamponade. (c) C. Cardiac compression will manifest with distended neck veins and cold clammy skin. (u) D. The onset of diastolic murmur is suggestive of valvular disease, not tamponade.

History & Physical/Cardiology A 22 year-old male received a stab wound in the chest an hour ago. The diagnosis of pericardial tamponade is strongly supported by the presence of A. pulmonary edema. B. wide pulse pressure. C. distended neck veins. D. an early diastolic murmur.

Explanations (u) A. Pulmonary edema may result with low output states as seen with myocardial contusions, but it is not strongly suggestive of tamponade. (u) B. Wide pulse pressure is seen in conditions of high stroke volume such as aortic insufficiency or hyperthyroidism. Narrow pulse pressure is seen with cardiac tamponade. (c) C. Cardiac tamponade will manifest with distended neck veins and cold clammy skin. (u) D. The onset of diastolic murmur is suggestive of valvular disease, not tamponade.

History & Physical/Cardiology A 25 year-old female presents with a three-day history of chest pain aggravated by coughing and relieved by sitting. She is febrile and a CBC with differential reveals leukocytosis. Which of the following physical exam signs is characteristic of her problem? Answers A. Pulsus paradoxus B. Localized crackles C. Pericardial friction rub D. Wheezing

Explanations (u) A. Pulsus paradoxus is a classic finding for cardiac tamponade. (u) B. Localized crackles are associated with pneumonia and consolidation, not pericarditis. (c) C. Pericardial friction rub is characteristic of an inflammatory pericarditis. (u) D. Wheezing is characteristic for pulmonary disorders, such as asthma.

Scientific Concepts/Cardiology Which of the following is the most common cause of arterial embolization? A. Rheumatic heart disease B. Myxoma C. Atrial fibrillation D. Venous thrombosis

Explanations (u) A. Rheumatic heart disease is a rare cause of embolization (u) B. Myxoma is a rare cause of embolization. (c) C. Atrial fibrillation is present in 60-70% of patients with arterial emboli and is associated with left atrial appendage thrombus. (u) D. Venous thrombosis may be a cause of embolization paradoxically, but is uncommon.

Diagnostic Studies/Cardiology 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

Explanations (u) A. Right bundle branch block is caused by a delay in the conduction system in the right ventricle. It may be caused by right ventricular hypertrophy or conditions with higher pulmonic resistance such as cor pulmonale. Hypertension, however, is likely to cause changes in the left ventricle rather than the right ventricle. (c) B. Long-standing hypertension can lead to left ventricular hypertrophy with characteristic changes noted on EKG. (u)C. See A for explanation. (u) D. ST segment elevation is a sign of acute myocardial infarction not hypertension.

Health Maintenance/Cardiology A postmenopausal woman is at greatest risk of death from which of the following? A. stroke B. heart disease C. ovarian cancer D. breast cancer

Explanations (u) A. See B for explanation. (c) B. Although women tend to be concerned about dying from breast cancer, heart disease is the number one killer of postmenopausal women. (u) C. See B for explanation. (u) D. See B for explanation.

Clinical Therapeutics/Cardiology Which of the following antiarrhythmic drugs can be associated with hyper- or hypothyroidism following long-term use? Answers A. Quinidine B. Amiodarone C. Digoxin D. Verapamil

Explanations (u) A. See B for explanation. (c) B. Amiodarone is structurally related to thyroxine and contains iodine, which can induce a hyper- or hypothyroid state. (u) C. See B for explanation. (u) D. See B for explanation.

Diagnosis/Cardiology A 56 year-old male with a known history of polycythemia suddenly complains of pain and paresthesia in the left leg. Physical examination reveals the left leg is cool to the touch and the toes are cyanotic. The popliteal pulse is absent by palpation and Doppler. The femoral pulse is absent by palpation but weak with Doppler. The right leg and upper extremities has 2+/4+ pulses throughout. Given these findings what is the most likely diagnosis? Answers A. Venous thrombosis B. Arterial thrombosis C. Thromboangiitis obliterans D. Thrombophlebitis

Explanations (u) A. See B for explanation. (c) B. Arterial thrombosis has occurred and is evidenced by the loss of the popliteal and dorsalis pedis pulse. This is a surgical emergency. Venous occlusion and thrombophlebitis do not result in loss of arterial pulse. (u) C. See B for explanation. (u) D. See B for explanation.

Clinical Therapeutics/Cardiology Which electrolyte abnormality is associated with an increase in the risk for digoxin toxicity?] A. hypercalcemia B. hypokalemia C. hypermagnesemia D. hyponatremia

Explanations (u) A. See B for explanation. (c) B. Decreased concentration of potassium results in the increased activity of cardiac glycosides by increasing tissue binding and decreasing renal excretion of digoxin. Potassium loss is the only significant electrolyte abnormality that significantly affects digoxin metabolism. (u) C. See B for explanation. (u) D. See B for explanation.

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

Explanations (u) A. See B for explanation. (c) B. Given the patient's long history of type 1 diabetes mellitus the patient most likely has vascular occlusive disease. Evaluation of arterial blood flow is assessed using the duplex scanner. X-ray of the L/S spine and right hip while not harmful may give information regarding bony structures. Venous Doppler ultrasound will not give information of arterial perfusion. (u) C. See B for explanation. (u) D. See B for explanation.

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

Explanations (u) A. See B for explanation. (c) B. Increased vagal tone is common in inferior wall MI; if the SA node is involved, bradycardia may develop. (u) C. See B for explanation. (u) D. See B for explanation.

Scientific Concepts/Cardiology The most common arrhythmia encountered in patients with mitral stenosis is A. atrial flutter. B. atrial fibrillation. C. paroxysmal atrial tachycardia. D. atrio-ventricular dissociation.

Explanations (u) A. See B for explanation. (c) B. Mitral stenosis leads to enlargement of the left atrium, which is the major predisposing risk factor for the development of atrial fibrillation. (u) C. See B for explanation. (u) D. See B for explanation.

Scientific Concepts/Cardiology What is the most likely mechanism responsible for retinal hemorrhages and neurologic complications in a patient with infective endocarditis? Answers A. Metabolic acidosis B. Systemic arterial embolization of vegetations C. Hypotension and tachycardia D. Activation of the immune system

Explanations (u) A. See B for explanation. (c) B. The vegetations that occur during infective endocarditis can become emboli and can be dispersed throughout the arterial system. (u) C. See B for explanation. (u) D. Glomerulonephritis and arthritis result from activation of the immune system.

Clinical Therapeutics/Cardiology 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

Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. Absolute contraindications to thrombolytic therapy include a previous hemorrhagic stroke, a stroke within one year, a known intracranial neoplasm, active internal bleeding, and a suspected aortic dissection. Severe, but controlled hypertension, use of anticoagulation, and active peptic ulcer disease are relative contraindications in which the risk/benefit ratio must be weighed in each patient. (u) D. See C for explanation.

Clinical Therapeutics/Cardiology A 74 year-old male is diagnosed with pneumonia. The physician assistant should ensure the patient is not on which of the following before starting therapy with clarithromycin (Biaxin)? Answers A. Lisinopril (Zestril) B. Furosemide (Lasix) C. Simvastatin (Zocor) D. Dipyridamole (Persantine)

Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. Statins are known to interact with the macrolides as they may cause prolonged QT interval, myopathy and rhabdomyolysis. (u) D. See C for explanation.

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

Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. This patient has 2 identifiable risk factors based upon the information provided. These include her age 68 and her history of cigarette smoking. (u) D. See C for explanation.

Diagnosis/Cardiology A 42 year-old male is brought into the ED with a complaint of chest pain. The pain comes on suddenly without exertion and lasts anywhere from 10-20 minutes. The patient has experienced this on three previous occasions. Today the patient complains of light- headedness with the chest pain lasting longer. Vital signs T-99.3°F oral, P-106/minute and regular, R-22/minute, BP 146/86 mm Hg. EKG reveals sinus rhythm with a rate of 100. Intervals are PR = 0.06 seconds, QRS = 0.12 seconds. A delta wave is noted in many leads. Based upon this information what is the most likely diagnosis? Answers A. Sinus tachycardia B. Paroxysmal supraventricular tachycardia C. Wolff-Parkinson-White syndrome D. Ventricular tachycardia

Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. Wolff-Parkinson-White syndrome hallmarks on EKG include a shorten PR interval, widened QRS, and delta waves. Sinus tachycardia has a normal PR interval and no delta waves. PSVT usually has a retrograde P wave or it may be buried in the QRS complex. (u) D. Ventricular tachycardia has a widened QRS as it originates in the ventricles.

Health Maintenance/Cardiology 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)

Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. ACE inhibitors have been shown to markedly improve survival and are also recommended for prevention of symptoms in patients at risk for heart failure.

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

Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Although medical therapy is important, revascularization is indicated when stenosis of the left main coronary artery is greater than 50%.

Diagnosis/Cardiology A 48 year-old male with a known history of hypertension is brought to the ED complaining of headache, general malaise, nausea and vomiting. The patient currently takes nifedipine (Procardia)90mg XL every day and atenolol (Tenormin) 50 mg every day. Vital signs reveal temperature 98.6°F, pulse 72/minute, respiratory rate 20/minute, and the blood pressure is 168/120 mmHg. BP reading taken every 15 minutes from the time of admission reveal the systolic to run from 176 to 186 mmHg and the diastolic to run from 135 to 150 mmHg. Physical examination reveals papilledema bilaterally. There are no renal bruits noted. The EKG is normal. Based upon this presentation, what is the most likely diagnosis? Answers A. Meningitis B. Secondary hypertension C. Pseudotumor cerebri D. Malignant hypertension

Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. Pseudotumor cerebri presents with papilledema, but not hypertension and is more common in young females. (c) D. Malignant HTN is characterized by diastolic reading greater than 140 mm Hg with evidence of target organ damage.

History & Physical/Cardiology What type of chest pain is most commonly associated with a dissecting aortic aneurysm? A. Squeezing B. Dull, aching C. Ripping, tearing D. Burning

Explanations (u) A. Squeezing pain is more characteristic of angina or esophageal pain. (u) B. Dull, aching pain is more characteristic of chest wall pain, possibly angina, or anxiety. (c) C. A dissecting aortic aneurysm often presents with a very severe ripping, tearing-like pain. (u) D. Burning pain is more characteristic of esophageal reflux, esophagitis, or tracheobronchitis.

History & Physical/Cardiology A patient had an acute inferior, transmural myocardial infarction 4 days ago. A new murmur raises the suspicion of mitral regurgitation due to papillary muscle rupture. Which of the following murmur descriptions describes this condition? A. A grade III/VI diastolic murmur heard best at the apex without radiation. B. A grade IV/VI systolic ejection murmur heard best at the base with radiation to the left clavicle. C. A grade II/VI systolic murmur heard best at the apex preceded by a click and without radiation. D. A grade IV/VI systolic murmur heard best at the apex with radiation to the left axilla.

Explanations (u) A. This is a classic description of mitral stenosis. (u) B. This is a classic description for pulmonic stenosis. (u) C. This is a classic description for mitral valve prolapse. (c) D. This is a classic description of mitral regurgitation. The papillary muscle rupture is a complication of an acute inferior transmural myocardial infarction, and results in a failure of the mitral valve leaflets to close. The direction of regurgitant flow of blood is toward the left axilla.

Clinical Therapeutics/Cardiology A 55 year-old diabetic female presents for a 3 month blood pressure follow-up. At the last visit the BP was 160/90 for the third consecutive visit. She was placed on an ACE inhibitor and educated regarding lifestyle modifications. At today's visit the patient complains of persistent annoying dry cough that has been going on since the last visit. BP today is 120/70. What is the best recommendation to control her BP? A. add a diuretic B. stop the ACE inhibitor and continue lifestyle modifications C. switch patient to an Angiotensin II Receptor Blocker (ARB) D. do nothing and recheck BP in 3 months

Explanations (u) A. This patient's blood pressure is controlled; there is no indication at this time to add an additional drug. (u) B. This patient's chronic dry cough is likely secondary to the ACE inhibitor, the medication should be stopped, however the patient needs something for blood pressure control. (c) C. This patient's chronic dry cough is likely secondary to the ACE inhibitor, the medication should be stopped. Angiotensin II Receptor Blockers (ARBs) are similar to ACE inhibitors for BP control, but do not cause cough. (u) D. This patient's chronic dry cough is likely secondary to the ACE inhibitor, the medication should be stopped to encourage compliance.

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

Explanations (u) A. Vena cava filters are used in the management of venous thromboembolic disease when anticoagulation cannot be done. (c) B. Embolectomy within 4 to 6 hours is the treatment of choice. (h) C. Amputation is done only when no viable tissue is present. Cutting off a viable limb is never a good idea. (u) D. Aspirin is used in the prevention and treatment of coronary disease and has no role in the treatment of peripheral arterial embolism.

Diagnostic Studies/Cardiology 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

Explanations (u) A. Venogram has been replaced by noninvasive tests due to discomfort, cost, technical difficulties, and complications, such as phlebitis. 56 (h) B. Thrombophlebitis is a venous problem, not an arterial one. Any unnecessary invasive procedure is potentially harmful. (c) C. Ultrasound is the technique of choice to detect deep venous thrombosis in the leg. (a) D. Impedance plethysmography is equivalent to ultrasound in detecting thrombi of the femoral and popliteal veins, but it may miss early, nonocclusive thrombi.

Diagnosis/Cardiology An 8 year-old boy is brought to a health care provider complaining of dyspnea and fatigue. On physical examination, a continuous machinery murmur is heard best in the second left intercostal space and is widely transmitted over the precordium. The most likely diagnosis is A. ventricular septal defect. B. atrial septal defect. C. congenital aortic stenosis. D. patent ductus arteriosus.

Explanations (u) A. Ventricular septal defect causes a holosystolic murmur rather than a continuous machinery-like murmur. (u) B. Atrial septal defect causes a fixed split S2 rather than a continuous systolic heart murmur. (u) C. Congenital aortic stenosis causes a crescendo-decrescendo systolic murmur heard best in the second intercostal space. (c) D. Patent ductus arteriosus is classically described in children as a continuous machinery-type murmur that is widely transmitted across the precordium.

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

Explanations (u) A. Verapamil is a calcium channel blocker and there is no associated rebound hypertension after withdrawal. (u) B. Lisinopril is an ACE inhibitor, which is not associated with rebound hypertension. (c) C. Clonidine (Catapres) is a central alpha agonist and abrupt withdrawal may produce a rebound hypertensive crisis. (u) D. Hydrochlorothiazide is a thiazide diuretic, which is not associated with rebound hypertension.

Health Maintenance/Cardiology A 72 year-old female is being discharged from the hospital following an acute anterolateral wall myocardial infarction. While in the hospital the patient has not had any dysrhythmias or hemodynamic compromise. Which of the following medications should be a part of her d/c meds? A. Warfarin (Coumadin) B. Captopril (Capoten) C. Digoxin (Lanoxin) D. Furosemide (Lasix)

Explanations (u) A. Warfarin is not indicated since there is no role for anticoagulation in this patient. (c) B. ACE inhibitors have been shown to decrease left ventricular hypertrophy and remodeling to allow for a greater ejection fraction. (u) C. The patient does not have any dysrhythmias so Lanoxin is not indicated. (u) D. The patient does not have any hemodynamic compromise or indicators of CHF.